Counteridentification, comprehensive countertransference, and therapeutic action: toward resolving the intrapsychic-interactional dichotomy.

Two dichotomous trends in thinking about countertransference and therapeutic action can be delineated historically as well as in clinical practice: the intrapsychic and the interactional. The author proposes a new usage of the concepts of counteridentification and comprehensive countertransference to help transform these dichotomizing tendencies into more useful, integrative therapeutic action across the broad spectrum of psychoanalytic treatment for patients from the neurotic to the most severely disturbed.     

A MODEL FOR INTEGRATING ACTUAL NEUROTIC OR UNREPRESENTED STATES AND SYMBOLIZED ASPECTS OF INTRAPSYCHIC CONFLICT

In psychoanalytic theory, the importance of actual neuroses—considered to be devoid of psychic content—diminished as Freud and subsequent analysts focused on unconscious intrapsychic conflict. This paper explores the relationship between actual neurotic and unrepresented states, which are believed to be best addressed through attention to countertransference, intersubjectivity, and enactments rather than interpretation of intrapsychic conflict. Models suggesting how actual neurotic states and symbolized intrapsychic conflict may interact with each other and environmental stressors are described. Symbolizing actual neurotic states and establishing meaningful linkages between somatic/affective experiences and intrapsychic conflict are viewed as necessary for effective treatment of many disorders.     

The analyst's body as tuning fork: embodied resonance in countertransference

Abstract: This paper examines the phenomenon of embodied countertransference: where the analyst experiences a somatic reaction rather than the more common countertransference responses of thoughts, feelings, images, fantasies and dreams. Discussion of clinical material considers neurotic and syntonic aspects. The analogy is made of resonance with a tuning fork. Several questions are posed: Why does countertransference resonate in the bodies of some analysts but not all? Why do those analysts who are sensitive to this, experience it with some patients but not with others? And what are the conditions which are conducive to producing somatic responses? It proposes that somatic reactions are more likely to occur when a number of conditions come together: when working with patients exhibiting borderline, psychotic or severe narcissistic elements; where there has been early severe childhood trauma; and where there is fear of expressing strong emotions directly. In addition another theoretical factor is proposed, namely the typology of the analyst.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

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.     

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 PSYCHOANALYST OF THE FUTURE: WISE ENOUGH TO DARE TO BE MAD AT TIMES3

What sort of patients do we have in psychoanalysis now, at the beginning of the third millennium, and what sort will we have in the future? In the author's clinical experience, the patients who are currently seeking help from the psychoanalyst use primitive defence mechanisms alongside neurotic ones. Most of them do not explicitly request psychoanalytic treatment, but this does not mean that they would not want it if they knew what it was. She argues that is the psychoanalyst's task to identify the latent request behind the ‘non‐request’. To conduct a psychoanalysis with such patients, the psychoanalyst has to identify and interpret both primitive and neurotic psychic mechanisms; moreover, he has to use not only language that speaks to patients but also language that ‘touches’ them, because these patients are difficult to reach through verbal symbolism. This implies that the psychoanalyst must be attentive to the bodily manifestations and bodily phantasies accompanying his countertransference feelings. The author shows through clinical examples what she means by ‘language that can touch patients’. The psychoanalyst gradually builds up this language while, at the same time, daring to discover in himself his own mad aspects and giving himself enough psychical freedom to accept them.     

Countertransference and the myth of the perfectly analyzed analyst

Countertransference is an inevitable feature of every psychoanalysis. Psychoanalysts are (and need to be) only human; psychoanalytic work is arduous and replete with stresses, strains, and deprivations; analysands tend to probe for vulnerabilities in their analysts that can be exploited in the interest of acting out neurotic wishes instead of analyzing them; and a training analysis cannot completely immunize a psychoanalyst against countertransferential reactions that impede analytic progress. Psychoanalysts must be vigilant to the emergence of countertransference reactions so that they can analyze and overcome them. Two illustrative clinical examples are provided.     

Roasting Ethics

What are the rules of the comedic roast? Initially, there might seem to be a tension between “the comedic” and “roasting” or “insult.” The comedic is concerned with the funny or mirth while insults are mean-spirited in nature, tools of injury. So how can the two be combined to produce something fun? In this article, I entertain a few views that attempt a resolution of this apparent tension. I conclude with a proposal that suggests when they are successful, roasts employ mechanisms that redirect attention from the joke's content to its formal properties; it is when those mechanisms fail that roasting becomes disagreeable.     

