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PubMed2005

Gender and psychotherapy with traditional men.

Therapists who are accustomed to operating in a world where gender roles are becoming increasingly androgynous may underestimate how foreign the experience of psychotherapy can be to "traditional" men. This paper describes the occurrence of transference and resistance encountered by female therapists when seeing male patients at a Veterans Administration (V.A.) Medical Center who identify with traditional American male gender roles. The discussion is informed by recent advances in the theory of male gender identity development and yields new insights into the typical defenses men may bring to the early phases of psychotherapy. Case examples from the authors' practices illustrate strategies for intervening with resistance and enhancing the therapeutic alliance. Common countertransference issues encountered by therapists working with "traditional" men are also discussed.

Combat Disorders↗

PubMed1981

Training psychiatric residents in chronic care.

Because of recent advances in the care of the chronically mentally ill, psychiatric residents need to have more specialized training in the treatment of this group of patients. The Massachusetts Mental Health Center has developed a training program in chronic care for psychiatric residents that is a combination of didactic presentations and placements in programs serving chronic patients. In learning to treat the chronically mentally ill, residents face a variety of clinical, countertransference, and supervisory issues. They must learn to conduct therapy that is rehabilitation-based; to combine their role as medical doctor with their role as psychiatric specialist; to work with a multidisciplinary team; and to coordinate patient care among serveral community agencies.

Attitude of Health Personnel↗

PubMed1982

Three-way interviews and psychiatric training.

The three-way interview is a helpful and sometimes necessary adjunct to the supervision of psychiatric residents who are treating disturbed inpatients. Direct bedside observation of the interaction between therapist and patient can reveal evidence of previously unrecognized countertransference difficulties in the beginning therapist. It also maximizes patient care by allowing detection and correction of diagnostic errors that have resulted from either underlying medical illnesses or drug toxicity. This supervision model resembles that used in teaching internal medicine, in which the house staff and the consultant share their observations.

Adult↗

PubMed1983

The treatment of antisocial and borderline personality disorders.

Because of continuing diagnostic confusion, little empirical evidence exists to guide the clinician in treating patients with antisocial and borderline personalities. However, there is an extensive clinical literature based on the experience of many workers in the field, and it is possible to outline broad areas of agreement and major controversies. The resistance of the patient and the intense countertransference be typically evokes make treatment difficult no matter what the approach. Most authors agree that treatment of the antisocial personality must begin in a residential setting with an active milieu if it is to have any chance of success. Severe borderlines may also require a great deal of structure to supplement psychotherapy; with them, however, the therapist can feel more optimistic about an approach stressing the clarification of maladaptive defenses and the interpretation of negative transference.

Antisocial Personality Disorder↗

PubMed1986

Psychiatric interventions for AIDS-spectrum disorders.

Although the medical and psychosocial problems posed by acquired immune deficiency syndrome (AIDS) are unique, interventions to treat AIDS-related psychiatric disorders are currently available. The depression, delirium, and denial that occur in medically hospitalized patients with AIDS respond to standard psychotherapeutic and psychopharmacological approaches. Outpatients with AIDS or AIDS-related complex benefit from clarification, abreaction, and support if the therapist accepts the regression associated with the sick role, focuses initially on somatic rather than on psychological concerns, and overcomes unwarranted fears of contagion. Patients with AIDS-related dementia are helped considerably by early diagnosis and planning, and patients with antibodies to the AIDS virus require a psycho-educational approach that includes stress inoculation and problem-solving techniques. The authors describe the above interventions as well as common countertransference responses that impede their implementation.

Acquired Immunodeficiency Syndrome↗

PubMed1987

A model for understanding and managing cycles of aggression among psychiatric inpatients.

A model developed at the Forensic Center of the Mendota Mental Health Institute for understanding and managing aggressive inpatients focuses on the dynamics of inpatient aggression and their impact on staff. Divided into cycles of physical and verbal aggression, the model incorporates staff responses to aggressive behaviors and outlines the responsibilities of the administration in helping staff deal with aggressive patients. It particularly addresses repetitive aggression and the importance of recognizing countertransference issues.

Aggression↗

PubMed1990

The therapist as representative payee.

The effects of the therapist's assuming control of the patient's finances through representative payeeship is discussed. The authors use case examples from an urban outpatient community mental health center to illustrate administrative issues, ethical conflicts, and transference and countertransference manifestations of payeeship. They favor an approach whereby the institution is formally the payee and a clinician is designated to manage a patient's account. For most patients for whom a clinician assumed payeeship, compliance with treatment increased, the number and length of hospitalizations decreased, and housing arrangements improved. Although designating the therapist as payee has a significant impact on the therapeutic relationship, in most cases the patient is so impaired that the benefits outweight the liabilities.

Adult↗

PubMed2000

Treatment of the older adult: the impact on the psychoanalyst.

