Transference, Psychic Reality, and Countertransference

The Plan Formulation Method from Control Mastery Theory and Management of Countertransference

The aim of this article is to show how the plan formulation method (PFM), an empirically validated method for case formulation based on control mastery theory (CMT), can help clinicians make sense of and use what they feel during sessions to better understand and treat their patients. We give a brief overview of the main psychoanalytic conceptions about countertransference, provide a brief introduction to CMT, and describe the concept of the plan and the PFM. We then show, using several brief clinical examples, how the components of the plan (patient's goals, pathogenic beliefs, traumas, tests, and insights) may help understand clinicians' in-session feelings.

Mechanisms of defense in clinical ethics consultation

Clinical ethics consultants respond to a multitude of issues, ranging from the cognitive to the emotional. As such, ethics consultants must be prepared to analyze as well as empathize. And yet, there remains a paucity of research and training on the interpersonal and emotional aspects of clinical ethics consultations-the so-called skills in "advanced ethics facilitation." This article is a contribution to the need for further understanding and practical knowledge in the emotional aspects of ethics consultation. In particular, I draw attention to defense mechanisms: what they are, why they exist, and how we might work with them in the setting of ethics consultation.

Mentalization, insightfulness, and therapeutic action: The importance of mental organization

Continuing debates over the relative importance of the role of interpretation leading to insight versus the relationship with the analyst as contributing to structural change are based on traditional definitions of insight as gaining knowledge of unconscious content. This definition inevitably privileges verbal interpretation as self-knowledge becomes equated with understanding the contents of the mind. It is suggested that a way out of this debate is to redefine insight as a process, one that is called insightfulness. This term builds on concepts such as mentalization, or theory of mind, and suggests that patients present with difficulties being able to fully mentalize. Awareness of repudiated content will usually accompany the attainment of insightfulness. But the point of insightfulness is to regain access to inhibited or repudiated mentalization, not to specific content, per se. Emphasizing the process of insightfulness integrates the importance of the relationship with the analyst with the facilitation of insightfulness. A variety of interventions help patients gain the capacity to reflect upon and become aware of the intricate workings of their minds, of which verbal interpretation is only one. For example, often it seems less important to focus on a particular conflict than to show interest in our patients' minds. Furthermore, analysands develop insightfulness by becoming interested in and observing our minds in action. Because the mind originates in bodily experience, mental functioning will always fluctuate between action modes of experiencing and expressing and verbal, symbolic modes. The analyst's role becomes making the patient aware of regressions to action modes, understanding the reasons for doing so, and subordinating this tendency to the verbal, symbolic mode. All mental functions work better and facilitate greater self-regulation when they work in abstract, symbolic ways. Psychopathology can be understood as failing to develop or losing the symbolic level of organization, either in circumscribed areas or more ubiquitously. And mutative action occurs through helping our patients attain or regain the symbolic level in regard to all mental functions. Such work is best accomplished in the transference. The concept of transference of defense is expanded to all mental structure, so that transference is seen as the interpersonalization of mental structure. That is, patients transfer their mental structure, including their various levels of mentalizing, into the analytic interaction. The analyst observes all levels of the patient's mental functioning and intervenes to raise them to a symbolic one. At times, this will require action interpretations, allowing oneself to be pulled into an enactment with the patient that is then reprocessed at a verbal, symbolic level. Such actions are not corrective emotional experiences but are interpretations and confrontations of the patient's transferred mental organization at a level affectively and cognitively consistent with the level of communication. Nonetheless, the goal becomes raising the communication to a symbolic level as being able to reflect symbolically on all aspects of one's mind with a minimum of restriction is the greatest guarantee of mental health.

The Presence of The Analyst in Lacanian Treatment

Transference implies the actualization of the analyst in the analytic encounter. Lacan developed this idea through the syntagm presence of the analyst. In the course of his seminars, however, two completely different presences emerge, with major implications for how the treatment is directed. In the light of Lacan's idea that the transference is constituted in Real, Symbolic, and Imaginary dimensions, it can be seen how in his early work the analyst's presence is a phenomenon at the crossroads between signifiers and images. From the 1960s onward, however, the analyst's presence comes to necessarily involve the Real. This means it points to the moment at which symbolization reaches its limits. The clinical implications of this later interpretation of the presence of the analyst as incorporating the Real are manifold and affect psychoanalytic practice with regard to the position and the interventions of the analyst. Specifically, interventions targeted at provoking changes in defenses against experiences of excess or senselessness are discussed and illustrated with case vignettes and a published case. With transference considered "the navel of the treatment," the necessity that traumatic material will emerge in relation to the analyst becomes clear.

