The patient's perception of the analyst: the hidden transference.

Just as the person of the analyst becomes a nidus for the manifestations of transference, so does the analyst's technique. When the patient misperceives person and technique, identifying the transference is not difficult. More complicated are those situations in which the patient's perception of the analyst and of his or her technique is congruent with the analyst's self-representation, or when the patient uses reality aspects of the analysis and the analyst as a resistance. Clinical material from the analysis of three patients is used to illustrate this.     

Privacy, reverie, and the analyst's ethical imagination

The author illustrates varying ways of using and thinking about forms of analytic reverie and the analyst's privacy. He discusses a few different registers from which the analyst can illuminate points of transference-countertransference enactment. The modality by which the analyst communicates these formulations of unconsciously held object relations and defenses varies and includes verbal interpretation through symbolic speech, interpretive action (Ogden 1994a), and, at times, interpretations that involve a construction of the analyst's subjectivity put forward to enhance the patient's understanding of enactments of the transference-countertransference. The author develops a concept, the analyst's ethical imagination, defined as the ways in which we consider and anticipate the implications of our interpretations.     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

What the analyst does not hear

In the clinical situation, the analyst fails to hear more than he or she hears and spends much time working in the dark. The author raises questions about how we can take cognizance of that state of affairs in our thinking about analytic work. A clinical example illustrates how, in an analytic atmosphere, a patient will correct an analyst's failure to hear. Some ideas are offered about how to maximize the patient's participation in that effort. The author suggests that the problem may not fall precisely under the heading of technique so much as reflecting the analyst's attitude.     

The holding function of theory

As multiple theoretical models contend on the American analytic scene, the holding function of theory emerges as a unifying theme. In addition to supplying an intellectual superstructure for the working analyst, theory provides a psychological presence--a sense of conviction, affective stability, reassurance, and self-esteem--that makes effective analytic work possible from the analyst's side. Ideological passions and differences arise from the vital need for the holding function in an intense and inchoate engagement like psychoanalysis. To show how adherents of different models use theory in practice, three clinical cases are reviewed, one from Betty Joseph, one from Lewis Aron, and one from the author. The last example reconstructs the analyst's subjective experience of treatment both in the selected hours and in terms of the analyst's preconscious use of theory.     

The unfolding and healing of analytic boundary violations: personal, clinical and cultural considerations

Jungian analysts are not exempt from an unconscious engagement in a group complex. The author hypothesizes that there is a silent, dark legacy of belief in the superiority of men's judgment and the inferiority of women's, left by Jung, that has had a wounding impact on some Jungian analysands. Conscious and public mourning may be needed to heal our cultural complex. The author, a woman, traces the origins of her own patriarchal complexes and reveals how in her first analysis these mingled with the patriarchal complex shared by Jungian institute, her two male analysts and their former analyst, a pillar of the institute's community. Her first analyst aborted her analysis to begin a personal partnership with her. Her second analyst unconsciously colluded with the first analyst in not exploring this outcome as a violation. This resulted in a second compromised treatment. The senior analyst who had been these two analysts' own analyst was consulted, and he too failed to address the transgression. After experiencing severe symptomatology, the patient entered a third analysis with a woman where transference and regression were the focus. Eventually, meaning was found in the confrontations with the particular Jungian organization and its ethics committee, who acknowledged the first analyst's behaviour to be unethical. The author sees this process as a paradigm for the enactment and healing of a group complex.     

The Analyst in the Pharmacy

The merging of medication and analysis has been more widely endorsed in recent years. However, the issue of the analyst needing pharmacotherapy and how its use presses on the analytic frame has not been considered. This essay will look at how the analyst's need for medication threads into the structure of treatment. Issues of stigma and shame triggered by medication use are discussed, as well as the treatment consideration of self-disclosure as an intervention. The author offers both objective and subjective data on this subject, and includes a clinical case example to illustrate how self-disclosure of medication status can offer greater degrees of freedom in a patient's analysis.     

