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PubMed1992

Transformations of transference.

Transference can be understood to have complementary aspects: the experience in the here-and-now of the relationship with the analyst and the repetition of old relationships. The concept of an enactment is proposed to describe the vivid reexperience of childhood relationships in the here-and-now of the analytic relationship. Countertransference contributions to the enactment are discussed. Transference transformation results from the juxtaposition of the regressive transference enactment and transference experiences that are new and novel to the patient. The analyst can promote such changes by his interpretation of resistances both to the reexperience of the transference repetition and to awareness of the new and novel elements that spontaneously appear in the relationship with the analyst.

Child↗
PubMed1995

The role of free movement in separation-individuation. A study of paralysis.

This paper reevaluates the role of free movement in the separation-individuation process through the special case of its absence. We put forward some ideas, formulated gradually during the psychoanalytically oriented psychotherapy of a paralyzed adult suffering from a narcissistic personality disorder. By analyzing the transference and countertransference in this case, we realized that the patient's inability to regulate his distance from his mother by free movement impelled him to use an alternative mode of regulating his object loss and re-engulfment anxieties. We elaborate on two alternative mechanisms to cope with these anxieties: the motoric mode of approaching-distancing, and the mode of idealization-devaluation, inflating and deflating the inner significance of the object. We discuss the implications of these modes for the stability of self and object experiences, their different use of the Doing and Being experiential modalities, and their relation to pathological narcissism.

Adult↗
PubMed1996

Lie as narrative truth in abused adopted adolescents.

Two case examples of abused adopted adolescents are discussed to highlight tension within the treatment relationship when the therapist is expected to accept without question a clearly unbelievable story. These examples illustrate how the lies of such youths can function as narrative truth. The unbelievable tales that emerge in the therapeutic work effectively alter the adolescents' perceptions about the perplexing loss of continuity, both internal and external, that occurred when they were removed from their homes. Characters in the stories represent fragmented self- and object-representations as victim, abuser, rescuer, and passive onlooker. Counterparts to the patient as victim, abuser, rescuer, and passive onlooker can be recognized in the therapist's subjective responses. If the therapist can use countertransference to inform an understanding of the treatment process, an appreciation emerges that the truth of the lie is in its impact. Decisions about how to intervene can then be crafted. The second separation-individuation intrinsic to adolescent development is understood to provide a ripe opportunity for this working-through process.

Adolescent↗
PubMed1997

Dynamic underpinnings of father hunger as illuminated in the analysis of an adolescent boy.

Growing sensitivity to the importance of the father in child development has contributed to research demonstrating the existence of "father hunger" in children who have lost their fathers (Herzog, 1982), manifested in serious problems modulating aggression. Vignettes from a five-year analysis of an adolescent boy who lost his father at age five are presented to demonstrate the complex psychodynamic underpinnings of father hunger. These clinical data lead to the conclusion that father hunger should be considered an ego state involving highly complex compromise formations manifested in fantasies. These are affected by the child's personal history with each parent, his or her developmental stage when the loss occurred, constitutional endowment, and the reaction of the mother to the father's death. The case material presented highlights the primarily defensive nature of the aggression characterizing father hunger. This essay also briefly discusses technical complications of analyzing such cases, including the patient's denial of mourning, management of the patient's aggression, transference-countertransference interactions, and a vulnerability to premature separation.

Adolescent↗
PubMed2000

The development and consequences of an aggressive symbiotic fantasy.

Chronic anxiety in a female patient was understood to have multiple meanings in relating to the mother through the fantasy of a symbiotic union. The origins of the fantasy are traced to the patient's poor relationship with a preoccupied and unavailable mother. The fantasy underwent several transformations under the influence of subsequent developmental phases and the special role of aggression in its elaboration. This paper illustrates the reciprocal interactions between separation-individuation and psychosexual development and their influence on the development of the self and gender identity, defenses against aggression, development of a sadomasochistic style, and transference-countertransference interactions. The symbiotic fantasy is seen as carrying the imprints of all developmental phases and as having multiple functions.

