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PubMed1989

Pseudostupidity and analyzability.

This paper seeks to heighten awareness of pseudostupidity and the potential analyzability of patients who manifest it by defining and explicating it, reviewing the literature, and presenting in detail the psychoanalytic treatment of a pseudostupid patient. Pseudostupidity is caused by an inhibition of the integration and synthesis of thoughts resulting in a discrepancy between intellectual capacity and apparent intellect. The patient's pseudostupidity was determined in part by his need to prevent his being more successful than father, i.e., defeating his oedipal rival. Knowing and learning were instinctualized. The patient libidinally and defensively identified with father's passive, masochistic position. He needed to frustrate the analyst as he had felt excited and frustrated by his parents' nudity and thwarted by his inhibitions. He wanted to cause the analyst to feel as helpless as he, the patient, felt. Countertransference frustration was relevant and clinically useful in the analysis. Interpretation of evolving relevant issues led to more anxiety and guilt, less pseudostupidity, a heightened alliance, and eventual working through. Negative therapeutic reactions followed the resolution of pseudostupidity.

Adult↗
PubMed1989

Emptiness as defense in severe regressive states.

This paper examines the empty states experienced by severely ill borderline patients. At times of stressful regression, these patients use complaints of emptiness to describe profound disturbances of affect, cognition, object relations, and bodily experience. Empty states may be seen as complex defensive configurations which protect a borderline level of psychic structure from the impact of aggressively charged object relations, and ward off further regression to states of fragmentation or fusion. Severely ill borderline patients consolidate an empty screen by means of a characteristic repertoire of primitive defenses consisting of various forms of projective identification, including bitriangulation and projective identification of psychic agencies, somatization, acting out, and specific alterations in cognition. The author describes the highly deviant organizations of the object world seen in empty states, and the complex and disturbing countertransferences which these states evoke.

Adult↗
PubMed1991

One kind of negative therapeutic reaction.

A case is reported in which a young man for several years experienced his analysis primarily as a source of pain. Each new insight he achieved was an occasion for increased distress rather than liberation. Considerable analytic work elucidating motives for this negative therapeutic reaction produced no change in it. Eventually, it could be determined that the patient's need to suffer within the treatment relationship served a specific form of denial in fantasy that has not, to the author's knowledge, been described elsewhere. The importance of covert libidinal, object-preservative aims in such frustrating and destructive impasses is discussed, as well as the role of countertransference enactment.

Aggression↗
PubMed1991

The relevance of the analyst's character and attitudes to his work.

This paper is intended to sensitize analysts to the role of their character in analytic technique. The relation of character to countertransference, its role in analytic style, in the introduction of parameters, and in transference neurosis, will be elaborated. The problem of matching and of accounting for our failures will illustrate the complex meshing of character with more traditional factors.

Adult↗
PubMed1992

The analyst's mistakes.

The analyst's mistakes are an inevitable aspect of his conduct of psychoanalysis. They result from the inherent uncertainties and ambiguities of the analytic process itself, and from the continuing effect upon analytic technique of the analyst's unresolved conflicts, as manifested in countertransference attitudes and enactments. Variables of clinical experience, skill, and the vicissitudes of the analyst's life also contribute to the susceptibility to error. When the analyst's mistakes result from his active engagement in the psychoanalytic process, they yield important clues for understanding clinical material as well as present potential obstacles to analytic progress.

Adolescent↗
PubMed1992

The analyst's style and its impact on the analytic process: overcoming a patient-analyst stalemate.

Analysts have characteristic styles in working with their patients. At times of crisis or stalemate, an alteration in style may facilitate the progress of the treatment. To illustrate the impeding effects of an analytic style at a particular phase of analysis, I describe a stalemate in the analysis of a severely self-critical patient. Recognition of the limiting effects of style on the treatment became apparent in a countertransference enactment, influenced by the patient-analyst match. Self-analysis and alteration in the characteristic style of the analyst resolved the stalemate and enabled the analytic work to progress.

Adult↗
PubMed1995

Telling about the analyst's pregnancy.

Pregnancy is one of several events in the life of an analyst which may affect an analysis, calling for special technical considerations. For the analyst, this exception to the tenet of anonymity, along with countertransference guilt, narcissistic preoccupation, heightened infantile conflicts, and intense patient responses, may stimulate anxiety that becomes focused on the timing and manner of informing the patient. For the patient, preoccupation with the timing of the telling may serve as a displacement from other meanings of the pregnancy. Candidate analysts may face particular difficulties managing the impact of their pregnancies on control cases. We address practical and technical considerations in telling, the transference and counter-transference surrounding it, ethical concerns, and the challenges of supervising a pregnant candidate.

Adult↗
PubMed1995

On focused association and the analytic surface: clinical opportunities in resolving analytic stalemate.