A case of sadomasochistic transference: the analyst's contributions to perverse enactments

A young woman who came for treatment of anxiety and depression is presented in a detailed case report. She developed an erotized transference that was predominantly sadomasochistic and included her intention to torture and castrate the analyst. The author demonstrates how the analyst's behavior, including countertransference contributions, assisted in shaping the vicissitudes of sadomasochistic transference paradigms. A collusion was established between patient and analyst in a manner that enabled the analytic dyad to work productively toward an eventual resolution of the patient's conflicts. The author discusses the case's complexities pertaining to enactments, while emphasizing the importance of carefully monitoring and addressing countertransference experiences that mold and shape such a collusion.     

Thinking with,and about,patients too scared to think: Can non‐interpretive maneuvers stimulate refl ective thought?

Patients incapable of higher-order (symbolic) thinking can often not tolerate evidence of the analyst's separate existence, particularly when that 'otherness' becomes evident in the process of the analyst's refl ecting upon and interpreting how the patient experiences or represents the analyst. The patient's intolerance of the analyst's efforts to think (refl ect upon and interpret) renders the usual psychoanalytic maneuvers employed to stimulate refl ective thought ineffective with such patients. Such patients have to learn to tolerate multiple perspectives before they can allow the analyst, or themselves, to think in the other's presence. The author presents two clinical vignettes that illustrate how the analyst's efforts to think about the patient were experienced by the patient as both intolerably distancing and as rejecting of an aspect of the patient's subjective reality. Working psychoanalytically with such patients requires the analyst to forgo the use of narrow interpretations that elucidate unconscious meanings and motives in favor of alternate technical maneuvers capable of facilitating the development of symbolic thinking and refl ective thought (insightfulness). These maneuvers include a demonstration of the analyst's willingness and ability to withstand (rather than 'interpret away') how he is being psychically represented by the patient, without becoming destroyed by, or lost within, the patient's characterization of him. Beside modeling a tolerance of alternate perspectives of one's self, other non-interpretive maneuvers that help facilitate the development of self-refl ective thought include: stimulating the patient's curiosity about the workings of his own mind by identifying incompletely understood behaviors or reactions worthy of greater psychological understanding, and insinuating doubt about the adequacy of the patient's explanations of such phenomena.     

The unreachable object? Difficulties and paradoxes in the analytical relationship with borderline patients

The author investigates the main difficulties the analyst encounters in borderline patient analysis, focusing on the specific way in which such patients put the analyst's mental functioning to the test and highlighting the most salient elements of the transference-countertransference dynamic. The author picks out several of the paradoxes that characterize the analytical relationship with these patients, who are constantly seeking contact with the object, which is inevitably traumatic for them. On the basis of highly detailed clinical material, the author demonstrates how - no matter which theoretical-clinical model is adopted - a specific technical problem with these patients is how to manage their intense destructiveness. With these patients, countertransferential difficulties are inevitably predominant because of the looming threat of the destruction of the analytical relationship. Maintaining a balance between the recognition-legitimization of primary narcissistic mirroring needs and the recognition-control of narcissistic demands and attacks on the analytical link is as crucial as it is complex. The paper examines the most important therapeutic and anti-therapeutic factors, highlighting the importance of countertransference analysis and self-analysis as ways of accessing as yet unrepresented elements of the patient and analyst respectively. Particular attention is given to the role played by the analyst's subjectivity and to the enactment.     

This art of psychoanalysis

It is the art of psychoanalysis in the making, a process inventing itself as it goes, that is the subject of this paper. The author articulates succinctly how he conceives of psychoanalysis, and offers a detailed clinical illustration. He suggests that each analysand unconsciously (and ambivalently) is seeking help in dreaming his 'night terrors' (his undreamt and undreamable dreams) and his 'nightmares' (his dreams that are interrupted when the pain of the emotional experience being dreamt exceeds his capacity for dreaming). Undreamable dreams are understood as manifestations of psychotic and psychically foreclosed aspects of the personality; interrupted dreams are viewed as reflections of neurotic and other non-psychotic parts of the personality. The analyst's task is to generate conditions that may allow the analysand-with the analyst's participation-to dream the patient's previously undreamable and interrupted dreams. A significant part of the analyst's participation in the patient's dreaming takes the form of the analyst's reverie experience. In the course of this conjoint work of dreaming in the analytic setting, the analyst may get to know the analysand sufficiently well for the analyst to be able to say something that is true to what is occurring at an unconscious level in the analytic relationship. The analyst's use of language contributes significantly to the possibility that the patient will be able to make use of what the analyst has said for purposes of dreaming his own experience, thereby dreaming himself more fully into existence.     