Work with the elderly challenges analysts in special ways. The author presents clinical material from her practice and from investigative interviews with nine treating analysts who report personal reactions and countertransferences to analytic work with twelve elderly patients. She concludes that the major challenges in work with the elderly come more from the analyst than from the patients. Issues arising from the analyst's unresolved feelings about aging, parents, loss, and death are revived in the treatment of the elderly in an especially intense form. In this paper many aspects of transference are considered, especially those relating to illness, loss, and the problems that flow from identifications of the older analyst with the patient. The affective reverberations in younger and older analysts with regard to the initiation of analytic treatment, the inevitability of moving in and out of real life crises, the sustaining of loss, and, particularly, the impending termination, are presented in the paper.

Aged↗

PubMed2001

Concurrent therapies: a model for collaboration between psychoanalysts and other therapists.

Many psychoanalysts treat individuals who are simultaneously in couples therapy or whose partners are in individual therapy. If such cases stall, some analysts may seek consultation from a colleague, though most have accepted the tacit historical prohibition against communication between therapists treating members of the same family. Experience, however, suggests that a certain form of communication between such therapists can have a powerfully enhancing effect on the concurrent therapies. After a review of the literature, the advantages, disadvantages, and impediments to collaborative cross-communication are examined. A model is then presented for use in ongoing discussion between therapists, and is illustrated with two clinical examples. The proposed model centers on the transference-countertransference configurations within the therapeutic field, and serves as an organizer highlighting areas for discussion.

Adult↗

PubMed2005

Caring and coercive aspects of the psychoanalytic situation.

Certain ambivalent reactions to undergoing analysis add content and intensity to the analysand's transference and to some extent to the analyst's countertransference. A significant share of these reactions may be attributed to the structure of the psychoanalytic situation. Among other things, analysands' reactions feature fantasized and sometimes realistic experiences of being coerced by their analyst's counter-transferences. However, to achieve a clear view of these coercive experiences, they must be considered in relation to another, equally weighty structural feature: ambivalent reactions to the analyst's concerned care. Observation suggests that an intervention can be experienced, simultaneously or sequentially, as both coercive and caring, and that, when analyzed, each of these experiences is usually found to be saturated with mixed feelings.

Coercion↗

PubMed1982

The choice of a name: "Dora" and Freud's relationship with Breuer.

I have suggested that Freud's choice of the pseudonym Dora for his eighteen-year-old hysterical patient, Ida Bauer, was over-determined. Dora, it seems likely, was named not only after Freud's sister's nursemaid, as Freud himself explained, but also after Dora Breuer, Josef Breuer's youngest daughter. This theory is based on an examination of the similarities in the lives and symptoms of Anna O. (Breuer's famous hysterical patient of 1880-1882) and Dora; on an analysis of the transferences and countertransferences in the cases of these two young women; and on evidences of the persistent significance of Josef Breuer in Freud's life after 1895. These specific inquiries also call attention to the nature of hysteria at the end of the nineteenth century and to the ever-present complexities of the physician-patient relationship.

Adolescent↗

PubMed1982

The patient's own pillow on the couch.

Material is presented from two hypochondriacal patients who insisted on using their own pillows on top of the bolster-pillow on the analyst's couch. A number of important transference fantasies are seen as underlying this unusual resistance to the progress of the analysis. In addition, the analyst's countertransference feelings are described.

Adult↗

PubMed1983

Treatment preparatory to psychoanalysis.

Many potentially analyzable adult patients with unimpaired egos require a period of preparatory treatment before entering psychoanalysis. There has been some concern that such face-to-face treatment, if done with the same analyst, would influence the subsequent analysis by stimulating inaccessible unconscious fantasies, gratifying infantile wishes, or making the analyst too "real." This would necessitate a change to another analyst after the preparatory treatment, in order that the analysis be unmodified and have the most profound and definitive effects. Increasingly, however, many analysts practicing in the classical tradition have found preparatory treatment compatible with progression to psychoanalysis with the same analyst. But neither this process nor the concerns about it have been described to any extent in the literature. This may be, in part, because of historical conceptions that the effects of psychotherapy rest mainly on suggestion, lack of a full theoretical framework for psychotherapy compared with psychoanalysis, and disagreement as to whether these procedures are dichotomous or on a continuum. In order to discuss most clearly the basic issues involved in preparatory treatment that progresses to analysis with the same analyst, a case is presented in which complex variables were at a minimum; the transition could be anticipated, so that interventions, which might complicate the analysis, could be avoided; and the preparatory treatment was necessary to attenuate specific resistances to the meaning of analysis. The patient described here resisted analysis as it represented the facilitator of a feared regression and the reactivator of warded-off libidinal and aggressive impulses and wishes which the patient experienced as more controllable in psychotherapy. The meanings and effects of the prior treatment and the transition on the analytic transference neurosis, resistances, countertransferences, as well as possible effects on analytic technique, are described. Although some effects on the analytic process were apparent, limitations were not observed. Also considered are advantages and disadvantages of this extension of analytic technique and why many patients, despite our best efforts, persist in avoiding analysis.

Adult↗

PubMed1983

The position and value of extratransference interpretation.

