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PubMed1989

Transitional phenomena, projective identification, and the essential ambiguity of the psychoanalytic situation.

Ambiguity, which is an intrinsic and essential aspect of the psychoanalytic situation, is related to the concepts of transitional phenomena and projective identification. The analyst's feelings of uncertainty that accompany this ambiguity are contrasted with a "pathological certainty." The consequences of the loss of ambiguity and the role of the analyst's countertransference in this process are described.

Adult↗
PubMed1989

Anorexia nervosa and unresolved rapprochement conflicts. A case study.

The psychoanalysis of a 16-year-old young girl with the classical signs and symptoms of anorexia nervosa: the early phase of treatment is described. The intense, disruptive, and affect-laden transference and countertransference engagement is selectively portrayed. Utilizing the developmental perspective of the separation-individuation process as formulated by Margaret Mahler, this segment of clinical material could be best clarified and appreciated. This developmental framework enabled the analyst and patient to make sense out of a relationship which initially seemed chaotic and to be stagnating. The reconstructive, interpretive interventions based on this developmental understanding, with particular focus on the rapprochement subphase of the separation-individuation process, appeared to have major therapeutic impact and allowed for ongoing psychoanalytic work and for personality growth. After a four year analysis, a seven year follow-up is outlined. Discussion and speculation are put forth as to the nature of the therapeutic impact in this case and, more generally, in clinical situations wherein there is evidence of a 'developmental lag'.

Adolescent↗
PubMed1989

Two subtypes of narcissistic personality disorder.

The spectrum of narcissistic disturbances described in the psychoanalytic literature is not reflected in the rather narrow criteria of the third revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R, American Psychiatric Association, 1987). Narcissistic personality disorder can be conceptualized as occurring on a continuum between two extremes. At one end of the continuum is the oblivious subtype, and on the other end is the hypervigilant subtype. These two entities may be distinguished by characteristic transference and countertransference patterns.

Countertransference↗
PubMed1987

Transference: current concepts and controversies.

In this paper I have presented a brief outline of some of the more important issues regarding transference. To summarize I shall restate ten transference issues heretofore discussed: What should be included in the definition of transference? Should it be defined narrowly or broadly? In what ways can transference be usefully viewed in relation to reality? What merit is there in distinguishing the working alliance from transference? Should self and object transference be differentiated? Should transference neuroses be discriminated from transference reactions on the one hand and from transference psychoses on the other? In addition to sexual and aggressive transferences, should sexualized and aggressivitized transferences, respectively, be distinguished? How may transference be conceived of as a vehicle of cure and yet also as a resistance to cure? What is to be said for the relative merit of the "here and now" versus the "there and then?" What is the role of transference in relation to insight on the one hand and to the therapeutic object on the other? What are some of the basic issues in countertransference?

Aggression↗
PubMed1987

A challenge to psychoanalysis: a review of the negative therapeutic reaction.

In this paper, I have summarized the large body of literature on the N.T.R. and noted that the term has been broadened from Freud's original definition of deterioration following improvement or correct analytic work to include a negativistic, ongoing narcissistic reaction with failure to recover. Like Freud, Klein became very pessimistic about reversing this phenomenon. The N.T.R. is a multidetermined but not unitary clinical phenomenon that has generated much controversy. Its dynamics involve interpersonal and intrapsychic elements. Aggression, revenge, and oppositional reactions interfere with analytic progress and may range from temporary to a characteristic way of responding in the analysis. Aggression, the reaction to early frustration and deprivation, plays a large part in the narcissistic organization. Patients who experience N.T.Rs. are shown to have strong narcissistic features. Interpersonally, conflict between longings for fusion and the wish for separateness is central. The transference-countertransference is made difficult by projective identification. Envy and narcissism are critical in the N.T.R. patient's intrapsychic dynamics. Clinical material illustrated the difficult interpersonal and intrapsychic factors that prevailed in a severe N.T.R. patient. The N.T.R. is an insidious obstacle to analytic success and one that requires mastery of the interpersonal and intrapsychic dynamics of the patient and the treatment situation.

Aggression↗
PubMed1988

Object relations theory in clinical practice.

