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PubMed1999

Getting in on the act: the hysterical solution.

The author recounts the case of Anna O from a contemporary psychoanalytic viewpoint, incorporating the additional information now available to us about Breuer's treatment of Bertha Pappenheim. Now the erotic transference and Anna O's 'oedipal illusion', which culminated in her hysterical pregnancy and labour, is evident to us, as it was to Freud, who did not publicly share his knowledge of Breuer's unhappy experience with this patient. Ernest Jones, in whom Freud did confide, wrongly dated the conception of the Breuer's baby in his biography of Freud describing it as a sequel to Anna O's treatment. In fact Mrs Breuer's pregnancy was concurrent with the treatment and the author suggests that it significantly influenced its course. Using the case of Anna O and one of his own the author postulates that a feature of hysteria is the use of projective identification by the patient to become in phantasy one or other member of the primal couple. A symbolic version of the primal scene between patient and analyst may then be enacted in the context of the erotic transference-countertransference that characterises these cases.

Fantasy↗
PubMed1999

Speaking in the claustrum: the psychodynamics of stuttering.

The author outlines the psychoanalytic theory of stuttering and, discussing material from the analysis of a stutterer and its transference and countertransference processes, puts forward a new hypothesis of the psychodynamics of stuttering in conjunction with Meltzer's theory of the claustrum. He argues that the stutterer is working out intolerable experiences of separation from the primary object and a resulting catastrophic experience of the oedipal situation through an unconscious fantasy in which anal qualities are conferred on the internal maternal object by a predominating hatred. The intrusive identification of parts of the self in the maternal rectum gives rise to a claustrophobic experiential world in which all obstacles that are encountered between self and object must be eliminated. The anal-sadistic object space of the claustrum is projected on to the external object space and thus also on to the mouth as the origin of the sound envelope, where it produces both a lifeless sound envelope and a torn content, i.e. stuttered sounds, words and sentences. Correspondingly, a dead speech melody and broken words have their parallels in object relations that are characterised by an attack on linking and by psychic withdrawal.

Adult↗
PubMed1999

Listening psychoanalytically to the Shoah half a century on.

The author discusses the repercussions of the Nazi genocide of the Jews on descendants of victims and survivors, with particular reference to identifications. A typical vampiric form of identification is discussed, in which the subject is stated to be neither alive nor dead, unborn, in an imageless, timeless and spaceless condition, and imprisoned in an earlier generation's traumas. Analysis of such cases must, the author shows, tackle the genocide-induced fantasies of a vampire complex involving infanticide and parricide in addition to the incestuous and parricidal wishes of the Oedipus complex. These ideas are illustrated by a case history in which the female patient concerned, although born after the Shoah, carried the unrepresentable parental traumas within her to the detriment of her affective and professional life. The patient was effectively linked with her mother in a deadly circulation through communicating vessels, which was repeated in the transference countertransference constellation and resulted in a disavowal of both birth and death, mediated by the genocidal project. The author shows how the analysand was gradually released from this vampiric fusion and became able to reappropriate her secondary narcissistic and oedipal identifications, the resulting triangulation opening the way to sublimation and creativity.

Adult↗
PubMed1999

Disappointment and disappointedness.

The author argues that the widespread affective experience of disappointment has not received the analytic attention it deserves, and that this is particularly the case for disappointedness as an outstanding feature of a way of life. Disappointedness is presented as a pathological organisation or character disorder that expresses specific unconscious fantasies and gives rise to disruptive transference-countertransference manifestations. The author singles out disappointedness as a special problem rather than, in the usual way, subsuming it under depressiveness or masochism and then assigning it a subsidiary or merely descriptive role. With the help of a case example, he attempts to illustrate the benefits of heightened clinical awareness of disappointment and disappointedness. These benefits include increased access to the compromise formations that can stand in the way of effective analytic work.

Adult↗
PubMed2005

Permeability and demarcation in the psychoanalytic process. Functions of the contact-barrier.

