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8. Projective identification, countertransference, and hospital treatment

Athina Alexandris Karnac Books ePub

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.

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

Athina Alexandris Karnac Books ePub

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).

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2. The analytic management and interpretation of proj ective identification

Athina Alexandris Karnac Books ePub

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.

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

Athina Alexandris Karnac Books ePub

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

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

Athina Alexandris Karnac Books ePub

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.

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