The many faces of self-harm

This paper explores why open dialogue on the subject of erotic transference and countertransference is so difficult and attempts to offer an understanding of these phenomena which might enable counsellors to work more confidently with it. It also briefly examines the author's own research on therapists' thoughts and experiences of erotic transference, seeking to differentiate between inappropriate sexual contact between clients and therapists and the experience of erotic transference in the context of therapy as a reworking of the Oedipal relationship. Case examples illustrating the experience of countertransference within the therapeutic situation and how its presence can act as a help or a hindrance are offered. The paper concludes by examining the need to reflect on the erotic transference in therapeutic work and proposes its usefulness as a therapeutic tool. Suggestions about how the erotic transference can be managed to therapeutic effect are also explored.     

Working with Adopted Clients

When working with clients who have been adopted, therapists must be alert to the fact that lack of information about the birth mother and feelings of rejection can lead their patients to use defense mechanisms and create fantasies that will affect the transference and countertransference. Using examples from both agency and private practice, this article helps the clinician understand how adoption has affected their client's lives both in and out of the therapy room and suggests ways to modify treatment with a greater sensitivity to adoption issues.     

Countertransference as a complex tool for understanding the patient in psychotherapy

This paper shows some of the complexities of the analytic relationship and processes in psychotherapy by focusing on the concept of countertransference. The development of the related concept of transference is briefly outlined and the history of the concept of countertransference and its place in the practice of psychoanalysis is presented. A clinical example is provided to illustrate some of the complexity of the issues that arise when the countertransference is used as a tool to understand the patient. Attention is drawn to the importance of sustaining the countertransference response until the transference aspects and the patient's unconscious communications have been recognised and understood. It is only at this point that an interpretation meaningful to the patient can be made.     

Spontaneous Personality Synthesis in Group Therapy

Combined therapy is defined as concurrent dyadic and group therapy with the same therapist. This paper focuses on a neglected aspect of combined therapy: broaching and exploring this question with one's individual, patient. The author shows how raising this question: (1) alters the therapeutic field whether or not the patient joins; (2) can sharpen the therapist's understanding of the indications and contraindications for group membership; (3) offers untapped therapeutic approaches and opportunities to clarify issues in the individual treatment; and (4) stirs up countertransference issues related to issues of profitability, the transference of the patient in individual treatment, and the transference of the group-as-a-whole. Several case examples are provided.     

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.     

A Farewell to Countertransference

The "discovery" of countertransference provided a much-needed corrective to the one-sided view of transference and a patient's pathology. Even if its usefulness in the development of psychoanalysis was indisputable, its days are numbered. When I present my clinical work at conferences, I am often asked questions about my countertransference. These questions contain numerous assumptions that are challenged in this paper. Treatment is discussed from a self psychological perspective to highlight the therapeutic value of enabling the patient to engage a selfobject transference. The concept of "projective identification" is also challenged. Systems theory, in which the therapeutic relationship is understood as a co-construction between therapist and patient, is proposed as a more effective model to deal with the issues formerly included under transference-countertransference.     

Medicating Patients in Psychoanalytic Therapy: Implications for Introjection,Transference, and Countertransference

If a patient comes for psychotherapy or psychoanalysis, why medicate him with psychotropic drugs? The answers to this question are explored and addressed from several points of view. The central hypothesis of this paper suggests that most of the reasons for medicating patients have to do with therapist's unresolved countertransference issues. Furthermore, medicating a patient may have deleterious effects on his introjected sense of self, and impacts the transference relationship in a significant way. The issues surrounding medication as adjunctive therapy are elucidated and clarified in terms of rationale, efficacy, and the impact on the psychotherapeutic relationship. Psychoanalytic solutions are offered and discussed.     

THE ANALYST'S WAY OF BEING: RECOGNIZING SEPARABLE SUBJECTIVITIES AND THE PENDULUM'S SWING

Whether the analyst finds the patient's emerging transference affectively tolerable or intolerable plays an important role in the analytic couple's negotiation of the configuration that the transference‐countertransference relationship ultimately assumes. If the analyst is deeply repelled by transference‐related roles to which he is assigned, patient‐ascribed attributions, or projection‐drenched interactions, he may react in violent protest, engaging in enactments that say more about his separable subjectivity than about the intersubjective situation. While there has been a recent trend to view enactments as a crucial aspect of psychoanalytic technique, this trend risks overlooking the way in which the analyst's way of being comes into play in the treatment.     

