Stumbling along in the Countertransference: Following Up Enactments with Balanced Therapeutic Interpretations

Abstract

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.

KEYWORDS:

• countertransference
• transference
• Kleinian theory
• archaic object relations
• projective identification
• acting out

INTRODUCTION

In the course of our work to uncover and work through each patient's unique core pre-oedipal fantasies and the subsequent oedipal elaborations and compromise formations, we discover many obstacles in the way of psychic change (Chessick, 1994). While the countertransference can be a remarkably helpful tool in unearthing and understanding the patient's internal struggle between self and object, the counter-transference can also become part of the overall pathology, playing out a mutual reenactment of archaic object relational conflicts. Newman (1988) discusses how many of our more difficult patients will work to prove their conviction of having no usable or reliable objects. I would add that they may act out their conviction that they are a useless or even dangerous object to others, including the analyst in the transference. Newman (1988) states that these patients will evoke complementary pathological responses from the analyst that only serve to prove their case that object relations must be controlled, avoided, or obliterated for the sake of either self or other. This notion is similar to the clinical observations of Betty Joseph (1989), who examines the moment-to-moment invitations and interpersonal as well as unconscious pull for the analyst to shift into certain paranoid or depressive countertransference states. Of most clinical concern are the situations in which the analyst is temporarily maneuvered by projective identification processes into paranoid schizoid experiences of counter-transference anxiety, competition, desperation, demand, or aggression that when acted out only serve to validate or intensify the patient's existing paranoid or depressive phantasies regarding love, hate, and knowledge.

At times, our communication about what we see occurring in the patient's transference and in the patient's internal phantasy experience may indeed be a cold splash of honesty and reality to the patient. However, with some counter-transference moments of acting out the analyst uses his or her interpretive authority to make a cold and cruel slap of honesty and reality. In other words, the message may be meaningful and helpful, but the tone or method of delivery may be a countertransference acting out of some type of projective identification-based transference dynamic being pushed into that clinical moment.

Making sure to link a useful interpretation to our confrontive splash of reality can be what helps us stay in the realm of clinical healing and out of the murky area of disclosure and the hurtful area of acting out. Often within a particular treatment, enactments are unavoidable, and we make a rush to judgment in our interpretive efforts. But, by closely monitoring our countertransference states of mind, we can still sometimes manage to follow it with a therapeutic shift to a more constructive interpretation that can also, sometimes, include a reference to the transference/counter-transference acting out that just occurred.

This is not an all-or-nothing, anything-goes approach. In fact, it is the acknowledgment of the inevitable, universal pull of the transference and the almost-predictable countertransference enactments that follow in almost all treatment settings. However, the analyst can become familiar with the projective identification-based transference-induced countertransference state that is unique to each patient and then find his or her analytic footing instead. Then, the particular form and flavor of the transference/countertransference acting out can serve to provide the ingredients for a valuable and transformative series of interpretations that explore that clinical moment and expand upon it.

CASE MATERIAL: NORMAL LEVELS OF COUNTERTRANSFERENCE ACTING OUT

David had seen me for more than four years following his discharge from the psychiatric hospital he had been taken to for severe depression. He continued on several medications and was part of an ongoing research study group following patients suffering from major depressive episodes.

When I started seeing David, he was dating a woman whom he treated in a rather condescending manner. This was usually triggered by him feeling furious with her emotional troubles impacting their relationship. While she certainly had some severe paranoid and obsessive issues that crippled her functioning, we gradually discovered that these situations brought David back to early states of anger and disappointment with his family of origin. He had spent most of his life resenting his family and feeling like he always had to be the one “to clean up their mess, bail them out, and educate them on the right thing to do.” Alcoholism, drug addiction, lack of education, financial problems, and chronic fighting were the norm for his family and David felt he was the only one that had managed to climb out of the fire. So, he looked down on them and resented that he had to care for them and never got the chance to be cared for by them.

In the countertransference with David, I found myself fluctuating between various complementary and concordant states of mind (Racker, 1957). On one hand, I felt I was much like him when I felt numb, bored, cut off, and not too interested in what he had to say. I was not motivated to be in touch with him emotionally. Externally, this was the result of being bombarded by his extremely sterilized, intellectualized, and stripped-down way of non-relating to me and others, usually fortified with countless details about his work day and work projects.

