Staying put in the Closet: Examining Clinical Practice and Countertransference Issues in Work with Gay Men Married to Heterosexual Women

Gay men married to heterosexual women seek psychotherapy for numerous reasons, not only to find a way out of their marriages. Therapists must identify their countertransference reactions to avoid pushing the patient either to commit to his marriage or leave it. The patient’s underlying problems should be addressed before the patient can explore the fate of his marriage. Therapists also need to be understanding of the patient’s attachment to his wife. In addition, therapists must be aware of the societal implications of homophobia on gay patients. This article discusses motivations for heterosexual marriage among gay men, examines two clinical cases, and addresses practice and countertransference issues. A version of this article was presented at the tenth national conference of the National Membership Committee on Psychoanalysis in Clinical Social Work on March 10, 2007.     

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.     

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.     

Clinical work with adolescents and their parents during family transitions: Transference and countertransference issues

This paper describes specific transference and counter-transference issues that commonly emerge in therapeutic work with adolescents and parents who are in the midst of family transitions such as divorce and remarriage. Psychoanalytic understanding and definitions of transference and countertransference are applied to short-term family-centered cases in which the parent-adolescent relationship is at particular risk. Case vignettes are presented in order to illustrate how transference and countertransference may guide or interfere with clinical interventions that are especially indicated with adolescents whose family structure has changed. Such interventions as well as the use of consultation are briefly described.At the time this paper was prepared, Ms. Springer was Associate Director and a senior clinician at the Center for the Family in Transition in Corte Madera, California. Funds for the research and clinical work that provided the basis for this paper were supplied by grants from the San Francisco Foudation. An earlier version of this paper was presented at the 66th Annual Meeting of the American Orthopsychiatry Association, New York City, March 31–April 4, 1989.     

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.     

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.     

The Monster Within: Countertransference Reflections on a Gay Adolescent’s Struggle with Sexual Identity

This paper concerns the author’s countertransference reflections on her work with a gay adolescent who identifies with powerfully destructive internal objects, including Hitler and the Monster. The author describes her countertransference inquiry through which she experiences her own potential destructiveness in order to help accommodate her adolescent patient’s rejected and disowned self states.

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.     

Envy in the transference and countertransference

This article defines envy and describes the various ways in which it may manifest itself, pointing out that there may be positive as well as negative effects of envy. These concepts are then applied to the psychotherapeutic situation, and the effects of envy in the transference, and particularly the countertransference, are discussed. Finally a case presentation demonstrates how the therapist's recognition and understanding of envy in the countertransference were used in a positive way and helped the therapy to proceed in a more productive direction.     

An abused child grows up and enters treatment

This article explores the dynamics which can occur in abused children by focusing on the long term treatment of a young woman who was physically, sexually, and emotionally abused as a child. Particular emphasis is placed on the understanding and management of the highly charged transference and countertransference which ensued.     

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.     

When Absence Speaks Louder than Words: An Object Relational Perspective on No-Show Appointments

The rates of no-show appointments in community mental health are reported to be as high as 50%. Yet there is a striking scarcity of clinical literature on this subject compared with the abundance of articles written from an administrative point of view. This paper describes a variety of countertransference responses to missed appointments. Drawing from object relations theory, the author maps out different pathways to guide thinking about the use of countertransference, listening to clinical material following a no-show appointment, and responding to organizational pressures. The paper aims to help practitioners make greater sense of the patient’s inner world and of what is going on in the transference-countertransference matrix.     

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.     

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.     

The Value of Hate in the Countertransference

The author looks at the experience of hate in the countertransference and develops the idea that hate can be of particular value to the treatment process. He begins with an exploration of the therapist’s needs and discusses how unmet self-regulatory needs sometimes lead to feelings of frustration and rage toward the patient. The author explores these ideas as they are connected to Winnicott’s (1949, 1971) work on aggression and Jessica Benjamin’s (1992) work on recognition and destruction. The author espouses a difference between rage and hate, where rage is seen as indicative of unmet needs, and hate is seen as a force that can emancipate the therapist from the encumbrance of unmet needs. Case examples are provided to show the utility of this perspective. Laurence Green, M.S.W., Psy.D. is on the faculty and a member of the Institute of Contemporary Psychoanalysis. He is Co-chair of the History Committee of the International Federation of Psychoanalytic Education. He is in private practice in Los Angeles, California working with children, adolescents and adults.     

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.     

Persephone Rising: Struggles in Female Adolescent Development in the Aftermath of Rape

Using formulations of female sexual development grounded in the Persephone/Demeter myth, this paper examines the treatment of two adolescent girls in the aftermath of rape. Case material is presented that illustrates the impact of rape on a developing adolescent girl’s relationship with her mother and on the transference to a female therapist. The nature of the mother/daughter relationship prior to the rape influences not only the treatment but the capacity of both mother and daughter to cope with the trauma of the daughter’s rape. Countertransference reactions and enactments related to developmental issues of separation/individuation as they are impacted by the trauma of rape and as they influence the course of treatment are examined in order to heighten awareness of possible pitfalls in treatment.     

Unforeseen Implications of Regulation to Authenticity in Clinical Practice

The authors, both long-time LCSWs, utilize an existential framework and postmodern lens to explore the implications of increased professional regulation in clinical practice. Specifically emphasized, are the themes of litigation-fear and the threat of license revocation that are prevalent in the field of clinical social work at this time. The authors argue that this “climate of fear” can lead to a slippery slope for a profession that has long valued the individual’s right (both client’s and practitioner’s) to self-determination, authenticity, and creativity and call for an increased conversation among practitioners about the desired role of regulation in the profession with the overall goal of protecting a true understanding of ethics in social work.     

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.