Learning about psychoanalysis combined with medication: a nonphysician's perspective

When medication is at play in an analysis, the nonphysician candidate or psychoanalyst faces conceptual and practical challenges, as well as countertransference risks and opportunities. A psychologist psychoanalytic candidate describes the treatment of an analysand who underwent a gradual uncovering and worsening of obsessive-compulsive and anxiety symptoms; at twenty-one months, the analysand introduced the topic of medication. These developments brought to light transference and countertransference themes connected to the analyst's status as a non-physician candidate; conceptual and practical uncertainties about medication in the context of psychoanalysis; the complex meanings of, and indications for, medication in this case; and the ramifications of a nonphysician candidate's referring a patient to a psychiatrist psychoanalyst for medication while being supervised by another psychiatrist psychoanalyst.     

Tom Thumb in hospital: The fairy tale workshop in a paediatric oncology and haematology ward

Abstract

Definitions of and attitudes towards countertransference have changed throughout the twentieth century. From being seen as a contaminant in the analytical process, countertransference has come to be seen by many therapists as a potentially useful source of information about a client and his or her problems. There are dangers as well as benefits associated with analysis and utilization of countertransference. This article reviews these issues and proposes some guidelines that therapists may find useful when contemplating their countertransference reactions to clients, and when considering how best to utilize these.     

Executive functioning and compliance in HIV patients

25 adult HIV patients were evaluated in a study of appointments, medication, and compliance with restrictions on sexual activity. The Executive Interview (EXIT) was useful in assessing these patients for cognitive difficulties; compliance with medication and countertransference issues were negatively correlated with EXIT scores.     

Concurrent group and individual psychotherapy in a psychiatric day hospital for depressed elderly

Concurrent psychotherapy is used in various settings for patients of different diagnoses and ages. The concurrent group and individual psychotherapy of older adults with depressive disorders in a psychiatric day hospital is described, emphasizing phases of treatment and transference and countertransference themes uniquely relevant to working with depressed elderly patients in a day hospital. Case examples are offered to illustrate these issues. The special technical considerations that need to be utilized when multiple therapists and settings are present are described. The model employs the use of an integrative, interactive group therapy, along with various other group treatments and antidepressant medication, with individual therapy serving a subordinate but organizing role.     

Countertransference in defense enactments

A clinical term is introduced to capture a defense that develops with the patient's deepening but fleeting awareness of painful transference feelings. The analyst's attention to countertransference in such situations is central to the analysis of these defenses. An attempt is made to distinguish defense enactments from other types of defenses, and to differentiate the analyst's countertransference reaction to this type of defense from countertransference reactions that might appear similar. The reasons for this dynamic in the interpersonal space are explored, and a clinical example that describes this phenomenon in the analytic moment is given.     

Potential Sources of Countertransference Among Religious Therapists

Relational approaches to counseling emphasize the monitoring of countertransference responses as a crucial component in the therapeutic process. Six potential sources of countertransference are discussed that are specific to religious therapists and which may be easily overlooked. These responses are related to the therapist's identification with a community of faith, and they may have a detrimental impact on therapy if they are not monitored. A brief overview of the historical and contemporary understanding of the concept of countertransference is presented. Recommendations are offered for the effective management of these countertransference responses.     

Technique and countertransference in Freud's analysis of the Rat Man

Freud's records of his treatment of the Rat Man constitute a unique document in the history of psychoanalysis. Through the years different analysts have used these records to support different theories about analytic technique. Certain non-interpretive interventions of Freud's have especially aroused their interest, and many reasons have been put forward to "explain" Freud's behavior. One reason never yet advanced and documented is that a countertransference tension may have been involved in one of these instances. This is surprising, since countertransference is a necessary part of every analysis. Evidence is presented that Freud's behavior may indeed have been under the sway of countertransference. Some recently discovered details concerning his early life are discussed as constituting a plausible background for ths countertransference enactment.     

Medicating Patients in Psychoanalytic Therapy: Implications for Introjection,Transference, and Countertransference

If a patient comes for psychotherapy or psychoanalysis, why medicate him with psychotropic drugs? The answers to this question are explored and addressed from several points of view. The central hypothesis of this paper suggests that most of the reasons for medicating patients have to do with therapist's unresolved countertransference issues. Furthermore, medicating a patient may have deleterious effects on his introjected sense of self, and impacts the transference relationship in a significant way. The issues surrounding medication as adjunctive therapy are elucidated and clarified in terms of rationale, efficacy, and the impact on the psychotherapeutic relationship. Psychoanalytic solutions are offered and discussed.     

The merits and problems with the concept of projective identification

This paper reviewed the merits of and problems with the concept of projective identification. On the negative side, lack of universal meaning of the term was cited. Personal countertransference receives little regard, while an isomorphic reading of patient feelings may be used to gratify omnipotent symbiotic analyst and patient fantasies. On the positive side, the concept offers a framework that can lead to deeper understanding of difficult therapeutic situations. It helps the analyst process and contain distressing feelings and eschews interpretation that can be destructive to the analytic process. Proper use of projective identification should engage the patient's ego rather than foster passivity and merger wishes. Case material was presented which illustrated problems with and merits of the concept. Personal countertransference, especially therapeutic omnipotence, was shown to receive insufficient attention. The important role of complementarity in projective identification was illustrated in the treatment of depression, a disorder which can offer difficult treatment resistances. In conclusion, the concept should not be used as a justification for analyst omnipotence and avoidance of countertransference responsibility. The concept, however, can lead to a deepening of the analytic situation if it is used with caution and respect for the patient's separateness.     