At the same time, I felt David was often judgmental of and even arrogant regarding his friends, family, and girlfriend, and I wanted to put him in his place with some form of judgment or criticism. In his transference, I felt David was being cold and aloof to me when he described his dependence on me as “glad to have an additional medical appointment along with my psychiatrist in which I can process the ineffective patterns of thought that lead to my depression.”

Other times, I found myself siding with him against his family. I felt outraged at their simple-mindedness and constant parasite-like dependence on David for money and advice. I felt sorry for him when he described his girlfriend's constant controlling ways and her tendency to heckle David about everything and anything. Based on our work together, I told him he probably did feel quite angry and upset over many things that would make anyone depressed, but that he felt guilty about it so he was extra depressed.

Overall, this fluctuating countertransference, a result of identification with his multiple states of conflict embedded within a strong reliance on projective identification, involved a third object. Over and over again, I was feeling either for or against one object and siding with or despising another. So, I was on his side against his girlfriend, feeling in synch with his family against him, or feeling sorry for his girlfriend as a victim of David's cold logic. Thus, a constant aggressive struggle existed in which he was upset with another and I was pulled in to side with either David or the other party.

During periods in which he was acting particularly cut off from me or intensely attacking his wife or family, I felt pushed to intervene abruptly or call him out on his nasty behavior. So, when he was putting down his wife or family, I felt offended due to being treated as the dumping ground for his narcissistic proclamations. I felt he was refusing to look at his part in things or to have any compassion or curiosity about the other person's plight. Initially overcome by this countertransference tension, a paranoid schizoid state of anxiety and anger, I was prone to want to lash out and put him down. Sometimes, I did this by saying, “That sounds pretty angry, like you think you are above them or entitled to have what you want when you want it.” While what I was saying was accurate and could be fine as an interpretation or confrontation, as soon as I said it I was aware of the slight degree of anger and critical demeaning attitude behind what I said. I was hit by a sense of guilt and remorse, signaling a depressive reaction to my initial attack.

So, I added, “Maybe there is something behind all that anger and aggression. Maybe you are sad that you never had the family you wanted and never have felt that others were there or are there for you. You withdraw because you feel no one is there for you so why bother. So, you are angry and entitled, fed up with others, but also very lost and sad that you can't find a way to connect with others.”

Here, I managed to regroup in the countertransference, stepping back from my emersion in David's projective identification process of paranoid and destructive fantasies. I moved into a more alpha function (Bion, 1962) version of containment that enabled me to interpret from a more depressive position perspective. His transference response to all this was somewhat of a parallel to my countertransference (Racker, 1957) in that David first felt guilty. He said, “You are right. I feel bad when I am like that. I shouldn't treat people like that. I just don't know what happens, I feel so upset. I think you are right about missing out on what I always wanted. I look around and everyone else seems to have had a family they could count on and parents who took care of them instead of the other way around. I can see they have their own issues and it's not a personal thing but it is hard to not take it that way.” So, here, we were now both functioning in a more mature, depressive manner, trying to understand and bear things that may or may not be in our control.

So, with David and with many other patients, I notice that when I am caught up in the projective identification process and become pulled into a countertransference interpretive enactment, I am initially making a paranoid schizoid remark, usually attacking, controlling, or judgmental. At some point, hopefully right away, the intensity of my remark, to me and only on occasion to the conscious reality of the patient, alerts me to my misstep. Then, through a sense of responsibility, intrigue, and guilt, I am able to rebalance myself and try to learn what the countertransference might be about and how to use it to find meaningful therapeutic direction. At that point, the initial remark that I regret can serve as a productive springboard from which to explore a less rigid and more expansive line of analytic investigation.

Over time, as we worked on David's anger, resentment, and entitled bitterness, my difficult countertransference states reduced as he felt less and less outrage and grievance. He was able to move from a more paranoid schizoid (Klein, 1946) state of feeling put upon and having to fight back to a place of genuine mourning for a family that never lived up to what he wished for and a painful lack of connection to his parents and siblings. This working through of loss and grief helped David to accept his girlfriend's flaws more so that he could start to talk with her about his feelings rather than act out in anger. This change led to them discussing issues and negotiating problems so that their relationship shifted to a much more satisfying experience for both. In the transference, David was able to make a gradual transition from his more obsessive, intellectualized, flat, and deadened way of relating to me to a more enlivened and engaging relationship. Over the last year, he focused more on the positive aspects of his life and feeling more competent and hopeful rather than angry and depressed.

