Transference,triangles and trajectories

In this article the author addresses the issue of the need to lessen the likelihood of a regressive transference neurosis in short-term therapy. He examines the role that active interpretation of the transference can have in shaping the transference so that it remains at the level of the transference that is ubiquitous. He explores the relationship between such an active interpretative approach and the need for the therapist to be empathic and sensitive to the patient and to allow space for a patient's independent discoveries. The author describes the role of the Central Therapeutic Focus, as a constellation of the Triangles of Insight, in guiding the therapist to select those manifestations of the transference to interpret, and in enabling the therapist to retain a stance that is sensitive and empathic. The Central Therapeutic Focus is contrasted with the concept of the Central Issue, and with the latter's more specific attention to the contribution that it makes to the therapist's communication of their empathic understanding of the patient's difficulties. The nature of the relationship between the therapist and the patient in short-term therapy is explored further and the connections between companionable interaction, ego-relatedness and the matrix of the transference are outlined. The author proceeds to consider the nature of the process of working through in short-term therapy and of the need to attend to the patient's external world as the place in which this can occur. The contribution of the Central Therapeutic Focus in shaping the trajectory through which the patient and therapist attend to the external world is examined. This in turn is linked to the identification of a patient's ordinary solution to their problem as a means of resolving their Dilemma. The article concludes with a case example that illustrates these themes.     

Fire at the theatre: (Un)reality of/in the transference and interpretation1

Only in Bion's extended idea of ‘waking dream thought’ is the oneiric paradigm of the cure (already an obvious Freudian principle) completely applicable. The author's basic hypothesis is that, by adopting this paradigm thoroughly, one can combine the radical antirealism which is expressed in the postulate by which all the patient's communications are transference‐connected (here meaning ‘false connection’‐i.e. as projection/displacement of elements of the patient's inner psychic world) with the ‘reality’ of the transference, that is to say with the conviction that the facts of the analysis are co‐determined by the patient‐analyst dyad and actually rooted in how they interact. The Freudian metaphor of the fi re at the theatre is reintroduced here to suggest the crisis of the therapist's internal setting and capacity for reverie, which occurs when the irreducible ambiguity of the transference is resolved defensively, either in the patient's external reality or in his unconscious fantasy constellation. The author gives three clinical examples. The fi rst shows some of the not necessarily negative effects of this temporary crisis. The other two vignettes show a way of listening to the traumatic events of the patient's life from a perspective (that of the ‘analytic fi eld’) which is thought to be potentially the most transformative and vital to the analytical relationship.     

‘The Ancient Cult of Madame’: when therapists trade curiosity for certainty

An experience in which the author followed his own objectives rather than the patient's, leading to a tragic end, is evoked as a frame for the presentation and discussion of a family treatment where the therapeutic process led by the therapist may have exceeded the needs and expectation of the family members. This is followed by a discussion about potential problems caused by a therapist's fascination for family stories, since its effects may be epistemologically discontinuous from, if not contradictory to, Cecchin's recommendation for ‘curiosity’ as a central dictum of the therapist's stance.     

Psychotherapeutic work with refugees: Understanding the therapist's countertransference

Abstract

Most therapists are chosen to work with refugees because they speak the language or come from the same cultural or racial background and/or have had experiences which resonate with those of the client. They are often people who can easily understand the clients' experiences, which creates interesting and potent therapeutic dynamics. They can offer a great deal of support to the person, but often with the high risk of over-identification. This paper is an attempt to examine from the therapist's perspective the complex dynamics involved in working with refugee clients. It is a collection of thoughts and feelings expressed in psychotherapeutic and supervisory work by different types of refugee mental health workers. It is an attempt to understand the therapeutic relationship further by focusing on the therapist's psychological response to the client. The paper will outline briefly some of the common themes reported by refugees, but the primary aim is to focus on the therapist's countertransference feelings. Countertransference in this context is defined as a personal psychological response, as well as consisting of socio-political components.     

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

That if real success is to attend the effort to bring a man to a definite position, one must first of all take pains to find him where he is and begin there. This is the secret of the art of helping others (Kierkegaard [] 1962, p.?27)

The aim of this study is to explore the importance, to the therapeutic process, of the relation between the patient's and the therapist's problem formulations and private theories of pathogenesis and cure. Four cases of young adults in psychoanalytic psychotherapy were compared, two with unequivocally positive and two with more ambiguous outcome at termination. The patients and therapists were interviewed about their private theories initially and at termination of therapy, and a qualitative comparison was made between the cases. In the two more successful cases the therapists had early in therapy perceived obstacles for the therapeutic work in the patients' ways of thinking, feeling, and relating, and made interpretative interventions focusing on these. This was not observed in the less successful cases. In the more successful cases the patient's and the therapist's private theories were more similar at termination than initially, whereas the opposite development was found in the less successful cases. One hypotheses generated is that the therapeutic process can be facilitated by a therapist listening to the patient's private theories, making interpretative interventions focusing on obstacles to the therapeutic work, including contradictions between their private theories, and monitoring the patient's reactions to these interventions.     

