Countertransference: Theory, Technique, Teaching

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A collection of papers on the Oedipus complex, divided into three parts: theory, practice and supervision. The contributors, who include Joyce McDougall, Hanna Segal, Otto Kernberg and Leon Grinberg, invite the reader to explore with them the processes affecting the therapist's mind - and, occasionally his body - during psychoanalytic therapy, and the reasons why the therapist thinks, feels, and reacts in a particular way. The full significance of these processes, referred to as "counter-transference" since Freud's time, has recently been recognized, resulting in the therapist's use of additional resources so that he or she can understand and help the patient more effectively.In the 1950s and 1960s, Paula Heimann and Heinrich Racker, following on Freud's own observations, made important contributions to the study of the countertransference, considerably enlarging upon the concept and re-evaluating the nature of the psychoanalytic therapeutic relationship as a result. Since then, several distinguished analysts have continued the work, exploring in the process a variety of complimentary concepts: Projective identification and counter-identification and their clinical relevance; the notion of the containing function of the therapist; unusual countertransference reactions, and the relationship between primitive aspects of the patient's personality structure and the intensity of countertransference.By elaborating on these and other prevailing approaches, it is hoped that this book will further illuminate the subject and draw attention to the substantial contribution which the recognition and utilization of the countertransference can bring to the analytic interaction.

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1. Countertransference

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Hanna Segal

As analysis developed, transference, at first considered a major obstacle in treatment, came to be seen as the fulcrum on which the psychoanalytic situation rests. Similarly, countertransference, first seen as a neurotic disturbance in the psychoanalyst, preventing him from getting a clear and obj ective view of the patient, is now increasingly recognized as a most important source of information about the patient as well as a major element of the interaction between patient and analyst. In her pioneering paper on the subject, Paula Heimann (1950) drew attention to the fact that, though not recognized as such, countertransference had always been a guide in psychoanalytical work. She suggested that Freud’s discovery of resistance was based on his countertransference, his feeling that he was meeting a resistant force in the patient. Once our attention is drawn to it, this view of countertransference seems almost obvious.

To take a single example, I had a patient who evoked in me a whole gamut of unpleasant feelings. It would have been very foolish of me to ignore these feelings or consider them my own neurotic reactions, since this patient’s principal complaint was her terrible unpopularity. Obviously, the way she affected me was a function of her psychopathology—a function of utmost importance to her, and one that it is crucial for us to understand.

 

2. The analytic management and interpretation of proj ective identification

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Thomas H. Ogden

Projective identification is not a metapsychological concept. The phenomena it describes exist in the realm of thoughts, feelings, and behaviour, not in the realm of abstract beliefs about the workings of the mind. Whether or not one uses the term or is cognizant of the concept of projective identification, clinically one continually bumps up against the phenomena to which it refers—unconscious projective fantasies in association with the evocation of congruent feelings in others. Resistance on the part of therapists and analysts to thinking about these phenomena is understandable: it is unsettling to imagine experiencing feelings and thinking thoughts that are in an important sense not entirely one’s own. And yet, the lack of a vocabulary with which to think about this class of phenomena seriously interferes with the therapist’s capacity to understand, manage, and interpret the transference. Projective identification is a concept that addresses the way in which feeling-states corresponding to the unconscious fantasies of one person (the projector) are engendered in and processed by another person (the recipient)—that is, the way in which one person makes use of another person to experience and contain an aspect of himself. The projector has the primarily unconscious fantasy of getting rid of an unwanted or endangered part of himself (including internal objects) and of depositing that part in another person in a powerfully controlling way (Klein, 1946, 1955). The projected part of the self is felt to be partially lost and to be inhabiting the other person. In association with this unconscious projective fantasy there is an interpersonal interaction by means of which the recipient is pressured to think, feel, and behave in a manner congruent with the ejected feelings and the self—and object—representations embodied in the projective fantasy (Bion, 1959; Ogden, 1979). In other words, the recipient is pressured to engage in an identification with a specific, disowned aspect of the projector.

