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.     

On the immediacy of unconscious truth: understanding Betty Joseph's 'here and now' through comparison with alternative views of it outside of and within Kleinian thinking

Psychoanalysis emphasizes that in discovering psychic truth what is needed is not abstract or distant knowledge of this truth but rather an immediate encounter with it. In this paper the author examines the meaning of this immediacy through the study of Betty Joseph's notion of 'here and now,' which in recent years has been most directly associated with it. The author shows how Joseph's notion of 'here and now' continues a legacy beginning in Freud and taken up by Klein regarding the immediacy of unconscious truth that differs from other available analytic formulations of the term. To highlight the uniqueness of Joseph's contribution the author goes on to examine what distinguishes it within the kleinian framework. She does this in part through comparison with the clinical approach of Hanna Segal, whose focus on unconscious phantasy adheres to the same foundational legacy. The author points to the differences between Joseph and Segal and their significance, which have not been sufficiently elaborated in the analytic literature. She argues that viewing these differences within the context of a shared perspective on the role of unconscious truth in the analytic process and task enriches our understanding of the complexity of kleinian thinking and the meaning of truth in psychoanalysis. This understanding is also furthered by the recognition that many uses of the term 'here and now' in the analytic literature refer to something very different from what Joseph refers to and are based on a perspective that is fundamentally opposed to hers.     

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 role of the analyst in the analytic cure during times of chronic crises

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.     

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.     

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.     

Insight and the analytic dyad

Insight reflects the unitary nature of psychic activity in contrast to the fragmentation created in abstracting categories for the purpose of study and discussion. The unique analytic clinical dyad offers a structure in which intrapsychic fragments can be actualized and integrated. As a result, the analyst's contribution is more crucially one of exploration than of revelation. Whatever the area of examination, past or present, the link to analytic immediacy offers the opportunity to make meanings meaningful, to convert known facts to psychic truths. The analyst's clinical task requires his private self-analysis as part of the collaborative exploration of how the patient's mind works. Higher level ego functioning, including acutely active remembering, is at times transiently loosened in order for the analyst to share in the clinical work of discovery. The words the analyst uses to communicate his understanding convey only approximate manifest meanings, though they structurally reveal deeper messages of importance to the patient. These verbal approximations help stimulate self-reflection in the analysand as a step in the process of gaining insight.     

Life-threatening illness in the analyst

The literature on practicing throughout a life-threatening illness is reviewed and important differences about attitudes toward self-disclosure are understood by noting a division between two perspectives on transference: "one-body" and "two-body" views. The analyst's use of self-disclosure is informed by the prominence given the interpretation of transference as against that given the patient's needs in the collaborative relatedness supporting the therapeutic alliance. Themes and illustrative clinical vignettes are presented from the author's own experience practicing during such an illness. Three phases of working during illness are delineated, each somewhat different regarding the analyst's state, and hence patients' needs and reactions. Recommendations are made regarding conditions that make it possible to work effectively during a life-threatening illness. The analyst needs help from his or her own analyst to make the clinically and sometimes ethically appropriate decisions about practice; while this is important in instances in which the analyst recovers, it is essential should the analyst become terminal and face more certain death.     

A patient's transference to the analyst's supervisor: effect of the setting on the analytic process

A case is presented in which the patient's transference to the analyst's supervisor became evident just prior to the switch from clinic to private patient status. The patient experienced the supervisor as a restraining father figure who protected her from acting on her erotic wishes toward the analyst. Analysis of this led to the recall of previously repressed memories of sexual wishes toward her brother, and the sense of protection from these wishes that she had gotten from the presence of her father. The literature on transference involving the supervisory constellation and the training setting is reviewed, and the concepts of split and institutional transference are examined. Factors inhibiting the analysis of patients' fantasies about the analyst's status as trainee, including the presence of the supervisor and the institute, are discussed.     

Psychic reality in the psychoanalytic process.

The case is made for regarding psychic reality as synonymous with subjective (conscious) experience, which is inherently open to, but not reducible to, unconscious determinants. Both analyst and analysand engage in the analytic relation and interaction from the perspective of their respective psychic realities. Thus, components of the analytic relation--transference/countertransference, alliance, and real relation--are forms of psychic reality. The tensions of subjectivity and objectivity are discussed in relation to the analytic situation, especially with regard to whether the patient's or the analyst's psychic reality is to be given priority or preference. The same reality, situation, or relationship can be viewed from different perspectives and subjected to varying interpretations without any one being exclusively true or false-each may be partially true and/or partially false. The patient's recounting of his history is a part of the patient's psychic reality that intersects with a necessarily divergent account constructed by the analyst. The ensuing dialogue seeks a form of real coherence that is mutually realistic and makes realistic sense for both parties. Reliance on subjective psychic reality becomes a possible, but precarious and potentially misleading, basis for analytic understanding without other observational (verbal and behavioral) or objective data.     

