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PubMed1988

Homosexuality and neurosis: considerations for psychotherapy.

Though there is no correlation between mental illness and homosexuality, there are unique concerns that play a role in symptomatology and psychotherapy around neurotic and characterological issues in gay patients. Homophobia, both in the therapist and in the patient, external and internalized, is the significant "hidden" factor. Lack of training around transference and countertransference issues with gay patients and lack of teaching about homosexuality in training programs contribute to the difficulties encountered in psychotherapy with gay people. There are some problems and concerns specific to being homosexual that may bring patients to therapy: "coming-out," deciding on sexual orientation, desire to change orientation, and a unique "AIDS neurosis." The therapist needs to have an objective knowledge of the gay community and be willing to examine personal beliefs and reactions to work effectively with gay patients.

Acquired Immunodeficiency Syndrome↗
PubMed2002

Patients' relationship episodes and therapists' feelings.

The idea that psychotherapists' feelings may reflect some aspect of the content in the patients' material has long been clinically accepted but on the whole poorly systematically studied. The aim of this study was to analyse associations between relationship episodes told by patients at evaluation interviews, and therapists' subsequent feelings towards the patients. In total, 28 psychotherapies with nine psychotherapists were studied. Before therapy started, the clients were interviewed separately by the eventual therapist and a second interviewer and six relationship episodes were written down by the interviewers. During the therapy, the therapists reported their feelings on a 'feeling checklist' after each therapy session. In a first analysis, the relationship episodes were categorized according to the CCRT system. The results indicated only scattered associations between CCRT categories and therapist feelings. The results were, however, difficult to interpret as it was found that the therapists' feeling patterns were quite homogenous for each therapist. Considering this, qualitative analyses were made of six therapies carried out by two therapists. These analyses revealed different but theoretically plausible patterns between the feelings attributed to the persons in the patients' relationship episodes and the therapists' subsequent feelings towards the patients. The results were interpreted as a confirmation of the purported relations between patient relationship episodes and therapist feelings, but also as pointing to the need to develop the understanding of these patterns. It seems particularly important to emphasize the importance of the therapist's own habitual feeling patterns when the impact of the patient's internalized relationship patterns on countertransference reactions is evaluated.

Adult↗
PubMed2000

The psychoanalyst and the transsexual patient.

The author remarks on the dearth of psychoanalytic literature concerning analyses of transsexuals and of clinical experience with such patients in general. Drawing on her personal work with transsexual patients at a specialised centre, as well as with children suffering from gender identity disorders and their parents, she is able to specify the factors which, in her view, make the psychoanalysis and psychotherapy of these subjects so difficult. In particular, they are totally focused on the body and on their intention of securing sex reassignment by hormonal and surgical treatments, so that they rule out the involvement of any psychic element. The psychic functioning of these patients is illustrated by some clinical vignettes, and the transference and countertransference problems are discussed. The author shows how the patients concerned have great difficulty in accepting a psychological approach to their problems; they do not speak the language of wishes and conflict, and claim to remember nothing of their childhood or past life. She concludes that transsexualism is a narcissistic disorder in which the constitution of the self has been profoundly impaired and that it is only since analysis have embarked on the treatment of non-neurotic patients that the condition has become accessible to psychoanalytic psychotherapy or indeed to psychoanalysis. The difficulties notwithstanding, the author considers that such work is worthwhile and that patients can benefit from it.

Adult↗
PubMed2000

Affect, language and communication. 41st IPA Congress plenary session.

The author discusses Hernández's enriching and clarifying paper, which directs us to the limitations of language with regard to affective movements that barely attain the condition of thinkability and thereby to the important and confusing topic of enactments, which are the lingua franca for the communication of dangerous and repudiated affects. Enactments bridge the interface between what is expressible, and inexpressible, between what is forgotten and what is pressing for revival, between reality and fantasy and also between one-person and two-person psychologies. Conceptually the term enactment facilitates the integration of the concepts of fantasy, projective identification and countertransference. Steiner's richly detailed and moving clinical report demonstrated the value of the concept of projective identification for understanding his patient's communication of affects. The concept has been neglected until recently by many US analysts; one source of confusion has been the assumed reliability of the analyst's emotional reactions as an indicator of what the patient is feeling. The author asks whether Steiner is speaking loosely or literally when he says that his patients put their feelings into him, citing examples to demonstrate that the value of the concept of projective identification would be enhanced by a clarification of this question.