Termination: the hidden face of analysis

Although the question of analytic endings has been the subject of many contributions and round tables, it always presents a theoretical and clinical dilemma that remains unresolved by the search for more explicit criteria. The problem of the final phase is a post‐Freudian development which coincides historically with the emergence of studies on the countertransference, and it presupposes prior questions concerning the goals and results of analytic treatment. The following question is posed: what is the specific psychoanalytic event of the final phase? The author begins by examining the theoretical issues linked to temporality and separation, clarifying certain clinical aspects linked to the precession of the countertransference in determining the ending, before going on to illustrate a number of indicators with a clinical vignette. He proposes that the movement which develops in analysis from the transitional relationship towards the patient’s capacity to ‘stand on his own two feet’ in the clinical setting constitutes a crucial factor in the decision to embark on the process of termination. The conclusion opens out onto ethical issues, in view of the prior necessity for a movement to occur in the countertransference.     

Ethics and the sexual countertransference

In this paper I shall suggest that, in addition to 'conscience', the archetype of Eros plays an important part in 'benign relatedness' and that this is what constitutes an ethical attitude. I also propose that the idea of 'benign relatedness' can provide us with a workable concept for those serving on Ethics Committees especially when our Code of Ethics is unclear or limited. I attempt to show that the analytic attitude is essentially ethical and define what I see as the analytic attitude as a way of demonstrating this. By discussing the neurotic sexual countertransference and unconscious identity I hope to clarify the main reasons for unethical enactments. I use examples of ethical problems, including a personal experience, to illustrate the kinds that occur and lastly I discuss how mourning plays an important part in the resolution and avoidance of these problems.     

Projection and projective identification: developmental and clinical aspects

Projective identification and projection are defined, described, and contrasted. Projective identification is seen as an early or primitive defensive operation, and projection as later or more advanced and derivative in nature. The developmental origins and adaptive functions of projective identification are examined with an emphasis on the cognitive preconditions for the operation of this defense. The varying functions of both defensive operations are described within the context of psychotic, borderline, and neurotic personality organization. Case material is presented to illustrate the diagnostic approach to and the clinical functions of projective identification, particularly its importance in contributing to complementary identification in the countertransference. Also illustrated is the technical management of severe transference regression under the impact of projective identification. Finally, alternative approaches to the diagnosis and interpretation of projective identification are discussed.     

Approaching countertransference in psychoanalytical supervision: A qualitative investigation1

A recent examination of the literature concerning countertransference and its developments reveals its clinical usefulness in different psychoanalytical cultures. Nevertheless, a shortage of publications is apparent with respect to its approach in supervision. The authors aim in this study was to examine the concepts of transference and countertransference and how countertransference is approached in supervision, in the training of candidates, at an institute of psychoanalysis belonging to a society affiliated to the International Psychoanalytical Association (IPA). Qualitative research was carried out, interviewing supervisors and supervisees. Through analysis of the material acquired, the authors classifi ed the data into initial, intermediate and fi nal categories. The principal fi ndings were subdivided into three categories: the concepts of transference and countertransference, psychoanalytical listening and the complementarity of the phenomena, and the approach to countertransference. The concepts of transference and countertransference predominantly used by those interviewed are based on the totalistic outlook. Countertransference in supervision has been approached in a more direct and objective way when compared with the previous period, although great care is taken to delimit the boundaries between supervision and personal analysis. The main aim of supervision is to broaden comprehension and to deepen the interpretations directed towards the patient. These fi ndings suggest that the evolution of the concept of countertransference in different psychoanalytical cultures and developments in the analytical fi eld are contributing to this change.     

