On dreaming one's patient: reflections on an aspect of countertransference dreams

This paper explores the phenomenon of the countertransference dream. Until very recently, such dreams have tended to be seen as reflecting either unanalyzed difficulties in the analyst or unexamined conflicts in the analytic relationship. While the analyst's dream of his/her patient may represent such problems, the author argues that such dreams may also indicate the ways in which the analyst comes to know the patient on a deep, unconscious level by processing the patient's communicative projective identifications. Two extended clinical examples of the author's countertransference dreams are offered. The author also discusses the use of countertransference dreams in psychoanalytic supervision.     

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.     

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.     

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.     

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.     

Some thoughts on empathy and countertransference

Two aspects of countertransference-namely, the countertransference reaction and empathic understanding-must be distinguished. The term countertransference should be reserved exclusively for the conscious reactions of the analyst emerging from the preconscious by virtue of the patient's current transferences; the term empathy should be used to denote a perspective whereby the analyst employs current countertransference reactions for an understanding of the patient's inner 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.     

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.     

Transference-countertransference

This paper concerns the dynamics of transference-countertransference as they reveal themselves in object relations and specifically in the psychoanalytic process. It is postulated that transference and countertransference cannot be viewed separately, that both analyst and patient exhibit transference-countertransference reactions, and that they are normal ingredients of the psychoanalytic process. Brief clinical illustrations are provided. Attention is called to special problems when the patient's defenses are primitive, and to the therapeutic value of the analyst's countertransference.     

ON MISREADING AND MISLEADING PATIENTS: SOME REFLECTIONS ON COMMUNICATIONS,MISCOMMUNICATIONS AND COUNTERTRANSFERENCE ENACTMENTS1

This author focuses on an aspect of transference countertransference interaction that enacted covertly is often overlooked. He argues that conflicts, needs and biases that may go undetected for lengthy periods of time are not infrequently contained within the analyst's accurate and technically correct interventions and that for defensive reasons, patients often suppress, deny or rationalise their accurate perceptions of these countertransference elements and fail to confront their analysts with them. The mistakes, miscommunications and misperceptions that arise as a consequence of the unconscious collusions that develop between patient and analyst can have a profound effect on the analytic work. Several clinical examples are presented to illustrate the operation of such covert communications in analysis and their impact on the treatment process.     

THE CONCEPT OF OBJECTIVE COUNTERTRANSFERENCE AND ITS ROLE IN A TWO-PERSON PSYCHOLOGY

Objective countertransference comprises those feelings the analyst experiences with the patient that are repetitions of feelings from the patient's life outside the analysis. It is viewed as being induced by the patient and is understood in the context of the patient's life, not the analyst's. The concept is used to understand the relationship of some of the analyst's feelings to recurrent interpersonal patterns in the patient's life. It has often been viewed as being incompatible with a two-person psychology. Here, in contrast, it is argued that objective countertransference is only one current within the analyst's total emotional response to the patient, and that it should be conceptualized as a component of a broader two-person psychology. However, the use of objective countertransference as a conceptual tool highlights aspects of the analytic relationship that differ from those emphasized in current two-person models. A case example is analyzed from both perspectives to illustrate their similarities and differences. Although the concept of objective countertransference can enrich the analyst's understanding of certain dimensions of the analytic relationship, it is not a theory of technique and it is not wedded to any particular style of psychoanalytic intervention.     

The Analyst’s Generous Involvement: Recognition and the “Tension of Tenderness”

I define the analyst’s generous involvement as inherent to human encounter and a necessary element of therapeutic process. When the analyst’s generous involvement goes missing, it can be read as a sign of disengagement and disconnection. Using as metaphor H. S. Sullivan’s concept of the “tension of tenderness,” I argue that the analyst’s recognition of a need or affect state in the patient evokes an internal tug constituting the analyst’s need to provide for what has been recognized. I elaborate on what the analyst’s generous involvement is, and what it is not, including countertransference pitfalls and corruptions that may masquerade as generosity. I engage a relational conversation with the radical ethical ideas of Emmanuel Levinas. An extended clinical vignette illustrates the challenges and conflicts entailed in the analyst’s finding an analytically useful form of expressing the tug of generous involvement in the immediate moment.     

The body in analysis: authentic movement and witnessing in analytic practice

This paper will describe a form of active imagination called authentic movement, in which attention is given to the somatic unconscious. In authentic movement, patients are encouraged to focus inward and attend to any bodily sensations, images and feelings which may arise. In the process of focusing inward on one's bodily-felt experience, images, somatic memory and the accompanying feelings which arise are then available to be explored as a communication from the patient's unconscious. Authentic movement supports the individual in linking image with affect in that the individual re-experiences the somatic aspect of symbolization. What was previously conserved on the somatic level as unmentalized experience, can now begin to be taken up into the mind, thought about, and made available for analysis. In authentic movement, the analyst acts as a silent witness to the patient's explorations. The quiet focused attention of the witness helps to create a secure containing environment in which the person moving can experience a sense of feeling held and seen. The function of the witness is to hold the patient's experience in his own mind, particularly what is not yet mentalized. The witness utilizes his somatic countertransference, including any images, feelings and bodily responses which are generated by what is being communicated non-verbally, as a means of understanding and responding to the patient's material.     