Affect↗
PubMed2000

From symbols to flesh: the polymorphous destiny of narration.

The author analyses certain aspects of the narration of a generally taciturn hysterico-phobic obsessional patient as they appear in the transference relationship, pinpointing its phallic mastery and the sadistic impact of the domination over the audience/analyst that underlies this mode of discourse. She examines them in relation to Proust's 'A la recherche du temps perdu', discussing the place of perversion in analytic listening and interpretation. She then outlines some of the key structuralist and formalist views of narration as a form of syntactic structure expanded by the resolution of an enigma via a hero's ordeal, arguing that if syntactic structure exists, it consists neither of affirmation nor of negation but rather of interrogation. The author notes that what makes psychoanalytic theory radically different from other interpretive theories is the co-presence of sexuality and thought: psychoanalysis reinforces the formal description of a signifying act by the unconscious psychosexual conditions of its possibility. She then discusses the poetic narrative of Nerval and also that of Proust, which is dominated by the acting out of perverse fantasy, the resulting polyphony of various psychosexual registers, its philosophical and metaphysical impact and its relevance to the analyst's own interpretive acts when formulating stories within the countertransference relationship.

Countertransference↗
PubMed2001

The psychoanalyst of the future: wise enough to dare to be mad at times.

What sort of patients do we have in psychoanalysis now, at the beginning of the third millennium, and what sort will we have in the future? In the author's clinical experience, the patients who are currently seeking help from the psychoanalyst use primitive defence mechanisms alongside neurotic ones. Most of them do not explicitly request psychoanalytic treatment, but this does not mean that they would not want it if they knew what it was. She argues that is the psychoanalyst's task to identify the latent request behind the 'non-request'. To conduct a psychoanalysis with such patients, the psychoanalyst has to identify and interpret both primitive and neurotic psychic mechanisms; moreover, he has to use not only language that speaks to patients but also language that 'touches' them, because these patients are difficult to reach through verbal symbolism. This implies that the psychoanalyst must be attentive to the bodily manifestations and bodily phantasies accompanying his countertransference feelings. The author shows through clinical examples what she means by 'language that can touch patients'. The psychoanalyst gradually builds up this language while, at the same time, daring to discover in himself his own mad aspects and giving himself enough psychical freedom to accept them.

Adult↗
PubMed2001

Prospero's paper.

The writer proposes that the interplay between the hermeneutics of psychoanalysis and literature can illuminate understanding of the transference and countertransference at large in an analytic treatment. Writing about the work with a young woman who had been persistently sexually abused as a child and who developed anorexia in her adolescence so severe that her life was endangered both by the illness and by attempts at suicide, the author finds his reading of Shakespeare's The Tempest a powerful informant to the work. Interpreting the object relations represented by Prospero and Miranda and the process of their integration into new mental structures lends the analytic work an additional level of understanding, in particular in relation to the oedipal bond between patient and analyst. When the analyst is confronted by the imminence of his own death towards the end of the analysis, his reading of Prospero's relinquishment of his magical powers and his release of his daughter into sexual maturity and independence helps the patient to replace her destructive inner objects with more reparative and benign ones as she develops a capacity for concern and mourning.

Adult↗
PubMed2002

The external observer and the lens of the patient-analyst match.

