Parallel process: Emotional and physical digestion in adolescents with eating disorders

Abstract

This paper explores the emotional processes involved in psychoanalytical psychotherapy with adolescents with eating disorders. The central discussion is of two clinical examples, both of whom were seen by the author at the initial point of engagement with the therapeutic process. Through paying attention to the qualities of transference and countertransference, the idea of parallel physical and emotional processes is seen to emerge as central to the understanding of these two young people and their difficulties. The second half of the paper goes on to develop a comparison between the characteristics of the object relations of the two adolescent patients and the quality of early object relations in babies who have feeding difficulties. The latter is discussed with reference to infant observation, particularly the author's study of 'Five infants at potential risk'. The conclusions drawn are, first, that the therapist needs to take into account, in the countertransference, the 'pull' towards responding to the patient collusively, or through repeating an invasive experience and, second, that the patterns of object relations which are seen in the adolescents and experienced by the therapist in the countertransference relate to prototypes of specific defensive configurations that can be described, through observation, as occurring in early infancy.     

Countertransference: A vehicle for reciprocal growth and repair in women psychotherapists treating women patients

In 1986 research the author described a constellation of gender related issues emergent in the transference and countertransference of women psychotherapists treating women patients. Shared gender-linked issues appear to foster special resonance between women psychotherapists and their patients. This paper posits that shared themes in the interplay of transference and countertransference can be reparative and growthful for the psychotherapist as well as her patient. Three examples from the author's clinical experience are used to demonstrate the process by which countertransference can give the patient greater access to unconscious material while simultaneously promoting growth in the therapist.     

Positive sibling transference: Theoretical and clinical dimensions

The sibling dimensions of transference and countertransference have been neglected in favor of a parent-child transference model. This preference for the parent-child model reflected the paternalistic, positivist assumptions of traditional psychoanalysis. Developments of collaborative and postmodern psychoanalytic therapies make the sibling transference more recognizable and understandable. This paper emphasizes the positive sibling transference; possible directions for further exploration of the sibling transference dynamic are indicated. Clinical illustrations are given from child and family therapies.     

Exploring the Therapeutic Relationship A Case Study

This paper is focused on the topic of the therapeutic relationship in systemic therapy. It is structured around the discussion of my experience of work with a particular family where the engagement issues were complex, and where there was the potential for a negative therapy sequence. The psychoanalytic concepts of transference, countertransference and projective identification are chosen to discuss my dilemmas — however, the differences between the analytic and systemic contexts of work are noted. Through the discussion of this case study, the potential benefits of using these analytic ideas to understand the therapeutic relationship in specific situations in systemic therapy are identified.     

When the going gets rough ... difficult points in treatment: Identification,exploration and working through (panel)

This paper is a summarized report of a panel presentation made by three analysts on the topic of resolving difficult points in the treatment of three of their patients through the understanding of countertransference and transference issues. The first analyst presented a case in which a stalemate was broken by addressing three different kinds of countertransference. The second presenter addressed an impasse in the treatment of her drug addicted male patient which was caused by positive transference and countertransference. The third analyst discussed the resolution of a critical point in the third year of treatment of a female patient which was uncovered by addressing the parameter of appointment scheduling. The candor and honesty of these presentations takes the reader into the heart of practice issues and illustrates how stalemates are resolved and treatment deepened. Audience reaction indicated that more such presentations which illustrate how analysts really work would be welcome.     

The trainee and the borderline client: Countertransference pitfalls

Acknowledging and overcoming hostile countertransference is a major problem in treating borderline personalities, especially for clinicians in training. Borderline personality dynamics and transference/countertransference phenomena are described, and a compendium of trainess' negative countertransference reactions is offered, following Maltsberger's and Buie's (1974) schema. Myths of omnipotence, seen as antecedents to countertransference reactions, are discussed briefly. A case example illustrates some of the ways that a trainee may inadvertently foster a negative transference/countertransference experience; it also discusses the roles of supervision and consultation in explicating the particular difficulties that the therapist and patient created. The necessity for and nature of limit-setting with borderline patients is noted.     

