Self-analysis: a fool for a patient?

In this paper I first reviewed the scanty publications on the subject of self-analysis. Although it was recommended by Freud as early as 1910 for every analyst, self-analysis turns out to have many pitfalls and to be quite a complicated and controversial procedure. There is no agreement on the proper technique of self-analysis in the literature, nor is there any discussion of the determinants of the particular choice of technique of self-analysis that is employed, nor even of the reasons why some analysts do not engage in it at all. Using clinical data gathered from written material of many years of self-analysis following the termination of a successful training psychoanalysis, I have attempted to elucidate some of the problems posed by this procedure. These problems are in some ways similar to formal psychoanalysis, but are in some ways contingent on the fact that it is basically a different technique. It is a solitary occupation and therefore suffers from the dangers of disintegration into autism, narcissism, and obsessional rumination. There is no living presence of an analyst to serve either as a transference figure or to make interpretations and stimulate the production of material. The identification with the analyst's analyzing function is far from simple in self-analysis because of the complex nature of the various internalizations of the analyst that take place over years of a formal training analysis. Thus, Ticho (1967) is correct when she claimed that self-analysis is a skill that the analysand has to acquire by himself or herself. An important phase of the beginning of self-analysis involves the working through of the separation from the psychoanalyst and the re-evaluation of the analyst and the analytic process. This results in a heightened sense of independence and autonomy, increased cohesion of the self, and maturation--which is manifested by greater autonomous ego functioning, a more mature sense of identity, and continued transformations of narcissism which highly valuable goals, on the basis of the data I have presented, can be approached through the process of self-analysis. Above all this stands the most important goal of self-analysis, the understanding of one's countertransference reactions. This is especially important in the treatment of seriously disturbed patients who become disruptive, and thus get labeled borderline, often as a response to unconscious countertransference manifestations from the analyst which are then experienced in the self-object transference as failures in empathy.(ABSTRACT TRUNCATED AT 400 WORDS)     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

Countertransference, conflictual listening, and the analytic object relationship

Analytic listening is an ongoing conflictual process, containing all the components of conflict and shaped in every moment by both the patient's and the analyst's conflicts. The mutual responsiveness that develops between analyst and patient stems from a complex conflictual object relationship, fundamentally no different from any other object relationship, in which countertransference at all times simultaneously facilitates and interferes with the analytic work. Detailed clinical process is used to illustrate these and related phenomena, including the use of signal conflict, the benign negative countertransference, the function of countertransference structures, and the analyst's use of projection. The analyst's affects, thoughts, and actions trace the shifting nature of the patient's transference and resistance, and the level of the object relationship continuously being created between patient and analyst.     

Transference-countertransference

This paper concerns the dynamics of transference-countertransference as they reveal themselves in object relations and specifically in the psychoanalytic process. It is postulated that transference and countertransference cannot be viewed separately, that both analyst and patient exhibit transference-countertransference reactions, and that they are normal ingredients of the psychoanalytic process. Brief clinical illustrations are provided. Attention is called to special problems when the patient's defenses are primitive, and to the therapeutic value of the analyst's countertransference.     

The role of the patient's remembered history and unconscious past in the evolution of Betty Joseph's 'Here and now' clinical technique (1959-1989)

The author historicizes one aspect of Betty Joseph's ongoing technical contributions in terms of its originating London kleinian context. Early on she drew upon both the patient's remembered history and unconscious past, linking these experiences in past-to-present transference interpretations in order to effect psychic change. In evolving the technique of 'here and now' analysis, Joseph came to emphasize a communicative definition of projective and introjective identification as well as the significance of enactments while marginalizing the use of part-object anatomical interpretative language. She gradually set aside directly linking the patient's past with the present, compelled now by making direct contact with her patients. She now tracked how difficult patients acted in and responded to interpretations from moment to moment. The author maintains that the explicit and implicit conceptual work of Wilfred Bion as well as Joseph's continuous group workshop for analysts led to an increased understanding of the patient's projective impact on the analyst's countertransference responses, and thereby increased the analyst's capacity with 'difficult to treat' narcissistic spectrum patients described by her colleague, Herbert Rosenfeld. In recent work, while Joseph continues to elucidate what patients recall about their early past, she formats her understanding in terms of a direct analysis of the structure of the patient's projected internal object relations in the transference. The analyst works with the patient's communications and enactments, with a greater emphasis on a more 'inside-to-outside' understanding of transference in contrast to the earlier 'past-to-present' work associated with both Freud and Klein. This investigation concludes with one example of Betty Joseph's significant impact on contemporary kleinian technique by taking up some of Michael Feldman's work. Now the analyst listens to the 'past presented,' the patient's projected internal world, as well as tracks how the patient hears and subtly mishears interpretations for defensive, equilibrium-maintaining purposes, as the analyst attempts to effect psychic change by widening the ego's perceiving functions.     