During the fourth year of his analytic treatment, things were going quite well but much busier and more hectic for David as he and his now wife began preparing for the arrival of their second child. He had been talking about how he might have to “really cut back the time he spends on things other than family.” We explored how he had always used work as an obsessive retreat into which he could withdraw, feel in control, and not be bothered by the shortcomings of all his objects. We also discussed how we would probably have to stop meeting for a while when his second child arrived. His desire to work less and spend more time with his family was important, as it was external evidence of his new ability to tolerate contact with the good object. Rather than tear down the good object with grievance and resentment, he was able to slowly tolerate the flaws and disappointments of the good object enough to allow himself to love and depend on it without feeling taken advantage of or abandoned. This was a gradual reversal of his enforced splitting (Bion, 1962) and a healthy measure of grieving that allowed him to tolerate and benefit from connecting with the good object (Ahumada, 2004).

A few months later, David began missing many of his weekly appointments and leaving messages about being overwhelmed with work projects that needed to be finalized before the birth of his second child, now due in a few weeks. I started thinking that he would probably tell me he was stopping treatment altogether since he would have to take a month off for the birth and then it would take a while for him to catch up at work. Plus, he would be helping with the baby after work. I thought it would be sad to see him go and that he could still profit from more work but that overall he had made enormous changes and internalized a significantly different image of himself and his objects during the course of our work together.

One day David arrived for his session and lay down on the analytic couch. He told me he was going to stop coming and said he thought it made “sense to stop at this time because of the baby and because of how I am doing overall.” But, he added, “I am also worried that you will be hurt by me saying this and I am scared that you will be offended. So, I guess I am wondering if you will approve of what I want to do or not.” After I gathered a few details about the manifest reasons he wanted to stop, such as his job pressures, the upcoming birth that very next week, and the expected new level of obligation to family that would take up more of his free time, I made a few interpretations.

I said, “You want me to judge you by approving or not approving, giving me all the power and you having to wait to hear my judgment. You also feel guilty and worried about how I will be, will I end up hurt or angry. Well, I think those are the very themes we have made a great deal of progress on but obviously there are still a few rough edges. So, I think you have made a great deal of very important progress. If you wanted to stay or come back later, I think you would profit from that too. But, if you stop coming now, I will survive and you probably will too. I am happy about your progress and that won't change if you stop.”

David said, “I am really glad to hear that I could come back. I wasn't sure. I do think I have made a lot of progress. In fact, my entire life has changed. When I started to see you, I was only dating Sally and I wasn't sure if I could ever commit to getting married, let alone put up with her issues. Now, I am married and have two kids! And, my life is really nice. We have a great family and I am not sorry for that choice. I can't believe I used to think that work was more important than her or the family. Now, I can't wait to get off of work and go home to see them. I love them.” David began to cry.

After a bit, David went on to say, “As you know, I have always wanted to let my friends know how much they mean to me but I can never find the courage. After we hang out for the day or the weekend, I want to tell them how much they mean to me but I feel so knotted up inside and too scared or nervous to say anything. I feel so bad because then they go away and never know how much I feel for them and how grateful I am to have them as friends. With our work together, I think I have become more able to start doing that, a little. I think it is now much more in reach, a possibility.” I replied, “I think you are trying hard to tell me about your feelings for me.”

David paused and then started to sob. He said, “Yes. I do feel that and want to tell you how much you have helped me and really showed me how to change my life. Everything in my life is so much better. I can't imagine how shallow and miserable I would still be if I hadn't come here for the last four years. I want to say thank you and tell you that I am really grateful for what you have done for me.”

In the countertransference, I was thinking of how rare it is to have such a successful, ongoing treatment and to hear a patient feel grateful and embrace the changes they worked on. At least in my private practice, it is much more the norm to encounter very difficult or hard-to-reach patients who terminate abruptly, maintain a generally negative transference throughout the treatment, or simply stop attending without any positive or negative feedback at all. I was reflecting on how this fragmented, choppy, and stormy or sterile profile is common and David's method of ending was so pleasantly different.

After a moment of silence, David said, “I bet you are so happy to have a job like this where you have everyone ending up so happy and grateful. It must be so satisfying to hear people tell you how their lives are improving and how much you have helped them.” In the countertransference, I felt an enormous push to say, “Actually, you have NO idea! Everybody is usually angry and ungrateful. And, I get blamed for their lack of progress.” I stopped myself and wondered what that might be about. In other words, I recognized it might be solely something about me that I need to look at and work on or it could be something that was a part of the projective identification-based transference David was engaging me with.