Erotized transference reconsidered: expanding the countertransference dimension

A reconsideration of the erotized transference from a contemporary perspective has been presented utilizing detailed case material provided by Stoller. The main thesis is that this type of transference, traditionally conceived as a product of a particular kind of patient often felt to be borderline, is better understood as arising in a specific intersubjective context involving both participants in the psychoanalytic situation. The focus is on the intricate interaction of analyst and patient, recognizing that either may serve as a selfobject for the other. This view assumes a more expanded countertransference role than recognized in the earlier literature. The psychoanalytic situation can be erotized by either or both participants. A corollary thesis is that the details of a patient's fantasy should also be viewed as codetermined and that imbedded within it might be the patient's subjective experience of the psychoanalytic interaction. Alluded to peripherally is that the erotized transference in the interaction between male analyst and female patient is, in part, a manifestation of traditional roles assumed in situations involving a male authority figure in close engagement with a female who perceives herself as relatively powerless. This issue has recently received considerable attention from writers who have addressed themselves to the important gender issues in psychoanalysis.     

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.     

Patient-therapist match: revelation or resistance?

Patient-therapist match is a relatively new yet frequently invoked concept within psychoanalysis. Despite Freud's appreciation of the influence of the analyst's past to his or her work within the analytic setting, psychoanalysts have historically held varied opinions about the degree to which the analyst's personality and conflicts affect the analytic process. As analysis was reconfigured as a two-person system, attention focused on the fit between patient and analyst. The literature on patient-therapist match is reviewed, and the conclusion reached that this intuitively appealing concept suffers from a lack of rigorous definition and operationalization. Many authors invoke match in ways that imply that it is real, static, external to the domain of analytic inquiry, and unaffected by analytic process. In its present form, the concept of patient-therapist match obstructs rather than facilitates analytic exploration and obscures rather than clarifies what happens between analyst and analysand in psychoanalysis. By suggesting that match exists as a reality outside the domain of transference and countertransference, analysts may overlook the importance of psychoanalytic technique in creating a sense of match. Analysts may attribute stalemated or limited analyses to a bad match, rather than tenaciously exploring the transference-countertransference configurations that remain at the heart of analytic work.     

Talking about medication

With the increasing use of psychotropic medication concomitant with psychoanalysis, attention must be given to the challenges created by complaints of medication side effects. When confronted with these side effects, analysts may experience specific, uniquely actualized countertransference anxieties that can prompt the abandonment of transference analysis. Particular countertransference fantasies that arise in combined treatments are examined, as are the reasons for the analyst's suspension of curiosity and openness and its clinical consequences. In these situations, effective analysis requires the analyst to be "bilingual," to hold in mind both the analytic and the pharmacological model.     

Self-criticism and unconscious grandiosity: transference-countertransference dimensions

The problems posed in understanding and working through the patient's layers of self-criticism are challenging for both patient and analyst. In particular, this paper explores some countertransference phenomena related to underlying grandiosity embedded in self-criticism. For patients who are self-critical, analyzing grandiose elements may create further grounds for self-reproach or open up new modes of self-experience and freedom. The paper tries to focus on how the analyst's experience of the patient's self-criticism often shifts over the course of analytic work. It is important for the analyst to not be crippled by a fear of considering the relevance of underlying grandiosity in relation to self-reproach. Understanding this dimension of self-reproach can help elucidate why it is so durable and refractory to interpretation. The patient has a stake in holding on to this self-punishment because it perpetuates self-regulatory fantasies. These fantasies sometimes relate to the feeling that the patient will be more successful or better loved by holding on to aspects of self-reproach. Sometimes these fantasies are based in competitive or dominant strategies related to winning out or retaliating over parents or siblings.     

What does the analyst want? Free association in relation to the analyst’s activity, ambition, and technical innovation

The author traces the history of free association, the "fundamental rule," through the Freud-Ferenczi relationship and controversy. The use of "activity," first proposed by Freud in 1910 with phobic and compulsive patients, was then championed by Ferenczi in the early twenties. The goal of activity was to enhance-or, more accurately, "to force"--the associations into the analysis. Subsequently, Ferenczi reversed himself, concluding that his analysis was re-creating the traumatic parental environment which originally caused the patient's neurosis. The far-reaching results of Ferenczi's change of heart included a redefinition of countertransference and added the techniques of "indulgence" and "relaxation" to soften Freud's emphasis on "abstinence" and "frustration. A vignette from the analysis of a dangerously self-destructive bulimic patient illustrates the value of free association in helping a patient feel understood by the analyst without pressure to give up her symptoms. Constantly monitoring his therapeutic ambition, the analyst demonstrates the value of free association in enhancing the patient's understanding of herself and of the survival value of her symptoms. This vignette highlights the fact that the analyst's therapeutic ambition makes freedom to associate even more difficult for the patient and inevitably intrudes on the analyst's evenly hovering attention. Of course for the analyst to have a therapeutic wish is necessary and desirable but for the analyst to demand change promotes compliance and hidden rebellion which limits the analysis.