Countertransference enactments informed by cancer in an analyst's child

The author's son was diagnosed with Hodgkin's lymphoma in the spring of 1997. She traces the impact of this trauma on her practice, with specific emphasis on her experience as both analyst and mother, and on the related countertransference feelings and enactments. The paper discusses in detail the analyst's effort to determine for each patient whether or not to disclose the fact of her son's illness, the internal conflict she experienced over those decisions, and the effects of her decisions on her patients. An extensive case discussion focuses on a patient who appeared to intuit in a dramatic fashion the traumatic events in the analyst's private life.     

Countertransference evolution in theory and practice

A framework is suggested for conceptualizing countertransference, based on expansion of the concept emerging subsequent to Freud's original view of the phenomenon: from Ucs to Cs, from reactions to transference to all reactions, from the analyst's neurosis to the analyst's functioning, from self-analysis to self-scrutiny, from obstacle to contribution. Particular attention is called to the advantages of maintaining the distinction between the patient's transference and the analyst's countertransference; the importance for successful psychoanalytic work of being aware of the subtleties of countertransference in work with neurotic patients, especially in contrast to the blatant countertransference experiences more disturbed patients thrust upon the analyst; the need for further investigation of the relations between the analyst's empathy, regression, and countertransference; the lack of understanding of and information about the homosexual countertransference, based on insufficient knowledge of the mechanisms of resistance to self-analysis, among other reasons; and the need for more reliable information about the limits of and indications for using countertransference responses in particular kinds of clinical situations, whether for informing the patient as to the analyst's responses to him, for informing the analyst in the interpretive process, or in formulating reconstructions. A clinical example provides an illustration of the complexity of countertransference-transference interaction and of the impact of countertransference on the transference.     

Analysis of transference: A North American perspective

Using detailed clinical vignettes, the author illustrates and compares several North American approaches to the analysis of transference, tracing their origins in Freud's works and in various post-Freudian conceptualizations, including the writings of Anna Freud and Charles Brenner. Particular attention is paid to the work of Merton Gill, Evelyne Schwaber, Paul Gray, and the British analyst, Betty Joseph. Discussed and illustrated are controversies over the broader and narrower views of transference, the interpretation of action in the analytic setting, earlier and later interpretations of transference with particular emphasis on the contrast between contemporary Kleinian and ego psychological perspectives, the role of extra-transference interpretation, and the concept of the transference neurosis. An argument is made for an integrative approach, drawing upon different emphases, depending on the clinical circumstances and the point of affective immediacy for the patient, which may or may not coincide with the point of affective immediacy for the analyst.     

Critical realism: distinguishing the psychological subjectivity of the analyst from epistemological subjectivism

To clarify the concepts of critical realism, subjectivity, and subjectivism, distinctions are drawn among ontological subjectivism, moral subjectivity, psychological subjectivity, and epistemological subjectivism. Psychological subjectivity, including the ongoing affective life of the analyst, is an essential aspect of the analyst's response to the patient, and may either facilitate or distort an adequate observation of transference and countertransference dynamics and of the psychic reality of the patient. Subjectivism in current psychoanalytic literature involves an argument that there is an "irreducible" subjectivity in the analyst, who is bound to see things from an incorrigibly personal point of view, such that there is no substantial subject-object differentiation between analyst and patient. Issues of authoritarianism in the analyst, or of pathological certainty, should not be confused with the issues of epistemological objectivism. The concept of critical realism or scientific objectivism includes the essential idea that there is no pure knowledge, no complete knowledge, that often evidence is insufficient for knowledge of some aspect of nature, and that care must be to taken understand what is sufficient knowledge in a given area, in this case clinical psychoanalysis. The question is raised whether "projective identification" makes the sorting out of "what comes from whom" impossible. It is argued that when free association is sufficiently facilitated, when there are enough corrections of the distortions wrought by transference and countertransference, when defenses are analyzed, and when sufficient subject-object differentiation is recovered, the analyst can get to know enough of the patient's psychic reality for the therapeutic and scientific purposes of psychoanalysis.     

