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PubMed1983

Process and non-process in analytic work.

The 'talking cure', named by Anna O. and discovered by Freud, has been widely expanded and diversified throughout our century. Our objective in this paper is to underline several points which seem to define the analytic process. We believe that forthcoming progress in psychoanalysis must arise from the study of clinical experience at its frontiers, at its topmost limits, in its failures. For this reason, we have concentrated our search on the analytic non-process, in the very places where the process stumbles or halts. This has led us to propose the introduction of several terms: 'field', 'bastion', 'second look'. When the process stumbles or halts, the analyst must question himself about the obstacle. The obstacle involves the analysand's transference and the analyst's countertransference, and poses rather confusing problems. The arrest of the process introduces us fully into the nature of its movement, its inherent temporality. If the process is to continue, then by what main-spring can we accomplish it? We describe this particular dialectic of processes and non-process as a task of overcoming the obstacles which describe its success or failure.

Countertransference↗
PubMed1982

Psychoanalysis and psychoanalytic psychotherapy of the older patient. A developmental crisis in an aging patient: comments on development and adaptation.

The psychoanalysis of a depressed 69-year-old woman is described briefly. She was seen four times weekly for two years and treated on the couch. The goal of analysis was modified in keeping with the concept of her problem as a developmental disturbance of aging. Here the aim of analysis was not extensive character change, as is usual in treatment of a person with neurotic disturbance, but help in making the necessary adaptive changes in the phase of aging. There was relatively less emphasis on the "archaeological" treatment model of uncovering the predisposing childhood neurosis, and more emphasis on analysis of the patient's current character structure and its underlying dynamics. The patient coped with threats of object loss and narcissistic injury by living through others, both helping and controlling them. The case exemplifies the way in which the analyst dealt with the patient's narcissistic injury of having to come for therapeutic help, the analyst's use of empathy and effort to understand transference and countertransference, and the course and results of the analysis.

Aged↗
PubMed1982

Neuroses and character disorders.

This paper emphasizes the importance of understanding and treating the aged with neuroses and character disorders. Although they are often neglected by mental health workers, the aged with these emotional problems form a far larger group than the psychotic aged who receive a greater share of attention. Stereotyped attitudes and commonly accepted myths regarding the aged encourage an attitude of therapeutic nihilism and pessimism. The unconscious motivation for ignoring the obvious distress of older people is discussed. Certain specific myths, such as the "rigidity" of the aged and the tendency to "wastebasket" and to view all pathology as organic or caused by aging alone, are discussed. The fear of the devouring older person is also explored, as well as the myth of "family rejection." A number of clinical examples are given of the types of emotional problems frequently seen among the noninstitutionalized older population. Each case is described from the standpoint of dynamic understanding and management. A trial of observation and psychotherapy is recommended in all situations, since even "organic" signs may be reversed. Generalizations concerning the aged as a group are avoided in the belief that they lead to further stereotyping and the discouragement of scientific investigation. Individual assessment and understanding are emphasized. The persistence of unconscious attitudes, fantasies, and wishes from childhood is pointed out, but it is emphasized that they may not always carry the same value and meaning throughout life. Certain patients achieve insight through treatment, along with a greater capacity to enjoy life than they had before. Others are comforted by the relationship with the therapist for both its "real" and unconscious meanings. Some require assistance in accepting and tolerating more regressive behavior, while others need help in accepting and assimilating their changing feelings about their goals, objects, and sexuality in old age. Reminiscences are emphasized as important sources of elevating self-esteem. Concerns about death and common countertransference problems in work with the aged are examined. The need to be flexible but not to "lean over backward" is emphasized. Patients understand a genuine offer of involvement and concern as the most precious gift.

Aged↗
PubMedDate not supplied

The use of psychoanalytic concepts in crisis intervention.