I said, “I think you mean we together have hung in there and made the commitment to work on your issues long enough to make some real progress. We hung in there together and started to see the rewards and the value of working out some difficult problems. You can see that and you are telling me that you are grateful for what we have done together.” David started to weep again. After a minute, he said through his tears of gratitude, “Yes. That is it. I want to thank you for that. Thank you so much!” I replied, “You are very welcome. I think you have just been telling me your feelings like you have wished you could do with your friends. You are finally being honest about the warmth and love you feel and expressing it directly.” David nodded emphatically.

After the session, I reflected on my countertransference experiences and came to a few insights. I think that my countertransference reaction of responding to his vision of me as always being surrounded by grateful, tearful patients expressing their deepest heartfelt emotions was too much for me. Through projective identification, I wanted to be like David, defending against closeness, turning away from any meaningful expression and instead focusing on my resentment for others. He had spent many years using his family as an easy target for bitterness and resentment. This allowed him to avoid any feelings of tenderness or gratitude that were part of the conflict and knotted internal bond with them. So, for a moment, I leaned in the direction of focusing on my difficult and nasty patients so I would not have to deal with the painful and exposed feelings of love and dependency that arose from David's comments.

I was not aware of all these details in the clinical moment. All I could make out in the heat of the exchange was my sudden and intense desire to utter these complaints and grievances to David to bulldoze over his vision of me being surrounded by love and gratitude. I simply could tell, from my immediate fantasy state, that something was up and I should approach with caution rather than blurt out my feelings or act on what was bubbling up in me. As a result of my quick self-containment, I was able to make an interpretation that was more in synch with his immediate anxiety that he was trying to avoid as well as the desire for attachment and his communication of love and gratitude. So, while not a completely conscious act, my analytic experience of staying more on balance and not acting out even when buffeted by strong desires or fears helped me to speak more to his immediate fantasies than to act out our mutual defenses against them.

CASE MATERIAL: COUNTERTRANSFERENCE MOMENTS OF CROSSING THE LINE AND THEN COMING BACK

Rebecca had been seeing me for about three years, twice a week sitting up, when she began a pattern of “trying to do things for myself and honor what I want.” She had enrolled herself in a salsa dancing class, which for Rebecca meant claiming “the right to have fun, enjoy my body, and not judge myself on some exacting level of perfection.” She felt good about these new ways of being in her life. She brought in several small art projects she had completed for me to see. This was significant since she had put her artistic side on hold for many years and this was a risk to show me and not be overcome with a feeling of me judging her, her disappointing me, or my not liking her anymore because of her “making it about herself.” This last part was an element of the transference we had worked on for years. She often worried that, with me and other men, she might cause a permanent fracture in the relationship if she showed too much of herself. She thought that it would go better to cater to us and not really ever have a presence. In fact, she would instead try to always give men the limelight and the final say.

For many years, I had struggled in the countertransference with how agreeable Rebecca could be, giving me the limelight and the role of the leader with final say. I felt I could easily lead her in almost any direction if I wanted to and she would respond with agreement and polite compliance. This was tempting at times as a way to feel in charge as her special guide and be able to control her at will. She evoked these moments in me by her extreme passivity, her idealization of my knowledge and skill, and her waiting to see what I would say or do rather than express herself as feelings and thoughts emerged. Indeed, I interpreted this as her “wait and see, put herself on hold just in case, hope for the best, wait on the sidelines” approach to me and to life.

When I noticed myself drawn to becoming her commanding overseer, I stopped short of this projective identification-based transference pull to act out her archaic fantasies of how object relations should or must be. Then, I was left with the counter-transference frustration of how much Rebecca seemed to refuse to have a mind of her own (Caper, 1997). Interestingly, Rebecca came to me after being in therapy for years with someone whom she said, “had her own agenda, told me about her frustrations with her own daughter's dating problems, and seemed to want me to do and be all that her daughter failed to do and be. I went along with it for a long time and finally was fed up at being completely ignored and having to cater to her. She never seemed to pay attention to my needs. So, I finally quit.” We had processed many times how in some ways she pulled for me to be exactly like this last therapist even though she also hoped I would be different and recognize her as an independent and separate person that I respected.

So, part of the work of shifting through Rebecca's transference was confronting Rebecca on the way that while she may want me to encourage her and allow her to have a mind of her own, she simultaneously censored and hid her mind from me. Joseph (2000) points out how some patients use compliance and agreeableness as a massive resistance to exposing their own minds. Bit by bit, Rebecca and I explored and worked through, often in a push-pull manner, the conflicts and fears she had regarding the safety of self and object when it came to allowing herself to think and feel.