The wish to regress in patient and analyst

The analyst's wish to regress is used as a paradigm of the "forbidden" topic of what analysts want from their analysands. The aim is to expand the subjective domain of analysts' awareness so that they can analyze better by grasping more of their temptations with patients before enactment can occur. Clinical examples illustrate how the author temporarily joined patients in wish-fulfilling mutual regression. Analytic process is disrupted when the analyst wishes to relinquish the more differentiated role of the containing and interpreting analyst in favor of more childlike relatedness both with the patient and with the analyst's internal objects. The author, expecting a more typical counter-transference, had not anticipated that he might temporarily join these nonpsychotic patients in mutual regression. It is suggested that in the face of analytic impasse analysts should consider whether they might temporarily have joined the patient in mutually regressive wishes that have taken them away from more responsible analytic functioning.     

Elements of analytic style: Bion's clinical seminars

The author finds that the idea of analytic style better describes significant aspects of the way he practices psychoanalysis than does the notion of analytic technique. The latter is comprised to a large extent of principles of practice developed by previous generations of analysts. By contrast, the concept of analytic style, though it presupposes the analyst's thorough knowledge of analytic theory and technique, emphasizes (1) the analyst's use of his unique personality as reflected in his individual ways of thinking, listening, and speaking, his own particular use of metaphor, humor, irony, and so on; (2) the analyst's drawing on his personal experience, for example, as an analyst, an analysand, a parent, a child, a spouse, a teacher, and a student; (3) the analyst's capacity to think in a way that draws on, but is independent of, the ideas of his colleagues, his teachers, his analyst, and his analytic ancestors; and (4) the responsibility of the analyst to invent psychoanalysis freshly for each patient. Close readings of three of Bion's 'Clinical seminars' are presented in order to articulate some of the elements of Bion's analytic style. Bion's style is not presented as a model for others to emulate or, worse yet, imitate; rather, it is described in an effort to help the reader consider from a different vantage point (provided by the concept of analytic style) the way in which he, the reader, practices psychoanalysis.     

On the countertransference of the patient: Transformations of the psychoanalyst's 'theoretical self' and their possible articulations with the vicissitudes of the analytic relationship

In this paper the author examines one of the many levels of the analyst/analysand relationship: the possible interaction between the analyst's mental routes in relation to theories (also meant, but not only, as internal objects) and the vicissitudes of the psychoanalytic relationships with his patients. The author assumes that an important variable affecting the transformation of certain therapeutic relationships is the change that takes place in the relationship between the analyst and that part of his internal world where his theories find their place. He names this part of his internal world 'theoretical self', and 'precipitates of the analyst's theoretical self' those complex formations, akin to more or less cohesive conglomerates, that are formed by his relationship to theories and to psychoanalytic institutions, and by the various, 'personal' internalised objects. The psychoanalyst will relate to these precipitates in a variety of ways, and he will make use of them mostly at an unconscious level in his analytical work; and his patient is likely to 'react' to them, almost chemically. The author also offers some working indications: the psychoanalyst, despite his knowledge of some aspects of his own countertransference, is in fact lacking in knowledge, unless he constantly does some extra work focusing on how his mental position (i.e. the relationship with the precipitates of his theoretical self) may intervene in any of the therapeutic relationships that he establishes-not necessarily in the same way in each of them. The author also illustrates his reflections and conceptualisations by reporting dreams and excerpts from sessions taken from three psychoanalytic treatments in the course of several years.     