Crises have a dynamic structure. Repressed neurotic conflicts and defects in ego organization determine vulnerability to specific stresses. Selection of focus in crisis intervention follows from the recognition of those rigid defensive patterns and adaptive incapacities which have either partially failed or been overwhelmed by the current stress. Aiming at the old problem in the new situation allows crisis work to go beyond symptom relief to improved conflict resolution and coping abilities. Therapeutic activity, rather than passivity, is the hallmark of crisis intervention and involves suggestion, abreaction, manipulation, clarification, and dynamic interpretation. Individuals in crisis are characteristically in a partially regressed state of transference readiness and availability, particularly as this involves intensified dependence wishes. Management of the transference requires recognition of negative, as well as positive, responses and the limitation of further regression that might lead to continual adaptive failure. A variety of specific countertransference responses are commonly evoked in crisis work. These must be recognized for effective treatment to proceed.

Adult↗
PubMed1981

Extra-analytic contacts: theoretical and clinical considerations.

The literature on the extra-analytic contact is reviewed and a case is presented in which the extra-analytic contacts of patient and analyst were analyzed. Three types of extra-analytic contacts are discussed: (1) those actively brought about by the patient; (2) those that are "accidental" for both parties; and (3) those that are anticipated by the analyst but not by the patient. The extra-analytic encounter can heighten latent transference and countertransference themes, clarify certain resistances, and serve as an index of therapeutic progress. It can also interfere with an analysis by raising false hopes for the patient and can dilute the analyst's position as a fantasied object.

Countertransference↗
PubMed1981

[Introduction to brief psychotherapy with a psychoanalytic orientation].

Introductory paper describing succinctly the technique of brief analytical psychotherapy as developed by one of the authors in Lausanne. The author tries to demonstrate that a single modification of the setting in comparison with psychoanalysis bends the therapeutic relationship towards a stressing of the importance of the "hic et nunc". If this phenomenon comes clearly to the therapist and is adequately interpreted, a "natural" associative process develops where the analysis of transference and countertransference takes a primordial place. This process is comparable with psychoanalysis as far as certain transference movements are concerned, but the working mechanisms are different.

Adult↗
PubMed1981

On some positive aspects of the negative therapeutic reaction.

The development of the concept of the Negative Therapeutic Reaction (N.T.R.) is followed through from the original description by Freud to that of later and contemporary psychoanalysts, revealing a considerable divergence of opinions as to the causes of the condition. It is suggested that in the more chronic forms the reaction is a special kind of acting out of the transference in the psychoanalytic situation, when it is also a particularly stubborn defence against the re-experiencing of pain and psychic suffering associated with early trauma. It is generally agreed that the N.T.R. is a challenge to the analyst's countertransference. On the other hand, it is also of positive value as an indicator of the state of the transference and the possibility that an especially painful area in the patient's psychopathology has been reached, requiring a further working through and better integration. Two clinical illustrations are presented in support of these theoretical considerations.

Adult↗
PubMedDate not supplied

Interpretations couched in mythical imagery.

Conventional guidelines favor terse, mundane, unambiguous phrasing of interpretations, and the use of fanciful interpretations is rare in psychoanalytic literature. Some theoreticians have advocated interpretations that have multiple meanings and evoke primitive sensory and emotional responses. The latter functions can be served by metaphorical and especially by mythical interpretations, and their use in analytic therapy is suggested. Mythical interpretations tend to help the patient experience and express the forbidden and irrational; they imply that the therapist has a deep understanding of the patient. These effects are attributable to the psychodynamic determinants of myths and their cultural functions. Mythical interpretations further tend to provide implicit gratification to the patient, foster regression, and influence the patient's perception of and response to the therapist. Indications for use have yet to be worked out beyond preliminary speculations, and countertransference possibilities appear substantial. All of these considerations bear on the therapist's discretionary use of mythical interpretations.

Countertransference↗
PubMedDate not supplied

The perils of homology.

A discussion of "Treatment Problems of the Hospitalized Physician" by W. W. Meissner, S.J., M.D. and Peter Wohlauer, M.D. Meissner and Wohlauer's paper describing the difficulties attendant upon the treatment of hospitalized physicians has implications for other homologous therapist/patient pairs. Therapists who include ethnic, racial, or ideological characteristics in their professional identifies must be prepared to deal with transference and countertransference problems which arise because of their similarities to their patients. A distinction between self-involved and self-effacing empathy is useful in understanding these vicissitudes of homologous treatment.

Countertransference↗
PubMedDate not supplied

Four questions. A discussion of "Introjection and the Idealizing Transference".

