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PubMed1996

Autistic barriers in the psychoanalysis of borderline adults.

The authors discuss Frances Tustin's work on childhood autism in order to clarify the nature and protective function of autistic barriers in adult patients who present challenging resistances in treatment. Tustin's thesis is that childhood autism constitutes a massive formation of avoidance reactions that develop in infancy to ward off traumatic awareness of bodily separateness. She describes two forms of childhood pathology that may develop: the encapsulated child who defends against all 'not me' experience by means of self-generated bodily sensations that augment the illusion of complete bodily continuity with the mother; and the entangled child who generates a protective illusion of being enfolded inside the body of the mother to minimise the experience of separateness. The transference resistances of borderline adults can be categorised according to Tustin's typology of encapsulation and entanglement. Clinical material is presented from the analyses of two borderline patients, one encapsulated and the other entangled. Despite seemingly different transference manifestations, both belong to the category of autistic barriers inasmuch as they ward off awareness of separation-induced injury to the primal self. The countertransference difficulties that the analyst encounters with patients who employ autistic barriers are discussed and treatment issues are reviewed.

Autistic Disorder↗
PubMed1996

Studies on hysteria one hundred years on: a century of psychoanalysis.

In this paper the author shows how 'Studies on Hysteria' ushered in a new century of psychiatry. While hysteria as a clinical entity remains as difficult as ever to define, the entire theoretical edifice of psychoanalysis rests upon it, as it allowed the discovery of the laws of conscious and unconscious thought and fantasy and thereby made it possible to explain symptoms and dreams. The author points out that many of the basic concepts of psychoanalysis are already to be found in the Studies and that, although some important ideas were thereafter forgotten, these have now come to be regarded as essential again. The notions of splitting and dissociation featured prominently in that seminal work and have now been reintegrated into mainstream theory. Present-day psychoanalysis is considered to have returned to its roots as embodied in the Studies, much less emphasis now being laid on the later concepts of drives, phases and libido theory. Female development and the woman's Oedipus complex are, in the author's view, as problematic as in Freud's day, perhaps because of his countertransference problems and neglect of the role of the mother, as exemplified in the Dora analysis. As the author shows, only the French analysts have remained consistently faithful to the concept of hysteria, whereas in other countries it no longer exists as a diagnosis. Yet the concept is stated to be important both historically and for clinical practice today.

Dreams↗
PubMed1997

The dental referral process. New insights.

Doctor-patient, doctor-doctor dental relationships are discussed. The dental referral process is a triad of patient, general practitioner and specialist and, in many ways, is dependent upon Freud's concept of transference-countertransference. The unconscious distortions of this process may affect the patient's treatment, as well as interpersonal and intraprofessional relationships.

Attitude↗
PubMed1997

Ethical aspects of competence for sexual relationships: a case of adult sibling incest.

A case of adult sibling incest serves as the occasion to review relevant literature and discuss issues related to competence to consent to sexual relations between adults. The case was presented at ethics rounds at the Massachusetts Mental Health Center (Boston, MA), and the resulting discussion is analyzed as to the decision making with which the treatment team is faced. The relationships among competence and competence assessment, autonomy, morality, and countertransference issues are also considered in this provocative case.

Adult↗
PubMed1997

When the analyst is ill: dimensions of self-disclosure.

This article examines questions related to the "inescapable," the "inadvertent," and the "deliberate" personal disclosures by an analyst. Technical and personal considerations that influence the analyst's decision to disclose, as well as the inherent responsibilities and potential clinical consequences involved in self-disclosure, are explored, with particular attention to transference-countertransference dynamics, therapeutic goals, and the negotiation of resistance. The author describes her clinical work during a period of prolonged illness, with case vignettes that illustrate how-self-disclosure may be regarded as both an occasional authentic requirement and a regular intrinsic component of clinical technique.

Breast Neoplasms↗
PubMed1997

Reverie and interpretation.

The analyst's reverie experience constitutes an indispensable avenue to the understanding and interpretation of the transference-countertransference and yet is perhaps the dimension of the analyst's experience that feels least worthy of scrutiny. Reverie takes the most mundane, personal, and private of shapes, often involving the minutiae of everyday life. Although the analyst's reveries are personal psychological events, I view them as unconscious intersubjective constructions generated by analyst and analysand. Three analytic sessions are discussed to illustrate the ways in which reveries are experienced as well as the process by which the analyst attempts to make use of this aspect of his or her experience.