Introjection, identification and projection are concepts that designate processes in which something is being put into or taken out of something else. These processes presuppose the overcoming of some form of separation between two entities. The permeability or impermeability of a fictive boundary between the representations of subject and object set the emotional tone of their coexistence. There are moments of complete diffusion, in which subject and object can no longer be differentiated, and moments of autistic enclosure in which the individual can no longer be reached at all. Permeability and demarcation result from the processing of stimuli carried out by the 'contact-barrier', as an ego function. Stimuli of internal, libidinal or aggressive origin, as well as 'impressions' of external origin, are classified and processed with the aid of various kinds of factors arising from coagulated object-relational experiences. Whereas for Freud the contact-barrier regulates the quantity of energy and found a topographical structure, Bion understands the contact-barrier as a psychic function that simultaneously regulates boundary demarcation and making contact. In the psychoanalytic process, the contact-barrier created by patient and analyst regulates the events in the transference and countertransference. An awareness of the struggle for contact and demarcation at the dynamic boundary representations that are constantly being recreated by both partners in the analytic process may be helpful in our clinical work. The author presents an examination of the ways in which patient and analyst make contact and demarcate the boundaries, which provides a better understanding of the dynamics of transference processes. He demonstrates this in relation to clinical material.

Humans↗
PubMed2005

Trauma, narcissism and the two attractors in trauma.

In this paper, the author sets out to distinguish anew between two concepts that have become sorely entangled--'trauma' and 'narcissism'. Defining 'narcissism' in terms of an interaction between the selfobject and the self that maintains a protective shield, and 'trauma' as attacks on this protective shield, perpetrated by bad objects, he introduces two attractors present in trauma--'the hole attractor' and the structure enveloping it, 'the narcissistic envelope'. The hole attractor pulls the trauma patient, like a 'black hole', into a realm of emotional void, of hole object transference, devoid of memories and where often in an analyst's countertransference there are no reverberations of the trauma patient's experience. In the narcissistic envelope, on the other hand, motion, the life and death drive and fragments of memory do survive. Based on the author's own clinical experience with Holocaust survivors, and on secondary sources, the paper concludes with some clinical implications that take the two attractors into account.

Ego↗
PubMed2005

Identifying marks of Latin American psychoanalysis. Towards the defininition of a River Plate model.

The author considers the influences that different psychoanalytic trends have had on the thought processes of psychoanalysts in the River Plate region. She begins by giving a history of the way in which these trends were shaped by the sociocultural context of the region, and of how the dialectical relationship between these two factors produced the River Plate region's (Argentina and Uruguay) own theoretical model. The author includes a study--albeit incomplete--of major local developments, and attempts to define the characteristics of a regional model. The model is based on the following parameters: the fundamental rules of evenly suspended attention and free association; the technical frame; links between theory and clinical practice such as transference-countertransference, resistance, identification, the analytic field; the concept of psychic change and its indicators; and the interpretive instrument. The author considers the past and present influence of Lacanian thought on this model. She concludes by reviewing some of these theoretical and clinical concepts.

Humans↗
PubMed2002

THE EXTERNAL OBSERVER AND THE LENS OF THE PATIENT-ANALYST MATCH.

A focus on the match between patient and analyst places attention on the dynamic effect of the interaction of character and conflict of both participants on the process that evolves between them. Match is neither a predictive nor static concept. Rather it refers to an unfolding transaction that itself shifts and changes during the course of analytic work. The treating analyst's perception of the effect of this match is by necessity limited by the analyst's own blind spots and other countertransference phenomena. Reporting the analyst's clinical experience to an analytically trained observer, external to the dyad, may broaden the analyst's perspective. Using the lens of the match, a colleague in the role of supervisor, consultant or peer can provide feedback from which the analyst may acquire insight. As a result of this process, the influence that the participants' similarities and differences have upon each other becomes clear to the analyst. This awareness, in turn, may lead the analyst to appreciate the effect of the analyst's stance of distance or closeness and to evaluate whether at this phase of treatment it is beneficial or detrimental to the analytic process. Clinical illustrations of the effect of the external observer's feedback in relation to the patient-analyst match are provided.

Journal Article↗
PubMed2005

Why perversion?: 'False love' and the perverse pact.

