The Atonement of the Alleged Perpetrator's Daughter: Understanding of Model Scenes and Space Attachment in Analytical Dance Therapy

In this rich paper the analysand Annabelle is sent by her analyst to the dance therapist who reports in great detail how Annabelle manages to throw off and—to a certain extent—integrate not only her own life-long misunderstanding but also those of her parents. The reason for Annabelle's referral was straightforward: the analysis had ground to a halt. Words no longer reached her. The reader is reminded of the emotive-relational-motor clusters described in Chazan's and Shahar-Levy's papers. Body image distortions and space misperceptions curtailed this patient's ability to function. When she began to bring her distress to her analytic dance therapy sessions, she could not associate verbally but made use of props her therapist had in store. As she slowly progressed toward true symbolization and expression, her therapist found herself embroiled countertransferentially. The patient's long-suffering mother was remembered as someone who would, or could, only give partial information about the family's history. The father had been a Nazi and was now blamed for all the suffering the family had lo endure. This fact resonated both with Annabelle's analyst and the dance therapist who managed to take a long look at their own family's records during that troubled time.     

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.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.     

Addictive states of mind

This paper explores the meaning of the pregnancy of the therapist as a challenge to the maintenance of the setting for therapy. The patient I shall describe was born ‘black’ in a ‘white’ family and was thus a challenge to her father's sense of paternity and her parents as a couple. She was the visual evidence of an infidelity. The problem had been denied in various ways, going as far as the attempt to deny her very existence. The therapist's pregnancy signified a betrayal of the ideal of a stable setting which was compounded by an earlier absence through illness. This ‘breaking of rules or promises' was then the setting for a re-working of the patient's story.

Setting, it is argued, can helpfully be seen as the mental space created by the partnership within the therapist between maternal and paternal relating to the ‘baby’ of the therapy. This enables a sense of negotiation and relationship in the creation of setting, which can include disruptions and other babies. At the same time the therapy had to work with a fundamental issue of illegitimacy or lack of belonging and the therapist's response to this. The ‘rules' of setting are a means to ensure a place to belong or attach to, but this work emphasized ‘setting’ and belonging as issues of relationship supported and enabled by our rules of engagement, but not reducible to them.     

‘Characters’ in psychoanalytic and interpersonal therapy: A comparison

In this paper the author considers how the therapist might listen to the characters talked about by his or her patients. In psychoanalytic therapy the emphasis is on listening to the patient's characters as though they are located in psychic reality and as representatives of the transference relationship, whereas in interpersonal therapy (IPT) the patient's characters are taken as inhabiting the realm of external reality. It is argued that clinical thinking in IPT would be enhanced by taking more account of psychic reality, which will make clearer the quality of external reality in which the patient's characters are located. It is also argued that both therapies share an interest in enabling the patient to find characters which can serve as holograms of previously unexpressed affective experience.     

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.     

Tactics and empathy: Defences against projective identification

In this paper the author argues that interpretations made when the analyst has not done the emotional work of recognising and bearing what kind of object she has become in the patient's psychic reality will be experienced as empty tactics – even lies – rather than interpretations of integrity. However, interpreting from a position of bearing the truth of the patient's perception will be technically difficult and indicate turmoil as the analyst struggles to take in the patient's view of her. If the analyst avoids integrating her own picture of herself with the patient's picture (despite giving voice to the patient's picture) the split inside the analyst will be felt and intensify the patient's need to split. Vignettes demonstrate how the analyst, believing she is trying to understand, may become a projective‐identification‐refusing object and the issue of the analyst's disclosure of her countertransference is examined. Ultimately, the author argues, a capacity to receive and bear projective identification requires empathy with both patient and analyst‐as‐patient's object, engaged in a process about which both are ambivalent.     

