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THE TECHNIQUE OF

Po/choanalytic
Po/chotherapy

VOLUME 11

Responses to Interventions
The Patient- Therapist Relationship
The Phases of P~chotherapy
ROBERT LANGS, M.D.
THE TECHNIQUE
OF

P~choanalytic
P~chotherapy

VOLUME 11

Responses to Interventions

The Patient- Therapist


Relationship

The Phases of Psychotherapy

JASON ARONSON INC.


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London
New Printing 1989
Copyright co 1983, 1974 by Jason Aronson Inc.
All rights reserved.
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who wishes to quote brief passages.

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Volume 11: ISBN 0-87668-105-4

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Northvale, NJ 07647.
There must be some quite special internal difficulty to
be overcome by the analyst in giving interpretations . .. for
there seems to be a constant temptation for the analyst
to do something else instead. ... The giving of a mutative
interpretation is a crucial act for the analyst as well as for
the patient, and ... he is exposing himself to some great
danger in doing so .... At the moment of interpretation the
analyst is in fact deliberately evoking a quantity of the
patient's id-energy when it is alive and actual and
unambiguous and aimed directly at himself. Such a
moment must above all others put to the test his relations
with his own unconscious impulses.

JAMES STRACHEY
The Nature of the Therapeutic
Action of Psychoanalysis
To my wife, Joan
Brief
Table
T able ofContents
of Contents

PREFACE (1983)
(1983) 21
21
VI. RESPONSES TO INTERVENTIONS 31
18. Confirmation of Interventions
18. 33
33
19. Failure to Confirm Interventions and Reactions to
19.
Missed Interventions 88
88
VII. THE PATIENT-THERAPIST RELATIONSHIP 141
20. The Patient's Reactions to the Therapist:
20. Therapist.' Funda-
mental Concepts 143
21. The Patient's Reactions to the Therapist:
21. Therapist.' Principles
of Technique 226
226
22. The Therapist's Reactions to the Patient
22. 292
292
VIII. THE PHASES OF PSYCHOTHERAPY 377
377
23. The Opening Phase 379
379
24. The Middle Phase 423
423
25. The Terminal Phase and After
25. 445
445
BIBLIOGRAPHY 523
523
INDEX OF CLINICAL MATERIAL 529
529
INDEX OF AUTHORS 543
INDEX OF SUBJECTS 545
Comprehensive
Comprehensi ve
Table of Contents: Volume II
11

PREFACE (1983)
(1983) 21
21
VI. RESPONSES TO INTERVENTIONS
INT'ERVENTIONS 31
31
18. Confirmation of Interventions 33
33
IMMEDIATE CONFIRMATION 34
THE RECALL OF PREVIOUSLY REPRESSED MATERIAL
MATERIAL'•
Dreams'• Fantasies and Childhood Memories
Dreams Memories'• THE
EXPRESSION OF OTHER PREVIOUSLY UNMENTIONED
MATERIAL • THE CLARIFICATION
MATERIAL' CLARIFICATION OF PREVIOUSLY UN-
EXPLAINED SYMPTOMS, OR SYMPTOM RELIEF •
INDIRECT CONFIRMATION • NEGATIVE RESPONSES
FOLLOWED BY CONFIRMATORY MATERIAL •- NON-
VERBAL INTERVENTIONS •.0 THE THERAPIST'S SILENCE
• THE SUDDEN APPEARANCE OF
APPEARANCE SYMPTOMS AND
AFFECTS DURING
DURING THE SESSION • CONFIRMATION
DESPITE REGRESSION • IMMEDIATE CONFIRMATION:
BASIC PRINCIPLES
DELAYED AND LONG-RANGE'
LONG-RANGE· CONFIRMATION OF CORRECT
INTERVENTIONS 81
81
19. Failure to Confirm Interventions and Reactions to
19.
Missed Interventions 88
IMMEDIATE FAILURE TO CONFIRM AN
AN INTERVENTION 89
THE LACK OF FRESH MATERIAL
MATERIAL'• VALID NEGATIONS OF
INTERVENTIONS • DIRECT AGREEMENT FOLLOWED BY
NONCONFIRMATORY ASSOCIATIONS
NONCONFIRMATORY ASSOCIATIONS'• OTHER FORMS OF
NONCONFIRMATORY RESPONSES
IMMEDIATE NONCONFIRMATORY
AND THEIR CONSEQUENCES
SPECIFIC TECHNICAL ERRORS AND 110
IRRELE-
EXCESSIVE ACTIVITY BY THE THERAPIST • IRRELE-
VANT,
VANT, GRATUITOUS AND
AND INAPPROPRIATE INTERVEN-
TIONS • ERRORS IN INTERPRETING • PREMATURE
INTERPRETATIONS DEEP INTERPRETATIONS
• TOO DEEP INTERPRETATIONS •
INTERPRETATIONS'• INEXACT
INCORRECT INTERPRETATIONS INEXACT INTERPRETA-
TIONS • MISSED INTERPRETATIONS
LONG-TERM INDICATORS
INDICATORS OF LACK OF CONFIRMATION 130

VII. THE PATIENT-THERAPIST RELATIONSHIP


RELATIONSIDP 141
141
20. The Patient's Reactions to the Therapist: Fundamental
Concepts 143
AND EXAMPLES
INTRODUCTION: SOME DEFINITIONS AND 143
THE TRANSFERENCE ASPECT OF THE PATIENT-THERAPIST
DYAD
DYAD 151
151
TRANSFERENCE'•
THE DISPLACEMENTS IN TRANSFERENCE The Trans-
ference Object • What is Transferred: The Content
Fantasies'• THE ROLE OF THE THERA-
of Transference Fantasies
PIST AND OTHER REALITIES • THE FORMS OF TRANS-
FERENCE REACTIONS • Transference as Conscious
Fantasies • Acting Out of Transference Fantasies
Fantasies'•
Transference as Belief and Intention • Transference
as Realistic Wishes and Intentions • Transference
Distortions • Psychotic Transferences .. Narcissistic
Transferences • Instinctualized Transferences •
Transference Symptoms • Transference as Inter-
the Therapist • SPECIAL
actions with the SPECIAL DIMENSIONS OF
TRANSFERENCE • The Identification of Transference
Manifestations • The Manifestations andand Role of
Transference in Psychotherapy • Work with Trans-
ference Manifestations in Psychotherapy • Trans-
ference as Resistance • Defenses Against Transfer-
ence Expressions • Transference Gratifications •
Preformed Transferences • So-called Transference
Cures
~ONTRANSFERENCE i\SPECTS
NONTRANSFERENCE ASPECTS 211
THE THERAPEUTIC OR WORKING ALLIANCE
ALLIANCE • ESTAB-
ALLIANCE'• MAINTAINING
LISHING THE THERAPEUTIC ALLIANCE
THE THERAPEUTIC ALLIANCE
ALLIANCE • DISTURBANCES IN THE
THERAPEUTIC ALLIANCE
ALLIANCE • OTHER REALISTIC ASPECTS
OF THE PATIENT- THERAPIST RELATIONSHIP • THE
BASIC AGREEMENT • REALISTIC POSITIVE ELEMENTS
IN THE RELATIONSHIP'
RELATIONSHIP • REALISTIC NEGATIVE ASPECTS
TO THE RELATIONSHIP

21.
21. The Patient's Reactions to the Therapist: Principles of
Technique 226
TRANSFERENCE REACTIONS 226
226
NEUROTIC TRANSFERENCES • Neurotic Transferences
as Resistances • Neurotic Transierence
Translerence Reactions
That Reveal Important Unconscious Fantasies •
TRANSFERENCE MANIFESTATIONS IN THOSE WITH
CHARACTER DISORDERS, AND
SEVERE CHARACTER AND IN BORDERLINE
AND PATIENTS •
AND NARCISSISTIC PATIENTS Aggressivized Trans-
ferences • Erotized Transferences • Narcissistic
Transferences • Psychotic Transferences
NONTRANSFERENCE ASPECTS 285
PITFALLS IN ANALYZING TRANSFERENCE MANIFESTATIONS 286
22. The Therapist's Reactions to the Patient 292
292
SUBJECTIVE EXPERIENCES AND
AND SELF-OBSERVATIONS OF
THERAPISTS 293
THE MYTH OF THE UNRESPONSIVE ("NEUTRAL" OR
"MIRROR") THERAPIST • MYTHS ABOUT
ABOUT COUNTER-
TRANSFERENCES • MYTHS ABOUT
ABOUT THE THERAPIST'S
GRATIFICATIONS • THE MYTH OF TOTAL EQUALITY BE-
GRATIFICATIONS
TWEEN AND THERAPIST
TWEEN THE PATIENT AND THERAPIST'• THE MYTH OF
THE THERAPIST'S OMNIPOTENCE AND
AND ITS
ITS CONVERSE •
THE MYTH OF THE TOTAL ISOLATION BETWEEN THE
THERAPIST'S EXTERNAL AND HIS PRACTICE'
EXTERNAL LIFE AND PRACTICE • THE
MYTH OF THE THERAPIST'S OFFICE AS A PLACE OF
FANTASY • THE MYTH OF THE EFFECTIVE, UNANA-
FANTASY UNANA-
LYZED PSYCHOTHERAPIST
PSYCHO ANALYSIS OF PSYCHOTHERAPISTS
THE PSYCHOANALYSIS 308
THE REFLECTION OF THE THERAPIST'S ERRORS IN THE
MATERIAL FROM THE PATIENT: IATROGENIC SYN-
DROMES
DROMES 308
SYNDROMES •
INTRODUCTION • MAJOR IATROGENIC SYNDROMES
Iatrogenic Depressions and Suicide
Suicide Attempts
Attempts'• Iatro-
genic Masochism • Iatrogenic Paranoid-like Symp-
toms; Impairments in Trust • Iatrogenic Obsessive
Reactions • Lesser Iatrogenic Depressions • Iatro-
Erotic and Erotized "Transferences" and
genic Erotic
Iatrogenic Acting Out • Violations of the Thera-
peutic Boundaries by the Therapist • So-called
So-called
Countertransference "Cures" • THE RECOGNITION OF
SYNDROMES • Types of Hostile
THERAPIST-EVOKED SYNDROMES
Countertransference Expressions • Common Res- Res-
ponses in Patients to Hostile Countertransferences
• Types of Seductive Countertransference Expres-
sions • Common Responses to Seductive Counter-
transference Behavior • Other Aspects of Counter-
transference Problems .' THE TECHNICAL HANDLING
OF THERAPIST-EVOKED REACTIONS IN PATIENTS
PATIENTS •
REFERRALS OF PATIENTS BECAUSE OF UNRESOLVED
UNRESOLVED
PROBLEMS • THE CONSTRUC-
COUNTERTRANSFERENCE PROBLEMS
TIVE
TIVE UTILIZATION OF THE THERAPIST'S SELF-
AW
AW ARENESSES

VIII. THE PHASES OF PSYCHOTHERAPY 377


377

The Opening Phase


23. The 379
379
THE MAIN THERAPEUTIC PROBLEMS 380
ANTITHERAPEUTIC MOTIVES FOR SEEKING
ANTITHERAPEUTIC SEEKING CONSULTA-
CREATE MISALLIANCES
TIONS; EFFORTS TO CREATE MISALLIANCES • Con-
scious Deviant Motives for Treatment That Are
Therapist·• Conscious
Concealed From the Therapist Conscious Deviant
Motives for Treatment That Are Revealed to the
Therapist Unconscious Deviant Motives for
Treatment
COMMON PROBLEMS FOR THE PATIENT 398
398
ACTING
ACTING OUT "SELF-CURES," "FLIGHTS INTO
HEALTH" AND REQUESTS FOR MEDICATION • CONCEAL-
CONCEAL-
AND FANTASIES
ING FACTS AND • PROLONGED OPENING
PHASES • EARLY
PHASES EARLY ATTACKS
ATTACKS ON THE THERAPIST
COMMON PROBLEMS FOR THE THERAPIST 410
410
FAILURE TO FOCUS PROPERLY'
PROPERLY • FAILURE TO EDUCATE
THE PATIENT
PATIENT ADEQUATELY
ADEQUATELY'• PREMATURE,
PREMATURE, OR TOO DEEP
DEEP
INTERPRETATIONS AND
AND CONFRONTATIONS
CONFRONTATIONS • BLIND
SPOTS AND
AND COUNTERTRANSFERENCE PROBLEMS
PROBLEMS IN THE
THERAPIST

24. The Middle Phase


24. Phase 423
423
TYPICAL PROGRESSIVE MIDDLE PHASES
PROBLEMS IN THE MIDDLE PHASES 435
PROBLEMS AND
INDICATIONS OF MIDDLE PHASE PROBLEMS AND STALE-
MATES • Unresolved and Repetitive Resistances
or Disturbances in the Therapeutic Alliance •
Lack of Therapeutic Progress .• Repeated Regres-
sions, Acting Out or Acting In • Acute Disruptive
Episodes • Any Serious Attempt to Leave Therapy,
Harm Others or to Suicide • Any Feeling in the
Therapist That the Therapy Is Not Progressing or
Moving Well·
Well • lTNDERLYING
UNDERLYING CAUSES OF STALEMATES
AND PROBLEMS • Poor Technique, Including Failures
AND PROBLEMS'
in Confrontation and Interpretation .• Countertrans-
ference Problems .• Impairments in the Therapeutic
Alliance • Problems in the Patient • Unresolved
Realities in the Patient's Life

l5. The Terminal Phase and After 445


445
THE TERMINAL PHASE 445
THE RESOLUTION
RESOLUTION OF SYMPTOMS AND TERMINATION
AND TERMINATION
SPECIAL PROBLEMS
• SPECIAL PROBLEMS IN THE TERMINATION
TERMINATION PHASE •
Gifts Offered by the Patient to the Therapist • Con-
tinuing the Therapeutic Work to the Last Moment
• Constructive Responses to Termination
Termination'• TERMINA-
TERMINA-
TION MADE NECESSARY BY EXTERNAL
EXTERNAL CIRCUMSTANCES
• Termination Necessitated by the Patient's Life
Circumstances • Termination Necessitated by the
Circumstances • PATIENTS
Therapist's Life Circumstances PATIENTS WHO
HAVE SPECIAL PROBLEMS WITH SEPARATION • PRE-
MATURE TERMINATIONS TERMINATION OF STALE-
• TERMINATION
EXTENSIONS OF THERAPY BEYOND
MATED THERAPY • EXTENSIONS
AN AGREED-UPON TERMINATION DATE
AN • Mutually
Agreed-Upon Termination Dates • Terminations
That are Largely Unilaterally Set
That
AFTER THE TERMINATION OF TREATMENT 513
513
THE PATIENT'S CONTINUATION OF THE THERAPEUTIC
WORK·• CONTINUING THE BOUNDARIES OF THE THERA-
WORK
PEUTIC RELATIONSHIP • SO-CALLED MAINTENANCE
MAINTENANCE
THERAPY·• WHEN THE PATIENT CALLS AFTER TERMIN-
THERAPY
ATION: THE PROBLEMS OF RESUMING THERAPY
ATION:

BIBLIOGRAPHY 523
523
INDEX OF CLINICAL MATERIAL 529
INDEX OF AUTHORS 543
543
INDEX OF SUBJECTS 545
Preface (1983)

The decision to pause and document a clinical position is a diffi-


cult one. When writing these two volumes, I was mindful of a
sense that while many of my ideas had crystallized, more were
evolving; yet I believed that there was sufficient conceptual clarity
and firmness to justify publication. As far as I can tell, The Tech-
nique of Psychoanalytic Psychotherapy has withstood the first test
of time. For many therapists it remains fresh, definitive, specifi-
cally helpful, and evocative. Nine years later, my expectation of
growth and change has also been amply borne out.
Volume 11 commences with an extensive discussion of responses
to interventions (chapters 18 and 19). Every intervention by a ther-
apist should obtain clinical psychoanalytic validation, and I note
with some pleasure that I have always demanded of myself a val-
idating methodology. In the present work, the revelation of previ-
ously repressed and unreported material is the hallmark of this
type of confirmation. At times, validation also emerges through an
allusion to a well-functioning figure. Both cognitive and inter-
actional-interpersonal forms of confirmation are identified, but
the latter is afforded only a secondary role. In addition, there is
the requisite that validation be surprising and often indirect - a
concept that foreshadows the more specific requirement that psy-
choanalytic validation involve meaningful indirect or derivative

21
22 PREFACE

expressions. I undertake a detailed study of nonvalidating re-


sponses and the consequences of erroneous interventions. While I
emphasize symptomatic regressions and impairments in the thera-
peutic alliance, I also give some attention to the patient's commu-
nicated unconscious perceptions of the therapist's errors.
It was necessary eventually to expand these studies of validation
and nonvalidation in order to specify a number of insights which
appear only in embedded or passing form here. In substance, it
became clear that both dramatically correct and strikingly incor-
rect interventions can produce new and previously repressed
material from patients. It therefore proved vital to examine the
manifest and latent implications of this previously unreported
material as an unconscious commentary (a mixture of valid deriva-
tive readings of the meanings of the therapist's effort and of dis-
torted responses) on the therapist's intervention. It was equally
essential to determine the degree to which the new material either
reinforces the therapist's intervention or, instead, is designed con-
sciously, and especially unconsciously, to correct the therapist and
set him or her along the right path. While newness remains an
important criterion of validation, consonant unconscious implica-
tion is a necessary addendum.
These chapters on the confirmation of interventions remain cen-
tral to the volume. Furthermore, they contain the seeds of my sub-
sequent work in this area. The discovery of certain flaws in the
first application of the validating process comes as no surprise or
disappointment. The fact that I established this critical precedent
looms far larger.
Certainly a discussion of the patient-therapist relationship is at
the heart of any book on technique. In chapters 20-22, I combine
the traditional intrapsychically oriented approach to the subject
with my own nascent interactional perspective. I realize that these
chapters advance views for which I have since criticized myself and
others. At the same time, in both embedded and definitive form,
the use of a communicative (adaptational-interactional) frame-
work is implied.
In my basic definition of transference (p. 148) the patient's reac-
tions to, and fantasies about, the therapist are founded on uncon-
scious fantasies (a standard statement) and unfold out of the
PREFACE 23

patient-therapist interaction (my specific addition). Clinical


material is used to demonstrate that the clinical referents, with
which I invoke the concept of transference, involve direct refer-
ences to the therapist or evidence of likely displacement figures.
Although my emphasis is on relationship (static) rather than inter-
action (dynamic and always interpersonal), I make quite explicit
that every transference reaction has a day residue - a precipitant or
adaptation-evoking context. It is here, then, that the adaptational-
interactional (communicative) approach to the understanding of
transference-based expressions from the patient has its beginnings.
Possibly the greatest shortcoming of this discussion is the failure
to recognize that every association from the patient has some bear-
ing on the therapeutic interaction and relationship, transference or
non transference. My more recent studies of how the therapist's
interventions create adaptive contexts to which the patient reacts
on manifest and derivative levels have led me to believe that this is
indeed the case: Every single communication from the patient has
a bearing on these evocative stimuli.
The nature of the therapeutic alliance, the basic therapeutic con-
tract, and the implications of the therapist's interventions are all
considered at length with regard to both transference and counter-
transference. I allude to the patient's valid unconscious percep-
tions of the therapist's' errors and elaborate on them in the chapter
on countertransference (22). The specific realization that many of
the well-founded and nontransference aspects of the patient's rela-
tionship with the therapist are based on such valid unconscious
perceptions lay at that moment in the future. The most recent find-
ing is that all of the patient's responses to the therapist's interven-
tions begin with valid unconscious perceptions and are then ex-
tended from that focal point. The patient's pathology comes into
play by serving as the means by which the patient organizes these
unconscious perceptions. It forms the basis for the patient's selec-
tion of those specific implications of a therapist's intervention to
which he or she will react.
This brings me, naturally, to my discussion of the therapist's
reactions to the patient (chapter 22). While I see now the place for
a more complete exploration of the therapist's sound or noncoun-
tertransference functioning, I continue to find that this area lends
24 PREFACE

itself only minimally to learning considerations. Of greater signifi-


cance are the delineation of specific sound techniques and the indi-
cation of the need for a clear means through which the therapist's
subjective awarenesses, the interventions to the patient, and the
patient's material itself can be monitored for signs of disturbance.
Particularly noteworthy in this chapter is my enumeration of
iatrogenic syndromes - probably the strongest and clearest fore-
runner of my later extensive studies of the patient's interactional
symptoms, syndromes, resistances, and so forth. It is here that the
therapist's contributions to the patient's difficulties (as well as
cure) begins to find definition. Here, too, originates the use of the
patient's material as a resource through which the therapist's
errors can be identified. Observations of this kind have proved
quite valuable in the development of the communicative view.
Despite my initial efforts, I show at this juncture a somewhat re-
stricted understanding of the therapist's interventions. Nonethe-
less, I am mindful of the possibility of both realistic and distorted
reactions to errors in technique, and of the fact that a therapist
may actually repeat in some form a past pathogenic interaction in
the patient's life. Thus, my incipient understanding of the patient-
therapist relationship is evident in these chapters, even though I as
yet lack a full sense of the continuous and spiraling conscious,
and especially unconscious, communicative interaction. My
empirical clinical base seems to have served me well.
The phases of psychotherapy are treated in the usual and well-
known classical psychoanalytic manner (chapters 23-25). Perhaps
most unique in this consideration is the effort to identify those
motives in patients seeking consultation or therapy that do not
involve a quest for insight and understanding in regard to their
neurosis. This is a precursor of my interest in patients' attempts to
obtain uninsightful or deviant modes of cure, as later reflected in
the concepts of therapeutic misalliances - a theme already present
in this volume-and framework-deviation cures (Le., relief
obtained by altering the ground rules of therapy). It is also the
dawning of my awareness of patients' efforts to destroy, rather
than generate, meaning and insight. Coupled with the discussions
of errors designed by therapists to create sectors of misalliance are
forays into the issues of the nature of the communicative inter-
PREFACE 25

changes between patients and therapists, the problem of attempts


to destroy meaningful modes of relatedness, and the important
area of un insightful modes of cure or symptom relief.
The subject of difficult patients concerns me to this day. In
chapter 23, on the opening phase of psychotherapy, I define the
nature of their psychopathology, their motives for destructive
attacks on the therapist and the treatment process, and the thera-
pist's best responses. In chapter 25, I discuss the posttermination
phase and the importance of maintaining there a sense of ground
rules and boundaries, and I touch on issues of the framework of
psychotherapy. All of these topics have continued to absorb me
and have since been the focus of considerable further study.
It appears to me now that it is indeed the concept of the adaptive
context, with its unfailing interactional implications, that lends
unique perspectives to these discussions of the patient-therapist
relationship. When I wrote this volume, I had recognized only the
most obvious implications of this particular approach for both
transference and countertransference. A large portion of my sub-
sequent work has entailed the extension and clarification of the
ideas first offered here.
It is my hope that this volume will provide the reader with a
sound, basic understanding of the therapeutic process and of the
human experience, and thus with a foundation on which to
develop personally as a therapist - and as a human being. It has
done just that for me.

Robert Langs, M.D.


New York, New York
A List of Subsequent Writings by Robert Langs, M.D.

The Therapeutic Interaction, 2 Volumes (1976)


The Therapeutic Interaction: A Synthesis (1976; from Part 2 of
The Therapeutic Interaction)
The Bipersonal Field (1976)
The Listening Process (1978)
Technique in Transition (1978)
The Supervisory Experience (1979)
The Therapeutic Environment (1979)
Interactions: The Realm of Transference and Countertransference
(1980)
Resistances and Interventions: The Nature of Therapeutic Work
(1981)
Psychotherapy: A Basic Text (1982)
The Psychotherapeutic Conspiracy (1982)
Intrapsychic and Interpersonal Dimensions of Treatment: A
Clinical Dialogue (1980, with Harold F. Searies, M.D.)
The Therapeutic Experience and Its Setting: A Clinical Dialogue
(1980, with Leo Stone, M.D.)
Classics in Psychoanalytic Technique (1981; editor)
Unconscious Communication in Everyday Life (In Press)
THE TECHNIQUE OF

Psychoanalytic
Psychotherapy

VOLUME 11

Responses to Interventions
The Patient- Therapist Relationship
The Phases cif Psychotherapy
VI

RESPONSES TO

INTER VENTIONS
18 Corifirmation cif Interventions

The patient's response to the therapist's interventions, or to his


failure to intervene (see Chapter 19), is the final fundamental link in
the sequence of listening, formulating, intervening, and listening
that constitutes a session. In the methodology of psychotherapy, the
response, by validating or invalidating the entire sequence, is in
many ways the key to our therapeutic work. Not only does it pro-
vide us with the material we need to test and elaborate upon our
hypotheses and interpretations, and to adjust them and our tech-
nique accordingly, but also it is the hallmark of the insight and
inner change that we strive to help our patients achieve. Confirma-
tion, and resolution of intrapsychic conflicts and of symptoms, go
hand in hand; the therapist must learn to recognize when his inter-
ventions are validated and especially when they are not.
Broadly speaking, confirmation is defined as a response to an
intervention that genuinely adds to the formulation presented. It is
a direct or, more usually, indirect and unconsciously determined
elaboration and clarification of some aspect of the context,
dynamics, unconscious fantasies, and intrapsychic conflicts alluded
to in the intervention. It is, then, some added and fresh fact or
fantasy that reflects a shift in defenses toward a lessening of
repression, flight and denial, and toward greater self-awareness,
with consequent availability of derivatives of previously repressed

33
34 RESPONSES TO INTERVENTIONS

material. This level of confirmation may also widen to include


complex modifications in neurotic symptoms and behavior, and
new, healthier and more flexible adaptations. (For background, see
Brenner, 1955; Kris, 1947; Kubie, 1952; Marmor, 1955; and
Schmidl, 1955.)
There are two major classes of confirmations: those that are
immediate and confined to the session in which the intervention is
made or to the several sessions immediately following; and those
that are more gradual and delayed, emerging over long periods of
therapy.

IMMEDIATE CONFIRMATION
Immediate, genuine confirmation of an intervention IS one of
the most gratifying aspects of our psychotherapeutic. endeavors.
But I must emphasize at the outset that a patient's direct conscious
agreement with the intervention does not constitute confirmation,
just as his immediate negation does not mean failure to confirm (see
Freud 1905 and 1937). Such immediate affirmations may reflect
anything from genuine corroboration, to misleading submissiveness
or a fear of angering the therapist, to a need to deceive and ridicule
him. It is the material that follows such initial comments that is
crucial. If the agreement is genuine, a new perspective or previously
repressed memory or fantasy will emerge; if it is false, the subse-
quent material will be stale, repetitious, isolated and empty. In the
latter case, this material at best will reflect unconscious fantasies
that the therapist has erred or has misunderstood the patient, and
some of the underlying reasons that led the patient falsely to agree
with a wrong intervention.
By and large, immediate genuine confirmations should follow
any correct intervention; operationally, the confirmation itself is
the corroboration of the validity of the intervention. We cannot
consider an interpretation or any other intervention to be valid
unless proper confirmation follows from the patient. This vital fact
makes it essential to listen in depth to his response to our words.
It also makes the problem of assessing the manifest and latent con-
tent and the genuineness of the response a very significant part of
Confirmation of Interventions 35

our work. Genuine confirmations must be distinguished from those


seemingly affirmatory responses that are actually an expression of
submissiveness or blind obedience to the therapist. All too often.
therapists mistake direct agreement with one of their interpretations
or the stale addition of a monotonously familiar memory or fantasy
for truly insightful or unconsciously meaningful confirmation-
which. of course, it is not. No positive and lasting inner change can
follow from such empty, intellectualized echoes. Learning to
identify true and meaningful confirmations is an ever-present chal-
lenge for every therapist. He is helped by the fact that individual
patients often have, unconsciously, characteristic ways of confirm-
ing or rejecting interventions, and these become useful guides. In
all, however. this is a treacherous area, with many pitfalls, and one
that takes a long time to master.
Patients are often quite clever and unconsciously creative in
finding ways to let the therapist know that he has correctly under-
stood and helped them, and I cannot catalogue every possible con-
firmatory response. By defining the more common means of
confirmation. however, I hope to enable the reader to grasp the
basic concepts and principles, and foster his sensitivity both to the
many possible variations in confirmatory communications, and to
the lack of true validation. The clinical vignettes in this and the
following chapter may be supplemented considerably through the
use of the Index of Clinical Material.

THE RECALL OF PREVIOUSLY REPRESSED MATERIAL


I have selected this category of confirmation first because of its
dramatic qualities and the excitement it generates in ongoing thera-
peutic work, and because it is a kind of response whose significance
is almost never at issue.

Dreams
I shall begin with a vignette:

Mrs. G.Y .• a woman with a borderline syndrome, had


just returned from a summer vacation trip and described
how she, her husband, and her three young children (ages
36 RESPONSES TO INTERVENTIONS

seven to eleven) had shared a hotel room for the week.


Her children had misbehaved and one of her sons had
strangely insisted that each kind of food that he ate be
on a separate plate. The patient herself had subsequently
developed abdominal pain after her meals. They had seen
a woman whose legs had been amputated, and this had
led the patient to fantasize being legless herself, punished
for some unknown reason, and being nursed by others.
To a query, she denied that the sleeping arrangements had
been a problem or that they had stirred anything up for
her.
In the next session, she described her guilt over hav-
ing had intercourse with her husband as her children
slept in the room that they had shared on the trip. She had
felt bad and had anticipated some kind of disaster. Her
stomach pain had also followed the sexual intercourse.
Further, her sons had seen her daughter nude and they
had all wrestled several times while in their bathing suits.
Based on this material, which I have condensed here,
the therapist intervened. He chose to interpret both the
patient's and her son's symptoms to her. He pointed out
how overstimulated and frightened her children had
apparently been, and suggested that her son's need for
separate plates reflected his struggle against the lack of
boundaries among the members of the family during the
trip, especially in regard to the sleeping arrangements.
He added that, considered as a communication from the
patient, this must also reflect her own anxieties, guilt and
struggles regarding the family's openness. He went on to
suggest that her stomach pains and fantasies of being
punished by loss of her legs reflected her own guilt and
need for punishment for exposing herself to, and having
had intercourse in the presence of, her children.
Mrs. G.Y. responded by suddenly recalling a dream
from the previous night, which she had not remembered
until then: there were five negroes in a room and she was
their captive; it was terribly dangerous and she fled
through a bathroom window.
Confirmation of Interventions 37
Since it was at the end of the session, the therapist
simply pointed out that the patient had had the dream
before he had said anything. The dream directly demon-
strated that she herself was quite aware of the anxiety-
provoking aspects of the sleeping arrangements on her
trip.
In subsequent sessions, this material was further
explored and clarified.

In briefly discussing this excerpt, I want to emphasize that no


single interpretation should be viewed in isolation, but rather as the
culmination of confrontational and interpretive work over the
course of each period of the therapy. Thus, while I have been dis-
cussing many clinical examples in relative isolation, the reader
should keep in mind that there is always a cumulative effect from
continuing interventions and the consequent changes within the
patient.
In assessing this vignette, let us first identify the indications for
an intervention. We must consider that the sleeping arrangements,
and the fact of intercourse in the presence of her children, consti-
tute acting out by the patient. Further, both the patient and her son
experienced symptoms, and for Mrs. G.Y. there was also disturbing
guilt and anxiety. In all, various regressions and symptoms provided
the therapeutic context for these sessions; an intervention was clearly
indicated.
Next, it is well to define the nature of these interventions and the
adaptive context to which they were addressed. The latter was not
explicitly defined in the therapist's comments until later, but it must
have included the separation from the therapist, whatever additional
problems might have existed between the patient and her family.
For the therapist's intervention to have been complete. this adaptive
framework should have been alluded to at some point.
As stated by the therapist, the first part of this intervention is a
confrontation of a denied reality: that the patient's children and she
herself had actually been disturbed by sharing the bedroom on the
trip. Next, came a general interpretation of the child's symptoms,
offered to assist the patient in understanding her son's and her own
anxieties and in dealing with them. A somewhat specific interpre-
38 RESPONSES TO INTERVENTIONS

tation of the patient's guilt and fantasies of punishment through loss


of her legs. and a more general reference to the guilty fantasies
represented by her stomach pains, was then offered, in the hope that
these would be clarified through further associations.
What effects on the patient can we postulate for these interven-
tions; how do we understand the recovery of the dream? It would
appear that the therapist's confrontations and interpretations served
to alter the patient's repressive defenses and the denial of her fan-
tasies and observations related to the sleeping arrangements on her
trip. The therapist's interventions also mobilized realistic concern
about the effects of the arrangement on her son-a strong motiva-
tion for the patient to overcome her avoidances. The therapist's own
willingness to face these issues may have aided the patient to do
similarly, while the interpretation helped her to identify and focus
upon her anxieties and guilt. and her partially conscious fantasies.
In this instance, the interventions were directed both at the defen-
sive denial (through the confrontation), and at the guilt, intrapsychic
conflicts. and related unconscious fantasies (through the interpre-
tation).
Now. we may ask whether and h0w the intervention was con-
firmed. The essential point is that the repressed dream added to the
therapist's formulation: its manifest content, supplemented and
reinforced by associations in the subsequent sessions, revealed the
patient's own unconscious awareness that the undue openness and
seductiveness of the sleeping arrangements (and "badness," as she
later associated to it: negroes are too open sexually) was a source
of conflict, anxiety. and guilt. The dream also seemed to contain
derivatives of unconscious sexual and rape fantasies about her hus-
band. and possibly her therapist; these did. indeed. later emerge.
In all, then. the appearance of the repressed dream reflected
shifts in the patient's defensive alignment and brought important
clues to further understanding the intrapsychic conflicts and fan-
tasies related to her symptoms and acting out. It confirmed the
therapist's intervention in a number of ways, many of them quite
unexpected; it also directly revealed that the patient herself had
already considered, on some level, a number of the fantasies and
issues with which the therapist had confronted her.
Incidentally this vignette is a good example of the way a thera-
Confirmation of Interventions 39

pist may help the family member in treatment understand the


intrapsychic conflicts of other family members and may indirectly
assist the latter to adapt more successfully to them. This can be an
especially useful technique, but only if the material is clear and the
patient's own therapy is not threatened or the focus deflected from
her (see Chapter 6).
Let us return now to the study of confirmations by the recall of
previously repressed dream material. Consider this clinical experi-
ence:

Mrs. G.Z. was a woman diagnosed as borderline,


whose father had left his family for more than a year
after a dispute with his wife when the patient was about
three years old. This, along with several later seductive
traumas at her father's hands, had left its mark on her;
there was a strong mixture of love and rage toward him,
and conflicted fantasies on many levels. When her father
became ill during her therapy, many dimensions of her
relationship with him were brought up, explored and
worked through. This was a stormy period in her treat-
ment, since there were many expressions of primitive,
vengeful and cannibalistic fantasies, which were accom-
panied by intense and terrifying guilt and fears of punish-
ment.
At a time when Mrs. G.Z. had become more aware of
these fantasies, better understood their source, and had
begun to resolve many of the conflicts they related to, she
began a session by describing a fantasy in which she was
talking to her therapist about her father and denying
any hatred of him, while her therapist insisted that she
did indeed hate him. She then described a recent illness
of her husband and depreciated the care he was getting
from his doctor. She had defended her own psycho-
therapy in the face of criticism from a cousin, however,
and had told a close friend about her father's early
absence-something she had always previously con-
cealed. She imagined openly criticising her father for this
desertion; at this point in the session, she became anxious
40 RESPONSES TO INTERVENTIONS

and began to detach herself from the therapist and the


theme at hand.
The therapist intervened. He began by reviewing the
rage Mrs. G.Z. felt toward her father and the ways she
dealt with it by acknowledging and then denying it. She
disowned her anger by attributing her own awareness of
it to others, such as the therapist, and by attempting to
divorce herself from the entire topic-as if these feelings
and the whole problem did not exist. He then added that
she was now finally acknowledging her anger at her
father and recognizing the childhood basis for it; it was
high time she faced it and dealt with it.
The patient then remembered a dream; in it, her hus-
band brings home a huge, noisy rattlesnake. He tells her
not to be afraid of it because it has been defanged and
milked of venom.
In the session, Mrs. G.Z. went on to recall another
dream of a rattlesnake that had occurred a few months
earlier; in it the snake had crushed and suffocated her.
She spontaneously recognized that her present dream
reflected her feeling that she need no longer fear her rage
at her father as she did just "a few months ago, but that
instead, she could accept her anger at him, and not punish
herself for these feelings. The therapist heartily agreed:
not only was her rage at her father now detoxified and no
longer destroying her, but also her father's hurts against
her no longer threatened her to the extent they once had.

Let us again begin our assessment of this material by formulat-


ing the indications for the intervention. Primarily, they include the
appearance of several defenses (denial, projection, and detachment)
and, especially, the fact that these turned into a major resistance in
the session-the detachment and flight, which may have been a kind
of derealization or defensive alteration in the patient's state of
consciousness.
The intervention itself appears to be a confrontation with the
patient's anger at her father and her defenses against it, and with
the patient's capacity (ego strength) to understand this anger and
Confirmation of Interventions 41

deal with it in ways less costly to herself. Its effects on the patient
included the lifting of a repressive barrier and the recall of a dream.
The dream reflected the patient's own prior awareness that she
could deal with her rage at her father and with her memories of the
hurts at his hands without undue disturbance. Why this dream was
repressed is not clear from the material, though it may have been
due to the patient's fear of giving up her helplessness, of facing more
feelings about her father, and of the deeper fantasies latent in this
manifest dream (in later sessions, associations to the snake were to
fears of her husband's penis, and to fears of being impregnated and
poisoned by it).
In any case, this dream particularly confirmed the therapist's
reference to the patient's changed capacity to tolerate her fantasies,
memories and conflicts about her father. This significant intra-
psychic change was the result of months of therapeutic work and in
that sense, was a confirmation of the validity of a whole segment of
this therapy (see below, p. 81, ff.).
One other finding should now be apparent: confirmatory
dreams not only verify interventions, but also add fresh material
and clues to additional unconscious fantasies relevant to the patient's
currently active intrapsychic conflicts. In this instance, Mrs. G.z.'s
associations in later sessions elaborated upon the manifest element
of the snake in terms of her sexual fantasies about her father-
especially her fantasies of devouring him or his penis and of poison-
ing him-and of the talion punishment of being poisoned by him
in turn; unconscious impregnation fantasies were also involved.
One further illustration also leads into the next category of
confirmation:

Mr. H.A., who had a severe paranoid-tinged character


disorder and was in once-weekly therapy, had decided to
terminate his treatment of several years after working
through and resolving many of his characterological and
symptomatic problems. There had been a few previous
abortive explorations of termination and the SUbject had
aroused considerable anxiety and reluctance in this
patient. A dramatic change in his relationship with
women, and the resolution of intense fears of being con-
42 RESPONSES TO INTERVENTIONS

taminated by contact with others and with many types of


dirty objects. had led to his decision definitely to termin-
ate his therapy after two more sessions-at the end of a
month.
In the session after making this resolution, Mr. H.A.
spoke at length about several dates with young women
that he had had during that past week, focusing on a girl
whom he liked though she was cold and aloof. He
described renewed anxieties about dating and then men-
tioned his continued resolve to terminate in the next
session. When he went on to ruminate for some time, the
therapist intervened.
He pointed out that the patient seemed to be avoid-
ing his thoughts about termination. Mr. H.A. responded
that he had had a dream; in it. he was driving his present
car to the gas station to pick up his old car, which had
been fixed. His associations to the dream were vague:
there was a period in his life when he "hung around" a
gas station, and he spoke more about his anxieties regard-
ing dating and of the dilemma of having two cars at the
gas station at the same time. The therapist then picked up
this last theme and played it back to the patient: a
repaired car and having two cars in one place-what did
that bring to mind? The patient responded: treatment
and having to return to it after terminating. He then
developed and explored his conscious fantasies about
wanting to remain in therapy, although he no longer
needed it.

Briefly, the indication for the first intervention was that of a


defensive avoidance and resistance (ruminating) in the session. The
intervention itself was a confrontation with the avoidance. The
response from the patient was to reveal a repressed dream (or had
it been consciously withheld?) which was rather disguised in its
manifest content. The associations led to a second intervention.
The indication for it was the therapist's suspicion that the material
contained an important repressed fantasy related to the termination.
The intervention itself was a query and confrontation. though it was
Confirmation of Interventions 43

designed by inference to lead toward an interpretation that was


not explicitly stated; in actuality, the therapist was getting at the
very fantasy that the patient later verbalized. The repair of the car
seemed to the therapist to refer to therapy (the repair process); and
with two cars in one place, he reasoned, one had to remain behind.
At this point in the treatment, with termination at hand, he pre-
ferred to have the patient recognize his own fantasy with as little
help as possible (see Chapter 25).
We see again that both confrontations and interpretations can
alter repressive barriers, and be confirmed and elaborated through
the recall of a previously unconscious or unreported dream. This
brings with it both manifest and latent content that further enrich
and develop the material from the patient.
Another confirmation is alluded to in this last vignette: the
recall of a previously repressed fantasy, exemplified above in the
report of the patient's fantasy of returning to therapy after termina-
tion. I shall now turn to this subject.

Fantasies and Childhood Memories


Confirmation through the recall of a previously repressed fan-
tasy or memory may involve quite recent occurrences or distant
childhood events or day dreams. The new recollection is, as a rule,
one that enriches the unfolding material and the patient's growing
insight, and lends weight to the content of the therapist's interven-
tion.
The following very condensed clinical examples are illustrative:

Mrs. H.B. was a neurotic woman who was working


through her wish for a son (she had only daughters) and
its basis, in part, in the wish to provide her father with a
son (he, too, had only daughters). These wishes had been
especially strong when her mother had had a laryngeal
tumor removed when the patient was eleven.
In one session, Mrs. H.B. described choking sensations
in her throat and difficulty swallowing. She then detailed
the recent death of an aunt and how she had imagined
dying herself. The therapist intervened here: he pointed
out that the patient's throat symptoms were a reflection
44 RESPONSES TO INTERVENTIONS

of her wish to substitute herself for her mother with her


father, as she had imagined doing when her mother was
hospitalized for surgery; as punishment for this wish, she
was taking on her mother's symptoms. Mrs. H.B.
responded that she had forgotten until then that her first
thought when she felt the choking had been that she had
something wrong with her larynx. She went on to describe
her anger with her mother over a recent incident and over
past hurts.

The indication for the intervention was the presence of a symp-


tom (the therapeutic context) and the derivatives of an important
unconscious fantasy related to it. The intervention was an interpre-
tation to the effect that unconsciously the patient wished that she
was her mother, and with her father, and that there was guilt asso-
ciated with this wish; further, that the fantasy was represented
through the symptom of choking-a disturbance that her mother
had experienced. Both the replacing of her mother and the punish-
ment for the wish were, then, expressed in this way. The material
also implied that death wishes against her mother, as expressed in
derivative form in the day residue of the dream-the death of the
aunt (the adaptive context)-were involved and related to the
patient's guilt. I shall not be concerned here with other fantasies
and wishes expressed by this symptom, which was, as we would
expect, highly overdetermined. The outcome of the present inter-
vention was the lifting of a relatively simple kind of repression, and
a confirmation of the patient's identification with her mother
through the recall of a previously repressed fantasy that represented
this identification in a fresh way.
The confirmation has the quality of an insightful recognition,
which enhances the patient's understanding that she had indeed
imagined being in her mother's place. This type of response to a
correct intervention through the recall of forgotten thoughts and
fantasies is a frequent and important means of confirmation and
insight.
In this next vignette, the memory that the patient recalled after
the therapist's intervention had been strongly repressed for many
years; it related to a childhood fantasy:
Confirmation of Interventions 45

Mrs. H.C., a woman with a borderline diagnosis, had


been in therapy more than a year when her father died.
She had responded to his death with considerable
depression, guilt, and intrapsychic conflict. At one point,
dreams and associations suggested fantasies of seducing
her father, of being raped by him, and of having his
baby-the latter in part as a denial of his loss. There was
intense guilt in response to these fantasies and strong
attempts at renunciation of them.
In the session to be discussed, Mrs. H.C. first reported
dreaming that a tall woman in black was seductively pur-
suing her father or her husband. The patient herself was
being held by two men, who were torturing her with an
eraser. She continued with a report of a fantasy in which
her mother killed herself and another in which she herself
took her own money from the bank and went off some-
where; she had even asked her husband for the bank
book. The therapist intervened here; he said to Mrs. H.C.
that her father was dead, and that in response, she was
imagining herself going off to search for him in order to
hold onto him sexually.
The patient responded by recalling for the first time
in many years the details of childhood fantasies of search-
ing for her father, who had been away from his family
for many long periods during her childhood. Then she
remembered a specific fantasy from about age eleven;
she had imagined becoming a chorus girl and being forced
to have intercourse with her employer.

Briefly, the indications for the intervention were the patient's


impulse to act out (the therapeutic context) and the evidence of an
important repressed fantasy with disguised derivatives in the
patient's association. The intervention offered an interpretation of
an unconscious fantasy of finding and seducing her father, related
to the patient's intrapsychic conflicts and depression about her loss
(the adaptive context), and the maladaptive, impossible fantasied,
and nearly lived out efforts to find him again. The content of the
fantasies, rather than the patient's defenses, was interpreted here
46 RESPONSES TO INTERVENTIONS

because it was related to previously interpreted fantasies and was an


extension of them; further, the defenses present seemed readily
modifiable disguises.
The patient's confirmatory response was to alter a defensive
barrier with the recall of several previously repressed childhood
fantasies that had been prompted by her father's earlier absences
and that were earlier versions of her current fantasies in response
to his death; in other words, the current trauma had repeated a past
one and rekindled the earlier conflicts, fantasies and attempts at
resolution (see Chapter 8). These memories extended and elaborated
upon the therapist's interpretation.
Additional confirmation from the patient followed in the next
session, when she reported considerable lessening of her anxieties
and depression, and notably improved controls that she had devel-
oped immediately after the session just described-a confirmation
via a reduction in symptoms (see pp. 55-57).
Now, consider another vignette:

Mrs. H.F., a woman with hysterical symptoms, was


working through her disappointment in having lost her
only son, a stillborn baby who had died with the umbili-
cal cord around his neck. The analysis of the many reper-
cussions, meanings, and genetic links to this experience
had led the patient back to her childhood and to the slow
emergence of memories related to a series of primal scene
experiences. Part of the sequences in several sessions
during this period included the following material:
Mrs. H.F. dreamt of eating celery. She associated to
having performed fellatio on her husband and to child-
hood fantasies of being married to her father. She recalled
another recent dream of flushing a mouse down the toilet,
thereby breaking its neck. (Previously, the patient had
recalled sharing a hotel room with her parents; there, her
mother had been terrified by a mouse.) The therapist
intervened; he pointed out that, from what Mrs. H.F. was
saying, it appeared that she had a fantasy of wanting to
swallow her father's penis. The patient, for the first time
in therapy, then recalled a childhood experience of seeing
Confirmation of Interventions 47

her father's penis as he bathed. As she explored this


recollection, another repressed memory unfolded, that of
a time when she walked into her parents' bedroom and
saw her father lying nude in bed while embracing her
mother.
In the next session, the memory of her mother's fright
with the mouse and several similar incidents were
described in detail. emphasizing the sense of violence and
the damage done to mice after they are caught. The thera-
pist pointed out that in viewing her parents in intercourse,
the patient must have imagined that her mother was being
attacked, harmed and even murdered. This reminded
Mrs. H.F. of something else that she had not remembered
for years: when she was somewhere between ages seven
and thirteen, and for a long while. she would fantasize
being tied to her bed and being raped by criminal men.
Many versions of these fantasies then emerged and were
recalled in great detail.

The presence of derivatives of repressed core fantasies indicated


the need for interpretations here. Thus. the therapist made a series
of interpretations of the patient's unconscious fantasies as they were
reflected in the latent content of the material. This then evoked the
recall of a series of previously repressed childhood experiences and
fantasies that provided confirmation of the interpretations by add-
ing meaningful links to the remembering, expanding the patient's
understanding, and fostering the working-through of her intrapsychic
conflicts about the loss of her son. The manner in which these recol-
lections fitted with the previous material, and consolidated and
added to it in unexpected ways, further attests to the genuineness of
the recall and its potential value to the patient. The working-
through of these memories was actually the turning point of Mrs.
H.F.'S therapy. They provided the missing genetic material needed
to understand and give her insight into her symptoms of choking in
her throat and her emotional problems in relating to her husband.
Let us then, review the main principles which apply to confirma-
tions through the recall of previously repressed material (see the
Index of Clinical Material for additional illustrations).
48 RESPONSES TO INTERVENTIONS

1. Confirmation via the recall of previously repressed dreams,


fantasies and childhood memories is a dramatic and positive
response to interventions.
2. Such confimations are usually one indication that treatment
is progressing and developing properly.
3. Responses of this kind are always the result of considerable
previous therapeutic work with the patient's defenses and with more
superficial and general fantasies.
4. These responses should not only confirm what has already
been confronted or interpreted, but also provide new derivatives
and fresh leads to additional aspects of the problem, ranging from
experiences and fantasies not previously reported in therapy to the
integration of material already known, but not as yet related to the
specific conflicts and symptoms at hand.
5. When such confirmations do occur, they should generally be
the focus of subsequent work in the sessions. Such modifications of
repressive barriers are usually a signal that the patient is prepared
to reveal and explore new and important material.
6. Confirmations of this kind most often follow correct interpre-
tations of unconscious fantasies that are disguised but detectable in
the patient's associations. At times, confrontations with important
defenses and resistances may have a similar effect.
7. The test of the genuineness and reliability of the newly
remembered material is its fit with the previous material, its indivi-
duality and freshness, and its contribution of further avenues into
new aspects of the problem under exploration.