 

3. Countertransference and the concept of projective counteridentiflcation

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Leon Grtnberg

I have made a fairly thorough study of the disturbances caused in analytical technique by the excessive intervention of projective identification on the part of the analysand, which gives rise in the analyst to a specific reaction for which I suggested the term “projective counteridentification”, and these have been published in various articles (Grinberg, 1956, 1957, 1958, 1962, 1979).

It is known that the psychoanalytical process is conditioned by a series of factors of different types. Among them it is important to single out the continual interplay of projections and introjections which develops during the analysis, on the part of both the analysand and the analyst. Starting from the approach of the latter, we can consider two co-existing processes: in one, the analyst is the active subject of those mechanisms of introjection and projection; in the other, he becomes the passive object of the projections and introjections of the analysand.

Reprinted and expanded from Leon Grinberg, The Goals of Psychoanalysis (London: Karnac Books). By permission of the author.

 

4. A parallel voyage of mourning for patient and analyst within the transference-countertransference voyage

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AthinaAlexandris

1. THE VOYAGE OF ARGO: OEDIPUS COMPLEX

Oedipus Rex is what is known as a tragedy of destiny.

His destiny moves us only because it might have been ours—because the oracle laid the same curse upon us before our birth as upon him.

Freud, 1900a, p. 262

This is the study of a father, our patient, who had a problem in choosing a name for his second son; he could not decide whether to call him Alexander or Jason. Neither of these names appeared in either his or his wife’s family lines. He finally decided on the name Jason.

George, our patient, attempted to “resolve” the problems related to his oedipal situation—and change his destiny as a result—by the use of myths, songs, and fairy-tales. Of special relevance here is the myth that he employed, namely, “The Voyage of Argo” or “Argonautica”, which was written by Apol-lonius of Rhodes some time in the middle of the third century B.C. [In the Argonautica of Apollonius of Rhodes, we have the only full account of Jason’s voyage in quest of the Golden Fleece, a tale that seems to have stood, in the estimation of the Greeks, second only to the great cycle of legends that centred in the Trojan War. Apollonius’ poem is thus unique. It has often been claimed that here we have the finest psychological study of love that the Greeks have left us (E. V. Rieu).J

 

5. Countertransference and primitive communication

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Joyce McDougall

Certain patients recount or reconstruct in analysis traumatic events that have occurred in their childhood. The question has sometimes been raised as to whether we treat this type of material differently from other analytic associations furnished by the patient. And if so, what are the differences? Ever since Freud’s discovery that the traumatic sexual seductions of his hysterical patients revealed themselves to be fantasies based on infantile sexual wishes, analysts have been wary of mistaking fantasy for reality. Nevertheless there are many “real” events that leave a traumatic scar on our patients—such as the early death of a father, having a psychotic mother, or a childhood handicapped by illness. When these events are within conscious recall, they inevitably present us with special problems because of the varied use the patient will make of them, and in particular because he will so frequently advance the argument that there is nothing to analyse in this material since the events “really happened”. They have, however, become part of the patient’s psychic reality and must therefore be listened to with particular attention.

 

6. Countertransferential bodily feelings and the containing function of the analyst

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Athina Alexandris Grigoris Vaslamatzis

Ah, this terrible pain before prophecy

Aeschylus, Oresteia

Introduction

Psychoanalytic psychotherapy to persons exhibiting borderline personality or, broadly speaking, primitive personality—brought to our attention phenomena taking place during treatment, that are beyond the verbal interchange of patient-analyst. Kernberg (1987) describes these channels of communication and considers that during the analytic therapy of borderline patients, “The emergence of dominant unconscious object relations in the transference typically occurs by means of non-verbal communication” (p. 205). Also, McDougall (1980) refers to primitive models of communication by the patient, which indicate that the patient has suffered pre-verbal, severe traumas or deficiencies during the early maternal relationship.

It is generally accepted that in the treatment of this kind of patients with primitive personalities and/or severe traumas, the understanding and use of countertransference is of special value. In these cases the analyst often faces bizarre and intense phenomena in the primitive transference of the patient. Also, the analyst has to handle his own intense feelings, which these patients usually provoke.