Parallel Process

Summary

This article addresses parallel processes between the author (a therapist) and client when each are mourning the death of their mother. Similarities and differences in their experience and reaction are discussed. The effect of the client's unexpressed grief from her early childhood loss is explored. The author also examines her own, more recent loss and develops a new perspective on its consequences. Tools are presented to help the client work on her grief, especially when the issue is “motherloss.” The impact of the therapeutic process on the client and author is delineated, and the client's reactions to ending her therapy are analyzed.     

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.     

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.     

Countertransference and containment in a patient with a psychotic mother

The importance of countertransference reactions in the treatment of a borderline patient with a psychotic suicidal mother is discussed. In such a case containment can be seriously disrupted by the violence of the patient's projections into the therapist. Where a psychotic internal object has been brought for treatment it is particularly important that the therapist be able to identify not only with the sane and mad parts of the patient but with the destructiveness and cruelty of the patient and her primary object. The difficulties of tolerating these relentless projections of madness and despair are increased by the multiple and confusing aims of the patient's excessive use of projective identification. The invasive and hostile aspects of this are often heavily disguised beneath idealization of the self and object as well as of madness itself. For the patient, attempts to interpret the idealization are moreover felt as an assault on the lost loved object, and the therapy then unconsciously becomes a persecutory experience for the patient. The therapist can thus be drawn into feeling the full force of the anger and hatred towards the real disappointing object and the sense of hopelessness about the reparative task. Although such feelings need to be tolerated, eventually some distance from the often-unpleasant fluctuations in the countertransference must develop if a useful degree of containment is to be achieved.     

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.     

The Powerless Therapist and the Helpless Borderline: Acceptance,Aloneness, and Dyadic Joining

The encounter between therapist and borderline patient brings with it a humbling experience of powerlessness. The therapist or helping agent must confront her or his own feelings of inability to change anything in the patient's mental or material life. With this comes a corresponding reality that the locus of therapeutic action remains very circumscribed indeed. Many therapists, particularly new ones to the field, may feel overwhelmed by anxiety, grief, guilt, and fear, tempting them to jump precipitously into interpretations or thinly veiled advice-giving—or, alternatively, to deflect emotion with hollow “empathic” mirroring. By actively getting in touch with and using his or her experience of powerlessness, however, the therapist can find a way forward that relies on dyadic joining and a more useful conception of the therapist/patient system (whose dynamics, as we will see, are also increasingly clarified thanks to emergent neuroscience findings). Central aspects of this approach have been present since borderline first appeared in the literature, continuing through more recent contributions, notably those of Marsha Linehan and the Dialectical Behavior Therapy (DBT) school.     

Rechtliche Grundlagen der psychosomatischen Rehabilitation Auswirkungen auf die Psychotherapeut-Patient-Beziehung

The legal foundation of psychosomatic rehabilitation, which amounts to more than half of all inpatient psychotherapies performed in Germany, includes the duty of the patient to cooperate, the pre-condition that there is a chance for increasing or restoring patient’s ability to work, and the obligation for therapists, to perform a socio-medical rating of patient's ability to work as well as a judgement about his/her credibility concerning the asserted handicaps and disabilities. All this has an influence on the relationship between psychotherapist und patient and leads to problems in the treatment especially of those patients, who wish to retire. For the psychotherapist not only counter—transferences may be difficult to handle but also role conflicts resulting above all from the challenge being simultaneously psychotherapist and medical expert, who has to rate patient's ability for work and his credibility. To keep capacity of acting, the psychotherapist should reflect these issues and make them transparent for the patient. Sufficient supervision is very important. This will not only improve patient's, but also pension scheme's profit.     

I Working with dissociative dynamics and the longing for excess in binge eating disorders

In this paper the author describes her work with a woman who, in her mid 20s, sought analysis for her non‐vomiting binge eating disorder. The paper explores how two aspects of Jung's view of the psyche as healthily dissociable were used to think about the potential for change contained within the explosive, aggressive energies in this patient's bingeing. The resultant approach takes the patient's splitting defences, dissociations and self‐destructive behaviour as a point of access to her unconscious. Seen in this way, these behaviours contain the seeds of recovery and are the starting point for analysis rather than defences against it. The paper also brings a number of Jungian and post‐Jungian ideas into conversation with aspects of contemporary thinking about subjectivity, identity and the longing for excess developed by Leo Bersani and Judith Butler.     