Life-threatening illness in the analyst

The literature on practicing throughout a life-threatening illness is reviewed and important differences about attitudes toward self-disclosure are understood by noting a division between two perspectives on transference: "one-body" and "two-body" views. The analyst's use of self-disclosure is informed by the prominence given the interpretation of transference as against that given the patient's needs in the collaborative relatedness supporting the therapeutic alliance. Themes and illustrative clinical vignettes are presented from the author's own experience practicing during such an illness. Three phases of working during illness are delineated, each somewhat different regarding the analyst's state, and hence patients' needs and reactions. Recommendations are made regarding conditions that make it possible to work effectively during a life-threatening illness. The analyst needs help from his or her own analyst to make the clinically and sometimes ethically appropriate decisions about practice; while this is important in instances in which the analyst recovers, it is essential should the analyst become terminal and face more certain death.     

A case of sadomasochistic transference: the analyst's contributions to perverse enactments

A young woman who came for treatment of anxiety and depression is presented in a detailed case report. She developed an erotized transference that was predominantly sadomasochistic and included her intention to torture and castrate the analyst. The author demonstrates how the analyst's behavior, including countertransference contributions, assisted in shaping the vicissitudes of sadomasochistic transference paradigms. A collusion was established between patient and analyst in a manner that enabled the analytic dyad to work productively toward an eventual resolution of the patient's conflicts. The author discusses the case's complexities pertaining to enactments, while emphasizing the importance of carefully monitoring and addressing countertransference experiences that mold and shape such a collusion.     

The disregarded analyst and the transgressive process: discontinuity, countertransference, and the framing of the negative.

This paper describes the difficulty of working with patients who have adopted conflict solutions common to perversion. These analysands' rapid shifts from one discontinuous mental state to another draw the analyst into a regressive transference/countertransference engagement characterized by alternations of actualized self and object representations. The analyst's disengagement from this regressive interaction is crucial, but difficult. A detailed clinical example illustrates the process of disengagement as well as the transformation of this transference into a more traditionally consolidated one. A technical approach is suggested and questions of representation and symbolization are explored.     

Countertransference in defense enactments

A clinical term is introduced to capture a defense that develops with the patient's deepening but fleeting awareness of painful transference feelings. The analyst's attention to countertransference in such situations is central to the analysis of these defenses. An attempt is made to distinguish defense enactments from other types of defenses, and to differentiate the analyst's countertransference reaction to this type of defense from countertransference reactions that might appear similar. The reasons for this dynamic in the interpersonal space are explored, and a clinical example that describes this phenomenon in the analytic moment is given.     

Working in the countertransference

Ferenczi (1988) described the procedure of mutual analysis, in which the patient and analyst switch roles for part of the time in the analysis. This procedure allowed patients in stalled analyses to make progress and enabled the analyst to overcome certain countertransference blocks but was ultimately rejected for certain drawbacks. Working in the countertransference is a modification of mutual analysis that retains some of its benefits and eliminates some of its drawbacks. In such work, the psychoanalyst's personality and psychodynamics become the center stage of the manifest content of the session; the analyst avoids interpretations of the transference and, instead, elicits the patient's detailed understanding of the analyst's psychodynamics. The analyst does not, however, generally volunteer his free associations or facts about his own life. This process allows deep work with patients with a predominance of projective identification. Working in the countertransference may be preferred in cases of severe psychopathology to other procedures for its lessening of the frequency, severity, and persistence of transference psychoses. The procedure is also a useful supplement to transference analysis with neurotic patients, for whom it can break through blocks caused by anxiety‐laden issues or countertransference impediments.     

The unreachable object? Difficulties and paradoxes in the analytical relationship with borderline patients

The author investigates the main difficulties the analyst encounters in borderline patient analysis, focusing on the specific way in which such patients put the analyst's mental functioning to the test and highlighting the most salient elements of the transference-countertransference dynamic. The author picks out several of the paradoxes that characterize the analytical relationship with these patients, who are constantly seeking contact with the object, which is inevitably traumatic for them. On the basis of highly detailed clinical material, the author demonstrates how - no matter which theoretical-clinical model is adopted - a specific technical problem with these patients is how to manage their intense destructiveness. With these patients, countertransferential difficulties are inevitably predominant because of the looming threat of the destruction of the analytical relationship. Maintaining a balance between the recognition-legitimization of primary narcissistic mirroring needs and the recognition-control of narcissistic demands and attacks on the analytical link is as crucial as it is complex. The paper examines the most important therapeutic and anti-therapeutic factors, highlighting the importance of countertransference analysis and self-analysis as ways of accessing as yet unrepresented elements of the patient and analyst respectively. Particular attention is given to the role played by the analyst's subjectivity and to the enactment.     

Anti-Semitism in the clinical setting: transference and countertransference dimensions.

