Transference and relationship: Technical Implications in the psychoanalytic process with a borderline patient

This paper reviews how the bond between the therapeutic relationship and transference is created, illustrates its technical management, and provides a basic methodology for the exploration of both transference and the therapeutic relationship. For this purpose, the current therapeutic relationship, the concept of affective dominance, the object relation triggered by transference, the past and present unconscious, and the relationship pattern (CCRT) applied to dreams will all be considered. The approach in this paper is based on an object relation conceptualization. Highlights of the theory underlying the technique will be illustrated in a succinct discussion of the clinical treatment of a borderline patient in psychoanalysis.     

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.     

Amelioration of transference resistance: substitute therapists in milieu group psychotherapy

Building upon Wolf's (1949) notion of the use of an alternate session in group psychotherapy, this paper suggests that an alternate therapist substituting for an absent regular therapist in milieu group psychotherapy can facilitate similar therapeutic benefits. The mechanism of this process of overcoming transference resistance is seen as twofold: (1) sessions with a substitute therapist allow patients to confront the infantilization often present in a milieu setting and experiment with more autonomous ego functioning. (2) Sessions with a substitute therapist create conditions which are apart from the ongoing process of the therapy group, thereby allowing for a therapeutic splitting process to develop wherein transference feelings about the regular therapist can be expressed to his or her "alter ego." Several case vignettes are presented in order to illustrate the clinical utility of a substitute therapist.     

An existential‐phenomenological counter‐theory of transference

The hypothesis of transference has become such a fundamental assumption for many therapeutic practitioners, that it is rarely questioned either in terms of its theoretical value or its function. This paper will critically examine the notion of transference from an existential‐phenomenological perspective and will argue the case for an alternative perspective. Further, it will seek to demonstrate that numerous and significant logical and applied problems arise with regard to the hypothesis of transference—problems which have a major negative impact upon the therapeutic relationship in general and upon the possibility of ‘encounter‘—or ‘meeting‘—between therapist and client. Finally, the paper will seek to show how, in many cases, the adoption of the hypothesis of transference can be seen as a defensive and power‐preserving (or enhancing) activity on the part of the therapist whose benefit to the client is, at best, questionable.     

Progressive triangulation in psychotherapy and the spiritual journey

Relationship triangles are usually considered symptomatic of family dysfunction in systems-oriented therapy, but they may also serve a progressive, transitional role in relationships. The author examines the phenomenon and function of “progressive” triangles in East and West spiritual traditions, and suggests that triangles comprising seeker, mediator, and higher power are common in both traditions, regardless of differing views of human nature. A progressive triangle in the therapeutic setting can be seen as a function of teleological transference, in which a seeker's spiritual aspirations are projected onto a mediator, who provides support and direction for its further realization. The implications of progressive triangulation and teleological transference in contemporary practice are discussed.     

Eine Therapiestunde mit einem Mörder

Although psychodynamic concepts may be helpful in identifying the complex interpersonal and manipulative processes that occur between inmates and therapists and to transform them into the therapeutic process they are hardly ever applied in a correctional setting. The author provides an insight into the psychotherapeutic work conducted in prison. The first part of the paper outlines the special conditions in which psychodynamic psychotherapy occurs in a social therapeutic intervention institution within the German prison service. Characteristic transference and countertransference constellations are described. Based on a verbatim report an account is provided of a therapy session with a serious violent offender. In his reflections on the session the author focuses on the effects on the transference process of, in the offender’s eyes, being both therapist and assessor at the same time.     

The Abuse of Power: A View of Sexual Misconduct in a Systemic Approach to Pastoral Care

The article explores the dynamics of transference and countertransference in hierarchical relationships which exist between clergy and lay persons, both in the parish setting, as well as in the pastoral counseling relationship. It is of utmost importance that the power differential be consciously acknowledged by pastoral caregivers so that appropriate boundaries can be exercised. All too often it is the negligent, careless, or unconscious disregard for this power dynamic by individuals providing pastoral care that has led to the sexual violations recently surfaced within our religious institutions. Acknowledgement of the imbalance of power, and its consequences for both clergy and parishioner, is essential in a systemic model of pastoral care.     

The manifestation of transference during early psychotherapy sessions

Despite the clinical use of therapeutic transference across various schools of psychotherapy, there have been relatively few empirical studies of this phenomenon, none of which has examined transference with a non‐pathological population. In this study, the core conflictual relationship theme (CCRT) method was used to examine the manifestation of therapeutic transference in the first three sessions of 22 counselling contracts with high‐functioning individuals. Factor analyses of the wish (W) and response of other (RO) components of the CCRT indicate a complementary pattern of relating in which the therapist is idealised and others are devalued. Within the response of self (RS) component, clients exhibited a concordant relational transfer whereby they had a negative response to both the therapist and others. Additionally, control issues emerged in the W component for significant others and in the RS component for the therapist.     

