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PubMed1984

The end phase of analysis: indicators, functions, and tasks of termination.

This paper considers the end phase of analysis. Beginning with a brief review of the literature on termination, specifically the indicators for initiating the termination process, we identify the structural attainments necessary for the patient to successfully complete the analysis and to maintain smooth post-analytic functioning. We stress in this regard the significance of self-analytic functions and the relative immutability of the transference neurosis. These points are illustrated with clinical examples. Our paper concludes with a discussion of the tasks and contributions of the analyst during the termination process. We make special reference to countertransference vulnerability resulting from the analyst's own termination experiences.

Adult↗
PubMed1984

Peer review, third-party payment, and the analytic situation: a case report.

The complexities of insurance coverage and peer review as they intrude into the analytic situation were discussed. The basic question was raised of whether becoming acceptable to major health providers through the peer-review program is truly a compromise of the analytic pact and a threat to the future of psychoanalysis. Practical as well as technical considerations facing the analyst when he is confronted with having to write a report to the patient's insurance company were elucidated. Countertransference feelings were emphasized. A detailed case illustration was presented to demonstrate that peer review, as it relates to third-party payment, need not compromise an analysis.

Adult↗
PubMed1985

On the vicissitudes of early primary surrogate mothering.

I have noted estrangement from biological mothers and intolerance of intimate relationships in patients with an early history of primary surrogate mothering. This observation facilitated discovery of such early histories in 31 of 102 patients I examined during a five-year period. With a review of the literature, and clinical examples, I attempt to associate the estrangement and intolerance with the mother's exclusion resulting from her infant's close tie to a surrogate and the infant's inevitable traumatic loss of the latter. In the analyses of screen phenomena, mother and surrogate mother transferences, all peculiar to that caretaking, the surrogate is seen to emerge from obscurity. In the clinical examples (limited to losses of surrogates following the infant's eighteenth month) screen memories, dreams, and eclipse are found to possess a common feature: the image of the surrogate is screened by that of the mother. Biological mother and, in the countertransference, the analyst play a significant role in perpetuating the concealment of the surrogate.

Adult↗
PubMed1992

"Incest--see under Oedipus complex": the history of an error in psychoanalysis.

This paper is intended as a contribution to the understanding of errors in our field. The title refers to the index entries "incest" in several classic psychoanalytic texts. In a way that is analogous to the defenses utilized by survivors of incest, psychoanalysis has both known and not known, avowed and disavowed, the traumatic impact of actual incest. It is argued that psychoanalysis erred in (a) focusing too heavily on the implications of incest for the Oedipus complex instead of its implications for every stage of development, and (b) missing out on the full and detailed description of the clinical pictures of incest victims and of treatment issues, including transference and countertransference. The author presents an overview of the history prompted by Masson's original attack on Freud for abandoning the "seduction hypothesis." Topics covered are: Freud's early papers, the Freud-Ferenczi controversy (1932), and the state of psychoanalytic awareness in the 1960's of the importance of actual incest. Certain features of our field make it all too likely that new errors can be generated that may similarly take decades to recognize and undo. These include the politics of our discipline, and negative attitudes toward systematic gathering and assessment of evidence.

Austria↗
PubMed1993

A transitional phase in our understanding of the psychoanalytic process: a new look at Ferenczi and Rank.

In The Development of Psychoanalysis, Ferenczi and Rank (1922) demonstrate an important transitional phase in the conceptualization of the psychoanalytic process. It is not the archaic language of libidinal flow that separates their work from modern psychoanalysis, but their insistence on the ideal of the analysts's objective authority, despite the implicitly more current interpersonal and structural understandings embedded in their sound principles of character analysis. Freud's early theory presumed the possibility that an analyst could be an objective observer of forces entirely within the patient. Today's theories must account for newer intrapsychic, interpersonal, and intersubjective realities--the analyst's subjective experience as well as his observing functions. In the decade preceding the monograph, implicit developmental, structural, and object-relational understandings began to emerge. A concurrent dramatic but unacknowledged change in the meaning of the terms "psychic reality" and "intrapsychic" also occurred. The controversies surrounding the monograph predicted many lines of development and dialectics for future theoretical discourse. The subjects of countertransference and empathy, almost entirely absent in the monograph, became major fields of study, and focal points for divergent schools in the new struggle to define the necessary roles of the analyst's interaction and subjective experience.

Defense Mechanisms↗
PubMed1995

The early history of boundary violations in psychoanalysis.

The notion of professional boundaries is a relatively recent addition to psychoanalytic practice. Freud and his early disciples indulged in a good deal of trial and error as they evolved psychoanalytic technique. The study of these early boundary violations illuminates the study of the evolution of the concepts of transference and countertransference. The recent publication of the correspondence between Freud and Jung, between Freud and Ferenczi, and between Freud and Jones has provided us with extraordinary insights into the boundary transgressions that occurred in the early days of psychoanalysis. The boundary violations of the analytic pioneers have contributed to the legacy inherited by future generations of analysts. Institutional resistance to addressing these difficulties in contemporary psychoanalytic practice may relate in part to the ambiguities surrounding boundaries in the training analysis itself.

