Search

The aftermath of complex trauma deeply impacts one's self-organization and interpersonal relationships, often resulting in clients who present to therapy with borderline characteristics and are typically labeled as difficult to treat. Further clinical complications with paranoid features may quickly place the therapist at a loss with respect to managing perceived and/or actual threats to client safety. Using psychodynamic theories, especially Kleinian understandings of psychosis and Winnicottian approaches to early disturbance and its impact on the emergence of self, this article provides a detailed case illustration that explores how a critical reflection of countertransference as “enactment,” “communication,” and “imagination” can help the therapist to understand the client's unconscious symbolic psychic struggles and to guide treatment selections in the therapy process. [ABSTRACT FROM PUBLISHER]

Attachment theory has been instrumental in identifying insecure disorganized attachment as a developmental pathway that leads to severe psychopathology in adults. Psychotherapy with these patients is challenging, offering a confusing pattern of relatedness, difficulties in mentalizing, problems expressing affect, utilizing dissociative defenses, and trying to gain an understanding of their subjectivity. This article provides a theoretical overview of disorganized attachment focusing on its etiology and how it presents throughout the life span. It reviews important therapeutic guidelines that help navigate the relationship with adults and presents a case study highlighting some clinical challenges. [ABSTRACT FROM PUBLISHER]

One of the characteristics of psychotherapeutic work with children and adolescents is parental presence, which introduces additional parameters into the setting and function of the therapist. Parental presence makes the existence of the external world constantly present, increasing the risk of bias in interpreting and understanding the intrapsychic world. Interference is common in the therapeutic setting, and mostly challenges the therapist's tolerance. Meetings with parents may trigger fantasies in the therapist's mind, which interfere with the game of identifications with the child and the fantasized parents. The common bond with the child creates conscious and unconscious reactions, and there is always the risk of the therapist being overwhelmed and losing his or her capacity to understand object relations and transference phenomena. The therapist's function may be influenced either through weakening of the symbolizing capability or through hampering the capability to understand the child's function of fantasy. Parents are always present, while the therapist's countertransference movements evolve. Given that the technique of interpretation is not always available, the main goal is to use countertransference challenges in the service of the child's psychotherapy, by understanding the child's internal reality, resistance, and experience, as well as the intensity and nature of external experiences within the family. [ABSTRACT FROM PUBLISHER]

This article considers daydreams as a means of understanding the patient and fostering the therapeutic relationship. Daydreams are considered along with fantasies and reverie. The usefulness of the therapist's reverie in response to the daydreams of a patient who is conflicted about being seen and known is explored. Daydreams are considered in relation to creativity—both analytic and artistic; and as a way of bridging inner life and external reality. [ABSTRACT FROM PUBLISHER]

Drawing on recent theory of the origin and development of gender orientation, this article explores the dynamics in the treatment of a 16-year-old female to male transgender adolescent. The debate over whether surgery, to change the body, or psychotherapy, to change the mind, is the appropriate treatment became a central conflict for the therapist in understanding the dynamics of her transgender patient whose goal was to be “cleared for surgery.” [ABSTRACT FROM PUBLISHER]

The encounter with clients from diverse cultural backgrounds may stir in the practitioners intense counter-transferencial reactions, which if unexplored may obstruct the helping relationships and interventions. This article presents and demonstrates a cultural competence training where such countertransference can be worked through. The training applies a combination of narrative analysis that emphasizes the active participation of the listener in the sense-making process and of the exploration of group processes from a psychoanalytically oriented point of view. Presented are four vignettes that demonstrate different types of countertransference and of the group process. [ABSTRACT FROM PUBLISHER]

In the course of a psychoanalytic treatment, many clinical situations create countertransference pulls or invitations to participate in enactments of various degrees. In these projective identification-based transferences, the patient is often successful in drawing the analyst into archaic object relational patterns of acting out. During these moments, the analyst must struggle to find a way to stay therapeutically balanced. The urge to rush to judgment with punitive, seductive, rejecting, controlling, or manipulative comments rationalized as interpretations must be managed. If these unavoidable countertransference enactments are managed and studied, they can provide useful information about the patient's internal struggles and can show the way to making more helpful and more therapeutic interpretations. Case material is used for illustration. [ABSTRACT FROM AUTHOR]

The life and theory of Sandor Ferenczi provide insight into both the historic admonition and the dangers of loving feelings in the therapeutic relationship. Ferenczi believed in the creation of mutuality in all analytic dyads. His refusal to subscribe to a hierarchical structuring of the treatment relationship led to his subsequent marginalization from the traditional psychoanalytic canon for nearly a century. On close inspection, however, he was a formative figure who laid much of the groundwork for current thinking about the intersubjective and relational approaches to treatment. Much of his life and theory can be understood through the lens of his relationship with Sigmund Freud. That relationship is closely scrutinized in the following historical examination. [ABSTRACT FROM AUTHOR]

This essay discusses the clinician's defense against and resolution of the experience of boredom in the countertransference as an incident of projective identification in the treatment of a woman with dissociative identity disorder. The essay details the inner mind of the therapist as she discovers both her own feelings and judgements of those feelings. As the essay progresses, she begins to grasp the significance of her discomfort in informing the therapeutic process. We watch as this material is made use of to move forward a stalled therapy into new territory. [ABSTRACT FROM AUTHOR]

Correction of the patient's distortion is often the focus of therapeutic treatment. However, the therapist's distortions, based upon pre-existing fears, which themselves are often rooted in greater societal issues and energized by the work with the patient (especially as they relate to issues of racial difference between the therapist and patient), can lead to clinical impasse. Just as an effective treatment relies upon the patient's opening up to correcting distortions, so too the therapist must be able to use transference response and become vulnerable to knowing and moving beyond his own fears and distortions. [ABSTRACT FROM AUTHOR]

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out. In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This "do my dirty work for me" approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out. Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment. All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification. doi:10.1300/J032v14n02_04 [ABSTRACT FROM PUBLISHER]

Managed health care policy has created dramatic changes in current clinical practice, and all too frequently, impacts the overall treatment plan. Clinicians making referrals for emergency hospitalizations can no longer rely on an in-patient, safe, holding environment. Rather the hospital's relationship and stance with managed care insurance providers determines the length of the hospitalization and the case management plan for patients, instead of the patient's need. [ABSTRACT FROM AUTHOR]

This article reflects my personal and professional dislocation resulting from the World Trade Center disaster. Through the act of writing and an active reading of the professional literature, I attempt to re-establish equilibrium, to restore confidence, and to rekindle a sense of purpose and meaning in the helping process, both for myself and for the reader. Examined is the literature related to memory and its connection to the phenomena of trauma, "psychache," compassion fatigue, vicarious traumatization, countertransference, and burnout. It concludes with guidelines for "being present" and for self-care. [ABSTRACT FROM AUTHOR]