Humans↗
PubMed1997

On an ethic of psychoanalytic technique.

The puristic aspect of the classical triad of technique--abstinence, anonymity, and neutrality--is evaluated vis-à-vis the influence of the patient's and the analyst's value systems on the psychoanalytic transaction. In the last decade an increasingly different valuation of affects, regression, and enactment has changed the meaning of this technical triad. Re-evaluation of enactment in the countertransference has been particularly striking in calling for a re-evaluation of our ethic of technique, resulting in the construction of seven other qualities to be added to the classical technical triad.

Ethics, Professional↗
PubMed1997

Reflections on some dynamics of eating disorders: 'no entry' defences and foreign bodies.

In the context of the treatment of eating disorders, the author describes a specific failure in the container/contained relationship (Bion, 1962) that goes beyond the experience of having projections rejected. She addresses the predicament of those patients who have not only lacked containment, but also perceived themselves as receptacles of unmetabolised phantasies and experiences projected into them by their parents. The author briefly refers to those patients who succeed in protecting themselves from this predicament by developing a 'no entry system of defences' that often includes anorexia. The main focus of the clinical exploration in this paper is the predicament of 'porous' patients, those who remain open to parental projections. The author suggests that in such cases the introjection of an object performing a function opposite to organising 'alpha function' can be hypothesised. She suggests the term 'omega function' to describe a disorganising, disrupting agent in the patient's internal world. The author makes reference to the type of countertransference experienced by the clinician working with the disorganised 'porous' patients, which is different from the type experienced in the treatment of patients prone to envious attacks and, in particular, to attacks on linking.

Adolescent↗
PubMed1997

Hitchcock's "Vertigo": the collapse of a rescue fantasy.

The author presents an interpretation of Hitchcock's 'Vertigo', focusing on the way in which its protagonist's drama resonates with the analyst's struggle with deep unconscious identifications, with the impossibility of maintaining detached objectivity or guaranteeing one's role as a reparative good object and with the dangers of grandiosity, omniscience and illusory control. The protagonist's 'countertransference love' crystallises around a rescue fantasy in which he is Orpheus striving to bring Eurydice back from Hades, or a Knight determined to behead an obscure Dragon endangering Beauty. Initially these key roles are sharply differentiated, through splitting and disavowal, which deprive the participants of their conflictual three-dimensionality. Eventually, however, the valiant Knight turns out to be as helpless and lonely as his Beauty, and in the final scene as ruthless and lethal as the Dragon. This interpretation is compared to numerous other views of the film offered in the literature. The survey and comparison of the various views leads to fundamental issues in the psychoanalytic study of art. Interpretations can be seen as unavoidably coloured by the (counter)transference of viewers. It is suggested that a film has no hidden true meaning, and a new individual significance emerges in the transitional space opened up by each viewer's encounter with the emotional universe of the film. A defensive emphasis on the pathology of artists and their work may alienate us from art, and blind us to ways in which we could learn from it personally and professionally.

Drama↗
PubMed1997

[Interpersonal aspects of suicidal psychodynamics].

Suicidal behaviour always occurs in the context of interpersonal relationships, making them highly emotional. This also applies to the therapeutic relation, heavily influenced by transferencies and projections of the patient. Suicidal behaviour elicits anxieties and aggressive feelings, and is, therefore, especially prone to facilitate negative countertransference reactions. If the therapist loses control over the therapeutic process, antitherapeutic acting out may easily occur. Constant self-monitoring in the sense of a continuous conscious reflexion of all ongoing processes and, if necessary, consultation with a colleague, are the best means to prevent uncontrolled counter-transference reactions.

Aggression↗
PubMedDate not supplied

[Psychopathology of violent behavior in mental disorders].