Despite the salient presence of Jews in the history of psychoanalysis, literature on the subject of anti-Semitism in the clinical setting is surprisingly sparse. This paper attempts to comprehend the reasons for the dearth of literature on this important topic. A clinical section then breaks the silence surrounding expressions of anti-Semitism in the consulting room. The major focus is on transference and countertransference reactions that arise with regard to anti-Semitism in the clinical setting. Since the first section is concerned with silence in the psychoanalytic community, its focus is primarily on countertransference issues that may hinder the analyst's understanding and use of anti-Semitic material. The second, clinical section focuses on the ways both transference and countertransference reactions combine and influence one another and how they may, when properly attended to, serve as catalytic tools for advancing therapeutic goals.     

The analyst's excitement in the analysis of perversion

The author believes that unconscious sexual excitement in the transference and countertransference is an especially problematic aspect of the analysis of perverse character pathology and that perverse sexual gratifi cation deserves a more prominent position in the clinical theory of analyzing perversion than that which has been assigned tacitly through analysts' routine focus on the defensive and destructive dynamics of perversion. He presents clinical material from the analysis of a perverse patient that illustrates the role of excitement in the transference perversion established in this analysis; and he asserts that gratifying perverse enactments occurring in the transference perversion can appear not only as conscious or unconscious excitement in the transference but also, at times most clearly, as the analyst's excitement. The author suggests that using a clinical theory that supports the analyst in understanding his excited responses as perverse countertransferences-i.e. evoked excitement complementary to the sexual component of a perverse transference-will assist him in locating and thinking about gratifying, perverse excitement in the transference where it is most usefully analyzed. Finally, he discusses some of the reasons why analysts might deny, suppress or otherwise avoid perverse countertransferences and in so doing contribute to sustaining perverse resistances.     

Induced emotional reactions and attitudes in the psychoanalyst as transference in actuality

The long hiatus between Freud's seminal paper on countertransference in 1910 and the contributions of the 1950s on totalistic countertransference is analyzed in terms of historical factors and others intrinsic to psychoanalysis. Induced reactions in the psychoanalyst as transference in actuality is differentiated from classical countertransference and the growing literature on totalistic countertransference, as well as from transferences involving the usual displacement and projective mechanisms. Several cases are discussed to indicate the wide range of psychopathology in which induced reactions occur and their value in reconstruction. The reasons for the confusing use of the concept, countertransference, for a variety of psychological processes in the analyst are cited, and a new model of five categories centering around modes of communication are posited: empathic transitory identifications, preconscious associations and imagery, induced reactions to transferences, induced reactions as transference in actuality, and classical countertransference. The relationship of induced reactions to classical countertransference is discussed, as well as implications of induced reactions as transference in actuality for internalization theory, and implicitly for the psychology of the self. Finally, some clinical issues in the use of induced reactions are eluciated.     

Talking about medication

With the increasing use of psychotropic medication concomitant with psychoanalysis, attention must be given to the challenges created by complaints of medication side effects. When confronted with these side effects, analysts may experience specific, uniquely actualized countertransference anxieties that can prompt the abandonment of transference analysis. Particular countertransference fantasies that arise in combined treatments are examined, as are the reasons for the analyst's suspension of curiosity and openness and its clinical consequences. In these situations, effective analysis requires the analyst to be "bilingual," to hold in mind both the analytic and the pharmacological model.     

Treatment of the older adult: the impact on the psychoanalyst

Work with the elderly challenges analysts in special ways. The author presents clinical material from her practice and from investigative interviews with nine treating analysts who report personal reactions and countertransferences to analytic work with twelve elderly patients. She concludes that the major challenges in work with the elderly come more from the analyst than from the patients. Issues arising from the analyst's unresolved feelings about aging, parents, loss, and death are revived in the treatment of the elderly in an especially intense form. In this paper many aspects of transference are considered, especially those relating to illness, loss, and the problems that flow from identifications of the older analyst with the patient. The affective reverberations in younger and older analysts with regard to the initiation of analytic treatment, the inevitability of moving in and out of real life crises, the sustaining of loss, and, particularly, the impending termination, are presented in the paper.     

Patient-therapist match: revelation or resistance?

Patient-therapist match is a relatively new yet frequently invoked concept within psychoanalysis. Despite Freud's appreciation of the influence of the analyst's past to his or her work within the analytic setting, psychoanalysts have historically held varied opinions about the degree to which the analyst's personality and conflicts affect the analytic process. As analysis was reconfigured as a two-person system, attention focused on the fit between patient and analyst. The literature on patient-therapist match is reviewed, and the conclusion reached that this intuitively appealing concept suffers from a lack of rigorous definition and operationalization. Many authors invoke match in ways that imply that it is real, static, external to the domain of analytic inquiry, and unaffected by analytic process. In its present form, the concept of patient-therapist match obstructs rather than facilitates analytic exploration and obscures rather than clarifies what happens between analyst and analysand in psychoanalysis. By suggesting that match exists as a reality outside the domain of transference and countertransference, analysts may overlook the importance of psychoanalytic technique in creating a sense of match. Analysts may attribute stalemated or limited analyses to a bad match, rather than tenaciously exploring the transference-countertransference configurations that remain at the heart of analytic work.     

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.