So, when I had changed all the art hanging on my office walls and she walked in and looked around, Rebecca had an extremely controlled reaction. First, she said in a very sedate and soft manner, “I see you changed a few things.” I said, “Yes. You are not saying what you think about the change.” After a minute of looking around, she said,” Well, I notice most of the pieces are horizontal.” Over the years, Rebecca had established a pattern of relating to me in this flat, distant, and non-relational manner. In the countertransference, I was left feeling alone (Shafer, 1995), cast aside, and unwelcome. I came to understand that this was a projection of her own feelings of both feeling left out and deliberately staying out of touch so she could avoid rocking the boat and being cast overboard.

I replied, “You seem to be anxious about telling me of your feelings about my office and my new art so you are being extremely diplomatic and safe by sticking with the mechanical angle the pictures are hanging at. To tell me more about how you feel, expressing your mind, must feel dangerous.” Rebecca said, “Oh! I see what you mean! Wow! I am doing that. It sounds funny now that I think about what I just said. Yes. I do think I am uncertain about just expressing what I think.” I interpreted, “You think I will be unhappy with what you think?” She said, “Not so much that you will be unhappy but that I don't know exactly how you will react. It is more the unknown.” I said, “So, it is easier to make it known by controlling it with logic and sterilizing it with diplomatic answers.” She nodded yes.

I said, “So, you still haven't told me what you think.” Rebecca said, “I kind of like that one. It reminds me of a sunset scene I wanted to paint in my art class. It gives me some ideas.” I thought to myself that she now rendered me and the art as non-dangerous, so she could use us and take us with her emotionally. In this case, she could use the art as an inspiration or internal guide to help with her own art project. So, she was internalizing me and my office in a helpful and safe way instead of an unknown and possibly dangerous way that she had to control, keep out, and neutralize. This pattern of careful avoidance of any mutual interaction with her objects in which she could play an equal and participatory role was a hallmark of her lifelong conflicts and the transference profile.

During the course of her analytic treatment, we had examined this way of being or not being, especially in how she picked boyfriends who were selfish, unreliable, and not willing to commit to a long-term relationship. But, Rebecca would wait and wait, hoping her object would one day change and decide to want her and love her. She felt that if she curtailed her own expressions of either positive or negative desire, she could keep the object around. By not causing any conflict, maybe the object would notice her and like her. So, she was the passive victim or ignored bystander in most of her relationships, including within the transference in moments such as the one involving the new artwork.

When Rebecca started her analytic treatment, she was grossly overweight and out of shape. During the time we spent together, we addressed how she was so out of touch with herself that she chose to tend to the needs of the object so much more than the needs of herself; she neglected her diet, overall health, and sense of self-confidence. Indeed, to have a defined healthy lifestyle of diet and exercise was a direct self-expression that Rebecca felt could interfere or endanger her chances of being noticed, accepted, or loved by the object. In fact, she was unconsciously convinced that to have such a self-definition would increase the chances of being passed over for love or outright rejected and punished.

In the last few months of treatment, Rebecca had secured a new base of self-definition by deciding to take up hiking and running as a fun activity for her own enjoyment and as a way to get into shape and lose weight. We had spent a fair amount of time discussing this and examining the fears and joys she had as she carved out this new territory that was exclusively hers. The idea that anything would be safe to claim as hers was a fragile feeling still as it pulled on intense fantasies of conflict, loss, and persecution. Specifically, Rebecca would return to feelings of uncertainty in which she remembered how her father, an angry alcoholic, would “become out of control if I dared to show my face or say what I thought, let alone ask for something.” Rebecca also grew up feeling responsible for her mother's chronic depression and eventual suicide. So, creating a sense of her own self that interacted with others in a truly separate and autonomous manner was dangerous and uncertain in her mind.

While Rebecca's hiking and running regime was going well and she was definitely losing weight and enjoying her new body image, she one day experienced a sudden shift. Rebecca came in and told me about how she had read about a new type of cellulite-removal process that was easier and “not surgical.” She spent most of that session and the next one telling me about how she had always been unhappy with her “fat thighs and big butt.” Rebecca said that even though she had managed to lose a fair amount of weight, she was never happy with her body and this new process she saw advertised seemed to be the “magical cure without the invasive surgical approach.”