Real relationship,working alliance,transference/countertransference and outcome in time-limited counseling and psychotherapy

Six client/therapist dyads (three therapists each working with two clients) were studied to determine how the real relationship unfolds over the course of time-limited treatment and how this unfolding relates to the development of the client/therapist working alliance, client transference, and therapist countertransference. We also examined how these indices of the relationship fluctuate as a function of treatment outcome. Results indicate that in general for all six dyads, therapists’ and clients’ ratings of the real relationship and working alliance were strong throughout treatment. However, patterns of real relationship and working alliance over the course of treatment varied between dyads categorized as more vs. less successful. Therapists’ countertransference was low, as was client transference, but differences in ratings were evident when the dyads were classified by outcome.     

Broaching and exploring the question of combined group and individual therapy

Combined therapy is defined as concurrent dyadic and group therapy with the same therapist. This paper focuses on a neglected aspect of combined therapy: broaching and exploring this question with one's individual patient. The author shows how raising this question: (1) alters the therapeutic field whether or not the patient joins; (2) can sharpen the therapist's understanding of the indications and contraindications for group membership; (3) offers untapped therapeutic approaches and opportunities to classify issues in the individual treatment; and (4) stirs up countertransference issues related to issues of profitability, the transference of the patient in individual treatment, and the transference of the group-as-a-whole. Several case examples are provided.     

Tom Thumb in hospital: The fairy tale workshop in a paediatric oncology and haematology ward

Abstract

Definitions of and attitudes towards countertransference have changed throughout the twentieth century. From being seen as a contaminant in the analytical process, countertransference has come to be seen by many therapists as a potentially useful source of information about a client and his or her problems. There are dangers as well as benefits associated with analysis and utilization of countertransference. This article reviews these issues and proposes some guidelines that therapists may find useful when contemplating their countertransference reactions to clients, and when considering how best to utilize these.     

The countertransference impact of autistic defence in an otherwise neurotic patient

This paper investigates the question of why, in the psychoanalytic psychotherapy of a patient with encapsulated autistic pathology, the steady maintenance of a therapeutically neutral stance can be especially difficult. Transference and countertransference vicissitudes are examined. The author notices that the patient's intolerance of ‘opposites’ (cf. Tustin, 1986), combined with extreme antipathy to having that intolerance noticed, can elicit corresponding, and potentially destabilizing, countertransference reactions. These reactions comprise an unstable tension between co‐existing pressures towards fusion with, or expulsion of, the patient, their co‐existence under further pressure to remain unnoticed. Until perceived, this state of affairs risks collusion with the pressure either to merge with or to expel the patient, and compromises the capacity to notice the detail of the transference process and even to notice co‐existent positive and negative transference images. Detailed clinical illustration is given, including a session where it was difficult to notice the patient's experience of a couple as a combined object. The author finds these observations of bipolar countertransference tensions illuminated by Green's concepts of positive and negative narcissism and of the disobjectalizing function, and specifically accounted for by Ribas's theory of autism as radical drive defusion.     

The therapist's pregnancy: Evocative intrusion

This paper is concerned with addressing the complex impact of the therapist's pregnancy on the analytic treatment process. The pregnancy is seen as intensifying the transference and countertransference material so that the therapeutic work becomes more strenuous as well as more fluid, with the potential for significant therapeutic change. The paper is divided into two parts. The first section attempts to conceptualise the meaning of the experience for the therapist and patient within the framework of psychoanalytic theory. Problems of technique and management resulting from the pregnancy are examined. One of the issues considered is the manner and timing of the patient's recognition of the pregnancy. The second section of the paper contains extensive clinical material illustrating the enriched transference and countertransference processes, and the access these allow to psychotic pockets of the personality, hitherto largely unavailable for exploration.     

Adolescents with learning disabilities: Psychic structures that are not conducive to learning

In this paper, I attempt to make links between theoretical concepts derived from the work of Bion (in particular, the 'ego-destructive super-ego', and the function he termed '-K' in thinking disorders) and the nature of the transference relationship that became evident in my clinical work with some adolescents with learning disabilities. I use three clinical examples to illustrate these ideas and suggest that learning can be facilitated for this patient group by addressing difficulties which arise in the therapist's countertransference related to the theoretical concepts cited above.     

A Pilot Study of a Method for Teaching Clinical Psychology Trainees to Conceptualise and Manage Countertransference

There is evidence that therapists' countertransference responses can affect the therapeutic relationship. There is also evidence that trainee therapists can experience difficulty understanding and managing countertransference. This evidence suggests the need for greater focus on countertransference in the training of professionals, such as psychologists, for whom therapy is a core activity. However, little is currently known about the best way of providing such training or the impact of such training on recipients. This pilot study examined clinical psychology trainees' responses to a teaching and learning method for conceptualising and managing countertransference. The method was designed to be accessible to a range of psychology trainees including those in cognitive behavioural therapy programmes. This article outlines the method and its pilot evaluation. An anonymous online questionnaire was completed by 55 trainees pre‐intervention and 40 post‐intervention. Qualitative methods were used to examine changes in trainees' analyses of countertransference pre‐ and post‐intervention, and their reports of understanding and managing countertransference. Trainees also rated the intervention. The majority of participants who completed the post‐intervention questionnaire reported that training increased awareness of or the ability to conceptualise countertransference. They reported strategies for managing countertransference, although they were less confident in this area.     