THE EXPRESSION OF OTHER PREVIOUSLY UNMENTIONED


MATERIAL
This is a large and more general category of confirmation, and
one that is, at times, difficult to judge. It includes responses to inter-
ventions that enhance insight, add new threads, integrate previously
disparate and unclear material, and bring something fresh to the
problems currently under exploration. The responses may take the
form of a reference to an event, thought or fantasy, or any new
information, that has not previously been mentioned in the current
context or session. The added associations, then, are not primarily
Confirmation of Interventions 49

repressed, but have the character of something already known but


never revealed or placed in the setting in which it is newly located.
It is the timing and placement of the additional material that is
important.
Technically, the therapist must differentiate these genuinely
fresh responses from the patient's more fiat, relatively empty, added
thoughts and from those that are repetitious and ruminative, gener-
ally defensive or compliant responses that enhance neither insight
nor the development of the material and the treatment (see Chapter
19). Meaningful new material may have a quality of surprise; it may
offer indirect validation as opposed to the more routine material or
the direct agreement lacking in latent implications that is found in
the less valuable responses. Meaningful responses may contain
derivatives of, or direct reference to, repressed fantasies that the
therapist had suspected but had not included in his comments to the
patient; less valuable responses lack such dimensions.
It is in this area, then, that the constant need to appraise the
value of the patient's response to an intervention is fraught with its
most trying aspects. There are virtually an infinite number of clues
to genuine as opposed to empty responses, and the therapist must
learn not only general guidelines such as those described here, but
also something of each patient's style of confirming or not confirm-
ing. One of the most crucial routes to a solid grasp of this problem is
the therapist's ability to be specific in his own interventions. Other-
wise, he is likely, through defensiveness or from lack of understand-
ing, to share relatively empty generalizations with his patients.
To accept disingenuous responses as confirmatory has many
obvious consequences: important defenses and resistances are
missed, and, indeed, often shared with the patient by the therapist;
characterologically-founded submissiveness or deceptiveness is un-
analyzed; and subsequent interventions are undermined since they
lack a foundation or are based on an incorrect consensus. No
genuine insight can evolve, nor can therapy deepen or develop
meaningfully. In all, then, this assessment of the patient's responses
to interventions is another vital job, one that should involve frequent
periods of rethinking and reassessing in which the therapist sits
back and listens afresh. The therapist must not narcissistically over-
invest in his own interventions, so that he has difficulty compre-
50 RESPONSES TO INTERVENTIONS

hending nonconfirmatory responses from the patient. There is a


natural tendency to place a special value on one's own formulations
and apparent insights; this is necessary if we are to speak affectively
(in moderation) and effectively to our patients, but all too often, it
leads the therapist to overlook the indicators that his timing is off,
that he is missing something important, that he is not being specific
or is being unnecessarily repetitious, or that he is just plain wrong.
In each of the clinical illustrations that follow, the therapist's
intervention was assessed as correct in supervision and the subse-
quent material was viewed as confirmatory. Material from subse-
quent hours contained new leads and insights developed from the
original intervention; in unsupervised patients. there was subse-
quently ample and elaborate validating material.

Mrs. H.G., a neurotic young woman, could not con-


ceive a child with her husband and was working through
fantasies of being impregnated by her therapist. She
described day dreams of meeting him socially and then
her wish for a child. She had been anxious coming to the
session and experienced a fleeting fear of being seduced
on the "bed"-she meant to say. "the couch"-by the
therapist. The latter intervened here: he told Mrs. H.G.
that she wished to be seduced by him so that she might
have a child with him. The patient went on to say that her
husband had joked that if his sister had another child, he
would adopt and raise him. She had been curious about
her internist and asked him if he had any children. She
then described fantasies that her husband was responsible
for their sterility, though this had not been established
medically. She had been told that her mother had had
difficulty conceiving her and that her father had blamed
her mother for it.

To formulate this material briefly: the intervention was indi-


cated because of the presence of a symptom, the patient's anxiety
(the therapeutic context) and because of the availability of readily
detectable and workable derivatives of important repressed fan-
tasies related to both the symptom and the patient's ongoing con-
Confirmation of Interventions 51

flicts. The intervention was in the form of an interpretation of a


current repressed fantasy.
The patient's response confirmed the interpreted wish for a child
from the therapist indirectly and through further, disguised deriva-
tives of the interpreted unconscious fantasy: first, by revealing a
derivative of Mrs. H.G. 's wish for a child through cohabitation with
someone else-her recollection that her husband would take his
sister's child (a projection and modification of the patient's direct
wish); and second, by revealing her curiosity regarding the thera-
pist's child-giving capacities, displaced onto her internist. This sup-
portive series of associations was then reinforced and expanded by
the revelation of the patient's fantasy that her husband was respon-
sible for her sterility.
Incidentally, Mrs. H.G. reported in the next session that her
anxiety was gone-another example of confirmation by the allevia-
tion of a symptom (see pp. 55-57).
In summary then, the patient's response to the intervention was
indirect and unconsciously revealing; it fitted the formulation offered
by the therapist and added to it. It was not a mere direct agreement
or an obvious addendum; in fact, the patient did not directly
acknowledge the painful truth of what the therapist had said, but
did so indirectly in several ways.
Here is another very condensed vignette that the reader can
formulate as it unfolds.

Mrs. H.H. was a depressed woman in once-weekly


therapy. Her father had died when she was three. He had
had some kind of bowel cancer, behaved crazily-pos-
sibly because of brain metastases-and died either before
contemplated surgery from a heart attack or during it
due to a massive hemorrhage-the patient was never sure.
Mrs. H.H. was to be hospitalized to have four impacted
wisdom teeth removed. She reported in a session prior to
the operation that she was extremely anxious and afraid
of dying. At first, she only intellectually acknowledged
the interpretation, from other associations, that this was
related to the death of her father and was based on her
unconscious fantasy that she would also meet with his
52 RESPONSES TO INTERVENTIONS

fate. Then she recalled that she was already collecting an


item from each of her children to take with her to the
hospital. The patient's need to undo and deny the pend-
ing separation from her children, and her wish that she
too could have held on to-and had never lost-her father
was then interpreted to her.
In the hour after the surgery, other material emerged,
particularly her anxiety that she would die preoperatively.
This was traced through her associations to the version of
her father's death as occurring through a preoperative
heart attack. She also reported an anxious dream experi-
ence of tumbling through space during the anesthetic,
which was traced to newly remembered childhood fan-
tasies of going to heaven and being with her father. She
had had a day dream that her son's head had been
removed and she had tried to figure out how to put it
back on; this was associated with fantasies she had as a
child that her father had been in pieces and her wish that
she could have put him together again. It also led to
associations which permitted the interpretation of fan-
tasies that the doctors had cut her father up and killed
him.

In this sequence, interpretations required by the patient's


anxieties (the therapeutic context) regarding her pending surgery
(the adaptive context) led to the revelation of many conscious, but
never discussed, fantasies and memories regarding the death of her
father, and to the subsequent recall of derivatives of unconscious
fantasies as well. The connections to the current context and to the
patient's anxieties, the fit, seeming genuineness and novelty of the
added material, and the ease with which the unconscious fantasies
could be translated from the manifest content of the material from
the patient support the therapist's belief that this material was
meaningful for her. Actually, it provided her with some of her first
insights into the many important consequences of the death of her
father and her reaction to it. It is also noteworthy because much of
it unfolded spontaneously from the patient once her defenses and
anxieties had been dealt with.
Confirmation of Interventions 53

Not all confirmations are dramatic. Often they can be detected


only briefly and by careful listening in depth, but they are suffi-
ciently clear to validate the intervention although the patient quickly
moves on to other problems. Two brief examples of this infinitely
variable kind of confirmation will suffice:

Mr. H.!., a young man with a borderline diagnosis,


had concealed from his therapist the fact that he had
been taking his mother's librium whenever he felt that he
needed it over the past week, justifying the use of a drug
not prescribed for him by alluding to the stress he was
having with his new job. Both the concealment and the
actual pill-taking were interpreted to the patient, in the
context of his recent efforts to thwart and attack the
therapist, as destructive of treatment, representing
attempts to depreciate and destroy the therapist, and as
ultimately harmful in depriving him of the chance to
develop his capacities to cope on his own. The patient
immediately remembered and reported for the first time
in his present therapy that he had made a suicide attempt
while in a rage at a previous therapist, using this same
kind of pill, and quickly went on to explore the many
reasons for his fury at his present therapist, who had
particularly angered him by not letting the patient deceive
and manipulate him in the previous session.

Here, an acting out led to a general interpretation of the patient's


rage at the therapist. Confirmation was dramatic: he had used his
previous therapist's pills in a prior suicide attempt. The implications
were clear and the patient went on to look at the specific reasons for
his rage at his present therapist.
Here is another condensed vignette:

Mr. H.]., another young man diagnosed as borderline,


was faced with his therapist's pending summer vacation.
In a session filled with remoteness and avoidance, he
mentioned a dream of being seduced by a boyfriend;
more rumination then followed. Sensing the obvious
54 RESPONSES TO INTERVENTIONS

transference fantasies related to holding onto and replac-


ing the therapist homosexually, and hoping to develop
them more specifically and to find links to himself, the
therapist asked the patient what came to mind about the
friend. Several vague and empty responses and further
rumination followed, but when no new meaningful
material emerged, the therapist, concerned lest the patient
act out, asked once more near the end of the session about
this friend, who previously had been remotely connected
with the therapist. Now the patient remembered that the
friend had recently lost a brother. With this added
material, the therapist could specifically relate the dream,
and the few associations to it, to his vacation, and to the
patient's view of it as a loss and a death; and he pointed
out in this context Mr. H.J.'S thoughts of a homosexual
replacement for him. The patient then recalled that in a
telephone conversation that he had mentioned earlier in
the session, he had in fact discussed the therapist's pend-
ing absence. He then went on to recognize and explore his
feelings about the separation and his conscious temptation
to act out homosexually while the therapist was away.

In this session, the query was indicated because of the patient's


potential for acting out (the therapeutic context) and the technical
need for derivatives and links that would enable the therapist to
relate the dream-fantasies to his pending vacation (the adaptive
context). The therapist pointed out the defensive avoidance here,
but this failed to modify it. His only hope, then, was to get through
to the latent content of the dream. Perhaps because the hour was
nearly over-a separation-possibly too as a response to the thera-
pist's persistence, which also reflected his concern, or as a result of
the earlier confrontation with his defenses, the patient finally
revealed an association which led to an interpretation of the
patient's fantasies and anticipated maladaptive response to the com-
ing vacation. Confirmation then consisted of the patient's recall of a
repressed aspect of an event already mentioned in the session; this
led to a direct exploration and understanding of the patient's
anxieties and fantasies about the pending separation.
Confirmation of Interventions 55

Any classification of the types of confirmation is made solely for


reasons of discussion; most confirmatory responses are a mixture of
new, previously repressed recollections regarding past and present
events and fantasies, and of various thoughts, realizations, and
experiences which were subjected to other kinds of defensive modi-
fications, for instance, by placing them out of their most meaningful
context.
Since I have already described a number of additional mixed
confirmations (see also the Index of Clinical Materials), I shall not
add further clinical material here, but move on to several other
kinds of confirmation that deserve separate identification and study.

THE CLARIFICATION OF PREVIOUSLY UNEXPLAINED


SYMPTOMS, OR SYMPTOM RELIEF
This category of confirmation emphasizes one quality and func-
tion of many confirmatory responses; their crucial role in illuminat-
ing the unconscious fantasies upon which symptoms and charac-
terologic disturbances are based and their basic role in ultimate
alleviation of the symptoms. This particular category of immediate
confirmation extends into one which is generally a long-term kind of
confirmation-the ultimate resolution of the patient's emotional
problems.
I shall give one brief illustration of this type of confirmation (see
also the Index of Clinical Materials).

Mr. H.K. had a paranoid character disorder, and had


developed a morbid fear of urine, imagining that it could
in some way destroy him; he had reached the point where
he threw away clothes on which he got urine. After
several years of treatment, while exploring this symptom
in the face of intense resistances that were repeatedly
interpreted to him, he reported a dream of slicing some-
thing with a sword while his mother watched. Associa-
tions led to hearing her urinate; this was linked by the
therapist to the patient's fears of her seductiveness. This
then led him to recall previously unreported conscious
sexual fantasies about his aunt.
56 RESPONSES TO INTERVENTIONS

In the next session, Mr. H.K. dreamt of coming to his


session with toilet paper and being told that his sister was
on the telephone, though he knew he had no sister. After
associating again to his mother on the toilet and ruminat-
ing for a while, he was asked by the therapist about the
reference to a sister. He then reported for the first time in
therapy that his mother had had a miscarriage. When the
effects of this incident on the patient were explored, he
recalled the two main day residues of the dream: an
article on abortions and another on in utero diseases.
Through this and other later material, the patient's fear
of urine was found to be based, on one crucial level, on
a deep and primitive fear of his mother, her genitals and
her murderous urine which had, in his childhood fan-
tasies, killed t~e aborted fetus. Symptom relief followed.

In brief, the patient's symptom was the therapeutic context and


indication for a series of interventions, largely in the form of inter-
pretations. A focal, symptom-related core unconscious fantasy was
interpreted here piece by piece. Initially, confirmation took the form
of the recall of incestuous fantasies and the development of the
material through the second dream. Interpretation and reconstruc-
tion of the patient's fantasies about his mother's miscarriage were
confirmed elaborately, though only one small segment of this work
is illustrated here. The recall of the repressed trauma-the mis-
carriage-in itself was strong confirmation of the validity of the
ongoing therapeutic work. Further, once the latent content of the
dream of the sister appeared, confirmation took the form of the
recovery of two of the specific day residues of the dream; both
proved richly meaningful.
Once the specific unconscious fantasies, represented as a com-
promise maladaptation by the symptom, were interpreted and
worked through, the symptom was no longer necessary, and was
given up and replaced by a healthier adaptation. Among the uncon-
scious meanings of the symptom, as revealed or hinted at here <and
there were other meanings which emerged later in therapy), were the
anxiety of being destroyed by his mother; a representation of
assaultive, incestuous fantasies toward his mother and especially the
Confirmation of Interventions 57
talion punishment for these wishes; and fantasies of having helped to
destroy the sibling who died and the talion punishment for this
deed. The symptoms served as a compromise expression of, and
adaptation to, these traumas and the intrapsychic conflicts and
unconscious fantasies evoked by them.
Symptom alleviation as confinnation of interventions includes
modifications in disturbed and acting-out behavior. The patient's
behavior itself may also communicate confinnatory fantasies and
should be explored for such latent content. We cannot, however,
consider the diminution or alleviation of symptoms to be inherently
and exclusively a confirmation of the correctness of the therapist's
interventions and ongoing work (see Chapters 21 and 22). At times,
symptoms are temporarily abandoned because of shifts in intra-
psychic balances caused by errors in technique and countertrans-
ference problems in the therapist. These may be termed "counter-
transference cures" (Barchilon, 1958) and may occur through a
therapeutic misalliance, the inappropriate reinforcement of defenses,
or by fostering a fantasy that is momentarily symptom-alleviating.
Such relief evolves from denial of the patient's pathology or of his
need for the therapist, and are common at times of the therapist's
vacation (a flight into health not necessarily evoked by counter-
transference); it may also occur at times when the therapist com-
municates to the patient his refusal to accept the latter's pathology
or his need that the patient unconsciously pretend to be well. Symp-
tom alleviation may also occur as a defense against aggressive and
seductive nontherapeutic behavior by the therapist: the patient does
not need him and is not affected by him.
Only a careful assessment of the manifest and latent content of
the material at the time of symptom alleviation can lead to a proper
decision regarding its basis-be it insight and inner change of a
lasting constructive nature, or temporary, nonconstructive inner
change. Long-term observations help in this decision. Significant life
experiences may contribute to variations in the symptom picture,
and must also be considered when such changes occur.

INDIRECT CONFIRMATION
Often, confinnation from the patient is indirect and does not
58 RESPONSES TO INTERVENTIONS

immediately elaborate upon the content of the therapist's interven-


tion. Instead, for the moment, the patient's unconscious realization
that the therapist has been correct is conveyed in associations to the
therapist's perceptiveness. This is a sign that additional meaningful
material will soon be forthcoming.
A common form of this type of confirmation is a reference to
some previous moment in treatment when the therapist was correct
in what he had said. Another variation is a reference to someone
who is smart, bright, and in tune or knowledgeable in some way;
the context makes it clear that latently this alludes to the therapist
and his recent intervention. This type of confirmation is not infre-
quent when the patient is dealing with material that is extremely
anxiety-provoking, and is tending to avoid direct and immediate
elaborations. Instead, he suddenly remembers a time when the
therapist had been helpful in the past or speaks for a while of a
positive relationship with someone else.
A variation of this response is offered in this vignette:
Mrs. H.L., a woman with a severe character disorder,
had a longstanding and severe problem with her body-
image. She had had many plastic surgical procedures and
was still not content. Now, she wanted to enlarge her
breasts. The material in her sessions revealed many
repressed fantasies relevant to the unconscious meanings
of this plan, bearing on her unconscious fantasies that she
had been castrated and wanted to restore her lost penis.
The therapist actively interpreted these fantasies and
attempted to devalue her attempts at resolution of the
related conflicts and anxieties by continued externally
directed surgical attempts at repair, rather than by a
working-through of her inner conflicts and fantasies.
In response to this, Mrs. H.L. dreamt that her husband
was dyeing his hair, which had turned prematurely gray;
it was quite an unnecessary step. As the therapist pointed
out and the patient agreed with a startled realization, this
was her own commentary on her plans for surgery.
Here, the therapist intervened because of the patient's potential
for acting out, and interpreted from her associations Mrs. H.L.'S
Confirmation of Interventions 59

unconscious fantasies of bodily damage and repair, adding a devalu-


ing confrontation. The latter was especially confirmed by the mani-
fest dream, while later associations led to further latent content
about the patient's body-image conflicts. The dream echoes the
therapist's confrontation in saying, in a sense : "You are right, the
surgery is unnecessary."

NEGATIVE RESPONSES FOLLOWED


BY CONFIRMATORY MATERIAL
The validity of an initially negative response to an intervention
can be ascertained only by subsequently listening to the material in
depth. Unfortunately, Freud's discussion of the question of assessing
the patient's response to an intervention in his paper on reconstruc-
tions (1937) has led to considerable misunderstanding. Freud
pointed out that a patient's direct agreement to a construction (or
any intervention) is of little significance unless it is followed by
indirect confirmation through new memories which extend the
formulation. A direct negation was seen only rarely as a legitimate
dissent and indicator of an error by the therapist; it most often
reflected the fact that the reconstruction was incomplete. Some
therapists have taken this to mean that every denial of an interpre-
tation or confrontation is actually a confirmation. This was cer-
tainly not Freud's intention; were this true. it would leave psycho-
therapists without a valid methodology, for indications of the thera-
pist's incorrectness essentially would not exist. In fact, it is quite
possible and necessary to develop the capacity to distinguish con-
firmation from failure to confirm, and validations from their
absence. We can also distinguish a negation which reflects defensive
denial and avoidance from one that is a genuine and well-founded
nonacceptance, owing to the fact that the therapist is, indeed, wrong.
Therapists are by no means infallible and errors are not uncommon
in psychotherapy. Patients generally will not truly accept incorrect
interventions and should not be expected to; they will most cer-
tainly respond differently to incorrect and correct interventions (see
Chapter 19). While a wish to suffer or to avoid, to submit or to be
abused, or any wish for neurotic gratifications through an anti-
therapeutic alliance with the therapist, will motivate some patients
60 RESPONSES TO INTERVENTIONS

to accept incorrect interventions, these neurotically-founded


responses can be identified from the content and context of the sub-
sequent material and from the patient's further associations; the
therapist must analyze indications of submissive types of agreement
and not share them with the patient (see Chapter 19 and Part VII).
In my supervisory experience, I have found that almost always
a patient's rejection of an intervention has been predicted in advance
in the course of the supervision. That is, after hearing the material
from the patient as presented sequentially in supervision and upon
evaluating the intervention myself, I have concluded that it was in
error-and the patient and I have agreed. Moreover, the subsequent
material from the patient manifestly and especially latently sup-
ported the negation of the intervention. Most often, the patient will
then unconsciously redirect the therapist's attention to the· main
area of his current conflicts and anxieties, so that an open-minded
clinician can follow the patient after a negated comment and
redirect his focus. I must, therefore, emphasize this point: most
negative responses by the patient to an intervention are valid and
not defensive, and they should direct the therapist to reassess his
formulation (see also Chapter 19). The discussion here will center
upon those exceptional situations where negative responses are
indeed defensive and further material from the patient contradicts
them and supports the therapist's comments.
My own direct clinical experiences help to clarify this problem. I
have found that the implications of an initially negative response have
varied. Certain patients (usually borderline and paranoid) charac-
teristically negate an intervention at first (see Freud, 1905), until
this need to deny is analyzed and worked through, usually with great
difficulty; others seldom do so. When patients of the second type
negate my comments, I am quick to reconsider matters; with the
former group, I proceed with caution, recognizing that I could be in
error, and awaiting further confirmation or its absence.
Negations that are followed by confirmatory material are a firm
reminder that we must not respond to a patient's initial disagree-
ment with our interventions with arguments or cajoling. Instead, we
must listen further and reassess silently.
I shall now illustrate this type of denial followed by confirma-
tion:
Confirmation of Interventions 61

Mrs. H.M. was a woman with a borderline syndrome


who was in therapy for severe depressions and problems
with separations of all kinds. In one session, she described
how her son and two daughters (ages eleven, nine and
six respectively) constantly battled over favors, feeling
unloved, deprived and envious if one child received any-
thing at all different from the other two. She gave many
examples and appeared totally unable to handle the situ-
ation or to convey to her children the inappropriateness
of their reactions. Basing his intervention on previous
material and the patient's descriptions of her own general
sense of deprivation vis-a-vis her husband and parents,
the therapist pointed out to the patient that she was hav-
ing difficulty handling her children largely because she
essentially shared their values and beliefs in this area.
At first Mrs. H.M. was shocked-how could the thera-
pist say that; how was that possible? It made her seem so
childish. She continued in this vein, somewhat stunned
and uncertain; then she paused and reflected. She next
recalled her battles with her brother over privileges and
favors from her parents, and her subsequent recall of
their rivalry offered further confirmation.

In attempting to understand negations that are followed by


supportive material from the patient, the therapist should concep-
tualize the basis for the initial denial. While it may stem from
anxieties and defensiveness within the patient, it may also reflect
some minor error in technique: poor wording, poor timing, or some
lack of tact.
In the clinical situation just described, it may have been that the
interpretation that the patient's own problems were interfering with
her dealing with her children evoked guilty feelings of responsibility
for these difficulties. Furthermore, the therapist's comment evoked
a negative self-image-that she was childish, not able to cope, and
immature. Lastly, there was the need to repress her own guilt-ridden
jealous and vengeful rivalry with her brother. These factors, among
others, and the anxiety and guilt that they evoked, led the patient
initially to deny the interpretation. Since it apparently was a correct
62 RESPONSES TO INTERVENTIONS

intervention, however, Mrs. H.M., motivated by her wish to face her


problems and to change, and out of her respect for the therapist
and her positive therapeutic alliance with him, continued to explore
the implications of what she had been told; once over her initial
shock regarding these disturbing implications, she found consider-
able support for it. There is no indication from the material that her
subsequent acceptance of the intervention was based on irrational
submissiveness to the therapist. The recovery of previously repressed
genetic connections and the unfolding of further material in later
sessions, as well as her improved ability to handle these problems
with her children, provides additional evidence of the validity of her
ultimate confirmation of the intervention. As we will see in the next
chapter, agreement that is primarily submissive is almost always
followed by indirect allusions to blind obedience and related themes
in the patient's associations.
Consider this second vignette:

Mrs. H.N. was a woman with a narcissistic character


disorder who was in psychotherapy, struggling to control
her promiscuous impulses. In the session immediately
preceding the therapist's summer vacation, she reported
dreaming that the therapist is at her house; she reassures
him that she will not seduce him. Then she is with her
mother and the therapist. Her mother asks the therapist
to play solitaire with her, and the patient becomes furious
and says that it cannot be done.
Associations were to sexual fantasies about the thera-
pist and links to seductive experiences with her father
when she was a small child. The therapist soon inter-
vened; he asked the patient why all this was coming up
at that time. Mrs. H.N., immediately recognizing the thera-
, pist's implication that it related to his coming vacation
(the adaptive context), blatantly denied this link. She
went on to ruminate about her lack of feelings regarding
the interruption in her treatment and about other trivial
matters. The therapist then intervened again, pointing
out that her dream itself reflected an undoing of the
separation and an attempt to deny her feelings of soli-
Confirmation of Interventions 63

tude, adding that she apparently hoped to repeat her


unusual closeness with her father; if this was not possible.
denial would prevail.
Mrs. H.N. responded that she had described a terrible
sense of aloneness to her girlfriend that morning and that
she had felt afraid and feared losing control. In her mind,
she was confusing her therapist, husband, and father, but,
much as the dream had ended with some kind of accep-
tance of her solitude and the separation (cf: "You can't
play solitaire with him"), she had told her ten-year-old
son that the time had come when he should no longer get
into bed with her. The therapist acknowledged this accep-
tance of separation without undue (i.e., incestuous) repair.
commenting to her that she could indeed now handle such
experiences without losing control.

Before considering my own discussion, I suggest that the reader


consider the indications for, and the nature of. these interventions,
and formulate the patient's response to them.
The therapist intervened in order to alleviate the patient's
separation anxieties and her potential for acting out (the therapeutic
context). Since the patient had not as yet alluded to his vacation in
the hour, he intervened with a question designed to bring out this
context of the material so that it could be properly analyzed. In a
sense, this was an implied interpretation : "Your dream was
prompted by something you have not mentioned-my vacation."
The patient thought of the therapist's vacation, only to deny it; she
could be aware of it only if she negated it. When the patient went on
to ruminate, the therapist reconsidered his formulation and inter-
vention. Strong defenses prevailed in the latter part of the session,
especially denial; he had not dealt with the patient's defenses before
moving toward the nature of her underlying fantasies, largely
because they had not seemed so strong initially.
The subsequent interpretation of the patient's rage at not being
able really to undo the separation and of the defensive denial which
then prevailed, recognized more precisely the patient's intrapsychic
conflict, fantasies, defenses and adaptive efforts. Confirmation fol-
lowed this more sensitive interpretation. It included indications of
64 RESPONSES TO INTERVENTIONS

renunciation that the therapist then emphasized, reinforcing the


patient's new adaptations, which were less costly to her and others.
If Mrs. H.N.'S initial denial was in part a consequence of the
therapist's own approach, it was also prompted by her rage at the
therapist for deserting her, and her need both to deny any longings
for him at such a helpless and vulnerable juncture, and to obliterate
the genetic ties to her incestuous longings and activities with her
father. As a rule, the therapist should be able to understand in depth
both the patient's original negation of an intervention and its subse-
quent confirmation. Repetition of interventions should generally be
avoided. The possible defensive meanings of the negation should
always be silently considered by the therapist; however, only if the
subsequent material from the patient (or the reconsideration of the
original associations) points toward such a use and only if added
clues to other, more relevant, conflicts and fantasies fail to emerge,
should the therapist attempt to interpret the negation as a defense.
He must be extremely cautious, since the negation is often a valid
one (see Chapter 19).
One last illustration will demonstrate another variation on this
theme:

Mr. H.O., a homosexual young man diagnosed as


borderline, had returned to therapy after his therapist's
vacation and spent a couple of sessions relating homo-
sexual acting out in a context and manner that clearly
unconsciously pointed to fantasies of revenge on, and
replacing, his absent therapist. This had not as yet been
interpreted to him, despite ample associations supporting
this hypothesis.
In his next session, Mr. H.O. ruminated about his
search for a girlfriend and his mistrust of women, and
about buying insurance. The therapist confronted the
patient with the fact that he was rambling. Mr. H.O. then
recalled a dream: he meets an old girlfriend on the
street; she is nice to him but he treats her like dirt. In
association, he remembered that this particular girl was
beautiful and warm, like his mother-an ideal woman.
But she had stood him up three times and his scorning
Confirmation of Interventions 65

her in the dream must have been his revenge on her.


When he then ruminated about his wariness regarding
women who had betrayed him, about his mistrust even of
his mother, who was so nice on the surface, and about his
need for revenge, the therapist intervened again. He
reminded the patient of his vacation, and commented
that the patient had had several homosexual affairs, with
which he seemed to have expressed his vengeful feelings
toward the therapist. His leaving the patient, he con-
tinued, had prompted Mr. H.O. to mistrust him and to
feel betrayed.
The patient responded that he somehow always dis-
agreed with the therapist when it came to his own feel-
ings about him. He was not aware of such feelings, but
the therapist could be right-the separation could have
stimulated these reactions. With that, the hour ended.
The patient called on the day of the next session to
cancel it because the hour conflicted with a job commit-
ment. He began the following session by apologizing for
his absence; he had known about it a week before and
should have mentioned it in the preceding session. He
described a dream from the morning of the present hour
(condensed here): he is trying to call the therapist to
cancel the last session; none of the phones work. He
reaches an operator who laughs and will not connect him.
The room that he is in is one in which he had once called
the therapist in a rage, because his father had not lent
him his car and he-the patient-had abruptly left home.
He goes to an office phone and still cannot get through.
Someone tells him that this means he is through with
therapy and he begins to choke. He awakened and pre-
pared to come to the session.
The patient went on to complain about not being able
to reach the therapist directly on the telephone. He had
made plans to be on vacation the next week. He felt that
the dream was a reliving of the cancellation of the session
earlier that week. After the patient ruminated for a while,
the therapist said that the patient did not seem to want
66 RESPONSES TO INTERVENTIONS

to come for his sessions; he wondered if the missed session


and pending absence reflected some kind of anger. The
patient denied this; he had planned the vacation some
weeks before (actually, while the therapist was on his
vacation). He then ruminated further, as he did the fol-
lowmghour.

Let us focus first on the patient's negation of the therapist's


initial interpretation-in effect. that the patient had been acting out
and dreaming about his revenge on the therapist for having been
away. Who is correct; the patient or the therapist? Does the negation
seem defensive or valid? Aside from some minor criticism that the
therapist could have expressed himself more clearly, using the
patient's idiom with him in order to get at the feelings and affects
involved, I would say that the therapist appears to have been essen-
tially correct. The patient had acted out and an intervention was
long overdue. The first dream and associations to it lent themselves
to an interpretation along the lines that the therapist pursued. Yet
the patient denied the intervention. Before considering why he did
so, let us deal with what followed and some related questions of
technique.
I believe that the therapist missed an excellent opportunity to
undercut the patient's denial at the beginning of the following ses-
sion. The patient began this hour by revealing that, at the very
moment he was denying any thoughts or fantasies of vengeance on,
or spurning of, the therapist, he knew that he would miss his next
hour and did not tell the therapist. I will not belabor the rest of the
material; the second dream manifestly reflects similar wishes: not
to make it to the session, not to give the therapist advance warning,
and even to terminate therapy entirely. Strikingly, every one of these
wishful fantasies is expressed in a form which includes a kind of
defensive denial; the patient does not want these things to happen,
he is the victim of them. The therapist's intervention in this hour
was unnecessarily weak and uncertain; it is an inappropriately ten-
tative and nonspecific intervention which to some degree shared and
strongly supported the patient's denial.
We can only speculate from this material why the patient denied
his fantasies in the face of clear derivatives, and of behavior and
Confirmation of Interventions 67

associations that subsequently confirmed the therapist's interven-


tion and contradicted his own denial. I suspect that the denial was
fostered by the therapist's own avoidance and denial of the patient's
separation reaction in the first few sessions after his return. In addi-
tion, denying the importance of a deserting love-object and of homo-
sexually-related fantasies toward the therapist is a common defense
in patients.
In principle, then, the therapist should accept a negative
response to an intervention as a directive from the patient to recon-
sider his formulation and to listen further. Subsequent material will
generally provide indications of one of the following alternatives:
1. Further lack of confirmation; the subsequent associations do
not support the intervention. Quite often, moreover, the patient will
manifestly or latently communicate something of what the thera-
pist had missed and indicate how he was in error, thereby putting
him on the right track-if he is listening properly (see Chapter 22).
2. Clear subsequent confirmation of the intervention, as the
patient reconsiders it and modifies his defenses against that part
which was correct.
3. Indications of the nature of the defense and the underlying
unconscious fantasies that have prompted the negation. If properly
understood, these defenses are then interpreted to the patient; con-
firmation of the initial intervention will follow if it is indeed correct.
Above all, the therapist should be prepared to find that he has
erred and should be flexible enough to reassess his formulations and
interventions when the patient responds negatively. It is at such
moments in therapy that we learn the essential value of listening to
the patient.
I shall reserve for Chapter 19 my discussion of affirmative
responses that are followed by nonconfirmatory and invalidating
associations. Here, I want simply to emphasize again that direct
agreement cannot be considered to be confirmation unless sup-
ported by subsequent validating material.

NONVERBAL INTERVENTIONS
I have already discussed (Chapter 17) the nonverbal, stylistic,
silently selective and unconsciously toned aspects of the therapist's
68 RESPONSES TO INTERVENTIONS

interventions. Throughout treatment, if this climate is indirectly


supportive, and if the therapist's concern, relative appropriateness
of interventions, consistency, and acceptance of the patient are
unambiguously conveyed, the patient will sense it, respond to it, and
develop and mature in the midst of it-at times he will even acknow-
ledge it. While such acknowledgements may be, on occasion,
straightforward, they are more often indirect, and communicated in
the latent content of the material. They come through quite fre-
quently after the patient has been helped through interpretations to
resolve a crisis and after major pieces of working-through. The
therapist need not, and usually will not, acknowledge such affirma-
tions directly to the patient, though they are comforting indicators
and feedbacks to him.
In contrast, when the atmosphere is not sound and counter-
transference problems are seriously interfering with the therapeutic
alliance and the therapeutic work, the patient will most certainly
sense it on some level, and communicate it directly or uncon-
sciously to the therapist. Developing a capacity to detect such latent
responses to our own errors and countertransference problems is,
of course, crucial (see Chapters 19 and 22).
The forms that confirmation of the therapeutic atmosphere
takes are legion, and highly individual. In principle, the therapist
should constantly and quietly search the material from the patient
for latent meanings related to the therapy and himself as a thera-
pist, and to the status of the therapeutic alliance. This is part of the
ever-present job of staying in tune with the realistic and transference
implications of the patient's associations (see Part VII); here I wish
to emphasize one aspect of that level of listening, that ranges from
a very general impression of the way the patient is responding, to
an understanding of the specific unconscious fantasies about the
therapeutic atmosphere that are latent in the material.
A few abbreviated examples will make this type of confirmation
clearer:

Miss H.P., an adolescent with a severe character dis-


order, was in a panic over the many meanings that her
therapist's forthcoming summer vacation had for her. She
felt that she was being abandoned by him to the mercy of
Confirmation of Interventions 69

her destructive parents, and being left to die; this evoked


in her intense longings for closeness or fusion with the
therapist and, in her frustration, great rage. She acted out
sexually to express many of these fantasies and created
a terrible family crisis. As much of this turmoil was being
worked through, a friend suggested that the patient leave
the area with her; this appeared to be a potentially self-
destructive, externally directed attempt to resolve the real
and intrapsychic conflicts evoked by the pending separa-
tion-a maladaptive kind of acting out which the patient
had often considered herself. Miss H.P. responded in a
variety of ways to this enticement; she made a direct
refusal and further refused this girlfriend's offer of drugs,
another previously used means of acting out; she told her
friend that she still had one reason to "hang around":
her treatment.

Miss H.P. was rather directly confirming her awareness that her
therapist, unlike her parents, was not out to destroy her, despite his
leaving her. She thus confirmed the unambiguous, positive, mother-
ing climate of the therapy and the positive qualities of the thera-
peutic alliance. Her actions also reflected the fact she rather desper-
ately wanted to live in peace without constant hassles with her
parents, and to find new means of adapting; she sensed the thera-
pist's support in this area. She chose this time of strife and of active
exploration of her separation anxieties to let the therapist know of
her faith in him, and, of course, to express further her need for him
and therapy.
Here is another vignette:

Mrs. H.Q., a woman with a borderline syndrome, was


working toward the termination of a very difficult but
rewarding psychotherapy. One major area of conflict for
her was that of separation and loss; her father had deser-
ted his family when she was two-and-a-half and her
mother had subsequently tended to cling to her in a
symbiotic fashion-a favorite device of the patient her-
self with her husband and children. This was one factor
70 RESPONSES TO INTERVENTIONS

which made termination a panicky prospect for her. In


one session, while working through her conflicts in this
area, she reported a dream; she is on an examining table
and a doctor places a needle into the corner of each eye,
removing a black substance. Associations were to her
obstetrician and to her wish for a child, which repre-
sented, she now knew, her wish for a replacement for the
therapist or for a lasting symbol of union with him. The
black substance was like tar or thick mascara; perhaps
now her eyes were open and could remain that way. She
then went on in some detail to describe her annoyance at
a repairman who had done a poor job of work in her
house.
The therapist intervened here; he told the patient that
these thoughts about the repairman hinted at some still
unresolved criticisms of, and anger with, him; she should
get it all out into the open. Mrs. H.Q. then described her
disappointment at not realizing her long-standing fan-
tasies of miraculous change through therapy. She had
spoken to another patient in the waiting room a week
earlier, and recalled now that she had discussed this inci-
dent in a previous session. She had been angry that the
other patient had made an effort to find out who she
(Mrs. H.Q.) was. In now discussing this experience, the
patient reported that she herself had directly tried to
discover the identity of the other patient in the hope, she
now realized, of holding onto the therapist through con-
tacts with this other patient, who would still be coming
to see him.
The therapist now addressed himself to the permis-
sion that the patient gave herself to live out her fantasies
and her inappropriate attempts at reparation (adapta-
tion); he commented on the consequences to herself of
such a life-style. Thus he acknowledged the patient's
inordinate fear of ending her therapy, her sanction of her
own inappropriate behavior, and her dishonesty about it;
he pointed out the implications that the patient would
unnecessarily resort to her pathological and maladaptive
Confirmation of Interventions 71

behavior when under stress in her life and that this would
prove costly to her.

I selected this vignette because, while it confirmed the therapist's


work with the patient and the therapeutic atmosphere on one level,
on another it simultaneously questioned that work: the patient still
tended to act out and conceal things. The therapist therefore
reviewed his technique and feelings about the patient at this time.
Was the acting out primarily a response to the stress of the termina-
tion and the already known excessive anxiety it created? (Mrs. H.Q.
had actually reached an optimal level of functioning and while she
knew that problems remained for her, she herself, not unreasonably,
had suggested termination.) Or was there something amiss in the
therapist's handling of her recent sessions? Further self-exploration
and listening to the material favored the former possibility. In fact,
for this patient, who had utilized blatant and primitive denials all
her life, the gift of sight was a striking achievement.
In principle, then, the therapist should listen constantly for direct
and latent communications about his technique with each patient,
the therapeutic alliance, and the atmosphere that he establishes and
maintains in treatmef!.t. Such responses constitute an ever-present
means of keeping his finger on the pulse of therapy. The affirmative
reactions generally need not be acknowledged by the therapist, but
should always be scrutinized for deceptive and appeasing implica-
tions. Negative responses call for self-scrutiny and reconsideration,
especially of his acceptance and "therapist-mothering" of the
patient, who cannot grow without the proper nutriments.

THE THERAPIST'S SILENCE


The therapist must learn how to establish whether his silence is
confirmed as appropriate by the patient (see also Chapter 19). As I
demonstrated in Chapter 11, silence is one of our most useful thera-
peutic tools, an intervention in its own right. Further, it prepares us
to listen to the patient's associations as they unfold, partly in
response to our inaction. We can then ask ourselves how the
material is developing in the face of this silence. If our impression is
positive and the session is going well, we can remain silent until an
72 RESPONSES TO INTERVENTIONS

intervention is necessary and feasible. We can be satisfied on arriv-


ing at such a point that our silence was the essential route to this
rewarding outcome.
If the material is unclear and not becoming clearer, we have
several considerations to review. Can we identify a specific resis-
tance and perhaps its motives-one we might then interpret or con-
front the patient with? Or is everything much too uncertain; a
continuation of silence is then in order. Uncertainty may be a sign
that the patient is avoiding or concealing something. If there are
clues to this, we can ask a prudent question. If not, as is most often
the case, we have no choice but to listen without speaking, though
we may, if the hunch is strong enough, ask the patient if something
is being left out. Patient waiting, when the therapist has indeed not
overlooked an indicated intervention, often culminates in a last-
minute revelation of the omission of a crucial event or fantasy. This
is the most dramatic kind of confirmation of the therapist's silence.
Often. however. matters are less dramatic and important material of
various kinds will quietly emerge toward the end of an hour in
which we have listened silently; they may be taken as full confirma-
tion of the appropriate use of silence by the therapist.
The therapist's silence can communicate to the patient that he,
in turn, has not communicated meaningfully to the therapist. It may
also. of course, convey the message that the patient is working well
and there is no need for the therapist to speak. The context usually
makes the intended implication clear to both parties.
I shall begin with an example of a session in which the thera-
pist's silence was confirmed as valid by the revelation of important
material toward the end of the hour-material which, I believe,
would not have emerged otherwise, especially if the therapist had
intervened prematurely. Such a move most often wil1lead to obses-
sive ruminating. as the patient unconsciously offers diversions from
the main conflict: if the therapist focuses upon these, the two will
then share an obsessive defense. Only by judicious silence can he
avoid such a misalliance.

Mrs. H.R., a woman with a borderline syndrome,


depression, and psychologically-based somatic symptoms,
was nearing the end of her therapy. Over several sessions,
Confirmation of Interventions 73
her dreams suggested latent erotic fantasies about the
therapist. In them, for example, a repairman came into
her home to seduce her and she went to live with a doctor
whom she knew socially.
At this time, she began one session by describing how
confused she had been in handling her children's prob-
lems. She had dreamt that her girlfriend had visited her
while she was ill in bed and prepared some exotic dishes
for her. In association, Mrs. H.R. spoke of fearing that
she might become ill and miss her sessions. She spoke of
her son being sick, and went on rather flatly about his
misbehaving while home from school. She then reviewed
a fantasy from her teens, which had been explored in the
previous hour; in it, she roamed the streets searching for
her father, who would go out alone at night. She had
resented the therapist's previous questions about these
fantasies and was also annoyed by his silence in the
present session, which was now drawing toward a close.
She had had a fantasy that her therapist discussed her
with his wife and that they had laughed at her. She won-
dered if he tape-recorded the se'>sions; something was
bothering her about him.
Early in the next session, Mrs. H.R. began to describe
odd thoughts about being somehow in love with the
therapist.

I selected an excerpt from this sequence of sessions because the


therapist's silence was crucial in fostering the slow emergence of
the unresolved erotic transference fantasies evoked by the pending
termination of the patient's therapy. Tactful verbal queries during
thh period had evoked anger and resistances, while the silence
enabled the patient to reveal her anxieties and fantasies at her own
pace. The therapist's silence was repeatedly confirmed by the
appearance of new derivatives of the central conflict. The fantasies
about the therapist reported at the end of the hour described here
are typical of the sudden important revelations that can occur when
a therapist has not sidetracked a patient by verbally intervening in a
trivial or incorrect way.
74 RESPONSES TO INTERVENTIONS

The therapist's use of silence may also be confirmed in other


ways:

Mr. H.Z., a young man in his early twenties, had been


in once-weekly therapy for three years because of a num-
ber of serious phobic and characterological problems; he
was a borderline patient. At the juncture in his therapy
to be described here, he had improved in many areas, but
maintained a rationalized refusal to venture out of his
house ovemight-one of his greatest fears. In his sessions,
there were almost no derivatives of the underlying uncon-
scious fantasies and conflicts related to this symptom,
and at a point when interventions were being rebuffed
and not confirmed in any way for some time, the therapist
became totally silent for a long while. In the session in
which this began, Mr. H.Z. spoke of his loneliness, and
of how he would not be able to face his fears unless the
therapist was with him. He would go crazy without mari-
j uana. He criticized the therapist for being silent: was
he trying to get rid of him; did he want to be paid for
doing nothing? The therapist, feeling that his interven-
tions were being used as support for the patient's lack of
movement in the therapy, and as an available protection
that precluded the need for outside gratification, remained
silent.
Mr. H.Z. came to his next session on time-something
he had not done in months. He described new efforts at
making friends and recalled his failure to adjust to the
separation from his mother when he began grade school.
A girl at work misuses everything that he says-he
should stop talking to her. The therapist's silence
reminded him of his father's withdrawal; he again
attacked the therapist for it.
In the next session, Mr. H.Z. described a fight with his
mother, and further ideas about meeting new people. He
fought with a woman at work and she withdrew; maybe
she did not want to participate in his sickness. In the next
hour, he reported having made several calls to new
Confirmation of Interventions 75
acquaintances-again something he had not done in
months.

I shall note here only that the patient twice communicated indica-
tions of his unconscious understanding and confirmation of the
therapist's silence: the references to people who misuse what others
say and to the woman who would not talk to him and participate in
his illness. These derivatives were nearly identical to the implicit
communication which the therapist intended to convey through his
silence. In addition, the patient's active efforts to find appropriate
friends outside therapy were a new attempt at positive adaptation,
and confirmed the therapist's impression that the therapeutic rela-
tionship had been inappropriately gratifying to the patient per se.
and was not being used as a vehicle for gaining inner change. Silence
helped modify this misalliance.

THE SUDDEN ApPEARANCE OF SYMPTOMS AND AFFECTS


DURING THE SESSION
A fascinating. paradoxical and difficult to assess confirmation
of a correct intervention is a response in which acute symptoms and
disturbing affective reactions predominate. Such reactions to inter-
ventions are almost always nonconfirmatory and suggest technical
errors and countertransference problems (see Chapter 19). More
rarely. however, especially when they occur immediately after the
intervention and during the session in which it was made. these
responses may be a regressively expressed confirmation which
fosters the analysis of the material at hand, including the responsive
symptom itself. A very careful study of the patient's subsequent
associations is needed to distinguish those symptoms which are con-
firmatory from those that are not; only when there is strong addi-
tional validation of the intervention can the therapist consider
symptoms as supportive of his comments.
Consider this clinical example:

Mrs. L.s. was a woman with a borderline syndrome


who had been acting out sexually and having acute
attacks of anxiety. At one point early in her therapy.
76 RESPONSES TO INTERVENTIONS

when she was discussing her mother, she had described


her image of her mother as empty and martyred. She had
also spoken of her own fears of being crazy.
In the next session, the one to be described here, Mrs.
L.S. mentioned that she had become anxious when her
husband questioned her about therapy and treated her as
if her opinion did not matter. She did not trust him, nor
her therapist, nor her mother who had sacrificed so much
of herself for the patient. She thought of her affairs,
and described them in some detail. The therapist then
interpreted these affairs, in this context, to represent an
attempt by the patient not to resemble her mother, to feel
like a meaningful person: She responded by describing
some intense sexual fantasies about her therapist; these
were interpreted (upwards, in terms of a displacement;
see Chapter 16) similarly as reflecting her wish to be a
real person. Mrs. L.S. reacted to this comment with a
sudden sense of anxiety and a burning in her chest. She
agreed with her therapist's impressions and added some
comments about not wanting to be a nothing.
In the following session, much new material about
her relationship with her mother and about her devalued
image of herself as a damaged woman emerged. The
symptoms had abated after the session and had not
recurred.

The therapist's interventions were made because the patient's


associations reflected one aspect of the unconscious meanings of her
affairs (the therapeutic context): they were a means for the patient
to be different from her depreciated mother, and a way to feel real
and to have contact with others. The anxiety and somatic symptoms
evoked by the interpretation, along similar lines, of the patient's
feelings toward the therapist were not subsequently analyzed since
they had quickly abated. They may have reflected anxiety about
deeper fantasies about her mother and the therapist; they may have
been a maladaptive way of reaffirming the patient's physical reality
(later material, including a dream in which she had no reflection in
a mirror, supported this formulation); or they may have reflected
Confirmation of Interventions 77

some fear that the therapist's upward interpretations deprived her of


closeness to him or were made out of his own anxieties. The unfold-
ing of meaningful material after the anxiety suggests, in any case,
that the symptoms reflected a confirmation that correct interven-
tions had been made and that one aspect of her anxiety and prob-
lems was being worked through.
In this vignette, no countertransference error could be detected
from the patient's material nor in the therapist's inner assessment,
but such errors are difficult to exclude. It must be emphasized
that in most situations where symptoms appear during or after
a session, they are negative indicators which suggest that the thera-
pist reconsider his formulations and his feelings toward the patient;
here, sanction of inappropriate sexuality may have been implied.

CONFIRMATION DESPITE REGRESSION


This last category is a most interesting and most treacherous
extension of the previous one. It comprises those quite rare
responses to a correct, properly timed and stated intervention that
~vokes from the patient both confirmatory material and an extended
regressive response: acting out, excessive anxiety, somatic symp-
toms, major resistances and disturbances in the therapeutic alliance.
We cannot overlook the fact that, on occasion. a correct interven-
tion weakens or undoes important defenses for the patient and thus
exposes him to the anxiety-provoking fantasies and memories that
the defenses had warded off. At other tImes, the therapist's com-
ments may contain a necessary narcissistic hurt or other painful
confrontation; it may bring into focus guilt-evoking experiences or
fantasies that prompt a negative reaction in the patient. Such inter-
ventions are necessary at some point in most treatments, but the
hallmark of their validity is the accompanying verbal and nonverbal
confirmations from the patient. In addition, the symptomatic aspect
of his reaction can often be anticipated, or at least readily compre-
hended, by the therapist.
This group of responses to an intervention must be differenti-
ated from reactions to erroneous and missed interventions, in which
there is essentially no confirmatory material from the patient in the
face of considerable regression. In this situation, the regression can-
78 RESPONSES TO INTERVENTIONS

not be readily understood as an expected outcome of the interven-


tion, though it is all too often rationalized as such. It is very dan-
gerous to consider that a particular regression is necessary and not
a sign of poor therapy on the ground that, very rarely, regressions
are part of the working-through process. Exceptional situations
must not be used to excuse poor psychotherapeutic technique. In
most instances, when the therapist has made a correct intervention
in the framework of a proper therapeutic atmosphere, clear con-
firmatory material will be at hand and little or no regression will
occur. Instead, progress toward better resolution, renunciations,
and adaptations will predominate. If more frequent and unpredict-
able regressions occur, the therapist must question his technique
and alter it accordingly. There are rare patients who characteristic-
ally respond symptomatically to major interpretive work; they
should be so identified and the basis for their responses analyzed.
Some are inclined toward negative therapeutic reactions, evoked,
for instance, by a need for punishment; to th~m progress is a threat.
I shall not discuss this complex topic here, but shall instead empha-
size the need for the therapist carefully to scrutinize his technique
and countertransferences when the patient responds symptomatic-
ally to his interventions; intra psychically determined adverse reac-
tions to the therapist's work must be distinguished from the negative
effects of poor technique.
I shall illustrate some clinical situations in which this combina-
tion of confirmation and regression occurred. These are often junc-
tures at which the therapist sees dangers both in intervening and not
intervening-he suspects that he is damned if he does, and probably
more damned if he does not. For example:

Mrs. H.S., was in once-weekly therapy because of a


profound, near-psychotic depression and suicidal impul-
ses. Early in her therapy, as she spoke of her mother, she
described an incident in her early childhood in which her
mother had blatantly endangered her life. The material
made it clear that this was actually an attempt on her
mother's part to kill her and that this experience was
significantly related to the patient's suicidal impulses; she
Confirmation of Interventions 79

wanted to kill the bad mother in herself and kill the bad
child that her mother had hated.
In the context of mounting suicidal impulses, the
therapist confronted Mrs. H.S. with the facts of her
mother's efforts to kill her and interpreted the links to
her own suicidal fantasies. She responded initially with
anger, a defense of her mother, denial, and dizziness, but
then added considerably more important historical
material about her mother and other family members.
These associations related to other destructive acts perpe-
trated against the patient and their role in her suicidal
thinking. Despite continued anger at the therapist and
periods of dizziness, Mrs. H.S., in the next hour, added
material that developed the theme of her using suicidal
threats as revenge on those who had hurt her.
Later in therapy, when confronted with her rage at
her father, who had once disappeared for about a year,
Mrs. H.S. dissociated herself and had amnesia for the
session. Soon after, however, she began to recall her
reaction to her father's disappearance and her fantasies
at the time.
Considerably later in the treatment, Mrs. H.S.'S father
became seriously ill and derivatives of sexuallongings for,
and specific sexual fantasies about him were reflected in
the material from the patient; they evoked intense guilt
and suicidal feelings. She reported a dream in which the
therapist held her closely, and associated to her worries
that her father might die. Interpretation (upward) of her
longings for her father led to rage at the therapist for
implying that she had sexual thoughts about her father;
her suicidal feelings intensified. Subsequently, however,
she recalled such longings from her childhood and under-
stood her hurtful rage over his desertion and the intense,
sexualized wishes for closeness to him that she had
developed in her childhood.