This paper outlines the psychoanalytic techniques derived from ego psychology-object relations theory. It stresses the centrality of affects to interpretation and describes how the focus on dominant object relations in the transference modifies the economic, dynamic, and structural criteria for interpretation. Clinical examples illustrate this technique across a broad spectrum of psychopathology. The technique for genetic constructions and reconstructions in the transference is described, and this approach is contrasted with other object relations theories. Finally, the application of this approach to countertransference and dream analysis is summarized.

Adult↗
PubMed1988

[Comments on the so-called "feeling of hysteria"].

By interpreting the concept of "hysteria feeling" as a manifestation of countertransference the author attempts to clarify the physician's dilemma in dealing with hysterical patients. "Hysteria feeling" is a complex of feelings in the physician as he develops increasing doubts about the authenticity of the patient's experiences and behaviour. By recognizing and interpreting the hysteria feeling, the negative course of confusion-involvement-doubt and disappointment can be transformed into a positive object relation.

Countertransference↗
PubMed1987

An ego psychology-object relations theory approach to the transference.

This paper summarizes an ego psychology-object relations theory and its application to psychoanalytic technique, particularly to the analysis of the transference. The relative importance of verbal, nonverbal, and generally relational "channels" of communication in patients with differing degrees of transference regression is examined. The use of countertransference reactions in formulating transference interpretations is reviewed. The relations between unconscious meanings in the "here-and-now" and unconscious meanings in the "there-and-then" are explored in the transferences of patients with varying degrees of severity of psychopathology. Differences with other theoretical approaches are highlighted throughout.

Adult↗
PubMed1987

Actions speak louder.

Case material is presented from three analyses in which dramatic, unexpected movements by patients on the couch dominated the analytic hours for long periods of time. The psychoanalytic literature pertinent to this area of acting in is reviewed, and some formulations regarding the shift from verbalization to motor behavior are presented. These center on the proposition that the patients had identified with aggressor parents who regarded actions, not words, as the ultimate conveyers of reality. The analyst's use of countertransference responses as clues to the understanding of the actions is discussed.

Acting Out↗
PubMed1986

Approaching the adolescent patient. Pitfalls and solutions.

Over the last three decades, there has been increasing interest in adolescent health care. However, although appreciation of adolescent development and pathology has grown, a crucial topic has been neglected--the influence of the physician's underlying attitudes on his or her treatment of adolescent patients. This review discusses four potential pitfalls in the physician's approach to the adolescent patient: cultural stereotypes, generalization of expertise, countertransference, and professional narcissism. Case presentations illustrate the problems inherent in these areas. Finally, practical solutions to these problems are presented through a systematic approach to an adolescent's office visit, including the use of interviewing techniques, questionnaires, and figure drawings.

Adolescent↗
PubMed1986

The influence of historical events on psychoanalysis: a case history.

Parts of the analysis of a patient are described, whose childhood had been overshadowed by serious traumatic experiences (death of father, flight). The interaction between these events which was dictated by recent history and the inner psychic world of the patient is investigated and consequences for the transference, countertransference and psychoanalytic technique are discussed. Special problems can arise when patient and analyst as members of the German post-war generation are equally confronted by the Nazi past during the analytical process.

Adult↗
PubMed1985

A proposed clinical approach to chronic and "resistant" depressions: evaluation and treatment.

Many patients referred to specialized affective disorder units in the 1970s because of chronicity, treatment resistance, or treatment failure were found to have been inadequately treated--most typically with suboptimal trials of one to two tricyclic antidepressants (TCAs). In the 1980s, patients are being declared "treatment failures" following a more sophisticated range of treatment efforts. In part, the change can be attributed to systematic feedback provided by mood clinics to referring clinicians and to nationwide educational efforts. Terminologic and conceptual issues are reviewed, and chronicity and treatment failure in patients with affective disorders are examined from a multifactorial perspective involving pharmacokinetic factors, patient compliance, adequacy of somatic treatments, physician countertransference, social and interpersonal aspects, nosologic considerations, and medical-neurologic contributions. A systematic approach for evaluating and treating such patients is outlined.

Alprazolam↗
PubMed1985

Resistance to alternatives to hospitalization.