The Psychology of the Psychopharmacology Triangle

Abstract

The psychopharmacological triangle generated by recent changes in mental health practices requires social workers to deepen their understanding of the psychological meanings of such treatment. Many clients receive concurrent psychotherapeutic and psychopharmacological interventions from different providers, creating a triangular treatment relationship. To facilitate a successful outcome, social workers will need to understand how meaning, transference and countertransference are stimulated by this arrangement. The literature on these issues as well as clinical experience will highlight specific issues requiring attention. By attending to these dynamics, the social worker can maximize the chances for a successful treatment outcome.     

Issues of Psychoanalytic Technique with Adoptees

Treatment issues relevant to the psychoanalytic treatment of the adoptee are presented; clinical formulation is encouraged within broad ego-diagnostic parameters. The adoptee's internal cathexis of the biological mother is identified as a core dynamic and the binary transference involving the adoptee's displaced relation to a dual set of parental representations is described. A metapsychological bias, predicated upon differential perceptions of the status of self and object representations is described and related to the adoptee's treatment. Various transference/countertransference dyads are discussed, as are corresponding technical considerations.     

Issues of Psychoanalytic Technique With Adoptees

Treatment issues relevant to the psychoanalytic treatment of the adoptee are presented; clinical formulation is encouraged within broad ego-diagnostic parameters. The adoptee's internal cathexis of the biological mother is identified as a core dynamic and the binary transference involving the adoptee's displaced relation to a dual set of parental representations is described. A metapsychological bias, predicated upon differential perceptions of the status of self and object representations is described and related to the adoptee's treatment. Various transference/countertransference dyads are discussed, as are corresponding technical considerations.     

Culture and Masculinity: When Therapist and Patient are Latino Men

Treating clients from diverse cultural backgrounds, and supervising clinicians who are treating clients of the same ethnicity and gender, are now common experiences in our mental health system. As the growth of minorities in the US greatly outpaces the training of minority clinicians, more attention to these situations is needed. Operating from the premise that interpersonal sensitivity is a fundamental aspect of cross-cultural and cross-ethnic sensitivity, we describe the treatment of a Latino male by a Latino male clinician, in this case both of Puerto Rican descent. We outline the contours of the therapy with a man whose life history included numerous incidents of humiliation and thwarted efforts at efficacy, mastery, agency, and competence, resulting in an adult character structure based on shame and self-doubt. We also discuss the challenges to the clinician posed by working with a man whose traditional upbringing mirrored his own, with all the positives and negatives that must be considered in the countertransference. We describe clinical and cultural reasons for various interventions, and their resulting outcome. The framework of a dynamic interpersonal therapy and the challenges of transference, countertransference, therapist disclosure, and working-through are covered.     

From delusion to play

Winnicott suggested that delusions are a failed form of play. Using Winnicott's theories of the play space, this paper illustrates through clinical material how the therapist can join a delusion and convert it into an area of play. Discussion includes an analysis of the use of play in working with the transference and countertransference as well as the therapist's resistances to engaging in play.     

Erotic and pseudoerotic elements in the treatment of male patients by female therapists

This paper describes some aspects of the clinical encounter between the male patient and the female therapist. Examples are given of transference involving erotic, as compared to pseudoerotic (dependency or aggressive) themes. Countertransference and countertransference problems are discussed.     

Boundaries & adolescents in residental teatment settings: what clinicians need to know

Working with adolescents in psychiatric treatment settings poses unique challenges related to boundaries. Staff are typically from a range of disciplines, and some are from nonregulated professions. Three potential boundary-crossing areas are touching, gift giving, and self-disclosure. To enhance quality of care, staff needs an orientation aimed at boundary education, including the concepts of transference and countertransference; an atmosphere of safety to discuss their observations of themselves and others; to be willing to provide feedback; and a sound knowledge base of adolescent growth and development.     