Adult↗
PubMed2002

Extra-transference interpretation. A defense of classical technique.

New psychoanalytic techniques stemming from various object relations and Kleinian frameworks have increasingly diverged from many of the principles of classical analysis, such as interpretations of genetic transference, resistances and reconstructions of the past. In contrast to the wide-ranging foci of classical technique, the so-called modern analysis is narrowly focused on the interpretation of transference in the here-and-now analytic relationship. This change in technique is attributed to paradigm shifts from Freud's intrapsychic metapsychology to two-person theories about internal object relationships, infantile phantasies and countertransference. This paper examines important elements of this broad issue through a specific focus on the controversy over the therapeutic value of extra-transference interpretations vs. here-and-now transference interpretations. An extensive review of the literature is followed by excerpts from published analyses to illustrate the different clinical styles of classical vs. modern analysis. Freud's actual analytic work with a patient is presented to show his natural, rule-free clinical style is very different from his early technique papers. Classical technique is also illustrated by a description of relevant aspects of the author's own training analysis with Anna Freud. Finally, a clinical vignette illustrates the author's approach to extra-transference material and its interpretation.

Humans↗
PubMed2002

A visit to the Budapest school.

Within the past ten years, there has been a growing interest among American psychoanalysts in the work of Sandor Ferenczi and his followers, the so-called Budapest School. Several collections of essays on Ferenczi have appeared, while his correspondence with Freud and his Clinical Diary were finally published and translated. In this paper, I will give an overview of the historical importance of the Budapest School analysts, and then focus on three overlapping areas of their interest that have been and will continue to be particularly challenging. First, their exploration, stimulated by Ferenczi, of clairvoyance and telepathy, as these relate to the analytic situation, to transference and countertransference. Second, the mother-child dyad in the first year of life and the importance of trauma in early development. Third, the theory of psychosis.

History, 20th Century↗
PubMedDate not supplied

Self-report versus interview data of women's subjective theories of illness: concordance and predictive validity in a psychosomatic-gynecological liaison service.

Between-method comparisons of patient data from standardized self-report instruments and corresponding patient interview data frequently have poor agreement. We investigated the concordance and predictive validity of self-report measures and expert-rated interview data of women's subjective theories of illness in a psychosomatic-gynecological consultation liaison service. 31 patients completed two questionnaires (KKG, PATEF) on subjective theories of illness and were interviewed with a semistructured instrument on the same topic at the time of the initial appointment and after 1.5 years. External criteria for assessing the predictive validity of questionnaire versus interview data were: follow-up participation and psychotherapy utilization during the follow-up interval. Questionnaire and interview rating data were only modestly associated. Rater concordance on the interview data was low. Neither the initial-assessment interview nor the questionnaire data had predictive validity for patients' participation in the follow-up. None of the interview rating data but a portion of the questionnaire data, had predictive validity for patients' utilization of psychotherapy during the follow-up interval. The cognitive conceptualization of subjective theories of illness may fail in patients with psychosomatic disorders, due to their very mode of experience. A wider approach that includes assessment of nonverbal communication and countertransference might be useful.

Adult↗
PubMedDate not supplied

Projective identification: a concept overburdened.

The term projective identification has been broadened from its original meaning as set forth by Melanie Klein to include the interpersonal sphere. A review of the psychoanalytic literature on projective identification shows varying uses, definitional problems, and conceptual confusion and raises serious questions regarding the possibility of integrating intrapersonal and interpersonal models of the mind. Clinical material is presented to show that phenomena commonly described as projective identification are variable, complex patterns of behavior that are not well understood. The author concludes that the major definitional and conceptual difficulties with the term justify that its usage be limited. At the same time, the powerful clinical phenomena--the transference-countertransference interactions--described as projective identification cannot be ignored.

Adult↗
PubMedDate not supplied

Substance abuse and B-cluster disorders. II: Treatment recommendations.