Trying to enter the long black branches: some technical extensions of the work of Frances Tustin for the analysis of autistic states in adults

The author suggests a number of technical extensions/clinical applications of Frances Tustin's work with autistic children, which are applicable to the psychoanalysis of neurotic, borderline and psychotic adults. These are especially relevant to those individuals in whom early uncontained happenings (Bion) have been silently encapsulated through the use of secretive autosensual maneuvers related to autistic objects and shapes. Although such encapsulations may constitute obstacles to emotional and intellectual development, are consequential in both the relational and vocational spheres for many analysands and present unending challenges for their analysts, the author demonstrates ways in which it may be possible to detect and to modify these in a transference-centered analysis. A detailed process of differential diagnosis between autistic states and neurotic/narcissistic (object-related) states in adults is outlined, along with several clinical demonstrations of the handling of a variety of elemental terrors, including the 'dread of dissolution.' The idiosyncratic and perverse use of the analytic setting and of the analyst and issues of the analysand's motivations are considered and illustrated. A new model related to 'objects in the periphery' is introduced as an alternative to the more classical Kleinian models regarding certain responses and/or non-responses to transference interpretation. Issues a propos the countertransference are also taken up throughout.     

Countertransference in family therapy

The intent of this article is to describe the importance of one psychoanalytic concept, countertransference, in family treatment by a review of the literature on the subject. Case illustrations will then be used to show how the supervisor of a family treatment case elicited the countertransference in order to move the therapy forward. Some thoughts with regard to training will be offered.     

The ghost in the group room: countertransferential pressures associated with conjoint individual and group psychotherapy

Conjoint individual and group therapy is a commonly used, effective psychotherapeutic treatment. The relationship between the conjoint therapists significantly influences the treatment. This article examines countertransference dilemmas of the group and individual therapists arising from the real and fantasied conjoint relationship. Case examples illustrate specific countertransference dilemmas. Therapists are encouraged to consider the possibility of difficulties with each potential conjoint treatment. Consultation and supervision are recommended to help the conjoint therapists identify and manage countertransference pressures.     

Mutilation of self and object: the destructive world of the paranoid-schizoid patient and the struggle for containment and integration

Using case material, I have described the three overlapping phases of treatment that occur with some borderline, narcissistic, or psychotic patients. These patients are dealing with paranoid-schizoid experiences of the self and the object. In this part-self, part-object world, many shifting, opposing, and contrary states of feeling and thought occur. Acting out is the first phase of analytic treatment. This is an externalization of persecutory anxiety, primitive guilt, and phantasies of annihilation. Projective identification, splitting, and denial are common and tend to make for difficult transference and countertransference problems. During the middle phase of treatment, pathological superego states and manifestations of death instinct color the analysis. The death instinct reacts defensively to the sadistic superego. Technically, the destructive internal conflicts created by these two elements must be clarified and interpreted in the transference. Flexible analytic management and containment are crucial supplements to ongoing interpretation. If these chaotic patients are able to stay in treatment for a period time, the acting out and the superego/death instinct phase gradually give way to phantasies of loss. This is still a paranoid-schinoid perspective of loss, making it persecutory experience. Although depressive anxieties do enter the picture, these still involve pathological anddestructive states of guilt and all-or-nothing threats of abandonment and attack. A case was presented in which the patient managed to continue into the third stage of analytic treatment, long enough to benefit frominternal, structure change. In this final stage, the patient "O" was able to acknowledge, work through, and integrate her prior feelings and phantasies of loss, persecution, and abandonment anxiety into more manageable and reality-based depressive functioning.     

The revival of "Dora": advances in psychoanalytic theory and technique

For nearly six decades after its publication in 1905, Freud's remarkable case of Dora remained untouched by critical comment. However, beginning in the early 1970's, an abundance of articles began to appear, which focused exclusively on the Dora case. The present paper reviews the literature of this so-called "Dora revival" in order to explain the historical and theoretical reasons leading to this extraordinary burst of research. Above all, two vital developments in the psychoanalytic discipline created the climate that fostered the Dora revival. First, there was a revolutionary change in attitude toward the phenomenon of countertransference: in contrast to the classical view of countertransference as a disruptive interference in treatment, analysts increasingly regarded countertransference as a pervasive and natural process, which could be potentially utilized to enhance understanding of the patient's unconscious conflicts and defenses. Second, there was enormous and rapid growth of a comprehensive psychoanalytic theory of adolescence and its treatment. Thus, based on a more favorable attitude toward countertransference, and a much improved understanding of the unique problems of adolescence, psychoanalysts could reexamine and better understand the decisive events that contributed to Freud's abortive analytic treatment of Dora.