Hope

Summary

The author describes her treatment of her first alcoholic client and observes how the process of providing hope to this client heightened the author's personal capacity to hope. Hope as an aspect of healing is considered and personal reflections on psychotherapeutic work with alcoholics are discussed.     

Three Phases of Treatment with Borderline and Psychotic Patients

Three distinct, yet overlapping, phases of treatment emerge when working with some borderline and psychotic patients. This are patients who test the ordinary limits of psychoanalysis, but can profit from its deep exploration. The first phase is colored by acting out, interpersonally and intrapsychically. An analytic envelope of containment is necessary to sustain the treatment. Interpretive holding and containing help the patient find a psychic receptacle capable of detoxifying violent projections. Many of these patients terminate prematurely. The second phase is centered around the patient's defensive use of the death instinct to extinguish or destroy certain parts of their mental functioning. This difficult standoff between parts of the patient's mind becomes replicated in the transference. The third phase reveals the more fundamental problem of paranoid～schizoid anxieties of loss and primitive experiences of guilt. These include fears of persecution and annihilation. Some patients abort treatment in the first or second phase and never work through the phantasies and feelings of loss. Nevertheless, much intrapsychic and interpersonal progress is possible. Given the instability and chaotic nature of these patient's object relations, the analyst must be cautiously optimistic in their work and realize the potential to help the patient even when presented with less than optimal working conditions.     

Mourning the Loss of the Idealized Self: A Transsexual Passage

Abstract

The few published psychoanalytic writings that exist regarding transsexual men and women tend to focus on the etiology of their gender identities and almost invariably define these patients as inherently pathological. Such myopic viewpoints leave no room for analysis and discussion of the transsexual patient's normal developmental process. In this paper, I use a Kleinian framework to depathologize the coping strategies employed by transsexual patients and to illustrate the importance of mourning in the development of a positive transsexual identity. A clinician who is able to sit comfortably with contradiction may facilitate the transsexual patient's mourning process—saying goodbye to the persecutory object of the past and letting go of the idealized image of the future.     

On the Psychoanalytic Treatment of the Depressive Personality

In order to discuss the depressive personality we have first to distinguish between this clinical entity and other types of depressive psychopathology that might also be chronic. The character traits and psychodynamics of the depressive personality confirm that there is a special group of patients, who belong to a depressive disorder continuum. The particular technical problems that depressive personality present are: (1) the inability to enjoy anything and the consequences of this on the therapist's experience and interventions, and (2) the negative therapeutic reaction which threatens the analytic process and the therapist's competence. If we combine transference/extratransference interpretations with an "empathetic understanding" approach to systematic confrontation and interpretation, we can therefore justify the need for a slightly modified psychoanalytic technique in the treatment of the depressive personality.     

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.     

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 impact of the health professional on the individual's experience of cancer: A psychodynamic perspective

Abstract

This paper examines how interactions with health professionals may come to influence the patient's experience of cancer. It considers the idea that the experience of cancer returns an individual to a state of dependence and lack of integration similar to that of the young infant. The subsequent interactions with health professionals can then be considered in light of its ability to hold the patient's un-integrated self and facilitate its re-integration.     

Projective identification,containment and sojourn in the psyche: Clinical notes on a specific type of transference-countertransference interaction

Abstract

This paper suggests that the interplay between transference and countertransference is considered to be a valuable channel of communication. The author puts an emphasis on the containing function of the analyst. The patient strives for an experience of an object (analyst) that tolerates and copes with the patient's projections. There are some moments when analysts feel themselves to be invaded, controlled or abused by their patient's products. As Bion has postulated, this situation takes the form of a sojourn in the analyst's psyche. Clinical vignettes are given to provide support for the ways in which the analyst contains and elaborates the projections of the patients in his or her own mind and the therapeutic role that these processes have.     

Interpretive acting-out: Unavoidable and sometimes useful

Abstract

Using one detailed case presentation, this paper examines the clinical hardship of making accurate and helpful interpretations that do not become part of the patient's defensive system. The author argues that interpretive acting-out is inevitable in the psychoanalytic process. But, if properly monitored, understood, and contained, these interpretive enactments can sometimes actually be a profit to the overall treatment. Issues of projective identification, countertransference, and the importance of realizing our transference role in the patient's changing phantasies are discussed throughout the case material.     