We can see in these excerpts that undermining defensive denial,


80 RESPONSES TO INTERVENTIONS

and confronting and interpreting guilt-ridden and anxiety-provoking


fantasies, can cause regressions of all kinds-symptoms, resistances
and ruptures of the therapeutic alliance, among others. At such
times, the therapist is much like the mother who must, if the child
is to function and survive, acquaint him with hurtful truths and the
pain of learning hard and real lessons of life. He is hurtful, but only
because it is unavoidable. The patient, in turn, feels the hurt and is
consequently enraged, but also somewhere recognizes the truth of
what was said and the fact that it is in his best interest to face it.
The result is usually a controlled or brief regression and the subse-
quent continuation of therapeutic work through added confirmatory
material. If, on the other hand, the hurt from the therapist was
unnecessary or erroneous, a more lasting regression and lack of
confirmation will prevail (see Chapters 19 and 22).
Mrs. H.S. tended to show negative reactions to apparently
correct interventions because she had great difficulty in accepting
any lessening of her suffering and in tolerating the closeness with the
therapist that was implicit in his helping her. She had both a deep
sense of guilt and a severe disturbance in basic trust.

IMMEDIATE CONFIRMATION: BASIC PRINCIPLES

The main principles for immediate confirmation are:

After making an intervention. the therapist must listen and assess the
patient's verhal and nonverbal responses.

He determines whether the patient's communications manifestly or


latently agree with and add to the intervention.
• Direct agreement has only a minimal, if any, value, and may even
conceal covert disagreement or reflect the need to submit to the therapist.
• Direct disagreement may be a valid objection, or it may be a last-
ditch effort at defensiveness and denial. Subsequent associations will
enable the therapist to decide between these alternatives.
• Most valuable among validations are indirect agreement and sup-
plementary material that are rich in unconscious implications and that
add to the trends developed by the intervention.

Absence of confirmatory material should be respected by the therapist


Confirmation of Interventions 81

as an indication that he needs to understand both why he has not obtained


confirmation and how he can more correctly reformulate the central
theme. Attention in depth to the patient's associations is a valuable
guide to such reassessment.
Among the most common forms of genuine immediate confirmation uf
interventions are: the recall of previously repressed thoughts, fantasies,
experiences, and childhood memories; the additiun of new and fresh
material of many kinds; the clarification of previously unexplained prob-
lems and symptoms; the alleviation of symptoms and changes in
disturbed behavior; the indirect acknowledgement of the therapist's
perceptiveness; and most rarely, the appearance of symptoms accom-
panied by these other forms of verbal confirmations.
• Each kind of confirmation should be studied for its freshness.
capacity to enlarge upon what was said by the therapist, and hints at
new avenues of understanding and exploration.
• The therapist should always be alert for confirmations that serve
only to submit to him or to conceal disagreement, and that are ultimately
defensive and undermine therapy. When this is the case, it will be reflec-
ted in the subsequent associations from the patient (see Chapter 19).
• In contrast, genuine confirmations enhance the patient's insight
into himself, resulting in inner change and symptom resolution.
Failure to recognize that an intervention has not been genuinely con-
firmed will lead to empty, aimless and ruminative work without meaning-
ful focus. Subsequent interventions wiIl be based on previously
unintegrated and un accepted comments from the therapist, and the entire
structure will be invalid and of no use to the patient. Conscious or
unconscious deception of the therapist is perpetuated and will undermine
the therapy.

In all, then, genuine immediate confirmations of the therapist's


interventions are a most fundamental facet of sound psycho-
therapy. By assuring the validity of the therapist's work. they con-
stitute an essential part of the technique and methodology ot
psychotherapy. and serve as a guarantor of structural change in the
patient.

DELAYED AND LONG-RANGE


CONFIRMATION OF CORRECT
INTERVENTIONS
We come now to a topic that I shall explore only briefly: the
82 RESPONSES TO INTERVENTIONS

delayed and long-range confinuation of correct interventions. Vali-


dation of an accurate and properly timed intervention is not limited
to the immediately following sessions. While I have, until now,
dealt with interventions as isolated entities, it must be apparent
that each intervention is, in actuality, a part of an integrated whole
on several levels. Each of the therapist's comments may be, for
example, grouped into those interventions which deal with one or
another of the patient's specific problems or intrapsychic conflicts
and fantasies. Or they may be classified as dealing with the reper-
cussions of a particular trauma or event. Eventually, interventions
combine to encompass an entire therapeutic endeavor. Thus, while
each correct intervention should be validated by one or more
specific confinuations, an entire sequence of interventions should
also find confinuation in ways that go beyond each separate vali-
dation.
In essence, this means that the flow of the patient's material and
the development of successive hours, should, in general, contain a
certain kind of freshness and unfolding that alternates, however,
with periods of dullness, resistances, reworking, and solidification.
Ultimately, of course, there should be symptom resolution and
characterological change. Each patient will have a distinctive
approach, and the variations are infinite, but there are certain
general characteristics of properly run therapy. Before delineating
these, I shall briefly summarize a sequence of several weeks in two
contrasting treatment experiences. They should enable the reader
to abstract the distinguishing features of a confinued treatment
situation in contrast to one that is not being validated.

Mr. H.T. was a young, single man with a borderline


syndrome who was in twice-weekly psychotherapy
because of his inability to leave home, and problems in
relating to others and in functioning in school. He had
been in treatment. for two years; his social and school
problems had improved considerably and his refusal to
sleep away from home overnight came into focus. He
realized on his own that he could not make further pro-
gress in his therapy unless he ventured out, and his thera-
Confirmation of Interventions 83

pist agreed. I shall briefly excerpt a series of sessions from


this period of his treatment.
In the first hour, he described battling with his
mother, a diminution in the frequency of his fantasies
that someone would break into his home during the night
and attack him, and spoke of plans to sleep at a friend's
house; these evoked excessive anxiety.
In the next session, he reported a dream in which he
is showering with a friend who has the same first name
as the therapist and who, as his room-mate, makes seduc-
tive overtures toward him. Associations were to holding
onto the therapist for safety and to tentatively deciding
for now not leave his (the patient's) house. Homosexual
anxieties and fantasies were interpreted to the patient
and related to his fears of sleeping out.
In the next session, Mr. H.T. fully retreated from his
plans to sleep out, rationalized this retreat, and attacked
the therapist-defensively, as the therapist pointed out.
In the next hour, Mr. H.T. reported a dream that he
was physically different from others. This led to a discus-
sion of his wish to change and his fears of it.
Over the next few sessions, the patient reported that
he had made a date for the first time in over a year and
had handled it well. It proved to be both progress and an
attempt to appease the therapist so that he would lessen
the implicitly experienced pressures on the patient to
sleep out. A battle with his mother evoked fantasies that
she would cut his head off; the therapist commented that
his primary dread actually was of his mother, and that he
then externalized this fear so that he could somehow hold
onto her. Mr. H.T. then recalled many of his parents'
battles with each other and their angry discussions of
divorce; he had not previously mentioned these in treat-
ment.
Then, at an outing with some friends, he had a sudden
thought of playing with the penis of one of the men
present. This was linked by the therapist to his fears of
84 RESPONSES TO INTERVENTIONS

sleeping out. Two ruminative sessions followed, but the


patient meanwhile arranged to and slept at a friend's
house without much anxiety. He quickly recognized that
his fantasy that his friend would seduce him homo-
sexually (through anal intercourse) reflected a wish with
which he was struggling himself. In the following ses-
sions, his feelings of being like a woman emerged, as did
his fears of being physically castrated and being made to
bleed if he were to act like a man. His thoughts of grab-
bing someone else's penis to possess for himself were
also described. All of this material unfolded for the first
time in the therapy and was reworked over several ses-
sions. When Mr. H.T.'S terror of women was pointed out
in this context, he recalled dreaming that his mother was
menstruating. Associations were to a television play
regarding an abortion and to his rage at, and fears of, his
mother.

I shall contrast this vignette with the following one:

Mr. H.U. was also a young man with a borderline


diagnosis, who was afraid to leave home, unable to relate
to others, and having considerable trouble in school. The
sessions I shall excerpt followed his therapist's vacation.
In the first hour, he described suicidal fantasies and
fears of not surviving the following week, when his par-
ents would be away. Variations on these themes were
repeated over and over, and no intervention was made.
In the next session, the patient ruminated about
school, his examinations, and his fears that he would
flunk out. The therapist said little and became ill himself
after that hour; he cancelled the next session.
In the following hour, Mr. H.U. was again suicidal,
with fantasies of hanging himself and fears of failing in
school. The therapist linked these two, suggesting that the
latter was causing the former. Both he and the patient
ignored the missed session.
In the next few sessions, the patient ruminated more
Confirmation of Interventions 85

about school and flunking out, saying too that it all


seemed like the "same old crap" to him: he was getting
nowhere with it. Belatedly, his rage. over the therapist's
vacation and illness was finally interpreted, and this led
the patient to remember a series of incidents which reflec-
ted his being a destructive child at home and to the
recall of dreams of monsters eating his mother up.
I shall stop here, since the material is sufficient to illustrate the
principles I want to establish at this point.
Which of these sequences develops and unfolds and is, in the
long run, confirmatory, and which seems stale, repetitious, and
regressive without apparent explanation? It is clear that the first
sequence fits the first description. We see there a major therapeutic
and adaptive context in the patient's difficulties in leaving home,
(he unfolding of aspects of the intrapsychic conflicts this problem
was evoking in him, the related repressed fantasies, and even some
genetic links. Alternating with this unfolding and the patient's pro-
gress were periods of regression and flight, understandable in light
of the defenses that the patient was giving up and the anxieties he
was facing. The sequence culminates with new insights, indications
of inner change and symptom relief.
In contrast, the second sequence is repetitive, defensive
throughout, regressive without confirmatory responses, and gener-
ally without the emergence of new fantasies or memories. It does
not develop or progress until the therapist finally makes a correct
interpretation that he had missed over several sessions, one that the
patient immediately confirmed with the recall of previously
repressed material.
If we contrast these last two vignettes and add other general
and typical observations, the following principles emerge:
There is a syndrome or cluster of identifiable features in a therapy that
is progressing owing to a proper therapeutic climate coupled with correct
interventions.

The characteristics of such therapy are varied. but they tend to have the
following features in some combination:
• An alternation between the unfolding of new material and defen-
siveness.
86 RESPONSES TO INTERVENTIONS

• Surprises in the material, with new leads and unexpected turns,


leading to the revelation of new fantasies and memories, and ultimately
to meaningful insights, understanding, and inner change.
• Material that does not reflect a submissive fear of, or need to feed,
the therapist, but is prompted by current life-events and relates to the
intrapsychic conflicts, adaptations, defenses and genetic links evoked by
them. Sequences should unfold through different kinds of communica-
tions: at one moment a recent event, then a memory, or a conscious
fantasy or a dream. In toto, the period of therapeutic work should have
coherence, should center upon a central theme and context, and should
be filled with latent, repressed derivatives that become increasingly less
disguised and more interpretable.
• The inevitable resistances that follow such unfolding should be
relatively short-lived, understandable as a reaction to the recent material
or as a defense against recent anxiety-provoking events, and analyzable.
Occasional periods of confusion or regression may occur, but these
eventually pass or are resolvable through exploration.
• Throughout, there should be a relatively constant flow of deriva-
tives of unconscious fantasies. The therapist's capacity to sense this flow
develops with experience; he must attempt to determine if the material
is empty, and does not organize around a central context and intrapsychic
conflict, or if it is, to the contrary, full of such expressions. Patients can
unconsciously turn themselves off; if this occurs, something is amiss and
must be dealt with.
Ultimately, confirmatory unfolding leads to a variety of positive changes
in the patient, depending on his pathology. 1 hese include:
• The diminution of symptoms, especially after a major fantasy-
memory cluster related to current conflicts has been interpreted and
worked through. Usually, lesser insights lead to minor symptomatic
relief as the material builds, often over months, toward a major piece of
working-through and insight.
• Increased ego development: controls over acting out, a greater
capacity for delay, and other improved ego functioning (reality testing,
object relations, adequacy of defenses, etc.). This is usually a slow
process and one developed through both confrontation and interpre-
tation, and in identification with the therapist. Superego modifications
occur in a similar way and on a comparable basis. Ultimately, the
specific experiences and unconscious fantasies underlying these dys-
functions should unfold, be interpreted, and be worked through.
• Characterological disturbances should be similarly, slowly modi-
fied.
• In summary, then, correct interventions and a proper therapeutic
atmosphere ultimately lead to symptom resolution, to modifications in
the ego and superego, to shifts in the patterns of instinctual drive dis-
Confirmation of Interventions 87
charge, and to characterological changes. While these are obvious tenets,
one must translate this into practical terms: if such changes do not
slowly occur, something is amiss and the treatment situation lacks long-
term confirmation and must be reassessed.

Well-run treatment is always characterized by periods of working-


through. Briefly, this means that a particular conflict, its genetic and
present roots, and the related unconscious fantasies are explored from
various angles over a number of sessions. One gets a feeling of increasing
depth of understanding and perspective, and the result should be some
lasting inner, structural change.
Unconfirmed therapy is predominantly stale and empty, not pro-
gressive, not deepening or widening in its scope, resistant and defensive.
and filled with ruptures in the therapeutic alliance and symptomatic
regressions (see Chapters 19 and 22).

The concepts developed here will take on more meaning when


we compare them in detail with unconfirmed interventions, disrup-
tive sequences of treatment, and totally unconfirmed therapies.
Toward this end, we may turn to the next chapter.
19 Failure to Corifirm Interventions
and Reactions to Missed
Interventions

This is a very complex area, involving not only proper identification


of a nonconfirmatory response, but also determination of the role
of the therapist's errors in evoking that response. General principles
can take us only part of the way toward understanding this subject.
For a full comprehension, we must investigate the relationship
between the patient and the therapist; this I shall do in Part VII.
In particular, I shall, in Chapter 22, focus on the therapist'S role in
nonvalidating responses by the patient and on the specific, counter-
transference-evoked, iatrogenic symptoms to which it may give rise.
Here, I shall describe the hallmarks of a nonconfirmatory response
and the general types of errors in technique that account for them.
Of course, the division is an arbitrary one: most often, unresolved
conflicts and problems within the therapist play a role in the tech-
nical errors he makes.
Nonvalidating responses from the patient fall into two cate-
gories: those that are immediately nonconfirmatory and those that
are delayed or extended over time. In discussing each type, I shall
utilize exclusively clinical experiences drawn from my supervisory
work. In every such instance, I listened to the material of the session
being reported to me in sequence. Then, in the cases discussed here,
I predicted, after the presenting therapist had described his inter-
vention, that confirmation would not follow. In some instances, I

88
Failure to Confirm Interventions 89

identified failures of the therapist to intervene where these seemed


definitely indicated, and observed the consequences. In all of this
material, then, failure to confirm was correctly predicted in advance
-a fact that lends support to the validity of my conclusions.

IMMEDIATE FAILURE TO CONFIRM


AN INTERVENTION
The immediate failure to obtain confirmation of an intervention
is not, it should be remembered, the final word on its validity. Sub-
sequent material in the particular session or in later hours can bear
out the truth of the comment that has been rejected. In my experi-
ence, however, this is quite rare: almost always, if an intervention
is unconfirmed on a manifest or latent level, it can be considered
incorrect; the therapist must reconsider his formulation. One of the
most important overriding principles that I wish to establish in this
chapter is that the therapist must learn to recognize from the
patient's responses to an intervention its conscious and unconscious
validity (see also Chapter 18). As therapists, we must acknowledge
the possibility of error on our part, and recognize the capacity of
the patient to consciously-or, more often, unconsciously-com-
municate reflections of such errors to us. This last is a most crucial
facet of our work with nonconfirmatory responses from the patient,
one that I shall develop in some detail over the next four chapters.
In essence, then, proper listening and specific interest in negative
feedback must be among our guides in psychotherapy. Our narcissis-
tic investment in our own utterances must not blind us to our mis-
takes. With this in mind, I shall now briefly identify and discuss
some common immediate responses to interventions that are to be
understood as incorrect and unconfirmed.

THE LACK OF FRESH MATERIAL


There is a triad with many variations that typifies the patient's
immediate responses to an incorrect intervention by the therapist:
first, nothing jells or crystalizes; second, no new or genuinely fresh
material follows-repressive barriers are not modified; and third,
90 RESPONSES TO INTERVENTIONS

defenses and resistances, including rumination and intellectualiza-


tion, prevail. These negative reactions may be expressed for a vary-
ing length of time, but it is characteristic for the patient, in his quest
for conflict- and symptom-resolution, eventually to return once
more to, or begin to express derivatives of, his actual current central
problems and source of anxieties. Following the leads he gives will
put the therapist back on the right track. The triad itself is one
with which every therapist should familiarize himself, and to which
he should be attuned. It is a very frequent indicator that he has not
made an accurate or truly meaningful intervention.
Let us now turn directly to some illustrations of this type of
nonsupportive response, focusing primarily upon its formal charac-
teristics. In this first vignette, the patient very quickly-though
indirectly-corrected the therapist. I suggest that the reader make
his own analysis of the material.

Miss H. v. was a young woman with a severe character


disorder, acting-out tendencies and asthma, who had
been in therapy for about a year. As her therapist's sum-
mer vacation approached, she felt panicky and reported
dreams of being with her therapist outside the sessions,
of being shot up with injections of drugs, of being
attacked and deceived by her father, and of someone
dying; all of these were worked with and related to the
coming separation.
Upon the therapist's return, she described one brief
asthmatic episode while he had been away, and a trip
she took with her sister, with whom she had many dis-
cussions about her therapy and the therapist. She men-
tioned, too, that her current boyfriend had left her, but
brushed it aside as insignificant since she was already
dating another fellow.
In the next session, she reported taking drugs and
provoking her parents, whom she had visited, into a battle
with her. She was annoyed at the therapist for staring at
her (a most unusual comment for her), and expressed
some annoyance regarding the sessions.
The therapist intervened and pointed out the patient's
Failure to Confirm Interventions 9]

anger at him, and the acting out of this rage through tak-
ing pills ,and the battle with her parents.
The patient nodded her agreement, but then asked
why the therapist thought it was him that she resented.
She went on to describe the details of her rejection by
her boyfriend, blaming herself for what had happened.
It soon became apparent, however, that underneath her
self-blame was a tremendous amount of rage at her
former beau. When this was pointed out to her, Miss H.V.
revealed that her boyfriend's reasons for leaving her were
both provocative and irrational, and as the therapist
pointed out, this was a replication of her parents' sense-
less attacks on her in the past. The patient picked up on
these themes and added to them considerably.
One last note: in the following two weeks, expres-
sions of the patient's hurt and rage over her therapist's
"desertion" subsequently emerged and were worked
through.

What happened in this vignette? In essence, this patient was in a


rage; her acting out was based on initially undetermined fantasies
related to this fury. At first, the therapist saw this primarily as a
reality-based and transference reaction to his vacation (see Chap-
ters 20, 21 and 22), which the patient, for reasons largely related to
desertions by her father, experienced as a hostile abandonment at
this juncture. He relegated the loss of the boyfriend to a secondary
status, perhaps underestimating the strong defenses, including
denial, with which the patient dealt with this latter trauma. These
two hurts are, of course, related, but the therapist, believing that
the anger at himself was primary and closest to the surface, chose to
deal with this level first.
The patient agreed with him, but then went on, in effect, to
disagree. Let us make note of this important aspect, which I shall
develop further later in the chapter.
Following her disagreement with the therapist, Miss H.V. first
ruminated for a while, but then spontaneously began to talk about
being jilted by her boyfriend in a manner that revealed important
unconscious fantasies and unexpressed affects related to that experi-
92 RESPONSES TO INTERVENTIONS

ence. This cannot be construed as an indirect confirmation of the


therapist's intervention. It is, instead, a fine example of a very com-
mon sequence following an incorrect interpretation-here, one that
was made at the wrong level:
1. Rumination, indicating a lack of confirmation, then
2. The patient spontaneously refocuses to material related to
the current central adaptive context and conflict.
The therapist must be prepared to listen and to allow the patient
to correct him. He can then reformulate and intervene accurately,
as was done with Miss H. v.
Notice, too, that once the intrapsychic conflicts regarding the
loss of the boyfriend were analyzed and worked through, the under-
lying disturbances related to the therapist's vacation re-emerged in
a meaningful way. This will occur, of course, only when the thera-
pist's timing has caused the error; that is, when he selected a cur-
re:1t1y wrong level on which to intervene, but has addressed himself
to a nonetheless pertinent area of conflict that is bound to come up
again.
Let us now take a look at a more unambiguous error and lack
of confirmation:

Mrs. H.W. had been in psychotherapy for about eight


months. She had a severe character disorder with psycho-
pathic trends and sought therapy because of a depression
resulting from her learning that her husband was having
an affair. She herself had been unfaithful some years
earlier with her husband's brother.
Before the session to be described, the patient had
separated from her husband and was living with her son
and her mother; she was considering divorce. In addition,
she had started a job and the therapist had agreed to
reduce her two weekly sessions to one since it seemed too
difficult to arrange otherwise-an issue both parties had
avoided-and termination was pending in three months
because the therapist was leaving the area.
In the session under study, Mrs. H.W. showed her
therapist her new car through his office window and then
detailed a host of problems she had had in obtaining
Failure to Confirm Interventions 93

insurance for it. She had implored her husband to sign


some forms for this purpose and he was angry, but did it.
The therapist asked where the money for the purchase of
the car came from and the patient described how she had
saved for the down payment and went on to other related
details. She then spoke of her new job and debated the
surface pros and cons (e.g., financial and practical mat-
ters) of a possible divorce from her husband. She
reviewed some comments from her son which indicated
that he wanted his father around, but added that she her-
self did not know how she really felt. The therapist sug-
gested that she felt just like her son did, and the patient
agreed, detailing again the problems that a divorce would
pose; she then further brought up the reasons that a final
break would be best for herself and her children. She did
not know what to do. The therapist next said that she was
trying to force him to decide for her; Mrs. H.W. went on
to comment on the difficulty of deciding. She once more
described in detail the positive and negative consequences
of a divorce.

Briefly, I would assess this session from the following vantage


points:
1. There is clearly no development of the material ih the hour
as a whole, no surprises and nothing fresh. It is flat and ruminative,
remote, and confined to realistic (nonneurotic) surface conflicts and
problems.
2. The therapist's interventions-a question, an interpretation,
and a ge'1eral-Ievel, so-called transference interpretation-in no way
modified the patient's rumination; none of the interventions was
followed by indirect indications of confirmation, despite some pass-
ing agreement from the patient.
This vignette, then, serves as another illustration of the way the
patient's initial agreement with an intervention (here, to the effect
that the patient felt as her son did) can only be assessed by attention
to the subsequent material. Often such agreement is a way of putting
off the therapist, of avoiding real feelings, or of maintaining a defen-
sive misalliance with him; all of these seem applicable here.
94 RESPONSES TO INTERVENTIONS

3. The reasons for the lack of confirmatory responses are, I


think, rather apparent from the material. Firstly, the therapist's
question is related to realistic and not to potentially neurotic prob-
lems; it lacks an intrapsychic context. It therefore fosters the
patient's own avoidance of inner conflicts and her use of obsessive
defenses; both the patient and therapist share in these defenses.
The therapist's interpretation that Mrs. H.W. felt as her son did
appears to be guesswork and, in all likelihood, an incorrect interpre-
tation. This, too, fostered the patient's rumination and distancing
from the therapist who did not understand her-a common form of
resistance and disturbance in the therapeutic alliance. Lastly, the
interpretation that the patient wanted the therapist to decide and
resolve her conflict for her also appears to be largely his own fan-
tasy; it is not clearly evident in the material, and there is no clear
expression of such a wish or apparent context in which to under-
stand it. It is a moot point, even though the interpretation is an
effort to get at the evident resistance.
In all, then, the therapist's constant flitting from one topic to
another, without clear adaptive and therapeutic context, produces
an obsessive form of "trivia therapy" (see Chapter 9) that is of no
help to the patient. As a result, both the patient and the therapist
are obsessed with the surface of the material, and with reality issues.
Both are preventing intrapsychic repercussions of these realities,
and the unconscious fantasies and intrapsychic conflicts that they
may have generated, from emerging.
4. Perhaps the most important therapeutic principle underlying
the nonconfirmations described here is this: as long as the therapist,
in reality, shares and fosters the patient's defenses in the sessions, he
will not effectively modify them; nor will the patient feel any need to
reveal or explore the latent threads of his associations since he
knows that he and the therapist will quickly return to ruminating,
guessing and making errors. Such participation by the therapist
precludes the meaningful development of therapy, and must be
looked for whenever resistances of this kind are present in the
patient.
I can further document this principle by briefly describing what
happened with this patient over the next few sessions:
Failure to Confirm Interventions 95

Mrs. H.W. continued to obsess about surface details


for two additional hours. In the third session, the thera-
pist finally, under the influence of his supervision, inter-
vened properly. He confronted the patient with the fact
that she was being repetitious and hollow (a confrontation
with a resistance). Mrs. H.W. responded by telling the
therapist that she had had an anxiety attack the previous
night, and she went on to report two dreams (for the first
time in months): she was at a birthday party and her
mother was trying to give her a piece of the cake. Her
husband was also there. The patient did not want her
mother to touch the cake and asked her husband to stop
her. He said that he did not care-let her do what she
wanted. In the second dream she was with a former
teacher, showing him her son's drawings. The teacher
told her that the boy could not draw and that she had
ruined him.
In association, Mrs. H.W. felt that the teacher repre-
sented the therapist. It was a dream of rejection; her
present boyfriend had recently avoided her. With these
comments, the session ended.

I ~ant briefly to note the following:


1. As long as the therapist shared with the patient her obsessive
and avoidance defenses and did not confront or interpret them to
her, the patient ruminated aimlessly and avoided her inner feelings,
conflicts, fantasies and symptoms.
2. No sooner did the therapist confront these defenses, than the
patient immediately gave them up and described both a symptom
and two rich dreams. We can speculate that her need to work out
her inner conflicts was able to assert itself only after the therapist
no longer nonverbally communicated to the patient his wishes that
she not inform him about her intrapsychic conflicts and symptoms.
The therapist's disinterest had been conveyed in his reducing the
patient's sessions without analyzing the move, in his confining him-
self to reality issues with her, and in his failure to confront her
defenses or to explore occasional clues from her associations that all
96 RESPONSES TO INTERVENTIONS

was not well. Thus, his eventual confrontation with her rumination
had a twofold effect: it enabled the patient to recognize her defen-
siveness and it communicated the therapist's willingness to explore
her pathology. The result was a dramatic change in her communi-
cations to the therapist. The period before this change may be
characterized as a countertransference "cure" in which the patient
appeared to be well largely, or in part, out of her responses to the
therapist's unconsciously communicated wishes that she not seem
neurotic. Further, the patient's readiness to forego the antithera-
peutic alliance for a proper therapeutic relationship demonstrates
that improper therapeutic attitudes and consequent therapeutic
impasses can be readily modified if the therapist becomes aware of
them and changes accordingly. The confrontation with the patient's
defenses was abundantly confirmed and enabled the therapeutic
alliance to be reinstated in place of the denial-based misalliance.
The dreams and the few associations to them suggest that the
patient unconsciously sensed her therapist's neglect or lack of care
and his wish that she not touch upon anything meaningful in her
associations (the first dream). The second dream may reflect even
stronger criticisms of the therapist's destructiveness: he is a bad
mother-a judgement represented, as it often is, through a self-
criticism. The patient's fantasies about the termination of her
therapy were among those most intensely repressed with the help
of the therapist, who actually pushed this patient away from him;
the dreams were the first hints of such fantasies. Later material
expanded on these derivatives.
In concluding my discussion of this vignette, I want to return
now to the original session described earlier; I shall summarize what
happened and how it could have been modified. In essence, the
failure to confirm occurred there because the therapist was working
in a non dynamic way, without intrapsychic focus. He made guesses,
and introduced thoughts of his own, which were not developed in
the material from the patient and not especially relevant to her inner
conflicts or resistances. What, then, could have been the correct
interventions in that session? And, how would we formulate the
main underlying reasons for these resistances? In supervision I
formulated the material as follows, after that first session.
The therapist should have been silent for most of the first hour;
Failure to Confirm Interventions 97

he might then have pointed out the patient's rumination toward the
later part of the session. Further, I suspect that underlying the
emptiness of the sessions are two factors: the tone of the therapy in
the hands of this therapist, who promoted surface rumination;
and the recent decrease in the frequency of the sessions, which both
parties acted out and then avoided. The unconscious fantasy that
underlies the patient's resistances and that may lie latent in the
material might well run like this : "You (the therapist) are seeing
less of me (the patient) and hurt me as my husband had; I do not
want to talk to you because I am angry and would rather drop you
altogether, except that I do need your help, for now."
For our main purposes here, however, let me emphasize again
the repetitiousness of the material, the lack of development despite
the therapist's interventions, and the lack of freshness or surprise in
the material after the interventions were made. In listening to
patients, such responses should be taken as failures of confirmation
and as directives to reconsider the assessment of the material and
the comments that were made; something is amiss.
Let us consider now another vignette in which nonconfirmatory
responses from the patient prevailed:

Mr. H.X. was a young man with a severe character dis-


order, faced with his therapist's pending vacation. He
spoke in the session at hand of money problems, of a
visit to a man whose children had deserted him, and of
not getting a birthday card for his own mother. The thera-
pist pointed out the patient's anger at his parents and how
he expressed it in many ways other than by leaving them
-a reference to a recent issue. Mr. H.X. responded by
ruminating about his parents and his often-detailed prob-
lems with them, and went on from there to a detailed
discussion of his job and of his philosophy of life. He
then spoke monotonously of a recent date and how
expensive his life was getting. He also remarked that he
realized that at times he rambled in the sessions.

From this material, I want to point out:


1. The therapist intervened much too soon m this session.
98 RESPONSES TO INTERVENTIONS

Further, he spoke without a defined context and lacked a correct


assessment of the patient's intrapsychic conflicts, and he focused on
a reality problem which had no intrapsychic depth for the moment.
Lastly, he ignored the most likely adaptive context for the material
and its latent content: the coming separation from the therapist.
2. As a result, the intervention-a confrontation or general
interpretation-was actually incorrect and was followed by rumina-
tion, a lack of focus, an absence of fresh material, and philosophiz-
ing. The patient himself alluded to this lack of confirmation in his
reference to his rambling in sessions.
3. The therapist avoided reference to his pending vacation and
the patient did the same; the two shared a defense. Probably, the
best interventions here would have been silence, waiting for clearer
derivatives of the patient's reactions to the pending separation,
interpretation of the relevant unconscious fantasies, and subsequent
listening for confirmation or its lack.
The reader might well contrast these flat responses, which consti-
tute supervisor-predicted failures to confirm interventions that take
the form of continued resistances and defensiveness, with those
responses described in Chapter 18, where we dealt with confirma-
tory responses. The therapist's ability to distinguish confirmation
from its lack is vital for the progress of the therapy. Extending an
intervention after nonconfirmation is much like building sandcastles;
the whole structure is unfounded and must inevitably collapse. If,
on the other hand, the therapist detects poor interventions by cor-
rectly assessing nonconfirmatory responses from the patient, he
will be in a position to attain a true understanding and by proper
interventions, reestablish the therapeutic work on a sound basis.
In summary, then, immediate lack of confirmation has the
following main characteristics:
1. Nothing jells; 'no new, or freshly-viewed old, material
emerges. No modification of repressive barriers occurs.
2. Resistances continue, often in the form of rumination,
shallow discussions of reality problems and events, or other emo-
tionally trivial matters.
3. Even careful listening for latent content reveals little that is
meaningful.
If we learn to recognize these features of nonconfirmation, we
Failure to Confirm Interventions 99

can then attend to our therapeutic tasks at such moments, which


are, largely:

To reassess and reformulate the material.

To determine the source of our errors, which are usually based on


countertransference problems or technical misunderstandings (see also
Chapter 22). These include:
• Failure to detennine the current central source of intrapsychic
conflict and anxiety-the correct adaptive and therapeutic context. This
will lead to interventions at the wrong level or to concentrating on some-
thing intrapsychically irrelevant or not currently pertinent (e.g., the
therapist's commenting on Mr. H.x.'s anger with his parents instead of
dealing with his feelings about his therapist's imminent departure).
• Incorrect listening to, and understanding of, the manifest and
latent content of the session, including a failure to detect the currently
central unconscious fantasies.
• The need to share with, and offer to, the patient defenses against
the current unconscious confticts and fantasies reflected in his associa-
tions-or any other type of therapeutic misalliance.
• Speaking out prematurely, in too intellectual a fashion, or non-
affectivel y.
• Attributing one's own fantasies to the patient and intervening on
such a basis.

To continue listening to the patient, rather than defending or elaborating


upon the unconfirmed intervention; the patient will often unconsciously
redirect the therapist onto the right track.

VALID NEGATIONS OF INTERVENTIONS


Directly negative responses to interventions are the source of
considerable confusion (see Chapter 18). Many therapists consider
all negations to be defensive denial, and deny the patient the right
of valid criticisms, direct and indirect, of their comments, or of a
legitimate perception that the therapist is in error. These therapists
create an anti therapeutic atmosphere in which they are always
right and the patient is always wrong, evoking what I have termed
"iatrogenic paranoia," among other syndromes (see Chapter 22), in
certain sensitive patients who feel suspicious and angered by their
loss of rights and forced helplessness. This consequence may go
100 RESPONSES TO INTERVENTIONS

unrecognized by such therapists, who also are unaware of the


inherent destructiveness of such a stance.
If negation of an intervention were not possible, psychotherapy
would be arbitrary, dictatorial, ineffectual, and without a method-
ology. Clearly, it is possible for a therapist to err and for the patient
correctly to sense this---consciously or unconsciously. Our clinical
methodology must acknowledge this fact and our technique must
be sufficiently developed so that we are able to distinguish between
a patient's defensive denials and his valid objections. I have already
discussed this problem in connection with defensive negations that
are followed by subsequent confirmation (see Chapter 18). Here I
shall illustrate negations that were supported both by the subsequent
material from the patient and by the supervisor's prediction that the
therapist was in error and the intervention would not be confirmed.
Again, let me repeat: almost every denial and negation reported
to me in supervision has proved to be valid. In my own work with
patients, negations of any kind are less common, but there too, I
find in most instances that I have been in error to some degree.
Only negations that are very quickly and clearly contradicted by
the subsequent associations from the patient tend to prove invalid.
Empirically, then, a negation is almost always an indication of an
incorrect intervention unless the subsequent material blatantly
demonstrates that the patient's disagreement cannot be justified, and
has been defensive.
I have illustrated valid negations earlier in this chapter and else-
where (see the Index of Clinical Material). As a further illustration
of this type of response, consider the following vignette:

Mr. LA. was a young man with a borderline diagnosis


who had flunked out of college, and was living at home
and holding a menial job. He had been talking about his
masturbatory conflicts and fantasies, and then began to
read a book on psychology, which was interpreted by the
therapist from the patient's associations as a flight from
this material.
In the next session, the patient reported having been
sleepless and that he was ready to move out of his house.
He was having tantrums; the therapist asked for details,
Failure to Confirm Interventions 101

which then followed. Mr. I.A. wondered if he wanted to


aggravate people. He also spoke of ending his therapy
and of reading again in psychology. The therapist said
that the patient was indeed trying to provoke everyone
and that he also seemed to be avoiding things by reading.
The patient then recalled having seen his mother nude
the other night, when her bedroom door had been ajar,
and spoke of his fear that his father would catch him
looking-he had not done so. After detailing this, he
ended the session by saying he did not follow the thera-
pist's comment about his being responsible for things. As
Mr. I.A. left this session, the therapist inadvertently
brushed hard into him as he escorted him to the door.
In the next hour, the patient ruminated about school
and about wanting to screw women. He spoke of his
father's battle with one of his brothers and how he, him-
self, held onto rotten people like his present girlfriend.
The therapist said that the patient was avoiding what
came up last session about his mother. The patient dis-
agreed: that had nothing to do with his problems, nor
with what was bothering him now; he could not trust the
therapist if he said things like that. The therapist then
said that his touching the patient must have gotten in the
wav of things and the patient responded that he did not
remember that happening.
In the following session, the patient described
improvements in his functioning for the first time in ten
months of therapy. He returned to his problem at home
and his feeling that his father was screwing him up. The
therapist linked this to his mistrustful and angry feelings
at the end of the previous session, and again related them
to his having brushed against the patient. The patient
now agreed with him, and then described how he was
especially angry with his father for not keeping his
mother in line.

I would note the following about this material:


1. Denials and negations can only be assessed if the proper
102 RESPONSES TO INTERVENTIONS

context and meanings of the material are understood. Here, the


therapist had initially failed to explore or deal with his brushing
, against the patient. As I pointed out in Chapter 6, such infractions
of the boundaries of the patient-therapist relationship take prece-
dence over other therapeutic work-since they do for the patient
(see also Chapter 22). Mr. LA. remained silent regarding the inci-
dent; other material and aspects of the associations from these ses-
sions suggest that he found feminine-masochistic, homosexual grati-
fication in it, and welcomed this as a defense against his incestuous
fantasies toward his mother. It was, under these circumstances,
incumbent upon the therapist to explore and interpret the related
fantasies.
2. I had predicted in supervision that the therapist had erred in
interpreting the patient's rumination in the third session reported
here as a flight from his fantasies about his mother; rather, its main
defensive use was as a means of avoiding his feelings and fantasies
about being touched by the therapist. While the two were related,
the contact with the therapist had to be resolved before the material
regarding his mother could be dealt with. As long as the therapist
himself had been inadvertently seductive with the patient, and had
not resolved this incident, he was in no position to help the patient
with his mother's inappropriate seductiveness. The therapist had
acted out in a manner unconsciously not unlike the patient's mother
and had, for the moment, created a mother-based misalliance in
treatment (see Part VII).
3. We must, therefore, conclude that the patient's denial of
the therapist's intervention was valid. The current central problem
for the patient was the therapist's behavior and not that of his
mother. However, a review of the patient's negation will indicate
that the matter is more complex; the denial is overdone and is in
part defensive, and was used to express the patient's underlying
mistrust of, and rage at, the "seductive" therapist. The patient
eventually expressed this mistrust directly, although he displaced
the cause of it onto the therapist's mistaken intervention.
4. Once the therapist recognized and correctly understood that
the patient was reacting first and foremost to the physical contact
with him, he made a general interpretation about the effects of this
incident; this the patient initially denied. Yet in the next hour, he
Failure to Confirm Interventions 103

reported that he was functioning better and criticized his father.


When this, too, was related to the incident with the therapist, the
patient (perhaps now convinced that the therapist did not wish to be
seductive or to avoid what had happened) directly agreed with the
intervention and added fresh material about his anger with his
father's over-permissiveness.
In summary, then, only attention in depth to the material from
the patient will enable a therapist to distinguish a defensively-based
negation from one that indicates a valid need for him to reassess
and reformulate. The latter is by far the most common case.

DIRECT AGREEMENT FOLLOWED BY NON CONFIRMATORY


ASSOCIATIONS
At times, a patient's direct agreement with the therapist's inter-
vention is followed by material that is clearly not confirmatory, for
instance, associations related to the patient's need to be submissive
and blindly obedient. Consider the following vignette:

Mr. LB., a young man with a borderline disturbance,


returned to his sessions after his therapist's vacation filled
with rage, which he had directed primarily against his
mother for nagging him, at a teacher for humiliating him,
and at a bus driver who refused him a transfer on the
way to his session-he could have murdered him for it.
The patient went on in this vein throughout his hour, and
the therapist made some minor inquiries, but no other
intervention.
In the next session, the patient reported a dream from
the previous week: he is in a hotel lobby in a foreign
country and a plane comes in for illanding but falls short
and explodes. Associations centered upon his fears for his
future and his school problems. The therapist intervened
here. He pointed out that the plane crash seemed to be
related to his fear of failing in school. The patient
agreed, and went on to say that on the previous night he
had had a flash or a premonition-a dream in which he.
saw a disastrous explosion; he feared premonitory
104 RESPONSES TO INTERVENTIONS

dreams. Once, he had dreamt that his parents were killed


in a car crash and he was afraid afterwards that it might
happen some day; a friend of his had once dreamt of
someone dying and it came true. The therapist intervened
again. (Can you detect a latent, disguised-repressed theme
that he is missing? Has the subsequent material confirmed
that the key to the dream and its manifest or latent con-
tent-and to the sessions-is the patient's fear of failing
in school?)
The therapist said that the patient seemed to fear
such potential power and the patient responded that, as
a child, his greatest dread in horror movies was of seeing
someone sitting innocently around who is then swallowed
up by something else-and dies.

I believe that this present topic is best illustrated by the thera-


pist's interpretation that the plane crash represented the patient's
fear of failure. In supervision, I disagreed with this intervention and
considered it to be an incorrect interpretation. Instead, I indicated
that the correct context of this material and that of the previous
session appeared to be the therapist's vacation, and the patient's
fantasies and other reactions to it. Thus, the correct formulation
(and interpretation) would have been to the effect that the dream of
the plane crash represented murderous rage against the therapist (in
a mother "transference"), who had deserted him. Despite the patient's
agreement with the therapist's general comment~with its inherent
lack of instinctual-drive material-both had endeavored to avoid the
patient's rage against the therapist, thereby sharing an obsessive
defense and denial. His subsequent associations indicate that not
only did he really wish the therapist harm (death-and with both
mother and father transference implications), but he also wished he
had the power really to make it happen. In essence, the further
associations do not deal with any kind of fear of failure, but with
murderous rage, as predicted in supervision. The patient's agree-
ment with the therapist's intervention was not supported and was
even contradicted by the subsequent material.
I want also to comment very briefly on the therapist's failure to
interpret the patient's displaced rage against him in the first session
Failure to Confirm Interventions 105

(a missed interpretation picked up in supervlslon and confirmed


with clear derivatives in the next hour). The therapist did not
understand how to work with material from patients in context, or
to deal with therapist-caused traumas before other possible con-
flicts. He also did not appreciate how human beings react intra-
psychically to traumas. The context here is a typical one, that of
the therapist's vacation; recognizing this would have made it easier
for the therapist to grasp the latent content of the session.
The errors in the second session are so representative of those
most often seen in student-therapists that I want to identify and
discuss them for a moment. They are important sources of noncon-
firmation. First, the patient reported a dream with a manifest con-
tent suggesting powerful feelings and fantasies. The associations, in
contrast, were ruminative. Technically, the therapist should, at such
a point, interpret the isolating defenses or directly ask for associa-
tions to specific elements of the dream. If no further derivatives of
unconscious conflicts and fantasies emerge, he can then wait for
further material in subsequent sessions or interpret the manifest
dream in light of the main context-if one is clear, as it is here.
Notice too, that the patient's references to worries about his
future and about failing are not specific, not evoked by a day residue
or current trauma, and are quite hypothetical. In general, such
indefinite threats are seldom strong enough to evoke adaptive
efforts and especially intrapsychic responses and conflicts. Real
threats and actual hurts generate adaptive efforts, though antici-
pated specific dangers may do so as well. Most often, however, a
concrete precipitate exists for intrapsychic disturbances; an actual
situation, viewed as traumatic by the patient, is, as a rule, the
initiator of the adaptive responses, real and fantasied. Thus, all
correct interpretations begin with a clear context and precipitate,
and go on from there to the patient's intrapsychic responses and to
the genetic background when feasible.
The therapist's interpretation, in isolation, of the plane crash as
representing the patient's fear of failure disregards all these basic
principles of technique. It also disregards the second hallmark of a
meaningful interpretation: that it include specific references to
instinctual-drive derivatives, where possible. Fear of failing is a far
cry from an explosive plane crash and is relatively barren of drive
106 RESPONSES TO INTERVENTIONS

expressions. Further, there is no indication here for an interpre-


tation upward. Thus, the intervention is not in tune. It also consti-
tutes an offer to the patient of an obsessive defense, which, typically,
the patient will accept at first. Eventually, however, as with Mr. LB.,
the patient foregoes this defensiveness and returns to what is really
bothering him, and to the expression of further derivatives of the
intrapsychic conflicts and repressed fantasies with which he actually
wants help. It is not uncommon, too, for these subsequent deriva-
tives to be less disguised than previously, as they are here; in this
vignette, the therapist's failure to properly understand the patient
undoubtedly also added to his rage and its expression.
We can learn a great deal from this vignette. The missed inter-
vention probably heightened the patient's anger and led to a need
to express the conflicts and fantasies more clearly, though still
indirectly; the incorrect intervention had a similar effect. Repeated
errors of this kind understandably damage the therapeutic alliance,
which becomes a misalliance between a therapist lacking in under-
standing and ability to help and a patient who is responding to this
with rage.
We must learn not to be lulled into confidence that we are right
by a direct affirmation from the patient. We must listen to the sub-
sequent material and decide for ourselves if it supports our
intervention, contradicts it, or goes nowhere. In the last two
instances, we must reconsider and correct the formulation.
The following clinical interlude reveals additional aspects of
this subject:

Mrs. I.e. had been in therapy for four months because


of a travel phobia and marital difficulties; she felt that
her husband used and depreciated her, but she was un-
able to modify their relationship or leave him. There had
been, in treatment, indications of a strong attachment to
the therapist and an erotic transference, though these had
not been explored very much. At this point in her
therapy, she had missed several sessions in the previous
month because of legal holidays, and had expressed her
wish to make up several future sessions that she would
Failure to Confirm Interventions 107

miss for the same reason-including one a week from the


first session to be described here.
In that hour, she began by saying that she had found
it difficult to come for therapy that day. She spoke of
her anger at her parents, her thoughts of leaving her
husband, and of refusing a minor surgical procedure be-
cause her doctor did not explain what would be done.
She regretted having asked for makeup sessions, and her
symptoms of anxiety and fear of traveling had intensified.
She needed a marriage counsel or, not psychotherapy.
She feared being harmed in some way and recalled once
enraging her father because she stayed out all night with
a date.
The therapist observed that something he had said
in the previous hour seemed to have upset her. Mrs. I.C.
complained that it was what he had not said-his silence
bothered her. She wanted a man all for herself. She
thought of leaving the session; the therapist said that she
seemed to feel that he wanted too much from her and
was pressuring her. She described feeling blank and re-
called that once she had been falsely accused of shop-
lifting; she had felt like a foolish child. The therapist
said that his remarks seemed to make her feel the same
way and were causing a disenchantment with therapy.
In the next session, Mrs. I.C. was furious about several
incompetent people with whom she had had to deal
during the week. Her husband was going away on a
business trip and she felt upset about it; she had refused
to go with him. She was afraid of flying and worried
about the pilot's ability to handle the plane. Here, the
therapist related her concern about others being com-
petent to himself, and noted her protective withdrawal
from him. The patient said that it was absolutely true-
she did worry about people's incompetencies. Her tele-
vision repairman had charged her for a visit and had not
even fixed the set. A while back, she had thought that
the therapist was incompetent because he seemed to use
108 RESPONSES TO INTERVENTIONS

cliches when he spoke of her missing a cancelled session


and wanting a relationship with him outside his office.
She herself did not deal with things; she was never
allowed to question her father and could never disagree
with him and his empty cliches. ,)he had to be approved
of and had to face up to doing things on her own. The
therapist said that her fear of her parents led to her
inability to resolve things with him and Mrs. I.e. agreed
-she could not say no to the television repairman. Her
parents brainwashed her; her father once wanted her hair
trimmed and thought it mattered to her, but it only
bothered him.

The comments that follow are based on a series of predictive


assessments made in supervising this patient:
1. The main source of error here was the therapist's failure to
recognize the primary adaptive task for the patient in these two
sessions-the pending session that was to be missed. Among his
additional errors were:
(a) The use of too many general, ill-defined interventions that
failed to begin with a specific day residue and end with specific
instbctual-drive expressions.
(b) The arbitrary manner in which he repetitively introduced
himself into his interventions without leads from the patient.
(c) A general repetitiveness to the interventions, which lacked
freshness and meaning.
(d) The failure to follow the patient's associations after his
interventions, and to recognize that they were not confirmatory;
there was nothing new or freed from repression in the patient's
reactio:1s and the material was not developing.
2. The patient's associations indicate that she felt deserted by
the therapist who had, because of the holiday, cancelled a coming
session, and that she subsequently felt, probably unconsciously,
that he failed to understand her feelings and reactions to this pend-
ing event-that he was incompetent to help her. This is a reason-
able appraisal on her part, and if themes of this kind appear in the
material from patients, self-scrutiny is indicated (see Chapter 22).
Failure to Confirm Interventions 109

3. Note that the patient's direct agreement with the therapist


after two interventions in the second session is not followed by
supportive and clarifying additional associations. Instead, the
patient discussed her need to agree to empty cliches, and to submit
to others to gain approval. She eventually alluded to her parents'
brainwashing her and to their self-centered failures to recognize her
concerns-only their own had mattered. Unconsciously, then, the
patient is, through derivatives, explaining why she has agreed with
the therapist's erroneous and empty cliches, and is expressing her
rage over having done so. Such associations are not uncommon when
submissive obedience has been the primary reason for the patient's
acceptance of an intervention.

