Working with and ‘seeing through’ the sexual transference in the psychotherapy of an adolescent boy

This paper explores the challenges and developmental opportunities of working with the sexual transference in psychotherapy with adolescents. Psychoanalytic contributions investigating the nature of adolescent sexuality and the developmental move from a narcissistic organisation to a capacity to form intimate relationships are reviewed, and the question of what happens when there is a lack of containment in infancy is addressed. The way in which unintegrated sexual impulses and phantasies can invade the therapeutic relationship is further discussed through the account of the weekly psychotherapy of a 16-year-old boy who formed a powerful sexual transference to his female therapist. The paper highlights how working through the sexual transference enabled this young man to face his developmental paralysis and begin to use the therapy as an opportunity for psychic growth.     

Case history of Farida: A year of psychotherapy with a girl who said she was sexually abused

This paper discusses how thinking about a playroom involves our thinking about the setting in psychoanalytical work with children in general - the physical as well as the human aspects - and how this encourages us to rethink some of the basic aims in psychoanalytic work. The paper describes the importance of the setting being such as to help the therapist to have the freedom to think and to feel what is going on in the child and himself. Links are then made with aspects of transference and counter-transference, and brief examples given.     

Transference and countertransference issues with sexually abused clients

Abstract

This paper explores some of the therapeutic issues which arise when working with sexually abused clients. It is suggested that both the client and the therapist may at moments take any of the three positions in the Oedipal triangle and that the mother, father and child status are interchangeable in the transference and counter-transference. It is also suggested that the Oedipus myth represents the failure of a family to contain sexual and murderous passions. I describe a Hindu myth which takes a similar triangle of passion but illustrates how containment is possible. It is proposed that this implies we need to re-evaluate the presence of the erotic in therapy in a more positive light. It is further suggested that the sexually abused client needs to experience the containment of passion if a healing process is to occur.     

Pete the diesel: Psychotherapy with a severely disturbed five-year-old boy

The psychic significance of the figure of the grandmother in psychodynamic psychotherapy has received scant attention. This paper develops the concept of the ‘grandmaternal transference’ in parent–infant psychotherapy and explores its identification, its possible functions and its therapeutic significance. The grandmaternal transference has special relevance to parent–infant psychotherapy since the grandmother often represents both the mother’s mother and the child’s grandmother and offers a unique third position between mother and child. Three clinical vignettes illustrate how the grandmaternal transference may operate in this third position. In the first vignette, the therapist becomes in the transference a containing grandmother thereby facilitating maternal containment. In the second case, the therapist may be experienced as a differentiating grandmother able to help mother and infant with separation and individuation. In the third one, the therapist is transferentially experienced as a paternal grandmother who acts as a pseudo-father able to embody the paternal function. In each of these positions, the transference and countertransference – whether positive or negative – require that the therapist responds to rather than enacts the grandmaternal role. The three configurations of the grandmaternal transference have different clinical manifestations and offer different therapeutic ports of entry.     

The ‘too muchness’ of excitement: Sexuality in light of excess,attachment and affect regulation

This paper brings together contemporary thinking about early attachment and affect regulation with our clinical and theoretical understanding of the problems of adult sexuality. In addition to recent theories of affect regulation and attachment, we incorporate Laplanche's idea of ‘excess’, which was an important transitional concept integrating real experience with fantasy in sexuality. We elaborate the idea of excess –‐ ‘too‐muchness’ –‐ to illuminate the early overwhelming of the psyche that affects the formation of sexuality. Linked to recent theoretical developments, this idea helps to grasp the relationship between sexual excitement and early affect regulation, showing how excitement becomes dangerous, thus impeding or distorting desire. The ‘too‐muchness’ of excitement recalls the experience of being a stimulated, overwhelmed, unsoothed child and influences later inability to tolerate sexual arousal and the excitement affect. A clinical case illustrates this connection between attachment trauma, anxiety about sexuality, as well as shameful experiences of gender identity as an area of trauma. We emphasize the importance of working through the terrors and desires of the mother–baby relationship as they emerge in the transference–countertransference in order to develop the ability to hold excitement and stimulation without experiencing the too‐much as the intolerable. This includes the working‐through of ruptures related to overstimulation as well as the delicate balance of attention to fantasy and intersubjective work in the transference.     