Social criticism in the process of interpretation (discussion)

Abstract

The author comments on Horst Petri's case presentation and gives reasons why he sees social criticism within the process of interpretation as inappropriate. Firstly he contradicts Petri's view of the severity of his patient's illness. He thinks a supportive therapy was not appropriate and he would have treated her by using conflict centered interpretations. Secondly he assumes that the analyst's social criticism forms an alliance with the analysand which excludes essential issues from the analytic work. And thirdly he reminds us that psychoanalysis doesn't spare a supposedly progressive attitude from criticism. Within the framework of psychoanalytic theory, the relativity of all value judgements forbids the analyst to tie himself down in the way Petri suggests.     

The dream of dreams

Abstract

This paper investigates the relationship between the therapist's use of the dream and the patient's use of the dream, both inside and outside the formal therapeutic setting.     

Conflict in psychoanalysis and in life

Abstract

Unconscious conflicts are at the center of Freudian psychoanalytic inquiry, in the psychoanalytic situation as well as in the theory of personality and pathogenesis. The core dynamic formulation, intrapsychic conflict resulting in new psychic formation, is addressed in the paper in the following steps.

First, the development of the concept of conflict throughout the history of Freudian psychoanalysis is reviewed. Next, the analytic and synthetic aspects of conflict theory are explored and the role of conflict in the development of personality organization and pathogenesis is clarified. Then, the contemporary extensions and elaborations of structural theory are presented.

To illustrate analysis focused on conflict, clinical material covering the phases of psychoanalytic process is highlighted. From the beginning stage of analyzing the patient's initial diffuse state of indifference and “weirdness”, analysis proceeds to address primary and secondary symptoms of impotence and exhibitionism and underlying passive-phallic personality organization with conflict around aggression. This leads to the patient's sense of mastery over previously enslaving and “immobilizing” internal turmoil.     

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.     

Anger - the hidden destroyer A psychodynamic approach with the physically disabled

Abstract

A basic challenge in the psychodynamic counselling of the physically disabled is the engagement of anger in relation to the patient's disability. Regardless of a patient's age at the onset of disability, they will exhibit anger, resentment and frustration for losses they may have, or perceive themselves to have, endured. Healthy physical and psychological adaptation requires the disabled patient to ‘cope’ with their anger. Feelings of anger may impede, obstruct or even derail the impetus towards healthy psychological and behavioural functioning. The manner in which we learn to negotiate the vicissitudes of daily life is linked to our selfobject development. This development does not end when we become adolescents or young adults, but continues throughout our life span. The normative, healthy psychological maturation required for adaptive behaviour is vulnerable to a wide range of impediments acquired at any point along the individual's developmental continuum. As clinicians we need to keep in mind that the self-regulation of internalized emotional states is transacted through a complex set of characterological and personality traits that may be impaired, or wanting, eventually leading to maladjusted psychopathological states. The therapeutic function of the clinician is to redress those ego deficits that stand in the way of a fully creative and productive life. The intended aim of this paper is to illustrate the manner in which I engage with those physically disabled persons presenting anger. I shall consider the use of counter-transference responses as behavioural in modifying various forms of anger formation manifested by disabled clients. It is my position that a positive shift in a disabled person's ego ideal through empathic transference will help to alleviate their underlying hostility and other forms of anger. The paper commences with a brief review of the experience of the disabled in Western society. I shall then turn to an examination of the psychotherapeutic approach underpinning my work with disabled clients. The third section will describe and illustrate, through case material, the clinician's use of self in the dyadic transaction with disabled clients.

The power of a positive therapeutic outcome lies in the clinician's ability to engage with the client despite emotional content, clinical aptitude or specific approach. Empathic attunement brings into operation those mechanisms underpinning the dynamic process integral to the approach used in the above cases. Countertransference issues sometimes intervene in the unconstrained flow of therapy. Regardless, those issues that are salient to the client and are incorrectly handled by the clinician will appear recurrently until satisfactorily addressed. Further, even when errors are made in sessions, outcomes may be positive.

