Impact upon therapy and the therapist when working with suicidal patients: some transference and countertransference aspects

The suicide, or attempted suicide, of a client/patient is something that a substantial number of counsellors and psychotherapists have encountered during their career. The literature indicates that this can be a cause of anxiety for many. In this paper the experience of psychotherapists working with suicidal patients is explored. One hundred psychotherapists were surveyed, by means of a postal questionnaire. Five follow-up interviews were conducted. The findings indicate that suicidal patients can evoke intense feelings within the therapist, and the meanings of this are discussed. The links with the concept of projective identification are particularly considered. It is noted how such feelings, experienced within the transference relationship and the therapist's own countertransference, can reflect the inner world of the patient concerned. The psychotherapists described how they felt themselves to have been affected by the work, both personally and professionally. Commonly mentioned responses included feelings of hopelessness and helplessness and a sense of failure. Finally, the respondents outlined measures that they believed to be vital for their own support. The importance of firm boundaries and staying in the therapeutic role is discussed.     

The impact of transference and countertransference in activity group therapy

The effective use of countertransference reactions in children's group psychotherapy is discussed. Countertransferences activated by the group dynamics or by the dynamics of individual group members must be analyzed and understood by the therapist if they are to be utilized. The analysis of resistances in children's therapy groups is enhanced by the therapists' awareness of their own countertransference reactions. Clinical examples are presented.     

On psychotic transference and countertransference

Following a brief discussion of the primary types of psychotic transferences, viewed from a theoretical position combining ego psychology with an object relations approach, the author presents detailed clinical material illustrating these transferences. The analyst's countertransference in work with such patients is also discussed in depth, including its use as a unique window into the patient's inner world.     

Supervision, transference and countertransference

The author discusses supervision, transference and countertransference as seen in the context of the clinical case of a patient who had been first seen as a training analysis case and who later, in a fortuitous way, was treated by the supervisor of the training analysis. The supervisor, who in the first instance did not recognize the patient, discusses the reasons for this unusual experience in terms of the presence and absence of transference during the analysis of this patient as a training case and the problems inherent in the task of supervising. The patient's feelings towards the first and the second analyst and the vicissitudes of transference and countertransference during the supervision of the training analysis and its influence on the presentation of the analytical sessions by the student are also detailed and discussed. The question of recorded supervision presentations and their possible influence on the dynamics of supervision is raised.     

Reflections on transference and countertransference reactions in the treatment of AIDS patients

Proceeding from experiences she made in the treatment of AIDS and pre-AIDS patients the author describes the psychodynamics of their situation and subsequently discusses the specific problems of transference and countertransference reactions. She also suggests the possible coincidence of social and personal fear of contact in the course of treatment.     

Omnipotence in the transference and in the countertransference

The concept of omnipotence refers to a primitive fantasy, a mechanism of defense, and a pathological psychic structure. Omnipotence and its derivative defensive operation, omnipotent control, are highly prevalent in borderline personality organization. Three clinical vignettes illustrate these mechanisms in the treatment of patients with borderline, narcissistic, and obsessive personality disorders, respectively. These vignettes illustrate the transference developments when omnipotence and omnipotence control are dominant, and the therapeutic approach to these conditions.     

Paternal empathy in the transference/countertransference relationship

This paper explores the process of paternal empathy within the context of the transference and countertransference relationship. The masculine and feminine elements of paternal responsiveness are described with implications for therapeutic resonance and mirroring. Case material illustrates the author's thesis.     

Types of sexual transference and countertransference in psychotherapeutic work with children and adolescents

The question of normal sexuality begins to arise in the treatment of severely sexually abused or sexually offending patients. The author suggests that it is an interesting and delicate moment during the process of recovery when less perverse, more normal sexuality appears mixed with, or even disguised by, the more habitual perverse fantasies. Writers in the adult field have drawn distinctions between perverse, eroticized and normal erotic transferences, and between Oedipal and post-Oedipal sexuality. Some have also distinguished between countertransferences in the analyst of an erotised versus a normal erotic nature. The paper discusses whether these distinctions could have any relevance for child patients. Freud and Klein have taught us much about the child's sexuality in relation to his interest in and attraction to his parents as sexual beings. But can we also detect some origins in earlier experiences in infancy of the child's later capacity to feel himself a sexual being capable of being wanted by an other? How might such a feeling of sexual self-worth differ from narcissism and from sexualised exhibitionism? The paper asks how therapists might deal with such problems and such possibly healthy developments.     

The impact of race and ethnicity on transference and countertransference in combined individual/group therapy

Interracial group psychotherapy is workable. Psychodynamics get cathected onto race; as this paper will show, the group process elicits feelings about racial and ethnic differences with greater intensity than in individual therapy. Analysis of race/ethnicity can be both problematic and growth enhancing for treatment. The process of identifying conscious and unconscious feelings and thoughts of race/ ethnicity can stimulate major resistance, which can engender difficulties in maintenance of a working alliance. However, the working through of these feelings/thoughts may have a catalytic effect and lead to a more rapid unfolding of core psychodynamic issues. Case material from a multi-racial/multi-ethnic therapy group illustrate these issues.The author wants to thank Drs. Nina Fieldsteel, Bob Addison, and Judith Caligor for their support and critical commentary, and Helene Kylen for her editorial assistance. An earlier version of this paper was presented in 1986 at Culture, Race, and Ethnicity in Group and Family Therapy, sponsored by Eastern Group Psychotherapy Society, New York University, and the University of Puerto Rico.     

Reality in analytic group psychotherapy: Beyond transference and countertransference

This study reports the results of a questionnaire, applied to therapists and their patients in 14 analytic therapy groups. It was found that the patients studied had an accurate perception of the group reality in the following dimensions: therapists' preferences for the members in their groups; power position held by each member in the group; and therapeutic benefit achieved by members in the group. Support was given to the existence of a relation among popularity, power position and therapeutic benefit; members who rated high in one of these variables generally were assigned a high position in the other two, and vice versa. These results suggest that patients in analytic group psychotherapy can be objective in their perceptions of the group reality, and that these perceptions are not always distorted by transference. The idea that, no matter how low-disclosing therapists remain, the patients in their groups will perceive their attitudes and feelings was supported by patients' accuracy in perceiving their therapists' preferences for members in their groups. These findings indicate the important role played by reality and the real relationship in psychoanalytic group psychotherapy.     

Impervious and intrusive: The impenetrable object in transference and countertransference

The author describes an internal object that he calls the ‘impenetrable object’ which has two characteristics: being impervious to the projections from the patient and being intrusive, i.e. projecting into the patient. It arises out of an early relationship with a mother who may be generally disturbed or traumatized so that she is unable to take in or tolerate the child's projections and may use the child as a receptacle for her own projections. He links the concept of an impenetrable object with other concepts such as Williams's ‘reversal of the container–contained relationship’ and Green's ‘dead mother’. If such an object dominates the patient's internal world, it can lead to severe difficulties in the analytic process. Interpretations may be experienced as violent projections from the analyst which the patient has to ward off and the analyst may enact an impervious or intrusive object in various ways. The author describes a case in which such dynamics played a significant role. He argues that intensive work in the countertransference is required to detect subtle enactments and allow a shift in the analyst, which in turn can enable change in the patient. He gives clinical material that demonstrates such work by the analyst and illustrates the shift from an impenetrable object to a more permeable one in the patient's internal world.