As she went on and on about this, I started to feel tense and somewhat irritated, thinking that she was joining the crowds of women signing up for Botox, liposuction, and plastic surgery, all with some form of intellectualization or justification but ending up a plastic replica of some ideal they had demanded of themselves. In the next session, Rebecca told me she had met with the doctor. After an examination, he told her she was not a good candidate for the procedure until she lost some more weight. For a moment, I thought I had misjudged this doctor as another plastic surgeon making money off of gullible women. Then Rebecca told me that he had recommended she sign up for his “holistic weight-loss program for only a few hundred dollars a month.”

I was immediately aghast to think that this doctor was now going to make money off of my patient in this way before she started paying for his other treatment. Rebecca told me he sold “special herbs that helped to flush out toxins and scrub out the old and unhealthy flora in the intestinal track.” He had gone on to tell her how certain meals can remain “stuck in the intestine for weeks or months, essentially rotting and preventing the intake of healthy vitamins.” Rebecca said, “So, these toxic particles need to be flushed out with his specially mixed blend of flora scrubbers.” Rebecca went on about this with excitement and said she felt lucky to have found this out and was looking forward to using the products and losing all her weight.

I sat there in shock that Rebecca would be so gullible. I felt she was being ripped off and preyed upon but I also couldn't believe she was being so ignorant as to go along with it. I felt angry and outraged, and compelled to express it. I said, “I find it interesting that you are an engineer with a biology background but you are ignoring the fact that this doctor is telling you things that go against the basic tenets of human biology. So, maybe you want me to know better than you, like you want me to have an opinion on your behalf instead of you realizing what you're getting into yourself.” Here, I was starting off with an acting out of my countertransference, evoked by her projective identification-based transference. I regrouped for a moment when I returned with an analytic interpretation regarding how she might be using me to voice an opinion instead of her having to own an uncomfortable feeling and express herself openly. So, I think I was on the right track with that comment. But then the countertransference enactment crept back in and I continued to lecture her.

I said, “There is no such thing as bad flora and certainly nothing that needs scrubbing. When I hear the whole thing, it reminds me of the popular scam in the seventies in which people were told they needed organic enemas or ‘colonics’ to cleanse their intestines of all the rotting, toxic matter that supposedly interfered with the absorption of positive minerals and vitamins. This is clearly a bogus scam to take your money so I am surprised and interested in what makes you dive into such a thing without giving it much thought.”

I could tell, in the back of my mind, that something was amiss in what I was saying because of how intense I felt about it. I felt I needed to convince her of my point and save her from this stupid waste of money and common sense. After I added a few more negative comments on the new herbal weight loss program, Rebecca told me that I “scared her because I sounded exactly like Ben.” This remark was like a splash of water on my face because Ben had been a former boyfriend who strung her along for years, dominating the relationship with his needs and always disappointing Rebecca, who stood around waiting for him to propose to her but ended up sad and unhappy after several years of being treated rudely, being ignored and rejected, and possibly being cheated on. Rebecca said, “I hate Ben. This is just like when he would make really strong negative statements about something, and that scares me.” When I asked for details, it turned out she meant the times when he voiced a very unilateral, strong, and sometimes aggressive opinion about something he had heard about, not necessarily from Rebecca. She said his way of stating his disagreement was very forceful.

Woken up from my state of countertransference enactment, I gathered myself from this paranoid schizoid splitting, devaluation, and control and tried to make a more balanced interpretation based on what seemed like my competitive or defensive attack on an oedipal rival. In other words, I noticed I seemed envious and jealous of her new doctor, who had such magical and wonderful solutions for her, and how she immediately fell in love with him and his potions. I felt as if she had sacrificed her own identity and opinions in the process. So, I said, “You seem to have really fallen in love with this new idea of instant weight loss and in the process given up your own ability to think or decide what is best. It looks like you are blindly falling in love with this idea.”

Rebecca replied, “I think I see what you mean. I don't like to admit it but you are right. I want the easy way out to my weight problem and this seemed like a magic fix. I don't have to do anything, exercise more, or anything. I just follow the doctor's advice, pay the money, and take the herbs. So, I guess I just want the easy way out without any work.” I said, “But, in the process, you are sacrificing your own identity, your own ability to think, and your own capacity to take control of your body and life. You have turned yourself over to yet another man.” Rebecca said, “Oh crap! I see it now. I have done that. It feels so much easier. I want the lazy, quick way and trade my own self over for that but I see how you mean that ultimately it is the same thing I have been doing my whole life. Crap! Why won't you let me do it? You had to call me out on it. I don't want to take ownership of my life and my weight problem. I wanted to hand it over to someone else.”