The frequency of violent behaviour in mental hospitals has been increasing in recent years. A number of factors may be responsible. Violent and dangerous patients are sent to hospitals, quite often against their will. This may lead to conflicts and assaults against the staff members. There are many factors, both in present situation and in biography, conductive to violent behaviour: unfavourable experiences in childhood (neglect, cruelty, sexual exploitation), psychopathic structure of premorbid personality, frustrations, and eventually deformations of world perception caused by psychotic symptoms. Various mental disorders may lead to the violent behaviour, but it is most frequently observed in exacerbation of paranoid schizophrenia, in young males, particularly in cases with systemized delusions, emotional turmoil and anger. Introduction of a person (nurse, physician, family member, other patient) into psychotic world may also lead to the attack. In particular cases it is difficult to foresee violent behaviour, but some indicators are known. There are very few investigations on the role of the staff in violent behaviour of patients. The danger may be brought by criticism, refusal and rejection, compulsory drug administration, undue limitations of the patient's liberty, or the opposite--no reaction to violations of institutional regulations. Psychopathology of the staff may also encourage the violent behaviour: inability to solve the transference and countertransference, reaction formation and denial are the most important. Fear exaggerates the feeling of danger and induces the staff members to avoid the patient, diminishing the possibility of influence and control of the patient's disturbed behaviour. Recurrent violent behaviour may be connected with brain pathology, so the modern diagnostic procedures may be indicated in such cases.

Brain Diseases↗
PubMed1976

Alan Strange as an adolescent: a discussion of Peter Shaffer's Equus.

Psychoanalytic knowledge of adolescence helps us to understand the protagonists of Peter Shaffer's play Equus. Alan Strang, the seventeen-year-old who maimed six horses, had undergone a retreat from oedipal wishes to narcissism typical of teenagers. His fragile attempts at achieving a sound sense of identity are undermined when his seeking of a noninestuous object produces panic and impotence. Dr. Dysart, the psychiatrist who envies his patient's passion, and fears hurting him through treatment, displays in an exaggerated way countertransferences often seen in therapists of adolescents. In addition, his doubts have some foundation in that the treatment he employs, catharsis, can encourage primitive defenses and the outpouring of uncontrolled, unneutralized drive derivatives. This is more likely to prevent adaptive creativity than the cure the doctor dreads. Finally, some technical problems in dealing with sublimations in psychoanalysis (which is not Dr. Dysart's form of treatment) are discussed.

Adolescent↗
PubMed1998

[Aggression and the psychic self].

In this paper we explore the idea of aggression as a defence against threats to the psychological self. This aspect of the self allows reflection about people in psychological terms and develops, in the first three years of life, through appreciation of mental states in the other. When the object is unpredictable or hostile, recognition of this is painful to the child, and his reflective function will not be adequately established. The defences of aggression or avoidance will be invoked very frequently. In time, aggression may become an organising influence in the construction of the self; pathological destructiveness then takes the place of emotional relatedness and concern for the other. Psychoanalytic treatment no longer works primarily by addressing conflict. Instead, particularly through interpretations of transference and countertransference, the analyst recreates an intersubjective process which enhances the patient's reflective self, this time in the safety of a benign relationship.

Adolescent↗
PubMed1998

Autism as the defusion of drives.

The author's metapsychological view of the dismantling and adhesive identification typical of infantile autism is that these phenomena result from the fate of the death drive and the libido in a situation of thoroughgoing defusion of the drives. He notes that Freud's original idea of the defused death drive was taken up by Ferenczi and then by Klein, who applied it to the situation at the very beginning of life. A clinical illustration is given and the author observes that this view has therapeutic consequences that are also relevant to the work of an institution and to the therapists' countertransference, in terms of the value of sadism and masochism in helping to fuse the drives. Fusion of the drives is presented as an important element of Bion's alpha or container function. This conception also tends to modify the therapist's attitude to the parents of autistic children. In the author's view, the fate of the libidinal component in autism has tended to be disregarded, but accounts for the phenomena of adhesiveness and auto-sensuality; the latter should in his opinion rather be called dismantled erotism, to emphasise the absence of the unifying function of forms of auto-erotism in integration of the self. The author stresses the lack of projection in autistic pathology and discusses its possible reasons.

Attitude to Death↗
PubMed1998

The enigmatic dimension of sexual experience: the "otherness" of sexuality and primal seduction.

Sexual experience has an "otherness" about it that distinguishes it from daily, habitual modes of experiencing and relating. This paper attempts to use Freud's and Laplanche's theories of primal seduction by the mother, who sends an "enigmatic signifier" or message of her sexuality to the child whom she nurtures. A tension arc is created between bodily sensations and the enigmatic other carrying over into adult life and constituting a bedrock for the sense of enigma and unfathomableness and the sense of the profound revelation that sometimes accompanies sexual experience. The author articulates links with transference and countertransference forms and offers new possibilities of understanding some clinical phenomena.

Adult↗