Focused association is a technique for exploring repetitive noncommunicative phenomena, especially those which occupy center stage during periods of analytic stalemate. This psychological content is studied by a two-part investigation of the particulars of the presenting "surface," involving (1) focusing and (2) association. The technique was originally devised by Freud to access the latent meanings of dreams. The effort departs from free association, calling upon more active analytic teamwork within a transference-countertransference context that is steadily considered and analyzed. The key "unverbal" material arising from this dyadic flux is descriptively preconscious, multimodal, widely variable in form, and not primarily lexical. A frequent finding is that these repeating ad hoc clinical phenomena, often categorized as resistance (especially transference resistance), are highly condensed and defensively rearranged compositions, like dreams, that have been internally structured by processes akin to dreamwork. Approached by focused association, such content yields unconscious derivatives that previously had been sequestered in repetitious, noncommunicative forms. This work allows the analyst to follow Freud's clinical maxim to "start with the surface" and provides relief for the analyst from the temptation to invoke global resistance interpretations when derivative communication and analytic movement have lapsed.

Adult↗
PubMed1996

"Someday ..." and "if only ..." fantasies: pathological optimism and inordinate nostalgia as related forms of idealization.

Fantasies whose core is constituted by the notions of "someday" and "if only" are ubiquitous in human psyche. In severe character pathology, however, these fantasies have a particularly tenacious, defensive, and ego-depleting quality. The "someday" fantasy idealizes the future and fosters optimism, and the "if only" fantasy idealizes the past and lays the groundwork for nostalgia. The two fantasies originate in the narcissistic disequilibrium consequent upon the early mother-child separation experiences, though the oedipal conflict also contributes to them. Both can be employed as defenses against defective self and object constancy as well as later narclssistic and oedipal traumas. This paper attempts to highlight the metapsychology and behavioral consequences of these fantasies as well as their unfolding in the treatment situation. It suggests six tasks to be especially important for analytic work with such patients: (1) providing and sustaining a meaningful "holding environment"; (2) employing "affirmative interventions"; (3) helping the patient unmask these fantasies and interpreting their defensive, narcissistic and sadomasochistic aspects; (4) rupturing the patient's excessive hope, analyzing the effects of such rupture, and facilitating the resultant mourning; (5) reconstructing the early scenarios underlying the need for excessive hope; and (6) paying careful attention to countertransference feelings throughout such work.

Countertransference↗
PubMed1996

Metalinguistic analysis of therapeutic discourse: flight into a second language when the analyst and the analysand are multilingual.

The choice of a particular language for the conduct of analysis becomes an important theoretical and clinical question when both the analyst and the analysand are multilingual and share the same languages. Shift from one language into another language during analysis is an equally important question. This paper offers an analysis of the flight into a second language by both the analysand and the analyst within the transference-countertransference matrix. The focus of the discussion is the communicative nature of the mother tongue vis-à-vis a second language. The author argues that unconscious fantasies and memories of early childhood experiences are built into the mother tongue and are brought to life in the analytic dialogue by way of that language. Shift into a second language is viewed as primarily defensive in nature. It is, however, noted that a second language may at times provide the only space where the analyst can meet the patient out of each of certain personal and cultural ghosts. Finally, since the mother tongue is viewed as the preverbal register of the transitional space, it is suggested that the working through of preoedipal issues be ultimately carried out in that language.

Adult↗
PubMed1997

A different perspective on the therapeutic process: the impact of the patient on the analyst.

The therapeutic process is considered from the perspective of its impact on the analyst. Analysts undertake self-scrutiny, focusing on transference and countertransference reactions, in order to facilitate the treatment of their patients. However, this self-reflection also serves to continue and enhance the analysts own personal understanding. In the course of analyzing patients, an interactional process develops in which many of the therapeutic aspects of analysis affect the analyst as well as the patient. A clinical example is offered to illustrate this process.

Awareness↗
PubMed1998

Perverse defenses in neurotic patients.

Distinguishing perverse defenses from the concept of obligatory perversion allows perverse defenses to be examined in neurotic patients. Perverse defenses against reality, one's conflicts, and relationships with others are connected with affect intolerance, difficulty with analytic collaboration, and analytic impasse. Perverse defenses, including the cultivation of states of distraction, excitement, and pomposity, as well as perverse sadomasochistic relations with others, protect against the unbearable: intense affects, painful ideas, and loving, committed need of a valued, distinct person. Patients' perverse, vindictive refusal to be reasonable provokes perverse countertransference reactions whereby the analyst stands in judgmentally and critically for the seemingly absent demands of reason, morality, and analytic progress.

Countertransference↗
PubMed2000

Cultural sensitivity training in mental health: treatment of Orthodox Jewish psychiatric inpatients.

We describe some of the cultural/religious issues which arose in the treatment of major psychiatric disorders among Orthodox Jewish inpatients at SUNY Health Science Center's University Hospital (SUH) in Brooklyn, New York. The distinct ways in which cultural and religious factors impacted on presentation, therapeutic interventions, and transference-countertransference reactions are noted. Specific reference is made to the use of religion by patients and families as a means of defense, rationalization or power-brokering. Via case vignettes, we explore ways of distinguishing between culturally appropriate vs. maladaptive behaviors in the Orthodox population. Practical solutions are suggested for sensitive ways to surmount culture-based barriers to effective inpatient therapy in this group.