The dynamics of empirically derived factors in the therapeutic relationship

The therapeutic relationship is the source of major concepts in psychoanalytic clinical theory. Such concepts as resistance, transference, countertransference, and the alliance are fundamental, even though there may be shifts in meaning between theoretical schools and clinical contexts. In the clinical psychoanalytic literature, disagreement exists over the nature of the alliance and its essential components. Empirical studies using reliable patient, therapist, and observer scales to assess the alliance demonstrate a correlation with psychotherapeutic gains. In the study reported here, thirteen patients were followed for 6 to 33 months of psychodynamic psychotherapy, during which time their views of the therapeutic relationship were assessed, and several experiential measures taken, all on a weekly basis. Statistical analyses reveal that the therapeutic relationship, as reflected in the patients' weekly responses to the St. Louis Therapeutic Relationship Rating Scale, has four distinct components: therapeutic alliance, resistance, transference love, and negative transference. On a week-by-week basis, the therapeutic alliance was the strongest predictor of improvement in patient-reported general adjustment, as reflected in such areas as self-esteem, positive affect, social relations, work productivity, satisfaction, and optimism. Time plots of the variables show the typical time course for the components of the therapeutic relationship, as well as for improvement on the experiential variables. Results indicate that the therapeutic alliance, transference, and resistance are central components of the psychotherapeutic relationship, which in turn predict the ongoing life experience of the patient.     

Psychoanalytic aspects of inpatient treatment

This paper looks at the experience of inpatient hospital treatment at the Cassel Hospital and how formal psychoanalytic psychotherapy, with its emphasis on the transference and the inner world, fits into that context and orientates itself to some of the realities of the setting. It outlines how psychotherapy and nursing can work to inform and enrich each other, and what is psychoanalytic about the overall work. A bridge of understanding is built using the patients' perceptions of, adjustment to and conflict about the inpatient setting, and the affective impact of the processes on patients and staff alike. Two clinical examples of severe child abuse family cases are given, the first of Munchhausen syndrome by proxy, the second in which a baby sibling had been killed. They show how in-depth psychoanalytic work with mother and child and individual psychotherapy of the child can be combined with psychotherapy of the parents and intensive work in the therapeutic community. Such a combination can contribute, even in cases of severe pathology, to the development of the relationship between mother and child and promote successful rehabilitation in the outside community.     

The therapeutic object relationship

This paper introduces the concept of the therapeutic object relationship in order to clarify our understanding of the nature of fully analytic work with the more regressive patient, which has unsystematically developed over the last 30 or 40 years. The need for such a clarifying concept seems to arise from several sources. Our analytic work with the more regressed patient appears to entail a relationship demand factor which cannot be usefully treated only as resistance to the development of the transference. These are patients with what may be described as object hunger emanating from faulted ego development and a disordered internal object world. This object hunger cannot be adequately met within the framework of the tacit, ordinary, good-enough environment of the concerned and nonjudgmental analyst. In addition, the literature on this subject still dichotomizes the relationship factor of treatment from the transference. The concept of the therapeutic object relationship appears to offer the possibility of a clinical and theoretical unification between transference and relationship. The major point of the paper may be described in terms of the manner in which we have progressed from Eissler's parameter paper of 1953 to the widened scope of analytic work made possible by object relations theory, developmental theory and observation of infant and child development. The face of analysis seems to have undergone profound modification from the early classical model to one in which developmental maturation, in addition to making unconscious conflict conscious, has become a matter for our concern. This change seems to require seeing the analyst as a special form of real object with whom the patient passes through a revised version of certain developmental pathways. The therapeutic object relationship is viewed as a potentially unifying concept which may make possible higher degrees of generalization about the variously unsystematized approaches to analyzing the more regressive, but nonpsychotic patient. Some history of definition of the analytic relationship in terms of transference or relationship is presented. In the course of the paper the therapeutic object relationship is gradually defined as one of: primal intimacy; increased permeability of boundaries between self and other; intensive empathic interaction; the evolution of self and object definition in a context of intimate relation with an object that is instrumental in this process; and the activation of transcendant forms of symbolic-creative intercommunication.(ABSTRACT TRUNCATED AT 400 WORDS)     

The symbolism of the story of Lot and his wife: the function of the 'present relationship' and non-interpretative aspects of the therapeutic relationship in facilitating change

Abstract The treatment of an adolescent patient preoccupied with thoughts about committing suicide is presented, as a vehicle for considering the significance of the 'present relationship' within the totality of the therapeutic relationship in bringing about change. The question of how the present relationship operates alongside the transference relationship is raised. It is argued that there needs to be more attention to and discussion of the therapeutic actions and re-enactments that take place within therapy which, while they may be viewed at times as unorthodox, may nevertheless be beneficial. This in turn can then lead to developments in technical and theoretical thinking based on clinical experience.     

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.     