The illumination of history

Formulations regarding the patient's history have not only played an important part in understanding the patient, but interpretations explicitly linking the present with the past have been seen as central to the therapeutic process. In this paper the author considers the role of historical reconstruction in bringing about psychic change. He emphasizes the therapeutic value that lies in the exploration of the way the patient's history is embodied in his internal object relationships, becoming manifested in the transference-countertransference relationship. The author presents clinical material which he suggests allowed the analyst to follow the way the patient's internal object relations, coloured by her history, became expressed and played out in the sessions. He suggests that, when these processes can be followed and addressed in the present, this may lead to a diminution in the underlying anxieties. This can thus promote psychic change by freeing the patient's capacity to achieve a sense of connection with her history, and to tolerate the meaning of what emerges, which illuminates both the present and the past.     

Tactics and empathy: Defences against projective identification

In this paper the author argues that interpretations made when the analyst has not done the emotional work of recognising and bearing what kind of object she has become in the patient's psychic reality will be experienced as empty tactics – even lies – rather than interpretations of integrity. However, interpreting from a position of bearing the truth of the patient's perception will be technically difficult and indicate turmoil as the analyst struggles to take in the patient's view of her. If the analyst avoids integrating her own picture of herself with the patient's picture (despite giving voice to the patient's picture) the split inside the analyst will be felt and intensify the patient's need to split. Vignettes demonstrate how the analyst, believing she is trying to understand, may become a projective‐identification‐refusing object and the issue of the analyst's disclosure of her countertransference is examined. Ultimately, the author argues, a capacity to receive and bear projective identification requires empathy with both patient and analyst‐as‐patient's object, engaged in a process about which both are ambivalent.     

A note on notes: note taking and containment

In extreme situations of massive projective identification, both the analyst and the patient may come to share a fantasy or belief that his or her own psychic reality will be annihilated if the psychic reality of the other is accepted or adopted (Britton 1998). In the example of' Dr. M and his patient, the paradoxical dilemma around note taking had highly specific transference meanings; it was not simply an instance of the generalized human response of distracted attention that Freud (1912) had spoken of, nor was it the destabilization of analytic functioning that I tried to describe in my work with Mr. L. Whether such meanings will always exist in these situations remains a matter to be determined by further clinical experience. In reopening a dialogue about note taking during sessions, I have attempted to move the discussion away from categorical injunctions about what analysis should or should not do, and instead to foster a more nuanced, dynamic, and pair-specific consideration of the analyst's functioning in the immediate context of the analytic relationship. There is, of course, a wide variety of listening styles among analysts, and each analyst's mental functioning may be affected differently by each patient whom the analyst sees. I have raised many questions in the hopes of stimulating an expanded discussion that will allow us to share our experiences and perhaps reach additional conclusions. Further consideration may lead us to decide whether note taking may have very different meanings for other analysts and analyst-patient pairs, and whether it may serve useful functions in addition to the one that I have described.     

Countertransference, conflictual listening, and the analytic object relationship

Analytic listening is an ongoing conflictual process, containing all the components of conflict and shaped in every moment by both the patient's and the analyst's conflicts. The mutual responsiveness that develops between analyst and patient stems from a complex conflictual object relationship, fundamentally no different from any other object relationship, in which countertransference at all times simultaneously facilitates and interferes with the analytic work. Detailed clinical process is used to illustrate these and related phenomena, including the use of signal conflict, the benign negative countertransference, the function of countertransference structures, and the analyst's use of projection. The analyst's affects, thoughts, and actions trace the shifting nature of the patient's transference and resistance, and the level of the object relationship continuously being created between patient and analyst.     

Embodying analysis: the body and the therapeutic process

This paper considers the transfer of somatic effects from patient to analyst, which gives rise to embodied countertransference, functioning as an organ of primitive communication. By means of processes of projective identification, the analyst experiences somatic disturbances within himself or herself that are connected to the split‐off complexes of the analysand. The analysty’s own attempt at mind‐body integration ushers the patient towards a progressive understanding and acceptance of his or her inner suffering. Such experiences of psychic contagion between patient and analyst are related to Jung’s ‘psychology of the transference’ and the idea of the ‘subtle body’ as an unconscious shared area. The re‐attribution of meaning to pre‐verbal psychic experiences within the ‘embodied reverie’ of the analyst enables the analytic dyad to reach the archetypal energies and structuring power of the collective unconscious. A detailed case example is presented of how the emergence of the vitalizing connection between the psyche and the soma, severed through traumatic early relations with parents or carers, allows the instinctual impulse of the Self to manifest, thereby reactivating the process of individuation.