A discussion of "introjection and the Idealizing Transference" by Theodore L. Dorpat, M.D. The analysis of a patient with a narcissistic disorder is the basis for Dr. Dorpat's thesis that introjections (i.e., object representations) of the analyst as a real person are the basis for subsequent identifications resulting in changes in the self. I disagree with his characterization of the material as representing an idealizing transference. I believe it is better understood as an example of an alter ego or twinship transference. His material demonstrates the crucial role of the analyst as a self-object in the transference, rather than as a real person. The hypothesis that a patient changes as a result of identification with the analyst suggests possible countertransference pitfalls: a rationalized expression of the analyst's unconscious archaic fantasies or the enhancement of the analyst's self-esteem. The perception of such identifications could reflect the personal experience of the analysand who seeks to acquire the characteristics of the training analyst, or they could be apparent rather than real, the result of other therapeutic factors. Dr. Dorpat's paper provides an excellent opportunity for consideration of these issues, but, at present, such introjection-internalization sequences cannot be accepted as scientific formulations.

Countertransference↗
PubMed1980

Origins, elements, and functions of therapeutic empathy.

Tracing the roots of empathy (within human history) descriptively to aesthetics and psychologically to the earliest mother-infant interactions, it is proposed that the ontogenesis and employment of mature empathy require repeated flexible--and, if necessary, sustained-access to its primitive levels, levels especially important to the analyst in the understanding of severely disturbed patients. Narcissistic disturbance in the analyst, while occasionally accompanied by a beneficial hypertrophy of primitive empathic capacities, tends to be particularly detrimental to the exercise of mature empathy. Countertransference is considered in this regard and in relation to therapeutic empathy evoked or impeded by unconscious fantasy--the latter proposed to be infrequently, if sometimes necessarily, a central element of therapeutic empathy, which more commonly may function inconspicuously at a preconscious level. In the analytic situation, it is suggested, empathy may often be addressed most usefully to focal conflicts (borrowing French's concept but not his precise definition) via the analyst's partial identification with the patient's self-in-depth, an entity which is acknowledged to be ultimately immeasurable and necessarily mysterious. Several aspects of the therapeutic employment of empathy are examined, including failures of empathy attributable to analyst, patient, or both, for worse and--potentially--for better; the role of empathy and empathic failure(real, imagined, and provoked) in the establishment of archaic negative transferences; and the assessment of abstinence as variable inherent in empathic exploration, with the inference that disciplined employment of empathy, rather than frustration per se, is likeliest to abet a therapeutic regression and to promote an enriching unification of the personality.

Adult↗
PubMed1995

[Management dialogue within multi-professional teams: contribution of psychoanalysis to integrated therapy of psychotic patients].

By means of case studies and experiences in supervising multiprofessional teams in psychiatric wards it is pointed out that the institutional frame of psychiatry is dynamically connected with the intrapsychic conflicts of the psychotic patients and their interpersonal defence. The understanding of the teammembers' countertransference prevents collusive patterns of relationship. This symbolizing process which is permanently endangered by the psychotic splitting mechanisms of the patients as well as by the institutional defence contributes to develop a "common language" in the multiprofessional teams. Furthermore psychoanalytic supervision enables the multiprofessional staff to understand the intrapsychic and the interactional dimension of the behaviour of the psychotic patient and to maintain their empathy even under difficult conditions.

Affective Disorders, Psychotic↗
PubMed1995

[Psychotherapy with dyssocial patients].

Psychotherapy of dissocial personalities is, even by psychotherapists, often judged sceptically. As obstacles are most of all mentioned the lack of motivation and the excessive acting out of these patients. Because of the development of the personality of dissocial people motivation in the ordinary sense can not be expected. But this does not mean that therapy is impossible. These patients are often rejected by therapists because they feel injured by the patients' rejection and by their devaluation of the therapeutic attention. We find the same dynamics concerning the excessive acting out or these patients. Problems in countertransference also arise because therapists must reduce their therapeutic ambitions and must be satisfied with improvements which-in their eyes-are negligible.

Acting Out↗
PubMed1995

The role of the father in a pre-suicide state.

