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PubMed1985

Psychological considerations in the use of psychotropic drugs with women patients.

The use of psychotropic drugs with women patients raises special considerations. In some settings women are medicated too readily, and in others they have inadequate access to comprehensive care that includes medication. However, judicious use of medications to relieve disabling symptoms frequently promotes productive psychotherapy. Either prescribing drugs or withholding medication may involve special transference and countertransference issues for the woman patient. Women also have special concerns and conflicts about the effects of psychotropic drugs on pregnancy and lactation and about side effects involving sexual functioning and change of appearance.

Abortion, Therapeutic↗
PubMed1986

Etiology and treatment of borderline personality disorder in adolescents.

The author reviews the complicated history of the concept of borderline personality disorder and associated diagnostic entities, especially as these conditions relate to adolescents. He examines current theories about etiology of borderline personality disorder, primarily those related to object relations theory and genetic vulnerability to the disorder. Because patients with borderline disorders are such a heterogeneous group and often carry other diagnoses as well, the treatments used are highly diverse. The author reviews principles of psychotherapy with borderline patients, including the difficulties of the negative transference and the intense countertransference that occur; hospital treatment; and pharmacologic treatment, usually aimed at target symptoms.

Adolescent↗
PubMed1986

First do no harm: short-term inpatient psychotherapy of the borderline patient.

Patients with borderline personality disorder typically are hospitalized in the midst of a crisis and in a state of acute regression. After a few days in which the patient is provided with containment and support, the therapist can assess whether the patient has the capacity for exploratory psychotherapy that may help in ego development or whether such psychotherapy may prompt further regression and dangerous acting out. For exploratory therapy certain conditions, such as an observing ego, a therapeutic alliance, and the therapist's ability to contain countertransference feelings and deal with the patient's projections, are essential. The therapist must be alert to common treatment errors that can undermine the patient's capacity to recompensate; they are likely to occur in the areas of empathy, confrontation, transference, interpretation and management, and the patient's attachment to pain.

Adult↗
PubMed1987

Predictors of response of antisocial patients to hospital treatment.

Although clinicians generally agree that patients with antisocial personality disorder should not be treated on general psychiatry units, little is known about the response to hospital treatment of personality disorder patients who have antisocial features or traits. In a study to identify predictors of positive and negative response to hospitalization, charts of all patients discharged from a private hospital with diagnoses of antisocial personality disorder or antisocial features over 52 months were reviewed. As a group the 33 patients did not respond well to treatment, and 70 percent left treatment prematurely. Significant predictors of negative response were histories of felony arrest and conviction; a history of repeated lying, aliases, and conning; and an unresolved legal situation at admission. Positive response was related to the presence of anxiety and an axis I diagnosis of depression. The authors believe that antisocial personality disorder is often underdiagnosed and that countertransference can present a significant obstacle to treatment of antisocial patients.

Adolescent↗
PubMed2000

The influence of the gender of patient and analyst in the psychoanalytic relationship.

An overview of current explorations of the influence of gender on the psychoanalytic situation is presented. The topic does not lend itself to simple generalizations because the accumulated experience of several generations of psychoanalysts is now merging with newer views of psychoanalytic technique, while at the same time psychoanalytic theory is being influenced by changing ideological crosscurrents and by new knowledge regarding the similarities and differences in the development of both genders. Major issues still open are the relationship between gender and sexuality and between erotic desire and love; the challenges of the boundary of the psychoanalytic relationship as a facilitating and containing frame for the exploration of oedipal conflicts; and the related temptations, prohibitions, and derivatives of the erotic tension in the transference-countertransference.

Culture↗
PubMed2002

The growth and transformation of American ego psychology.

The roots of ego psychology trace back to Sigmund Freud's The Ego and the Id (1923) and "Inhibitions, Symptoms and Anxiety" (1926), works followed by two additional fundaments, Anna Freud's The Ego and the Mechanisms of Defense (1936) and Heinz Hartmann's Ego Psychology and the Problem of Adaptation (1939). It was brought to full flowering in post-World War II America by Hartmann and his many collaborators, and for over two decades it maintained a monolithic hegemony over American psychoanalysis. Within this framework the conceptions of the psychoanalytic psychotherapies evolved as specific modifications of psychoanalytic technique directed to the clinical needs of the spectrum of patients not amenable to psychoanalysis proper. This American consensus on the ego psychology paradigm and its array of technical implementations fragmented several decades ago, with the rise in America of Kohut's self psychology, geared to the narcissistic disorders, and with the importation from Britain of neo-Kleinian and object-relational perspectives, all coinciding with the rapid growth of the varieties of relational psychoanalysis, with its shift in focus to the two-person, interactive, and co-constructed transference-countertransference matrix. Implications of this intermingled theoretical pluralism (as contrasted with the unity of the once dominant ego psychology paradigm) for the evolution of the American ego psychology are spelled out.