Austria↗
PubMed1996

On trauma, perversion, and "multiple personality".

The role of perverse sexuality as an organizing influence in "multiple personality" is explored in this paper. Following a brief review of psychoanalytic thinking on sexual trauma and perversion, the author discusses his own views on dissociation and "multiple personality." A clinical case is then presented in which transsexualism, homosexuality, and sadomasochistic heterosexual practices were manifested during altered ego states. Analysis of the transference revealed the centrality of sadomasochism in this patient. It is hypothesized that various perverse structures may be formed within these seemingly autonomous, amnestic states, in order to contain anxiety and encapsulate the aggression which resulted from early psychic trauma. Issues relating to diagnosis, countertransference, reconstruction, and psychoanalytic technique are discussed also.

Adult↗
PubMed1996

Suggestion and veridicality in the reconstruction of sexual trauma, or can a bait of suggestion catch a carp of falsehood?

Freud used the term suggestion in psychoanalysis in different ways, including suggestion as an integral part of the transference and suggestion in the sense of undue influence or technical error. This distinction can be expressed in terms of the patient's suggestibility (capacity for transference) and the analyst's unwarranted suggestion or persuasion representing countertransference, theoretical bias, or a departure from technical neutrality. Whether suggestion is explicit or implicit, the effects of suggestion and suggestibility may be mutual and reciprocal. To the extent that a psychoanalyst maintains the goal of technical neutrality, undue suggestion is likely to be minimal. To the extent that it occurs for transferential or countertransferential reasons, suggestion may itself be analyzed. Problems of suggestion are more likely to occur and persist when they are part of the analyst's theoretical orientation, influencing the course of the analysis and expressing compromise formations for both patient and analyst. At times, even tentatively stated words or unintended behaviors of the analyst can have a dynamic impact that may not be readily analyzed. The analytic situation itself may have retrospective (nachträglich) action. A previously published case is described in which an apparent enactment led the analyst to urge a reconstruction of sexual abuse even though the patient never actually recalled what was presumed to have been fellatio. The need for technical neutrality and alternative reconstructions in such cases is considered. The degree to which the personality and goals of the analyst influence the course of reconstruction remains a vexing issue for psychoanalysis as a scientific endeavor. There is a need for detailed analytic case studies in which alternative reconstructions can be compared by investigating opportunities for external confirmation or falsification.

Adult↗
PubMed1998

A new analytic dyad: homosexual analyst, heterosexual patient.

The paradoxical thesis is presented that the extraordinary aspect of the analytic experience of a homosexual male analyst and his heterosexual male analysand is that it was ordinary, that the fundamental processes of transference, countertransference, and analysis of defense and resistance were determinative. The unique variations of these processes with this particular patient are explored. The patient entered treatment unaware of the analyst's homosexuality, which he discovered during the analysis. The course of this discovery, its transformations, its defensive uses, its transference meanings, and its fate in the termination are delineated. Through viewing the patient's reactions to the analyst's homosexuality as potential entry points to the transference, the analytic process was enhanced and facilitated.

Adult↗
PubMed1999

The role of the preconscious in psychoanalysis.

The analytic process inevitably involves the interdigitation of the intrapsychic structures of both patient and analyst. This interplay is expressed in transference-countertransference interactions. Drawing a dichotomy between intrapsychic and interpersonal factors as central agents of psychic change is a faulty construction. Affective, behavioral interchanges between patient and analyst reflect their individual intrapsychic organizations and their interplay, which influence the form and nature of psychological change. The safer both patient and analyst feel in relation to each other, the more freely will they relax their customary cognitive controls and permit the emergence of preconscious responses. Preconscious resonance between patient and analyst is likely to facilitate the lifting of repressive barriers and the emergence of unconscious material in both participants. The integration and reworking of old conflicts then becomes possible. The role of the preconscious in facilitating the analytic process is illustrated. Creative use of preconscious processes requires the analyst's self-discipline to preserve the analytic role and keep the treatment safe for both participants.

Consciousness↗
PubMed1999

The reconstruction of reminiscence.

The lifting of repression and of infantile amnesia was an original aim and goal of clinical psychoanalysis. Memory may be more or less reliable and authentic. However, it tends to be subjective, self-serving, and selective, and there are different memory modalities and systems. The recovery of repressed childhood memory has been largely subsumed under the analysis of unconscious conflict and fantasy. "Hysterics suffer mainly from reminiscences," and these reminiscences interweave with and contribute to reconstruction, which is intrinsic to psycho-analysis. Memory and reconstruction are subject to the influence of special interests, transference, and countertransference. Since open questions remain concerning preoedipal, and particularly preverbal, reconstruction, external confirmation may further both the analytic process and analytic research. The process of reconstruction integrates and transcends memory, facilitating personality reorganization.