THE EXTERNAL OBSERVER AND THE LENS OF THE PATIENT-ANALYST MATCH

A focus on the match between patient and analyst places attention on the dynamic effect of the interaction of character and conflict of both participants on the process that evolves between them. Match is neither a predictive nor static concept. Rather it refers to an unfolding transaction that itself shifts and changes during the course of analytic work. The treating analyst's perception of the effect of this match is by necessity limited by the analyst's own blind spots and other countertransference phenomena. Reporting the analyst's clinical experience to an analytically trained observer, external to the dyad, may broaden the analyst's perspective. Using the lens of the match, a colleague in the role of supervisor, consultant or peer can provide feedback from which the analyst may acquire insight. As a result of this process, the influence that the participants' similarities and differences have upon each other becomes clear to the analyst. This awareness, in turn, may lead the analyst to appreciate the effect of the analyst's stance of distance or closeness and to evaluate whether at this phase of treatment it is beneficial or detrimental to the analytic process. Clinical illustrations of the effect of the external observer's feedback in relation to the patient—analyst match are provided.     

Playing one's cards face up in analysis: an approach to the problem of self-disclosure

A policy of consistent willingness on the analyst's part to make his or her own views explicitly available to the patient is discussed and illustrated by clinical vignettes. Playing one's cards face up is contrasted with contemporary conceptions of selective self-disclosure by the analyst, especially with respect to the way ground rules for the analytic treatment relationship get established. The objective of the analyst playing his or her cards face up is to create a candid dialogue, thus facilitating maximally effective collaboration between analyst and patient. Concerns about the analyst's self-disclosure foreclosing exploration of the patient's unconscious fantasies and transferences, or intruding upon the patient's autonomy, are addressed, as is the relation between self-disclosure and an individual analyst's personal style.     

Hearing voices: the fate of the analyst's identifications.

Using detailed clinical examples, the author illustrates the function of conscious and unconscious identifications with former training analysts, supervisors, teachers, and theorists in the mind of the working analyst. As compromise formations, analytic identifications are the product of loving and aggressive wishes, defenses against those wishes, and self-punitive trends that accompany the analyst in the work. The analyst's stance at any given moment has an identificatory history that may become conscious at certain times with certain patients. While the analyst's identifications modify over time, following a predictable developmental path, they are never fully given up, but consciously and unconsciously remain an active part of the analyst's inner life. During the clinical hour they are responsive to both the analyst's and the patient's conflicts, and they coexist in a dynamic reciprocal relationship with the patient's inner life.     

Losing a training analyst for ethical violations: A candidate's perspective

The author presents her experience as the analysand of a training analyst who was investigated and expelled for ethical violations with another patient, including sexual-boundary violations, during her analytic training. While boundary violations by training analysts are not uncommon, the particular trauma experienced by 'bystanders' such as candidates and supervisees is not discussed in the literature, nor the response of institutes to the educational problems that are generated. The author illustrates the complications for candidates that arise from the dual roles of training analyst as educator and analyst when he or she faces investigation or censure, including isolation and secrecy, which promote various splits in the candidate, analytic dyad and group, as well as loyalty conflicts. The discussion covers three phases of the author's experience as a candidate-analysand, namely the period encompassing the institute's ethics investigation, the announcement of findings to her and to the institute as a group, and the ensuing individual and group dynamics generated by her analyst's expulsion from the institute and revocation of his medical license. Theoretical perspectives are utilized to understand the group regression, including contamination and contagion fears, which occurred in the wake of the training analyst's expulsion, and the impact of these processes on the candidate, including the pressure to function as a 'container' for projections of the group. Implications and recommendations for candidates and institutes are made for dealing helpfully with trainees who are affected by the process of dealing with a training analyst's ethical violations. Short-term and longer-term outcomes of the experience are considered.     

Can transference interpretation as expert evaluation be analyzed?]

Usually the patient is excluded from the evaluation procedure which is necessary to carry out psychotherapy or psychoanalysis. Neither does he know the report of his treating analyst to the expert, nor the latter's report to the medical insurance company that covers the cost of his treatment. In his article, the author suggests to include the patient actively in this process, by giving him access to the evaluation procedure. He maintains that, as long as the procedure is unknown to the patient, its subconscious meaning cannot be analysed, and the analyst's contribution to the process of transference in this area remains obscure.