Ego↗
PubMed2002

Consummated mother-son incest in latency: a case report of an adult analysis.

Reported cases of mother-son incest are very rare in the psychoanalytic literature; the fact of such incest, however, may not be so rare as has generally been believed. A detailed case report of the analysis of an adult with a history of severe physical, sexual, and verbal abuse, including consummated incest with his mother during latency, is considered in the context of other reported studies. The author raises some issues of resistance and countertransference that may influence the reporting, treatment, and perhaps even recognition of cases of mother-son incest.

Adolescent↗
PubMed2003

Being a candidate: its impact on analytic process.

Despite its crucial importance to psychoanalytic training, the control analysis has received surprisingly little scrutiny by psychoanalytic writers. How the candidate's training influences analytic process--a critical feature of the control analysis--is examined. In keeping with previous contributions, it is found that the candidate's training experience does indeed influence analytic process. It is argued, however, that focusing on the influence of training itself, as some authors have done, moves discussion away from the meanings of training for each candidate and from how these meanings bear on the interplay of transference and countertransference in the control analysis. Detailed case examples illustrate how one candidate's experience of training was drawn into his control analyses in the form of enactments, supporting the conclusion that attention to the particular ways in which training influences each candidate's analytic work is critical to the candidate's psychoanalytic education.

Adult↗
PubMed2003

The thrall of the negative and how to analyze it.

From clinical material of patient-analyst pairs caught up in negativistic transference-countertransference enmeshment, the defensive functions of negativism are explored for both patient and analyst. Fascination with and dread of the negative intersect as patients struggle to avoid terrifying aspects of self and other. The analyst works to avoid being trapped in negativism within the dyad. Containing, metabolizing, and transforming the dyad's mutual destructiveness and mutual love enable analyst and patient to feel safer with both. How to play with the negative, to engage the patient in play at the intersection of destructive negativism and dangerous love, is described.

Affect↗
PubMed2004

Analytic neutrality, anonymity, abstinence, and elective self-disclosure.

Recent contributions to the psychoanalytic literature propose new ways of understanding analytic neutrality, anonymity, abstinence, and self-disclosure. They advocate elective self-disclosure by the analyst as an antidote to the allegedly game-playing quality of transference and resistance analysis. The analytic relationship, they assert, becomes unreal when attempts are made to observe the principles of neutrality and abstinence. Both are seen as ill-conceived because of the irreducible subjectivity and unwarranted authority of the analyst. These relational and interactional views are criticized because (1) they ignore the fact that transference and resistance analysis have from Freud onward been accepted as minimal criteria qualifying a clinical process as psychoanalytic; (2) elective self-disclosure carries metapsychological implications dismissing not only Freud's theory of motivation but motivation as a basic feature of human personality; (3) they do not recognize interpersonal relations as mental events and so do not consider the ego's ability to create intrapsychic representations of object relations; (4) elective self-disclosures within the empathic parameters of the analytic situation are themselves unreal compared to the reality of the patient's experience with other objects. Abstinence and neutrality as ideals facilitate maintenance of an internal holding environment or container for the analyst's countertransference.

Humans↗
PubMed2004

How can we know what we need to know? Reflections on clinical judgment formation.

What distinguishes a psychoanalyst from any other psychologically minded, empathic human being? This seemingly simple question goes to the heart of our profession, the way we see ourselves as competent clinicians. To understand a patient's material beyond ordinary empathy--that is, to come to a clinical judgment--we need to step out of the dyadic, countertransference situation and reflect what we've experienced in reference to our clinical theories. An analytic vignette shows how a theoretical background can be used to understand and interpret to a patient in a way that is deeply meaningful.

Cognition↗
PubMed2004

The role of the analyst in the analytic cure during times of chronic crises.

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.

Adult↗
PubMed2006

Autistic defenses in agoraphobic syndrome: "flat" objects and the retardation of projective identification.

The function of autistic defenses in the generation of agoraphobic symptoms is explored in the case of a patient treated in psychoanalytic psychotherapy. The therapist's growing awareness of autistic modes of relating in the case facilitated various changes in the transference relationship. Although oedipal concerns are seen as important, a formulation is presented whereby autistic modes of generating experience are viewed as fundamental to an understanding of agoraphobic experience. Clinical findings in the transference-countertransference relationship led to the additional observation that the retardation of defensive forms of projective identification further contributed to the patient's agoraphobic difficulties. This formulation is tied theoretically to the idea that agoraphobic experience occurs when the dialectic between paranoid-schizoid and autistic-contiguous modes of generating experience collapses. The treatment implications of these observations are briefly explored.