In this paper, the author works with the awareness that perversion is a socially, historically and theologically loaded term, at the same time as it may be the latest frontier in psychoanalysis, both clinically, and in relation to contemporary art and culture which emphasize the perverse. Positioning itself against tendencies to deny the existence of a category of 'perversion' or, inversely, to abuse it for the power that accrues from the act of diagnosing, she also points to other liabilities in the history of the treatment of this term, such as the narrowing down of perversion to the exclusively sexual domain, or, alternatively, the overextension of it to polymorphously erotic practices that enhance sexual excitement. The paradoxes of perversion and the difficulties of distinguishing the perverse from the non-perverse are addressed. The case is also made that, in order to understand perversion, one must unlink it from the narrow notion of sexual practice and see what is involved on a deeper level--an approach initiated when psychoanalysis turned to perversion as a defense against psychotic anxieties, and began considering the necessary place of perversion in the transference--countertransference. Two features common to both sexual and non-sexual perverse relations are the seductive and bribing aspects of perversion, and its means-ends reversal. Perversion is a haven for the disguising of hatred and suspicion as excitement and (false) love. Displaced child and beating father, entitled child and seductive mother, are both prototypes of psychoanalytic reflection on parents who excite, deceive and corrupt their children and establish perverse pacts with them. The notion of the perverse pact is foregrounded in Alice's analysis, where first the resurrection and then the dismantling of such a pact were effected through various analytic means.

Adult↗
PubMed2005

A disturbance of interpreting, of symbolisation and of curiosity in the analyst-analysand relationship (the patient without insight).

The author examines the function of the analyst who may distort the unconscious communication with the patient by means of the expression of his countertransference. He studies a disturbance in curiosity and in symbolisation in a patient with a narcissistic pathology. Both problems were related to this failure in interpreting. The curiosity of the patient, which initially seemed to be non-existent, was found to be directed towards investigating the mind of the analyst, this being his sole purpose. The disturbance in symbolisation was manifested as a constant verbal acting out, which was expressed as verbal communication empty of meaning. A change in the interpretative attitude enabled a modification in the objective of the curiosity, which became focused on investigating his own inner world, and the emptiness of the verbal communication was replaced by representations. This change in communication allowed the analyst to relate the facts of the psychoanalytic relationship both with the patient's phantasy and with the events in his history. An idealised identification with destructive aspects of the mother towards the father was discovered. This idealisation had been sustained by the analyst by means of his errors in interpreting. The author explores disturbances in symbol formation and in the use of symbols, and he considers the different states of emptiness.

Acting Out↗
PubMed2001

Gone but not forgotten: declarative and nondeclarative memory processes and their contributions to resilience.

Cognitive psychology research challenges traditional psychoanalytic understanding of memory. The memory of facts and events is now referred to as declarative memory. Nondeclarative memory systems, in contrast, process patterns of perception, emotion, and action without representing the past in terms of any consciously accessible content. The author examines the contributions of declarative and nondeclarative memory processes to resilience. Declarative memories can promote resilience through their capacity to evoke soothing emotional responses. Nondeclarative memory processes can foster resilience through underlying the capacity to elicit and maintain supportive relationships. The concept of nondeclarative memory has potential to inform the understanding of essential psychoanalytic phenomena, including transference, countertransference, and enactment.

Affect↗
PubMed2001

Interviewing violent patients.

A clinical attitude to the interview of violent patients is outlined, which enables maximum safety for the clinician and usefulness of the interview findings. This approach emphasizes careful monitoring of subjective states in the patient and clinician. The author suggests an emphasis on clinical knowledge of the DSM-IV and psychodynamic diagnoses of potentially violent psychiatric patients; self-awareness of transference and countertransference; and self-care including attention to personal physical and emotional needs, de-escalation, and self-defense skills. Finally, there is need for a safe therapeutic context within which to work.

Adult↗
PubMed2003

Working with pathological and healthy forms of splitting: a case study.

The author illustrates through a case discussion how he understands the concept of splitting and how he makes use of that understanding in tracking, and at times, interpreting movement of the unconscious transference and countertransference. He views splitting not simply as a primitive defense but also as essential to early emotional development and to healthy psychological maturation in the course of analytic work. In the analytic relationship discussed in this article, the author presents both aspects of splitting--as a primitive defense and as a healthy movement toward new and more complex object relatedness. Difficulties arise when one fails to distinguish pathological from healthy but immature forms of splitting. Healthy splitting in its beginnings represents an important developmental step that serves as a transition to ambivalence and mature integration. The author demonstrates the importance of the analyst's capacity to distinguish pathological splitting from healthy splitting during periods of analytic impasse.

Dissociative Disorders↗
PubMed2003

The development of an attachment-based treatment program for borderline personality disorder.