Therapeutic Work with Trauma,Revictimization, and Perpetration: Bearing Witness,Offering Hope,Embracing Despair

ABSTRACT

This paper offers a case study of a survivor of childhood incest who in adulthood has become a victim of violence in her relationships with chosen partners and is concerned that she herself may be a perpetrator of sexual abuse. It examines selected literature on attachment, dissociation, transference/countertransference, role responsiveness and sadomasochistic therapeutic enactments, the two-system superego model, and the triadic self. The paper focuses on long-term treatment dynamics with survivors of cumulative trauma and explores such psychodynamic psychotherapy issues as the therapist as a perpetrator of violence, the development of sacred space, authenticity, and the importance of both offering hope and embracing despair in this work.     

The manifestation of transference during early psychotherapy sessions: Exploring an alternate data source for therapist narratives in transference research

Introduction: Previous transference studies have compared in‐session client narratives about significant others to in‐session client narratives about the therapist, limiting data to the information that clients are willing to share with the therapist. Method: The first three sessions of 30 therapies with high‐functioning individuals were examined using the Core Conflictual Relationship Theme (CCRT) method. Client narratives about others were drawn from the psychotherapy sessions and client narratives about the therapist were drawn from a Participant Critical Event (PCE) interview conducted after the third session of therapy. Results: Factor analyses of the CCRT components indicated several relational patterns: a complementary pattern of relating characterised by a devaluation of the therapist and idealisation of others; a concordant relational transfer where clients feel bad with both the therapist and others; and as clients experience control issues with significant others, they wish to adopt a submissive stance toward the therapist. The results suggest that the source of therapist narratives may influence the results of transference research.     

On psychoanalytic figures as transference objects

One of the tasks that analysts and therapists face at a certain stage in their career is how to develop a way of psychoanalytic thinking and practising of their own. To do this involves modifying or overcoming the transferences established during their training or early career. These transferences are to one's teachers or training analyst, investing them with authority and infallibility, and to received theory, which is treated as though it were dogma. The need to free oneself from such transferences has been discussed in the literature. There is, however, another kind of transference that the developing therapist also needs to resolve, which has received little attention. This is the transference made on to a key figure in the psychoanalytic tradition. Such a psychoanalytic figure will be seen as the originator of or embodiment of those theoretical ideas to which one becomes attached, and/or as standing behind one's training analyst or seminal teachers who become a representative of that figure. The value of an investigation of one's relationship to a psychoanalytic figure is that it is an excellent medium for revealing one's transference, as the figure in question is not a real person but only exists through his/her writings. The body of the paper consists of an extended example of such an analysis, that of my own transference on to the figure of Winnicott. In this example I illustrate how my evaluation of Winnicott's ideas changed from seeing them as providing answers to all my clinical questions to no longer satisfying me in some areas of my work. This change in my relationship to Winnicott's theory went hand in hand with a modification in my transference on to the figure of Winnicott, from seeing him as endowed with authority and goodness to an appreciation of him as a still sustaining figure but now with limits and flaws. In the final part of the paper several questions arising out of my analysis are posed. Can the pull of writing such an account in terms of dramatic rupture rather than gradual and partial change be avoided? Should my account be regarded purely as a form of self‐analysis or does it have anything to say about Winnicott himself and his theory? And do some psychoanalytic figures attract more intense or sticky transferences than others?     

The unconscious

A discussion of the unconscious leads naturally to Freud and to a theory on subjectivity we may designate as de-centred. The unconscious reminds us that not only do we not know ourselves. In the core of our subjectivity, we have to acknowledge the notion of otherness. Re-reading Freud's text, The Unconscious, from 1915, the current author emphasises the character and function of the unconscious as radically different from what we know about conscious processes. This allows for the concept of the preconscious, which the author links to Winnicott's intermediary area and Green's tertiary processes. Taking as point of departure Freud's differentiation of word presentation and thing presentation, the author points to Freud's introduction of the term thing-cathexies of the object as designating the primal psychic representation. The Freudian perspective is broadened, encompassing the notion of otherness as discussed by Laplanche and Aulagnier. Concluding the paper, the author draws some implications for psychoanalytic technique, focusing especially on transference.     

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 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.     