Part I of this two-part article described the characteristics and clinical features of the patient population that presents with both a B-cluster personality disorder and substance abuse. It also included guidelines for the clinician. Part II presents further recommendations for the treatment of this population, taking into account how the combination of these disorders manifests itself. The treatment approach should be kept simple and easy for patients to understand and should promote their ability to think rationally about the effect of their emotions on their behavior and its outcomes. A firm structure is critical to compensate for the lack of internal control of these patients and to prevent the manipulation that results from their view of the instrumentality of others. Denial, resistance, countertransference, and relapse to addictive behaviors are all potential barriers that are often encountered when attempting to treat this population. Group therapy with this population presents unique challenges to the clinician. As with individual therapy, a firm structure is imperative, with the clinician in charge of process and content.

Antisocial Personality Disorder↗
PubMed1988

Health care professional education and AIDS.

The pandemic of AIDS and related infections due to the human immunodeficiency virus (HIV) has associated issues which present specific needs for health care professional education. These include (a) the spectrum of an evolving incurable infectious disease epidemic with new concepts in pathobiology and treatment; (b) specific phobias generated by the pandemic, including fear of the risk (albeit low) of occupational transmission, phobia of death and dying young, homonegativism and substance abuse phobia, fear of helplessness, and transference and countertransference issues; (c) the traditional role of health professionals as health information resources in the face of newly generated clinical and biopsychosocial information, which is often skewed by media presentation and patient consumerism; and (d) occupational stress associated with (a), (b), and (c) and the potential for practice "burnout." These problems are addressed by specific health professional education in traditional and novel forms. Before- and after-AIDS-HIV education knowledge and attitude assessment and AIDS-HIV knowledge documentation will improve health professional and community response to the epidemic, optimize patient care and related interactions, and decrease nosocomial transmission of HIV.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill.

OBJECTIVE: Given the recent publication of Dutch guidelines for euthanasia of the mentally ill, our aim in this paper is to review the clinical role of the psychiatrist in assessing patients who seek euthanasia or physician-assisted suicide. METHOD: Three areas are examined that are informative of the role of the psychiatrist in assessing patients who desire death: recent surveys of psychiatrists' attitudes, empirical and clinical studies, and treatment issues. RESULTS: Demoralisation and depression emerge as pertinent clinical issues worthy of psychiatric intervention. The role of the psychiatrist is complex and includes issues of assessment, systems, countertransference and treatment. CONCLUSIONS: Dutch guidelines for physician-assisted suicide in the mentally ill generate serious concern given the uncertainty of prognosis, potential range and variability of outcome of treatments of suicidality and the boundary violations that are involved for the psychiatrist. The guidelines have the potential to dangerously alter the practice of psychiatry and should be condemned.

Attitude to Death↗
PubMed1998

Treatment of survivors of political torture: administrative and clinical issues.

Treatment of survivors of political torture is a new field, the symptoms of survivors are many and difficult, clinicians in general are not experienced in treatment, and there is little money available. Both administrative and clinical decisions often must take into account political realities not found in other treatment environments. To overcome these obstacles has required building an agency with a small economy, a sense of community among its workers, flexibility about the presence and pervasiveness of politics, the ability to address countertransference, and goals that allow workers to cope with the difficulty and size of the problem of torture.

Caregivers↗
PubMed1986

Treatment progress in 20 patients with multiple personality disorder.

Attempts to follow the treatment progress of patients with multiple personality have been limited to a few single case studies and, in the only large series, to those most successfully treated. This study followed the treatment progress of 20 patients for a mean of 39 months after intake. The study included a detailed history, neurological examination, and psychological testing on each patient. At follow-up each patient was interviewed and a questionnaire was completed by his or her therapist to assess treatment response. Although nine patients achieved partial or full integration, complete integration was maintained by only five. During therapy the unintegrated patients experienced emotional trauma at approximately twice the rate as did the patients who eventually became integrated. Psychodynamic psychotherapy and hypnosis were the most widely prescribed therapies. The improvement in multiple personality appeared to proceed in a stepwise fashion from acceptance of the diagnosis to integration. The progress of therapy was hindered most commonly by the overuse of the mental mechanisms of repression and denial, the continued utilization of secrecy, which began during child abuse, and the production of numerous crises. The most common countertransferences included anger, exasperation, and emotional exhaustion. Although the psychotherapy of patients with multiple personality is tedious and time consuming, it can be eminently successful if the patient and therapist persevere.