A focus on the match between patient and analyst places attention on the dynamic effect of the interaction of character and conflict of both participants on the process that evolves between them. Match is neither a predictive nor static concept. Rather it refers to an unfolding transaction that itself shifts and changes during the course of analytic work. The treating analyst's perception of the effect of this match is by necessity limited by the analyst's own blind spots and other countertransference phenomena. Reporting the analyst's clinical experience to an analytically trained observer, external to the dyad, may broaden the analyst's perspective. Using the lens of the match, a colleague in the role of supervisor, consultant or peer can provide feedback from which the analyst may acquire insight. As a result of this process, the influence that the participants' similarities and differences have upon each other becomes clear to the analyst. This awareness, in turn, may lead the analyst to appreciate the effect of the analyst's stance of distance or closeness and to evaluate whether at this phase of treatment it is beneficial or detrimental to the analytic process. Clinical illustrations of the effect of the external observer's feedback in relation to the patient-analyst match are provided.

Adult↗
PubMed2002

Reporting a dream accompanying an enactment in the transference situation.

Patients with pathological organisations of the personality present the analyst with considerable technical difficulties. One of these problems arises from the fact that, in such patients, dreams frequently are not being used for communication of unconscious meaning, but instead for purposes of manipulation of the transference situation. They then represent attempts to identify the analyst with a part of the patient's self or with a particular internal object in order to draw him/her into collusive enactments. Following the work of Bion and Segal the paper presents a two-dimensional model in order to clarify the structure and use of dreams in this situation. The model may serve as a background orientation for the analyst in the clinical situation, as is subsequently illustrated in a detailed clinical sequence with a borderline patient. To conclude, the author suggests that whenever tendencies towards acting in are predominant, the interpretation of the enactment should generally be given preference over the interpretation of the dream content. The possible advantages and disadvantages of both strategies of interpretation are discussed. Finally, the author highlights consequences that arise when dealing with countertransference.

Acting Out↗
PubMed2003

Miscarriages of psychoanalytic treatment with suicidal patients.

The author describes a particularly perilous frontier on the psychoanalytic landscape--namely, the treatment of suicidal patients with serious personality disorders. Using a clinical example of egregious boundary violations by an analyst, he describes specific countertransference pitfalls that lead to mishandling the patients' expressions of suicidal despair. These include disidentification with the aggressor, failure of mentalization, collapse of the analytic play space, reactions to loss in the analyst's personal life, omnipotence, envy of the patient and masochistic surrender. The author emphasizes the unique vulnerabilities that accompany analytic treatment of such patients.

Adult↗
PubMed2003

On not being able to dream.

In this paper, the author explores the phenomenon of not being able to dream (as opposed to not being able to remember one's dreams) from three different vantage points. First, from the point of view of psychoanalytic theory, he discusses Bion's idea that the work of dreaming creates the conscious and unconscious mind (and not the other way around). A person who cannot dream is unable to generate differentiable conscious and unconscious experience and, consequently, lives in a psychic state in which he is unable to differentiate waking from sleeping, dreaming from perceiving. The author then approaches the problem of the inability to dream from the perspective achieved by a literary work. He discusses a Borges fiction that creates, in a singularly artful way, the experience of not being able to dream. Finally, the author utilises the vantage point of a detailed account of a clinical experience to explore what it means not to be able to dream. He describes an initial state characterised by the patient's proliferation of unutilisable 'psychic noise' which, over a period of years, led to the analyst's experiencing 'reverie-deprivation' and brief periods of countertransference psychosis. Two analytic sessions are presented and discussed in which psychological work was done that contributed to an enhanced capacity on the part of both patient and analyst for genuine dreaming - both in sleep and in analytic reverie states.

Countertransference↗
PubMed2003

Recent theoretical convergences in psychoanalysis and their epistemological importance.

In this paper, the author starts by examining the recent occurrence of an increasing receptivity and critical exchange between different schools of psychoanalytical thought. Among its consequences have been convergences in the understanding of countertransference, especially through the hypotheses of projective identification and countertransferential enactment. The prevalence of these hypotheses points towards the fact that the community of analysts is bringing about an informal and convergent clinical research conducted by a wide and heterogeneous range of its members. The importance and epistemological relevance of this kind of 'informal clinical research' for the construction of psychoanalytical knowledge is emphasised. This process in psychoanalysis is compared with the evolution of knowledge in other scientific areas, highlighting their similarities and their differences. The author shows how Freud's 'mystic writing-pad'model can be expanded to represent the object of psychoanalytical investigation and to bring a better understanding of the reason why the hypotheses of projective identification and countertransferential enactment occupy such a central position in psychoanalysis. In addition, consideration is given to how this kind of research can help in the difficult task of finding criteria for the evaluation of different psychoanalytical concepts. Finally, the author demonstrates how, using this approach, some of the important divergences in contemporary psychoanalysis can be viewed from a new perspective.