Adult↗
PubMed1981

The resident and the borderline in-patient: a supervisor's perspective.

The problems of residents working intensively with borderline inpatients in a general hospital psychiatric unit area described. The resident feels pressure because of inexperience with intensive psychotherapy, and the high visibility of working in a closely supervised team setting. The border line patient baffles the resident with his defensive activity characterized by splitting, erotization, idealization, and negative therapeutic response. These difficulties complicate supervision, necessitating the supervisor's alertness to being caught in team splits or collusion with the resident's unrealistic hopefulness or nihilism. Supervision must actively address the resident's countertransference and the supervisor's counterresponses. Clinical vignettes illustrate the various problems.

Borderline Personality Disorder↗
PubMed1982

The professional woman as patient: a review and an appeal.

The unique problems that the professional woman brings to therapy are presented here. It is the author's contention that the career woman's difficulties are not adequately realized or understood by many male therapists. Many of these patients are disappointed with or highly critical of their therapy with male psychiatrists. Two sub-groups of professional women are described: the married professional woman and the unattached professional woman. There are critical sex-role relate issues and countertransference problems which arise with the male therapist: professional woman patient dyad. Other implications for male psychiatrists are outlined and suggestions offered toward therapist enlightenment.

Female↗
PubMed1982

Co-therapy in a clinic for schizophrenia.

In the outpatient treatment of schizophrenia, the routine practice of providing each patient with two co-therapists results in several benefits: reduced dependency, increased expertise, objective monitoring, added support and morale for the therapists, more obvious and therefore more reversible countertransference, more obvious and therefore more treatable "splitting" and "projecting." Despite these benefits, problems arise in the two-therapist arrangement. They are discussed under the following headings: loyalty conflicts; limit setting; crisis management; family work. The authors report on techniques of co-therapy problem prevention and problem resolution. Though not always successful, co-therapy continues to be a useful model of service delivery to schizophrenic outpatients.

Ambulatory Care↗
PubMed1984

An effective therapeutic intervention with adolescent in-patients in love.

Easson noted in 1967 how little had been published on intimate (frequently sexual) involvements between adolescents in in-patient settings and remarked how staff attitudes and countertransference feelings frequently resulted in an unsatisfactory resolution of such occurrences. Since that time the literature has remained sparse, yet the phenomenon and the problem of how best to deal with it persists. The present case study of two female in-patients "in love" attempts to demonstrate the usefulness of a simple and presumably infrequently used mode of intervention in promoting therapeutic growth and facilitating ward management. Rather than attempting to separate the two patients and deal with issues of their relationship individually, the existence of the relationship was acknowledged and accepted, and conjoint meetings which explored its troublesome aspects were held with them and their respective therapists. Provocative behaviour on the ward diminished, some insights were gained and their separation due to the discharge of one of them was effected with minimum turmoil. While certain factors specific to the case may have contributed to the outcome, the success of the intervention, nonetheless, warrants further application and study in the clinical arena.

Adolescent↗
PubMed1986

Personal therapy and the student therapist.

The effect of a therapist's personal psychotherapy on patient therapy outcome appears to be mixed. Some studies have shown that experienced, analysed therapists obtain better clinical results, but experience seems to be the important factor. Others have found no difference regardless of the therapist's personal therapy. Considerations favoring personal therapy include: awareness of the unconscious and of countertransference, increased empathy, minimizing blind spots, validating theory and method by first hand experience, and understanding how one's own defenses interfere with the therapeutic process. Those against personal therapy affirm there is no direct effect on competence, and there may even be detrimental effects (during residency); for example, inexperienced therapists in personal therapy appear to be less available to their patients because of their own preoccupations. Students' tendencies to identify with their analysts and pressure to conform in an analytic milieu might tend to decrease the number of therapists with varied orientations. The boundary between supervision and personal therapy is often unclear. In both, similar techniques may be used, but the goal of supervision should be to help the student to understand emotional problems and resistances which might interfere with the therapeutic process. Supervisors should make a compromise between purely didactic and therapeutic approaches. Despite the lack of conclusive evidence, supervisors should be encouraged to be less neutral and give advice and information to trainees who are in need of or who ask about personal therapy.

Adult↗
PubMed1987

Some psychodynamics of non-compliance.

With up to 50% of psychiatric patients refusing medication at some time during therapy, non-compliance can become a major treatment difficulty. This problem is compounded by the countertransference responses evoked within the therapists, and their tendency to react solely with information and exhortation rather than attempting to view non-compliance psychodynamically. When exploring with empathic concern, a number of common dynamic issues can be seen as playing a major role in drug refusal. Commonly at work are issues relating to projection, denial, identification, and transference difficulties that emerge in a relationship where a therapist offers a patient a pill.

Adult↗
PubMed2006

Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors.

BACKGROUND: A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide. DISCUSSION: Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication. SUMMARY: The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards.

Aged↗