The treatment of borderline personality disorder (BPD) remains controversial. The authors have developed an evidence-based treatment program rooted in attachment theory that integrates research on constitutional factors with environmental influences. BPD is conceived of as a disorder in the self-structure brought about through environmentally induced distortion of psychological functioning, which decouples key mental processes necessary for interpersonal and social function. The primary mental function involved is mentalization, which is enfeebled by an absence of contingent and marked mirroring during development. Treatment strategies target mentalization in order to foster the development of stable internal representations, to aid the formation of a coherent sense of self, and to enable to borderline patient to form more secure relationships in which motivations of self and other are better understood. Destabilization of the self leads to emotional volatility, so treatment also needs to focus on identification and appropriate expression of affect. This article describes some of the techniques used to enhance mentalization within the context of group and individual psychotherapy. Targeting of current symptomatology and behavior is insufficient. Therapists need to retain their own ability to mentalize, maintain mental closeness, focus on current mental states, and avoid excessive use of conflict interpretation and metaphor while paying careful attention to the use of transference and countertransference.

Affect↗
PubMed2003

Long-term treatment of an addictive personality.

There is infrequent discussion of long-term psychotherapy of persons with addiction, particularly in the self-psychology literature. In addition, some question whether long-term psychotherapy can be helpful in severe psychiatric disorders. The author describes the treatment of a woman with multiple diagnoses, including bulimia and alcohol and drug addiction, which took place over a period of almost 7 years. These issues are addressed from a self-psychological perspective, with progression of the treatment from early facilitation of a selfobject transference to more intense selfobject transference-countertransference states. Behavioral interventions (e.g., recommendation of inpatient chemical dependency treatment) are also discussed. The author describes the patient's dramatic progress and subsequent regression. Finally, there is a discussion of the addiction from self-psychological and biological perspectives of this woman's particular developmental and treatment issues, as well as a discussion of the confrontation and limit setting in a self-psychologically oriented treatment.

Adult↗
PubMed2004

A psychoanalytically oriented combined treatment approach for severely disturbed borderline patients: the Athens project.

A psychoanalytically oriented combined treatment is considered beneficial for severely disturbed borderline patients, especially during an acute crisis. The proposed treatment comprises hospitalization and specialized psychotherapeutic inpatient treatment, individual psychoanalytic psychotherapy, and psychiatric management. It is important to take into account that during inpatient treatment, projective identifications and splitting mechanisms are activated, involving different members of the therapeutic personnel or other patients. The mental health team--the psychiatrist, the nurses, the assigned psychotherapist, and other members of the therapeutic personnel--should work together in the context of teamwork in order to explore transference and countertransference manifestations. This function promotes empathy and understanding of the patient's inner difficulties. A combined treatment approach can help the patient stabilize his or her condition and develop awareness and motivation for undertaking long-term treatment and individual psychoanalytic psychotherapy, with the prospect that therapy will be maintained after the patient's discharge.

Acute Disease↗
PubMed2006

The three R's of group: resistance, rebellion, and refusal.

I describe three constellations of group life and group process: resistance, rebellion, and refusal. In resistance, an individual or group remains antagonistic to conscious but not unconscious thinking, the latter manifested in derivatives, including symbol and symptom formation, transference-countertransference, and enactment. Rebellion functions on the level of conscious thinking, manifested in challenge, defiance, and the possibility of sociopolitical action. The basic premises and values of the group and/or leader are at the center of the controversy, to be addressed on that level. Refusal establishes a mental boundary between what is considered appropriate and inappropriate. Unconscious as well as conscious processes of feeling, thinking, and meaning making are refused entry, left undeveloped, rejected, or obstructed. Working with refusal requires appreciating how and why the mind and its thinking operations are being suspended. The theoretical framework is applied to a case example.

Humans↗
PubMed2001

Group psychotherapy for adolescents comorbid for substance abuse and psychiatric problems: a relational constructionist approach.

The group psychotherapy of adolescents comorbid for psychiatric and substance abuse problems is fraught with inconsistent attendance, frequent verbal and physical disruptions by the adolescents, and intense countertransference toward patients and their parents on the part of treating staff. A relational constructionist approach assists staff and patients in overcoming these obstacles and in focusing on the adolescents' search for personal meaning. Multiple group psychotherapy conducted in a combined day treatment and high school program is described and illustrated by case examples during the course of a year of treatment. These examples illustrate the importance of a relational non-hierarchical approach to adolescent patients by treating staff.

Adolescent↗