Psychoanalysis is a two‐way street

The paper discusses psychoanalysis as a mutual exchange between the analyst and analysand. A number of questions are raised: What was Ferenczi's and the early psychoanalysts' contribution to the interpersonal relational dynamics of psychoanalytic treatment? Why did countertransference become an indispensable tool in relationship‐based psychoanalysis? Why is the transference‐countertransference dynamic seen as a special dialogue between the analyst and analysand? What was Ferenczi's paradigm shift in the trauma theory? How did he combine the object relation approach with Freud's original trauma theory? The paper illustrates through some case study vignettes the intersubjective and intrapsychic dynamic in the process of traumatization. We can look at countertransference as an indicator of the patient's basic interpersonal experiences and traumas. Finally the paper discusses countertransference in the light of attachment theory, connecting the early initiatives of inter‐relational approaches in psychoanalysis with recent research.     

Problem-oriented sessions: Presentation of a method for therapeutic work within a narrow time frame

Abstract

A method of problem-orientation has been developed as a delimited psychotherapeutic procedure comprising four sessions with a psychotherapist. The distinguishing feature of this method is the distinct time frame, within which the therapist grasps the patient's current situation and difficulties. The sessions are disengaged from considerations about the need for further treatment. The therapist appeals to die reflective part of the patient and attempts to awaken their curiosity about themselves in order to explore inner associations concerning core problems. The four problem-oriented sessions are offered during the initial telephone contact to the person who wishes to gain a greater understanding of their own part in their difficulties and who is able, already in the introductory telephone conversation, to embark upon an exploratory dialogue about these problems. The sessions are strongly characterized by this short-term perspective; the intensity increases and attention is sharpened. The stance adopted by the therapist during die sessions is one of balancing a non-appraising, empathic and confirmatory listening aimed at making connections with reality and a faith in the patient's resources and capacity to maintain a sense of responsibility for their life; an approach which limits the patient's tendency to regress. Transference is not interpreted explicitly but is used by the therapist to understand the patient. Supervision is an important and essential component, whereby the therapist receives help in increasing understanding of that which is played out during the sessions and also of their own counter-transference. This understanding constitutes the foundation of the therapist's tentative formulations of that which is central in the patient's problems.     

Countertransference disclosure and the asymmetry/mutuality dilemma

No single issue illustrates more clearly the interpersonal therapist's struggle between asymmetry and mutuality than countertransference disclosure. On a theoretical plane, all versions of interpersonal psychoanalysis share a comfortable tolerance for a central dynamic tension between the mutual influence of the participants and the asymmetry inherent in a relationship that emphasizes understanding the motivations of only one participant. This same marriage of concepts has, however, been a source of considerable confusion within the area of technique. The practitioner is charged with the technical implementation of the theory and must define the line between asymmetry and mutuality in everyday interactions with patients. Difficulty tolerating the ambiguity caused by the tension between asymmetry and mutuality results in the understandable urge to seek a definitive and unwavering position on countertransference disclosure.

Dimensions of the therapist's struggle include complex decisions concerning the primary unit of study (patient or relationship), the sequence of exploring new and old object transference experience, the use of disclosure with or without concurrent understanding, an assessment of the patient's capacities to tolerate disclosure, and, lastly, the initiation and frequency of disclosure interventions. An integrative perspective on the tension between mutuality and asymmetry allows the dialectical relationship between these principles to reach a constantly evolving equilibrium unique to each patient based on the moment of clinical interaction.     

Book Reviews

Abstract

There are many brief, demanding, aborted cases that no one ever writes about. The typical psychoanalyst or psychoanalytic psychotherapist, however, has many outpatient cases that are shortlived, intense encounters with very disturbed patients. Rather than ignore these encounters as non-analytic or non-instructive, I think these cases add to our knowledge about the mind and its functions. In addition, it is unrealistic to think we can always help a very anxious and disturbed person to enter the treatment process with immediate success. It is more instructive to apply the analytic method and offer the patient what we can and have both analyst and patient learn as much as they can in the time they are able to stay together. Using case material, I show the Kleinian approach to working analytically with these difficult patients. Whether focusing on transference or extra-transference material, the analyst interprets the patient's internal phantasies and anxieties regarding the self and the self's important objects. This analytic stance tends to relieve the immediate anxiety and set the stage for potential self-reflection and the start of basic working-through processes.     

Seeing and Being Seen: Courage and the Therapist in Cross-Racial Treatment

ABSTRACT

Correction of the patient's distortion is often the focus of therapeutic treatment. However, the therapist's distortions, based upon pre-existing fears, which themselves are often rooted in greater societal issues and energized by the work with the patient (especially as they relate to issues of racial difference between the therapist and patient), can lead to clinical impasse. Just as an effective treatment relies upon the patient's opening up to correcting distortions, so too the therapist must be able to use transference response and become vulnerable to knowing and moving beyond his own fears and distortions.     