Vulnerability,Resilience, and Surviving Destruction: Discussion of “The Analyst’s Experience of Trust and Mistrust”

In this response to Danielle Novack’s intellectually astute and clinically rich paper on the “analyst’s trust,” I reflect on the valuable ways in which Novack elucidates this undertheorized aspect of the analyst’s experience and reconfigures trust/mistrust as a meaningful intersubjective dimension of the therapeutic relationship. Novack shows how attending to shifts in trust/mistrust can provide valuable clues for deciphering the transference/countertransference. While I strongly agree with her construction of trust as a psychoanalytic achievement, I question the notion that the analyst’s trust is a necessary condition for her participation. Novack’s work on the analyst’s trust joins a broader contemporary conversation about potential overreaches in the relational paradigm, which I discuss. Finally, I consider the implications of Novack’s work for specifying the factors that underly resilience and engaging a conversation about surviving destruction in contemporary relational psychoanalysis.     

Getting real in analysis

The author uses a detailed clinical example to illustrate how reality testing can create rather than foreclose opportunities for analytic investigation. He proposes that authentic analysis of transference within the treatment relationship requires close and explicit attention to be paid to considerations of reality, but in a way that does not require the patient to defer to the analyst's view. The author reconsiders certain conceptions of a special psychoanalytic reality, of regression in clinical analysis, and of the nature of free association, suggesting that they tend to discourage the realism necessary to effective psychoanalytic work. In this context, he underlines the importance of ongoing reference to therapeutic outcome as an aspect of reality, and reflects upon the impact of the reality of the analytic treatment setting and the question of termination.     

Analysis of transference: A North American perspective

Using detailed clinical vignettes, the author illustrates and compares several North American approaches to the analysis of transference, tracing their origins in Freud's works and in various post-Freudian conceptualizations, including the writings of Anna Freud and Charles Brenner. Particular attention is paid to the work of Merton Gill, Evelyne Schwaber, Paul Gray, and the British analyst, Betty Joseph. Discussed and illustrated are controversies over the broader and narrower views of transference, the interpretation of action in the analytic setting, earlier and later interpretations of transference with particular emphasis on the contrast between contemporary Kleinian and ego psychological perspectives, the role of extra-transference interpretation, and the concept of the transference neurosis. An argument is made for an integrative approach, drawing upon different emphases, depending on the clinical circumstances and the point of affective immediacy for the patient, which may or may not coincide with the point of affective immediacy for the analyst.     

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.     

Clinical reflections on self-attack

This paper reflects on the clinical phenomena of mental and physical self-attack as encountered in everyday psychotherapeutic practice in the NHS. The author considers two distinct but closely related internal dynamics which he terms ‘melancholic’ and ‘antilibidinal’. In both, there is a sadomasochistic structure which serves a number of defensive purposes for the individual. The origins and functioning of these structures are explored in the clinical material. These defensive systems are often perversely rewarding for the patient and highly resistant to change. The author discusses some of the major obstacles to working therapeutically in this area, and emphasizes the role of the transference and countertransference in helping the therapist to understand who is doing what to whom within the therapeutic relationship and within the patient. Although the paper deals with theoretical issues the emphasis throughout is on clinical understanding and effectiveness within a (mainly) once-weekly analytic setting.     

On trying something new: effort and practice in psychoanalytic change

This paper describes one of the ingredients of successful psychoanalytic change: the necessity for the analysand to actively attempt altered patterns of thinking, behaving, feeling, and relating outside of the analytic relationship. When successful, such self-initiated attempts at change are founded on insight and experience gained in the transference and constitute a crucial step in the consolidation and transfer of therapeutic gains. The analytic literature related to this aspect of therapeutic action is reviewed, including the work of Freud, Bader, Rangell, Renik, Valenstein, and Wheelis. Recent interest in the complex and complementary relationship between action and increased self-understanding as it unfolds in the analytic setting is extended beyond the consulting room to include the analysand's extra-analytic attempts to initiate change. Contemporary views of the relationship between praxis and self-knowledge are discussed and offered as theoretical support for broadening analytic technique to include greater attention to the analysand's efforts at implementing therapeutic gains. Case vignettes are presented.     

The centrality of the psychoanalytic setting and the changing aims of treatment. A perspective from a theory of object relations

The psychoanalytic setting, which includes the bond between analysand and analyst, is the foundation of psychoanalytic treatment. This object tie, although in the here and now, and "real", is demarcated from ordinary life and can be thought of as existing within a different level of reality. The psychoanalytic setting is subject to symbolic transformations that enable non-specific developmental conflicts to be worked through. I have described this transformation as the "dependent/containing transference," which I have compared and contrasted to the highly variegated and specific "iconic" transference (transference neurosis). This view of the psychoanalytic setting leads the analyst to pay special attention to problems of entrustment and safety and to the communicative process that regulates the closeness and distance between the two participants.