Biomedical Research↗
PubMed2003

Psychoanalysis as a creative shaping process.

The author first explains the concepts of creativity, play and aesthetic experience. He then outlines the psychoanalytic process as a creative one that shapes reality. Making a link between psychoanalysis and the humanities, he demonstrates that creative play is a fundamental aspect of the human experience of reality. Aesthetic experiences during the psychoanalytic process are comparable to the play by which children structure their world and artists' activity in following their urge to shape. Furthermore it is shown that creative actualisation testifies to a quasi-biological need for coherence and structure. Through modern hermeneutics, the truth claims of aesthetic shaping can be established in epistemological terms. The basic principles of hermeneutics--historicity, linguisticity and communicative experience--find their psychoanalytic counterparts in memory, representational shaping and transference-countertransference. Psychoanalysis is demonstrated to be simultaneously a science and an art. On the basis of a case history, aesthetic experience is shown to constitute a specific and unique form of access to psychic reality. Aesthetic experience and creativity do not only aid recovery from 'bad psychological states', they are also indispensable for the entire understanding of internal and external reality. It is possible to develop this understanding through a creative psychoanalytic attitude.

Attitude↗
PubMed2004

Narcissistic configurations: violence and its absence in treatment.

'On narcissism: An introduction' constitutes a turning point in psychoanalysis. Although narcissism is a concept which has not been explicitly referred to by many important thinkers for decades, it could be said that there is no paper written in psychoanalysis since Freud that does not implicitly take into account the modifications in thinking that the work brought about. In this paper, the author contrasts two types of narcissistic configurations: in the first, the intolerance of the other is dealt with by expulsion and violence; in the second, by withdrawal. The author contrasts patients who express manifest violent behaviour with patients for whom the violent behaviour is absent but who, nevertheless, present similar background histories, which might have led to a prediction of violence. They are also profoundly different in terms of what they provoke in the countertransference. In addition, this paper argues that the treatment of narcissistic personalities has allowed in recent years the understanding of a modality of depression. Following Green, the author argues that, instead of a fruitless debate that involves evolutionary issues around the concept of narcissism, it is necessary to distinguish the narcissistic aspect in any analytic relationship, to identify the narcissistic transference in different types of psychopathologies.

Adult↗
PubMed1999

On discriminating and not discriminating between affect and representation.

The topic involves two issues. They can be related either to different clinical pictures or to divergent opinions about the same clinical facts. But the above mentioned opposition can be found in Freud's work. Listening in analysis differentiates between situations where the distinction of affect and representation is blurred within the general frame of communication and others where this distinction imposes itself because of the critical or chronic character of the predominance of affect. Problems about the discrimination between affect and representation in the unconscious are elucidated in the light of their structural differences. The notion of the psychical representative of the drive announces the reference to the further notion of instinctual impulse. Later on, in Freud's theory, the notion of instinctual impulse has encompassed the distinction between affects and representation. Contemporary authors have, in their vast majority, chosen to refer preferably to object relationships. Nevertheless, the problems raised by Freud remain unanswered. It is with the clinical picture of borderline personality disorders that the lack of discrimination between affect and representation becomes evident. A detailed description is presented of the forms of transference where the irrepresentable prevails, accompanied by feelings of being overwhelmed, repetition compulsion, acting out and somatic reactions. In the countertransference, the affects of helplessness, despair and even the impossibility of grasping the meaning of the patient's communication are frequently met in the analyst. In these clinical pictures, intermediary formations, i.e. psychic organisations where primary processes structures the unconscious, are impaired. One is struck by the limitation of the capacities of representation and by the importance of phenomena related to negative hallucinations specially focused on thought processes, The communication is frequently self-contradictory, the transference oscillating between disembodiment and primitive fusion. The object has a paradoxical status; it is at the same time everything and nothing, the transference being incomprehensible and unanalysable. Different hypotheses are presented to explain the importance of destruction. Finally, the author presents a hypothesis for the deficiency of these intermediary formations because of the absence of continuing cathexis from the primary object at certain important moments of the relationship. It is the establishment of theses intermediary formations that will permit the acceptance of the separation from the object, the child now being able to rely on his own internal creations. However important the influences of the relationship to the other in the genesis of affects, the internal orientation towards the body of the psychic processes is what constitutes the core of the primordial psychic world.