When actions speak louder than words: Verbal and nonverbal wrangling in the therapeutic arena commentary on paper by F. Diane Barth

Patients’ use of language in the analytic setting can undergo extreme and sometimes surprising fluctuations. Seemingly articulate and engaging patients retreat to the concrete in their use of words, disconnecting verbal expression from one's internal experience. Are these fluctuations indications of limitations in the patient's capacity to put experience into language, or are they indications of the emergence of otherwise unacknowledged aspects of self into the treatment arena? Shifts in the use of language (both patient's and therapist's) can be opportunities to question the work of the analysis. Whether one uses these moments to expand the boundaries of the analytic technique or to expand the boundaries of the analytic relationship—or both—is the question posed in this commentary.     

The Psychotherapeutic Utility of the Five-Factor Model of Personality: A Clinician's Experience

This article summarizes experience using the five-factor model of personality, operationalized by the NEO Personality Inventory (NEO-PI), to facilitate psychotherapy treatment with 119 private-practice, outpatient, psychotherapy patients and their family members over a period of 2 years. Trait theories such as the five-factor model implicitly challenge the premises of much clinical theory, yet they can be useful to clinicians, as they provide a detailed, accurate portrait of the client's needs, feelings, proximate motives, and interpersonal style. I suggest that: Neuroticism (N) influences the intensity and duration of the patient's distress, Extraversion (E) influences the patient's enthusiasm for treatment, Openness (O) influences the patient's reactions to the therapist's interventions, Agreeableness (A) influences the patient's reaction to the person of the therapist, and Conscientiousness (C) influences the patient's willingness to do the work of psychotherapy. Fundamental questions raised by the five-factor model about the nature of psychopathology and psychotherapy are discussed.     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.     

A Sense of Orders

This paper provides an introduction to some of the basic concepts of the provocative French psychoanalyst Jacques Lacan. It illustrates the ways in which these concepts color the therapist's understanding of the patient as the therapist's attention is guided by the patient's expressions of thought and feeling. The response of the therapist is motivated by the interface which develops between this understanding and theoretical underpinnings. Clinical vignettes illustrating Lacan's mirror stage and his three basic orders, the Real, the Imaginary, and the Symbolic punctuate the explanations of these concepts. The paper weaves observations on the signification of language with examples of clinical interpretations.     

Initiating psychoanalysis

This paper explores the coincidence of two substantial difficulties: where gross external interruptions to the psychotherapy (caused by the psychotherapist's miscarriage and subsequent pregnancy) paralleled circumstances of violence and abandonment in the patient's childhood and adulthood.

When two such difficulties coincide and are added to by time constraints, the question of what can be salvaged from the treatment arises. Two risks are discussed: that of withdrawing into a purely supportive, potentially collusive mode of treatment and, second, the risk of challenging the patient's denial (of damage to the therapist as well as evidence of any other damage) in a manically reparative, intrusive, way that is more to do with the therapist's wishes to avoid her guilt at letting the patient down.     

Self‐analysis and the development of an interpretation

In spite of the fact that Freud's self‐analysis was at the centre of so many of his discoveries, self‐analysis remains a complex, controversial and elusive exercise. While self‐analysis is often seen as emerging at the end of an analysis and then used as a criteria in assessing the suitability for termination, I try to attend to the patient's resistance to self‐analysis throughout an analysis. I take the view that the development of the patient's capacity for self‐analysis within the analytic session contributes to the patient's growth and their creative and independent thinking during the analysis, which prepares him or her for a fuller life after the formal analysis ends. The model I will present is based on an over lapping of the patient's and the analyst's self‐analysis, with recognition and use of the analyst's counter‐transference. My focus is on the analyst's self‐analysis that is in response to a particular crisis of not knowing, which results in feeling intellectually and emotionally stuck. This paper is not a case study, but a brief look at the process I went through to arrive at a particular interpretation with a particular patient during a particular session. I will concentrate on resistances in which both patient and analyst initially rely upon what is consciously known.     

The internal world of the juvenile sex offender

This paper explores the consequences of the therapist's two successive pregnancies on a female patient. The second pregnancy was felt to be particularly difficult and disturbing. One of the central reasons was that after the patient's birth, the mother had a disabled child, followed by a stillbirth and soon after that the father left to marry another woman. Using Freud's concept of deferred action I will argue that my second pregnancy revised these earlier traumatic experiences.

The patient seemed to have incorporated and identified with a damaged maternal object that at the time of the original trauma was left husbandless, depressed and suffering from panic attacks. Although the therapist's healthy pregnancies seemed to reassure temporarily, it was difficult for the patient to hold onto a view of a helpful and productive therapist, one separate from this damaged internal mother. This was particularly so during and after the second pregnancy, where there was a marked absence of an idea of a third object, a father or a husband, who could help the patient deal with this pregnancy, her only escape was to retreat and act out.

The acting out was in part identification with a fleeing father and in part a defence against the absence of such a third object, so that it was used as a way of avoiding claustrophobic feelings of being trapped with the damaged mother. Her feelings of triumph then produced much guilt, and impeded reparation.

Another important issue that two successive pregnancies bring, are feelings of guilt in the therapist for exposing the patient to two major disruptions. In this patient's case it exacerbated the internal reality of a damaged maternal figure.