I interpreted. “You are relating to me and others in that way, being dependent and sacrificing yourself in order to get us to take over and give you love and quick fixes, but you lose yourself in the process, waiting for someone else to define you, like with your last therapist, your old boyfriend, and with your parents.” This last comment about her parents was based on years of examining the way she felt she had to always wait and see what her parents were up to and never risk expressing herself for fear of making her parents angry and out of control. She had altered her actions because of a fear that her mother might become more depressed and kill herself, which in fact she did.

When Rebecca left at the end of that session, she said, “Wow. That was really intense. I didn't expect all that. You really laid it all out there!” I was left to struggle with a fairly intense countertransference state of guilt and anxiety. Did I overdo it? Did I express too much? Did I make her angry or depressed? Would she recover from it? I realized I was suddenly in the same place of guilt and fear that she lived in growing up and as an adult. Through projective identification, I was now in her shoes. I had to find a sense of self-security and self-containment in which I could not simply ignore my level of acting out and manically deny its possible effects but also not immerse myself in a torturous self-blaming and persecutory conviction that I had sent her over the edge. I had to feel confident that we were both okay and resilient enough to continue, to be curious, and to find a way to learn and grow from the experience. In other words, I had to believe that this moment might leave us intact or even bring us closer rather than pull us apart or cause a terminal friction.

In the next session, Rebecca began by telling me that what I had said really made her think and, while she was pretty blown away at first and felt I had called her out on a few things, she said it “was really new and important.” She went on to say that she realized how indeed she was “turning off my common sense and the 2+2 reality that anyone would have seen about the quick-fix herbal diet.” Rebecca told me, “I felt you really called me out on how I sort of threw myself at the doctor and took whatever he said or sold at face value without questioning it or having my own ideas about whether it was good or bad. In a way, I did want you to make the decisions for me and I guess I was doing that with him too. What really hit me later was how in my wanting a quick fix to my overeating, I was being just like my mother. She had so many emotional problems and needed help, like the help I get here. But, instead she took the quick fix of drugs and drinking and felt she had an instant solution when really she had no solution and was in fact instead being controlled by all the drugs.”

After listening to Rebecca, I interpreted that initially she didn't like how I “called her out” and wished I would do the work for her, expressing things that might be controversial or full of conflict so she didn't have to look at them. I said, “You don't like it when I call you out but part of you is saying it leaves you with a chance at a new freedom of being more yourself instead of having to simply follow me or him and do as we please.”

Rebecca began to cry and said, “I wish someone had called my mother out on her behavior but no one ever did! I had to go along with it and all I wanted was for my father to stand up and tell her to stop taking drugs and be my mother! Instead of paying attention to me and being my mother, all she did was be self-absorbed and take drugs and either ignore me or yell at me. So, I think I was envious that you could so easily call me out when I have such a hard time doing that without feeling like there will be a terrible consequence. At the same time, I really liked having you call me out and make me think of how I was ignoring myself, wanting the quick fix, and letting that doctor tell me what to do with my life. I do need to think for myself more and express myself but I think I want someone else to do that for me.”

I interpreted. “You want me or someone to take care of you and love you. But, you think I will only do that if you give up your identity and put yourself on hold until I call the shots.” Rebecca said, “I wanted my father to call the shots and make my mother love me. I was a kid and shouldn't have had to tell her that myself; it wasn't my job. But, I was scared if I did she would kill herself. And, she ended up doing that anyway!”

Over the course of the next month, Rebecca brought up numerous examples of situations with men she was dating and situations at work in which she felt she wasn't getting what she wanted or felt she disagreed with something and then “called the person out.” We talked about how she was able to start a reasonable, calm dialogue with the person and discuss the differences she was feeling but the difficult conflict inside her was that it felt like she was “calling them out” in an aggressive, confrontive way that could cause them to be hurt or push them to hurt her, reject her, or abandon her. Bit by bit, we worked through these anxieties and the associated fears of giving up her attachment to this less-than-ideal object and in her mind possibly have nothing ever again. We also explored how the urge to “let her parents have it” and “call them out” was tainting her ability to gauge how she was actually interacting with others.

Contemporary Kleinians try to relate the patient's current internal struggle to early infantile experiences as well as to process them within the immediate moment-to-moment transference situation, clinically known as the total transference situation (Joseph, 1985).