Response to “Poison Cookies” Discussions

This is a response to the discussions of the case presented by this author. Responding to the discussions has allowed the author to pull together her own ideas about the case as well as about the work we do. The author sees Sheldon (Shelly) Bach's view of sadomasochism as a particular type of object relationship as informing her own point of view. Next comes a discussion centering on Steven (Steve) H. Knoblauch's emphasizing the importance of the internal symbolic world of the patient. The author makes the point that understanding the level of differentiation of the internal objects in the patient's representational world is important in thinking about the types and timing of interventions the analyst makes; for example, those which Mary-Joan Gerson describes in her comments. Finally, the author addresses Sue Grand's response, especially her emphasis on the importance of siblings in our patients’ histories and the resulting sibling transferences to the analyst.     

Marco Conci interviews Stefano Bolognini

Abstract

This paper suggests that the understanding of intersubjectivity, which refers to “the dynamic interplay between the analyst's and the patient's subjective experiences in the clinical situation”, is crucial for psychoanalytic work. The analyst's inner experiences, from the first moment that he or she thinks about or meets the patient, belong to an intersubjective situation. Not only are these experiences a valuable channel through which the inner experiences of the patient can be understood, but—as Theodore Jacobs puts it—they are often complementary to that which comes from the patient. The author tries to illustrate the above through the study of the analytic process in the psychoanalytic therapy of a severely disturbed patient. This therapy from its very early phase led to the reawakening of some of the analyst's old conflicts. The patient's difficulties in tolerating the limits of the analytic setting and using free association are discussed, as are his enactments. The analyst's close observation of the interaction between her and the patient, the permanent engagement with her countertransference, and the use of her inner experiences with the patient helped her to contain the enactments, defined the nature of her interventions, and contributed to the analytic process.     

Reply to Panel Follow-up Questions

When both therapist and client share a traumatic event, there are multiple levels of vulnerability to traumatization for the therapist. Our personal vulnerability is not only a backdrop for our clinical work but also an acknowledged fact in many therapeutic relationships, a situation that changes the frame of the work. In addition to clinical challenges, shared trauma increases a therapist's vulnerability to vicarious traumatization; VT is defined as the negative transformation of the therapist's inner experience as a result of his or her empathic engagement with and responsibility for a traumatized client. Emphasizing the importance of awareness, self-care, meaning, and community, the article summarizes important steps to anticipate, address, and transform the therapist's experience of vicarious traumatization.     

Discussion of Presentation by Joseph Newirth

Discussing Joseph Newirth's case from a modern Freudian perspective, I explore possible sources of the patient's degraded view of herself, her ambivalent feelings toward men, and her fears of sexuality. I also discuss the course of the treatment, noting that both the patient's progress and the core of her resistance centers on her complex relationship with her analyst. This has been the source of healing and of avoidance of her inner world of imagination and fantasy. I further suggest that active confrontation of the patient's defensive use of her relationship with her analyst would enhance the substantial gains that she has already made.     

Évaluation des enjeux narcissiques à partir du test de Rorschach au terme d’une psychothérapie

The goal of this study is to evaluate, using the Rorschach, the evolution of one patient's narcissistic investments after two years of psychoanalytically oriented psychotherapy. Both quantitative and qualitative measures of narcissism on the Rorschach were studied in depth in this test-retest study. Results indicate that quantitative measures of narcissism and egocentrism were decreased after two years of psychotherapy. The patient also presented doubt concerning her self-worth, as well as new perceptions of her vulnerabilities and her need for shoring up. Increased flexibility concerning narcissistic investments was evident, which weakened the patient's Ego and containing capacity; this facilitated work on depressive issues.