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8. Projective identification, countertransference, and hospital treatment

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

Karnac Books ePub

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.

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

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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1. Countertransference

Karnac Books ePub

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.

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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.

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