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PubMed1982

On the relation to the self as an object.

Perhaps the most important object relationship is that relation that each person has to the self as an object of perception, facilitation, and object presenting. In this paper I examine how a person's idiom of being reflects a form of management, and I discuss how in intrasubjective, subvocal space, the self is objectified in the most ordinary sorts of ways. I discuss how each person is an object of handling within the dream space, and I indicate how intersubjective relations always imply a relation to the self as an object. In my view, each individual transfers elements of that maternal care system that handled them as an object when in infancy and childhood by relocating this parental care system into the person's own way of managing themself as an object. As such, in the clinical situation the psychoanalyst can observe how this particular form of transference (to the self as object) manifests itself and furthermore how some of the patient's responses are legitimately viewed as countertransferences: that is, specific reactions to the transferred parental system. I conclude this paper with a brief discussion of how the psychoanalytic situation is uniquely designed to facilitate this self as object relation in so far as the patient must narrate himself to the analyst, and I focus on how the analyst's object, is internalized by the patient and how this alters his own previously arranged self as object relationship.

Adult↗
PubMedDate not supplied

On speaking of oneself by name.

Speaking of oneself by name is studied. Such behavior occurred with unusual frequency in the case of a patient with predominantly narcissistic character pathology who underwent brief psychotherapy for a stress response syndrome following his wife's suicide. A content and context analysis of this phenomenon showed that the patient would refer to himself by name as a characteristic defense in response to severe threats to his self-esteem. An object-relations perspective proved useful in clarifying dynamic aspects of this defensive maneuver, which depended for its effectiveness on the evocation of self-images negating guilt and shame. In addition to the patient's character style and the nature of the stress event, the framework of the therapy and the therapist's countertransference responses to the patient were other factors influencing the appearance of this behavior. It is concluded that referring to oneself by name reflects at least momentary disturbance in the sense of self and may be unusually prominent and frequent in narcissistic pathology. A study of the phenomenon appears to elucidate an important step in the building of self-representation from the self-object representations of the symbiotic phase: the concept of "I" becomes possible through the reconciling of a sense of physical and psychic separateness with the need for emotional relatedness to others. Where problems of this early developmental phase are reactivated in the treatment situation, the patient's relationship with the therapist is the vital bridge toward a more coherent sense of self.

Adult↗
PubMed1982

Extramarital affairs: clinical approaches in marital therapy.

Extramarital sexual relationships constitute one of the most common problems encountered in marital therapy. They present both of the marital partners with highly emotionally charged dilemmas that must be resolved. Once believed to occur because a married person was weak, immoral, or neurotic, they are now understood to occur because of a variety of reasons. While almost a third of these cases end in divorce, others respond to appropriate treatment so that the marriages may be maintained, although with varying degrees of happiness for these couples. Countertransference issues for therapists are major issues in treating these couples and may require special referral procedures.

Adaptation, Psychological↗
PubMed1980

Affects and their non-communication.

The non-communication of affects is the most evident form of defence in a certain group of narcissistic patients. This non-communication of affects may take the direct form of a state of non-relatedness or may be disguised as the communication of false affects or affects that serve the function of inducing corresponding feelings in the object. We have examined in detail the motives for this non-communication and its implications for a more general theory of affects. Although the motives are variegated we have observed the recurrent wish to control omnipotently the affects of others. We have understood the induction of dysphoric affects in the transference and countertransference as the wish to recreate actively what has been experienced passively. It is an attempt to bring the trauma arising from the external world into the internal world and thus to create an illusion of mastery and control. This is analogous to Freud's description of the child's game in 'Beyond the pleasure principle".

Adult↗
PubMed1981

The psychiatric physical examination - Part I: methodology.

The frequency of medical findings in psychiatric patients is quite high. Regardless, none of the responding psychiatrists in a recent survey do routine physical examinations. In response to this survey, the authors describe a method of rapid physical examination specifically designed for the psychiatric patient. The average duration of the examination in 75 patients was 16.9 minutes. There was no evidence of negative transference or countertransference. The level of competency required was that of a medical student, yet there were 8.2 physical findings per patient with 5.3 physical findings per patient being unknown previously.

Humans↗
PubMed1981

Iatrogenic disease or doctor-patient collusion?

"Iatrogenic disease" may be a misnomer and would be better termed "syndyadogenic disease"--literally, a disease caused by two people working together. Most iatrogenic disease is a result of an unconscious coequal collusion between doctor and patient. Using the psychoanalytic concepts of transference and countertransference, three patterns of doctor-patient collusion are seen: the needy child-omnipotent parent posture, the Pollyanna posture and the persecutor-victim posture.

Adult↗
PubMed1981

Narcissism and adaptation to indignity.