OTHER FORMS OF IMMEDIATE NONCONFIRMATORY


RESPONSES
There are countless other ways in which patients respond to
incorrect and ill-timed interventions-not just by ruminating, by
failing to develop material, and by direct negation. Many have
already been illustrated (see Index of Clinical Material) and others
will soon be detailed; here I shall list the most common additional
nonconfirmatory reactions. They include:
1. The appearance of acute symptoms, including those that are
psychosomatic and those that are neurotic, during or after the
session.
2. Acting out during the session (acting in) or after it.
3. Regressions and deterioration in ego functioning of all kinds,
hoth during and after the session.
4. Disturbances of therapy and the therapeutic alliance, which
can include seductions of, and attacks on, the therapist; latenesses
and absences; and threats to terminate and actual premature ter-
mination.
We will return to these responses at the end of this chapter and
again in Chapter 22. Now, however, I want to focus on some of
the basic reasons for the therapist's failure to attain confirmation
of his interventions.
110 RESPONSES TO INTERVENTIONS

SPECIFIC TECHNICAL ERRORS AND THEIR


CONSEQUENCES
I have already discussed aspects of these problems (see Chapters
11-17), and I shall be very selective here. I shall not discuss further
misapplications of silence, confrontations and supportive interven-
tions; instead, I shall deal primarily with the therapist's excessive
activity without proper context, his irrelevant comments, and various
types of errors in the use of interpretations. One main goal will be
to establish how the therapist can identify such errors and how they
may be corrected.
I have already in part described the main indications that an
intervention is incorrect. By and large, these indicators are similar
regardless of the type of error, but in addition, the material from
the patient will reflect reactions to the specific error made by the
therapist. Thus, the patient reacts to incorrect interventions with a
general disurbance plus specific direct and indirect fantasies and
behavioral responses to the particular error. It is from a correct
understanding of such responses that the therapist becomes aware
of his mistakes and reformulates so that he may intervene properly,
sometimes doing so by acknowledging the error and then clarify-
ing its consequences with the patient (see Chapter 22). Let us turn
now to some specific problems.

EXCESSIVE ACTIVITY BY THE THERAPIST


It is not uncommon for therapists to offer too many interven-
tions, not as a meaningful construct of a specific interpretation
presented in a specific context, but as a more or less random
smattering of comments without a clear framework (see Chapter 9).
Such scattered work is not only unproductive and unconfirmed,
but it also offers a poor model of therapeutic work and of the
therapist to the patient, and provides him with a set of obsessive
defenses and a pattern of defensiveness through confusion as well.
In themselves, therapeutic interventions that are unrelated to a
correct context and to a current traumatic and adaptive task offer
little or nothing to the patient.
Patients react to out-of-context interventions with rumination,
Failure to Confirm Interventions 111

intellectualization, confusion, and feelings of not being understood.


They show more extensive nonconfirmatory reactions and regres-
sions if this type of work persists. On the other hand, they respond
to excessive random activity in the therapist with disruptions in
the treatment and in their lives that are generally even more intense,
and their fantasies reflect images of the therapist as attacking,
smothering, destroying, controlling, and overwhelming.
A brief vignette will illustrate these points and demonstrate how
physical illness, in patients prone to react in that way, belongs
among the regressive syndromes evoked by errors in technique.

Mrs. LD. was a patient with a severe character dis-


order, who was depressed after her husband had separ-
ated from her and their three children. She had been in
treatment several months when her therapist went on
vacation. Soon after, she herself planned her own vaca-
tion-owing to her job, it could not coincide with that
of the therapist-to begin less than two weeks from the
first session to be described here.
She began that session by describing a cousin who
had recently left her husband, neglecting the feelings of
her children in the process. The patient herself hid her
own desires to be rid of her children. Another friend
was dying of uremia due to hepatic and renal failure
caused by an antibiotic; she had recently given birth.
Mrs. 1.D. was depressed because of her friends. The
therapist told her that she spoke as if none of the distress
was in herself, and as if her friends put ideas into her
head. The patient ruminated about the same topics she
had alluded to earlier in the hour, and the therapist then
said that she was talking about mothers and children.
When the patient responded that children could be
important, the therapist said that she was uncertain and
trying to get him to solve things for her.
The patient next ruminated about her mixed feelings
toward her children. She then described her vacation
plans, in which she would be with them, and her fears
that her mother would be angry at being left alone, and
112 RESPONSES TO INTERVENTIONS

would worry about all of them; she had a habit of bath-


ing and inspecting the patient's children on their return
from a trip. The therapist asked about this, and when
it was clarified, he reminded the patient that her mother
constantly criticized her as a poor mother. Mrs. I.D. said
that when her husband had left her, her mother faulted
her and not him. She was angry and told her mother not
to be devious-to be direct!
There were then some details about friends who had
lost parents and several comments by the therapist about
the patient's concerns that her friends' mothers often
accused'them of being bad. The patient recalled having
lost her father when he divorced her mother and left the
area; she also spoke of how her mother opposed the
therapy. The patient then said that she had never gone
anywhere with her father and had never vacationed with
him. She wanted help from her mother and the therapist
without being smothered.
Briefly, in the next hour the patient ruminated about
her menstrual period, which she experienced as blood
spilling out of her without her having control over it,
and spoke of the pregnancies she had had. She canceled
the following session and in the hour after that, she
described a bladder infection; the symptoms were such
that she might have made the missed hour anyhow, or
she could have been justified in being absent-neither
was clearly the case. She then ruminated about her hus-
band's lack of concern for their children; she would not
let him see them too often, and she insisted that he stick
to their separation agreement. Her mother, she added,
never understood any of this-or anything for that matter.

It has not been possible in this summary to convey the truly


excessive, random, pressing comments made by the therapist in the
first hour described here. Long before the patient's indirect reaction,
I had expressed in supervision the feeling that the therapist was
totally overwhelming the patient-and that he had missed the main
context of the material as well.
Failure to Confirm Interventions 113

The primary adaptive task for this patient in these sessions


seems unmistakably to be the patient's pending vacation and the
therapist's own recent absence. The therapeutic context or task is,
therefore, to interpret the patient's fantasies about these separations
and then her possible acting out (by missing a session) and somatic
illness as likely expressions of related fantasies (e.g., revenge and
denial of need, and a somatic expression of need for the therapist).
The fantasy derivatives most likely revolve around the therapist's
imagined anger at her for leaving him, and the reverse; possible
seductive thoughts about being inspected by him on her return; a
view of the separation as a bloody bodily loss; and longings to go
away with him as she had wished with her father.
When these fantasies and the interventions related to them were
missed, and the therapist instead commented without context, the
patient unconsciously conveyed her sensitive reaction to his
behavior: he was devious and not direct; he was smothering her;
he did not understand; and he was a bad mother. Meanwhile, she
regressed, lost focus in the sessions, and become physically ill.
Much of this could have been corrected if the therapist had recog-
nized the indications from the patient that he was in error.

IRRELEVANT, GRATUITOUS AND INAPPROPRIATE


INTERVENTIONS
These are a common source of unrecognized difficulties in
psychotherapy (see Chapter 6). While the therapist must learn to be
relaxed and free in his relationship with the patient and in his com-
ments to him, there are, as I have delineated, definite boundaries
and limits; to go beyond them may disrupt the therapeutic alliance
and the therapy itself. As therapists, our function is to help the
patient understand himself and, through both the therapeutic rela-
tionship and insight, develop better adaptations for, and resolution
of, his intrapsychic conflicts. Gratuitous remarks of all kinds,
irrelevancies, uncalled-for comments about others, and inappro-
priate remarks to and about the patient are usually made by thera-
pists out of their own inner conflicts and neurotic needs, and not
in the service of the patient and his therapy. They are disruptive
and are generally defensive, seductive or destructive in nature.
114 RESPONSES TO INTERVENTIONS

Such comments must be distinguished from brief expressions of


concern regarding an illness in the patient or a serious illness in a
relative, or after the death of a family member, and from the usual
cordialities and concerns appropriate to the patient-doctor relation-
ship (see Greenson, 1967, 1971, 1972). The remarks to be studied
here go considerably beyond such necessary kinds of human feelings.
By and large, patients react to ill-advised comments with seduc-
tiveness and aggression of their own, disruptions in the therapeutic
alliance and therapy, and with a variety of repressed fantasies
directly related to the nature of the destructive comment. The
derivatives of these fantasies are in the latent content of the material
from the patient.
The proper corrective response to such incidents includes con-
trolling and avoiding these comments in the future. and exploring
the patient's fantasies and reactions to them. In doing so, it is well
to acknowledge the inappropriateness of the remarks. This corrects
the reality error, resets the therapeutic alliance, and permits an open
analysis of the inner conflicts evoked by the errant comments.
Such incidents are seldom reported to me in supervision,
although anecdotes from colleagues have reflected the many dangers
of this behavior. The following two incidents will serve as general
reminders:

Mrs. I.E. was a depressed woman with a poor mar-


riage, who had been in therapy about ten months when
she called her therapist to cancel two sessions because
she was ill. The therapist doubted her excuse and insisted
that recent difficulties that they were having in her ses-
sions were causing her to want to miss her hours. The
patient said that she had been to her internist, who told
her that she had the flu and should stay at home for at
least three or four days. The therapist said that he would
call him to verify this.
The following week. when the patient came for her
session. the therapist stated that he had corroborated her
story with her physician. The patient felt vindicated and
said that she had felt fine during the past week. A sudden
Failure to Confirm Interventions 115

insight had generated this positive mood; she had realized


that her husband was a meddling fool and far more stupid
than she was. It helped her to feel that she was not such
a bad person after all.
In subsequent weeks. however, Mrs. I.E. became very
depressed and found reason repeatedly to criticize the
therapist and to threaten to terminate her treatment.

Here, the mistrust of the patient, the direct doubting of her


statements without apparent reason, and the actual checking up on
her are all infractions of the boundaries of the therapeutic relation-
ship, and undermine any possible basic trust of the therapist. The
patient's initial elation over the therapist's meddling was soon
replaced by distrust and rage; the therapeutic alliance had been
badly damaged.

Miss I.F. was a young woman in therapy because of


multiple acting-out problems, including promiscuity and
a severe characterological disturbance. In her present
therapy, whenever she felt hurt, misunderstood, or criti-
cized by the therapist, she would, often with considerable
justification, recall her previous psychotherapy with a
man who had held her hand and kissed her at times. She
had initially felt elated over his attachment to her, but
soon felt used and enraged, and left him. The experience
had made it difficult for her to trust her present thera-
pist; it appeared to contribute to her hypersensitivity to
the least hurt in anything that he said. It also stimulated
an erotized reaction to him that was especially difficult
to explore and resolve.

Many factors contributed to this patient's difficulties in therapy


and all that one can conclude here is that there was considerable
evidence that the intimacies between the previous therapist and
patient were high among the causes of her current pathological
behavior and conflicts, and of her problems in establishing a reason-
able therapeutic alliance.
116 RESPONSES TO INTERVENTIONS

ERRORS IN INTERPRETING
In Chapter 14, I offered a classification of errors in interpreting;
here I shall discuss each briefly, emphasizing the main reactions of
patients to the particular error in question. Often, there is an overlap
among these categories, but I shall separate them for purposes of
discussion (see the Index of Clinical Material for supplementary
examples).

Premature Interpretations
This is a rather common error, characterized by the therapist's
talking too soon, often quite quickly after the start of the session,
and by his failing to wait for a clear context, for sufficient and clear
derivatives of the central intrapsychic conflict, and for supportive
evidence for his silently formulated hypothesis. Often, such interpre-
tations are made on the basis of a single isolated or several strongly
defended and disguised derivatives of an unconscious fantasy, long
before the patient is ready to deal with the subject. Such interven-
tions are often the product of the therapist's impatience and his
need to be overcontrolling, and the reflection of his own neurotic
fantasies, predelictions, and defenses, such as his wish to avoid
topics other than the one he refers to in intervening.
When a therapist speaks too soon, his rate of error in identifying
both meaningful psychic problems and unconscious fantasies, and
the main adaptive task and response in the patient, is bound to be
quite high. Some therapists characteristically speak too soon; others
do so only when areas related to their own conflicts and sensitivities
are touched upon. In all, the therapist can identify these errors by
reviewing the timing of his interventions when they are not con-
firmed, and recognizing his undue haste and the lack of definitive
material and context as a basis for what he had said.
A brief clinical example will provide clues to the characteristic
reaction to a premature interpretation:

Mrs. I.G. had been in therapy about five months; she


was depressed and unhappy in her marriage. She had
been upset over missing several sessions because of legal
holidays and anticipated one or two more such absences.
Failure to Confirm Interventions 117

She had raised the question of makeup hours; it had been


explored and refused. At the end of one session, as all this
was being discussed, the therapist told the patient that
he would be on vacation for two weeks, beginning three
weeks from the present hour.
Mrs. I.G. was ten minutes late to the next hour, and
spoke of having been confused last session. She recalled
discussing her husband in that hour and spoke now of
her fears when he was away on business. She would like
a windowless house so no one could break in. Could the
therapist tell her why she was so afraid? It was better
that he would not. She would like her husband to treat
her like a child; he had approached her sexually the night
before and she withdrew. She felt confused. The therapist
suggested that the patient had been upset since the pre-
vious session because of his announcement at the end of
the hour of his coming vacation.
Mrs. I.G. said that she had thought he might leave her
permanently; she had gotten lost coming to this session.
She was often around incompetent people; her husband
tricked her and changed for the worse after their mar-
riage. After some random thoughts, she spoke of how
her father would tease her and make her cry. He never
called and never helped them financially; he refused to
go out of his way for her when she was younger and even
now. He would never lend her money even when she was
in trouble; she could never ask for anything extra. She
had to be independent of him. The therapist said that his
vacation was for her like being deprived of something
she needed, and that was why she was late. The patient
stated that the therapist had now mentioned his vacation
a second time and seemed to be dwelling on it; she was
confused. As she left, she asked about the two pending
holidays; the therapist said that only one would be the
occasion for a missed hour.
In the next hour, Mrs. I.G. said that she felt that the
therapist was trying to set her up to think a certain way.
She had been thinking of him as a man and questioned
118 RESPONSES TO INTERVENTIONS

whether he was really going away. She wondered why he


never smoked his pipe, which was on his desk, when she
was there; he was not being honest with her and she could
not trust him. Her husband had used her early in their
marriage, and had refused relations with her. She felt that
she would be dispensed with if she did not comply. The
therapist said that she felt discarded by him and feared
being replaced during the coming breaks.

We may consider the therapist's initial interpretation as prema-


ture. This was suggested to him in 'supervision, and much of what
followed was explicitly anticipated. There were very few available
derivatives of the patient's reaction to his pending vacation and
those which were present were well disguised and remote; she had
not established it as the adaptive context of the hour. Nor were
there nearly enough associations for her to recognize that they
referred to her conflicts about being left by the therapist. In fact,
with separation reactions in particular, patients often feel helplessly
enraged and vulnerable; defensive denial prevails and the therapist
should take special pains to permit the material to unfold so that
its meaning is virtually unmistakable.
The patient's reaction to the intervention was to provide at first
brief confirmation, with a fantasy of permanent loss, but then she
began to ruminate. Eventually, she produced derivatives related to
wishing to be treated in some special and extraordinary way. When
the therapist, now both prematurely and probably incorrectly, inter-
vened and interpreted these associations as related to deprivation
at losing him, she did not confirm, and she then offered a corrective
association. As predicted in supervision, the patient seemed to be
focusing on her wishes that the therapist would make up the session
to be missed for the holiday, and was hurt by his refusal to do so.
This was confirmed by her last comment in the first hour.
We see then that a premature intervention is one that touches
upon an area of conflict that exists for the patient, but which is still
largely repressed and unavailable for exploration. As a result, some
fragments of confirmation may follow, but these are usually soon
replaced by confusion and efforts to redirect the therapist to the
currently central conflict area.
Failure to Confirm Interventions 119

The reactions in the second hour reported here are a response to


the two prior interventions, and are characterized by suspiciousness
and mistrust of the therapist and erotic fantasies about him-
responses evoked by the therapist's errors, and determined both by
the nature of his mistakes and the patient's psychopathology (see
Chapter 22). The therapist's final intervention shows a failure to
appreciate the correct main source of the patient's fantasies-his
interventions-and demonstrates too, how readily one may intro-
duce his own fantasies into an interpretation (his reference to being
replaced, which was not in the patient's associations). It is a reminder
to listen accurately and to interpret in keeping with the specific
derivatives in the patient's associations. Lastly, this vignette illus-
trates the consequences of missed interventions, since the main
interpretation available from the material from the patient was not
made.
Other observations reveal that premature interpretations alone
can evoke mistrust and negative fantasies about the therapist. Con-
fusion, agreement then contradiction, denial, and intensification of
repressive defenses are also common reactions. When repeatedly cut
off by premature interventions, patients are silently enraged and will
often talk about angry, controlling, insensitive people. One patient,
when his therapist modified and controlled this habit, directly
expressed enormous relief over being able at last to talk and be
heard by the therapist.

Too Deep Interpretations


Too deep interpretations should be considered when the thera-
pist interprets sexual and aggressive fantasy content to the patient
at any time during therapy, especially in the opening phase (see
Chapter 23). When these are not confirmed, he should wonder if he
has set off too much anxiety by interpreting a fantasy, or has over-
looked important defenses that should have been analyzed first. We
learn from such experiences with nonconfirmation of "id material"
not to underestimate the repercussions of interpreting fantasies and
memories related to primitive aggressive impulses and to sexual
impulses of all kinds.

Miss I.J. was a young woman with a borderline syn-


120 RESPONSES TO INTERVENTIONS

drome who had been in therapy for four months because


of social anxieties and depression. It soon became clear
that she had strong latent homosexual problems. In one
session, she described the seductiveness of a girlfriend
and revealed a pair of overt homosexual dreams in which
this girl was fondling her. She had told this friend of her
dream and the latter expressed open love for the patient.
In the session, she went on to describe a series of adoles-
cent homosexual fantasies and a fear that she was crazy.
In the next hour, the patient described an impulsive
affair with a man she had just met through her job. The
therapist interpreted this as a flight from her homosexual
fears and asked a series of questions regarding these
anxieties. The patient reitera'ted what she had already
said.
In the next hour, she described a temper tantrum
against her father, who had pressured her to move out of
her parents' apartment; there also were thoughts of leav-
ing therapy. She felt that the therapist was after her and
wanted something from her in the previous hour; she did
not know what it was. She had not slept well since the last
session and felt angry with the therapist. She had accepted
a ride home from a young man who was a patient in the
clinic in which she was being treated. She had dreamt
of being outside her grandmother's house, trying to climb
a tree. Between two trees was a spider web, wet after the
rain; she was afraid of being bitten by the spider. In
associating, she recalled food being stored in her grand-
mother's basement and the spiders that were there; she
was afraid of being touched by them and of being trapped
in the basement.

While the patient was regressing because of her girlfriend's open


seductiveness, the therapist's ill-timed interpretation of her flight
fr'")m the homosexuality into a heterosexual experience, and his
untortunate queries about that homosexuality, heightened her
anxiety and produced a mixture of rage, mistrust, and fear of the
Failure to Confirm Interventions 121

therapist-a disruption in the therapeutic alliance that produced a


threat of premature termination.
By and large, patients react to this type of error with more
intensity than the others I shall describe in this section. Interventions
must therefore be properly timed and stated with great sensitivity.
If not, the therapist can set off intense anxiety and even panic, and
disrupt the patient's intrapsychic balances and adaptations, sorely
overtaxing his defenses. The result is often a major disruption in the
therapeutic alliance and in therapy, with direct attacks and rage at
the therapist and at times, premature termination. Associations at
such times relate to paranoid-like fantasies of terrifying seductive
and destructive people and animals, to fears of losing control or
going crazy, and to fantasies-or intentions-of fleeing treatment.
Recognition of these errors as quickly as possible is essential,
since considerable difficult work is necessary to undo these disrup-
tions and restore a calm and safe therapeutic atmosphere to what-
ever extent is possible.
A common area for both premature and too deep intervention-
both confrontations and interpretations-is that of the patient's
relationship with the therapist. Since we will study this matter in
detail in Chapter 21, I shall only briefly illustrate it here.

Mrs. K.V. was a divorced young woman with a


moderate character disorder and depressive tendencies.
She had been in therapy for about fifteen months when
her therapist indicated to her that he would be leaving
the clinic in which she was being seen, and offered her
the option of terminating her therapy 0r continuing with
him in his private practice.
Mrs. K. v.'s response to this situation was to review
very briefly her improved functioning at work and to
decide tentatively on termination, though her recognition
that her relationships with men were still unresolved
prompted her to leave the matter open. Themes of lone-
liness and of being deserted--e.g., by her father when he
died, began to appear in her associations, as did fantasies
of being senselessly murdered. She spoke in one session
122 RESPONSES TO INTERVENTIONS

of intensifying her sexual involvement with her current


boyfriend because of her concern that he would take a
job outside the area and she would lose him. She spoke
vaguely of how she saw all of her relationships with men
in a sexual light, and of a book in which a woman
destroyed a man-she could do that, she feared. In a
dream, she was going to the supermarket with her son
and her boyfriend was there; she felt that she must leave.
The session ended before she could associate directly to
the dream.
After missing an hour because her friend's car, which
she had borrowed, failed to start, Mrs. K.V. began the
next session by describing a sense of anxiety in coming
to her session. She described the problem with her
friend's car, emphasizing how little she had been told by
the mechanic who came to fix it. Her pediatrician recom-
mended a tonsillectomy for her son, and the patient was
skeptical. She recalled her own tonsillectomy and how
she had been tricked by her parents into going to the
doctor's office, and how she had felt abandoned by them
and been terrified by the procedure. She had been afraid
that she would choke on her tonsils and connected that
fear with a recurrent choking sensation she used to get in
her throat. Surgeons were sadistic and cruel; maybe that
was how she saw all men.
The therapist here said that Mrs. K.V. seemed to be
furious at him for not explaining his recommendations to
her and for deserting her by terminating her therapy; he
clarified his reasons for feeling that if the patient wished,
they should continue her therapy until she resolved her
conflicts with men. Mrs. K. v. said she had thought of the
therapist when the mechanic was so uninformative, and
described her view of men, including her father, as cruel.
After her surgery, she had had a passion for chocolates.
Men did not care to listen to her; they wanted something
more sexual. The therapist said that Mrs. K.V. apparently
was having sexual thoughts about him, alluding to her
previous comment about the way she sexualized every-
Failure to Confirm Interventions 123

thing, and added that this must make it difficult for her
to come to her sessions. It also accounted for her missing
sessions and not wanting to continue her therapy-she
must see the offer as a seduction.

It was at this point in supervision that I assessed this last inter-


vention as premature (there were too few derivatives available
regarding the patient's erotic fantasies about the therapist, and no
clearcut bridge to him in her remote sexual thoughts), and too deep:
the material did not justify an interpretation or confrontation with
sexual fantasies about the therapist; more superficial concerns about
being abandoned and about being harmed-possibly related uncon-
sciously to her own sense of rage at the therapist for terminating-
were far more evident in the patient's associations. I thought it also
possibly incorrect in part; the missed session might have been
unavoidable. It was therefore predicted that validation of this inter-
vention would be lacking, and that the patient would regress in
some way, probably by developing anxiety-related symptoms as she
had in response to past erroneous interventions by the therapist.

In the session following the therapist's comments,


Mrs. K. v. said that she tended to confuse her boyfriend
with her therapist. She did have sexual thoughts about
her boyfriend but turned things off upon thinking about
her therapist.
Briefly, in the following hour, Mrs. K.V. spoke in great
detail about her boss at work and how she had no idea
what he was talking about when he recently criticized her
work. Her symptom of choking sensations in her throat
had returned. She generally just went along with her boss;
she would quit before he fired her. He was inclined to
force the issue unnecessarily when a problem came up.

The material from the patient after the therapist's intervention


is, indeed, nonconfirmatory. No elaboration of the patient's
reactions to termination is evident on any accessible level. The
patient's associations reflect primarily her unconscious perception
of, and reaction to, the therapist's premature and too deep inter-
124 RESPONSES TO INTERVENTIONS

vention, and includes a iatrogenic (therapist-evoked) hysterical


symptom (see Chapter 22). A disturbance in the therapeutic alliance
is evident, but the unconscious fantasies on which the choking
symptoms are based are not clear.

Incorrect Interpretations
I have discussed in this and other chapters the errors caused by
the therapist's failure to listen to, and misunderstanding of, the
patient's associations and his interpreting on the wrong level or
quite incorrectly (see the Subject Index and the Index of Clinical
Materials). Patients usually respond to incorrect interpretations with
confusion, rumination and some anger. They go on unconsciously
to correct the therapist and set him back on the right track.
Repeated errors of this kind may lead to a sadomasochistic mis-
alliance or premature termination.

Inexact Interpretations
We are indebted to Glover (1931) for first descriping inexact
interpretations and their effects in offering defensive displacements
and substitutions to the patient for his most disturbing intrapsychic
fantasies. His emphasis was on interpretations that dealt with only
one part of a group of disturbing fantasy-systems. He distinguished
these from incomplete interpretations, which correctly deal with
repressed fantasies bit by bit, rather than permanently ignoring a
major aspect of such fantasies. These observations are one of the
first attempts to deal with a relatively neglected area of erroneous
interpretations.
I would add only this: incomplete interpretations are part of
our usual and correct technique; we always interpret repressed fan-
tasies piece by piece. Inexact interpretations, on the other hand,
offer a defensive avoidance of specific unconscious fantasies to the
patient. We can recognize them when the material from the patient
is subsequently ruminative and then presses on to express deriva-
tives of the fantasies that we are missing. Continuation of symptoms
in the patient points toward such oversights. Often, therapists avoid
fantasies in areas related to their own unresolved intrapsychic con-
flicts (see Chapter 22), and each of us must locate and deal with
these potential blind spots.
Failure to Confirm Interventions 125

Missed Interpretations
When negative reactions appear in the material from the patient,
and we have not intervened, we must learn to ask if we have missed
an indication for an intervention and failed to make a necessary
confrontation or interpretation.
In discussing a therapist's failure to intervene at an appropriate
and sometimes even crucial time in therapy, we must acknowledge
the many difficulties inherent in determining that an intervention
has, indeed, been missed. It is of some importance to establish
indications of omissions so that we may learn to listen for them in
the material from the patient. In this effort to define such indicators,
I shall again exclusively draw upon data taken from situations in
which I predicted that a significant intervention or series of inter-
ventions had been missed and in which subsequent material con-
firmed the prediction both in my view and that of the therapist.
Missed interventions have specific clinical consequences. In this
section, I shall illustrate the short-term consequences, and in the
final section, address myself to the long-term repercussions of both
missed and erroneous interventions.
All kinds of confrontations and interpretations can be missed.
These two illustrations will provide a starting point for a discussion
of the basic principles involved.

Miss I.H. was a teenager with a severe character dis-


order. Her therapist arrived late to his office and began
her session ten minutes late. In the session, the patient
said that she was afraid while waiting for him and then
spoke of her seductive cousin, and of her fear of her
parents' return from a trip-would they be nasty? She
went on to describe her fear of losing her closest friends.
As the therapist ended the hour, she expressed annoyance
with him and his obsession about time. (The therapist did
not make up the lost ten minutes.)
The patient failed to show up for the next session.
In the next hour, Miss I.H. spoke of decreasing from
two sessions to one per week so she could work. The
therapist recommended staying with the two weekly ses-
sions. She questioned the value of therapy at length,
126 RESPONSES TO INTERVENTIONS

spoke of feeling unworthy, and said that she had missed


the previous session to meet her parents at the airport.
She was jealous of the therapist's other patients and
curious about him. She had had a day dream, but she
would not reveal it.
In the next session, Miss I.H. described at length a
battle with her mother, whom she provoked and screamed
at; she feared having a nervous breakdown. She again
complained about therapy and wanted to decrease her
sessions. The therapist said that she was disillusioned
with treatment and jealous of his other patients, and that
this was why she wanted to decrease the sessions. Miss
I.H. said that he did not understand her at all; her parents
felt that therapy was hurting her.

I would make these points about this vignette:


1. The therapist had failed on many levels: human, in not
recognizing the hurt to the patient in eliminating ten minutes from
her session, in not making it up, and in then charging her for a full
hour; technical, in failing to maintain sound and fair ground rules,
to hear the derivatives related to the patient's reaction to the lost
time (her anger at his time--consciousness and her own withholding
of the day dream), and overall, to deal properly with the reper-
cussions of this error; and countertransference, in his aggressive
persistence in not remedying the real deprivation and hurt to the
patient.
2. The missed interventions include failing to correct the basic
injustice and to make up the lost time, in order to correct the real
error, a step which must precede the verbal intervention and without
which nothing else can be properly clarified (see Chapter 5). The
therapist also failed to interpret the patient's behavior and her
acting out-through missing a session and battling with her mother
-in the context of her rage at him; thus he missed an opportunity
to interpret both the rage displaced onto her mother and the self-
hatred evoked by his hurt. The patient then turned away from the
therapist because he had failed correctly to ascertain the true source
of the patient's disruptive rage at him.
3. The consequences of these missed interpretations include:
Failure to Confirm Interventions 127

acting out against her mother; signs of regression in ego function-


ing; increased anxiety reflected in the patient's fear of going crazy;
depression and self-castigation; acting out against the therapist by
missing a session and wanting to decrease the sessions; and direct
criticisms of the therapy and therapist-especially the sensitive and
correct statement that he did not understand her.
This remark, made in response to an inadt>quate and empty con-
frontation, was a valid negation, which was supported by previous
and later material.
4. Notice thilt the therapist's acting out without insight has
promoted a therapeutic atmosphere where the patient acted out in
turn, toward him and others (unconscious sanction is implied). The
therapeutic alliance has been ruptured by his behavior and especially
his failure to correct it; a therapeutic misalliance prevails.
5. In all, there is every sign of deterioration in the functioning
of the patient and no development of the material, except as it
reflects the patient's responses to what had happened with the thera-
pist. Thus, a real provocation by the therapist has evoked a reaction
in the patient based on her relationship with her mother; as we will
see, this is quite frequently what we mean when we describe so-
called "transference reactions" in psychotherapy (see Part VII).
6. Lastly, the specific communications in the patient's acting
out and associations give strong latent clues to the source of these
nonconfirmations and the disturbances evoked by the therapist's
missed confrontations and interpretations.
The following vignette is another condensed illustration of a
missed interpretation:

Mr. I.K. had been in therapy for about six months,


primarily because of a problem in setting a course for his
life; he had been drifting, though he worked and went to
school at various times. He had a moderate character dis-
order.
He had missed a session to stay with a boyfriend in
another city and upon his return, spoke of his pleasant
vacation, of being excluded by his friends in adolescence,
of avoiding drugs, and of his plans to play the guitar at
a musicale for his friends.
128 RESPONSES TO INTERVENTIONS

In the next hour, he reported a dream: either he or


his father-it was his father-was performing with the
guitar in front of a huge audience. It began well, but then
he made mistakes and faded away. In another dream,
the patient was in a clinic and had a cut from his anus to
his testicles. In associating, he spoke of fears of his father
being killed in an accident and of the performance he had
actually given with the guitar-it had not gone well. He
ruminated about fears of losing his masculinity and a
girlfriend who is confused about her sexual identity. He
was afraid of his teachers when he spoke in class; they
would be suspicious that he was on drugs.
In the next hour, he described oversleeping and not
going to work, and his plans regularly to miss one of his
two weekly sessions for the remaining six weeks of the
summer. He had dreamt of a girl he had seen in the
clinic; she came into his house from the back door and
brought a cat into his bedroom. As he thought about the
dream, he recognized that the cat was like a tiger. He
thought that the therapist looked depressed.
He was thirty minutes late to the next session. The
therapist pointed out his disruptions of treatment, and
said that the patient seemed to feel that his therapist was
sick and could not help him. The patient said he did not
expect the therapist to be hospitalized, though he won-
dered who conditioned the conditioner.

In this vignette, we see evidence of a missed major interpretation


regarding the patient's fears of the therapist and therapy, speci-
fically, his unconscious fantasies that he will be killed, attacked, cut
(almost expressed directly as being castrated), or just die in the
process. This was the basis for his massive flight from treatment,
especially since it went uninterpreted. Acting out in his failure to
work was also involved.
Let us now turn to some general principles regarding the effects
of missed interventions. Failure to intervene at significant moments
in therapy leads to :
Failure to Confirm Interventions 129

1. Heightened resistances, rumination and lack of development


of the material.
2. Associations reflecting a conscious-or more often, uncon-
scious-awareness that the therapist has missed something and does
not understand, with specific disguised clues to the nature and con-
tent of the missed intervention.
3. Regressions, with anxiety, psychosomatic and neurotic symp-
toms, and other disturbances.
4. Acting out.
5. Thoughts of termination and criticisms of the treatment and
therapist. Seductive or angry fantasies toward the therapist are not
uncommon. In all, there is a major disturbance in the therapeutic
alliance and often a misalliance has been created.
6. Most patients will persist in expressing derivatives of the
uninterpreted conflicts and fantasies. This permits the alert therapist
to probe himself and the material from the patient, and discover
what he is missing. Then he can reformulate and offer the correct
interventions.
In concluding this section, I want to point out that patients'
responses to incorrect and missed interventions are very much alike.
A typical sequence is as follows:

N onconfirmation.

Resistance and rumination.

Return to the main unconscious conflicts and fantasies.

If the patient is still mishandled, ruptures in the therapeutic alliance and


symptomatic regressions.

Reflections of the patient's unconscious perception of the therapist's


error; continued unconscious efforts to return to the main conflict.

If the patient is still mishandled, any of the following:

• Premature termination.
• Acceptance of a sadomasochistic therapeutic misalliance.
• Depression and disheartened movement into new problems.
130 RESPONSES TO INTERVENTIONS

This sequence anticipates my discussion of long-term indicators


of unconfirmed therapeutic work; let us turn now directly to that
topic.

LONG-TERM INDICATORS OF LACK OF


CONFIRMATION
As a group, these indicators constitute the characteristics of
poor psychotherapy, one that is probably dominated by technical
errors. This syndrome or group of syndromes (see Chapter 22) is so
typical that illustrations become quite repetitious. We must, as
therapists, learn its manifestations and acknowledge our own contri-
butions. Too often, this is denied and the patient is blamed for the
poor course of therapy. He was "too sick" or "too angry" or "too
resistant to be helped" is the rationalization. Most often this is
irrelevant to what has gone wrong in the therapy and actually
untrue, in whatever sense it is meant.
On the other hand, since I have been emphasizing the much-
neglected role of the therapist in the disturbances and disruptions
that occur in psychotherapy, I want here to make brief note of the
role that the patient may play in such problems. At times, when
faced with valid psychotherapy and confrontations with himself and
his inner conflicts, a patient will indeed prefer to take flight regard-
less of how delicately, firmly, or sensitively the therapist handles
and interprets the situation to him. Traumatic life events during
therapy, or the exploration, however cautious, of terrifying inner
fantasies and genetic experiences may, at rare moments, prompt an
unanalyzable and unresolvable flight from treatment. Or a deeply
disturbed patient may, without provocation from the therapist, in
deep loneliness and because of significant inner pathology and mal-
adaptive propensities, develop a psychotic or erotized and unman-
ageable transference and flee. Furthermore, whatever the stimulus
from the therapist, the patient's personality and psychopathology
will determine his specific reaction (see Chapter 22), and the ulti-
mate responsibility for it must be his.
My main points are these:
1. Such primarily patient-evoked, unanalyzable disruptions in
Failure to Confirm Interventions 131

therapy are actually quite rare. They should be for any therapist a
unique and profound reminder that he is not, indeed, omnipotent
and that there are limitations to what he as a psychotherapist can
offer a patient.
2. Whenever such disturbances do occur, they call tor a deep,
searching study of the therapist himself, the therapeutic milieu, and
his interventions-for conscious and unconscious errors of omission
and commission.
3. While every therapist will, and does, make errors, we hope to
learn to keep these relatively minor and innocuous, and especially
to develop the capacity to detect those errors, modify their sources,
and correct them. Major or repeated errors are detrimental to
healthy psychotherapy.
4. As therapists, we should recognize our responsibilities to our
patients and for their therapy, that our part in the therapeutic inter-
action is quite real (be it conscious, as it should largely be, or
unconscious), and that our behavior with the patient on every level,
verbal and nonverbal, is a crucial determinant of the outcome of the
therapy.
On this note, we can study the general syndromes of poor
psychotherapy. I shall begin with further material regarding the
therapy of Miss I.H., which I have described elsewhere in this book
(see Chapter 13 where much of this material is presented from a
different vantage point) and to whom I referred earlier in this chap-
ter when discussing missed interventions. I shall pick up the therapy
where I left off and ask the reader to follow it critically.

In her next session, Miss I.H. described a vaginal


infection and an examination by a doctor that evoked
sexual fantasies and fears of being raped. She spoke of
wanting close friends, and was annoyed with the thera-
pist's silence. He must have many admirers, she said,
adding that he probably came from a party the time that
he was late. The therapist said that the patient was
expressing wishes to be grown up and mature. The
patient agreed: she wears a ring and pretends to be
engaged.
132 RESPONSES TO INTERVENTIONS

She missed the next session, blaming a school obliga-


tion. In the following hour, she said that she was fright-
ened about cancelling and feared that the therapist would
drop her. The therapist then said that she was angry
about the ten minutes he had been late and had failed to
make up, and that this was an error on his part which he
would like to correct by extending the present hour. At
first, Miss I.H. denied any feelings about this, but then
acknowledged her anger and said that she had again been
thinking of terminating. She reported a dream: her house
was on fire, no one was home and she felt no guilt; her
room did not burn. She recalled setting fire to some
furniture in her basement as a child and added that she
would like to do it to the therapist's desk.
In the next hour, she ruminated about battles at home
and the way her mother turned to her for support, and
spoke again of fears of being raped. She said that she
was concealing something embarrassing and would not
reveal what it was. The therapist expressed his wish to
help the patient, but said that her concealing things made
it difficult to do so. The therapist's tone was one of anger,
and the patient was unresponsive.
In the next hour, she reported this dream: she is
driving a car with a baby in it over a bridge and goes off
the bridge into a river. As she tries to save herself and
the baby, an ocean liner bears down on her. She fears
being chopped up, and her head coming off. She tries to
get out of the water and fears drowning.
Her subsequent thoughts were that maybe something
like that had happened to her before she was born. One
night, she thought she heard a burglar in her house and
had locked her door in fear. She reviewed her terror of
bugs, and how she had once nearly been raped by a friend
of her cousin after the two of them had tied her down.
The therapist said that the baby in the dream suggested
that the underlying theme was sexual. The patient won-
dered how he got to that and the therapist brought up
her concealing; she refused to talk about it.
Failure to Confirm Interventions 133

In the next hour, she again complained about the time


of her sessions and referred to her dream of the baby.
After the previous session, she had hallucinated dead
bodies in cars; later, she fought with her girlfriend, who
tried to analyze her. The therapist suggested that the
previous session had upset her. Miss I.H. denied this, but
was furious that her therapist was staring at her, like her
mother sometimes did. He said that she felt toward him
as she did toward her mother. She then felt that the
therapist was playing games with her and that nothing
was happening in her therapy. She was afraid that he
would not be there for the next session. She felt like
walking out and actually left a little before the hour was
at an end.
In the next session, she spoke of feeling lonely and
rejected, of a friend who took LSD for the first time, and
of a group session given by a therapist at school that she
had attended and liked immensely. She thought of quit-
ting her therapy or continuing but also joining the group,
and wondered what her therapist thought about that. He
said that this was an extension of her leaving early last
time and she interrupted him angrily, asking for a straight
answer for once. She wanted to change therapists and
grew more angry. He pointed out that she did not accept
anything he said and she responded that she would teach
him not to beat around the bush-she was leaving, and
for good. Her therapist said that she should come back,
but she left; she did not return.

Before discussing this vignette, and the implications it has for


the issues at hand, let us acknowledge the plight of this young and
inexperienced therapist. It will prove easy to criticize him, but I fear
that many therapists quickly forget their own similar errors and
experiences; so let us discuss this material critically, but in all
humility.
I shall review the material presented here sequentially, com-
menting on some salient points and then use the findings to sum-
!Darize the signs and symptoms of a pending therapeutic failure.
134 RESPONSES TO INTERVENTIONS

1. The first session described here hints at erotic fantasies about


the therapist (see the material from this patient reported on pp.
125-26, which also indicates that this was a latent and uninter-
preted theme over several sessions); however, as the associations
unmistakably indicate, these unconscious fantasies were prompted
by her therapist's rejection in coming late and not making up the
lost time (see Chapter 22). In this light, the therapist's intervention
in that session was incorrect, a general remark made without context.
The patient directly agreed with it, yet missed the next session. The
acting out against therapy suggests both that the therapist has been
incorrect and that he has missed an important intervention, relating
to Miss I.H.'S reaction to his lateness and her erotic fantasies about
him. Perhaps both the patient and therapist are sharing defenses
against the former's erotic fantasies about the latter, and the entire
subject is avoided.
2. In the next session, the patient expressed a fear that her
therapist might react destructively toward her; this is probably a
derivative and extension of the unresolved problem of his insensi-
tivity about the lost time. This fear of the therapist may also
account for her agreeing with him earlier. The therapist finally cor-
rected his error and his intervention was confirmed with the report
of a previously repressed dream (this is possibly the only correct
and confirmed intervention in this whole sequence of sessions).
With the dream and Miss I.H.'S associations, her rage at the therapist
is virtually undisguised. Here, the therapist initially missed an
opportunity to ask for further associations to the dream (might they
have related to the erotic transference?), and he failed to interpret
the patient's rage and its source in his behavior.
3. In the next hour, rape fantasies emerged and with them there
was a rupture in the therapeutic alliance: the patient was con-
sciously concealing things from the therapist. His somewhat con-
frontational appeal that she let him help her, which was possibly
seductive, was met with no direct response. Here, the patient's
resistance might well have been interpreted as a flight in terror of
losing control of her sexual and angry fantasies; this would have
been more specific. The therapist became openly angry with the
patient, and was feeling very frustrated.
Failure to Confirm Interventions 135

4. The dream of the baby and of the flight from the boat which
is bearing down on her followed. The manifest content and associa-
tions point to further fantasies about the therapist, such as being
raped by him, and about her need to escape before she is damaged-
loses her head.
The image of the therapist as pursuing and attacking her appears
to be rooted in both in a projection of her rage at him and in her
response to his growing impatience anger with her. This latter is
further reflected in his comments at the end of the session where he
seems to have been drawn into a battle with the patient. Both parties
repeatedly used anger as a defense against the patient's emerging
sexual fantasies.
The therapeutic alliance is eroding and has been replaced by a
mutually hostile misalliance, which seems to be prompting the
patient to think of leaving therapy altogether as a response to the
antitherapeutic, destructive climate of her treatment.
The therapist's intervention that the dream was sexual was a
wholly inadequate general interpretation. It reveals a lack of
understanding that further infuriated the patient; it was not con-
firmed. It is a hollow interpretation, devoid of context; the patient's
specific conflicts and fantasies, and their precipitates in the treat-
ment situation, were missed entirely.
5. In the next hour, we see a regression in the patient's ego
functioning and the appearance of a new symptom reflected in her
hallucinations (this is an iatrogenic psychosis, probably of an hysteri-
cal type; see Chapter 22). The therapist ignored this therapeutic
context and indication for an intervention, and the adaptive context
related to it (i.e., the precipitates in the growing disorganization of,
and battling in, the therapy), and chose to make a random comment
based on minimal material, to the effect that the patient saw him like
her mother. This constituted a failure again to understand the com-
munications from the patient; and again several interventions were
missed. The therapist might have related the dead persons to her
thought that the therapist would not be at the next session, and to
the patient's rage at him for not understanding her and for becoming
angry with her (notice how one must anchor such interpretations in
the true reality precipitates). These technical errors prompted her
136 RESPONSES TO INTERVENTIONS

to act out against the therapist by leaving the session early. Action
and accusation predominated at this point, and thOUght and the
search for insight faded into the background.
6. In the last session, the patient's feelings of hurt and rejection
were intense. The reference to the drug-taking by a friend may con-
ceal the patient's own use of drugs, a not uncommon response
to disruptions in therapy. The patient acted out further by going
into another therapy situation, though we might well consider this
to be adaptive on one level since she was not being helped in her
present treatment. Yet she did not deal with this problem directly,
and when the therapist failed to interpret the specific meaning of
this acting out and began another general interpretation, the patient
left treatment abruptly, in a state of rage, and terminated prema-
turely-very mnch in the manner predicted by her dream of fleeing
the boat. We can consider this outcome an episode of countertrans-
ference-based (iatrogenic) acting out and premature termination (see
Chapter 22).
The signs and symptoms of troubled therapy and poor technique
are undoubtedly becoming rather familiar to the reader. I shall
simply summarize the main features here:
1. Ruptures in the therapeutic alliance, often with the creation
of seriously pathological misalliances.
2. Major resistances reflected in the manner in which the patient
communicates in the sessions. Underlying fantasies may be covered
over, and this will often alternate with periods during which the
patient makes desperate attempts to communicate the nature of his
conflicts and fantasies, and his unconscious awareness of the sources
of the disturbances in the therapy and the therapist.
3. Acting out, not only outside the therapy situation, but also
characteristically against the therapy and therapist. This latter
includes latenesses, absences, verbal attacks and criticisms of the
therapist, concealing things from him, blatant lack of cooperation,
and abrupt and premature termination. Outside therapy, inappro-
priate battles with others, sexual involvements, drug-taking, and
school or job disruptions will occur.
4. The appearance of new symptoms of all kinds. This includes
physical illness, psychosomatic illness, and the whole gamut of
psychological disturbances.
Failure to Confirm Interventions 137

5. Ego regressions such as impaired thinking, loss of controls,


or disturbances in relating.
6. Dreams and associations that center upon the disturbances
within the treatment.
7. Failures of confirmation prevail unless the problems in the
therapist's work are corrected, and the repercussions for the patient
analyzed and resolved as much as possible.
8. The usual unfolding of material is impaired or even halted.
The sequence in which outside reality precipitates evoke inner con-
flicts and fantasies, which are then explored and analyzed, no longer
characterizes the treatment. There is an undue preoccupation with
matters related to the therapy itself. The sense of progress toward
symptom relief is also lost.
In all, these are the main general features of unsuccessful
therapy. Its exact form in any given instance will be determined by
the therapist's particular errors in technique and the patient's par-
ticular behavioral and fantasied responses. When difficulties of this
kind occur during the course of therapy, the therapist must pause
and examine his technique, seek out his errors and countertrans-
ference problems, and make efforts to resolve them.
These signs of therapy in trouble appear repetitively. In my
supervision of this case, I repeatedly predicted the acting out,
regressions, and the possibility of termination, based on prior
observations of comparable chaotic episodes and on the material at
hand. In another such vignette that I recently observed, repeated
surface-oriented interventions, missed interpretations, and prema-
ture, excessive interventions unconsciously angered the patient and
evoked repeated acting out, conscious doubts about the therapy, a
psychosomatic urticaria, and finally flight from the treatment.
We must learn to detect indications in the communications from
patients of errors in technique as early as possible, so that we can
reassess our technique, and identify and correct the errors. At times
of heightened resistances, persistent questioning of the therapy by
the patient, unduly intense reactions to--and preoccupation with-
the therapist, acting out, continued ego impairments, and regressions
of all kinds, the therapist must ask himself if anything he has done
or missed has evoked this in the patient. How, then, can we distin-
guish such resistances and regressions from those evoked by the
138 RESPONSES TO INTERVENTIONS

patient's life situations and traumas, by his own inner pathology,


and those that are a reaction to the necessary and correct, but
upsetting, therapeutic interventions that are part of the inevitable
fluctuations in the course of therapy?
Reactions to extra-therapeutic traumas, and those resistances
that follow a specific confrontation or interpretation, as well as a
period of difficult working-through, are all fairly easy to identify.
Trauma-evoked responses are clearly related to and follow upon
external hurts and frustrations, and can be understood in such con-
texts. The symptoms that such experiences evoke respond to correct
interpretations of the conflicts and unconscious fantasies related to
the trauma, and are largely brought under control on that basis.
Momentary regressions which follow a painful or anxiety-provoking
intervention, or a significant piece of therapeutic work, are also
identified by the sequence of events, and they are usually self-
limiting and readily worked through. They respond to analysis of
the repercussions and meanings of the new insights, and the real
and transference meanings of being confronted with something
important, but painful, by the therapist. Treatment itself is seldom
threatened to any significant extent and the disturbance in the
therapeutic alliance is short-lived.
In essence, then, regressions that are not evoked by technical
errors are usually readily related to a trauma outside or inside
therapy, which can be identified relatively easily and worked
through accordingly. Those disturbances that are evoked by single
errors and quickly grasped by the therapist may be acknowledged
by him and then analyzed. On the other hand, those problems that
are due to be repeated, unconscious errors by the therapist are
more serious and generally impossible to resolve without his recon-
ceptualizing the situation and resolving his own inner disturbance.
This leads us to a final question: what was really going on
between this therapist and patient? Why did the patient flee her
therapist and treatment? Was her dream of being attacked a fan-
tasy and a projection of her own impulses onto the therapist, or a
correct, unconscious assessment of the therapist's real, though pos-
sibly unconscious, unresolved problems and fantasies. And, if this
patient did indeed sense her therapist's problems, why did she run
from him instead of discussing them directly with him and trying
Failure to Confirm Interventions 139

to correct the situation? How did her own fantasies and past experi-
ences influence her behavior during this period of difficulty?
And on the therapist's side. we might ask: why did he persist in
his hostile error and not make up the lost time? Why did he fail to
interpret the patient's anger and sexual fantasies. and confront her
with the hints of her intentions to flee? What interfered with his
work here?
These few questions are sufficient to make it clear that we have
reached the point where we must study and understand the relation-
ship between the patient and the therapist if we are to find the
answers to these most crucial problems. I shall, therefore, now turn
to this vital area and explore it thoroughly in the next three chap-
ters. Then, on the basis of that analysis. I shall, in Chapter 22,
return to the subject of technical errors in intervening.
VII

THE PATIENT-

THERAPIST

RELA TIONSHIP
20 The Patient's Reactions to the
Therapist: Fundamental Concepts

INTRODUCTION: SOME DEFINITIONS AND


EXAMPLES
I shall begin this exploration with several clinical vignettes that
reflect various dimensions of the patient's relationship with his
therapist. With their help, we may begin to comprehend the nature
of this relationship from the vantage point of the patient. They will
also confront us with some of the technical problems with which we
often must deal; these will be studied in Chapter 21.
Every writer on the subject of the patient-therapist relationship
inevitably builds upon the genius of Freud, who first studied this
interaction in depth, beginning with his work with hypnosis (Breuer
and Freud, 1895) and then with the evolution of his psychoanalytic
method. Freud learned much through his experience with Dora
(1905) about this dimension of the therapeutic situation, and went
on from there to develop masterful insights into the phenomenon
of transference, its crucial importance in psychoanalysis, and the
techniques with which it should be analyzed (Freud, 1912a and b.
1913, 1914a and b). Modern psychoanalytic contributions to the
subject include, for example. Blum, 1971a and b; Greenacre, 1971;
Greenson, 1967 and 1971; Kanzer and Blum, 1967; Kohut,

143
144 THE PATIENT-THERAPIST RELATIONSHIP

1971; Loewald, 1960 and 1971; Stone, 1961; and Weinshel, 1971-
among many others.
Efforts to define the patient-therapist relationship in psycho-
therapy have been based on these and other significant psycho-
analytic contributions (see Jackel, 1966). I have already alluded to
some of them in Chapter 1; in this chapter, I shall elaborate upon
their clinical implications in some detail.
Let us now return to the clinical material that was being
developed at the end of the previous chapter. The reader may
recall the questions and issues raised there in connection with
the therapy of Miss I.H. To these, one may add the following: Are
this patient's feelings, fantasies and behavior toward her therapist
to be identified as transference reactions related to her past relation-
ships or as currently appropriate and realistic feelings-or are they
both? What evoked these fantasies and responses; where did they
come from? How should they have been handled?
Next, consider this material:

Mrs. I.L. sought therapy because of episodes of severe


anxiety that followed a series of affairs. She candidly
stated in her first session that she still did not know what
to pursue: another lover or treatment. She was unhappy
with her husband, who did not gratify her sexually, and
described herself as a "doer" and a manipulator of others.
She feared becoming promiscuous and knew that she ran
from anything that threatened her. In a review of her life
history, it emerged that she had always been unusually
close to her father and had begun to be troubled when
he had had a serious heart attack.
Psychotherapy was arranged and the ground rules
established, and in the next session, Mrs. I.L. described
her affairs and complained of the therapist's coldness.
In the following hour this continued, as did requests
for medication, which were explored and found to reflect
her need for immediate relief and concrete reassurance;
no drugs were prescribed. She described her problems in
achieving orgasm and the hurts involved in losing her
IQvers.
Patient's Reactions: Fundamental Concepts 145

In the next session, Mrs. I.L. was anxious and reported


having had a series of sexual fantasies about her thera-
pist while coming to the session. She had dreamt that
he and she were on the couch that was in his office
(the patient, however, sat at his desk during her sessions).
The therapist's wife and the patient's mother came in;
the latter suggested that the patient work for the thera-
pist. She went on in the session to speak of hearing things
about the therapist and his wife; of another man who
wanted to seduce her; of an affair with an unsuitable man
in her college days; of a very promiscuous girlfriend; and
of wanting more closeness with her therapist.