Hospitalization has endured as the predominant form of psychiatric treatment for serious mental illness, despite accumulated evidence that outpatient treatment, ranging from halfway houses to day programs to traditional clinics, is equal or superior to inpatient treatment. Reasons for the apparent reluctance to use alternatives to the hospital include social prejudice against community treatment, economic disincentives, administrative chaos, training, professional sociology, and the countertransference meanings of hospitalization. The foregoing is not an argument against hospitalization, but rather an argument for being very clear about policy objectives and treatment goals. If these objectives and goals are made explicit, proposals can be evaluated for their efficacy. If community tenure, the assumption of responsibility for him or herself, and relinquishment of the patient role are goals, then hospitalization must be examined more skeptically. For society, this means the assumption of more responsibility for the establishment of a system of mental health care, for enunciating national policy goals and implementing them consistently, and for committing the necessary funds and manpower to this endeavor. For the clinician, it means examining the clinical efficacy of his or her treatment recommendations and distinguishing between responsibility for the patient's treatment and responsibility for the patient's life. The abdication of social responsibility for the patient and the assumption of omnipotent clinical responsibility for him or her lead inexorably to more institutional and more restrictive treatment, even in the absence of evidence that such measures are therapeutically effective.

Community Mental Health Services↗
PubMedDate not supplied

Medication and transitional phenomena.

Winnicott's concept of transitional phenomena is employed as a means of further understanding the effect of medicine and the medication-giving process itself. Particular facets examined include the "soothing" function of medication, the placebo effect, and medication compliance, as well as countertransference difficulties encountered in administering the medicine. Medication as a transitional object is viewed largely as a creation along the self-object interface, with the "potential space" between patient and therapist recapitulating aspects of the original dyad. This usage of medicine as a transitional object, or its ultimate abandonment as such, is presented in terms of the vicissitudes of internal object relations, with clinical case examples to clarify particular issues.

Adult↗
PubMed1979

Being with a psychotic child a psycho-analytical approach to the problems of parents of psychotic children.

The reactive and adaptive responses of parents to their overtly psychotic children are described and an attempt is made to reconstruct the specific mother/infant interactions contributing to the development of different types of childhood psychosis. The concepts of 'maternal structure' and of 'delusional primary maternal preoccupation' are found to be relevant in this context. These considerations throw light on some aspects of countertransference encountered by workers in this field and of creative search in general. Whilst exploring parental psychology and psychopathology this paper attempts to outline the psychodynamic environment of the psychotic child at the various stages of his life and dis-ease. It emphasizes the value of the psychoanalytical approach as a guide in such an exploration and as a source of hope for better understanding and more effective interventions, both therapeutic and prophylactic.

Adaptation, Psychological↗
PubMedDate not supplied

Unthinkability and psychosomatic symptoms.

W. R. Bion (1952) has pointed out a connection between alterations in the development of the "apparatus for thinking thoughts" and psychosomatic symptoms. Many authors have used this insight, from their own points of view, as a basis for describing this deficiency in thought and in the capacity to formulate images related to the development of psychosomatic symptoms (Krystal & McDougall 1979; Segal, 1950, 1958). This paper applies this hypothesis to a clinical case in which special emphasis is given to the symbolic deficiency, its effect on transference-countertransference, and its relation to falsification, "hyposymbolization," and to a specific phenomenon that could be called "hypersymbolization," in which many meanings are embodied in the same symbol.

Countertransference↗
PubMedDate not supplied

The role of facial expressions in the holding environment.

The significance of a visual dialogue between patient and therapist in assisting tension regulation for patients with severe narcissistic injury is proposed. Non-verbal interactions may unfold spontaneously and contribute to development of a "holding environment" in its broadest sense. There will be inevitably both countertransference and real elements in this bipersonal field. The development of a visual holding environment at a symbiotic level may be based on a counter-transference response by the therapist of an earlier need to "hold or be held." It has been suggested that it is difficult for the therapist to feel a "gleam in the eye" for patients who have missed early mirroring. Developmental stages of treatment involving active mutuality of eye contact, considered a "language of silence" beyond verbal interpretation, are suggested. These observations agree with Searles' paper that facial expressions form a bridge to personal relatedness.

Countertransference↗
PubMed1984

Some implications of former massive traumatization upon the actual analytic process.

The treatment of first and second generation patients, having been traumatized by social catastrophes (like German concentration camps), puts a heavy burden on the therapist. To overcome this, the therapist must clearly realize what goes on in himself (countertransference) to avoid unsuitable interpretations and acting out. This counts even more if the therapist himself has undergone social trauma. Two case studies are included, which illustrate how the author could further the analytic process. Especially with masochistic-regressive patients the analyst has to accept and use his temporary identification.

Countertransference↗