Countertransference evolution in theory and practice

A framework is suggested for conceptualizing countertransference, based on expansion of the concept emerging subsequent to Freud's original view of the phenomenon: from Ucs to Cs, from reactions to transference to all reactions, from the analyst's neurosis to the analyst's functioning, from self-analysis to self-scrutiny, from obstacle to contribution. Particular attention is called to the advantages of maintaining the distinction between the patient's transference and the analyst's countertransference; the importance for successful psychoanalytic work of being aware of the subtleties of countertransference in work with neurotic patients, especially in contrast to the blatant countertransference experiences more disturbed patients thrust upon the analyst; the need for further investigation of the relations between the analyst's empathy, regression, and countertransference; the lack of understanding of and information about the homosexual countertransference, based on insufficient knowledge of the mechanisms of resistance to self-analysis, among other reasons; and the need for more reliable information about the limits of and indications for using countertransference responses in particular kinds of clinical situations, whether for informing the patient as to the analyst's responses to him, for informing the analyst in the interpretive process, or in formulating reconstructions. A clinical example provides an illustration of the complexity of countertransference-transference interaction and of the impact of countertransference on the transference.     

The Barker: A Synchronistic Event in Analysis

The author uses a synchronistic event that occurred in a session with a patient to examine both the personal and archetypal symbolism of the transference/countertransference relationship. The archetypal images of the trickster and the dog are important in understanding the meaning of the event, and the author draws from these amplifications an understanding of how countertransference elements temporarily intruded upon the relationship. On the basis of the symbolism of the synchronistic occurrence, the author then discusses the rectification of these countertransference interventions and the results of such rectification with the patient.     

Early trauma and affect: the importance of the body for the development of the capacity to symbolize

In this paper I aim to outline the importance of working clinically with affect when treating severely traumatized patients who have a limited capacity to symbolize. These patients, who suffer the loss of maternal care early in life, require the analyst to be closely attuned to the patient's distress through use of the countertransference and with significantly less attention paid to the transference. It is questionable whether we can speak of transference when there is limited capacity to form internal representations. The analyst's relationship with the patient is not necessarily used to make interpretations but, instead, the analyst's reverie functions therapeutically to develop awareness and containment of affect, first in the analyst's mind and, later, in the patient's, so that, in time, a relationship between the patient's mind and the body, as the first object, is made. In contrast to general object‐relations theories, in which the first object is considered to be the breast or the mother, Ferrari (2004) proposes that the body is the first object in the emerging mind. Once a relationship between mind and body is established, symbolization becomes possible following the formation of internal representations of affective states in the mind, where previously there were few. Using Ferrari's body‐mind model, two clinical case vignettes underline the need to use the countertransference with patients who suffered chronic developmental trauma in early childhood.     

The working alliance and the transference/countertransference relationship: Their manifestation with racial/ethnic and sexual orientation minority clients and therapists

Theoretical propositions are offered about the interrelations of three key concepts in psychotherapy: specifically, the working alliance, on the one hand, and both transference and countertransference, on the other. The role these concepts play, including the interactions between them, is extended to the areas of race/ethnicity and sexual orientation. We examine working alliance, transference, and countertransference considerations for therapy dyads in which at least one of the participants is a member of a racial/ethnic or sexual orientation minority group. Our hope is that this theoretical examination will generate further research and theory development on working alliance, transference, and countertransference where cultural factors such as race/ethnicity and sexual orientation are implicated in the therapeutic relationship.     

When transference isn't transference: Iatrogenesis of multiple role relations between practicing therapists

Charismatic, grandiose and authoritarian senior therapists often develop complicated relationships not only with practicing therapists who are their colleagues, but also their friends, supervisees, as well as patients. The patient/therapist in a multiple role relationship with such a senior person may be extremely vulnerable and very unaware of the true nature of the problem Under certain conditions, some of these patient/therapists have suffered ego dysfunction and decompensation which appeared to be iatrogenic in origin rather than due to the patient's transference resistance. The implications of these issues for the field of psychotherapy, and underlying dynamics in vulnerable patient/therapist's, and in grandiose, narcissistic group leaders, are highlighted, along with ways of identifying the intrapsychic, interpersonal, and institutional roots of this problem An earlier draft of this paper was presented at the 1990 Meeting of the American Group Psychotherapy Association in Boston.