I shall break off this vignette here, though I shall add additional
material later. Let us raise more questions: What are the implica-
tions and meanings of this material? Is this transference, fantasy,
or real wishes? What has precipitated the patient's behavior,
dreams and fantasies-what is their context? And what should be
done in dealing with this patient at this point in her treatment?
Before beginning to develop answers to these trying questions,
I shall offer several additional, briefer vignettes:
A young girl with a severe character disorder, Miss
I.M., was faced with her therapist's vacation. While pre-
viously communicative on many levels, she began to fall
silent during her sessions and misbehaved at home, pro-
voking battles with her parents. She suddenly had an
impetuous affair. In her last session before this separa-
tion, she reported a fantasy of stepping in front of a car
and being seriously injured. Associations related to
infuriating times in her childhood when her mother had
disappeared for the day and had been hospitalized when
she was four; Miss I.M. would sit alone and imagine
herself dying, and her mother reacting with considerable
distress and guilt.

What has evoked these responses and how are we to understand


them? What has happened to the ongoing therapeutic relationship,
and why has it changed?
146 THE PATIENT-THERAPIST RELATIONSHIP

In another vein:

Mr. l.N. was a borderline young man who entered


therapy after a panic reaction while working at a resort
hotel. Initially, it was learned that the patient was strong-
ly in conflict about his mother, who had attacked him
both physically and verbally throughout his childhood
and adolescence, often quite irrationally. His father was
a highly critical and somewhat withdrawn man whom the
patient openly despised.
In the early months of his therapy, the patient contra-
dicted and fought with virtually everything that the
therapist said. After much therapeutic work this dimin-
ished, but the patient, while now functioning well in
many areas, restricted himself in other ways; he would
not leave his house overnight nor would he date a girl.
Any attempt on the therapist's part to explore this prob-
lem was met with rationalizations and rage. As long as
this topic was avoided, the patient was content and said
little of dynamic import in his sessions.

How would you characterize this patient's relationship with his


therapist and what is the basis for it? What problems are involved?
How are they to be handled?
I have raised many questions regarding the patient-therapist
relationship and now I want to begin to answer them. We are all
aware of transference; more recently, the real or realistic relation-
ship between the patient and the therapist, and the working or
therapeutic alliance have become centers of interest (Zetzel, 1956;
Greenson, 1965 and 1967; Greenson and Wexler, 1969). A brief
preliminary overview of the subject will be a useful guide to the
detailed exploration of this difficult terrain which will follow.
Psychotherapy begins as a relationship between two persons, a
patient who is seeking help for some kind of emotional or neurotic
suffering. and a therapist who is competent to offer such help. In the
main, the patient and therapist experience this relationship quite
differently, and their roles, gratifications, anxieties and frustrations
also differ considerably. But there are similarities (see Tarachow,
Patient's Reactions: Fundamental Concepts 147

1963), primarily in the basic object needs of both parties, and in the
anxieties and conflicts evoked by these needs, especially because
ultimately it is therapeutically necessary that they be largely frustra-
ted for both.
Beginning with this relationship and interaction, out of which
the therapeutic atmosphere is created, the therapeutic work pro-
ceeds. Guided by the therapist, this eventuates into an exploration of
the patient's neurotic conflicts and their intrapsychic basis in
unconscious fantasies and memories, ego dysfunctions and genetic
factors. The relationship between the two participants may recede
into the background or may come strongly to the fore. It is always
of great importance. whether it proves to be an asset to the explora-
tion of the patient's problem, a means of analyzing these problems
when they become enmeshed in the relationship itself, or a disrup-
tive obstacle to the therapeutic aims.
The patient-therapist dyad entails a complex relationship with
many dimensions, conscious and unconscious. real and fantasied.
The realities are influenced to varying degrees, as we would expect,
by the unconscious fantasies and memories-the inner set-of each
party; the dimension of fantasy is evoked, in turn, more or less. by
aspects of those realities. Discussions of psychotherapy have cen-
tered on the most crucial dimensions of this relationship, selecting
one or another aspect for focus.
Reversing the historical sequence which began with Freud's
studies of transference and only recently concentrated on the real-
istic aspects of the patient-therapist relationship. we can first con-
sider the realities of this interaction (see Greenson, 1965, 1967, and
1971). These begin with the decision of the two parties to work
toward alleviating the patient's symptoms-the main basis for the
therapeutic or working alliance (Zetzel, 1956; and Greenson, 1965).
Other realistic aspects of the patient-therapist interaction include
the sensitivities and insensitivities and the human qualities of each
person, the hurts and gratifications that occur for both. the ground
rules and boundaries that are established, and the therapist's abili-
ties and inadequacies, including his errors in technique (Greenson,
1972). Reactions to these realities are secondarily influenced by the
patient's or therapist's personality structure and past relationships
and experiences.
148 THE PATIENT-THERAPIST RELATIONSHIP

Then, there are the predominantly fantasied aspects of this


relationship. There is, of course, considerable overlap between the
two dimensions, but we attempt to isolate and identify those
reactions in fantasy and behavior, occurring in either party in
which the reality circumstances or precipitate play a lesser role
than intrapsychic fantasies. Those distortions in the perception of
the realities of the treatment situation that are drawn from child-
hood relationships are termed transference and countertransference
reactions. Some writers would include under this heading influences
of current outside relationships and those projections of the patient's
or therapist's own fantasies onto the other person that are not pre-
dominantly genetically based. They would for instance, define
as transference a patient's projection of his own current rage at the
therapist or at someone else onto the therapist, so that the patient
inappropriately believes that the therapist is angry with him. I use
the terms transference and countertransference broadly to include
all such distortions, though I always attempt to define the basis for
the misperception, be it in the present or in the past. Largely, how-
ever, I shall focus here on these reactions as they are determined by
early childhood relationships.
Thus, transference alludes to the archaic, infantile, primary-
process-dominated aspects of the patient's reaction to, and fantasies
about, the therapist. These responses, founded on unconscious
fantasies, unfold out of the patient-therapist interaction; they are
part of the patient's continuous efforts to adapt to this relationship
and to his life conflicts, and to the intrapsychic conflicts they each
evoke.
The patient's side of this relationship is constantly influenced by
communications from the therapist. There is a continuum of reac-
tions, which range from those that are predominantly realistic and in
keeping with the reality stimulus, to those that are predominantly
unrealistic and disproportionate to the reality stimulus that has
evoked them. The former do have a genetic and intrapsychic ele-
ment: the patient's response to any reality is based on his inner set-
fantasies and memories-and the behavior of the therapist may, in
part, be reminiscent of the reactions of an important person in his
childhood. The latter, while dominated by inner fantasies, are
Patient's Reactions: Fundamental Concepts 149

generally not projected onto a blank screen, but are evoked by some
reality stimulus within or outside the therapy, which serves as the
adaptive reality for the response.
Despite this continuum, it is crucial to distinguish as far as pos-
sible these two groups of reactions within the patient, and to
recognize the main source of a given fantasy or behavior that
involves the therapist. The therapist must be able to perceive when
he has been insensitive, traumatizing or in error, and when there is
essentially no basis for the patient's view of him as such. He must,
therefore, have a firm grasp on the realities of the therapeutic
relationship if he is to differentiate the patient's appropriate and
inappropriate reactions to himself.
The therapeutic alliance is an especially important reality of the
treatment situation. Maintaining this conjoint agreement is essential
to the continuation and progress of therapy. For both parties, this
alliance has both realistic and unrealistic elements, which are based
on various amalgams of conscious and unconscious fantasies. It is
both current, and embedded in past relationships and experiences.
Ultimately, in a sound therapeutic alliance, mature desires for help,
and to be helpful, should predominate. Deviations and pathology
in this area may be understood as ruptures in the therapeutic
alliance as the development of antitherapeutic misalliances. They
may eventuate at the conscious or unconscious behest of either
party, though both generally participate.
Other realistic aspects of the patient-therapist relationship lie
in the framework of treatment and the qualities of the mutual
interaction. They are sometimes alluded to as the nontransference
aspects of this dyad, but they may serve as the stimulus for impor-
tant unconscious fantasies and behavior in the patient. They may
also be intensely influenced, at times, by transference fantasies,
which then become a major determinant of the patient's reactions
to these realities.
On the other hand, predominantly transference-based responses,
which may be expressed directly or indirectly and unconsciously,
are influenced by the actualities of the therapeutic relationship.
At times, strong realities within or outside therapy set off trans-
ference reactions; at other times, the patient consciously, or more
150 THE PATIENT-THERAPIST RELATIONSHIP

often unconsciously, seeks to evoke reactions in the therapist or


in others that will justify or foster his own transference fantasies.
The interaction between reality and fantasy is perpetual.
In defining a particular realistic or transference complex within
the patient, it will help to distinguish two interrelated aspects: (1) the
perception of the stimulus; (2) the reaction to it (see Schur, 1953, for
a similar model regarding the role of the ego in anxiety; this is prob-
ably a general model of human behavior). In dealing with (1),
we must distinguish the realities of the stimulus, whether it is a
trauma imposed upon the patient or a situation sought out by him,
and the influence of conscious and especially unconscious fantasies
and memories on his assessment. This evaluation is in itself both
conscious and unconscious; once the patient has integrated it, he
will react in a wide variety of ways, ranging from fantasies about
the therapist and therapy to actual wishes about him; each of these
reactions may also be displaced onto others.
The characteristics attributed to the patient-therapist relation-
ship are present in other twosomes, including the psychoanalytic one,
but the psychotherapeutic dyad does have distinctive attributes.
These are influenced by the personality and psychopathology of
both parties; the setting of therapy, such as the face-to-face mode
and frequency of visits; and the therapist's level of activity. In all,
the intensity of this relationship is less than that in psychoanalysis,
yet greater than in most nonfamily relationships; it is also in many
ways an exquisitely sensitive one. The patient will react strongly to
the communications from the therapist, especially those which reflect
impairments in his therapeutic stance including chronic attitudinal
difficulties and specific technical errors. In addition, seemingly minor
events may precipitate intense transference-based reactions-
fantasied, behavioral and symptomatic. By and large, in psycho-
therapy, such reactions are not especially primitive or divorced
very much from the nature of the reality precipitate, and they tend
to occur episodically rather than be sustained over the entire
therapy. As a result, we do not observe an organized transference
neurosis in psychotherapy; most of the time, we observe isolated
transference reactions, most of which are evoked by such events
as the therapist's vacations or errors in technique.
We are now ready to study the patient's relationship with the
Patient's Reactions: Fundamental Concepts 151

therapist in detail. I shall begin with the predominantly transference


dimension, since a full understanding of this aspect facilitates the
study of the largely nontransference aspects of the relationship.

THE TRANSFERENCE ASPECT OF THE


PATIENT-THERAPIST DYAD
Transference may be defined as those responses to the therapist
that are primarily based on, and displaced from, significant child-
hood figures, especially parents and siblings (see Greenson, 1967).
These reactions are precipitated by some event within or outside
therapy, an adaptive context; they are relatively inappropriate to the
stimulus and to the behavior of the therapist. Their primary source
is intrapsychic, lying in unconscious fantasies and memories, and
the response of the patient is more in keeping with the early relation-
ship than with the present one with the therapist. At times, aspects
of a recent relationship or current fantasies within the patient may
also be displaced onto the therapist.
Although based on fantasies evoked by a particular stimulus,
transference reactions vary both in the form they take-whether
symptoms, fantasies, behavior, affects, or defenses against these
expressions-and in their structural makeup, i.e." the instinctual,
drives, superego and ego functioning reflected in the response. Trans-
ference reactions are always adaptive in nature and however they are
classified, their ultimate adaptive or maladaptive functions must
be kept in mind.
With this as our framework, we can now dissect the different
aspects of transference reactions.

THE DISPLACEMENTS IN TRANSFERENCE

Since transference implies a major displacement and is often


identified on this basis (e.g., as a mother or father transference), I
shall begin with this aspect.

The Transference Object


The usual displacement in transference is from a person ("ob-
152 THE PATIENT-THERAPIST RELATIONSHIP

ject") in the patient's childhood onto the therapist. The displacement


may entail repetitive traumatic experiences or center upon a single
acute trauma. In both instances, the cumulative effects of the past
relationship are usually present. The therapist should identify not
only the object, but also the main period in the patient's life from
which the pertinent transference fantasies are drawn, and the timing
of any acute traumas involved.
Let us look at the clinical material developed at the end of
Chapter 19 and at the beginning of this chapter for evidence about
the nature of transference objects. The therapist must be alert for
reference to past persons when transference reactions prevail; often
a single passing allusion will be the only clue.
In the case of Miss I.H., the therapist's actual insensitivities,
hurts, and errors in technique were at issue, and her responses were
not primarily transference. It would be difficult, for instance, to
establish a mother transference from the situation in the therapy
when the reference to the patient's mother appeared. While other
material from the patient revealed that her mother had been incon-
siderate and punitive throughout the patient's childhood, we cannot
state that the patient displaced and projected her perception of her
mother. as drawn from this earlier period, onto her therapist. We
might better describe the situation as one in which the therapist's
behavior resembled that of the mother; to some extent the patient's
experience with the latter influenced her perception of, and reaction
to, the former. This is generally the situation with real traumas
caused by therapists-they evoke memories of past, comparable
traumas which, in turn, influence the patient's perception and
response. Such situations are generally considered transference
contaminations and gratifications and reality-based reactions (see
pp. 204-05), rather than primary, intrapsychically-evoked transfer-
ence reactions.
However, there is evidence of some primarily transference-
dominated responses in Miss I.H. The dream of the destructive
boat may have been related to fears of being attacked by her mother,
who was mentioned later on by the patient. I would suspect that
this transference is based on very early experiences. since a phallic-
penetrating mother image is implied; however, it is much more
clearly related in the patient's associations to rape fantasies deriving
Patient's Reactions: Fundamental Concepts 153

from childhood and adolescent experiences with her cousin. Other


material, reported earlier in her therapy, indicated that childhood
sexual experiences with both of her brothers (mutually mastur-
batory sexual play) and with her father (exhibitionism on his part
and voyeurism on hers) were also the basis for this dimension of the
patient's transference fantasies toward the therapist. The therapist's
behavior again played some role in evoking these latter fantasies,
but was ~ot as critical as the intrapsychic and genetic factors. Thus,
we may consider these fantasies as primarily transference; the
transference objects are the patient's brothers and father, and the
period sT)anned is most of the patient's infancy and childhood, into
her adolescence.
We see that transference reactions are overdetermined, layered,
and condensed. They have their origins in a multiplicity of early
relationships. The manifestations of transference responses at any
given moment in therapy may be drawn from earlier experiences
with several important persons and from several different life periods.
I have already suggested that we cannot describe the situation
between this patient and her therapist altogether as a displacement.
In such a model of transference, conceived solely as a displacement
from the past and as entirely inappropriate to the present, the
therapist is seen as contributing relatively nothing. The patient's
inner needs, memories and intrapsychic fantasies are considered
the sole generators of the transference fantasy. perception. or
behavior. However, such a hypothetical model is impossible in
reality: even a therapist who is supposedly quite neutral or warm
will evoke an emotional and fantasied response. In any relationship,
there is mutual participation and experiencing, and conscious and
unconscious interaction; these contribute in some way to any pre-
dominantly transference reaction in the patient. Whether or not we
define a reaction as "transference" depends on the degree to which
infantile, primary-process-dominated, intrapsychic fantasies-psy-
chic reality-predominate.
Thus, Miss I.H.'S therapist was actually quite destructive, un-
helpful, angry and, unfortunately, somewhat inept. Her view of him,
while reminiscent of her view of her mother. was quite realistic.
We have here not a projection and displacement, but a repetition
of an earlier trauma: the aggressiveness and lack of understanding
154 THE PATIENT-THERAPIST RELATIONSHIP

of the patient's mother have been freshly recreated by the therapist.


If we keep this fact in mind, we can recognize that not all reactions
to the therapist are primarily transferences, even though there may
be a genetic connection between the patient's perception of the thera-
pist and of an early, significant figure. We will also now understand
that the therapist plays, at times, a significant role in evoking the
reality-based and transference fantasies and reactions of the patient
and that there is a continuum of such influence from minimal-see,
for example, the case of Mrs. I.L.-to maximal as with Miss I.H.
The form of the patient's reaction is in large measures his
responsibility. The precipitate may indeed shape the patient's
response, but so will his own personality and previous ways of deal-
ing with the transference object. Transferences are based upon real
ex.periences with these early objects and the patient's intrapsychic
conflictual and fantasied responses. These earlier resolutions and
adaptations, or maladaptations (symptoms), are important in shap-
ing the patient's current reactions when comparable experiences
occur with others. These may be quite clearly similar to the past
events, or more or less fant~sied as similar by the patient. Here again
there is a continuum, though most of the time in psychotherapy the
present stimulus for the transference reaction is much like the past
realities, especially when the therapist is using poor technique and is
in error. Such resemblances will tend to interfere with the resolu-
tion of the neurotic transference contribution of the patient to the
situation (see Chapter 21).
In dealing with displacements in transferences, it is always
important technically to determine both the transference object
(person) from whom the fantasies are displaced and the age from
which the specific, currently relevant fantasies have been drawn.
To whatever extent possible, the therapist should search for the
specific experiences and fantasies on which the transference is based.
Locating this age range helps the therapist to understand the level of
the patient's functioning at that time, so that he will work in the
idiom that then prevailed.
Turning now to another example, we may observe that the
erotized (sexualized) transference of Mrs. I.L. was based on a series
of specific seductive experiences, and a highly seductive ongoing
relationship, with her father, until she was about ten years of age.
Patient's Reactions: Fundamental Concepts 155

This, then, was a father transference, but it was not precipitated by


the therapist's seductiveness, for which there was no evidence,
although his concerned neutrality and necessary frustration of some
of the patient's needs undoubtedly played a role. Whether any out-
side experience also set off this response is not clear from the
material; none can be detected.
In her transference fantasies and behavior, the roots of Mrs.
I.L.'S transference in her earliest childhood could be readily detected.
In her longings for her therapist, there were fantasies of fusion,
references to ghosts, primitive and terrifying anxieties, and images
of herself as fragmented and made whole by the union with the
therapist. In essence then, the patient was attempting to view her
therapist in terms of her past relationship with her father and to
recreate, in her relationship with the therapist, her earlier erotic ties
with her father, all in the face of his possible loss through illness.
Later sessions revealed seductive experiences with Mrs. I.L.'S male
cousin and brothers; these occurred in her childhood and adoles-
cence and contributed to the overdetermined nature of the transfer-
ence and to more sophisticated versions of it.
As the dream about the therapist suggests, a deeper root for
this transference-another transference object-relates to the
patient's mother. The longings for unlimited closeness with the
therapist had their basis in the narcissistic ways in which Mrs. I.Lo's
mother used her daughter to gratify her own needs and failed to
respond adequately to those of her child. Here, then, the transfer-
ence expressed longings for a closeness and gratification of which
the patient was deprived in her infancy and childhood.
Notice too that this transference complex is a continuation of
Mrs. I.Lo'S general transferences-and the fantasies and behavior
based on them--outside, and prior to, her psychotherapy. Trans-
ferences are, of course, an inherent part of all object relationships.
Psychotherapists and the setting of the psychotherapy evoke trans-
ferences, and special versions of them, because they become impor-
tant objects for the patient. Such transferences are a mixture of
positive, adaptive and constructive fantasies, and pathological, mal-
adaptive and disruptive ones. It is the latter that we generally find
necessary to analyze and resolve.
Another session from the therapy with Mrs. I.L. will demonstrate
156 THE PATIENT-THERAPIST RELATIONSHIP

how transferences appear and are assessed by the therapist for their
infantile object and period:
In a session early in her treatment, this patient described an
unsatisfactory sexual experience with her husband on the previous
night. She then recalled sleeping in her parents' bedroom until she
was seven, and nightmares from her infancy in which her father and
a ghost were chasing her. She must have heard her parents having
intercourse. She could recall her father looking at her in her crib,
and admiring and adoring her; he took her with him everywhere.
She would sit on his lap until he stopped doing it when she was ten.
She began masturbating at that age, with fantasies about Superman
and Lois Lane. Her friend was in love with her therapist. Mrs. I.L.
had seen the therapist's car and felt aroused. She enjoys fellatio and
having her own breasts sucked on; she had been having day dreams
of this kind about the therapist. She felt anxious.
Here we see a sequence in which the patient's early and then
repetitive exposure to her father sexually led to overstimulation and
anxieties, and to masturbatory fantasies with a powerful though
unreal object. The sequence leads to the therapist and wishes to
take his penis into her and to be sucked on in return. In the absence
of any seductiveness by the therapist, we may consider this to be a
father transference based on infantile experiences with the patient's
father and the fantasies that they had evoked, prompted here by a
frustrating sexual experience with her husband. In assessing the
displacements in transferences, the therapist should maintain the
adaptive framework and not consider the infantile object in isola-
tion.
Miss I.M., who was referred to at the start of this chapter,
withdrew in her sessions and acted out sexually in anticipation of
her therapist's vacation. Her associations, interestingly enough, indi-
cated that the underlying unconscious transference fantasies related
to revenge on her mother through self-harm, feelings deriving from
childhood experiences of feeling abandoned by her mother's absence
and from a specific trauma when her mother was hospitalized. The
early age at which this occurred and the intensity of the patient's
feelings of desertion, which suggest a repetitive problem (this was
borne out later: Miss I.M.'S mother had had a lengthy postpartum
depression after her daughter's birth) are factors in the patient's
Patient's Reactions: Fundamental Concepts 157

propensity to act out concrete reparative measures when faced with


a separation.
Here again, the transference reaction has not occurred in vacuo,
but has clearly been set off by the therapist's pending vacation. The
transference quality of the patient's reaction is revealed in her
irrational fantasies, her inappropriate rage, and the associations to
her mother. The basic fantasies involved are unconscious-repressed
-another common characteristic of many transference reactions.
In essence then, a real piece of behavior by the therapist, which in
this instance was fully expected in the course of therapy and did
not in any way reflect some difficulty or error in technique, evoked a
regressive reaction-behavioral and fantasied-in the patient, pre-
dominantly based on a mother transference. One last point: hints
in the material of a simultaneous father transference (she had fought
with him at the time) were borne out much later during other periods
of anticipated separations from the therapist.
We see again that transference reactions are overdetermined and
reflect a hierarchy of fantasies and experiences with several early
objects. As a rule, one set of fantasies-one type of transference-
predominates. The therapist must explore such transference reac-
tions one layer at a time, when necessary.
The transference of Mr. I.N. was manifested in a fixed, irrational
way-a dimension I shall soon discuss. Apparently, these reactions
arose as a response to the therapist's well-intended interventions and
to qualities of the therapeutic atmosphere itself. It may be that this
patient was terrified of the closeness and understanding implied. Or
it is possible that he misperceived the positive dimensions of the
therapist's stance, distorting it into threatening hostilities. The
displacement figure was initially his mother, and the material from
the patient indicated life-long, repetitive traumas. Later, similar,
though less pervasive, traumas from his father were associated with
the patient's rage at, and mistrust of, the therapist.
These pervasive transferences demonstrate another way in
which transferences are expressed by the patient, that is, through
his general relationship to the therapist. The therapist learns a great
deal from the way the patient experiences and relates to him in their
interaction, as long as he is aware of how he is relating to the patient
himself.
158 THE PATIENT-THERAPIST RELATIONSHIP

During the later phase of Mr. I.N:S treatment, he maintained a


comfortable attachment to his therapist, though it apparently was
not based on a therapeutic alliance designed to help him change his
level of functioning, but instead, reflected a wish to create a mis-
alliance to perpetuate the status quo. Associations revealed no
period in which he had maintained such a comfortable tie to his
mother or to his father, siblings or any substitute parent. We must,
therefore, suspect that the transference was being used to gratify his
longings for an idealized mother figure. Essentially, then, this trans-
ference was based on a fantasied and idealized relationship that was
a reaction against Mr. I.N.'S real relationship with his parents. We
can see now how complex the roots of transference reactions and
fantasies may be. It is also evident that the transference here is being
used to achieve direct gratification and to undermine the treatment;
that is, it is serving as a powerful resistance and means of inappro-
priate gratification-aspects that we shall soon explore.
To summarize the main points so far:

1. One of the first tasks in understanding transference is that of


tracing out its intrapsychic roots and determining the person (or
persons, since transference is overdetermined) to whom the patient
related in the past and on whom the patient's needs, fantasies, and
behavior toward the therapist are primarily based. Such a person is
identified as the transference object; we ascertain his or her identity
by listening to the associations from the patient when reactions to
the therapist prevail. As a rule, this earlier-and occasionally con-
temporary-person is referred to in these associations. In addition,
the therapist may be able to recognize parallels in the fantasies and
behavior toward himself and to this earlier figure.
2. The therapist also attempts to identify the period from the
patient's life during which the present therapist-related fantasies and
responses prevailed in the relationship with the early figure. This
provides clues to the patient's relevant level of functioning, fan-
tasizing and reacting; these will affect his current response to the
therapist. If we are dealing with very early experiences, we expect
a more primitive reaction and group of fantasies than with trans-
ferences drawn from later ages, such as from latency and adoles-
cence. Transference responses derived from very early periods of
Patient's Reactions: Fundamental Concepts 159

the patient's life have prominent pre-oedipal and nonverbal quali-


ties, and will tend to be more irrational and inner-based, and less
related to the current reality of the therapeutic situation. Transfer-
ences drawn from later periods will be more verbal, structured,
oedipally and post-oedipally tinged, and based more on a mixture of
primary and secondary process thinking. We may expect certain clus-
ters of repressed fantasies to predominate in the different periods of
the patient's life; these color his specific transference fantasies and
reactions, and his general attitude toward therapy and the therapist.
In psychotherapy, the goal is to identify as many of these dimen-
sions of the transference as possible, recognizing that often only
partial information about the specific persons, events, and time
period will become available. The identification of these ties to the
patient's past is then used to understand the patient's current reac-
tions to the therapist and the intrapsychic conflicts and adaptations
reflected in them.
3. Many transference feelings, fantasies and behaviors are
largely based on crucial, wholly or partly repressed, genetic experi-
ences with a particular person, and on the related intrapsychic con-
flicts and unconscious fantasies. Other transferences are based
primarily on cumulative traumatic aspects of infantile and child-
hood relationships. In all, transferences are repetitions of the past
as it really happened, or was imagined or idealized.
4. We were dissatisfied with any notion of transference defined
solely as a projection from the patient onto the therapist de novo
and without a precipitate (day residue) in the patient's current life
or in the reality of the therapist's behavior and the therapeutic
situation. Every transference reaction, then, has a grain of truth to
it. We saw, too, that transference is only one aspect of the patient's
relationship to the therapist, though I have not yet defined the other
aspects in any detail.

What is Transferred: The Content of Transference Fantasies


Having identified the person, the relationship, and the life-period
on which transference fantasies and responses are based, let us now
briefly define their content. This content, while ultimately uncon-
scious, finds expression both in conscious fantasies-day dreams-
and in other derivatives and displacements.
160 THE PATIENT-THERAPIST RELATIONSHIP

If we turn now to the clinical material under discussion, we see


that reflections of transference fantasies occur in a multiplicity of
forms. Miss I.H., for example, was consciously in a rage at her
therapist, and unconsciously wanted to murder him. She had uncon-
scious rape fantasies that combined sexuallongings for the therapist
with ideas of being damaged or punished by him. She also
envisioned being attacked, a response which is in part a projection
of her own inner needs, and in part an accurate, though distorted,
appraisal.
We see that transference fantasies and behavior may be based
on all sorts of instinctual drives and related fantasies, with the
attendant superego and ego aspects, such as guilt and the recollec-
tions of real and fantasied threats and dangers. All aspects of the
past relationship, the way the patient handled it, the way the other
person really behaved, and the various needs and fantasies experi-
enced with this person, are involved in the transference. Transfer-
ence has often been called a form of remembering and repeating;
any aspect of the early relationship and the patient's reactions to it
can be recreated in the transference.
Do the other vignettes bear this out? Mrs. I.L.'S predominant
transference related to intense sexual longings for intimacy with
her therapist, based on a erotized father transference that stemmed
from early sexual experiences with her father: his actual seductive
behavior, her fantasies of seduction, and the other conscious and
unconscious fantasies this evoked. Deeper longings for union with
her frustrating mother were also hinted at, and later material con-
firmed this. Indications of considerable guilt and difficulties in
handling these fantasies and impulses-ego dysfunctions and failures
in defenses-are also a part of the transference picture. The defen-
sive aspects of this transference complex are notable: they include
defenses against destructive wishes related to the patient's parents
and the therapist, and the use of denial in creating these fantasies.
In the session with Mrs. I.L. described on p. 156, the main
transference fantasies were of being physically close to the therapist,
incorporating his powerful penis, and offering her breasts for him
to nurse at. She responded with anxiety to these fantasies, and gave
little evidence of adequate defenses or superego reaction.
Miss I.M. was transferring onto her therapist many aspects of
Patient's Reactions: Fundamental Concepts 161

her experiences with her mother, and their intrapsychic repercus-


sions. These ranged from her sense of loss and depression, and the
use of withdrawal and denial as defenses against, and responses to,
being hurt by her mother and the therapist, to the self-harmful
fantasies that typified the way in which Miss I.M. had handled her
rage against her mother.
Here, too, we see layering of all kinds, notably of various con-
flicts, responses, and transference fantasies, with the mother trans-
ference covering an underlying erotized transference based on her
relationship to her father.
Mr. I.N. perceived his therapist as attacking, much as his mother
really was. Of course, he also attempted unconsciously to evoke
anger in the therapist by frustrating and attacking him, and further,
used his fantasies of being attacked, in part, to deny his own
destructiveness and project it into the therapist. In this transference,
he was remembering and recreating in his own mind a multitude of
traumatic experiences with his mother, which evoked hatred of her,
self-condemnation and self-hatred, and a myriad of other fantasies.
The emphasis on the destructive aspects of the relationship with
both the patient's mother and the therapist served as a defense
against erotic fantasies toward each of them, and against the specific
recollection of sexual experiences with his mother.
Transferences, then, are layered in still another way. Not only
do different transference objects and different periods of the patient's
relationship with each transference object appear, but one cluster of
transference fantasies generally covers another set of transference
fantasies. There are a multitude of potential transference fantasy
systems; they form a hierarchy with one serving to cover and repress
another. In therapy, we generally explore one set at a time, usually
those that are evoked by some present context and activated for the
moment, analyzing whatever dimensions are available for explora-
tion.
The predominant transference in the second phase of Mr. I.N.'S
treatment was that of a gratifying mother transference in which
latent reactive fantasies of being cared for and protected by a good
and magical mother predominated. Since it interfered with the
treatment, one can suspect underlying destructive fantasies and
deeper meanings to this transference, but I shall not develop the
162 THE PATIENT-THERAPIST RELATIONSHIP

confirmatory material here. The trend of the patient's associations


at this time was primitive, irrational, and filled with magical quali-
ties, suggesting very early roots to this transference.
Other transference fantasies will be evident in the many
vignettes presented in this and other chapters (see the Index of
Clinical Material). Let us summarize the main points regarding
transference perceptions and fantasies:

1. The conscious and unconscious fantasies, recollections, past


realistic perceptions and misinterpretations, superego elements, and
ego responses, reflected in transference fantasies run the gamut of
possibilities.
2. In understanding transference responses, the therapist must
identify the specific memories, experiences, and inner fantasies that
they contain. He looks, too, for the ways in which the transference
reflects the specific intrapsychic conflicts and subsequent adapta-
tions or maladaptations that the patient made to them in the past
and in the present. He then defines their effect on the present trans-
ference response.
3. The therapist is interested not only in the conscious and
unconscious content of the transference reaction, but also in the way
the patient expresses it, handles it, and adapts to what is stirring
(see p. ).
4. Transferences reflect much about the nature of the patient's
predominant instinctual drives, superego responses, and ego func-
tioning on all levels, including object relating, defending, and synthe-
sizing. Transference reactions, then, are not merely a matter of
instinctual-drive expressions, but reflect ego functioning both in the
past and in the present. In all, they are based on unconscious fan-
tasies and memories that reflect the patient's past and its interaction
with the present. and the patient's total personality, conflicts and
adaptive resources.
5. In psychotherapy, we generally find that only fragments of
a total transference fantasy system are available at any given
moment. Often, transference reactions are fleeting and tend not to
build in an extended way unless repetitively stimulated by some
traumatic event within treatment or outside.
Patient's Reactions: Fundamental Concepts 163

Now, let us move on to some of the unexplored issues that our


discussion has raised to this point. The role of the therapist and of
other current realities in evoking or prompting transference
responses is probably the most misunderstood of these.

THE ROLE OF THE THERAPIST AND OTHER REALITIES


If we review the clinical material, we can reach some immediate
conclusions about this problem. We cannot help but acknowledge
that Miss I.H.'S transference reactions to her therapist were prompted
by the latter's behavior. Is there also a day residue for each of the
transference responses in the other cases that I am dealing with?
Clearly, yes. As we saw in Chapter 9, the reality precipitates may
at first not be immediately available in the material from the patient,
but we can readily discover such day residues in each vignette,
though their roles in determining the nature of the patient's
reactions vary.
The therapist's erroneous and actually provocative behavior
played a major role in evoking Miss I.H.'S transference fantasies and
behavior. With Mrs. I.L., the therapist did little in this regard,
though the setting of treatment and facts about him as a person-
a young therapist, his interest in the patient, and his couch-did
contribute to or affect the form of her transference fantasies. Notice
too that Mrs. I.L. had been especially stimulated by learning certain
facts about her therapist. As it turned out, she had actually uncon-
sciously sought out this information. Patients themselves may
indeed develop specific reality precipitates as part of their ongoing
adaptive efforts to resolve real and inner conflicts.
For Miss I.M., the therapist's vacation-a piece of real, but not
antitherapeutic, behavior on his part-prompted the transference
response. Lastly, Mr. I.N.'S transferences were evoked by the thera-
pist's efforts to help him and his role as an expert and healer, roles
very natural and appropriate for a therapist. No acute episode
prompted most of the responses, which recurred almost regardless of
the moment in therapy. Here, then, the day residue played a minimal
role.
In all instances there were current external reality precipitates
164 THE PATIENT-THERAPIST RELATIONSHIP

of the transferences as well. Miss I.H. 's transference fantasies had


been stimulated by het vaginal examination, the seductive byplay
with her cousin, and real battles with her mother. Mrs. I.L. was
sexually frustrated with her husband, and Miss I.M. fought with her
mother and arranged to be seduced. Mr. I.N. also constantly battled
with his mother during this period of his treatment, suggesting too
that his transference reaction was displaced from his current rela-
tionship with her.
All these current outside experiences also played a role in the
occurrence and timing of the transference phenomena in therapy.
The reader can further review the many other relevant vignettes
presented throughout the book (see The Index of Clinical Material).
The principles that evolve from these observations will be clarified
in the remaining parts of this chapter. They are:

1. Transference reactions are prompted by current realities


both outside and within therapy. These are the day residues and
adaptive contexts for transferences.
2. The external realities that evoke significant transference fan-
tasies and reactions usually take the form of acute frustrations and
traumas with important persons.
(a) These transferences occur as part of the patient's attempt at
adaptation to such new traumatic or conflict-evoking experiences.
(b) In proper psychotherapy, my experience indicates that such
outside events are important and at times crucial triggers for trans-
ferences, though in poor psychotherapy they are most often over-
shadowed by the therapist's errors and problems as precipitates of
transferences.
3. Real experiences with the therapist are among the most
important precipitates of transference fantasies and responses.
Among these precipitates, it is important both theoretically and
technically to distinguish several quite different types of day
residues:
(a) Transference responses evoked primarily by the therapeutic
setting or the valid therapeutic stance of the therapist.
(b) Transference responses evoked largely by appropriate,
ongoing interventions by the therapist. Most interpretations and
confrontations evoke some transference reaction; though these often
Patient's Reactions: Fundamental Concepts 165

do not disturb the therapy and need not be brought into focus,
they may at times form the core of important transference res is-
tances.
(c) Transference responses evoked by behavior unrelated to
interventions, including billing the patient, separations, termina-
tion of the treatment, and unexpected interruptions during sessions
(see Weiss, 1973). This category extends into unexpected outside
meetings with the therapist and information learned about his per-
sonallife (facts that can distort or shape the transference aspect of
the patient's reactions to the therapist).
These are the three main kinds of reality precipitates of transfer-
ences evoked by the therapist in which his countertransferences or
errors play no significant role.
(d) Transference responses, evoked most often by deviations,
interventions and failures to intervene, that are largely a reflection of
errors in technique and countertransference problems in the therapist.
These usually have the manifest or latent qualities of a real injury
to, aggression against, or provocation or seduction, of the patient.
This category extends, of course, from inadvertent but uncon-
sciously motivated touching of the patient to actual seductions or
direct attacks on him. It may include such behavior as the therapist's
insistence that the patient discuss his feelings about the therapist;
when this is ill-timed and inappropriate, it may actually be a power-
ful aggression against, and seduction of, the patient (see Chapter 22).
Technically, it is crucial to distinguish those therapist-evoked
transference reactions that are based on his erroneous behavior from
those where the therapist's behavior has been correct. Often this is
difficult to assess, requiring considerable insight and self-knowledge
on the part of the therapist.
The extent to which the therapist has provoked the patient's
response, and to which that response is appropriate (realistic) or
inappropriate (based more upon the past and therefore, transfer-
ence), both determine whether a particular response is defined as
realistic or transference. As alreadly pointed out, transferences have
real precipitates and, in part a real basis; and realistic, appropriate
reactions to the therapist have roots in the past. The distinction is,
however, technically useful, since the therapist must deal with the
patient's responses honestly and realistically. If reactions to the
166 THE PATIENT-THERAPIST RELATIONSHIP

therapist are not in keeping with reality, this must be established:


and if they are attuned to reality-consciously or unconsciously-
this must not be denied. The technique of handling responses to
the therapist, including transferences, will depend, among other
factors, on the reality that has evoked it, especially the therapist's
behavior.
4. Empirically, patients are especially sensitive to their thera-
pist's behavior and extraordinarily sensitive to his errors. In the
many situations that I have observed where correct behavior by the
therapist (e.g., an absence due to illness or a holiday) is com-
pounded by an error in technique (e.g., having a secretary call the
patient or forgetting to tell the patient about the pending holiday),
the patient has reacted most strongly to the error (see Chapter 22).
5. While the day residues for transference reactions provide the
context, and are vital for understanding these responses (see Chapter
9), and play some role in the specific reaction of the patient. The
nature of the transference fantasies and reactions is primarily deter-
mined by the patient's past experiences and their intrapsychic conse-
quences. Transferences are basically primary-process-dominated
and irrational, related more strongly to the past than the present.

THE FORMS OF TRANSFERENCE REACTIONS


As we have seen, the core of a transference reaction is an uncon-
scious fantasy. At issue here, then, is how the patient expresses and
adapts to these fantasies and the intrapsychic conflicts they evoke.
Transference manifestations are more or less disguised derivatives
of the underlying unconscious fantasies. They may take the form of
conscious fantasies, real expectations and even delusions, symptoms,
and behavior of all kinds-many factors are at work, including the
precipitate, the age-period being tapped, the nature of the instinc-
tual drives, and especially the ego functioning of the patient.

Transference as Conscious Fantasies


Transference fantasies may be expressed through direct fan-
tasies about the therapist and therapy, but also in displaced forms as
fantasies about others. These fantasies, in turn, influence the
pafient's behavior and reactions with the therapist and elsewhere.
Patient's Reactions: Fundamental Concepts 167

They are without behavioral intent or may extend into such inten-
tions. They include relatively appropriate fantasies with minimal
distortion, those that are more primary-process-dominated, and
those that are delusional (see pp. 174-76).
The least distorted and most positively-toned transference fan-
tasies are often embedded in the therapeutic alliance and form part
of the silent background of a progressing treatment. They must be
distinguished from the patient's mature, nontransferential sense of
trust and respect for the therapist, and his constructive, not
idealized, expectations of treatment. These minimal distortions are
often not explored in psychotherapy unless they become the source
of an important resistance or a reflection of a central intrapsychic
conflict (these are among the main general indications for interven-
tions regarding transference; see Chapter 21). Minimally distorted
idealizations of the therapist, some overinvestment in his role as a
safeguard and protector, and exaggerated and benevolent mother-
ing ties to him are among such transference fantasies. Often, they
must be worked through during the termination phase of psycho-
therapy, as the following vignette illustrates:

Miss I.P. was a young woman who had been in therapy


for almost two years for a moderate character disorder,
tendencies to act out and asthma. Her relationship with
her therapist had been a generally positive one through-
out. When at her most reasonable behest, he agreed to
work toward termination with her. the patient became
angry with her fiance and nearly broke her engagement;
she also began to wheeze. In the session in which she
described these problems, she went on to report that she
had dreamt of a dog biting her and of being disliked by a
rock group, the Grateful Dead. In association, she said
she felt that the therapist no longer liked her and that he
was terminating her therapy to punish her for having
missed a recent hour. She recalled how furious her father
was when she had disappointed him in the past.
In another session soon after that one, she reported
having dreamt that her father, fiance and therapist were
her enemies. As she went on to explore her rage over
168 THE PATIENT-THERAPIST RELATIONSHIP

termination, she expressed thoughts of becoming a doc-


tor. She realized eventually that this was unrealistic and
spoke of simply wishing to remain with the therapist. She
began to help her friends with their problems and effected
a major reconciliation with her mother, with whom she
had often argued.
In another hour, she spoke of the ways in which
American soldiers were exposed to death in Vietnam and
her own guilt over being alive. Associations led to her
sense of safety and protection while in therapy, and her
deep sense of loss in terminating it. She dreamt of a
teacher, a man of whom she was very fond. They were
close, but it was not sexual. He was a photographer; the
patient thought of photographing the therapist's office
for her collection. She spontaneously recognized her
wishes to possess the therapist who would, in her fan-
tasies, protect her from all harm, adding that she felt
that her recent wheezing also had something to do with
wanting him inside of her.

In this vignette, we see a variety of transference manifestations,


including conscious fantasies, acting out (against her boyfriend),
and symptoms (the asthma). We may note that the relatively
benign transference fantasies of the therapist as the protective
father and mother figure had not been expressed in conflict-related
derivatives until termination came up. For example, wishes for
union with the therapist, which were about to be frustrated on every
level, were now expressed and worked through; it was apparent in
retrospect that these fantasies had been silently present throughout
the therapy and had contributed to the working alliance. As they
were frustrated and then worked through, the unconscious incor-
porative fantasies on which this transference was based emerged
more and more clearly.
Lastly, note how the transference fantasies described in this
vignette were maintained as such; the patient neither believed that
her therapist was really filled with hatred for her nor did she
actually attempt to seduce or possess him. These are the pre-
dominant qualities of transferences expressed as neurotic fantasies.
Patient's Reactions: Fundamental Concepts 169

Transferences confined to fantasies may be quite distorted and


primary-process-dominated. In the vignette just presented, the fan-
tasies of the therapist as a protector from death and of incorporat-
ing him through her respiratory tract or by photographing his office
reflected this. Other material demonstrated that the fantasies were
based on early experiences and disturbances in the patient's relation-
ship with her mother, who was very depressed and aloof in Miss
I.P.'s infancy, and they reflected primitive unconscious fantasies
developed during that period in her life. The temporary asthmatic
symptoms also suggest regression and failure to adapt adequately
to the transference-evoked intrapsychic conflicts, but the patient's
ability to eventually control these somatic expressions and restrict
the expression of her transference conflicts to the fantasy level
showed that she could adapt without undue disturbance.
Transference fantasies that indicate mistrust of the therapist, or
those that attribute seductive and hostile designs to him, may be
confined to the fantasy level as with Miss I.P., though often they lead
to acting out. Such fantasies deserve as full exploration and resolu-
tion as is possible in psychotherapy, especially when they interfere
with the therapeutic alliance and the unfolding of treatment (see
Chapter 21).
As a further illustration, we can take Miss I.H.'S dream of the
baby and the boat, its context, and her associations to it. These
reflected a variety of unconscious fantasies: being raped; being
destroyed bodily; the wish for a baby from the therapist; and the
wish to flee both him and the treatment-all transference fantasies
reflecting the patient's inner conflicts and anxieties, which had been
triggered largely by the therapist's insensitivities and provocations.
Other transference manifestations largely confined to fantasies
include Mrs. I.L.'S erotic fantasies and dream about her therapist,
although she was repeatedly struggling with her impulses to act out
these fantasies with the therapist or someone else. In the session
separately described with this patient, her conscious fantasies were
of mutual sucking between herself and the therapist. Miss I.M.'S
fantasy of being hit by a car is another example, as are Miss I.P.'s
fantasies and dreams that the therapist hated her, and that he was
an enemy. At appropriate moments in the therapy, these merit
exploration, analysis and resolution (see Chapter 21).
170 THE PATIENT-THERAPIST RELATIONSHIP

Acting Out of Transference Fantasies


Transference fantasies are an important source of acting out
that is directed both against the therapist and therapy, and against
others; in fact, when major acting out occurs in psychotherapy,
underlying transference fantasies should always be silently investi-
gated by the therapist as a likely contributor, especially if the
acting out is directed against therapy. Both erotic and hostile trans-
ference fantasies may be acted out; their translation into behavior
suggests that the patient has difficulties with his controls and
defenses--ego impairments. Acting out is far more common with
certain character disorders, with borderline and narcissistic patients,
than in those with neurotic difficulties. It is most important
for the therapist to recognize the implications of the fact that
a transference fantasy has been lived out. This alerts him to ego
dysfunctions and, technically, leads him to deal with the patient's
poor controls. Too often, therapists focus solely on the unconscious
and conscious fantasy content of transference manifestations, and
fail to distinguish the different ways that patients deal with these
fantasies and especially their implications for the patient's ego
functioning.
Acting out of transference fantasies may be a response to pain-
ful but necessary experiences with others or with the therapist. A
vacation at an inappropriate moment or a painful period of explora-
tion may evoke intense transference reactions. These are generally
better controlled, however, than responses to the therapist's human
failings and errors in technique. At such moments, the patient is less
prepared for the disturbing intrapsychic conflicts and fantasies
evoked, and his defenses are less adequate. Acting out of the trans-
ference elements in the patient's reaction at such times is far more
frequent than in those situations where errors in technique have not
triggered the reaction. Further, since such errors are often a form
of acting out by the therapist himself, and he is thereby less available
as an ally and a secure figure, the patient is more likely to act out.
Here again, we see that it is vital to identify the stimulus for the
transference fantasies that are being acted out; the correct technique
for dealing with the behavior will vary in critical ways according to
the source (see Chapters 21 and 22).
Patient's Reactions: Fundamental Concepts 171

While all acting out is communicative from the patient and may,
at times, be an experimental effort toward new adaptations, careful
investigation of the transference fantasies is usually indicated, since
such behavior can often be severely disruptive of the patient's life
and treatment.
The clinical material contains some salient examples. Miss I.H.
acted out her transference rage at the therapist through her destruc-
tive behavior with her mother and, in part, through her direct anger
culminating in her abrupt termination of therapy. Her seductive
transfer-ence fantasies were acted out with her cousin. By and large.
this behavior, based primarily on unconscious transference fantasies,
was disruptive to her life-adaptation and destroyed her therapy.
Miss I.M. acted out her sexualized longings for closeness and
union with her therapist by having an impetuous affair when he
was going on vacation. She also acted out her transference rage by
not talking to her therapist for long periods in her sessions, and
thereby disrupting the therapeutic alliance (a form of acting in).
Mr. I.N. acted out transference rage at his therapist in his dealings
with his parents and friends; the transference roots were established
through the sequence of events and associations (see pp. ] 86-94). He
also acted in by angrily disrupting therapy early in his treatment
and by failing to produce meaningful material in the later stages:
the therapeutic alliance was impaired.
In all, then, acting out of transference fantasies can create major
hazards for the patient and his treatment.