In the self-examination that followed a patient's suicide attempt, the author was worried by three features which he had observed in an earlier suicide attempt by another patient: (1) the father had not featured in the analysis as much as would have been expected, (2) the suicide attempt occurred during a period when the time and place boundaries of the analytic setting were in jeopardy, e.g. the patient was absent from sessions; and (3) this coincided with the author having temporarily underestimated the suicidal risk. These three features were illuminated by a transference to a father who did not claim his child for himself and offer an alternative to fusion with a dangerous mother. Although the patient's suicide fantasies were based on a pathological bond with his mother, during the pre-suicide state the internalised father who had failed to protect his son from mother was evoked in the countertransference to function as a sanction for the suicidal act.

Adult↗
PubMed1995

Hypnotically recalling dreams during analysis.

This study described the procedure, the theoretical rationale, and clinical material relating to the hypnotic recalling of dreams during periods of protracted "dreamless" analyses. Two clinical examples were used to demonstrate the efficacy of using a special hypnotic procedure close to the analytic free-association method for the remembering or recalling the dreams. Discussion of the clinical material found: 1. the main factors contributing to a "dreamless" analysis were to be found in the transference-countertransference resistances of the analysis; 2. the justification for introducing the special hypnotic procedure as a parameter in the analysis was discussed and confirmed; 3. the remembering-recalling of the first dream--following the hypnotic intervention--lead to the recovery of a critical childhood memory; and 4. the parameter of using hypnosis as a method of breaking the intractable resistance of a "dreamless" analysis did not become an alien force which intervened whenever strong resistances appeared. On the contrary, it seemed to serve as a temporary therapeutic mechanism for allowing an energy shift to occur in the all-or-none defensive state of a "dreamless" analysis.

Adult↗
PubMed1994

On formulations to patients.

For the author, the psychoanalytic clinical fact can only be an arbitrary fragment detached from the totality of the situation, which alone specifies it and which comprises the different forms of formulations that are proposed to patients. Using the difference established by Freud between what is and what is not analysable as a starting point, he distinguishes between two radically different analytic situations. To illustrate, he extracts, from the same cure, a 'fact' constituted of two moments; one 'this side of analysability, the other at its limits. He calls 'homogeneous' the neurotic moment in which transference and countertransference are similar in nature, and he calls 'heterogeneous' the 'limit' situation in which predictabüity is absent, and in which change, when it occurs, is one of divine surprise. The author advances an hypothesis on the factors at work in the changes that subsequently occurred, particularly in the case of the 'limit' situation, drawing from the therapeutic experience of the 'psychoanalytic psychodrama' and from the work of Jean Laplanche. A single generating principle would thus be involved, based on the action of the unconscious seduction contained in the unknowable, 'enigmatic', part of verbal and nonverbal messages, it grounds its transforming action in the following sequence: unconscious seduction, limited traumatic penetration, symbolisation, i.e. the emergence of meaning in the aftermath.

Adult↗
PubMed1994

Validation in the clinical process.

The combined analysis of the predominant themes, (a) in the patient's communication of his subjective experience, (b) in the patient's nonverbal behaviour and linguistic style, and in (c) the countertransference, provide indications for the main focus of the analyst's interpretive work, as well as potential evidence, in the corresponding changes in those three areas, of confirmatory or disconfirmatory aspects of the patient's reaction to the interpretation, thus providing the material for validation of the interpretation in the analyst's mind. Exploring a patient's responses to his interpretive interventions in the light of these criteria permitted the author to validate one interpretation at a 'right level in the right moment', to discard other interventions as too superficial, and to characterise one interpretation as probably premature.

Adult↗
PubMed1994

Clinical facts or psychoanalytic clinical facts?

A clinical fact is defined by the field in which it is situated. In the field of psychoanalysis, the author makes a distinction between psychoanalytic clinical facts arising outside the analytic situation, for example, during interviews or in the applied psychoanalysis, and psychoanalytic clinical facts arising within the psychoanalytic situation, where they find their full value in the transference and countertransference relationship. The author gives two illustrations of this. The characteristics of psychoanalytic clinical facts are that they are observable and communicable, and that they have at the same time a fixed and a transformational aspect. During a preliminary interview it is fruitful to use psychoanalytic clinical facts to open the patient to his/her psychic life through contact with the psychoanalyst.

Adult↗