 

7. Countertransference reactions commonly present in the treatment of patients with borderline personality organization

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VamikD. Volkan

This chapter is concerned with countertransference reactions usually experienced by analysts during the course of treating borderline patients. These reactions are commonly shared, and they are more than just reflections of the analyst’s own unresolved childhood conflicts. The type of countertransference about which I am writing here is very much a part of the psychoanalytic treatment of borderline patients.

Boyer (1961) stated that the analyst’s unresolved counter-transference is one of the major impediments to success in treating regressed individuals. As far as I know, Boyer was the first person to introduce this concept in the psychoanalytic literature of North America, although European writers, especially the English (Balint, 1968; Heimann, 1950; Khan, 1964), implied something similar, as did Racker (1968), writing from South America. Boyer’s study of the analysts counter-transference during the treatment of regressed patients was supported by collaborative work with Giovacchini (1967), and by the independent work of Searles (1953, 1986). Their pioneering studies attracted considerable interest in this subject and, recently, a review of relevant literature has been compiled by Boyer (1990). Here I am simply acknowledging the influence of the writings of Boyer, Searles, and Giovacchini on the clinical technique I use with regressed patients, especially concerning the role of what I call “common” countertrans-ference manifestations, as an aspect of my technique. I should point out, however, that my metapsychological understanding (Volkan, 1975, 1976, 1979, 1981, 1987) of the psychic organization of such patients has followed the object relations theory as described by Jacobson (1964) and Mahler (1968) and as systematized by Kernberg (1967, 1975a).

 

8. Projective identification, countertransference, and hospital treatment

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Otto K Kernberg

My principal purpose in this chapter is to illustrate the pivotal function of projective identification within the therapeutic milieu of the hospital. What follows is a detailed description of crises in the treatment of two patients undergoing long-term inpatient psychiatric treatment. These patients suffered from very different psychiatric illnesses; hence their cases illustrate some features of hospital treatment that cut across different types and degrees of severity of psychopa-thology.

Lucia

Lucia was single and in her late twenties—an attractive and intelligent but emotionally unstable Latin-American musician who had been educated in this country [United States) and whose very wealthy parents financially supported her and her artistic career. She had a history of chronic drug and alcohol abuse, repeated serious suicide attempts, and chronic interpersonal difficulties at work and in intimate relations.

Lucia was the youngest of three children; her older brothers had left home many years earlier, and for all practical purposes her parents treated her as their only and major concern. Father was seductive rather than loving in his interactions with Lucia and basically controlled by her mother, clearly the dominant personality in the family. Mother was a highly emotional, extroverted, charming yet also intrusive person, who, in subtle ways, attempted to control Lucia’s life while yet remaining strangely indifferent or even hostile to her at a deeper level. For example, Lucia suffered from an allergy that prevented her from eating certain types of sweets; mother periodically sent her packages of those very sweets from Latin America, even after the hospital psychiatrist initially assigned to the case had discussed the issue with her.

 

9. Some thoughts on insight and its relation to countertransference

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Athina Alexandras Grigoris Vaslamatzis

Introduction

Much has been written about insight, in both the broad and narrow sense of the term. Hatcher (1980) pointed out that insight is not a simple matter but a complex process in psychoanalytic therapy that depends on the interplay of several factors. Kris (1956) and Blum (1979) stated the view that in psychoanalytic therapy the therapist’s main task is to provide and facilitate the patient’s insight. Insight on the part of both patient and therapist have also been discussed, as has insight in relation to the psychoanalytic situation, interpretation, working through, goals of therapy, transference-counter-transference, and the patient’s individuality. In the literature, however, there are rather few clinical examples supporting the theories.

This paper will present clinical material from two cases of psychoanalytic therapy in an attempt to illustrate how counter-transference is related to the patient’s insight, but mainly how countertransference affects the kind of insight the therapist chooses to offer his patient. The clinical material is taken from cases supervised by the authors.