Transference as Belief and Intention


These are two very important. often overlooked, interrelated
forms of expressing transference fantasies. At times the patient has
intentions toward the therapist that he experiences as quite real-
actual wishes and desires regarding him; and secondly, he may have
unfounded beliefs about the therapist that are also quite real to
him, and that range from distortions to delusions. If the real quality
for the patient of these fantasies and impulses is intense and altered
only intermittently or not at an, we are dealing with a psychotic
transference; if they are more readily surrendered, they constitute
a "borderline transference." A number of dysfunctions contribute
to these types of transference expressions, including overintense
172 THE PATIENT-THERAPIST RELATIONSHIP

instinctual drives that are poorly controlled and not well modulated
by the ego, an archaic superego, and other impairments in ego
functioning, especially as regards object relationships, reality test-
ing and experiencing, perceiving, and integrating.
In addition to these types of transference expressions, there are
those narcissistic patients who actually expect adulation and admira-
tion of their own grandiose self-image, or wish to idealize and idolize
their therapists.
I shall discuss each of these manifestations briefly.
Transference as realistic wishes and intentions. Failure to
recognize the role of the ego in dealing with transference-based
fantasies and impulses has led many therapists to believe that all
transference manifestations are fantasied, and lack any component
of active intention toward direct gratification, especially with them-
selves. At times, this belief also reflects the therapist's denial of all of
the reality dimensions of his relationship with the patient. Such
therapists are often the unprepared recipients of sudden aggressive
or seductive acts by their patients, events which may occur largely
because they have not recognized the patient's poor controls, his
failing perspective on the therapeutic relationship, and his intensi-
fying transference wishes.
Patients experience their impulses toward their therapists in a
whole range of ways, from the denied and repressed fantasies
already discussed to real desires to act-a different level of ego
functioning altogether and a difficult technical problem (see Chap-
ter 21).
Mrs. I.L. is a case in point here: she not only fantasied seducing
her therapist, but also seriously considered having an affair with
him and for a while, thought it could indeed occur if she so desired.
She rationalized these expectations by alluding to her experiences
with men, including certain professionals, and with her father in
her childhood. There was little reason for her not to believe such
an outcome was possible, she stated, referring also to reading about
therapists who actually have intercourse with their patients. Of
course, another crucial factor was her own impaired ego function-
ing, which interfered with her capacity to distinguish the therapist,
through her experiences in treatment with him, from these other men.
The failure to differentiate between individuals is an important facet
Patient's Reactions: Fundamental Concepts 173

in technical work with such problems (see Chapter 21). The degree
to which Mrs. I.L. remained immersed in her impulses and had
difficulty gaining distance from them was another factor in her
transference distortions. She had difficulty scrutinizing her needs
and checking out the possibilities for gratification in external reality;
her perception of the latter was excessively influenced by her
internal fantasies and impulses. Thus, a multitude of ego dysfunc-
tions is reflected in her intentions.
This situation was, in all, the expression of an erotized borderline
father transference with strong narcissistic elements. The patient's
intrapsychic fantasies and conflicts were precipitated by her sexual
disappointment with her husband, her frustration regarding the
therapist's relative distance, the stimulation of learning about his
personal life from her own friends, and her attempted seduction by
another man. As far as we can see, the therapist had in no way be-
haved seductively or nontherapeutically. Later material, incidentally,
revealed that disturbing memories about her past life, and anxiety-
provoking fantasies prompted by her negative experiences with her
husband and other men, were beginning to emerge at the time when
her desires for her therapist became most intense. The seductive
designs were, therefore, in part an effort to deflect the focus of the
treatment from these recollections and fantasies, and their humili-
ating implications. Thus, the transference was both a reflection of
psychopathology and unconscious fantasies, and a strong resistance
to the therapy.
These transference impulses, experienced as quite real by the
patient, were controlled to the extent that no actual seduction was
attempted; and late in the session in which they were reported and
analyzed, Mrs. I.L. was able to feel their inappropriateness and, in
the next session, even the ridiculous nature of her wishes. These
qualities-the temporary loss of perspective, but without total belief
in the distortions or acting out, and the subsequent establishing of
distance and control-are among the hallmarks of borderline trans-
ferences.
The technique of dealing with transference impulses of this type
is distinctly different from that used with neurotic transference fan-
tasies that are not acted out as destructively nor translated into real
intentions. For both, exploration in depth is indicated, although in
174 THE PATIENT-THERAPIST RELATIONSHIP

psychotherapy, the more disturbed forms of transference may also


call for assistance in reality testing, differentiating the therapist from
other persons, and interpretation upward (see Chapter 21).
Transference Distortions. Often, the borderline or psychotic
patient misinterprets the therapist's behavior (silences or interven-
tions), basing such distortions, which to some degree he believes, on
past experiences with others in his family (usually parents). The
patient's misconceptions must, however, be distinguished from cor-
rect assessments of the therapist's behavior and fantasies. This is
another reason why the therapist must be as conscious as possible of
his feelings, fantasies and behavior; otherwise, he cannot accurately
assess the pathology in the patient's reaction. The patient, when
distorting, misinterprets to some extent the therapist's feelings
toward him, either because his behavior seems to correspond to that
of a past figure, or because, for some intense intrapsychic reason,
he has come to represent and be poorly distinguished from that
figure. Often, the patient draws the illogical conclusion that the
therapist's underlying motives and fantasies are the same as they
actually were, or were imagined to be, in that other person-the
transference object. This transference distortion can be distin-
guished from other distortions in the image of the therapist, such as
those resulting from projections onto him of the patient's own fan-
tasies and impulses, which may in themselves range from neurotic
fantasies to psychotic distortions.
Once again, these transference distortions reflect a number of
impairments in ego functioning. Sometimes, the actual behavior of
the therapist differs from that of the earlier figure, but the patient
misperceives the two as quite similar or identical. Or, the therapist
may in some trivial way behave like a past person and is seen then
as being entirely like the earlier figure (a failure in distinguishing
the part from the whole). Thus, one therapist's brief silences with
his patient were seen as brutally sadistic because her father had
often used the "silent treatment" to punish her. Her resulting mis-
trust of the therapist and belief in his sadism interfered with the
therapeutic alliance and the entire treatment. We see here several
kinds of ego impairments: a failure to distinguish past from present
persons, or to consider other aspects of the therapist's behavior that
contradict the sadistic image, occurring as a result of failures of
Patient's Reactions: Fundamental Concepts 175

perception and because of internal denials, and the splitting off of


contradictory perceptions; and, finally, the persistence in internal
beliefs despite real contradictions.
Mr. LN.'S perception of his therapist early in his treatment was a
transference resistance of borderline and near-psychotic proportions.
His belief that the therapist, in his silences and in his interventions,
was attempting to control, attack, abuse, seduce, and provoke him
was near-delusiunal. These beliefs, based on a mother transference,
led him, in many sessions, to lose control and to rage against the
therapist. He would find exception with everything said to him and
grossly distort what he had heard. He would fail to distinguish
between himself and the therapist, recalling his own associations as
interventions by the therapist. By the next session, he would genet:-
ally have recovered, only to repeat his reaction when threatened
once again by something that the therapist said.

Psychotic Transferences
Consider these two vignettes:

Mrs. LQ. was a woman diagnosed as paranoid schizo-


phrenic who came into psychotherapy because of severe
depressions and confusing beliefs that her internist was
in love with her and wanted to marry her. These latter
convictions were based on glances he had given her and
influences from his apparently innocuous remarks to her.
Her history revealed a rather chaotic childhood at the
hands of two disturbed parents, and open sexual con-
tacts with her father and brother.
At one point in her therapy, after much reality test-
ing, analyzing, ego-building, and working-through, with
consequent resolution of her delusions about her internist,
Mrs. I.Q. had a terrible battle with her husband. A severe
depression followed; in the next session, she described
her wish to marry her therapist. She alluded to apparently
irrelevant comments of his that had led her to believe
that he loved her and was just waiting for her to express
herself; she was convinced of the truth of her ideas.
Another patient, Mrs. I.R. was in therapy because of
176 THE PATIENT-THERAPIST RELATIONSHIP

severe depressions and suicidal impulses; she had an


ambulatory schizophrenic illness. Her history revealed
that her mother had once. during an apparently psychotic
episode when the patient was quite young. actually
attempted to drown her at the beach. This was but one
acute episode in a childhood filled with extremely trau-
matic. disruptive experiences.
Whenever this patient was helped in her therapy and
became actively involved in it. she would respond with a
reactive and murderous rage at her therapist. and with
suicidal impulses. For example. in one trying period dur-
ing which she was filled with intense suicidal thoughts.
she found the therapist's interventions very helpful, essen-
tially because he conveyed a strong belief in her right to
survive and in her as a p~rson that counteracted her own
enormously depreciated self-image. Interpretations of the
dynamics of recent events that had provoked murderous
feelings of rage at her mother and of evidence that this
fury was turned against herself in response to her intoler-
ance for her hatred. had been couched in a manner
designed to improve her self-image.
Mrs. I.R. experienced and acknowledged an intense
sense of relief and then panicked: it was a trap; her
therapist was no different from the others-she could
smash his head in. The rage mounted and she left the
session in a storm of fury. despite all efforts at interven-
ing. In the next hour. the rage and mistrust continued,
but had lessened; it took several additional sessions to
help her to reestablish her equilibrium.

As we would expect, psychotic transference reactions reflect


major disruptions in ego functioning. including poor reality testing
with delusional beliefs. inability to distinguish inner fantasies from
outer realities. and projections onto the therapist of inner fantasies
and memories that are then responded to as external realities.

Narcissistic Transferences
Patients suffering from primarily narcissistic disturbances relate
Patient's Reactions: Fundamental Concepts 177

in a special way to their therapist. This has been described as


transference-like by Kohut (1971), in that the patient treats the
therapist largely as an extension of himself, and as one form of
benign and malignant regression by Balint (1968), who commented
that these patients have pervasive requirements for gratification in a
therapeutic relationship--only their needs matter-and noted that
they sought primary love, a "harmonious mix-up" with the therapist.
Such transferences are characterized by the search for real gratifica-
tions from the therapist, and by intense self-absorbed needs. These
patients commonly expect that the therapist will participate in
merging fantasies and offer mirrorlike praise of the patient's
grandiose and exhibitionistic self, and anticipate that the therapist
will accept their idealized and omnipotent view of him. With such
patients, empathy and resonance are crucial; without some degree
of participation and exchange, always within the limits of the appro-
priate therapeutic relationship, such patients are disruptively trau-
matized and the therapy will fail. In Balint's terms, the therapist
must become the medium for the patient's existence in the sessions,
much like the water in which a swimmer is immersed or the air that
a person breathes. The patient often experiences the therapist as an
extension of himself and manipulates him as if this were so
(KohuL 1971).
A brief illustration of this type of transference occurs in the fol-
lowing interlude in the therapy of Mrs. I.S., who was in treatment
because of episodic affairs, a sense of depression, and a bleak out-
look on life. She had been assessed as having a narcissistic character
disorder with depressions.

She had been in therapy for a year and a half when


her husband changed jobs. There were financial pressures
and delays in paying her fees. She was in arrears for two
months when she began a session by describing how her
friend had probably shoplifted a purse while they had
been together at a local dress shop. She feared being
tested by the therapist and failing. She had dreamt of a
dark staircase, which she described, fearing that someone
lurked beneath it in the dark. She recalled fears of the
dark in her childhood and spoke of money pressures at
178 THE PATIENT-THERAPIST RELATIONSHIP

home. The therapist asked how things stood with his fees,
and Mrs. I.S. explained that she could have paid part of
what she owed to him, but did not do so because she felt
embarrassed. She had dreamt that a former lover was
Nasser, and spoke of regretting her affair with this man.
She stared at the therapist's drapes and felt herself hyp-
notized and merging with them. The therapist intervened
as the hour ended, doing so in an insufficient way; I shall
return to this aspect of this session in the next chapter.
In the next session, Mrs. I.S. described how upset she
had been after her session. She was angry at her thera-
pist-he seemed to feel that nothing had changed in her.
She had shopped with her son and had seen a beautiful
girl of a type admired by her husband. She thought of kill-
ing herself and her son while driving home. She had asked
her husband about the therapist's fee and he had been
annoyed; maybe she should stop coming to her sessions
for now. She had dreamt on the night of the last session
that she was talking on the telephone from her mother's
house to her girlfriend Norma (her therapist's first name
was Norman) and looked down: she was bleeding vagin-
ally with large clots; she went to attend to herself. In
associating, she recalled a time when she had slept at an
aunt's house and saw through her aunt's nightgown that
she was hemorrhaging vaginally with a heavy menstrual
flow. Before her marriage, she herself had missed a period
and then hemorrhaged with clots in an apparent mis-
carriage. At this point in her hour, she began to smoke a
cigarette. The therapist intervened again; I shall describe
this work in Chapter 21.

I have not detailed here the interventions that restored the


patient's sense of worth and the therapeutic alliance; I shall simply
note that the therapist showed considerable empathy and correct
recognition of the stimulus for these reactions and its meanings for
the patient (see Chapter 21). The material serves here to indicate
how sensitive this patient was to her therapist's realistic inquiry
regarding his fee-this was for her a deep narcissistic hurt and
Patient's Reactions: Fundamental Concepts 179

disrupted the therapeutic alliance. This disturbance is reflected in


the dream of leaving the telephone because of the vaginal bleeding,
in the patient's fantasies of killing herself and her son, and in her
behavior in the session. The inquiry evoked feelings, based on a
mother transference, that the therapist wanted to be rid of her,
to abort her, and a reactive transference depression of suicidal
proportions. The dream represents the hurt as the loss of a fetus;
the mother-child union is disrupted and a part of herself is lost.
Only sensitive responses to this patient's real and intense sense of
pain and loss were able to reinstate a proper therapeutic atmosphere.

Instinctualized Transferences
A type of transference that is most often seen in borderline or
narcissistic patients. or those with certain character disorders, and
that poses special problems, is the instinctualized transference,
erotized or aggressivized (see Blum, 1971a, 1971 b: Freud, 1915:
Nunberg, 1951; Rappaport, 1956 and 1959; and Swartz, 1969). In
such patients. there are intense wishes for gratifications that go
beyond the usual limits of the therapeutic relationship. This type of
transference is usually based on early disruptions in the mother-child
relationship-a strong pre-oedipal factor-and on later overt over-
stimulation, and sexual and aggressive traumatization, by one or
both parents; it is manifested either in seductive overtures toward
the therapist and the actual or near-belief in the possibility of a
sexual liaison, or in direct aggressions against him; these are usually,
but not always, verbal and always strongly rationalized. These trans-
ferences are often, then, directed toward transference gratifications
(see pp. 204-06) by the patient, and they are difficult to manage (see
Chapter 21).
Instinctualized transferences generally reflect overintense, poorly
managed instinctual drives; a corrupted, impaired, and archaic
superego; and ego dysfunctions regarding relating. reality testing,
defenses and controls.
Some patients with this type of problem repetitively seek to
gratify themselves directly with the therapist, or with others, by
displacements, in a gross or more subtle manner. Other patients of
this kind. in contrast. vehemently defensively deny such impulses,
which are actually repetitively searching for discharge; they are
180 THE PATIENT-THERAPIST RELATIONSHIP

aloof. overguarded and defensive, and terrified of experiencing any


feelings toward the therapist at all, dreading any possible loss of
control. They maintain a cold distance from the therapist and
others. at much cost to themselves.
The narcissistic base for such transference expressions in
selected patients is to be found in a grandiose self-image or an
excessive idealization of the therapist, and a narcissistic search for
union and merger. With others, it reflects borderline psychopath-
ology or severe characterological problems.
In our case material, Mr. LN.'S senseless and repeated attacks on
the therapist in the early part of his therapy presented a borderline
aggressivized transference. Mrs. I.L. presented an erotized transfer-
ence that appeared to be more narcissistic in nature.
Let us now integrate the major points in this discussion of trans-
ference expressions by listing their main dimensions:
Transference reactions are based on unconscious fantasies. They range
from relatively minor neurotic fantasies to fantasies that influence the
patient's attitudes and behavior, and are acted out in a well-rationalized
way; they also include distorted and delusional beliefs and perceptions
on which disruptive behavior-irrational acting out-is based.
Transference reactions may contain reflections of severe psychopathology
in keeping with the inner disturbances of the patients instinctual-drive
needs, superego functioning, and especially ego functions. The varying
severity of such psychic impairments has important implications for the
technique of dealing with transference material (see Chapter 21).
• Neurotic transference manifestations are confined to inner fantasies
that are usually ego-alien and without significant belief or intention, and
that may be displaced and acted out in a manner that is well rationalized
and in keeping with the situation, through which they find expression.
These are generally described in terms of erotic and aggressive transfer-
ence fantasies and wishes.
• Borderline transference manifestations are based on inner fantasies
that are maintained with some degree of ego-syntonicity, belief in their
validity, and intention to carry them out. They are often displaced and
acted upon (acted out) in a poorly disguised manner and in a poorly
justified situation; and there may be, at times, a tendency to live these
impulses out directly with the therapist in some attenuated way; this
generally does not, however, extend into actual behavior toward him,
but remains confined to a verbal level. Rapid recovery and perspective
follow these more distorted expressions of transference fantasies, while
the displaced acting out may be strongly maintained and secondarily
Patient's Reactions: Fundamental Concepts 181

rationalized without much insight into its essential basis in unconscious,


and sometimes blatantly verbalized, transference fantasies.
• Psychotic transference manifestations are characterized by delu-
sional beliefs, misperceptions, ego-syntonicity with lack of insight,
irrationally acted-out displacements, and a tendency toward direct living
out of the patient's impulses toward the therapist.
• Narcissistic transferences are those in which the patient demands
that acceptance of himself and his needs be the sole climate of the
therapy or that the therapist permit the patient to idealize and aggrandize
either the therapist or the patient himself. These patients are exceedingly
sensitive to the nonverbal communications from the therapist. to any
impairment in the therapist's empathic understanding, and to any
disturbance in the harmonious mix-up they seek to obtain in their inter-
action with the therapist.
• A special type of usually borderline or narcissistic transference is
that of the instinctualized transference, erotized or aggressivized. These
patients hope to achieve gratifications from the therapist-so-called
"transference gratifications"-that go beyond the usual boundaries of
the therapeutic relationship.

Transference Symptoms
Transference reactions in patients of any diagnostic category
may be manifested as neurotic or psychotic symptoms. The key to
identifying these symptoms as transference-based lies in finding, in
the material from the patient, that the main unconscious fantasies on
which the disturbance is based fall into the realm of transference.
Thus, such symptoms can only be defined through their analysis in
therapy, although the prevailing context-primary adaptive task-
often provides important initial clues; when reactions to the thera-
pist are central. acute symptoms are often transference-based (see
pp. 186-94).
Turning to the vignette with Miss LP., we see that her asthmatic
symptoms occurred in the context of termination and were based
on a series of transference fantasies evoked by this pending event.
The sequence of her associations indicated that her symptoms were
related to unconscious fantasies about dying, about running breath-
lessly away from the therapist-father who would harm or rape her,
and about incorporating the omnipotent protective therapist-mother.
Later material confirmed fantasies of perishing without the protec-
tion of the therapist, and of wishing to destroy and incorporate him.
Both father and mother transferences were involved.
182 THE PATIENT-THERAPIST RELATIONSHIP

Another vignette will illustrate this type of symptom:

Mrs. LT. had been in therapy for about six months


when her therapist planned a two-week vacation; she had
been diagnosed as having a moderate character disorder
with depression and anxiety symptoms.
As her. therapist's vacation drew near, Mrs. LT. had
spoken of her feelings that her hw,band was too distant
and unavailable, of how she was searching to be part of
someone's dream, of wanting to be special and receive
extra compensations and love, and of a man whom she
had seen outside her house-she was afraid that he was
a rapist. Much.of this had been interpreted to her as a
reaction to the pending separation from the therapist.
She began one session at this time by alluding again
to this man whom she had seen-he looked nice this
time. She felt strong sexual tensions. She always wanted
extras and never tolerated interruptions, especially when
her parents moved to California and when her grand-
mother, who had been so loving to her, had later joined
them. Her life was half over and there was so much she
disliked about herself. She detailed ways in which her
parents had neglected and short-changed her, and then
the manner in which her husband also deprived her of love
and closeness. The therapist then spoke of her longings
to be part of her husband. Later in the hour, when the
patient questioned him repeatedly and, receiving no
response, said that she was angry and wanted to retreat
into sleep, he said that she withdrew angrily when he did
not answer her questions. She spoke of feeling indecisive
and he said that she seemed to want him to provide
answers for her; Mrs. LT. said that she was confused.
She began the next session by saying she felt that in
the last hour, the therapist had been pushing buttons and
turning her feelings off and on. She had gone home and
cleaned out her closets rather than merely wiping off the
superficial dirt. The therapist had seemed harsh; she had
thought that he understood her feelings. Her mother
Patient's Reactions: Fundamental Concepts 183

mechanically gave her two weeks of help after each of her


children was born and then left. Her two sons, who
shared a room, cried when the light was turned off at bed-
time; Mrs. I.T. felt that there was no peace.
She thought that the therapist had been playing with
her emotions in the last hour to test her and to get her to
feel. She had a strange symptom afterward: she felt she
was going to have a miscarriage; it was a very unpleasant
sensation. Her husband could not impregnate her because
he had had a vasectomy; she had been thinking a lot
about the therapist. The therapist alluded to her earlier
fantasies of surrendering herself to him and of achieving
a harmonious union with him; now that the relationship
with him was disrupted, she had quickly aborted the fruits
of that union.
Mrs. LT. responded that the therapist made sense. She
had been furious because he twice missed her allusion to
her life being half over and to wanting to finish her
therapy before it was too late. The hospital in which the
clinic was located was a citadel for her and a provider;
she had had her children there and trusted the staff. She
had thought of going to her internist while the therapist
was away.

In assessing this vignette, it is well to begin with the context and


trace out its intrapsychic consequences. The primary adaptive task
initially was the therapist's vacation; to this. one must add his
sudden loss of sensitivity to the patient's conflicts related to this
trauma as reflected in his comments toward the end of the first hour
described; this was identified at the time in supervision, and a
reaction in the patient was predicted for the following hour.
In that hour, the patient did indeed focus directly and indirectly
on the therapist's loss of perspective and his somewhat annoyed and
harsh comments, which shifted her away from her fantasies about
his pending departure. Such a moment of conscious awareness and
direct comments about the therapist's technical errors is rare in the
patients that I have studied (see Chapter 22); unconscious percep-
tions predominate. reflected here, for example, in the patient's
184 THE PATIENT-THERAPIST RELATIONSHIP

reference to her own disregard of superficial dirt and interest in


deeper problems-closets.
The patient's reaction, however, reflecting as it does her own
intrapsychic conflicts and fantasies, became tinged with paranoid-
like feelings, as well as feelings of injury at being misunderstood.
The therapist had indeed shattered the sense of oneness and union
that she had been developing, and she had experienced the sensa-
tions of the abortion as a transference symptom reflecting her uncon-
scious fantasies of hurt and loss. The earlier object on which these
fantasies were based is unclear.
The therapist's intervention regarding the transference symp-
toms was essentially correct and confirmed by the associations to
the citadel, safety, pregnancy, and the search for a replacement for
him. In the next hour, the last session before the therapist left, Mrs.
I.T. was calm, well integrated, and symptom-free.
This transference symptom, and any transference manifestation,
cannot be correctly understood or interpreted without a proper
assessment of the context and the true nature of the therapist's
prior interventions; it was crucial for the interventions that led to
resolution of the patient's symptom that the therapist recognized
his harshness in the previous hour and saw the validity of the
patient's complaints (see Chapter 22). In general, the therapist must
also correctly assess the intrapsychic meanings (psychic reality) and
consequences within the patient of the reality precipitate, and even-
tually focus on the patient's maladaptive responses-whatever the
reality.
We see again that transference fantasies are evoked by a specific
day residue and elaborated through the patient's intrapsychic reac-
tions based largely on his past relationships. Why pregnancy and
abortion fantasies are focal in Mrs. I.T.'S transference fantasies did
not emerge at this time. though conflicts about not being able to
have more children and the central current task of adapting to a
separation-undoing it by a pregnancy-did contribute. Often, in
psychotherapy, the picture is incomplete, though, as we see, suc-
cessful working-through and symptom resolution can be achieved
with the fragments that are available (see Chapters 21 and 22).
Patient's Reactions: Fundamental Concepts 185

Transference as Interaction

Beyond those specific interludes when transference fantasies


and manifestations are especially intense and focal, the patient's
manner of relating to the therapist reflects a whole range of fantasies
and attitudes that are based primarily on transferences or reality.
Often, this characteristic response to the therapist's relating and
intervening proves critical to the outcome of treatment, especially
when mistrust and caution are prominent. There is a strong non-
verbal component to this dimension of transference, which is
embedded in the earliest relationships of the patient. Not unnatur-
ally, the therapist's capacities for empathy, intuition, and nonverbal
response are important here.
It has undoubtedly become clear that the patient's transference
fantasies-indeed, all of his fantasies and intrapsychic conflicts-
can be assessed and understood only in light of his interaction with
the therapist and others (perhaps it would be well to call this the
adaptional-interactional framework; see Chapter 22). Each therapist
sets his own tone for his relationship with his patients, and each
patient responds in his own highly characteristic way to the realistic
and conscious, as well as the unconscious, communications from the
therapist. The therapist's understanding of the qualities and implicit
meanings of the patient's attitude toward him is crucial here. He
tunes in on the patient's level of trust or distance, his tendency to
interact openly or cautiously, or to respond to the therapist's inter-
ventions by moving closer to him (e.g., by adding confirmatory
material) or bv moving away (e.g., by becoming remote, ruminative,
and defensive). Such repetitive responses tend to be strongly embed-
ded in transference elements that are often difficult to reach in
psychotherapy, and therefore difficult to analyze and modify (see
Chapter 21).
As brief illustrations: Miss I.H. tended to wish for intense close-
ness with her therapist, and was preoccupied with thoughts of his
personal life and his other patients. This contributed to her deep
distress when he was in any way insensitive to her needs. Mrs. I.L.
was also extremely affected by the least variation in her therapist's
attitude and manner of interacting with her, including his momen-
tary lapses. Miss I.M., on the other hand, tended to maintain a
186 THE PATIENT-THERAPIST RELATIONSHIP

moderate sense of distance and seldom spoke directly about the


therapist except for interludes before his vacations and termination.
At such times, she would pull away from him for a few sessions and
appear self-absorbed, and then eventually return to active inter-
actions with him. Mr. I.N. was initially exceedingly sensitive to his
therapist, seeing him as an enemy and constantly alert for attack; he
responded to all interventions by disagreeing, pulling back, and
actively disrupting his relationship with the therapist. Later on in
his treatment, he maintained a kind of contented aloofness, con-
trolling his rage.
When such transference elements in each patient's relationship
to the therapist become sources of resistances or important fantasy
content, the therapist seeks to reach the unconscious fantasies and
earlier experiences on which they are based. Miss I.H. and Mrs. I.L.
both had very aloof and narcissistic mothers and very seductive
fathers. and experienced unconscious longings for union with these
frustrating mothers and for incestuously tinged closeness with their
fathers. Miss I.M. tended to mistrust her parents, who had trauma-
tized her, but she had learned to trust her internist. who had
referred her to her therapist. This preformed transference (see
pp. 206-07) and her own sound ego functioning enabled her to distin-
guish her therapist from her parents, and to trust and relate well to
him. Mr. I.N.'S deep mistrust of his parents. who had been blatantly
insensitive and destructive. and his own poor ego functioning con-
tributed to his guarded. paranoid transference.

SPECIAL DIMENSIONS OF TRANSFERENCE


As has become clear, transference fantasies and reactions are
essentially adaptive and maladaptive responses to some current
stimulus within or outside of treatment. I want now to focus on some
of their specific functions and additional dimensions in psycho-
therapy. beginning with the issue of their identification.

The Identification of Transference Manifestations


The decision that a given fantasy--even when it is manifestly
about the therapist-is essentially a transference reaction rather
than one primarily related to an outside conflict is, at times, difficult.
Patient's Reactions: Fundamental Concepts 187

Premature introduction of transference interventions, or the failure


to make such interventions when indicated, can have strikingly
detrimental effects on the patient and the therapeutic alliance (see
Chapter 21).
In the main, there are no special techniques needed beyond
listening to the patient and sorting out his associations (see Chapter
9). Using these fundamentals, we can, however, ultimately develop
some special guidelines for determining that a reaction is one of
transference. As we would expect, the key to this assessment is the
determination of the current primary adaptive task and the subs~
quent tracing out of the central intrapsychic conflicts, fantasies and
memories it has evoked in the patient. A few guidelines will help
us here:

When something potentially or actually disruptive occurs in therapy, the


therapist should listen to the patient's association with transference
reactions in mind as an organizing factor. Most common among such
disturbances are:
• All interruptions in therapy generated by either person, including
vacations, illnesses, absences for any reason, and the beginning and end-
ing of treatment.
• The therapist's errors in technique and insensitivities, especially
major or repetitive ones (see Chapter 22).
• Any deviation in the boundaries of the patient-therapist relation-
ship and in the ground rules of the therapy, including the introduction
of any parameter by the therapist.
• Any especially moving and important moment in therapy and any
notably painful interlude or intervention.
When a person in the patient's life has frustrated and hurt him, part of
the reaction may be to turn to the therapist, realistically or unrealistically,
for special help and repair. At such times, transference fantasies may be
intensified. However, these must be distinguished from reactions primary
to this outside hurt that are defensively displaced onto the therapist.
Care must therefore be taken to diDerentiate intensified transference
reactions and longings-and defenses aRainst them-from the use of the
transference to communicate intrapsychically related fantasies that center
upon traumatic incidents with, and fantasies about, an outside person,
and the use of transference fantasies as a defensive distraction from such
an outside conflict. Of help here are these perspectives:
• Sensitivity to adaptive tasks, and the order of their importance
intrapsychicaIly and in terms of human concerns for the patient.
188 THE PATIENT-THERAPIST RELATIONSHIP

• Awareness that a major trauma or ongoing outside conflict with


figures important in the patient's life will usually be a central concern for
the patient and his therapy.
• Awareness that the therapist's errors in technique and human fail-
ings will virtually always be a crucial day residue for the patient. and
usually disruptive to the therapeutic alliance. These must take prece-
dence over other therapeutic tasks; then, the work with the patient's
other life-problems may be effectively continued (see Chapter 22).
• Separations from the therapist need not prove to be the source of
significant intrapsychic conflicts for the patient, or they may, especially
in narcissistic, depressed, and some borderline patients, require intensive
exploration because of maladaptive responses. The therapist must follow
the patient's associations to determine the nature of his reactions, includ-
ing displacements onto outside figures.

The therapist should, as a matter of technique, follow the patient's


primary focus on his life-problems, and deal with transferences when
they disrupt the therapeutic alliance or become embedded in crucial
intrapsychic conflicts, thereby becoming the vehicle for insight into
important fantasies (see also Chapter 21).
The therapist should neither foster nor avoid a patient's concentra-
tion on himself.
Silent listening, which confirms that the derivatives in the patient's
associations are organizing around day residues related to the therapist,
and confirmation from material subsequent to an intervention, are both
necessary to validate an assessment of a response as transference-based.
Nonconfirmation, disruptions in the therapeutic alliance, and regressions
indicate that the therapist must reformulate.

To illustrate these principles. the reader may recall again how


the therapist's errors had evoked a major response in Miss I.H.,
which preoccupied her and related to virtually all the manifest and
latent content of her sessions at the time. In this context, her quarrel
with her mother was primarily a displacement of transference
anger, rather than a central issue with her which was then displaced
into anger at the therapist. This anger was primarily therapist-
related.
For Miss I.M., separation was especially traumatic, and in the
material related to her therapist's vacation, we see a sequence of
acting out and fantasy responses that readily relate to separation
anxieties on a manifest and latent level, and to unconscious fantasies
about fear of. and adaptation to, separation.
Patient's Reactions: Fundamental Concepts 189

Mrs. LL. was reacting intensely to her therapist at the beginning


of her psychotherapy; this proved to be the main context for her
associations in the early sessions. She was, however, also concerned
about her marriage and her continued affairs, a complex situation
that included some degree of displacement from transference reac-
tions. The transference fantasies themselves had an important ele-
ment of displacement from her husband and lovers, and were used
in part defensively to shift the focus away from her intense conflicts
about them.
In the vignette presented later in the chapter, Mrs. I.L.'s transfer-
ence longings presented a similar mixture: the main functions of
these fantasies apparently were to provide gratifications not present
in her relationship with her husband and to deflect the focus from,
while communicating fantasies about, her intense real and intra-
psychic conflicts about him.
With Miss LP., termination appeared to be the central issue, and
her quarrel with her fiance, while serious, seemed to be secondary,
and largely a vehicle for acting out her rage at the therapist. The
issues in such a dispute must be weighed carefully; any real conflict
must be recognized, though its use to live out unconscious fantasies
about the therapist and termination must be analyzed if the problem
is to be resolved. Without such working-through, the unconscious
displacement from the therapist would motivate continued battles
with her fiance.
With Mrs. I.T., there was an interplay between the transference
and the patient's difficulties with her husband. Her sexual frustra-
tions with him had intensified her fantasies about the therapist and
these became central before his vacation; on the other hand, her fan-
tasies about the therapist contributed to her anger with her husband.
Such interweaving is frequent and typical.
One last brief illustration will clarify the manner in which direct
references to the therapist need not primarily involve transference
conflicts.

Mrs. I.u. was a woman with a severe character dis-


order and depression, related to a multitude of dysphoric
fantasies about her body. She came to one session after a
year of therapy and began immediately to question the
190 THE PATIENT-THERAPIST RELATIONSHIP

value of being in treatment with a male therapist. He


would not understand her feelings about her body and
herself as a woman. She thought of changing to a female
therapist; men are insensitive animals. She had been
deeply hurt the previous night by her husband, who had
joked to friends about her small breasts. She had cried
for a long while.
In the absence of any reference to, or awareness of,
any precipitate for this material emanating from her rela-
tionship with himself, the therapist pointed out that Mrs.
LU.'S rage at him seemed to have been set off by her hus-
band's remarks and reflected her anger with him, which
was being deflected onto himself. Mrs. LU. paused, and
agreed directly; she then went on to detail some additional
incidents with her husband and further fantasies about
her conflicts regarding her body.

Here, the context of the patient's anger with the therapist


emerged as the patient associated; it centered upon the trauma with
her husband and the references to the therapist were clearly dis-
placed from him in this hour.
Besides the primary adaptive task, there are a number of specific
clues to whether transference manifestations, or any allusions to
the therapist, are central or peripheral to the patient's main intra-
psychic conflicts:
1. The sequence of the patient's associations will indicate if an
area is central, or a defense against the patient's more disturbing
problems. Often, though not always, the first material in the hour is
more central, but a final assessment of this aspect depends on an
evaluation of the total sequence of the sessions.
2. The area toward which the patient directs most of his
defenses is generally the most conflicted and disturbing for him.
Thus, if the transference is denied, the therapist should suspect that
it is more crucial; if it is advertised openly, it may be serving as a
means of avoiding another, more anxiety-provoking conflict and
problem in the patient's outside life.
3. The area around which the manifest and latent content of
Patient's Reactions: Fundamental Concepts 191

the material from the patient organizes most readily is usually more
central.
4. Is the therapeutic alliance and therapy disturbed? When it is,
the transference and relationship to the therapist is often central;
when it is not, it is usually less focal.
5. Which problem seems most hurtful, upsetting, and important
to the patient? Answering this is a long step toward making the
decision.

The following vignette is illustrative:

Mrs. J.B. was a woman with one child who was


separated from her husband; she had been in therapy for
about six months because of depressive episodes, ten-
dencies to act out, and a moderate characterological
disturbance. At this point, late in December, her therapist
took a long vacation to which the patient had little con-
scious reaction. However, she suddenly showed intense
concern that her present boyfriend would abandon her
and sought out a series of new and old friends. These
actions and the patient's associations, which related them
to fantasies about the therapist's "desertion," went unin-
terpreted until after her (the therapist's) return, when
some work was done with them in the face of serious, self-
harmful acting out by the patient.
During the two months after the therapist's return, it
became clear that the patient's anticipation of the termina-
tion of therapy, which would occur that June because the
therapist was leaving the clinic at which she was being
seen, was very much on her mind even though she had
not directly alluded to it. She had settled her relationship
with her boyfriend and was attending to her divorce when
she began to miss sessions because of minor illnesses or
so-called urgent business.
At this time, Mrs. J.B. began a session after two missed
hours by asking again if her boyfriend could get into
treatment with the therapist in July, after she herself
could no longer come in or better still, if the therapist
192 THE PATIENT-THERAPIST RELATIONSHIP

could begin to see him now. Mrs. J.B. felt that he could
relate well to the therapist, who was doing such a good
job with herself. One of the patient's friends had seen
some very destructive therapists. Mrs. J.B. knew what the
therapist was thinking: she wanted her boyfriend to come
as a surrogate and replacement for her because of the
separation-it was not so. She was concerned about her
boyfriend and feared that he would leave her once she
got her divorce. His mother had never been at home and
had often deserted him, much as Mrs. J.B.'S husband had
repeatedly done by going out at night without her. She
was afraid her husband would try to take their child from
her; she felt depressed, but realized it was actually anger.
Her brother had betrayed her and sided with her hus-
band. She had left her parents without reason or warning;
now she understood how they felt.
At this point, the therapist intervened and told the
patient that she seemed to have feelings about both her
boyfriend and her therapist leaving her, and that she
wanted to hold onto the therapist through her boyfriend
and was angry about termination, having expressed that
in her recent self-destructive behavior. Mrs. J.B. responded
that she was not aware of her anger, but that when she
showed such feelings as a child, her father would sternly
chastise her. She could express anger at her child, and
was in a rage at an older man who was sharing her apart-
ment and not paying his part of the rent; she was afraid
of saying so-he would retaliate. She got angry when
someone used her. With the therapist, it was different-it
was like meeting someone who was already married. No-
she corrected herself-it was more as if her daughter got
leukemia and was going to die in six months; there would
be nothing she could do about it. Could not the therapist
treat her boyfriend instead of her next July?

This· is a poignant vignette, with a most moving metaphor


regarding the effect on the patient of a termination that is necessi-
tated by reasons outside the patient's needs (see Chapter 25). It
Patient's Reactions: Fundamental Concepts 193

here illustrates a not uncommon dilemma for the therapist. What is


central to the patient's concerns and angry feelings: the possible
loss of her boyfriend or the pending loss of her therapist? These
points seem most relevant to such a decision:
1. What is the main adaptive context?
The therapist's vacation and plans to terminate the therapy
seems to loom most prominently as traumatic adaptive contexts for
Mrs. J.B., while loss of her boyfriend seems more hypothetical and
less pressing. The anticipation of a termination of her therapy with-
out any consideration of her needs is a highly traumatic and painful
loss; the concerns about her boyfriend, while important to the
patient's future, are less urgent.
While the two day residues are related; it is important to make
the primary problem central to the therapist's interventions. Let us
therefore consider other clues:
2. Where are the patient's main defenses?
Denial of feelings and fantasies about the therapist and therapy
is a prominent defense for Mrs. J.B. in this session. In contrast, the
patient avows to be worried about losing her boyfriend. This sug-
gests stronger conflicts about the former situation.
3. What is revealed by the sequence of the patient's associa-
tions?
The patient begins the hour by asking if her boyfriend can
replace her with the therapist, implying, as the patient herself states
in the form of a negation, a continuation of her ties to the therapist.
Often, what comes first in the hour is most crucial. Again, this points
to termination as the main current source of intrapsychic conflicts
for the patient, rather than worries about her boyfriend.
4. Which theme organizes the material best?
Again, I would opt for the termination theme as a better fit.
While Mrs. J.B. fears loss of both persons, that of the therapist is,
for her, senseless and unfair. Latent content-disguised derivatives
of unconscious fantasies-related closely to this topic and other
themes tied to termination in her associations include the reference
to destructive therapists, to the surrogate replacement who will undo
the loss, to parental desertion, to betrayal by her brother, to Mrs.
J.B.'S leaving her parents without reason, to being used (a common
feeling in clinic patients who are terminated because of clinic policy
194 THE PATIENT-THERAPIST RELATIONSHIP

alone), and to the slow death of her own child. These last themes
followed the therapist's intervention and confirmed the current
importance of the aspect that related to her.
5. Was the therapeutic alliance or therapy disrupted?
The patient had been missing many sessions. This pointed to
transference issues as an important likely source of current con-
flicts.
All the indicators that are of use in deciding whether trans-
ference or outside conflicts are primary to the patient in a given
session pointed, in this situation, toward the former. The patient's
response to the therapist's intervention confirmed this assessment,
which was predicted in supervision on the basis of the patient's
opening remark. These guidelines should become integral to the
therapist's continuing assessment of transference material, and of
indications for interventions in this area (see Chapter 21).

The Manifestations and Role of Transference in


Psychotherapy
While I have indicated in passing something of the range of
transference manifestations in psychotherapy, and shall focus on
their interpretation in the following chapter, I want here to inte-
grate some basic concepts. To what extent can, or should, work
with transference derivatives play a role in ongoing psychotherapy?
There is no single answer to such a question, but much can be said
about the range of possibilities. Two related questions that must be
discussed are: do we observe organized transference neuroses in
psychotherapy? And, do transference phenomena ever become over
the long run, or should they ever be made, the central focus of the
therapeutic work? In effect, how extensively does the psychothera-
pist work with transference manifestations? Many of the therapists
I have supervised have attempted to center their therapeutic interest
here, without a full understanding of the disruptive influence that
this may have for the therapy or an awareness that his may deflect
the focus from other more pertinent problems. There are many
hazards and issues in dealing with transferen~; here I shall discuss
these problems largely in connection with twice-weekly psycho-
therapy, though the same principles apply, in the main, to psycho-
therapy of any frequency.
Patient's Reactions: Fundamental Concepts 195

Do we observe transference neuroses in p~ychotherapy? In dis-


cussing this question, I shall, of necessity, rely on my direct and
supervisory experiences over the years. I have found the following:
1. An organized transference neurosis may be defined as an
emotional illness that evolves from, and is an elaboration of, trans-
ference responses and fantasies. As such, it implies that the basis for
the patient's symptoms during therapy is largely related to, and is a
major recapitulation of, his past relationships, experienced in the
present with the therapist. A transference neurosis is more pervasive,
elaborated, and organized than isolated transference symptoms or
other passing transference manifestations.
2. In my experience, patients in psychotherapy generally do not
develop the symptoms of a transference neurosis. In the first place,
the intensity of the involvement between the patient and therapist
is kept within limits by such factors as the time elapsing between
the two (or three) weekly sessions, the use of the face-to-face mode,
the limits of the mutual commitment, the restrictions on the depth of
the therapeutic work, the extent of the therapist's activity, and the
overall limitations on the degree to which the patient can regress in
such a setting.
(a) As we have seen, however, transference psychoses may
occur more readily in psychotherapy, because of the more
overwhelming role that inner conflicts and fantasies play in
psychoses.
(b) Some borderline patients attempt to involve themselves and
their pathology with their therapists, producing a borderline trans-
ference syndrome. If this persists, I have found it difficult to work
with, and primarily a source of resistances and disruption of the
therapy. It is not, by and large, a workable vehicle for insight and
change. The therapist should aim at resolution, rather than enhance-
ment, of such manifestations.
(c) With narcissistic disorders, the interaction between the
patient and his therapist will tend to have considerable importance
throughout the therapy, largely because of the patient's excessive
sensitivities. An extended transference-based syndrome is not the
rule, however.
3. From all this, it follows that we cannot realistically expect to
find a spontaneous, analyzable transference neurosis, or promote the
196 THE PATIENT-THERAPIST RELATIONSHIP

development of one, in psychotherapy, and our technique should be


geared toward such a fact.
(a) Even when such a neurosis appears transiently, we cannot
expect to be in a position to explore such symptoms in detail and
depth. This is an inherent limitation of psychotherapy. The deriva-
tives of such fantasies are not available in sufficient elaboration and
concentration to permit the detailed analysis of the genetics,
dynamics, and conscious and unconscious fantasies involved.
(b) In addition, these same limitations would make such a
syndrome relatively unmanageable and the source of considerable
chaos.
(c) Because such a neurosis involves transference feelings and
fantasies about the therapist, it is generally more difficult to deal
with for two parties who are face-to-face than symptoms that are
evoked by causes external to the therapy. The resistances involved
are more intense and more difficult to manage.
(d) Often, what appears to be a transient transference neurosis
is actually much more a realistic reaction to a therapist's repeatedly
incorrect behavior and interventions, and is best viewed as a
primarily therapist-evoked, rather than transference, neurosis, one
that has special attributes and necessitates special techniques (see
Miss I.L. and Chapter 22).
I would, therefore, conclude that a transference neurosis is quite
rarely, if ever, manifested in patients in psychotherapy. Further,
should extended symptoms appear and the patient's associations
center primarily on the therapist, they should alert him to counter-
transference problems, to a search for spxific contexts and precipi-
tates for the syndromes, and to the need to analyze and resolve the
problem rapidly, lest it disrupt the therapeutic alliance and entire
treatment.
In contrast, transference manifestations and transient trans-
ference-based symptoms are common in psychotherapy, and are
readily analyzed and interpreted-within ill-defined limits-when
indicated. They may be a source of important insights for the patient
and critical in the resolution of resistances in therapy. The general
goal, then, is to focus on such material when necessary, to analyze
and resolve the related intrapsychic conflicts and symptoms as far as
Patient's Reactions: Fundamental Concepts 197

possible, and to restore the focus to the patient's life problems. Let
us now define this area of work more clearly.

Work with Transference Manifestations in Psychotherapy


What follows is a brief and condensed discussion, based on my
clinical experience, of an area fraught with many misconceptions
and misunderstandings; the basic points are these:
1. Many patients establish an early, positive and trusting thera-
peutic alliance that is not marred by erotic or mistrustful and hostile
fantasies.
(a) With such patients, the therapist must be constantly on the
alert for disruptive transference manifestations that may be promp-
ted by some event inside or outside therapy, or by the patient's
reaction to material fraught with guilt and anxiety. He can, how-
ever, expect to do effective work with the patient based primarily
on the exploration of his extratherapeutic life-problems and result-
ant intrapsychic conflicts. Generally, he should not search out,
overemphasize or even allude to passing transference manifestations
as long as the therapeutic work goes well. With such patients, work
with transferences will be minimal.
(b) When transference material from these patients is, for a
moment, a major vehicle of unconscious fantasies or a major part
of a resistance, it should be analyzed and resolved quickly, fostering
a return to the most workable central focus of the therapy: the
patient's life-problems and their neurotic aspects.
2. With other patients, transference material will play more of
a role in the treatment, but probably never be the recurrent centra1
focus.
(a) Transference should always unfold from day residues within
and outside therapy, and not from the proddings of the therapist.
(b) When disruptive sexual and aggressive transference fan-
tasies emerge, the therapist aims at focused analysis, insight, and
resolution. Elaboration due to overexploration will usually prove
disruptive and will be experienced by the patient as seductive or
hostile.
3. When material related to the therapist becomes central in
the sessions, the therapist must search out any possible role he has
played in evoking it. As mentioned above, day residues evoked by
198 THE PATIENT-THERAPIST RELATIONSHIP

errors and countertransference must be distinguished from those


due to appropriate interventions and behavior.
In all, then, therapists should not attempt artificial~y to induce
transference reactions, or make them the center of the therapeutic
work when they appear in passing or in a relatively inconsequential
form. Overemphasis on transference manifestations can be in the
service of disruptive forces within the therapist and will most often
undermine the treatment.
On the other hand, failure to deal with critical transference fan-
tasies and especially resistances can also totally undermine a
therapy. As always, there is no substitute for sound clinical judg-
ment and sensitivity.
Under varying circumstances (e.g., at times of separation, as
responses to outside traumas that prompt an intensification of feel-
ings toward the therapist, and in response to the therapist's errors),
transference fantasies may indeed reveal, and reflect the modified
reliving of crucial, repressed fantasies and memories related to the
core of the patient's relationships, neurosis and symptoms. Such
material must, indeed, be used to analyze and resolve the underlying
conflicts and symptoms. As a rule, such work can be concentrated in
several sessions, often dramatic, and the patient will then spontane-
ously shift again (not as a resistance, but as a further elaboration of
the material at hand) to outside stimuli and day residues, and the
responses they evoke.

Transference as Resistance
I have already alluded to ways in which transference phenomena
can interfere with the flow and development of psychotherapy (see
Blum, 1971a; Freud, 19l2a, 19l4b; and Greenson, 1967-among
others-for a full treatment of this subject as it applies to psycho-
analysis). I have so far emphasized the content of transference fan-
tasies, their unconscious and conscious meanings and genetics, and
their role as conveyors of the patient's psychopathology and past
relationships. Their role in interfering with the search for inner
change and in disrupting the therapeutic alliance (see pp. 215-21) is
also of significance. Since this topic is closely related to the thera-
peutic alliance and the technique of interpreting the transference
(see also Chapter 21), I shall be brief here.
Patient's Reactions: Fundamental Concepts 199

To begin, a review of the four main vignettes out of which this


discussion is being developed reveals the ways in which the respec-
tive transference manifestations served as resistances:
With Miss I.H., transference became a major dimension of a
critical breakdown in the psychotherapy and was one source of the
patient's abrupt termination. Miss I.H. responded to her therapist's
depriving her of part of her session, and to his provocations, with
anger and sexualized longings that were based on a number of
different earlier relationships with transference figures who had hurt
and seduced her in the past: her father, mother, and brother. Under
the sway of these transference feelings and fantasies (and of course,
some appropriate anger and mistrust; see Chapter 22), the treatment
foundered and resistances in many forms predominated-silences,
disruptive anger with the therapist, and acting in. With the added
pressures of her mounting rage and the intensification of her sexual
fantasies, compounded by the therapist's failure to intervene in an
adequate and helpful manner, these resistances heightened both
consciously and unconsciously, and took on added fantasied and
acted-out representations: the wish for a child from the therapist;
the wish for, and fear of, his sexual attack; and the fantasy of
destroying-devouring-him. It all culminated, as we know, in her
abrupt termination, as an acting out of unanalyzed transference
fantasies and a response to real provocations.
Miss I.H.'S transference resistances were the expression of many
fantasies. We see too that transference resistances are complex
phenomena, not to be defined by general descriptive terms such as
"silences," "acting out" and the like, but in terms of the specific
underlying situation and the latent unconscious fantasies and con-
flicts. In this way, the contribution that transference reactions make
to resistances can be properly understood.
Notice too that the transference fantasies themselves may seri-
ously disrupt treatment. As the patient's transferred rage and sexual
wishes intensified, they disrupted her entire perception of the thera-
pist and treatment, interfered with the therapeutic alliance, and
deflected focus from the patient's ongoing neurotic problems onto
her relationship with the therapist. While both parties can always
gain something from understanding and working through such
experiences, the traumatic and disruptive aspects make such gains
200 THE PATIENT-THERAPIST RELATIONSHIP

very risky; working-through of the evoked intrapsychic conflicts can


be accomplished far more safely in other ways.
Mrs. I.L.'S erotized transference also threatened to destroy her
treatment and therefore served as a major hazard and potential
roadblock to its development. However, because the therapist had
not precipitated these reactions and handled them well, they were
resolved without threat to the therapy (see Chapter 21).
Miss I.M.'S transference fantasies evoked silences, acting out, and
other behavior that never actually threatened the continuation of
her treatment. Mr. I.N., on the other hand, expressed repeated trans-
ference fantasies which disrupted treatment both through negative,
hostile fantasies and later, those related to his clinging to the thera-
pist and not resolving his symptoms. This latter transference resis-
tance was based on unconscious longings for closeness to, and union
with, a good mother figure and not primarily on fear and mistrust.
It was also a transference gratification because it was not directed
toward promoting improved functioning and symptom resolution,
but was designed to maintain a symbiotic tie detrimental to such
goals; it constituted a symbiotic misalliance.
If we consider Mrs. I.Q. and Mrs. I.R., we can add the observation
that transference psychoses can also be part of strong and critical
resistances to treatment. Both of these patients experienced trans-
ference beliefs that disrupted their therapeutic alliance and the
therapeutic process itself. Without modification of these beliefs,
little therapeutic progress was possible.
One last point: not all transference fantasies serve as, or evoke,
resistances. As we shall see, certain transference fantasies reflect
efforts at adaptation, not only to an acute stimulus, but also to the
patient's continuing intrapsychic conflicts. They therefore primarily
convey critical unconscious fantasies and modes of adaptation
which, when properly analyzed, contribute to the positive outcome
of treatment.
To conclude this section, I shall summarize the main principles:

1. We must understand not only the content and genetic roots


of transference manifestations, but also the use to which the patient
puts them-their adaptive aspects.
2. Among the most common uses of transference responses is
Patient's Reactions: Fundamental Cont-epts 201

resistance to the unfolding of the work of the therapy. As such,


transference may be used to disrupt treatment and the therapeutic
alliance, and may also be a crucial part of major resistances to the
analysis of unconscious fantasies.
3. Failure to analyze the resistance aspects of transferences can
lead to major disruptions of therapy and even premature termina-
tion. These phenomena are therefore a major indication for inter-
ventions by the therapist. As we know, interpretations of resistances
generally take precedence in therapeutic work.

