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.     

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.     

Sex makes a difference—How gender affects the therapeutic relationship

Because gender issues create obstacles or advance progress, this paper discusses how gender differences affect therapy. The psychoanalytic approach in the four treatment dyads of female therapist-male patient, male therapist-female patient, female therapist-female patient, and male therapist-male patient is presented to suggest propensities. A developmental focus on gender's effect on the therapeutic relationship is indicated by the theoretical rationale from psychoanalytic literature, and by clinical practice discoveries. Because therapists' perceptions about gender identity, gender roles and sexual partner orientation affect responses to patients, countertransference is considered. Acknowledgement of gender components within the transference is recommended if therapists are to provide the best treatment possible.     

Termination: When the therapist leaves

Despite an expansion of our knowledge about loss and grief little has been written on the experience and techniques employed during a forced termination. This article examines the theory, applications of theory, and transference/countertransference issues surrounding the author's experience as she moved to another state and transferred or terminated with her patients.Paper presented at the Fourteenth Annual Symposium of the New York Center for Psychoanalytic Training, March 1989.     

Roundtable Discussion on Sexuality in Development and Treatment II: Clinical Application

This article explores the interesting, yet underinvestigated, phenomenon of unconscious communication. Newer psychoanalytic theories, which have expanded on the centrality of the analyst's subjectivity as well as the patient's experience of that subjectivity, have opened up the analytic space to explore the complexity of transference–countertransference dynamics. Detailed clinical process material is provided to determine if a coconstructed unconscious dialogue ensues, or if, in fact, the intrapsychic dynamics of patient and analyst are on independent yet parallel tracks. Several current theoretical issues are raised, such as how one- or two-person metapsychological frameworks can influence clinical process; the complex nature of enactments; the use of self-disclosure; and the possibility of unconscious communication.     

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.     

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.     

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.     

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.     

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.     

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.     

Supervision of trainees: Tending the professional self

This article seeks to demonstrage how self psychological concepts can be applied to the process of training psychotherapists in a variety of clinical and community settings. The author examines the role of clinical supervision in the development, consolidation, and maintenance of a cohesive professional self. The role of selfobject experience, needs, transference, and countertransference as manifested in the supervisory relationship is elaborated. Supervisor and supervisee form a self-selfobject unit, through which the trainee's anxieties and vulnerabilities can be managed. This selfobject matrix enables maintenance of self-esteem, expansion of cognitive understanding, and structure building in the arena of the professional self. To achieve these ends, the supervisor forms an empathic alliance with the internal, subjective experience of the therapist. The importance of focusing on the self experience and selfobject needs of the therapist in training via an empathic mode of observation is illustrated by several examples and vignettes. The application of theory to practice is emphasized, with examples chosen from a variety of clinical settings and modalities.     

Treatment of noncustodial fathers: Gender issues and clinical dilemmas

This article addresses issues involved in the treatment of fathers who do not have custody of their children. It reviews literature on demographic trends and discusses fathers' reactions to loss of child custody. Assessment and treatment guidelines are offered so that clinical practice may become more responsive to the needs of the population. Gender concerns, particularly as they relate to transference and countertransference, are also discussed.     

Countertransference and its potential for abuse

The definition of countertransference ranges from pathological and inappropriate responses of the psychotherapist/psychoanalyst based on inner issues and conflicts (hence an obstacle to cure) to a position that countertransference feelings and reactions provide useful information in understanding the patient and contribute constructively to the curative process. This later definition can enhance and expand the analytic inquiry. However, with this expanded conceptualization, abuses of countertransference can have damaging impact on the patient. This presentation will undertake to explore one aspect of such abuse and speak to the specific influences that contribute to the misuse of countertransference in the therapeutic situation.     

Gender related themes of women psychotherapists in their treatment of women patients: The creative and reparative use of countertransference as a mutual growth experience

Women in contemporary American society internalize the negative attitudes toward women that have been part of the sociocultural milieu in which they were raised. These attitudes, transmitted during the earliest phases of a woman's development, within the intimate framework of her object relations, are then reinforced by the prevailing culture. Feelings which derive from these attitudes becomes reactivated in a woman psychotherapist's countertransference, leading to a dynamic interplay with her female patient.This study describes countertransference themes experienced by women therapists treating women patients. Its conceptual framework is drawn from psychoanalytic theory, and it is one of the few studies based on in-depth explorations of the feelings and conflicts of the therapists themselves.     

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.     

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.     

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.     

The borderline patient: Theoretical and treatment considerations from a developmental approach

In recent years, there has been growing awareness and concern about the number of patients who do not fit the standard diagnostic criteria for neurosis or psychosis. As the state of knowledge about borderline personality disorders has grown, its enlarging literature has become filled with metapsychological abstractions which attempt to clarify subtle and complex data. In general, research on borderline phenomena differentiates this syndrome from other diagnostic groups according to its special characteristics of transference and countertransference, difficulties in treatment, patients' problems in intimate relationships, and patients' uses of primitive defense mechanisms including splitting and projective identification.This paper will explore a particular theoretical perspective on the borderline phenomenon, as well as a specific treatment modality, both developed by James Masterson, M.D. It will also discuss major developmental issues which contribute to the difficulties experienced by the borderline patient population, including issues of early mother-child interaction, arrests in the rapproachment stage, and the failure of empathic responses. Finally, the author will present a case to illustrate how the use of a developmental approach can facilitate treatment.