Adolescent↗
PubMed2000

Psychotherapy with women survivors of sexual abuse.

The essential elements of psychotherapy with women who were sexually abused in childhood are outlined. The author begins with a brief discussion of the prevalence and impact of childhood sexual abuse. She reviews the assessment of patients who may have been the victims of such abuse and then describes the three stages of treatment for such patients. The article concludes with a discussion of the importance of considering issues of transference and countertransference in providing psychotherapy to women survivors of sexual abuse.

Journal Article↗
PubMed2001

Psychodynamic psychotherapy with the elderly.

The authors first review issues related to the life cycle and the significance of time for older adults. They then consider the types of psychopathological problems that can occur in older individuals and discuss the indications for and the goals and effectiveness of psychodynamic psychotherapy in older patients. The next section of the paper addresses technical aspects of psychotherapy with older patients, including transference, countertransference, and process issues. The article concludes with a consideration of practical problems (e.g., vision or hearing deficits) as well as other types of challenges that may need to be dealt with in providing psychotherapy to older patients.

Journal Article↗
PubMed2004

Reflections on psychodynamic psychotherapy supervision for psychiatrists in clinical practice.

Much has been written about psychotherapy supervision for trainees in psychiatry. Psychiatrists are also encouraged to receive supervision when dealing with difficult patients or when involved in personal events that have the potential to have an impact on their psychotherapeutic work. Nevertheless, a literature search, conducted through Medline, revealed few publications dealing with supervision of psychiatrists who conduct psychotherapy in clinical settings after completion of training. This article discusses the issues involved in psychotherapy supervision for the supervisor, supervised psychiatrists, and their practice settings and patients. The author first discusses the benefits of psychotherapy supervision for psychiatrists in clinical practice, including helping psychiatrists maintain and improve psychotherapeutic skills, assistance in dealing with patients who have complex or especially challenging problems (e.g., personality disorders, intractable depression, difficulties with compliance, complex psychosocial problems), addressing ethical concerns, boundary issues, and transference and countertransference, and helping psychiatrists deal with personal issues that may cause difficulties in providing psychotherapy or issues that arise in working with a multidisciplinary team. The author then reviews key issues related to the supervisory process, including group versus individual supervision, the role of the supervisor, different supervisory styles, and factors that can contribute to feelings of shame or vulnerability in the supervisee. The author also discusses different supervisory styles, clarifies the distinction between therapy and supervision, and discusses issues that arise in the supervision of experienced psychodynamic therapists. Barriers that may keep psychiatrists from seeking psychotherapy supervision are reviewed. Finally the author discusses the supervision of those acting as supervisors for other clinicians.

Education, Medical, Continuing↗
PubMed1998

The body in analysis: authentic movement and witnessing in analytic practice.

This paper will describe a form of active imagination called authentic movement, in which attention is given to the somatic unconscious. In authentic movement, patients are encouraged to focus inward and attend to any bodily sensations, images and feelings which may arise. In the process of focusing inward on one's bodily-felt experience, images, somatic memory and the accompanying feelings which arise are then available to be explored as a communication from the patient's unconscious. Authentic movement supports the individual in linking image with affect in that the individual re-experiences the somatic aspect of symbolization. What was previously conserved on the somatic level as unmentalized experience, can now begin to be taken up into the mind, thought about, and made available for analysis. In authentic movement, the analyst acts as a silent witness to the patient's explorations. The quiet focused attention of the witness helps to create a secure containing environment in which the person moving can experience a sense of feeling held and seen. The function of the witness is to hold the patient's experience in his own mind, particularly what is not yet mentalized. The witness utilizes his somatic countertransference, including any images, feelings and bodily responses which are generated by what is being communicated non-verbally, as a means of understanding and responding to the patient's material.

Adult↗