Defenses Against Transference Expressions


While this subject is of considerable importance in psycho-
analysis, where work with transference is central and critical (see
Greenson. 1967 and Blum, 1971a, 1971 b), it is generally less crucial
for psychotherapy, though at times it proves to be a major issue.
Some patients characteristically repress and deny any irrational or
inappropriate feelings and fantasies about the therapist and therapy.
TheIr associations even in response to strong day residues and
traumas from the therapist lack derivatives related to the intra-
psychic conflicts such experiences are bound to evoke. Such patients
usually remain somewhat aloof from the therapist; though they may
be cordial. if reserved. The underlying reasons for this stance are
usually related to early traumas in their relationship with their
mothers and a lack of basic trust, and reflect fears of closeness to
the therapist and of all kinds of irrational fantasies. Progress with
these patients is often slow: they are especially likely to remain
uninvolved with the therapeutic work and they are prone to prema-
ture termination of their treatment (see Chapter 25).
If treatment is progressing and the therapeutic alliance is essen-
tially stable and secure, there is no need for the therapist to focus
on this defensiveness. However, when therapy is stalled or its con-
tinuation is threatened, exploration and analysis of this difficulty in
manifesting transferences is indicated if derivatives permit; if latent
content related to this problem is lacking, confrontation with it may
be the only possible means of enabling the patient to continue in
treatment. It is, at best, a difficult type of defense and resistance to
modify in psychotherapy.
202 THE PATIENT-THERAPIST RELATIONSHIP

Mrs. LV. entered therapy because her husband was


having an affair and wanted a separation. While she was
depressed. she reported no emotional symptoms except
for periods of excessive weight swings. Late in her
therapy. which lasted about seven months. it emerged that
she had well-controlled phobic anxieties with excessive
fears of heights and illness.
Her therapy was characterized by a strong focus on
her realistic conflicts with her husband. with almost no
expression of the unconscious fantasies and intrapsychic
conflicts they seemed to create for her. These were evi-
denced. however. by periods of near-starvation and then
gluttony. and by her sudden decision. at a point when
her marriage seemed reinstated. to divorce her husband
and live with another man whom she hardly knew-a
decision which prompted her to terminate her therapy.
All of this was strongly rationalized. and while the patient
agreed that her behavior seemed odd. she produced little
that went beyond that assessment.
She would often complain that the therapist did not
help her with her problems. but this was rationally
founded on the fact that he had little to say about these
real issues except for occasional empathic comments or
helpful clarifications and confrontations.
According to Mrs. LV:S description. her mother was
insensitive and their relationship varied. sometimes close
and at other moments distant. While there were hints
that the patient had some deep mistrust of her. there was
no apparent way that this could be effectively connected
to her distant stance with the therapist. Absences and
lateness were rationalized as expressing a real problem in
getting to her hour or as a reflection of the therapist's
failure to help her resolve her problems with her husband.

In all. the therapy ended when the patient rather impetuously


"resolved" her problem in her marriage. Throughout. Mrs. LV.
maintained her distance and avoided derivatives of unconscious
fantasies of all kinds, including those related to the therapist and
Patient's Reactions: Fundamental Concepts 203

therapy. In his formulation of these problems, the therapist sus-


pected that he was dealing with a mistrustful mother transference,
fears of primitive fantasies, and anxieties related to bodily harm in
close relationships. His efforts to develop these latent themes were
not successful.

Under more favorable circumstances, both interpre-


tation of the source of the anxieties that promote repres-
sion and denial of transference material, and the related
unconscious fantasies, can modify these defenses. This
was seen in the therapy of Mr. LW., a young man who
entered therapy because of difficulties with his college
work; he had a moderate character disorder and depres-
sive illness. His father was a dentist who had practiced in
the family home, and his mother had been ill several times
during his childhood, severely so when the patient was
four and a sister was born.
Initially, Mr. LW. was guarded and distant, yet easily
depressed by any negative tone in the therapist's com-
ments. After filling in some historical material, he focused
on his realistic problems, such as those with school work
and with his parents and sister, whom he saw regularly.
When this had continued for some months, the therapist,
over several sessions, gently confronted the patient with
his defensiveness and avoidance of dreams and fantasies.
Then, guided by a few passing references to the patient's
father, he suggested that the patient's earlier experiences
with his father and observations of the suffering of his
father's dental patients was a factor in this defensiveness.
Responding both to the therapist's consistent concern and
warmth, and to these interventions, the patient recalled
several traumatic experiences connected with his father's
practice. He began to recall his dreams, and their content
and his associations to them, as well as material from
other sources, led to the unfolding of Mr. LW.'S central
intrapsychic conflicts, which were related to his mother's
illnesses and separations from her because of them.
204 THE PATIENT-THERAPIST RELATIONSHIP

In conclusion, then, strong defenses against transference mani-


festations may be left unexplored unless there is a threat to the
treatment. An approach that combines nonverbal communication
of consistent concern and tolerance of the patient and his irrational
thoughts, with sensitive confrontations and interpretations of the
anxieties and fantasies underlying this resistance, may aid the
patient to modify this maladaptive stance.

Transference Gratifications
It is inevitable that patients will endeavor to gratify transference
fantasies with the therapist or, by displacement, with others. These
efforts are pronounced in some patients, especially those that are
narcissistic and borderline. In general, gratifications of transference
fantasies, since they are irrational and related to the sources of the
patient's neurosis, will undermine other efforts by the patient to
resolve his intrapsychic conflicts. This is one essential meaning of
the rule of abstinence (Freud, 1915, and Greenson, 1967). Thus, the
therapist must detect any way in which he participates in or permits
such satisfaction of transference wishes, and shift to a nongratifying
stance, though not in a punitive way, and then explore and analyze
the transference involved. Continued participation in these forms of
gratifying neurotic needs will lead to a misalliance and undermine
the therapy. This subject was explored in som~ detail when we con-
sidered the ground rules of psychotherapy, since the patient-and
therapist--often use deviations from the boundaries and limits of
their relationship as a vehicle for such gratifications (see Chapters 5
and 6; the therapist's role in such problems will be studied in detail
in Chapter 22).
In addition to positively-toned satisfactions, some patients gratify
transference fantasies by evoking antitherapeutic reactions in their
therapists; if, for instance, they can provoke a moralistic thera-
pist to condemn acting out, this gratifies needs to be scolded
and beaten by an earlier figure. Such needs are then repeated in
reality with the therapist rather than frustrated, expressed in deriva-
tives from the patient, and analyzed.

Mr. I.N., who came for his sessions and did virtually
no therapeutic work, presented a form of transference
Patient's Reactions: Fundamental Concepts 205

gratification difficult to analyze and resolve. Constant


search by the therapist revealed no particular way in
which he was fostering this stance and confrontations with
it did little to modify it. It was, however, a repeated topic
in his treatment (see Chapter 21). A dream which was
reported during these explorations is pertinent. It fol-
lowed a session in which the therapist had pointed out the
patient's misuses of the therapy situation and seriously
questioned the value of continuing his sessions if this
could not be modified. In the dream, a young man, who
was a close friend of the patient, calls him into a bath-
room, and the patient wants to masturbate in front of or
with him. When no relevant associations followed, the
therapist pointed out that this was an apt picture of Mr.
I.N.'S treatment: the patient was self-indulgently satisfy-
ing himself as he--the therapist-looked on or somehow
participated. The patient angrily denied the implication
that he did not want therapy or change for himself.
He began the next hour with a unique comment of
agreement with the therapist: he had been right about
the therapy. On the night after the previous session, Mr.
I.N. had dreamt of being with a nude boy who looked
older somehow, though he had a small penis; they mas-
turbated each other. The patient said that he recognized
that he had been trying to involve the therapist in his
sickness and to make him into a nothing. He related the
boy to a childhood homosexual experience and spoke of
how the discovery of that incident had disturbed his
mother.

This vignette illustrates one unconscious meaning of transference


gratification; there are a whole range of additional pathological
unconscious fantasies that patients attempt to gratify directly with
their therapists. Sensitivity to such issues is essential; the therapist
should especially search for possible participation. Mr. I.N.'S dream
of mutual masturbation may have reflected a number of things: a
wish for such participation by the therapist; a perception of the
therapist's contribution through his continuation of the stalemated
206 THE PATIENT-THERAPIST RELATIONSHIP

therapy; or the detection of some other way in which the therapist


was unwittingly gratifying the patient's neurotic needs. Only deter-
mining which of these possibilities is actually central can lead to
correct interventions and necessary modification in the therapist's
stance and ultimately in the misalliance.
Transference gratifications must be distinguished from those
appropriate gratifications available and necessary to both partici-
pants in therapy; I shall discuss this distinction further in the final
section of this chapter and in Chapter 22.

Preformed Transferences
As I indicated in Chapters 3 and 4, the therapist can detect
transference manifestations in many initial telephone calls and first
sessions, and these are relatively uncontaminated, non-therapist-
evoked transferences-although the therapist's telephone responses
quickly offer day residues to prompt the elaboration of these and
other transference fantasies and reactions in the patient.
These preformed transferences may be based on earlier experi-
ences with parents and siblings, and are often colored by past
experiences with other physicians and therapists. They may be the
basis for initial mistrust or trust, and are dealt with only when they
are part of early resistances and if they threaten the therapeutic
alliance and the continuation of treatment. An especially powerful
source of such transferences is constituted by early childhood
experiences in which a family member died; the negative images of
the therapist that this provokes are often quite primitive and difficult
to elicit and resolve. Similar difficulties in analyzing apply to experi-
ences with a previous therapist, especially when this has been
largely traumatic (e.g., a seduction, much hostility, or termination
because the therapist died) and when there was an unsatisfactory
outcome. These anticipatory transferences are also a reflection of
the patient's pretherapy character structure, attitudes, and means of
relating, whatever their earlier roots.
In our clinical material, we can detect in Mrs. I.L. a preformed,
mistrustful, deprivation-anticipating, sexualized transference based
on an overdetermined father and mother transference. As it turned
out much later, this was also founded on earlier experiences with
Patient's Reactions: Fundamental Concepts 207

physicians. especially a serious illness that left her father's leg


permanently crippled.
Mr. I.N. had a preformed. deeply mistrustful mother transfer-
ence. with some roots related to traumatic experiences with his
father. and to a failure to improve in treatment with a previous
therapist.
These preformed transference elements are an important part
of the patient's initial expectations. his conscious and unconscious
set toward the therapy and therapist. and the kind of therapeutic
alliance he first develops with the therapist (see p. 212 if. and
Chapter 21).

So-Called Transference Cures


Freud (1913) first noted that a patient's symptoms may disappear
in analysis primarily as a result of transference. and several writers
have pursued this lead (see Oremland, 1972. for a review of this
subject). The concept of "transference cure" refers to symptom
alleviation that is based on transference wishes for the therapist's
love; this the patient hopes to gain by becoming symptom-free.
It may also be based on transference identification with the thera-
pist so as not to experience his loss. I shall not explore this compli-
cated subject here. except to note that these modes of symptom
alleviation must be distinguished from so-called "countertrans-
ference cures" in which the therapist's unresolved problems con-
tribute significantly to the apparent positive changes in the patient.
My observations. especially in supervision. suggest that this form
of symptom alleviation is far more common in psychotherapy than
those evolving out of transference love and identification with the
therapist (see Chapter 22).
As for apparent transference cures, then, this term will be used
here to refer to those patients who show relatively sudden resolution
of their symptoms in the context of material suggesting that positive
transference fantasies. or defenses against negative transference
fantasies, are central to the change. Such changes are to be dis-
tinguished from symptom relief that evolves from insight and work-
ing-through. Often correct interpretation of the basis for trans-
ference-related symptom relief will prompt a reappearance of the
208 THE PATIENT-THERAPIST RELATIONSHIP

symptoms; at other times, such "cures" are temporarily main-


tained and lead to termination. While theoretically, such an avenue
of symptom modification would be expected to be fragile and
uncertain, I have no data with which to pursue this issue. With
patients who continue their therapy, transference-based symptom
relief tends to fluctuate with the climate of the transference and
not to provide stable symptom resolution.
Most of the transference "cures" that I have observed in
psychotherapy derive, interestingly enough, from the patient's de-
fensive denial of need for the therapist, and arise most often in
response to his vacations and to forced terminations, i.e., those
necessitated by clinic rules or by a move by the therapist, rather
than the completion of the therapeutic work (see Chapter 25).
These responses have the quality of transference-based flights into
health (Oremland, 1972).
As a brief illustration of these points, consider the case of Mr.
I.N., who established a kind of transference-based alleviation of
one aspect of his symptoms when he began to control his outbursts
of rage against his parents and hold a steady job. The transference
fantasies related to the therapist as an overidealized and all-caring
parental figure who would, up to a point, protect him from harm.
Later exploration and working-through helped solidify these gains.
This is a. not uncommon sequence-transference-based change
followed by structural change-but therapeutic work is necessary
to achieve it. The uncertainty of this symptomatic improvement
was revealed in the patient's failure to resolve his additional symp-
toms and his refusal to terminate therapy. Since this is an ongoing
treatment, I cannot describe any final resolution.
Turning to another vignette, Mrs. I.T., to whom I alluded on
pp. 182-83, entered therapy, as I said, for phobic symptoms includ-
ing a fear of riding on buses and subways. Soon after treatment
was under way, in the climate of a strongly positive feeling that
her therapist was interested in and concerned about her, she re--
ported that she could travel without much anxiety. Other associa-
tions showed transference elements to this response: there were
present latent erotic fantasies with intense wishes to please the
therapist, based on a father transference, and also feelings of total
safety and protection-comparable to those described in the
Patient's Reactions: Fundamental Concepts 209

earlier vignette-based on her longings for a protective mother.


When the therapist then went on vacation early in her treat-
ment, Mrs. I.T.'S symptoms returned, amidst associations of her
disappointment in her parents and husband. They were somewhat
alleviated once the therapy was resumed, but the patient later
experienced anew the symptoms reported in that first vignette just
before another vacation by the therapist.
We see here the kinds of fluctuations that the therapist may
expect to see with transference "cures." Such reactions generally
occur with neurotic symptoms. and not with character traits that
are more entrenched in the patient's functioning and less modifi-
able through unanalyzed transference fantasies. The alleviation of
symptoms, while characterologic and interpersonal problems con-
tinue, is not uncommon in patients at the outset of therapy. and
is usually based on a strong real and transference tie to, and fan-
tasies about. the therapist. These symptoms generally reappear
with separations from the therapist. other traumas, or pending
termination; at such times they may be analyzed and worked
through.
Transference-based denial of need for the therapist seemed to
be a major factor in the following clinical experience:

Mrs. L.T. had been in therapy for eight months be-


cause of anxiety and fears of the dark. robbers, and being
harmed physically in some way; she had a moderate
characterological disturbance.
Her anxiety and phobic symptoms had fluctuated
during the early months of her therapy. to some extent
in line with the climate of the transference. but they
had continued to disturb her somewhat throughout that
period. In the session before the therapist took his vaca-
tion. Mrs. L.T. spoke of how well she was feeling. She
was going to bed early and sleeping late; maybe it was
an escape. Her son was to have surgery and was afraid
of doctors and anesthetics; he was just like her. She tried
to hide her fears from the children. especially her fears
of lightning and the dark. She had thought of missing
the present session because she was at a friend's house
210 THE PATIENT-THERAPIST RELATIONSHIP

and felt so well. She might move to Florida with her


family. Her mother lived there now; she was a woman
who used to scream a lot and did not care about her
children very much.
In the session immediately after the vacation, Mrs.
L.T. said that she had felt exceedingly well during the
two weeks that the therapist had been away, and that
she felt ready to terminate her treatment. The therapist
suggested that she explore this decision and the patient
justified it on the basis of her symptom relief. She then
went on to speak of her mother, who had been a success-
ful local actress and an independent woman who had
always bragged about her children even though she was
never around to take care of them. Her mother had been
neglectful and had caused the patient's stomach pro-
blems and fears of eating in restaurants; mealtimes at
home were always moments when her parents fought
and threw things at each other. Mrs. L.T. felt that she
had gotten along not because of her mother, but despite
her. She then described the plans for her son's tonsil-
lectomy.
In the next hour, Mrs. L.T. described her son's sur-
gery, which had been carried out after the last session,
and reported that her symptoms had returned in full
force. Oddly enough, she had no symptoms until after
she had taken her child home and her husband had gone
out of town, leaving the patient and her son alone. She
feared being killed in her sleep and recalled her own ton-
sillectomy, emphasizing her fears of being harmed or
killed by the doctors. The therapist's office was in an
isolated place, someone could threaten to kill him and he
could not call for help.

We may formulate that Mrs. L.T.'S transference-based symptom


relief developed out of her unconscious fantasies of being deserted
and neglected by her therapist, much as her mother had done
repeatedly in her childhood-a mother transference. Just as Mrs.
L.T. had mobilized herself as a child and had functioned well
Patient's Reactions: Fundamental Concepts 211

despite her mother, indeed, so as to deny need for her mother's


care, she similarly pulled herself together in the therapist's absence.
Once he returned, the patient's denial gave way, and she expressed
her fears of being alone and her rage at the therapist in disguised
derivatives of concern that he might be murdered and in her fears
about herself. The role of her son's surgery-another context for the
reappearance of her symptoms----<:annot be assessed here, though it
is of note that it was only after her husband had left her in her time
of need (a repetition of the mother's and therapist's traumas) that
her symptoms reappeared.
In all, then, symptom exacerbation and alleviation may both
occur during ongoing psychotherapy based primarily on transfer-
ence fantasies. Careful scrutiny of the material from the patient,
including the context and latent content of his associations, will
enable the therapist to recognize the role of transference reactions in
these fluctuations. Transference "cures" tend to be unstable and are
best analyzed to permit more stable resolutions of the patient's
symptoms. At times, they serve as important resistances to the
unfolding of treatment and therefore require exploration to foster
further therapeutic work.
Technically, this must be balanced with the tenet that the
therapist should not challenge or undermine such ego integration,
however fragile or temporary it may be. It does represent a positive
adaptation to loss or some other trauma, and the patient may be
able to build more stable adaptations on the basis of this one.
Patience and tolerance, helping the patient to delay any immediate
wish to terminate, and continued exploration will, as a rule, lead to
regression and reappearance of the patient's symptoms. If not, such
a response may be structuralized and reflect the crystallization of the
gains made in treatment. Only when it seems to be leading to prema-
ture termination must such a response be urgently explored, ana-
lyzed, and resolved.

THE PATIENT'S RELATIONSHIP WITH


THE THERAPIST:
NONTRANSFERENCE ASPECTS
There are many dimensions to the patient-therapist interaction
212 THE PATIENT-THERAPIST RELATIONSHIP

that are primarily realistic and nonneurotic, though intrapsychic


and genetic factors contribute to them secondarily. It has already
been established that there are no essentially genetically-founded
transference reactions to the therapist and treatment without a day
residue-a reality context that provides a kernel of current truth to
the transference response (Freud, 1937). Similarly, we may expect
from the outset that any primarily appropriate-non transference-
response to the therapist and treatment will have personal and
intrapsychic elements to it as well. The patient's response to the
realistic dimensions of treatment are strongly influenced by his past
relationships and experiences, and by his current inner set and
fantasies, which color his interpretation of the realities and his
responses to them. Autonomous and nonconflicted ego functions
also contribute to these assessments and reactions, including mature
object-relatedness, sound reality testing, unencumbered perceiving,
and appropriate sensitivities to the therapist.
Included in this primarily realistic interaction between the
patient and therapist are the actual framework and ground rules of
the psychotherapy, the respective roles of each participant, the
gratifications and hurts that unfold from each toward the other, and
a variety of other actual experiences. These realities have a great
influence on the unfolding of the therapy and on the expressions
of the patient's intrapsychic conflicts. The therapist must be in tune
with the way both he and the patient experience their fluctuations
and nuances, lest the basic atmosphere of the therapeutic situation
be disturbed. The importance of this aspect of the patient-therapist
relationship had led to the isolation of one aspect of it, through the
idea of the therapeutic or working alliance (Zetzel, 1956 and Green-
son, 1965 and 1969). Let us, then, begin with this dimension.

THE THERAPEUTIC OR WORKING ALLIANCE


The therapeutic alliance between the patient and therapist is
basically a reality-oriented partnership geared consciously and un-
consciously toward the alleviation of the patient's symptoms. The
working relationship between the two is basically cooperative, non-
neurotic and sensible. It is founded on the mutual recognition of the
patient's emotional problems and symptoms, and the therapist's
Patient's Reactions: Fundamental Concepts 213

special technical skills as a professional who can assist the patient


in achieving symptom-relief. This working alliance, then, is the
primarily rational, reality-oriented, secondary-process-dominated
basis for treatment. Its establishment and continuation safeguard the
sometimes painful unfolding of the therapeutic work and maintain
perspective in the face of disturbing moments in the patient-thera-
pist interaction.
But there are also less rational, primary-process-dominated roots
to the therapeutic alliance on both sides. The patient, for example,
sometimes hopes for magical relief or cure through love; the thera-
pist may have fantasies of omnipotence. As a rule, these unrealistic
and transference (and countertransference) contributions will even-
tually disturb the therapeutic rapport and require analytic modifica-
tions.

Establishing the Therapeutic Alliance


Both the patient and therapist contribute to the building and
maintenance of the therapeutic alliance (Greenson, 1965 and 1969).
Its initial development on the patient's part depends on his motiva-
tions for therapy, his anticipations regarding treatment, and his
capacity to trust and to form working relationships in general and
the special kind of relationship necessary with the therapist; this
includes his being the prime communicator, yet at the same time the
person who is in need of help and therefore selectively passive and
open to the understanding imparted to him. He must accept the
so-called "tilted relationship" between the two (Greenacre, 1954)
without undue disturbances. In addition to acknowledging his need
for help and tolerating his role as a patient, he must also be capable
of direct cooperation with the ground rules of therapy, including
those related to free associating and to revealing himself to the
therapist. Beyond this, he must have a capacity to express deriva-
tives of his unconscious fantasies as they are related to his current
conflicts and symptoms. These are the essential communications out
of which his verbalized contribution to symptom resolution is
achieved, and the patient must be capable of making them available
to the therapist. He must both experience his relationship with the
therapist and observe it with perspective (the so-called experiencing
and observing egos; Greenson, 1967).
214 THE PATIENT-THERAPIST RELATIONSHIP

Patients vary in the manner and extent to which they are able
to establish a firm and optimal therapeutic alliance at the start of
therapy. Because such an alliance enables the patient to tolerate
painful moments and regressions in treatment without leaving it,
disturbances in his capacity for a mature working alliance must be
explored and revised in the opening phase of therapy (see Chapters
4 and 23).
For his part, the therapist's contribution to this alliance begins
with his professional skills and his capacities for warmth, concern,
and a judicious combination of sympathy and distance. His lack of
bias, his ability to be logical and sensible, sensitive also to the
irrational elements in the patient, and, as appropriate, explanatory
and analytic, also contribute from the outset. The explicit and
implicit ground rules that he establishes and his manner of interact-
ing, with all that it imparts to the patient, are also important in his
quest for a working relationship that is positively toned, honest, and
realistic. His personality, fantasies, and clinical manner all color his
efforts.
Therapists also vary in the manner and extent to which they are
capable of contributing to a mature therapeutic alliance. I shall
discuss the therapist's role in greater detail in Chapter 22.

Maintaining the Therapeutic Alliance


The therapist monitors many aspects of the patient's communi-
cations, including especially their reality elements-the real experi-
ences and conflicts-and the unconscious fantasies therein con-
tained-the intrapsychic conflicts. He assesses their relevance to
the patient's outside problems, real and neurotic, as well as to the
therapeutic relationship, real and neurotic, and to the patient's per-
ception of himself and the therapist, including the transference and
counter transference. Monitoring the climate of the therapeutic
alliance is especially important, both because of the risk that the
patient may terminate treatment abruptly when it is impaired, and
because, less extremely, its disturbance generally reflects the inter-
personal aspects of the patient's resistances to therapy. It reveals the
extent to which the patient is accessible to the therapist's interven-
tions and contrariwise, the extent to which he may reject them
primarily out of negative feelings toward the therapist. Thus, if the
Patient's Reactions: Fundamental Concepts 215

working alliance is askew, therapeutic work directed toward analyz-


ing and working through the problems in this alliance must take
precedence over other therapeutic endeavors (see also Chapter 21).
The patient's positive contributions to the working alliance
include his capacity to experience negative feelings toward the
therapist and to scrutinize them, to regress and to communicate in
depth on the one hand, and to assess, understand, and integrate
on the other. It includes his ability to recognize the meaning of the
therapist's interventions and to tolerate the latter's reasonable
silences, and to take in and utilize what the therapist offers to him.
He must be able to tolerate necessarily hurtful interventions and
silences with an appreciation of the long-range goals of therapy. He
must, at times, show an understanding of the therapist's errors and
unnecessary hurts, with reasonable but not protracted anger and
comment, and without undue rage, disruption, and loss of perspec-
tive. In addition, his ability to limit and work with those irrational
and transference-based fantasies that disturb the therapeutic alliance
is important.
In the face of the patient's psychopathology, maintenance of a
strong working alliance, it is clear, taxes his resources in many ways.
The therapist contributes his lack of seductiveness or hostility,
his consistent search for understanding and insight, his neutrality,
and his tolerance without undue or deviant reaction to the patient's
communications and-should they occur-attacks or seductiveness.
Important are correct understanding of the patient, accurate and
helpful interventions, and creation of an atmosphere of reasonable
gratification, in which the patient is aware of the therapist's concern
and the slow resolution of his own neurotic rlifficulties. His ability to
avoid repetitive difficulties and to work through the patient's
responses to inevitable momentary lapses, and his skill in analyzing
all disturbances in the relationship itself, are significant factors.

Disturbances in the Therapeutic Alliance


As we would expect, disturbances in this alliance during ongoing
psychotherapy may emanate from either the patient or therapist.
They may be in the form of acute disruptions due to some sudden
cause or to the accumulation of repeated difficulties that culminate
in a climatic disturbance; or they may take the form of chronic
216 THE PATIENT-THERAPIST RELATIONSHIP

impainnents, anti therapeutic alliances or misalliances, which under-


mine effective therapeutic work (see Chapters 4 and 23).
Acute disturbances in the therapeutic alliance that stem primarily
from the patient have a variety of causes. They may occur in
response to a traumatic event outside treatment, which may, for
example, generate displaced anger at, or an excessive need for, the
therapist, or rage that he failed to protect the patient. They may
occur in response to correct behavior by the therapist, such as neces-
sarily painful interventions or his vacations, incidents that evoke the
patient's anxiety, mistrust, hostility, or inappropriate seductiveness
toward the therapist. They may occur too when unrealistic and more
magical expectations of the therapist are frustrated. And they may
unfold when transference fantasies from any source and of any type
invade the more mature and realistic elements of the patient's rela-
tionship with the therapist and thereby disrupt it.
More chronic disturbances in the therapeutic alliance stem
largely from the continuing eruption of the patient's intrapsychic
conflicts, unconscious fantasies, and transference fantasies into his
relationship with the therapist, eroding and marring it. The patient
endeavors to create a therapeutic misalliance in which his inappro-
priate and neurotic needs are gratified, rather than worked through
and resolved. He may attempt, for example, to give sadomasochistic,
seductive or manipulative colorings to the therapeutic relationship,
or to gear it primarily toward goals other than symptom-relief
through inner change (see Chapters 5, 6. and 23). Chronic maladap-
tive and unanalyzed impainnents in the therapeutic alliance usually
develop with the participation of the therapist (see Chapter 22);
efforts to maintain such misalliances must be detected and analyzed.
Some patients are especially prone to acute disturbances in the
therapeutic alliance, while others attempt to foster misalliances of
various kinds. The therapist must anticipate and resolve such
propensities, since all patients will try to create misalliances.
Disturbances in the therapeutic alliance that stem from the
therapist are probably the greatest single threat to the continuation
of treatment and will be explored in detail in Chapter 22. Here. let
us turn to our clinical material to illustrate some aspects of the thera-
peutic alliance and its problems (for additional vignettes see the
Index of Clinical Material).
Patient's Reactions: Fundamental Concepts 217
With Miss I.H., the therapeutic alliance in the sessions described
in Chapter 19 went from one that was generally cooperative to one
that was mistrustful, angry and prompted efforts at closing herself
off from the therapist. The complexity of the therapeutic alliance is
reflected in the observation that while she consciously balked at
cooperating with the therapist, she continued to reveal derivatives
of her fantasies; unconsciously, she continued her efforts to com-
municate with the therapist and to resolve both her intrapsychic
conflicts and her problems with him.
This disruption in the therapeutic alliance was evoked primarily
by the therapist's errors and possibly by several outside experiences
of the patient-her parents' return, her cousin's seductiveness and
her vaginal examination. The form in which this disruption unfolded
-the missed sessions, anger with the therapist, the regressive symp-
toms, the abrupt ending of the therapy-reflected both the patient's
psychopathology and the nature of the disturbing stimuli; it
expressed her reality-oriented, nonneurotic functioning as· well.
After all, there are adaptive qualities to a decision to terminate
therapy with a therapist who has been repetitively destructive and
unable to understand her, though the abrupt and chaotic way in
which this was done gives a pathological dimension to the patienfs
behavior.
Mrs. I.L. came into treatment with a seductive and mistrustful
attitude and had difficulty from the outset in establishing a firm
and clear therapeutic alliance; considerable work was necessary to
help her modify this difficulty (see Chapter 21). The disturbances in
her alliance with the therapist arose primarily out of her early life
experiences with both parents (basic transferences), and later experi-
ences with professionals (later transferences), and their intrapsychic
consequences.
Mrs. I.L. initially sounded out her therapist on a mutually seduc-
tive misalliance in which transference gratification rather than
mature therapeutic work would prevail. The therapist's persistent
refusal to cooperate with this, and his consistent interpretation of
these wishes, eventually enabled her to work them through and
renounce them.
Her early cooperation with the therapist also involved magical
expectations. These were reflected in fantasies and dreams that por-
218 THE PATIENT-THERAPIST RELATIONSHIP

trayed the therapist as all-knowing, the bountiful mother-breast, and


the totally protective father.
Mrs. I.L. had major narcissistic pathology, and typically, was
enormously sensitive to the least hurt and negative intonation, or
the slightest lack of empathy, in the therapist. As a result, there
were many momentary-and more rarely, extended-ruptures in
the therapeutic alliance and stormy periods in her therapy. How-
ever, she always regained her perspective, though the therapist's
sensitivity to the sources of her distress proved critical in helping
her to do so. These disruptions, which also interfered with her
functioning at home, became less intense and less frequent, to the
point of virtually disappearing, as her therapy progressed. Toward
the end of her treatment, trust and respect for the therapist, and a
cooperative search for understanding, prevailed, though she
remained sensitive to any lack of mutuality between herself and the
therapist.
Until her therapist's vacation was announced, Miss I.M. had an
overtly trustful therapeutic alliance with him, though there were
hints of underlying wariness, which were not especially disruptive.
This is striking in the light of her poor relationship with her parents.
The anticipation of the separation, however, evoked a mother trans-
ference: Miss I.M. experienced the vacation as if it were a hostile
desertion, and responded with mistrust, silences, and acting out.
Throughout the ensuing disturbance of the therapeutic alliance,
however, the patient maintained a commitment to explore and
analyze her distress.
Mr. I.N. was at first intensely mistrustful of, and angry with, his
therapist, despite his avowed intention to cooperate with him. This
rational wish was repeatedly disrupted by the patient's intrapsychic
conflicts and needs, and his distorted view of the therapist. It took
months of therapeutic work to establish a resemblance of a working
relationship, and a firm and mature alliance never really eventuated.
Instead, he constantly strove toward a sadomasochistic misalliance,
and later, a protected, gratified misalliance in which inner change
was relegated to the background. Here, aspects of his mother- and
father-transference fantasies intruded on the working relationship,
and he defensively projected his own hostile-and later, homosexual
-impulses onto the therapist. His autonomous functioning within the
Patient's Reactions: Fundamental Concepts 219

therapeutic situation was generally impaired, though with thera-


peutic work, these acute disturbances could be resolved. Vacilla-
tions of this kind in the therapeutic alliance are characteristic of
many borderline patients; for them, therapeutic work in this area
is of prime importance.
Mrs. I.Q. and Mrs. I.R., experienced delusional and near-delu-
sional feelings toward their therapists, evoked at various times by
outside hurts, and within therapy, largely by the threat posed by
their therapists' warmth and understanding of them; their thera-
peutic alliances were plagued by major disturbances, to the point of
almost complete disruption of treatment. However, both did main-
tain some thread of a working relationship with their therapists,
though with Mrs. I.Q., despite all therapeutic endeavors, this ulti-
mately deteriorated because her delusions about the therapist
destroyed her working perspective; her quest for psychotic transfer-
ence gratifications made therapeutic work with her infeasible.
Mrs. I.R. was in a terrible dilemma about this working relation-
ship. On the basis of past experiences, especially with her mother,
she was basically mistrustful and anticipated betrayal at every turn.
She remained guarded and distant for long periods, even sitting
across the room from the therapist in her sessions. Closeness to him,
and being understood and helped, heightened her mistrust, but also
evoked intense longings for the therapist as a representation of the
idealized mother and father whom she had never had. This, in turn,
created fears of total need for, and surrender to, the therapist. Her
sense of guilt because of her outbursts of rage against the therapist
and others, and her degraded, worthless self·image, led her to feel
undeserving of help from the therapist. Still further, her level of
anxiety and ego functioning was such that, at times, she was unable
to comprehend and retain the simplest comments from the therapist.
In all, the working alliance was a fragile one easily disturbed by a
variety of causes, and in constant need of repair.
Having sampled various types of therapeutic alliances and the
problems that arise with them in the course of therapy, I shall
summarize my main observations in this area:
The therapeutic alliance is the mutual and cooperative determination of
the patient and theranist to work toward resolution of the patient's
symptoms through lasting inner change. It is, on the surface, the mature,
220 THE PATIENT-THERAPIST RELATIONSHIP

rational, and trusting aspect of the patient's relationship with the thera-
pist. The counterpart in the therapist is his offer to help, his concern for
the patient, his technical skills, and his ability to create the conditions
under which symptom-resolution may occur (see Chapter 22).

On the part of the patient, the therapeutic alliance may be precarious or


impaired in the course of treatment by a wide range of causes; these
include:
• Initial and often deep-seated suspiciousness or anger that lead to
mistrust of, and struggles against, the therapist.
• A seductive stance in which the patient attempts to make therapy
a sexualized situation, or one of lasting dependency or symbiotic grati-
fication, thereby creating major misalliances.
• External life events during therapy which evoke a heightened rage
against, or excessive need for, the therapist.
• The emergence in therapy of disturbing material that creates dis-
ruptive anxieties and fantasies.
• Intense or disturbing transference fantasies that erode the thera-
peutic alliance and the mature, primarily realistic partnership on which
it is based.
The therapist, for his part, may intervene or behave in a manner that
disrupts the therapeutic alliance. Such behavior ranges from incorrect or
missed interventions, to acts of seduction and hostility on various levels
(see Chapter 22), to unnecessary deviations in technique.
Thus, while it is primarily a conscious and appropriate mutual coopera-
tion, the therapeutic alliance is based both on realistic and on unconscious
factors, including genetic experiences and related transference fantasies,
fantasies related to the meanings of the patient's illness to him and of the
relief he gains from it, and the unconscious meanings of a cooperative
venture that may be highly erotized or aggressivized for either or both
parties.
A firm therapeutic alliance is essential for the progress of therapy and the
unfolding of insight and emotional growth. It offers the patient a secure
object relationship and safe setting in which to reveal himself, and a
stable tie that aids him in maintaining his perspective during stormy
periods of the therapy.
For the therapist, the security of this alliance enables him to inter-
vene at times in a manner that is, necessarily, painful to the patient,
knowing that the latter will attempt to tolerate and understand him
without acutely disrupting or terminating the therapy. A firm alliance
generally assures a serious, rational consideration of these interventions
by the patient, including his understanding that they are, by and large,
made in his best interests. This adds to the patient's capacity to accept
Patient's Reactions: Fundamental Concepts 221
the narcissistic hurts and constructive criticism such comments may con-
tain, and promotes the entire process of working-through within the
patient (see Chapter 17).
Impairments in the therapeutic alliance are a crucial form of resistance
to treatment. They therefore merit primary focus and take precedence
over other aspects of the therapeutic work. On the other hand, when this
alliance is going well, little or no therapeutic focus is placed on it.
The therapist must be alert always to subtle and insidious impair-
ments in this alliance. They may range from recurrent, strongly ration-
alized disagreement with seemingly well-supported interventions, to
recurrent, therapist-lulling agreement with virtuallv everything the thera-
pist says, though this is not followed by true confirmation or integration
by the patient. Blind submission is as much a reflection of a poor thera-
peutic alliance as is blind rage or seductiveness.
The following classificatory comments help us to understand the technical
implications of disturbances in the therapf'Ufic alliance:
• Not all resi&tances pose threats to the therapeutic alliance, but all
disruptions to this alliance are major and crucial resistances.
• Disruptions in the working alliance may be characterized by:
(a) A disturbed alliance that is partly ego-alien for the patient and
a matter of therapeutic focus for him and the therapist.
(b) A disturbed alliance that is ego-syntonic for, and rationalized by,
the patient and that he resists analyzing. In this situation, there may be
few or no intrapsychically meaningful associations, creating a serious
crisis for the therapy and a likelihood of acting out with premature ter-
mination. Or there may be many latently meaningful associations with
which the therapist can analyze the unconscious meanings and roots of
the disturbance; here, matters are serious, but analyzable.
• Most often, there is some degree of mutual participation in dis-
ruptions of the therapeutic alliance; such conditions are called a thera-
peutic misalliance or an antitherapeutic alliance .
• In all, with disturbances of this alliance in which the therapist
participates on any level, his exploration of the problem with the patient
must include a brief acknowledgment of his own contribution to the
situation, supplemented by a clearcut shift to non participation on his part.
Without these, the misalliance cannot be modified (see Chapters 21
and 22).

OTHER REALISTIC DIMENSIONS OF THE


PATIENT-THERAPIST RELATIONSHIP

Some of the realistic aspects of the patient-therapist relationship


222 THE PATIENT-THERAPIST RELATIONSHIP

carry crucial intrapsychic meanings for the patient, while many do


not have significant, inner-fantasied and conflict-related reper-
cussions. The therapist must be prepared, however, to find that any
one of these real dimensions may become especially meaningful or
may serve as a major resistance for a particular patient at some
period in his therapy, taking on strong conflictual and geneti~
transference dimensions that must then be analyzed.

The Basic Agreement


I have explored in considerable detail in part 11 of this
book the realities of the basic agreement between the patient and
the therapist, as well as its possible inner-conflictual and genetic-
transference repercussions. Now that we have a better understand-
ing of the therapeutic relationship, let us briefly review these funda-
mental ground rules of therapy, and expand on the principles we
need in dealing with them as the vital framework for therapy.
1. The therapist's agreement to treat the patient, and the
patient's consent to be seen at a certain frequency, pay a specific fee,
and comply with other ground rules, are always perceived according
to unconscious fantasies and set, and past experiences and transfer-
ences. As long as the patient adheres to them, however, they should
form part of the relatively silent, positive backdrop for the treat-
. ment. Passing references by the patient to these realities should be
silently examined by the therapist for unconscious meanings, and
considered for their potentially disruptive elements, but need not
be brought into focus unless there is a clear and unmistakable
indication that one of them has become the nucleus of important
repressed fantasies or resistances.
2. In general, these realities will become a vehicle for such
fantasies and resistances whenever some event in the patient's out-
side life or in the treatment sets things off. The loss of a job may
bring up the fee, but so may the patient's exploring exceedingly pain-
ful conflicts, fantasies and memories, as may distressing, anxiety-
and guilt-ridden areas of self-awareness that prompt him suddenly
to reassess his finances. In the spirit of flight and resistance, he may
then claim that his precarious financial situation is rendering it
impossible for him to continue treatment. Such resistances must be
dealt with in terms of their basis in reality, the unconscious use of
Patient's Reactions: Fundamental Concepts 223
the reality as a rationalization and resistance, and the timing, which
emphasizes the defensive use to which it is being put. The variations
are infinite and each instance must be dealt with on all of these
levels (see Chapters 5 and 6).
3. These realities also become a vehicle for important fantasies
and resistances evoked by behavior in the therapist. As we have
seen, this may range from correct but hurtful, necessary interven-
tions to those that are a reflection of errors and countertransference
problems. A therapist's failure to recognize his own contribution to
the situation can make the problem unanalyzable and unresolvable
especially if a deviation in the ground rules is involved.

Realistic Positive Elements in the Relationship


There are many inherently positive, protective and supportive
aspects to the therapeutic situation for the patient who is in psycho-
therapy. The therapist's tolerance, understanding and actual help
are real experiences that evoke both appropriate and inappropriate
-transference-reactions. For many patients, the therapist is, in
reality, one of the few truly concerned and consistently helpful per-
sons in their lives. The patient's response to this is usually only
partly transference-that is, based on past longings and relation-
ships; it is also quite appropriate. This can also create very sticky
ties to the therapist for the patient and make final resolution of his
symptoms and termination of treatment quite difficult, especially
for deprived and lonely individuals. The reality-based attachment
shades into transference gratifications of inappropriate needs and
primarily neurotic ties-a misalliance.
Mr. I.N., for example, clung to his symptoms and to his therapist
in part, because he felt safe with him, could express feelings that he
otherwise bottled up or was attacked for, and saw him as an ally
and refuge to turn to when he got himself into difficulty. However,
the inappropriate, unconscious hostility and dependency involved
was reflected in the great difficulty the therapist had in helping him
to value and utilize his autonomous functioning and to feel that he
could handle the threat of others and of his own impulses. This was,
then, both a transference and real problem: the patient often did
not understand his impulses, conflicts, and disruptive affects until
his therapist had intervened. Yet he refused to give up his ties to the
224 THE PATIENT-THERAPIST RELATIONSHIP

therapist out of transference-based rage and mothering needs.


Miss I.M. was involved in a mutually provocative relationship
with her parents, in which the latter expressed not only unconscious,
but at times blatantly conscious, wishes that she were dead. They
often frustrated and assaulted her during periods of crisis and sug-
gested that she do away with herself if it was all too much for her to
handle. Her therapist proved to be a real buffer between herself and
her parents, though he consistently insisted that they work things
out between themselves. Despite that, the parents would call him
as they began to realize their inability to control their murderous
rage, and they would regain their perspective in their brief talks with
him. The same appeal for help with controls and perspective came
from the patient and was provided to her through the very process
of exploring and thinking through, and through the therapist's inter-
pretations and other interventions. Assistance in the ego develop-
ment of all parties was therefore necessary and real; without it,
autonomy would not have been achieved.
Such real dependency, though momentarily constructive and
necessary, can be a terrifying threat, as we saw with Mrs. I.Q. and
Mrs. I.R. It is not to be artificially fostered or imposed on the patient
in what would then perforce become a seductive and depreciating
stance on the therapist's part. But his real role as a helper must be
recognized and where it creates an undue attachment and resistance
against termination, it must be worked through.
Other real aspects of the patient-therapist relationship arise at
times of crises and unusual events in the patient's life (Greenson,
1972). When such events occur as a death in the patient's family,
and when he suffers from or recovers from a serious illness, expres-
sions of condolence and concern by the therapist have a place in the
therapeutic relationship; without them, he may appear indifferent
and cold (see Chapter 22). In those rare circumstances where a
patient learns of a serious event in the life of the therapist, expres-
sions of concern on his part must be accepted by the therapist and
not defensively analyzed as if they were primarily transference
responses unless they later shade off into such reactions.

Realistic Negative Aspects to the Relationship


The therapist, as I have stated repeatedly, may in reality respond
Patient's Reactions: Fundamental Concepts 225

to the patient in a variety of ways that are actually anxiety-


provoking, seductive, or aggressive. The patient's response to such
incidents has a transference basis, since it will be founded on his own
past experiences and relationships as related to the real precipitate
involved, and on his own pathology, character, and usual adaptive
or maladaptive responses, but there is a significant element of reality
involved. This reality must be acknowledged and integrated into the
working-through of the patient's responses to it and the conflicts
generated (see Chapter 22).
External and internal events may affect the intensity of the
patient's involvement with his therapist and his transference reac-
tions, but there are certain inequalities inherent in the therapeutic
relationship regardless of such acute reality events (see Greenacre,
1971 and Greenson, 1967). The patient must tell the therapist every-
thing, pay the fee, may not receive answers to all of his questions,
does not set vacation schedules, and is relatively passive in regard
to interventions. These, too, may be used for resistances and when
explored, should not be denied by the therapist, but faced by both
parties as necessary for the positive outcome of the therapy.
Lastly, there is the reality of those patients who evoke in their
therapists various degrees of justified annoyance and other negative
feelings. This is a complex and sensitive issue, which I shall consider
in Chapter 22; here let us recognize that certain patients are indeed
unduly destructive or repulsive in some way, and bring to their
relationship with the therapist real, negative elements with which he
must deal.
On this note, then, I conclude my discussion of the patient's
relationship with the therapist. Let us now turn directly to the
problems in technique that the patient's relationship with him poses
for the therapist.
21 The Patient's Reactions to
the Therapist: Principles
cif Technique.

TRANSFERENCE REACTIONS
There are a myriad of fantasies, reality-based or transference, and
often unconscious, that form a part of the silent undercurrent of
psychotherapy. As events (day residues) occur, these transference
fantasies become interwoven with the patient's current responses
and adaptations, and, once mobilized, evoke reactions and behavior
within and outside therapy. As I have already stated in Chapter 20,
when such transference reactions become part of resistances dis-
ruptive to the therapeutic alliance, or the vehicle for the expression
of important unconscious fantasies, they must be explored, analyzed
and worked through.
In principle, the therapist is faced with the need to maintain a
delicate balance, attempting neither to overemphasize the patient's
relationship with him and the passing transference references in his
associations, nor to avoid the necessity of dealing with transference
manifestations when they are central and related to the patient's
current intrapsychic conflicts and resistances. Either extreme will
generally disrupt the therapy and compound the technical problems
that confront the therapist. Thus, it becomes essential for him con-
stantly to monitor the associations from the patient for transference
material, and to grasp when it is pertinent and when it may be

226
Patient's Reactions: Principles of Technique 227

allowed to pass. Every therapist will make mistakes in this area, but
consistent attention to the patient's associations and to his reactions
both to interventions related to the transference and to failures to
intervene will enable him to correct his errors when they occur.
In Chapter 20, I discussed, in general, how to determine whether
a transference reaction is critical or not. Here I shall explore the
techniques for handling transference material from patients of
different diagnostic categories and the specific, positive indications
for transference confrontations and interpretations.
In working with transference manifestations, the therapist must
bear in mind that he is interested not solely in fantasy content, but in
its adaptive framework. It should, moreover, be understood that
the distinction between the resistance and revelatory uses of trans-
ference reactions is artificial, serving heuristic purposes. As with
any psychical material, all transference fantasies serve defensive and
revealing functions in various proportions. Our line of approach is
to deal with defensive and resistance aspects before tackling the
conflict-related content that they embody; as we shall see, the former
merges into, and is one of the most productive avenues toward, the
latter.

NEUROTIC TRANSFERENCES

Transference reactions that are based primarily on neurotic


fantasies mayor may not be acted out. Each manifestation of this
kind must be judged by itself for content and meaning. Does it merit
an intervention, or should it be allowed to pass, since it is non-
disruptive, or not especially relevant to the patient's current intra-
psychic conflicts? Some ·clinical vignettes will help us to answer this
type of question.

Neurotic Transferences as Resistances


Neurotic transference fantasies may reflect basic or underlying
mistrust, anger, seductiveness, and other fantasies about the thera-
pist that lead to withholding and defensiveness; they may be
generated primarily as a defense against other anxiety-provoking
material; and they may be acted out in ways detrimental to the
patient and the treatment. In any situation where the primarily
228 TIlE PATIENT-THERAPIST RELATIONSHIP

transference fantasies about the therapist serve in large measure as


defenses and disruptors of the therapeutic alliance, the specific form
and genetic roots of these manifestations also reveal something
about the patient's character and pathology, and his intrapsychic
conflicts and adaptations to them. Therefore, in exploring and
resolving the resistance aspects of these fantasies, the therapist also
endeavors to interpret their unconscious meanings and roots.
The following clinical material illuminates transference-based
fantasies about the therapist that have arisen mainly as a defense
against, and concealment of, emerging nontransference fantasies and
other threatening aspects of the therapeutic work.

Mrs. LX. was a depressed woman with a moderate


narcissistic character disorder. Her father died soon after
she entered therapy and during her second year of treat-
ment, her mother arranged a move to the West Coast to
live near the patient's sister and sold the house in which
the patient had lived until she had married.
As these events unfolded, the patient spoke very little
of them, rationalizing that her mother was a bitch and
that she would not miss her. The patient felt depressed
and tearful, but blamed it on quarrels with her husband.
In one session at this juncture. Mrs. LX. reported several
dreams. In one. she is with a buxom, motherly friend.
In another, her own house is empty because her husband
has left her. In that dream. her mother asks her to help
her fix several walls that are damaged. The patient tells
her mother to leave her alone; she does not want to be
bothered. The walls look like those in her mother's house.
In the last dream, Mrs. LX. is ahout to be attacked by a
group of bandits.
When the patient ruminated about trivial details
related to manifest elements in the dreams, the therapist
decided to intervene. Considering that much of the mani-
fest dream content was transparently related to her con-
flicts regarding her mother's pending move. the therapist
attempted to cut through or bypass the patient's res is-
Patient's Reactions: Principles of Technique 229

tances; he asked her directly what had prompted these


dreams and whether she could sense what was really
upsetting her. Mrs. LX., who had in the past worked
through a number of erotic fantasies regarding her thera-
pist, at first said that she thOUght they must have some-
thing to do with him. Then she said no-it must be her
mother's leaving. The therapist agreed and the patient
went on to talk of the memories, both happy and saq,
that would be gone with the loss of that house, and of the
death of her father.
Mrs. LX. began the next session by saying that a girl-
friend of hers had seen the therapist at a play. She went
on to describe a series of erotic fantasies about him. She
had thrown a farewell party for her mother, and described
how upset and tearful her mother was about leaving. She
had dreams of seeing the therapist; of an empty house;
and of a flooded restaurant. Associations were to thoughts
of old boyfriends and to her husband's teasing her about
the therapist. The latter intervened here.
He said that the patient was using her erotic fantasies
toward him to avoid her conflicts and feelings about her
mother's leaving, feelings which-as in her dream of the
previous session-she wanted to disown. He went on to
say that, while some of her longings for her mother might
be conveyed in these fantasies about himself, they were
being used primarily to avoid the apparent sense of
emptiness also referred to her dreams. The patient then
recalled another dream in which her daughter was lost in
a nearby town. In association, she recalled a motherly
friend who lived in that town.