Having initially briefly reviewed and then compared and contrasted the contributions of Kernberg and Kohut to the theory and treatment of narcissistic problems, the attempt was then made to evaluate critically their merits and possible short-comings. It was felt that in pushing back the frontiers of pathology to earlier and earlier developmental phases there has been an associated tendency to postulate "essentially preverbal unconscious communication' between therapist and patient where empathy tends to minimize or replace free association and other secondary process communication as the analytic therapeutic tool. The view was put forward that both Kernberg and Kohut emphasized the countertransference dangers involved in treating patients with narcissistic problems at the expense of recognizing the communicative, adaptive aspects of the feelings evoked and provoked by such patients. There was the question raised whether new self psychologies were required or merely the modification of existing theories. This was especially relevant to proposed changes in viewing the place of drives and the Oedipus complex. Finally, an attempt was made to show that along with object-related developmental conflicts and traumas, life presents us all with a series of indignities related to narcissistic traumas that we must cope with from infancy to senescence, and not least among these traumas are those related to being an analytic patient.

Adaptation, Psychological↗
PubMedDate not supplied

A developmental view of identifications resulting from maternal impingements.

This paper attempts to understand in early developmental terms one of a group of patients who demonstrate a powerful identification with a conflicted aspect of their mother. In addition to the strong identification with the maternal pathology, the group is characterized by a history of maternal impingements (Winnicott) through which the infants were exposed to the conflicted psychological state of the mother. A case history of a psychoanalytic psychotherapy emphasizes the vicissitudes of the transference and countertransference. The patient presented had been exposed to premature awareness of separateness from the mother as a result of the maternal impingements. The identification with the maternal pathology is seen primarily as a defensive attempt to create the illusion that the characteristics of the impingements were actually a creation of the patient herself. This defensive identification was strengthened by the mother's inability to be responsive to the patient, except in so far as the patient entered into the "beam" of the maternal pathology. Parts of the work of Melanie Klein, Winnicott and Greenacre which make up the theoretical context for the developmental formulation of the type of identification under discussion are presented and several clinical implications of the developmental formulation are discussed.

Adult↗
PubMed1978

Outpatient management of the borderline adolescent.

In summary an attempt is made in this paper to describe the psychopathology of the borderline patient. Descriptive features of the syndrome in children, adults and adolescents are given based on the respective work of Pine, Masterson and Kernberg. The psychic structures of the borderline patient are discussed with their resulting treatment implications. Genetic considerations with their effects on the psychotherapy of the borderline are reviewed. Finally the outpatient treatment strategies of the borderline adolescent are presented in detail including countertransference issues frequently encountered in the course of their treatment.

Acting Out↗
PubMedDate not supplied

Expiation as a defense.

This paper presents a specific defense mechanisms that leads not only to the stagnation of the analysis but also makes it difficult to terminate analysis. The predominance of what I call "expiation" demands continual punishment of the self and of internal objects in contrast with reparation. It is essential for the patient to maintain the immobilization of the analyst and of the analytic work. This defensive constellation aims at protecting the patient from the pain that comes from the guilt brought from the realization that his good and loved object is the same one that he hates and has attacked. Expiation is to be distinguished from the negative therapeutic reaction as well as from other problems in psychoanalysis. A case is presented. There is also a discussion of the relevant psychopathology and of the technical problems expiation poses, with particular attention to countertransference.

Adult↗
PubMed1980

Management of violent patients in a psychiatry walk-in clinic.

The authors discuss a systems approach for managing violent psychiatric outpatients. Multiple care-giving and brief, as needed visits within an outpatient walk-in clinic setting can provide empathic care for those violent patients who become too threatened by the intimacy of individual therapy, and who often reject treatment. The walk-in clinic can provide the violent patient and his therapist sufficient "distance" from each other, so that excessive transference and countertransference reactions--which can lead to acting out and violence--are diluted. Case vignettes illustrate how the walk-in clinic can treat violent patients falling under a variety of diagnoses, and prepare them for eventual acceptance of more traditional therapies. This approach may assist community clinics who are increasingly involved in the treatment of violent patients.

Adult↗
PubMed1995

Delusions in the transference. Psychotherapy with the paranoid patient.

This article has attempted to combine a theoretical and practical approach to the challenge presented in psychotherapy of paranoid and delusional patients. The essential ingredients of psychotherapy of non-psychotic patients--such as the frame, the therapeutic alliance, transference, countertransference, and interpretation--all play roles in the psychotherapy of paranoid, psychotic, delusional patients as well. Differences in defense mechanisms and dynamics and their working through, however, can make unfamiliar the factors that are basic to any psychotherapy. A familiarity with the unique problems of psychotic individuals in psychotherapy may help to make the work less bewildering and frightening, although no less challenging.

Adult↗
PubMed1995

The nurse-patient relationship and victims of violence.

