Countertransference and containment in a patient with a psychotic mother

The importance of countertransference reactions in the treatment of a borderline patient with a psychotic suicidal mother is discussed. In such a case containment can be seriously disrupted by the violence of the patient's projections into the therapist. Where a psychotic internal object has been brought for treatment it is particularly important that the therapist be able to identify not only with the sane and mad parts of the patient but with the destructiveness and cruelty of the patient and her primary object. The difficulties of tolerating these relentless projections of madness and despair are increased by the multiple and confusing aims of the patient's excessive use of projective identification. The invasive and hostile aspects of this are often heavily disguised beneath idealization of the self and object as well as of madness itself. For the patient, attempts to interpret the idealization are moreover felt as an assault on the lost loved object, and the therapy then unconsciously becomes a persecutory experience for the patient. The therapist can thus be drawn into feeling the full force of the anger and hatred towards the real disappointing object and the sense of hopelessness about the reparative task. Although such feelings need to be tolerated, eventually some distance from the often-unpleasant fluctuations in the countertransference must develop if a useful degree of containment is to be achieved.     

Countertransference as a complex tool for understanding the patient in psychotherapy

This paper shows some of the complexities of the analytic relationship and processes in psychotherapy by focusing on the concept of countertransference. The development of the related concept of transference is briefly outlined and the history of the concept of countertransference and its place in the practice of psychoanalysis is presented. A clinical example is provided to illustrate some of the complexity of the issues that arise when the countertransference is used as a tool to understand the patient. Attention is drawn to the importance of sustaining the countertransference response until the transference aspects and the patient's unconscious communications have been recognised and understood. It is only at this point that an interpretation meaningful to the patient can be made.     

Countertransference envy toward the religious patient

Four illustrations have been presented which demonstrate the uses and interpretations of envy in countertransference reactions to religious patients. To be sure, envy reactions to any patient are significant, whether they simply distort the therapist's perception or contribute to a deeper understanding of the patient. In the case of the religious patient, envy reactions in the therapist may serve as an additional instrumentality for under-standing the ways in which the dynamic determinants of religious behavior and metaphor become enmeshed in and also transform the pathology of the patient as well as the therapeutic process itself. Both the constructive and destructive object relational implications of envy must be borne in mind by the therapist in order to adequately explore the range of reciprocating forces between therapist and patient. Primitive mechanisms such as projective identification and psychotic transference are particularly prone to evoke envy reactions of surprising intensities, yet an empathic attitude will usually enable the therapist to differentiate the true source of his envy as he more carefully comprehends the quality of object relational and dynamic needs such envy serves.     

Countertransference as a corrective emotional experience in existential family therapy

An existential approach to family psychotherapy should be cognizant of both individual human development and family life cycle growth. In Existential Family Therapy a family developmental challenge often occurs when the developmental progression needs of one family member challenge the pace of total family developmental progression. In such a situation intervention by the therapist should occur in a way that facilitates both individual and family developmental growth. Such interventions often best occur through the creative and controlled use of the family therapist's countertransference feelings in a way that helps the family accept and master its developmental challenges. Case material is provided to illustrate the described intervention approach.     

Countertransference as a prototype: The development of a measure

Countertransference is a concept that is widely acknowledged, but there exists little definitional consensus, making research in the area difficult. The authors adopted a prototype theory (E. H. Rosch, 1973a, 1973b; see C. B. Mervis & E. Rosch, 1981, for a review) to examine this construct because it conceptually fits well with constructs that elude explicit definition. In Study 1, 45 experienced psychologists highly agreed with the prototypicality of 104 different examples of countertransference providing support for the presence of a prototype. In Study 2, the usage of this prototype in a sample of 35 trainees was related to ability to perceive countertransference in a case example drawn from the literature and positively correlated with self-reports of their experiences of countertransference but not with their self-reported ability to manage countertransference once it was manifest. Implications for training and research are discussed.     

A psycho-analytical approach to the assessment of a psychotic patient

SUMMARY

When approached from a psycho-analytic point of view, psychotic states reveal a wide variety of patterns. Some of these are so complex and so rigid in their organisation as to render the patient quite unsuitable for formal psychotherapy. Others are more benign and accessible to a psycho-analytic approach.

The attempt to assess whether a psychotic patient might benefit from psycho-analytic psychotherapy can be facilitated by the use of certain psycho-analytic concepts which provide “ground rules” for decoding psychotic communication, for understanding the psychotic patient's experience and how it has come about.

This paper represents an attempt to show how the psychoanalytic approach to such understanding can help in the management of the case and open the way for psycho-analytic psychotherapy within the N.H.S. Although extremely limited in its provision of skilled psychotherapy, the N.H.S. provides an extremely rich potential for effective understanding, care and treatment of the psychotic patient if the psycho-analytic approach is sufficiently well understood and implemented.     

On the psychoanalytic treatment of a psychotic breakdown

The author discusses the four-session-a-week psychoanalysis of a patient in psychotic breakdown with outbursts of violence. The analyst's first appearance in the transference was as a "rattle" (the noise made by his shifting in his chair), which constituted undeniable evidence of corporality--first the analyst's and then the patient's--leading eventually to the awareness of there being two separate persons in the psychoanalytic relationship. This case highlights the analyst's need to function in a particular way, and to allow him- or herself to be used in a particular way, in working with very disturbed patients, where issues of the body-mind relationship and of separation from the other are often central to the analytic work.     

Countertransference as an Ally in Sexual Therapy

SUMMARY

This paper illustrates a constructive use of a persistent countertransference response of a therapist towards a client in sexual therapy. The recognition that the transference resistance from the client had multiple motivations assisted the therapist's constructive use of the countertransference to facilitate the treatment process of the couple.     