Adult↗
PubMed1983

Psychotherapy of the characterologically difficult patient.

The increasing number of characterologically difficult patients in psychiatric practices has produced a plethora of theoretical formulations, treatment strategies and techniques. The major shifts in theoretical emphasis from drive theory to object relations theories and self-psychology has encouraged many psychiatrists to treat these patients in psychotherapy. The heterogeneity and variability of clinical profiles represented in this group of patients, however, still prevents prescription of "the" treatment of choice for this patient population. A major focus on treatment considerations in this paper is the assessment process with emphasis on determining the capacities for inter-personal relationships, psychological mindedness, empathy and psychological soothing of self and others. The advisability of establishing a "contract" as a prerequisite to treatment is suggested as an important factor in determining outcome. Other particular treatment issues are addressed such as frequency of sessions, "secrets", premature provocation of intense affect, medications, consultations, hospitalization, self-mutilation, substance abuse and indications for termination. The complex vissicitudes of the transference and countertransference processes with this group of patients is pointed out especially those feelings of helplessness and range sometimes experienced in the counter-transference. Long term intensive psychotherapy with many of these patients probably still belongs to the area of therapeutic heroics. Hard evidence for good and poor outcome is scarce and therapeutic zeal is too often based on anecdotal testimonial from adherents of one approach or another.

Adaptation, Psychological↗
PubMed1983

Self-esteem in psychotherapy.

Self-esteem is a concept which is central to our understanding of a person's sense of well-being. Impairments to self-esteem due to the effects of past experience coupled with the impact of present circumstances often precipitate the entry into psychotherapy. The psychotherapy situation itself can be a potent source of self-esteem for both patient and therapist because it involves the two major factors that energize self-esteem needs: engagement in an important activity and involvement in an intimate relationship. This paper suggests that whether or not they are the focus of the therapy, self-esteem needs can be exacerbated due to the context of the situation and the fit between patient and therapist, as well as the transference and countertransference.

Countertransference↗
PubMed1984

Psychotherapy with the boring patient.

Boredom is an unpleasant affective state which may be evoked by monotonous sensory input and reduction of an individual's internal instinctual and fantasy activity. Certain difficult patients have the capacity to evoke boredom in their psychotherapists and unless technical modifications are used, therapy quickly reaches an impasse and may be terminated on the grounds that the patient is 'not psychologically-minded.' Chronically boring patients have an impaired capacity for symbolization and can be identified by their non-symbolic communicative style. This reflects an inner struggle with primitive mental states due to fixation at, or regression to, the paranoid-schizoid developmental position. The patient may use projective identification to discharge unbearable psychic tension into the therapist whose boredom is partly a defense against this. Alternatively, the patient may create impenetrable barriers with language by making 'attacks on linking' which are tantamount to attacks on the therapist's peace of mind. The therapist should initially interpret the form and function of the patient's communications rather than the contents. In a manner comparable to a mother's interaction with her young child, the therapist can help the patient acquire a greater capacity for symbolization, including the ability to accurately label and verbalize different affective experiences. Careful analysis of the countertransference will identify the patient's projective identifications, provide valuable information about the patient's primitive mental life, and prevent anti-therapeutic projective counter-identifications. The patient will become less boring as he learns to use symbols and as his primitive anxieties are resolved.

Boredom↗
PubMed1990

Fatal attraction: the ethical and clinical dilemma of patient-therapist sex.

This article reviews the existing literature on the subject of patient-therapist sexual contact. Seven point one percent to 10.9% of male therapists and 1.9% to 3.5% of female therapists admit to engaging in intimate contact with patients. Offenders tend to justify their behaviour as being at least innocuous if not beneficial for the patients. The consequences to the patients include increased psychological and psychosomatic complaints, greater mistrust and anger towards men, hospitalization and suicide. Transference and countertransference issues which account for this behaviour are explored as is the issue of post-termination involvement. Education of physicians and residents concerning the temptations and dangers of this type of contact is strongly recommended.

Attitude of Health Personnel↗
PubMed1997

Effect of diagnosis on countertransferential responses to child psychotherapy patients.

Examined the impact of patient diagnosis on countertransferential responses to hypothetical latency-aged child psychotherapy patients meeting criteria for Dysthymia, Conduct, and Borderline Disorders. Three subtypes of countertransference (CT) were measured: positive (e.g., nurturant feelings), negative (e.g., boredom), and CT-related activity (e.g., tendency to refer patient to another therapist). All three subtypes were found to vary significantly as a function of diagnosis. Of the three diagnostic groups, Dysthymic patients elicited the highest degree of positive CT; Conduct Disorder patients, the highest degree of negative CT; and Borderline patients, the highest degree of CT-related activity. Neither patient and therapist gender nor therapist experience was significantly related to any of the CT scores; however, therapist psychological distress was found to be significantly associated with negative CT and CT-related activity for all three diagnoses.

Adult↗