 

10. The patient-therapist fit and countertransference reaction in the light of frame theory

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Hector Worries

Bion has captured the concept of the frame in his metaphor of the artist in whose painting “something has remained unaltered and on this something recognition depends” (Bion, 1977, p. 1). The invariants of a painting by an impressionist and a realist would convey different meanings. The frame has been compared by Bleger (1966) to the mere background of a Gestalt that may evolve into a figure. The background would be the constant, the invariant factor or the non-process, and the figure the transformation, the variable or the process. The frame is therefore the invariant element that is “the receiver of the symbiosis” (p. 513) and in that sense expresses the maternal configuration. The analytic process itself is pregnant with ambiguity and multiple meanings and does not contain the symbiotic experience. The frame acts as a support of the analytic process but does not accept its ambiguity. It is similar to the child’s symbiosis with the mother, which enables him to develop his ego in a background of safety and support. Within the frame or the container, there is a space and an analytic atmosphere, which may have certain characteristics—that is, optimal distance, refusal to play a role, neutrality, self-effacement, and benevolence. The analytic frame is deliberately unbalanced in order to activate unconscious meanings. The frame of transference expectations usually finds sufficient fit with what is transpiring in the analytic frame.

 

11. Transference-countertransference Interactions in the supervisory situation: some observations

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Theodore J. Jacobs

Although it has long been recognized that transference-countertransference Interactions play a role of importance in supervision as they do in analytic therapy, this aspect of the supervisory situation has received comparatively little attention in the literature. Racker (1968) has observed that one source of a therapist’s countertransference reactions in the treatment situation is his relationship with his supervisors and teachers. The therapist’s emotional responses to these figures of authority, Racker noted, often colour and influence his perception of his patient. For this complex set of interactions, Racker coined the term “indirect countertransference”.

In their pioneering study of psychoanalytic supervision, Fleming and Benedek (1983) noted that learning is inevitably affected by the transferences that develop between student and teacher, and they expressed the view that “disturbances of equilibrium in the learning alliance need to receive as much self-examination by a supervisor as is expected from a student” (p. 80). By way of illustration, the authors cited an example in which a supervisor, working with a candidate who made repeated errors and seemed not to be able to make effective use of supervision, found herself feeling increasingly frustrated and helpless. She could neither treat the patient nor analyse the candidate. As a consequence, the supervisor’s manner of teaching was decisively influenced by her emotional reactions to the student. Her supervisory style became more vigorous than usual, her tone sharp as she used the force of her personality to underline her remarks. This way of teaching intimidated the student and created problems in the learning alliance. Until the supervisor understood and could modify her approach, little effective learning could take place.

 

12. Some transference-countertransference issues of the supervisory situation: a dream about the supervisor

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Grigoris Vaslamatzis

A supervisee’s dream about the supervisor is presented in this chapter. The dream coincides with the patient’s reverting to her earlier symptoms during the termination phase. As a result of this the psychotherapy had to be prolonged.

Unfortunately, little is seen in the literature on the dynamics and dysfunctions of supervision. In his important paper, Pedder (1986) indicates the difficulties that may arise when transference problems occur in psychotherapy supervision towards the supervisor. Heising (1976) and Sandell (1985) also pointed out the threat of the negative influence that supervision might have on the therapeutic outcome.

The objective of this study is to elucidate further the trans-ference-countertransference issues that arise between trainees and supervisors, as well as their consequences on the psychotherapy.

The supervision

Dr D was a third-year psychiatric resident, married, in her mid-thirties. She was considered a very intelligent young physician, and everyone felt that she was pleased to present the material of her cases. She was very enthusiastic to have her first patient in psychotherapy, and after the termination she asked to be assigned a second case of brief psychoanalytic psychotherapy (Vaslamatzis & Verveniotis, 1985). Her second case was a female patient who presented with anxiety attacks and somatic symptoms. She was single and clung to relationships with motherly-behaving older men. The patient’s mother had died three years previously, and it was at that time that her symptoms had first appeared. The evaluator had been the supervisor himself, who had decided about the patients suitability for brief psychotherapy (up to 30 sessions). The patient had agreed to this limit.

 

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