Affect↗
PubMed1999

The psychoanalytic psychotherapy of a mentally retarded man.

In this paper, the author discusses the psychoanalytically informed treatment of a 25-year-old patient, who at the beginning of treatment was severely developmentally retarded. The patient showed repetitive behaviours (tapping his fingers, tying and retying his shoelaces); visual and auditory hallucinations, delusions, vague to absent ego boundaries; inability to do simple maths, tell the time, read or write; and angry vulgar outbursts accompanied by occasional throwing of objects. He was bewildering and unresponsive to various psychological and physical treatments that had been performed since his infancy. The patient had been examined by a variety of medical and psychological specialists, but he seemed to belong in no particular place in the system of health-care providers. All courses of drugs that were tried proved ineffective. This author presents clinical material from a psychoanalytic psychotherapy that resulted in remarkable improvement in the patient's capacity for self-reflective thought as well as in his capacities for more mature object relationships and work. More specifically, the author discusses aspects of the treatment he thinks were most pivotal: (1) the interpretation of sensation (autistic) states; (2) the use of countertransference derived understandings of the patient's intra- and intersubjective experiences to guide his interventions; (3) the use of sensation-based communication in a verbal form of play.

Adult↗
PubMed1999

The secret: study of a perverse transference.

This clinical communication describes the analysis of a perverse transference in an overtly bisexual man. An intricate interplay between heterosexual and homosexual relations enabled him to maintain some heterosexual functioning and to counteract or evacuate intolerable affects and vengeful impulses--originating from early traumas--through perverse acting out with sexual partners. Building on the notion that patients with sexual perversions recreate aspects of their perversion in the transference/countertransference relationship, where it must be analysed, the author illustrates through detailed clinical material how she was drawn into the fabric of her patient's perversion and how this was worked through. She offers an object-relational understanding of his perversion as a complex erotised defensive/reparative/vengeful manoeuvre permitting the disavowal and magical reversal into triumph and sexual pleasure of perceived threats to his personal or sexual identity. Engaging or changing in analysis evoked fears of losing his identity by surrendering to the analyst, rooted in the patient's early experience of serving as his mother's fetish-object. The author suggests that the patient needed to turn the analyst into a perverse partner (disavowing her other-ness) in order to reverse and triumph over this core trauma. She attributes the good treatment outcome to the detection and working through of the perverse transference and monitoring of her countertransference.

Adult↗
PubMed2006

'The newspaper reader': on the meaning of concrete objects in a psychoanalytic treatment.

The author investigates the meaning of concrete objects in the psychoanalytic treatment of a severely disturbed patient for the development of his inner world and the analytic process. She includes a survey of relevant theoretical concepts with an emphasis on Winnicott and Bion. It is shown that the objects served basic defensive functions both within the analytic relationship and for the precarious intrapsychic state of the patient. The author describes the technical dealing that led to a structural change. From the comparison of the initial dream and a later dream, Mr N's inner development from total inclusion in the object to triadic reality of separated, repaired objects becomes discernible. The author shows how this progress was facilitated by his use of concrete objects as links between his psychotic and non-psychotic parts, as well as by the specific way the analyst handled the paradoxical transference- countertransference. She also illustrates the thesis that the developmental steps described are crucial for the capability to digest psychic pain by symbolization instead of discharging it in a destructive-violent way.

Adult↗