Stirred by Kafka's A Country Doctor: An Exploration of Psychoanalysts' Styles, Vulnerabilities, and Surrealistic Journeys

Using Kafka's short story A Country Doctor and clinical examples as vehicles, the author demonstrates the centrality of psychoanalysts' styles and life experiences to the psychoanalytic process. Albeit charged with a distinct facilitative task, psychoanalysts inevitably bring their qualities as "fellow sufferers" (to use D. M. Orange's term) into their sessions. They experience pressures placed upon them as the "subject presumed to know," as Lacan describes. They encounter the ubiquity of self-deception, facing many unknown and unpredictable elements as they surrealistically travel through time with their patients. While understandably wanting to take refuge from their vulnerability, psychoanalysts cannot escape the influence of their individualistic and idiosyncratic natures on the transformational encounters they facilitate.

Reflections on Becoming an Older and More Experienced Psychotherapist

In this article, I describe how greater self-awareness and increased affect tolerance changed my clinical work with patients. I provide a clinical example to illustrate how my personal growth occurred. Blind spots, created through both conflict and ignorance, are discussed. My acceptance of my limitations in general, as well as those that come with age, and the awareness of the limitations of time itself all increase as I age. Grief and mourning become more central in my work. My comfort and confidence increase, but awareness of my age makes me more selective about whom I will treat. I treasure the work more than ever and experience the benefits of mutual peer supervision increasing over time. I hope to convey what a privilege it has been to be a psychotherapist.

Recognizing Charles Rycroft

This article aims to outline, in brief, the life and work of Charles Rycroft. He had been one of the brilliant and fecund psychoanalysts of the second half of the Twentieth century, although his legacy has unfortunately often been neglected. The author suggests that this might have been because of his withdrawal from the British Psychoanalytic Society, which made him, in many ways, "invisible" to his own colleagues and that continues even today-more than ten years after his death-to preclude a real recognition of his personal and original clinical thinking and working style.

Privacy and disclosure in psychoanalysis

The tension between privacy and disclosure in psychoanalysis operates in various ways in analyst, supervisee, and supervisor. Analysts need to maintain the privacy of their patients by keeping their material confidential; they also need to know and share their own internal conscious conflicts to be able to discover unconscious conflicts and their characterological ramifications. Clinical writing is one vehicle for the exploration, discovery, and communication of transference-countertransference issues and other conflicts stimulated by clinical work, but it does not provide the perspective that comes from sharing with another person. Telling a trusted colleague what we think and feel in relation to our patients and ourselves enables us to see our blind spots, as well as providing perspective and affect containment in our work. Mutuality in peer supervision tends to reduce the transference. The special problems of privacy and disclosure in psychoanalytic training are addressed, as are the ways the analyst's belief in maintaining privacy may affect the analytic process and therapeutic relationship.

The patient's experience of validation in psychoanalytic treatment

The importance of the patient's experience of validation is not a new one in psychoanalytic thinking, and can be traced throughout the literature. However, its role as an essential aspect of the psychoanalytic process, particularly in working with intrapsychic conflict, has traditionally been underappreciated. It is argued that validating interventions have an important role in psychoanalytic treatment, and that they often serve to open up, rather than foreclose, the analysis of transference. Marsha Linehan's conceptualization of the role of validation in Dialectical Behavioral Therapy provides a unifying framework for a more extensive psychoanalytic consideration of validation. After a review of the psychoanalytic literature, a number of conceptual issues are discussed that have complicated thinking about validation from a psychoanalytic perspective. Two clinical examples are presented, one from the author's psychoanalytic practice and one from his own analysis. Both illustrate how active validation by the analyst can play an essential facilitating role in the psychoanalytic process.

The analyst's countertransference to the psychoanalytic process

There is countertransference, not just to individual patients, but to the process of psychoanalysis itself. The analytic process is a contentious topic. Disagreements about its nature can arise from taking it as a unitary concept that should have a single definition whereas, in fact, there are several strands to its meaning. The need for the analyst's free associative listening, as a counterpart to the patient's free associations, implies resistance to the analytic process in the analyst as well as the patient. The author gives examples of the self-analysis that this necessitates. The most important happenings in both the analyst's and the patient's internal worlds lie at the boundary between conscious and unconscious, and the nature of an analyst's interventions depends on how fully what happens at that boundary is articulated in the analyst's consciousness. The therapeutic quality of an analyst's engagement with a patient depends on the freeing and enlivening quality, for the analyst, of the analyst's engagement with his or her countertransference to the analytic process.

Patients reading about themselves: a stimulus to psychoanalytic work

Patients' reading of their psychoanalysts' papers about them as a vehicle for psychoanalytic work is a relatively new phenomenon in the field. Over the past five years, reports of analysts' employment of their writing in this fashion have begun to appear in the analytic literature. This paper presents clinical illustrations of this specific use of analysts' writing. These illustrations were drawn from interviews with analysts who published clinical articles in Psychoanalytic Dialogues between 1995 and 2003. The author considers some of the clinical and scientific implications of this use of papers written for publication.