During normal development, the infant has both feelings of love and hatred toward the breast, and these lead to fantasies of injured, dying, or dead objects as well as angry and retaliatory objects that create an internal world of persecution, despair, and eternal emptiness (Steiner, 2004). Klein (1935) has described how identification with these damaged or diseased objects can lead to somatic problems that only begin to shift when depressive fantasies are worked through and sufficient mourning takes place. When I first met with Rebecca, she coughed and wheezed continuously. She sneezed all the time, blaming it on allergies for which she took large amounts of allergy medication. I pointed out to her that she usually began coughing more intensely when we were discussing something that made her feel more anxious. By her third year of analysis, she no longer sneezed or wheezed. In the fourth year, she had stopped taking her medications and almost never coughed.

The more Rebecca was able to own and bear her own feelings and thoughts regarding love, hate, and knowledge toward others, the more she was able to acknowledge, understand, and utilize her feelings and thoughts regarding love, hate, and knowledge to care for herself. In other words, as she worked out her conflicts around loving her objects, hating her objects, and wanting to understand them more actively, she was able to permit herself to be loved, draw limits around how she was treated, appreciate learning about her own identity, and come to respect her own desire to be understood by others.

SUMMARY

These two clinical cases illustrate the common yet difficult nature of working with countertransference during the course of psychoanalytic treatment. The nature of countertransference is an always-present force that constantly, inevitably, and even predictably draws us into very personal forms of acting out to very personal reactions to the transference and projective identification processes so universal in our patient's presentation. These periods of acting out by the analyst can be minor and fleeting or major and chronic.

At one end of the spectrum, these countertransference stumbles can be highly useful as a way to truly “taste” the dramatic forces at play in the patient's core fantasies and unconscious conflicts. This in turn can lead us to new insight, which can be passed on in the form of helpful interpretations. At the other end of the spectrum, we may be drawn into various enactments that are ongoing and only serve to validate or even intensify the patient's suffering and anxiety.

Contemporary Kleinians (Waska, 2010b) provide a clinical approach that acknowledges unavoidable countertransference enactments that can be studied and utilized in favor of the overall therapeutic work and enable the analyst to make his or her way through difficult impasses to more clinical clarity. Modern Kleinians (Waska, 2010a) have shown how projective identification is often the cornerstone of a patient's transference state. As such, the analyst has an ongoing pull to embody various aspects of self and/or other from the patient's archaic object relational world.

Throughout most analytic treatments, but especially with those more erratic, entrenched, and disturbed patients struggling with more primitive paranoid or depressive fantasies, the analyst is subjected to constant invitation to be a part of unresolved unconscious tales centered on themes of love, hate, and knowledge. Sometimes, these countertransference seductions are intense and obvious; other times they are more subtle and hard to detect. Some countertransference feelings are more easily detected because they go so against the analyst's own sensibilities. Others are so in line with the analyst's everyday perceptions that they go unnoticed.

Another confusing aspect of successfully monitoring the countertransference, as evidenced by the two cases presented, is determining exactly how the patient is using us in the projective identification process at any given moment. We may be enlisted to be the healthy, assertive, exploratory mind of the patient so he or she doesn't have to think or know. So, we are left with the pleasure and dread of old, current, or new knowledge about them or others. We may be pulled into feeling as persecuted or depressed as the patient does, feeling his or her guilt and anxiety so the patient feels rid of such elements. We may be molded into a variety of positive or negative figures from the patient's assortment of parental objects, authority figures, lovers, teachers, guides, judges, and prophets. We may find ourselves cast in the role of the third object, an oedipal placeholder in the patient's fantasy of the desired object and the object to compete against, avoid, or give into.

As one can tell, analysts have countless uses in the patient's projective identification endeavors to communicate, attack, resolve, amend, or avoid his or her core self and any close relational experience with another. All of these psychological efforts on the patient's side create an ongoing, ever-changing matrix of feeling and thought in the analyst, shaping the countertransference into a rich and dense motif that provides both valuable clues toward a helpful interpretive focus and a quicksand-like hall of mirrors that blind us, hold us back, and encourage repetitive enactments.

The Kleinian approach provides a helpful therapeutic road map to catching ourselves when inevitably pulled into the countertransference abyss and a way to shift to a more constructive line of interpretive exploration. We can use the counter-transference to enrich our working knowledge of the patient's transference conflicts in the here and now as well as their past object relational struggles. Finding out how and why the patient wants us to be positioned in the countertransference can show us to “take it personal” in a helpful manner rather than take it in an impersonal or reactive manner.