Working with countertransference

The transference-countertransference relationship is only one of five modalities of relationship that research has identified as potentially present in the therapeutic encounter. This paper gives the background and definition to one aspect of this - the countertransference - and traces the development of the concept from Freud's first use of the term in 1910 to the contemporary view that it is a useful tool of psychotherapy. The first part explains its connection with the Kleinian concept of projective identification and discusses its elaboration by the object relations school. There is general acceptance nowadays that the countertransference contains a great deal of information about the client's psychological world. It is therefore important to understand this process and the authors have identified three main dimensions to countertransference. These are its vector (or direction and force), its variance (the quality it represents), and its valence (its effect on the client). The second part of the article illustrates, through the use of example and metaphor, how these three dimensions are defined and can be recognized. Common themes and paradigms of countertransference are identified and discussed along with some ways in which experience has shown how these might be contained and worked with constructively. Finally, a clinical vignette is presented in which some of the dimensions of countertransference are identified and used to understand the client's psychic world and foster therapeutic change.     

Experiences of Countertransference: Reports of Clinical Psychology Students

While historically linked with psychoanalysis, countertransference is recognised as an important component of the experience of therapists, regardless of the therapeutic modality. This study considers the implications of this for the training of psychologists. Fifty‐five clinical psychology trainees from four university training programmes completed an anonymous questionnaire that collected written reports of countertransference experiences, ratings of confidence in managing these responses, and supervision in this regard. The reports were analysed using a process of thematic analysis. Several themes emerged including a desire to protect or rescue clients, feeling criticised or controlled by clients, feeling helpless, and feeling disengaged. Trainees varied in their reports of awareness of countertransference and the regularity of supervision in this regard. The majority reported a lack of confidence in managing their responses, and all reported interest in learning about countertransference. The implications for reflective practice in postgraduate psychology training are discussed.     

On countertransference enactments

This communication focuses on the relation of countertransference to psychoanalytic technique, calling attention not to the more obvious forms of countertransference that have been commented on by previous writers on the subject, but to its subtler ones. Often well camouflaged within the framework of traditional, time-tested techniques, this aspect of countertransference may attach itself to our way of listening and thinking about patients, to our efforts at interpretation, to the process of working through, or to the complex issue of termination. Less recognizable than its more boisterous counterpart and in some respects less tangible, this side of the problem of countertransference is no less important. For it is precisely those subtle, often scarcely visible countertransference reactions, so easily rationalized as parts of our standard operating procedures and so easily overlooked, that may in the end have the greatest impact on our analytic work.     

The Mastery of Countertransference or Mynothaur's Labyrinth

This paper considers the fundamental change introduced by Ferenczi in 1919 by proposing the use of countertransference as an instrument. Basically it reconsiders the concept of analytic neutrality; mastery of countertransference is reached through tolerating it, overcoming resistances against it, demanding a very intense involvement of the analyst, as opposed to the image of the surgeon or the mirror. The paper analyzes the implications of this position for psychoanalysis. It places these concepts in the scientific and personal context in which it was written, then follows the later developments of these ideas in Ferenczi's own work, as well as in that of some other authors, and comments on the effects of these ideas on the psychoanalytic movement. Finally it poses some questions regarding our present use of countertransference in clinical work, with two brief vignettes highlighting these points.     

Antidepressant medication in the treatment of agoraphobia: A critical review

The present article critically examines research on the use of antidepressants in treating agoraphobia. A number of studies have shown certain classes of antidepressant medication, namely tricyclic antidepressants and MAO inhibitors, to have beneficial effects on certain aspects of the agoraphobic syndrome. However, these studies must be interpreted with caution in light of two major methodological shortcomings, i.e. sole reliance on paper and pencil outcome indices and the confounding of the pharmacological effects of the drug with exposure to feared situations. Recent research, aimed at correcting for these methodological problems, seriously question the efficacy of antidepressant pharmacotherapy by itself as a treatment for agoraphobia. Moreover, it is argued that the disadvantages of drug treatments namely agoraphobics' reluctance to take medication, physical side effects and relapse upon withdrawal of the medication, caution against their routine use in clinical practice.     

A behavior-analytic conceptualization of the side effects of psychotropic medication

A range of behavior-much deemed problematic by society-is treated with behavioral methods or psychotropic medications. Although the processes associated with behavioral interventions have been investigated using conceptual, experimental, and applied analyses, less is known about the behavioral processes associated with the use of psychotropic medication. Psychotropic drugs produce at least two types of effects of behavioral interest: (a) primary effects of drug action on target behaviors and (b) side effects that change the target or other behavior. Although an empirical literature exists regarding the former effects, little attention has been given to the latter topic. In this paper we offer a conceptual analysis of the side effects of psychotropic medication. We propose that the side effects of various drugs can influence behavior by functioning as motivating operations, conditional or discriminative stimuli, or by establishing new response-reinforcer relations. This conceptualization may facilitate the empirical analysis of how psychotropic drugs change behavior.     

Countertransference as Projective Identification

SUMMARY

While all countertransference reactions call upon the therapist to examine his/her internal family and unresolved issues, many instances of countertransference can best be understood as originating from and replicating and clients' internalized object relations. In this way, countertransference can be likened to projective identification. By processing countertransference as a form of projective identification the couples therapist can more effectively comprehend and work with important relationship problems. This article outlines the process of analyzing and responding to these kinds of countertransference reactions.