Whatever the initial purpose that brings a physically disabled person to therapy there will eventually be a need to address issues around their condition. It is not enough to ignore or accept a client's earliest statement that their disability Ms not a problem'. They may initially not have come into therapy for problems concerning their disability; however, the particular disability will ultimately play an important role as to how and what the person feels, thinks and believes about him or herself. In general, psychodynamic counselling with the physically disabled requires knowledge of disability issues as well as of counselling procedures. Those working with the disabled need to understand their own personal issues through analytic work and continued supervision. Working with the physically disabled can be overwhelming, frustrating and exhausting, but in the end is most rewarding.     

The Importance of Gender in the Psychoanalytic Relation (Discussion)

Abstract

The Importance of Gender in Psychoanalytic Relations (Discussion). Int Forum Psychoanal 1992;1:32-36. Stockholm. ISSN 0803-706X

Patients assimilate the analyst's gender, appearance, age and the prevailing cultural climate into the transference. Differences in gender between analyst and patient may stir up a variety of social conventions, stereotypes and characterological ways of relating to same or different gendered people. Analytic inquiry must focus on the patient's invariant organizing principles, the themes along which a person organizes his or her experience. Two papers presented at the August, 1991 meetings of the International Federation of Psychoanalytic Societies, that addressed the effect of the gender of each of the participants in the analyst-patient relationship are discussed.     

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.     

Transformation of Narcissism and the Intersubjective Therapeutic Exchange

Abstract

Clinicians and researchers have redefined adolescence and depression in adolescence and no longer consider depression as typical of “normal” adolescence. Depression during the teenage period is differentiated from a depressed mood, replete with misery and anguish, and depression proper, i.e., a real illness with specific symptoms which are depressive equivalents. These symptoms often include aggressivity, substance abuse, school refusal, and delinquency. A detailed case presentation is offered of a 17-year-old depressed, substance abusing adolescent who shares his lyrics and heavy metal rock music in sessions, thereby transforming his aggression and narcissism. Use of self psychology and intersubjectivity theory stimulated the formation of a therapeutic alliance and a corrective selfobject relationship, with this young patient's subsequent gains in self-regulation, decreased temper eruptions, and school involvement.     

Psychoanalytic identity and the external world: Interaction between psychoanalysis and health service systems in Sweden

Abstract

This paper continues the exploration of the clinical phenomenon of analytic contact. The author demonstrates, through case material, the essential ingredients of psychoanalysis to be not frequency or use of the couch, but rather the moment-to-moment analysis of the patient's transference state and phantasies of what it means to establish relational contact with their objects and with themselves. The nature of the treatment can be shaped, prevented, perverted, or fostered by the patient's phantasies and unconscious conflicts into something more analytic or less analytic. Interpretation needs to include the exploration of the patient's attempts to change the treatment into something that is often a replica or a repetition of archaic object relations. The typical patient in psychoanalytic treatment is struggling with rather profound pathology and as such tends to create a significant stand-off with the analyst when analytic contact is forming. Analytic contact is often threatening to these patients in very primitive and alarming ways that must be gradually understood and interpreted if the treatment is to survive and remain a primarily analytic journey rather than be transformed into a more supportive counseling or a pathological re-enactment of conflictual phantasy states.     

The Relationship Between Marital Satisfaction,Marital Stability,Nuclear Family Triangulation,and Childhood Depression

This study was to examine the effect of triangulation on depression in children. Clinical samples and nonclinical samples were taken from Utah and Illinois. Families were assessed for marital satisfaction and stability, family triangulation, and children's depression levels by the Marital Adjustment Test, Marital Status Inventory, Nuclear Family Triangulation, and Children's Depression Inventory. Results showed children's depressive symptoms to be most strongly linked to fathers' level of marital satisfaction, marital stability, and perceived family triangulation. Mothers' variables did not affect children's depressive symptoms .