Interpretive work in milieu groups

Interpretive work in milieu psychotherapy groups aims to bring concealed and hidden material to the fore so that it can be discussed openly. A host of clinically important issues thrive in the milieu, about which the patients are fully aware, but are unable to discuss. Two types of interventions are described whose goal is to overcome resistance to discussion; they are clarifying interpretations and making a parallel statement. Clarifying statements help patients understand their experience in the milieu; they are interpretive when they bring avoided material into the open. In those instances where resistance to discussion is great, the subject first appears in metaphor, is worked with, and then emerges in a displaced form. Working indirectly with metaphor and displaced material can serve to overcome transference resistance. The therapist then need only ask a direct question or make a statement in order for the avoided material to emerge. The combination of working with displaced material followed by a question or statement that is framed in terms of that theme has an interpretative function.     

To Dream,Perchance to Think: Discussion of Papers by Noelle Burton and Christopher Bonovitz

This is a discussion of papers by Noelle Burton and Christopher Bonovitz, which explores clinical work with patients who are either developmentally incapable of articulating symbolic thought or immersed in a transference–countertransference position in which abstract thinking is foreclosed.     

On the nature of intuitive and delusional thought: Its implications in clinical work with psychotic patients

The author tries to differentiate intuitive imagination from delusional imagination and hypothesises that psychosis alters the system of intuitive thinking, which consequently cannot develop in a dynamic and selective way. Scholars of different disciplines, far removed from psychoanalysis, such as Einstein, Hadamard or Poincar, believe that intuitive thinking works in the unconscious by means of hidden processes, which permit a creative meeting of ideas. Thanks to Bion's work, psychoanalysts have begun to understand that waking thinking is unconsciously intertwined with dream‐work. The delusional construction is similar to a dreamlike sensorial production but, unlike a real dream, it remains in the waking memory and creates characters which live independently of the ‘dreamer's’ awareness. It is a dream that never ends. On the contrary, the real dream disappears when it has brought its communicative task to an end. In the analysis of psychotic patients it is very important to analyse the delusional imagination which dominates the personality and continuously transforms the mental state, twisting emotional truth. The delusional imagination is so deeply rooted in the patient's mental functioning that, even after systematic analysis, the delusional world, which had seemed to disappear, re‐emerges under new configurations. The psychotic core remains encapsulated; it produces unsteadiness and may induce further psychotic states in the patient. The author reports some analytic material of a patient, who, after a delusional episode treated with drugs, shows a vivid psychotic functioning. Some considerations are added on the nature of the psychotic state and on the therapeutic approach used to transform the delusional structure. This paper particularly deals with the difficulty in working through the psychotic episode and in ‘deconstructing’the delusional experience because of the terror connected with it. In the reported case, the analytic work changed the delusional construction into a more benign one characterised by phobic qualities. The analysis of the psychotic transference allowed the focus to be on the hidden work which had been continuously influencing the transferential picture of the analyst and the patient's psychic reality.     

The psychotherapy of parenthood: towards a formulation and valuation of concurrent work with parents

This paper explores the process and value of concurrent work with parents when their child is being treated in individual psychotherapy. The position taken is that psychoanalytic understanding generally and the specific formulations presented in this paper have a broader applicability in other aspects and approaches in child and adolescent mental health practice. The central issues are the interweaving of knowledge of family processes, child development and psychopathology, and the uses that can be made of an understanding of transference and countertransference. A particular formulation is presented in relation to aspects of the work that constitute ‘child guidance’ and those that may be considered as ‘psychotherapeutic’ in relation to parental psychopathology. We have coined the term ‘the psychotherapy of parenthood’ to give this work the status it deserves and to define a boundary within which to explore the areas and levels of this complex work. Some practice and training implications are considered.     

‘Get me out of this dream!’: making a therapeutic alliance and working in the transference with a psychotic adolescent boy

This paper discusses the challenges of struggling to build and maintain a therapeutic alliance with a psychotic adolescent boy who did not share an allied perception of reality with his therapist, and who insisted that his therapist did not exist. The paper poses the question of whether, under such circumstances, it is ever appropriate or tolerable to make transference interpretations. Drawing on detailed clinical material, the author attempts to make sense of how it was possible to make some contact with his patient, given these technical difficulties.     

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.