A Strange Invitation: On the Ordinary Problem of Pornography

Pornography in the clinical psychoanalytic situation is an ordinary problem that is most effectively approached in the manner a psychoanalyst would any other part of a patient's experience that registers in the transference/countertransference in order to be worked with. However, because pornography often seems to do with sexual excitement, it may evoke more anxiety than other kinds of material in an analysis and so may lead to a transference/countertransference situation that can feel difficult to handle. This essay examines several aspects of pornography—how it produces its effects and what sort of product it is—but also discusses how an analyst works to regain what feels like a useful therapeutic stance when pornography has been part of the clinical dialogue. This involves the tension that grabs hold when ideas generated by applied psychoanalysis combined with volatile subjective experience of pornography produce a specific countertransference situation.     

‘Somebody Else's Roadmap’: Lived Experience of Maudsley and Family‐based Therapy for Adolescent Anorexia Nervosa

The Maudsley and more recent family‐based therapy manualised approaches are positioned by some as the gold standard, evidence‐based therapy for adolescent anorexia nervosa (AN). However, a significant proportion of adolescents and their families either discontinue this therapy and/or find that it simply does not work for them. These adolescents and families are under‐represented in the literature on therapeutic interventions for adolescent AN. This paper begins to address this gap with an in‐depth qualitative case study that explores the lived experience of Maudsley family therapy (MFT)/family‐based therapy (FBT) for one female adolescent (age 14 years) and her family over the period of 3 years (ages 11–14). Although initially handing over the responsibility for her eating was comforting and reinstated a sense of control in the family system, these experiences were not maintained. When she did not progress past the first phase of FBT, she and her family experienced the approach as blaming. She felt silenced and family alliances were weakened. This paper analyses how the family members negotiated and preserved their identities within this disabling context.     

TREATING A HIGH-RISK MOTHER–CHILD RELATIONSHIP

In this paper, the author presents detailed clinical material to portray the experience of intensive therapy shared with a young school-aged boy and his very troubled mother. The therapy involved a challenging combination of triadic sessions along with dyadic child-therapist sessions observed by the boy’s mother from behind a one-way mirror. The discussion centers on the impact of complex transference and countertransference experiences and recommends conjoint sessions as the first option when treating young school-aged children in relationship with a highly troubled parent. I am indebted to Jacqueline Hanley for her support and encouragement, without which this paper might not have been written. Thanks are also due to Jack Howard MLS for his reference assistance.     

Transference and countertransference in the treatment of adult survivors of abuse with a somatoform disorder

The understanding of transference and countertransference has changed a great deal since Freud introduced the terms. A case example indicates one way the patient’s and clinician’s past experiences and expectations interact to create a here and now relationship that is highly influenced by transference/countertransference. The understanding of both terms as aspects of a mutually constituted interaction has practice implications for the treatment of adult survivors of abuse who have a somatoform disorder.     

Shit is good: Mental health social work with lives of squalor

This paper investigates the phenomenon of three clients living in squalor, all of whom have severe and enduring mental health problems, and are on the caseload of a mental health social work team. By thinking about the clients both individually and as a group, within a psychoanalytic framework, it attempts to understand their squalor in a new way, with particular regard to the transference and countertransference experienced by the practitioner. By making use of social work literature as well as that concerning organisations and community care, it also discusses the impact these clients make on the wider community around them, and examines some of the dilemmas faced by the practitioner. The implications for social work are serious and far-reaching and these are discussed with regard to long-term intervention as well as professional and personal scrutiny.     

Spontaneous self disclosures in psychotherapy

The closeness and intensity of feeling that develops between therapist and patient raises complex issues related to the therapist's neutrality, the transference, the countertransference, the therapeutic alliance, and the very essence of the curative aspects of the relationship. The issue of the relationship of self disclosure and the evolving transference, countertransference complex is discussed. It is suggested that on some occasions, the pressure a therapist feels to spontaneously disclose something intimately personal is an indication that the therapeutic role has become reversed and the therapist is using the process to heal a vulnerability in himself or herself. The patient unconsciously participates in the interest of safeguarding the treatment process. In such instances the self disclosure need not interfere with the evolving transference. It may lead to great spontaneity in the process and to opening areas of affect previously unreachable. Self disclosures cannot be viewed as technical innovations to avoid stalemates in clinical practice. Rather, they are facts of our clinical life, facts that must be explained and understood rather than judged and condemned.