The role of extratransference interpretation in the theory of technique has been insufficiently defined and only tangentially discussed. Extratransference interpretation refers to interpretation that is relatively outside the analytic transference relationship. Although interpretive resolution of the transference neurosis is the central area of analytic work, transference is not the sole or whole focus of interpretation, or the only effective "mutative" interpretation, or always the most significant interpretation. Extratransference interpretation has a position and value which is not simply ancillary, preparatory, and supplementary to transference interpretation. Transference analysis is essential, but extratransference interpretation, including genetic interpretation and reconstruction, is also necessary, complementary, and synergistic. Transference is a repetition that requires analysis of its genetic sources in childhood conflict and fixation. Transference and reality, past and present, are newly defined, understood, and integrated in the analytic process. Transference fantasy cannot be clarified without understanding the "grains of truth" to which it may be anchored in reality inside and outside the analytic situation. The analyst's real attitudes and attributes may influence the transference and transference analysis. Countertransference also tends to evoke transference reactions which are unique to each patient, so that there are contributions from both parties to the analytic process and the analytic data. Analytic understanding should encompass the overlapping transference and extratransference spheres, fantasy and reality, past and present. A "transference only" position is theoretically untenable and could lead to an artificial reduction of all associations and interpretations into a transference mold and to an idealized folie à deux.

Conflict, Psychological↗

PubMed1984

Pathological narcissism in childhood.

Matt's analysis yields a number of theoretical and clinical implications. It demonstrates that narcissistic character pathology can exist in childhood and shows how family dynamics may contribute. The clearly defensive function of Matt's pathology and his later progress through normal infantile narcissism toward further development suggest that the pathogenesis of narcissistic pathology resides neither in regression to an infantile position nor in untamed infantile narcissism. Rather, as the case demonstrates, narcissistic pathology actually reflects a pathological formation of the self used for defensive purposes. Matt's analysis also shows how such pathology in children may be effectively resolved through interpretation. Finally, the analysis demonstrates the peculiarities of the countertransference in such cases and how they may be pivotal in the course of treatment.

Child↗

PubMed1985

Empathy and psychoanalytic technique.

I have attempted to review the major psychoanalytic contributions to our understanding of empathy within the psychoanalytic situation. In doing so, I have discussed the relation between empathy and identification, reviewed aspects of the metapsychology of analytic comprehension, and have described the role of the analyst's evenly hovering attention in empathic responsiveness, as noted by several analytic investigators of empathy. The interrelations between empathy and countertransference have been described, and neutrality issues as they relate to empathy have been noted. Certain themes around the development of empathy have been grouped together and critically examined. The work of Kohut with regard to empathy has been discussed in relation to earlier psychoanalytic contributions of which it is an outgrowth and expansion. The changes in meaning and emphasis of empathic processes in Kohut's works have been described and critically reviewed. Empathy in its popular usage refers to the capacity of one person to communicatively partake, in a limited way, in the experience of another. In its differentiation from sympathy and pity, its noncritical or value-neutral character is emphasized. This description of empathy indicates its relevance to psychoanalytic technique, which shares many similar characteristics. Empathy is a general or superordinate term for many more specific aspects of the sensitive interpersonal interactions in the intimacy of relationships like the psychoanalytic one. Attempts to assign a particular psychoanalytic technical meaning to empathy or build clinical and developmental theory around empathy are limited by the multiple referents and generality of the concept. Empathy as a term has its place as descriptive of the analyst's emotional relatedness to the patient. It does not refer to any specific psychoanalytic technical intervention or theoretical construct; rather, it describes in a general way the sensitive, tactful, and experience-near way in which the analyst approaches the inner life of his patients.

Affect↗

PubMed1987

Projection and projective identification: developmental and clinical aspects.

Projective identification and projection are defined, described, and contrasted. Projective identification is seen as an early or primitive defensive operation, and projection as later or more advanced and derivative in nature. The developmental origins and adaptive functions of projective identification are examined with an emphasis on the cognitive preconditions for the operation of this defense. The varying functions of both defensive operations are described within the context of psychotic, borderline, and neurotic personality organization. Case material is presented to illustrate the diagnostic approach to and the clinical functions of projective identification, particularly its importance in contributing to complementary identification in the countertransference. Also illustrated is the technical management of severe transference regression under the impact of projective identification. Finally, alternative approaches to the diagnosis and interpretation of projective identification are discussed.

Adult↗

PubMed1989

Pains and gains: a study of forced terminations.

The forced termination of psychoanalysis, such as occurs when the analyst makes a geographic move, uniquely disrupts the analytic setting. This paper recounts the author's experience of terminating a full-time private practice of psychoanalysis and psychoanalytic therapy for such a move. The limited literature on the subject is reviewed with a focus on the use of technical variation in the forced termination situation. The author delineates three areas of interaction with patients where technical variation proved in her experience to be of value: dealing with countertransference and counter-reaction, providing information about the move, and the consideration and process of referral for continued therapy. As opposed to what would be predicted from a classical psychoanalytic perspective, the use of such technical maneuvers seemed to facilitate rather than impede analytic work. These variations in technique served at crucial times to maintain the analytic alliance, to preserve the patient's capacity to recognize and make use of transference, and to provide avenues for resolving past traumas in the transference and the actual loss of the analyst. The concept of the analyst as a new or useable object is proposed as providing a theoretical framework for understanding these observations.

Adaptation, Psychological↗