Somatic Countertransference as Evidence of Adhesive Identification in a Severely Traumatized Woman

This paper discusses the use of somatic countertransference as a means of learning about the patient, about projective and adhesive identification and about the object relating nature of the most traumatized and withdrawn part of the personality. It assumes an elemental knowledge of British Object Relations and uses clinical material to illustrate the hypotheses that somatic countertransference is an indicator of a very elemental communication occurring from the aspect of the psyche that is united in a body mind or mind body. The paper assumes that this body mind was object seeking at birth and perhaps before. Because these early aspects of the personality are non verbal and non conceptual, the analyst must rely not only on the verbal material in a session but on the emotional and sensual experiences within the transference and the countertransference. Such reliance requires a faith in one’s own intuition without a certainty that one is “right.” Because speaking of such early experience is difficult, often writers and analysts appear more certain than they are. This is a hazard of this type of analytic work. What I am writing about is conjecture or imagination or dream, but I am suggesting that such dream work is a valuable tool for analysis.     

The role of psychoanalytic assessment in the management and care of a psychotic patient

The pressure on mental health services to move patients on quickly, and the emphasis on the recovery model, can encourage a superficial assessment of the patient's difficulties. The author argues that a narrow definition of the medical model based on the presence or absence of symptoms ignores the deeper psychic structures that govern thinking and behaviour over time. A psychoanalytic assessment can offer a dynamic picture of deeper psychic structures in the patient's internal world. This is particularly important with psychotic patients who may successfully use denial and rationalization to cover up their underlying psychopathology. The developmental perspective inherent in the psychoanalytic view can also give a picture of the patient's propensity to repeat certain aspects of his/her psychopathology. In addition, a psychoanalytic approach may shine some light on the relationship between relapse and risk behaviour.     

Conditioning and post-hospital generalization of nondelusional responses in a chronic psychotic patient

An operant conditioning approach was successful in getting a chronic psychotic patient to give factual answers to direct questions that had previously elicited only delusional responses. Multiple baseline and reversal controls established that the changes were due to the experimental procedure. The subject was a female patient classified as paranoid schizophrenic who had persisted in giving bizarre responses to direct questions regarding her identity, age, and personal history during 26 yr of hospitalization. She was discharged after factual answers to these questions had been obtained, but operant conditioning trials were continued in the community to promote generalization. Two follow-up interviews were conducted 36 and 52 days after discharge to evaluate generalization. No generalization was found in the first interview, but the second gave evidence of some generalization.     

Countertransference in the movies: effects on beliefs about psychiatric treatment

This study examined the effect of viewing the movie Lovesick on college students' beliefs about countertransference and psychiatric practice. Consistent with the concerns of Gebbard and Gebbard (1985) that the public may develop erroneous beliefs about psychiatry from watching such movies, after seeing the film subjects were more accepting of sexual behavior between analyst and patient and were cynical about the motivation of the mental health professions in prohibiting such behavior.     

Countertransference as active imagination: imaginative experiences of the analyst

Active imagination is at the heart of Jung's elucidation of depth psychology. Yet, in the discourse of present day analytical psychology theory it is not always given the serious attention accorded to some other Jungian concepts. Active imagination emerges spontaneously within the 'third' area--the imaginal or dynamic field--in-between patient and analyst. It is commonly regarded as the patient's experience but I am proposing that, looked upon as the analyst's experience as well, active imagination offers a distinctly Jungian way of understanding some forms of countertransference. I am describing what I think many present-day analytical psychologists already do in their clinical practice but, as far as I know, it has not been theorized in quite this way before. The intention is to exploit the unique contribution of our Jungian heritage by reframing certain profoundly symbolic countertransference-generated imagery as active imagination. In this article these are differentiated from other less complex forms of imaginative countertransference through examples from clinical practice. The point is that such countertransference experiences may activate the symbolic function in the analyst and thus contribute to the mediation of emergent consciousness in the analysand.     

Therapist as Subject: A Review of the Empirical Countertransference Literature

This article presents a synthesis of the research on countertransference (CT) that has been conducted since the last major review of CT literature was published in 1977. The past quarter century has witnessed a growing body of research on CT marked by methodological improvements and increasing conceptual sophistication. In this article, the authors critically review this research, noting implications for counseling practice, making connections to relevant theory, and suggesting directions for future research on CT.     

Countertransference in the Group Psychotherapist

This report describes a pilot study of a waiting-list group (preliminary process group [PPG]) that provided treatment for applicants to a university affiliated, urban mental health center. All individuals on the treatment waiting list were informed of the PPG. This semistructured group, meeting weekly, began with members presenting their problems, followed by free discussion, and ending with goal setting for the next week. Approximately one seventh (35 out of 262) of the clinic's applicants during a 4½-month period chose to enter the PPG. They differed from those who chose not to particpate (wait list) by being older and less educated. Approximately 80% of both wait-list and PPG participants subsequently entered therapy. Significantly more PPG patients than those on the wait list entered group treatment. The PPG served clinic needs by providing prompt service for self selected individuals and by supporting the group therapy program.     

Varenicline-induced mixed mood and psychotic episode in a patient with a past history of depression

Varenicline is a promising agent with demonstrated efficacy in the promotion of smoking cessation. However, from the time of initial trials, it has been associated with significant psychiatric adverse effects. We describe a case where mixed mood and psychotic disturbance developed in an individual with a history of depression and a family history of bipolar disorder. Based on this case, we hypothesize a possible mechanism of action for these adverse effects and preventive measures that could be undertaken in its effective use.