Adult↗
PubMed2006

Paul Gray's narrowing scope: a "developmental lag" in his theory and technique.

A cental thesis of Paul Gray's work is that a "developmental lag" pervades modern psychoanalysis in its failure to assimilate and apply knowledge gained about the role of the unconscious ego in intrapsychic life. But Gray himself, it is proposed, has become a victim of a new "developmental lag," of his own construction. As he somewhat single-mindedly pursued the ramifications of his "developmental lag" concept, Gray may have foreclosed on some noteworthy ideas developing around him. The most important example is his claim--herein refuted--that proper interpretive technique can avoid being infused with transference. He also seems to have rejected the theoretical importance of the internalization of the analyst and the clinical usefulness of countertransference. While emphasizing defense analysis, he ignores defenses such as splitting, denial, and disavowal as substantive problems for his technique of close-process attention. Gray's "undoing" of the rapprochement between "ego analysis" and "id analysis" by viewing the matter as an either-or proposition undermines the very real value of his contribution to the field.

Consciousness↗
PubMed2006

The absence of a future: the effect of past experience and current developmental conflicts on a midlife analysis.

The four-year analysis of Mr. T, a highly intelligent, successful professional who entered analysis primarily because of a depression is presented; he had had no previous therapeutic experience but was very curious about analysis. The analytic work led to the discovery of a deeply held unconscious conviction of premature death that was related to interaction among the effects of a traumatic parental divorce during childhood, estrangement from both parents prior to their deaths, and signs of aging and illness in midlife. Before this analytic work the patient was unable to conceptualize, let alone plan for, late-life developmental experiences such as retirement and grandparenthood. Transference-countertransference themes are discussed, as is the importance of an understanding of midlife developmental concepts to successful analytic work with patients in this age group.

Age Factors↗
PubMed1977

Ambiguity in speech.

Ambiguity in speech during analysis is one manifestation of transference. Four types of ambiguity are illustrated. Each ambiguity communicates an unconscious wish or intention and the defense against this wish or intention. In each type of ambiguity, transference manifestations are expressed in the form of speech and not alone by its content, as we are accustomed to identifying the transference. Each type of ambiguity within the analysis expresses fear to responsibility and recrimination for libidinal or aggressive intentions. In some patients, the combinative ambiguity or malapropism expresses the fear of reprisal through the transformation into a self-inflicted injury. The pronominal ambiguity may express a feared and wished-for fusion with the analyst. The analyst's ambiguous interpretations are properly used to encourage associations, but at times may reflect lack of understanding and be a manifestation of countertransference.

Adjustment Disorders↗
PubMed1978

Candidates' evaluation of psychoanalytic supervision.

The origins, methods, results, and discussions of a project undertaken by the advanced candidates at the Denver Institute for Psychoanalysis have been described. This project was designed to examine the supervisory process and to compile a consensual critique of individual supervisors from the candidate's point of view. We have included vignettes of supervisory experiences. It became our purpose to: (1) Develop a set of criteria by which the strengths and weaknesses of supervisors can be evaluated, (2) Involve the candidate in assessing his own learning needs, (3) Promote the objective assignment of supervisors, an assignment determined by the patient's problems, the candidate's learning needs, and the supervisor's varying capacities and abilities to effectively understand these problems and deal with these needs, (4) Expand the supervisory process to include what we felt were often unconscious or hiterto unacceptable issues, such as the function and use of countertransference, and the detection and open discussion of transference dilemmas between analyst and both patient and supervisor, (5) Stimulate dialogue at all levels of psychoanalytic education on the patient-analyst-supervisor relational system.

Adult↗
PubMed1984

Fear of humiliation.

This paper explores the ontogeny of fear of humiliation, conceived of as an important organizing affect-laden fantasy in certain narcissistic personality disorders. The influence of the pleasure of the parental object in sadistically humiliating is emphasized in the overdetermined genesis of this fear. While, in elaboration of Loewenstein's (1957) and Eidelberg's (1959) contributions, "seduction of the humiliator" is a fundamental defensive process observed in masochistic characters, identification with the humiliator is a sadonarcissistic defense observed in work with certain narcissistic personality disorders. The countertransference potential to enjoy humiliating such analysands, as well as the defensive functions of fear to humiliation, are noted.

Fear↗