Vicarious traumatization is a phenomenon that recognizes that the exposure of persons, other than the victim, to the specifics of trauma material or the reenactment of traumatic experiences transmits the emotionally laden aspects of the original violence and thus is a source of emotional arousal and distress for the nurse working with victims of violence. This source of emotional arousal shapes the underlying approach--avoidance dynamic of countertransference responses that strain the empathic connection necessary for a safe and constructive nurse-patient relationship. Case consultation and supervision are necessary to protect the integrity of the nurse-patient relationship. The current isolating changes in the work setting cut the nurse off from needed support and guidance in working with victims of violence. The emotional risks inherent in working with victims of violence require that the nurse seek professional support for the interpersonal aspects of practice.

Arousal↗
PubMed1995

Triangular space and the development of a working model in the analysis.

Two clinical examples are presented in order to demonstrate how the analyst uses what he perceives to be the patient's impact on his ability to think, in constructing an effective psychoanalytic working model. The two clinical cases, very different in character and in the countertransference difficulties they cause, lead to the construction of quite diverse working models, although an oedipal illusion plays a central role in both. The presentation is based on the premise that psychic space exists and that the shape of the psychic space of one individual affects by way of projection the shape of the psychic space of another. In the discussion the author traces Bion's concept of the working model and the abstractions which can be developed from it, as well as the use of Bion's theory in Britton's discovery of the effect that a patient's personal model of the oedipal situation can have on the mind of the analyst.

Depressive Disorder↗
PubMed1995

Trauma and termination.

The author suggests a particular reading of the thesis put forward by Freud in 'Analysis terminable and interminable' that an effective and more definitive conclusion may be expected in analyses of cases with traumatic aetiology. This reading shifts the emphasis from the patient's history to the possibility of its crystallising in focal nuclei emerging within the analytic relationship under the pressure of the termination. The revival of separation anxieties which cannot be worked through, and their crystallisation in precipitating traumatic events, may give rise to decisive psychic work allowing the analysis to be brought to a conclusion. Two case histories are presented to show how the end of the analysis assumes the form of a new trauma, which reactivates in the present, traumatic anxieties from the patient's own infantile history. In the first case a premature birth and in the second a miscarriage, originally experienced as isolated automatic events without time or history, are relived in the terminal phase as vicissitudes of the transference, so that new meaning can be assigned to them and they can be withdrawn from the somatic cycle of repetition. The powerful tendency to act out and the intense countertransference pressure on the analyst are discussed in the light of the specificities of this phase, which is crucial to the success of the analysis. This leads to a re-examination, in the concluding notes, of some theoretical questions inherent in the problem of the termination and, in particular, to a discussion of the ambiguous concept of a natural ending.

Adult↗
PubMed1995

Eating disorders, addictions, and unconscious fantasy.

Using concepts from object relations theory, the author extends the theories of eating disorders advanced by Freud and Bruch. Ogden's sensation-based autistic-contiguous position, Tustin's related concepts of autistic shapes and objects, and Fairbairn's theory of object relations are related to the addictive nature of eating disorders. A clinical illustration demonstrates how these recent theoretical concepts can help explain the unique qualities of the transference and countertransference that develop when working with eating disorder patients.

Adult↗
PubMed1994

Addictive sexual behavior.

Case material is presented from two patients suffering from addictive sexual behavior. The term addiction is used because of the intense, driven quality of the behavior and because of its mood-elevating effects. Psychodynamically, the patients' sexual acts helped to undo feelings of rejection at the hands of their mothers and to enhance feelings of lovability and of self-esteem. The behavior also helped to neutralize powerful feelings of rage toward the mother. In one patient, the acts also helped to ease inner turmoil related to an underlying attention deficit disorder. I speculate that some adults with addictive sexual behavior may have underlying attention deficit disorders. In both my patients, the sexual behaviors served the self-regulatory function of alleviating inner feelings of anhedonia and depression. When they decreased their sexual activities during the course of the treatment, they required adjunctive antidepressant medication. The underlying meaning of the medication and countertransference attitudes toward such patients are explored.

Adult↗
PubMedDate not supplied

The personal knowledge of family physicians for their patients.

The physician-patient relationship has always been of interest to family physicians. This paper describes a component of the physician-patient relationship in family medicine, originally identified by Michael Balint, that operates parallel to and in conjunction with the biopsychosocial model: the family physician's personal knowledge of patients. The physician's personal knowledge of patients is a personal information network about particular patients who the physician has cared for over a series of encounters spanning several years. It is a detailed portrait painted with layers of fact, intuition, and experience and is comprised of a mix of clinical art, science, psychodynamics, and ethics. It may be factual, intuitive, or contain components of countertransference; it differs from Kleinman's concept of explanatory model in that it belongs to the physician and is employed for the benefit of the patient. It is neither paternalistic nor static. The family physician's personal knowledge for his or her patients is a seldom-measured but common component of the process of making medical, ethical, and pragmatic patient care decisions. The presence of this knowledge and its skillful use may mark one difference between novice and seasoned clinicians. Qualitative methods are most appropriate for exploring the breadth and depth of this concept, while quantitative methods are useful for studying its implications for clinical decision making and quality of care in family practice.

Aged↗