I shall confine my discussion to the points relevant to the


analysis of transference manifestations:
1. In this instance, the erotic fantasies toward the therapist
appeared while the patient was struggling with her feelings and
fantasies about a major life trauma: her mother's move. The
dreams reflected feelings of emptiness and fears of losing control-
230 TIfE PATIENT-THERAPIST RELATIONSHIP

being flooded-and strong defensive efforts at denial and avoidance.


The latter prevailed throughout the two sessions and were rein-
forced by many displacements.
(a) Context-the primary adaptive task-was the key to the
therapist's assessment of the defensive role of the transference fan-
tasies. While the observation of the therapist by the patient's friend
undoubtedly provided a secondary adaptive context, the patient's
associations centered upon and organized best in the context of her
mother's move. Of the two day residues, we would expect this move,
with its uniqueness and multiple implications, to be of greater
consequence for Mrs. LX.
(b) Another clue that the transference was secondary and
defensive here is the sequence of the material: the problem with
the mother emerged first and was then avoided. The patient's reac-
tions defended against awareness of the implications of this topic.
After the therapist intervened with a question that lessened the
defenses against the affects and fantasies related to her mother's
move, the patient shifted focus onto the therapist and her transfer-
ence fantasies.
(c) Once the therapist determined that the patient's defenses
were mainly directed toward her reactions to her mother's move,
not the transference, he could then regard the former as the main
source of anxiety, depression, and conflict.
(d) The absence of a major disturbance in the therapeutic
alliance-a common occurrence with many transference conflicts-
also lends weight to this assessment.
2. The above sequence of decisions led to the therapist's inter-
pretation, confirmed by the recall of the repressed dream.
The therapist also interpreted in a preliminary and general way
some of the displaced longings for the patient's mother that were
expressed in the transference fantasies. In this instance, transference
hntasies served largely as a defense against more painful material
related to the pending loss of the patient's mother. The relationship
with the therapist here serves the same purpose as other resistances
that cover, avoid, and deny painful central conflicts. We term these
"transference resistances," and since they are being used defensively,
to block the unfolding of the patient's underlying crucial conflicts,
Patient's Reactions: Principles of Technique 231

the therapist deals with them first, much as he would with any
defense and resistance.
Consider now another condensed vignette:

Miss I.Y., an adolescent with severe characterological


problems and tendencies to act out, returned to therapy
after her therapist's summer vacation with tales of sexual
promiscuity, battles with her parents, and excessive drug
use. Associations centered upon her desperate search for
someone to hold onto. After these themes were repeated
several times. an intervention was made.
The therapist pointed out the temporal relationship to
his vacation. and said that her behavior reflected both her
rage at him and her longings to hold onto a replacement
for him regardless of the cost of herself. There was little
confirmation of this from the patient. and instead. she
described her mounting rage at her parents, who were
actually being very destructive and provocative. The
patient wanted her therapist to explain to her parents the
roots of her own provocative behavior and had thoughts
of leaving treatment. Associations to the recent vacation
led to further interpretations of the way the patient was
living out her rageful revenge on the therapist in her
behavior toward her parents. References to a friend's
abortion followed. leading to the interpretation that Miss
I.Y. had experienced the therapist's leaving her at a time
when she needed help, much as if it had been a sudden
abortion.
The patient settled down considerably over the next
few weeks. Then her father walked around their house
undressed and later precipitated a fight with the patient
over a minor annoyance. Their mutual rage mounted and
the patient left home, not telling her parents where she
was.
She continued to come to therapy and mentioned that
she expected her parents to call the therapist, and was
surprised that they had not-or had they, she wondered.
232 mE PATIENT-mERAPIST RELATIONSHIP

She went on to describe an episode of vomiting after din-


ner at the friend's house where she was now staying. She
recalled conscious fantasies that she had been poisoned
by the friend's mother for flirting with her husband.
Considerably more related material followed, enabling
interpretation of the patient's sexual fantasies toward her
father and her fears of her mother because of them.
Later on, in another context, these fears were related to
the patient's mistrust of the therapist. Peace was eventu-
ally restored.

I shall again confine myself to the main issues arising from this
vignette:
1. The main context for the patient's initial acting out was the
therapist's vacation-a common day residue for unresolved trans-
ference fantasies. Here, the repetitive battles with Miss I.Y.'S
parents must initially be viewed as a secondary adaptive task and
source of intrapsychic conflict, and essentially a means of acting out
her transference reactions. Once the transference material was
worked through, the order of importance of these two contexts was
reversed.
(a) At first. the patient's defenses were directed primarily toward
the transference, suggesting that it was the main source of her
difficu1ties.
(b) The patient's initial denial of feelings about the therapist,
and her pressure to have him step out of his usual role, suggest
impairments in the therapeutic alliance. which in turn point toward
transference issues as the prime source of conflict.
2. Acting out of transference fantasies, as a major resistance
and source of disturbance, must be the therapeutic focus until it is
resolved. Technically. the therapist utilizes confrontations and
interpretations of the specific adaptive context, defensive use,
underlying fantasies, and genetic roots of transferences. In this
vignette, the fantasy of having been aborted is one such unconscious
transference fantasy related to the resistances and acting out. It had
genetic links to the patient's mother, who had not wanted to be
pregnant with the patient. Other transference connections were not
available at the time. As I pointed out in Chapter 20, work with
Patient's Reactions: Principles of Techj,ique 233

transference manifestations in psychotherapy is often piecemeal


and incomplete, though sufficient to resolve the underlying conflicts
and maladaptations.
3. When the family crisis was at its height, the therapist did not
pursue the patient's transference-based mistrust of him, but centered
his work on those outside issues. Later on, he was able to analyze
this aspect of the patient's transference and relate it to her mistrust
of her mother and to its roots in a series of early childhood traumas
and deprivations.
In principle, we do not pursue every reference to the therapist,
even when negatively toned. If there are more critical problems and
if there is no particular threat to the therapeutic alliance, the thera-
pist can allow the reference to pass and return to it when later
material permits.
The following very condensed vignette illustrates how trans-
ference fantasies may evoke disruptive behavior toward the thera-
pist; this is another way in which transference serves as a resistance
(see the Index of Clinical Material for other examples):

Mr. I.Z., a young man with a severe character dis-


order, returned to therapy after his therapist's vacation
with plans to go on an apparently inessential business trip
two weeks later. Associations centered upon the patient's
mistrust of men and on his father's unreliability, nasti-
ness, and lack of warmth and understanding; the patient
had advised both of his brothers to leave home since
there was no way of handling their father. He recalled
borrowing money from his father and the latter's con-
stantly berating him when he failed to repay the debt.
The patient himself had just walked out on him one day.
Other associations were to his mother, and a mistrust of
her that was much more vague. For the rest of this hour,
the patient ruminated and was quite remote.

How would we formulate the material, and what intervention


should have been made? Briefly:
1. The therapist's leaving the patient-the main context for
this hour-evoked strong mistrust and some ill-defined sense of
234 TIlE PATIENT-THERAPIST RELATIONSHIP

danger and possible harm. This was based on both a father and
mother transference, and the former seemed more accessible for the
moment.
2. The transference anxieties, conflicts and fantasies were un-
doubtedly factors in the patient's decision to go away and miss two
sessions-an acting out of transference fantasies. The material sug-
gests that this was more than a talion revenge on the therapist,
although the specific underlying fantasies are unclear; they imply a
desire to avoid a hurtful and insensitive person.
In this way, the transference produced a major resistance to
therapy and a disturbance in the therapeutic alliance, expressed
through an acting out directed at the therapy and therapist in the
form of planning to be away; it was also conveyed in the patient's
ruminating in the session-another way of being distant from the
therapist. As we know, this is a prime therapeutic context and
indication for interventions.
3. The therapist could have pointed out to Mr. I.Z. that his
vacation had led the patient to see him as hurtful, dangerous, and
untrustworthy, like his father. and contributed to his decision to
get away from him for a while, much as he had done. and had
advised his brothers to do, with his father. This might have led to
more material related to the specific fantasies and genetics involved.
The therapist could also have interpreted the patient's rumination
similarly: it was a kind of detachment and flight from himself as an
insensitive, hurtful person.
4. In principle, virtually every absence and major disruption in
treatment and the therapeutic alliance proves to have transference
elements, which should be detected and interpreted since they relate
to critical resistances.
It is, I hope, more clear now how transference fantasies may be
used maladaptively to avoid other anxiety-provoking events and
fantasies, to deflect the focus away from the patient's main intra-
psychic conflicts, and to disrupt the therapeutic alliance and therapy
through chaotic or harmful acting out of the transference fantasies
outside and inside treatment, thus warding off the analysis of
unconscious fantasies and conflicts. I shall present one more way in
which transference fantasies serve as resistances:
Patient's Reactions: Principles of Technique 235

Mrs. J.A. was a woman with a moderate masochistic


character disorder who sought treatment because of
depression and a marriage in which she was suffering
terribly. Her husband, a divorce attorney, was a tyrant,
and she spent her first session detailing ways in which he
had been unfaithful, physically hurtful, and generally
insensitive throughout their marriage. It also emerged
that she feared leaving him and felt vulnerable to attack
by strangers when alone.
As this unfolded in detail over several sessions, Mrs.
J.A. repeatedly wondered how telling the therapist all of
this would help her. She just did not see how it would,
and kept doubting that she should be in therapy at all.
The patient then began one session by saying that she
realized that her husband was sending her to the therapist
as a replacement for himself. He had raged against her
the other night, but it was pointless discussing it; she
wondered about medication. She again felt that the
treatment would do nothing for her. Her husband wanted
assurances from the therapist that she would not divorce
him; he had been a bit nicer on the weekend.
When asked what came to mind about the assurances
that her husband wanted, the patient said that she had
no thoughts about it. She then described an episode in
which he had severely beaten her. When further doubts
about therapy were mentioned, the therapist intervened
again. (Can you suggest why and how?)
The therapist pointed out that the patient spoke
repeatedly of staying on with her husband and of antici-
pating further harm from him, and from others, and that
she had exactly those anticipations of him in therapy.
The patient seemed startled and uncertain. She
recalled that she had imagined that her husband had
actually called the therapist, who had then persuaded
him to be nicer to her. To an inquiry, the patient said
that she had thought that the therapist had concealed the
call from her. and added that she recognized that her
fantasy was one in which the therapist made a major,
236 THE PATIENT-THERAPIST RELATIONSHIP

hurtful breach of ethics. She then recalled a most reveal-


ing dream related to her ongoing conflicts; I shall not
detail it here.
I would emphasize these points:
1. This is a situation where mistrustful transference was based
on the patient's nuclear wishes to be hurt or to suffer (a masochistic
constellation). Her anticipations were seriously undermining the
development of a therapeutic alliance and threatened a premature
termination to the therapy. They had to be interpreted and, it was
to be hoped, resolved as quickly as possible, but only when the
patient's associations would permit it. If the situation deteriorated,
a confrontation with the problem could have been used as a last
resort. Otherwise, a sadomasochistic misalliance might prevail.
Here the transference fantasies seriously undermined the entire
therapy; they had to be analyzed before other work could be under-
taken. This is a not uncommon task in the opening phase when
initial efforts by the patient at misalliance are evidenced (see
Chapter 23).
2. In this session, the unconscious link between the patient's
husband and the therapist stood out, as did the threats to the thera-
peutic alliance. The therapist interpreted the patient's fears of being
harmed by him (though for the moment, he ignored the underlying
masochistic wishes); thus he emphasized to the patient that these
anticipations were an aspect of her longstanding problem with her
husband and not coincidental fears, and hinted at her own role in
these anticipations.
(a) In essence, the therapist was attempting to demonstrate to
this patient that her doubts about therapy were not based on reality
but on fantasies.
(b) Confirmation was strong: the patient revealed a specific
previously repressed fantasy of being hurt by the therapist, and her
recall of a meaningful dream reflected a resolution of her resistance
for the moment, and a new trust in the therapist and sense of safety
in the treatment setting, with a willingness to reveal more about her
inner self. The misalliance gave way to therapeutic alliance-for
now.
(c) The genetic basis-transference object, etc.-was not yet
Patient's Reactions: Principles of Technique 237

available. This resistance related to the heart of the patient's


neurosis, but could be analyzed no further so early in the therapy.
Despite these limitations, the therapist's interpretation modified the
patient's defenses.
3. The technique of relating a specific transference fantasy or
behavior to similar responses to other persons who are not the
original transference objects (e.g., friends, strangers, husbands and
wives, children) has been termed "sharing the transference." In
essence, the therapist may use such comparisons to establish the
meaning of a transference fantasy, as demonstrated here; or he
may begin with fantasies related to himself and demonstrate how
these are similar to the patient's responses to others in his current
life (see p. 250 if.). This latter route is chosen specifically to dilute a
too-intense transference involvement or to demonstrate that the
patient's responses to the therapist are by no means unique, but
are related to his life-problems outside therapy and to his intra-
psychic conflicts and methods of responding to them.
To summarize the main principles regarding the technique of
analyzing neurotic transference resistances in therapy:

1. Transference fantasies, and behavior based upon neurotic


transference fantasies, may be the underlying basis for disturbances
in the· therapeutic alliance or may be mobilized by the patient in
response to some threat in his outside life or within the treatment,
so that they disrupt the flow of therapy.
2. When transference resistances are evident, they are prime
indications for interpretation, especially of their maladaptive
aspects.
3. At times when the therapeutic alliance is disturbed, the
therapist should reassess the status of the patient's transference-a
dimension that he should constantly monitor. Transference-based
resistances are among the most frequent causes of such problems.
4. In interpreting transference resistances, the therapist en-
deavors to identify the adaptive context, the unconscious fantasies
and especially the instinctual drive derivatives, and the genetic roots
of the transference material.
5. A good rule of thumb in deciding whether to address oneself
238 THE PATIENT-THERAPIST RELATIONSHIP

to the transference in a given session is to pursue such interventions


only when the patient has in some way alluded to the therapist or
therapy. unless a major disruption in the therapeutic alliance or
other resistances prevail.
Neurotic Transference Reactions that Reveal
Important Unconscious Fantasies
Neurotic transference manifestations in behavior and fantasy
may be the means by which a patient communicates unconscious
fantasies and memories related to his main intrapsychic conflicts and
symptoms. On the whole, such material builds quickly in psycho-
therapy, is interpreted when the derivatives are expressed. and is
worked through over several additional sessions. While the patient
may allude to such derivatives later on in his therapy, and even
develop some aspects further, work of this kind is generally not
sustained or excessively detailed in this therapeutic modality,
especially with neurotic patients and with those who have mild or
moderate characterological disturbances. For this reason, a sensitive
ear and a good sense of timing are especially useful in dealing with
such manifestations.
To help us arrive at some principle of technique in this area,
consider this vignette:
Mrs. J.D. was a married woman with hysterical throat
symptoms--choking and gagging-and an hysterical
character. She had two daughters and no sons. In one
session that occurred when she was well into her therapy.
and very soon after a friend had adopted a son. she
recalled some details of her own childhood with her two
sisters and alluded to her father's disappointment that he
never had a son. She also spoke of her mother's hos-
pitalization when she (the patient) was about ten years old
and how she, as the oldest child, attempted to run the
household at that time. She described feelings of anxiety
when she saw her friend, and on coming to her session.
In the next hour, she spoke of her resentments against
her husband for' his pettiness and coldness, and of her
anger with her therapist, who had not made up a session
which she had missed because of a brief vacation taken
Patient's Reactions: Principles of Technique 239

with her family. She felt anxious and expressed again her
longings to have a son. She had a fantasy of meeting her
therapist at a party and imagined being seduced by him.
The therapist pointed out the patient's deep dis-
appointment in not bearing a son and her consequent
anger at her husband, and suggested to her that she had
fantasies of being impregnated by him in the hope of
having a son. This interpretation was confirmed when
she then recalled that she had investigated and found out
that her intemist had three boys. She strongly hinted at
fantasies regarding his ability to produce sons and went
on to recall again the details of her mother's hospitaliza-
tion and her closeness to her father at that time. The
therapist then suggested to her that her longings for a
son through him (the therapist) must be related to child-
hood fantasies of having a son with her father-granting
him his unfulfilled wish. This was confirmed over the next
few sessions, in which guilty, conscious incestuous fan-
tasies, and memories of primal scene experiences,
emerged for the first time in her therapy. There were also
expressions of her deep disappointment in, and rage
against, her father because he had favored one of her
sisters. This led to fantasies of oral impregnation by him
and to impulses to attack and swallow his penis.

The following aspects of this vignette are pertinent to our topic:


1. It is an example of the way transference fantasies can be an
important means of expressing unconscious fantasies related to a
patient's central conflicts and symptoms. When they so emerge, they
should be fully interpreted.
2. There is, secondarily, a resistance aspect to these transfer-
ence fantasies, since they do involve an implicit invitation to the
therapist to end treatment by having an affair. Note that this patient
expressed these desires as fantasies and showed no actual wish or
expectation that they might occur. This is, then, an erotic trans-
ference (confined to fantasy) and not an erotized transference (with
real expectations of fruition).
3. The day residues (adaptive contexts) evoking these transfer-
240 mE PATIENT-mERAPIST RELATIONSHIP

ence fantasies were: her not having a son; the friend's adoption of
a baby boy; her disappointment in her husband and quarrels with
him that she herself evoked, in part because of her inner fantasies;
and her feeling hurt by the therapist, who did not give her a
special make-up session.
4. The main transference fantasy evoked by these precipitates,
in interaction with the patient's inner set and potential unconscious
fantasies, was that of being impregnated by, and having a son with,
the therapist. This was a current version and displacement of child-
hood fantasies of being impregnated by her father and giving him-
and herself-a son. Such a fantasy, largely unconscious, was promin-
ent when she was ten years old and her mother was hospitalized,
and the patient became the mistress of the house.
There are hints of many additional transference fantasies and of
other earlier roots to them in primal scene experiences, with wishes
for a phallus of her own, for compensation for various hurts, and
considerable rage over the frustration of these fantasied wishes. I
shall not develop these further here.
S. As a matter of technique, the transference fantasies merited
interpretation because they were evoking anxiety and were part of
the central fantasy network on which her symptoms were based.
The therapist made her unconscious wish for impregnation and a
son conscious, and then linked it to reconstructed similar fantasies
and wishes toward her father from age ten (much previous material
had pointed toward them as well); later, these fantasies were related
to her symptoms of choking.
6. The interpretive-reconstructive work, in essence, was to:
(a) Identify the immediate reality precipitates (contexts) for the
transference reaction.
(b) Interpret the current source of the patient's anxiety, the
related unconscious fantasies, and the adaptation to the traumas
with which the patient was currently dealing.
(c) Trace the transference back to the original person toward
whom these fantasies and adaptations were directed, identifying the
time of their occurrence and their context, thereby dealing with the
displacement and the genetics involved.
Once the interpretations were made, the therapist sat back
and listened to the subsequent material for confirmation and elabora-
Patients Reactions: Principles of Technique 241

tion. The patient's associations soon shifted away from the transfer-
ence and focused on her past life.
Termination, with all of the powerful anxieties and fantasies
it evokes, is a period in which transference fantasies may be
prominent (see Chapter 25). The real and final separation serves as
a traumatic day residue for the patient and therapist. I shaH illus-
trate briefly here:

Miss J.E. was a depressed adolescent who had been


underachieving in school. During a year of twice-weekly
psychotherapy she gained better controls, and worked
through much of her depression, which was based
primarily on hostility toward her mother, who treated her
quite badly, and her response to it with feelings of low
self-esteem and self-harmful acts of revenge. During the
year of treatment, there were periods of resistance based
on mistrust of the therapist and traceable in the material
from the patient to a mother transference.
Miss J.E. and her therapist mutually agreed that she
was ready to finish her therapy and they set a termina-
tion date; she welcomed the opportunity to be on her own
and develop further. In the last few weeks of treatment,
she found a new boyfriend with many good qualities (in
contrast to previous ones who were generally very
troubled), and showed little feeling about termination.
In her last session, she reported a dream that her boy-
friend had left her and she had to go to a hospital; there
would be no one to talk to. She went on to describe a trip
that he had taken earlier that week and spoke of how she
missed him. Rumination followed and the therapist asked
about the hospital. The patient reported for the first time
in her treatment that a year prior to the beginning of her
therapy, her father had been hospitalized with a gastric
hemorrhage and had been in shock; he had nearly died.
The doctor was blamed for the crisis; she herself had felt
unaffected by it. (This last hour was drawing to a close:
what would you have done?)
The therapist felt that he should begin his interven-
242 THE PATIENT-THERAPIST RELATIONSHIP

tion-to the last-with the patient's defenses and there-


fore alluded first to her failure ever to have mentioned
what must have been, though she denied it, a very
frightening and crucial experience for her. He next
referred to her similar persistent denial of any feelings
about terminating. He then went on to identify the con-
tent of her fantasies and the transference elements in
them: her dream, in the context of termination, showed
that she was experiencing his loss much like that of a
trusted boyfriend, and beyond that, much like the near-
death of her father. He added that she had a lot to think
about on her own now, since the hospitalization of her
father probably had a great deal to do with the depression
and other difficulties that she had experienced during the
year before she began treatment.

To comment on this material briefly:


1. The therapist's handling of the transference and other
material in this vignette was sound and representative of how
transference material should be interpreted in context and traced to
its sources as far as the patient's associations permit.
2. This vignette demonstrates how the therapist's interventions
should relate the transference material to the patient's current
adaptive tasks, and to his symptoms and neurotic problems where-
ever possible. We see, too, that it is important to maintain proper
principles of technique when dealing with transferences. The inter-
pretation of defenses first remains a valid tenet to the very end of
treatment.
3. The day residue here for the transference material was the
pending termination of the therapy; this provided the context in
which the material could be understood and interpreted. The inter-
pretation made by the therapist attempted to delineate:
(a) The transference object-the person on whom the displace-
ments to the therapist were based; here, this was Miss J.E.'S father.
(b) The period from which it was drawn. Note here that it was
a rather recent experience with the patient's father; earlier roots
would undoubtedly have emerged, but we should not underestimate
the importance of this later trauma.
Patient's Reactions: Principles of Technique 243

(c) The defenses involved. Here we saw denial, repression,


avoidance, and displacement, among others.
(d) The specific fantasies and conflicts to which the transference
material is related-the near-death of the patient's father and all of
its repercussions.
One last vignette illustrating essentially neurotic transference
reactions will round out the principles we need for dealing with
such manifestations:

Mrs. J.F. was in psychotherapy because her daughter


was planning to marry a young man from a "backward"
foreign country, whom she regarded as a poor and de-
graded marital choice. This move threatened Mrs. J.F.'S
life-long dreams of a close tie with her only daughter that
would be modeled upon, and a more perfect and less-
conflicted version of, the intense involvement she had
had throughout her life with her own mother; this rela-
tionship had strong symbiotic and intensely ambivalent
qualities for the patient. She responded to her daughter's
intentions with feelings of rage, which were strongly
denied, and a severe depression. In her second year of
treatment, the patient's intense denial of her rage at her
daughter was in the process of being significantly modi-
fied. In addition, her hatred of her mother for attempting
to seduce, control, and smother her with destructive
maneuvers and complaints had begun to emerge. Mrs.
J.F.'S daughter officially announced her engagement at a
time when the patient's mother was due to return from
a long trip. In addition, one of Mrs. J.F.'S two sons, dis-
turbed by the situation with his sister, had begun to have
difficulties in school for the first time; the patient had
unconsciously promoted this by permitting unnecessary
absences. She was confronted with this latter fact by the
therapist, and became acutely depressed and angry with
him.
In the following sessions, this rage continued: the
therapist had rocked the boat and she was furious with
him. She remembered hearing about therapists who
244 THE PATIENT-THERAPIST RELATIONSHIP

seduce their patients and were otherwise unethical. To


alleviate her anxiety. she had. for the first time, taken
medication that had been previously prescribed by her
internist. In the following hour. she raged that she was
not better and wanted shock therapy. She had had a fan-
tasy that her son had been killed in a car accident. Her
daughter's wedding was set for a date in the near future.
and she felt devastated and alone. She would not tell her
mother about it for a while when the mother returned.
Her husband had not handled the situation with her
daughter well, and now he criticized Mrs. I.F. for what
was happening.

Let us pause here to consider the following:


1. The precipitates of the patient's reaction to the therapist
are:
(a) Mrs. I.F.'S daughter's engagement and its extensions: her
son's poor work and her husband's attack on her.
(b) The therapist's confrontation of her contribution to her
son's problems.
(c) Her awareness of her destructive fantasy toward her son.
2. In all, these were severe narcissistic blows to this patient at
a time when her denial mechanisms had been modified. Her thera-
pist's confrontations were painful to her and intensified the guilt
she already felt about the manner in which she had raised her
daughter. The awareness of contributing so clearly to her son's
problems was therefore extremely painful to her and heightened
her self-condemnation. The external events also intensified her sense
of guilt and her anger at the various members of her family. Thus.
events both inside and outside therapy prompted Mrs. I.F.'S
responses to her therapist.
3. This response is a mixture of reactions to the real. thera-
peutically necessary-though possibly poorly timed-hurts and
guilt evoked by the therapist's confrontation and the emergent fan-
tasy. The meanings of this confrontation colored the patient's per-
ception of the entire therapeutic relationship. based largely on past
relationships (transferences) in which we may suspect her mother
played a prominent role.
Patient's Reactions: Principles of Technique 245

(a) The response to the therapist has another component that


I have not emphasized until now; the wish to be punished by him
because of the guilt Mrs. J.F. was experiencing. While this is un-
doubtedly modeled on earlier experiences in which she had behaved
badly and sought punishment from one or both of her parents,
there is also a strong current wish to suffer at the therapist's instiga-
tion and to provoke him into acting in such a manner.
(b) The intermixture of realistic wishes and transference fan-
tasies is striking. The latter undoubtedly include the displaced
fantasy of her son's death. Here we have a repressed transference
fantasy displaced onto her son, though repressed, murderous rage
at her daughter, husband, and mother also contributed to it.
(c) We can observe here two kinds of transference fantasies:
those displaced onto others, in the form of the fantasy of the acci-
dent to Mrs. J.F.'S son, and those directed primarily toward outside
figures that are displaced onto the therapist, e.g., the patient's rage
at her daughter, which was being vented at the therapist.
(d) Notice that the specific transference object is unclear in
this material. There are hints that the patient's mother plays a
significant role, but later material actually bore out ties to b0th
parents. The displacement of anger from her husband and daughter
were more current roots of the rage at the therapist.
4. I want to reemphasize the following:
The modification of defenses, the breakthrough of previously
repressed fantasies, and painful and guilt-provoking confrontations
are among the proper technical interventions that can evoke trans-
ference responses to the therapist which, in turn, contain repressed
fantasies or represent major resistances (both were true here). Such
expressions. when not based on technical errors, are generally
readily manageable and resolved through proper interpretations in
context.
5. In intervening, the therapist must identify the crucial precipi-
tates, the main fantasies, the basis for the disrupted therapeutic
alliance in transference and reality, and the roots of these elements.
In this vignette. both rage and guilt (and unconscious sexual fan-
tasies? -note the reference to seduction) from a multitude of
sources disrupted the therapeutic alliance; thus the reactions to the
therapist became a major resistance, which had to be analyzed.
246 THE PATIENT-THERAPIST RELATIONSHIP

The therapist, over several sessions, actually interpreted much


of what I have already described. He brought up the patient's anger
at him for his confrontation and her efforts to avenge herself on
him at any cost to herself; her guilt and the various sources of it,
and her wish to be punished by him; and her rage that he had some-
how not prevented her daughter's engagement (one of Mrs. I.F.'S
unconscious motives for seeking treatment). He pointed to her fury
at her children and husband, and her use of self-hurtful measures
to make them (and her therapist) feel guilty and as a means of gain-
ing her revenge on them (this was modeled on her mother's manner
of expressing aggression); and lastly he stressed the clear indications
that the patient no longer needed to handle her rage at such a great
cost to herself, but could find better means at her disposal for
resolving her conflicts, as evidenced by the fact that she had talked
to her daughter, son, and husband and made tentative peace.
Over several more sessions, much of this was worked through
and the patient was relieved. She then dreamt that she was old, and
in bed and crippled; her daughter was caring for her. Direct associa-
tions followed: her cousin had attempted suicide when her husband
had left her and she had been put to bed. Her daughter would nurse
her in her old age. When Mrs. I.F. was ill, her husband had taken
care of her, while her mother had deserted her. Treatment had
helped her to feel better. Several sessions of ruminating followed.
I shall again interrupt the vignette to highlight a few more
points:
1. Successful working-through of the initial hostile transference
fantasies about the therapist brought out a new set of fantasies about
him. In essence, the therapist had become the good-mother figure,
who would nurse the patient as long as she was ill.
(a) But meaningful communication and insightful work then
stopped. The material during this period indicated that the patient
now wanted only to be the helpless sick child and to be nursed.
This became an obstacle to progress-a transference resistance, an
effort at misamance-which had to be resolved.
(b) It is not uncommon for such resistances to follow a period
of understanding by and help from the therapist, and symptomatic
relief. In the meantime, the patient's rage at her daughter was made
clearer: the shock therapy meant self-destructive revenge on her,
Patient's Reactions: Principles of Technique 247

but then the fantasies changed: being ill meant being cared for by
her. The patient was able to express longings for later closeness
with her now that her hatred was being worked through.
2. As with Mr. I.N., the symbiotic, good-mothering transfer-
ence wishes toward the therapist, based on fantasies of being cared
for by an idealized mother, and on real wishes for care without dis-
ruption or work towards insight, became a new resistance and had
to be modified.
3. Technically, the therapist found ample material to demon-
strate to the patient that she was now turning toward him for the
mothering she had always longed for and could no longer expect
from her daughter. He pointed out that this prompted her to turn
away from further examination of her conflicts. Then, in a rather
benign atmosphere, a considerable number of repressed tmumatic
experiences with Mrs. I.F.'S mother and daughter emerged, and were
worked through with considerable relief of her depression and
anxieties.

Mrs. I.F. next began to bring up termination, since it


became clear that she had come to terms with her rage at,
and relationship with, her daughter. She was also relat-
ing well to her son, husband, and future son-in-law, had
worked through much of her long-standing, repressed
rage at her mother and the symbiotic tie to her, and was
now no longer depressed.
At this point in her therapy, she dreamt that her
daughter was pregnant and that her friends were leaving
their husbands. In another dream, one of her sons was
watching a nude couple who were in a movie. There was
complete avoidance of this dream in her session and then
the revelation for the first time in the therapy that her
husband was a poor and disinterested sexual partner; they
very rarely had relations. Several sessions of rumination
followed, with some expressions of Mrs. I.F.'S anger at
being terminated. Then there emerged a dream of enticing
her therapist seductively and of feeding an attractive
man-with associations to breast feeding.
The therapist now intervened. He pointed out that
248 THE PATIENT-THERAPIST RELATIONSHIP

the patient was experiencing her termination as something


like the loss of her mother and her nursing breast, and
was responding with sexual fantasies of seducing the
therapist and having a child with him, in order to hold
onto him.
Briefly, in the following sessions, Mrs. J.F.'S repressed
prostitution fantasies emerged, including an intense fear
of losing control sexually. She recalled experiences in
which men other than her husband made sexual overtures
that greatly tempted her, but to which she did not accede.
Fantasies of intercourse as a feeding experience and
moment of union emerged from the material, and then a
dream of sitting on her father's lap led to a long detailing
of the previously repressed history of his blatant seduc-
tiveness during her childhood and adolescence.

Working-through the implications of this material and its mean-


ing for termination, that is, as a transference-loss of the erotic ties
to her father, enabled the patient to finish treatment with consider-
able insight. and with changes in her ego and character, superego
and id. She had better controls and lessened dependency. had
resolved much of the inner psychological corruption and forbidden
fantasies with which she had struggled all her life. experienced a
marked increase in her self-esteem. had reworked her sexual rela-
tionship with her husband, and now handled her anger more suc-
cessfully.
I shall discuss this last part of the vignette by again highlighting
certain points:
1. We have here an erotic transference, which was prompted
by the pending termination of treatment and the husband's failure
to gratify the patient sexually.
(a) Basically. the transference was composed of unconscious
fantasies which, with modification of the patient's defenses and
intensification of the underlying instinctual wishes, became con-
scious first in derivative form and then more directly.
2. This erotic transference served as a resistance to termination
(wanting the therapist sexually instead of leaving him) and to the
exploration of the underlying unconscious and genetic aspects of the
Patient's Reactions: Principles of Technique 249

meaning of termination for the patient. The transference also con-


veyed in its manifest and latent content-and, with proper inter-
ventions, led directly into--crucial unconscious conflicts and child-
hood experiences that were pertinent to the patient's emotional
problems and difficulties in terminating her therapy.
3. The erotic transference fantasies initially centered upon the
patient's mother: longings for intrauterine union, wishes to recap-
ture the actual extended period of breast-feeding in her infancy, and
desires to gratify all of her idealized longings for closeness with her
mother.
(a) These fantasies served a now-familiar dual purpose: first,
they were derivatives of intense pre-oedipal longings for her mother;
and second, they served to cover and defend against sexual long-
ings for her father (which had pre-oedipal, oedipal and post-oedipal
aspects).
(b) Interpretation of the mother transference fantasies led to the
emergence of the repressed experiences and fantasies related to
the patient's father transference.
4. Thus, this reaction to the therapist was a layered one, and
had to be dealt with and interpreted piece by piece. The roots of
the transference that related to Mrs. J.F.'S father were most intensely
repressed because of the great anxiety and guilt associated with
them, and emerged only as the erotic transference fantasies toward
the therapist were explored, initially without reference to their
genetic roots, but in terms of the patient's current disappointment
with her husband, her anger over the loss of her therapist, and her
wish to hold onto him sexually; only then did the ties to the patient's
father emerge for interpreting.
5. If we review the different sections of Mrs. J.F.'S treatment,
we can see how feelings and fantasies about the therapist vary with
external life situations, the events in the sessions, the patient's char-
acter and psychopathology, and the extent to which her usual
defenses are modified to permit the emergence of repressed
memories and fantasies.
(a) This sequence is not one that can be anticipated in advance,
but it will occur in some form in successful th~rapy (see Chapter 24).
(b) With patients such as Mrs. J.F., transference material plays
an important role in the analysis of both resistances and core,
250 THE PATIENT-THERAPIST RELATIONSHIP

symptom-related conflicts and fantasies. With others. this material


is less prominent. though the therapist must always be on the alert
for it.
I have covered a great deal of territory beyond the basic inter-
pretation of neurotic transferences when they are part of critical
resistances or reflect key repressed fantasies. I have done so in the
hope of giving the reader a feeling for the various ways in which
transference reactions impede or promote the unfolding of therapy.
and fluctuate in the course of the treatment. Technically I have
emphasized interpretation of such fantasies. of their adaptive role.
and of the cost to the patient of the particular adaptation that he
has made. Borderline. psychotic. and narcissistic transference mani-
festations, and those in severe character disorders, require additional
or different principles of technique.

TRANSFERENCE MANIFESTATIONS IN THOSE WITH


SEVERE CHARACTER DISORDERS, AND IN BORDERLINE
AND NARCISSISTIC PATIENTS
The uses of transference either to resist or to reveal by those
with severely disturbed character disorders, and in borderline and
narcissistic patients are, by and large, comparable to those by
neurotic patients, with certain important differences; I shall focus
on the major technical problems that transferences pose for the
therapist working with patients in these categories.
Let us begin with a patient with a severe character disorder who
had very poor controls. While she never expressed direct intentions
to gratify herself in her relationship with her therapist, she man-
aged to threaten her entire therapy through her transference-based
disruptive behavior.

Miss J.G. was ~n asthmatic woman in her early twen-


ties; she had been diagnosed as having a serious mixed
characterological disturbance with a propensity to act
out. After about half a year of therapy, she had regressed
with the advent of her therapist's vacation, which had
Patient's Reactions: Principles of Technique 251

occurred while her father was away for a business con-


vention. so that she had been left home alone with her
mother.
Dreams in anticipation of these events revealed intense
homosexual fears, which were interpreted upward as
fears of being too close to her mother and which also
reflected a myriad of disguised sexual longings for her
father. Considerable guilt accompanied both sets of fan-
tasies; the patient expressed unconscious wishes to be
punished (killed. drowned) and to regress to a helpless,
nonsexual state of dependency. There was much acting
out, including sexual intercourse with several men in
near-pUblic circumstances, which might easily have come
to the attention of her mother. The rage at her parents,
who were themselves quite provocative, and at her
therapist, who had left her; her sexualized longings for
safety in fusion with him; and her guilt-ridden wishes for
punishment were all interpreted to her. as were the
blatant manner in which she acted out these feelings and
fantasies, and the consequences to herself.
There had been a brief episode of wheezing, and
associations related it to fantasies of punishment and
union through incorporation and through being nursed;
it also reflected fantasies of murderous revenge on her
therapist, in a transference related to both parents, for
his desertion: she could smother him, as she smothered
herself through her wheezing in punishment for her
impulses.
During the vacation. the patient moved out of her
house to live with two working girlfriends, jeopardizing
her therapy since she had recently lost her job and relied
on her parents to pay for it. She also increased her illicit
drug intake and suffered with moderate wheezing.
During the period following the therapist's vacation.
she was guarded and mistrustful in her sessions. She
reported that she had eaten clams and had vomited. and
fantasies of having been poisoned emerged in her associa-
252 TIlE PATIENT-THERAPIST RELATIONSHIP

tions. References to the therapist being in collusion with


her parents enabled him to interpret her deep mistrust of
him.

I want to pause and develop several points from the highly con-
densed material I have presented here, because the therapist added
several crucial interventions to the above interpretation.
I shall leave it largely to the reader to formulate the clinical
situation described here, and the appropriate and fantasied, realistic
and transferred, feelings toward the therapist and therapy that the
patient experienced. In essence, his vacation had evoked feelings
and fantasies of abandonment, rage, longings for fusion, and
revenge-all with attendant guilt, based on early experiences with
both parents, especially her mother. Most of the underlying trans-
ference fantasies were acted out or expressed somatically. Through
disaplacements, homosexual anxieties and rage at her father's leav-
ing were additional sources of her reactions to the therapist at this
time.
Beyond this formulation, there are several critical aspects:
1. The patient's acting out endangered the continuation of her
treatment. Although the therapeutic alliance remained largely
intact, if she continued to provoke her parents, they would terminate
the therapy; the patient had no funds to pay even the minimum
clinic fee.
Thus, the patient had to be, and was, confronted with this fact,
that her chaotic behavior could well have real and costly conse-
quences for herself and her treatment. The therapist noted her wish
to disrupt the psychotherapy in order to be avenged on him and
her parents, and said that she seemed to feel that all of this destruc-
tiveness was worth it, but would it be?
Here the therapist was attempting to enhance such ego functions
as anticipation, recognition of consequences, and controls, as well
as assisting the patient in assessing the cost of her adaptations.
These are measures that are frequently used in dealing with trans-
ference manifestations in impulsive and borderline patients.
2. Not only was the patient's rage at her therapist markedly out
of proportion to the real stimulus, but the patient was fusing (and
confusing) him with her realistically destructive parents.
Patient's Reactions: Principles of Technique 253

This introduces another important concept, one that I shall


elaborate upon later: with a severely disturbed or borderline (and
psychotic) patient, the therapist must eventually confront the failure
to distinguish between past and present objects (persons), and
especially between the therapist and the patient's parents. This
failure of a group of ego functions renders transference fantasies
quite real to such patients, and their reactions are notably distorted.
Technically, then, the therapist must not only identify trans-
ference objects (sources) and repressed transference fantasies, but
especially with more disturbed patients who have impaired ego
functions, confront them with their failure to distinguish the trans-
ference object from the present object-the therapist. This is a
frequent and crucial technical oversight; whenever an unrealistic
transference fantasy (and note that it must be unrealistic, not a
correct perception of something unconscious in the therapist; see
Chapter 22) is maintained persistently, or a reaction to the therapist
is especially inappropriate, an intervention of this type is indicated
(see below). In our quest as therapists for dynamics and genetics, we
must not overlook the need to assist patients to repair their ego
dysfunctions. The rest of the therapeutic work proves fruitless and
even anxiety-enhancing without this fundamental job.
In keeping with this, then, Miss J.G.'s therapist pointed out that
she was not differentiating him from her parents. The patient had
worked with him for six months, he added, and she knew that he
had not betrayed her, yet she continued to expect and believe that
he would or had.
3. With reactions to the therapist that threaten the continuation
of treatment or, via displacements, create disruptions in the patient's
life, the therapist must not only interpret the dynamics of the situ-
ation-precipitates, conflicts, anxieties, and conscious and uncon-
scious fantasies-but must also work with the patient's ego dys-
functions and the real consequences of his maladaptations. It is
unclear in this instance how much of the patient's acting out origin-
ated in transferenc~ fantasies and how much arose in direct reactions
to her parents' hostilities; each contributed to and enhanced the
other. Note too how willing this patient was to suffer and to destroy
treatment for revenge or in flight.
Impairments in Miss J.G.'s ego functions reflected in these trans-
254 THE PATIENT-THERAPIST RELATIONSHIP

ference expressions include poor controls, impaired reality testing,


failures to distinguish between persons, distortions of perception
and belief, and impairments in object relationships. All must be
matters for confrontation and interpretation in the context of the
patient's associations and behavior. When such impairments are
pronounced, the therapist should actively aid the patient before
premature termination or disastrous acting out occur.
Let us now follow the clinical material further:

With mounting anxiety and guilt, Miss J.G. began to


discuss seductive experiences with her father from her
childhood. There were distinct hints of sexual fantasies
about the therapist, acted out in part by the patient's
accidentally brushing against his foot and also, by dis-
placement, through further promiscuity. She had thoughts
of quitting treatment. She then reported a dream that her
mother came to take her home from her friend's apart-
ment and told her that she did not have asthma but had
diabetes. Associations were that diabetes could prove
fatal rather quickly, and that emotional problems could
be caused by high and low blood sugar; if this was the
source of her difficulties, it would prove that her therapist
had been wrong all along. She realized that she had
missed her mother, and she had spoken to her by tele-
phone, but she still responded to her mother's peace offer-
ings by provoking her into a rage.

Let us discuss the implications of this added material and the


principles of technique that evolve from them:
1. Erotic transference fantasies in patients with poor controls,
even when not experienced as real possibilities, often evoke intense
disorganization, anxieties and guilt. Such patients, when experienc-
ing impulses that they fear, often act out outside treatment or pose
a serious threat to the therapeutic alliance and a risk of premature
termination. This is especially so in young women and adolescent
girls who are in treatment with male therapists. The earlier the
therapist senses such fantasies, the better; if they appear to be
intensifying, they should be dealt with:
Patient's Reactions: Principles of Technique 255

(a) Interpretation of fantasy content-such as pointing out that


the patient wants to seduce, or be seduced by, the therapist as she
had once been involved with her father-would only intensify the
patient's anxiety, gUilt, and failure to separate the therapist from
her father, and would increase the likelihood of ego disorganization
and anxious flight. This would be a technical error and an inappro-
priate use of a genetic interpretation.
(b) Instead, the therapist must deal with the content of these
fantasies in the context of ego support, emphasizing their adaptive
and defensive uses, and interpreting upward (see Chapter 16).
Here, the therapist pointed out that Miss J.G. was becoming fright-
ened by her heightened sexual fantasies toward him, but added that
they were in part an expression of a need to find some desperate
means of holding onto him and, in addition, a depreciation of him.
He then went on to suggest that they take stock of her frantic
behavior so that she might begin to control it. He reviewed the
precipitates of these actions and emphasized the inappropriateness
of her sexual fantasies and behavior, the terrible cost to herself in
pain and guilt, and, using prior material related to a friend who
gradually deteriorated and eventually killed herself, the ruin to
which she knew she was heading. She might well have her revenge
or find a protector, but she would destroy herself in the process.
2. The therapist also interpreted the guilt and wish to suffer,
using the dream in which Miss J.G. gave up one illness only to suffer
with another that was more serious in her eyes-the diabetes that
replaced her asthma.
(a) He stressed the patient's attempt at transference acting out
and at attaining transference gratifications with him: in her wish to
suffer, Miss J.G. was attempting to provoke her tolerant therapist
into giving up on her as her parents had.
This effort at reliving in the relationship with the therapist a
past relationship, usually with a parent or sibling. is not uncommon
in those with character disorders and in borderline patients. It is
motivated by displaced guilt, rage or longings for closeness, and by
a wish to justify, and find sanction for, the patient's defenses or
pathology through the therapist's erroneous participation. Interpr~
tation, not acting out with the patient, must be the response, as it
was here so that a misalliance is not created.
256 THE PATIENT-THERAPIST RELATIONSHIP

(b) Attempts to entice or provoke the therapist into mutual act-


ing out, into sanctioning the patient's pathology and gratifying his
inappropriate needs, are not uncommon in more disturbed patients.
The therapist must be alert to, and avoid, these real attempts to
involve or anger him, lest a misalliance be created.
In this situation, the therapist, sensing his own frustration, used
it to understand this wish in the patient, and interpreted it to her
using the elements of the dream, her fantasies, and her behavior,
which reflected her wish to chide and provoke him.
3. The therapist also did something important, that goes
beyond his specific interventions, and that I have not yet emphasized
sufficiently. He responded to the patient in a manner that was
entirely different from her parents. The implications are clear:
(a) Ideally, the therapist does not participate in acting out with
the patient, or, as I put it before, does not join in transference grati-
fications or misalliances with him. He is neither particularly angered,
frustrated, or sexually aroused or seduced, and he does not respond
to the patient with inappropriate hatred, reprimands, punishments,
and seductions of his own.
(b) On the other hand, the therapist does not stand by silently
while the patient destroys the therapy and his life. He makes inter-
pretations and confrontations that are intended to help the patient
reestablish controls; in this way, his realistic therapeutic concern is
conveyed and insight is offered.
(c) There must be a genuine difference from other figures in the
patient's life in the therapist's stance. If it were feigned or acted, in
this instance, it would have repeated the deceptions of the patient's
parents and made the therapist in reality a partial replica of them.
Should that have occurred in any way, the patient would have
been justified in seeing him as she saw her parents (reality and mis-
alliance would replace transference) and there would be no reason
for her to alter her perception of the therapist or of herself.
(d) It is this critical difference in the therapist's response, as well
as his insight-oriented interventions, that enables the patient to
change, and to attain a new view of others. Through it, too, new
identifications are tacitly encouraged, and these occur in the ego,
superego and id. Such modifications are interrelated, but the
presence of a stable, accepting, truly understanding, correctly inter-
PatientTs Reactions: Principles of Technique 257

vening therapist is an important stimulus for effecting such lasting


inner changes.
With borderline patients and those with character disorders,
therefore, realistic and transference responses to the therapist after
separations, traumas external and internal to therapy, or the break-
through of repressed fantasies, can be quite disruptive to treatment.
They form resistances that endanger the therapy and require con-
siderable clinical skill. While they usually contain fantasies and
reflect ego dysfunctions central to the patient's pathology, their
disruptive aspects take precedence. The therapist must not only
identify the precipitates and conflict-related content of such
responses, but also offer ego support on various levels. With such
patients, real differences from destructive figures in the patient's life,
expressed in noninfantilizing and unseductive ways, reinforce inter-
ventions.
Another disruptive form of response to the therapist that is seen
primarily in borderline and narcissistic patients, and in those with
more severe character disorders, is the erotized or aggressivized
transference. Miss J.G. may well have been experiencing such a
transference; the material is not conclusive on this issue. Here, two
other patients provide the material from which we may derive the
principles we need for handling this type of reaction.
Aggressivized Transferences
To illustrate this problem, I shall return to Mr. I.N., the man in
his early twenties who sought treatment because he failed in every
attempt that he made to leave home and had recently been unable
to maintain a living arrangement with a young male friend (cf. pp.
258-59). Mr. I.N. had a menial job, despite his college education,
and little social life. Previous treatment in his adolescence had failed
to effect any lasting change. This earlier therapist had seen the
patient and his family, and from the patient's undoubtedly dis-
torted reflections of what had happened, he had been manipulative
and overintellectual, and had had little success in reaching the
patient's inner and unconscious conflicts.
Mr. I.N.'S stance in treatment was apparent from the outset: he
was blatantly mistrustful, angry, and argumentative. It quickly
emerged that he and his mother incessantly watched over each other,
258 THE PATIENT-THERAPIST RELATIONSHIP

and repeatedly found mutual fault. They attacked each other so


often that there was never a lasting moment of true peace. His
father was more withdrawn, but also pervasively critical.
Let us focus here on Mr. I.N.'S relationship with his therapist. A
sample session that occurred after about two years of therapy will
exemplify it, but first I shall briefly characterize aspects of his early
treatment.

In the two years' time, much peace at home was


achieved and the patient had taken a better job, though
he still had not left home. Initially, his rages at the thera-
pist had been blind and pervasive; they were often evoked
by some minimal or innocuous comment and were largely
out of tune with reality. If a confrontation or an interpre-
tation was offered to him, Mr. I.N. would find some excep-
tion to it despite its basic validity, deny it, and then turn
against the therapist for one reason or another. Blaming
others and the therapist, and poorly conceived rationaliza-
tions, were used to support this denial; he cast doubts on
the therapist's intentions and capacities.
With repeated interventions, including work with the
therapeutic relationship of the kind that I shall discuss
below, it became necessary to confront Mr. I.N. with the
static state of his treatment; he had made no attempt to
date or to sleep overnight away from home. In response,
he began to reveal some of his previously repressed under-
lying anxieties and conflicts, his heretofore concealed con-
scious fears, and derivatives of his unconscious fantasies.
In essence, these related to homosexual urges and violent
heterosexual fantasies strongly tinged with incestuous
elements, and to fears of unbridled rage and of losing
control on other levels. Leaving home was equated with
the murder and loss of his mother, to whom he secretly
clung, camouflaging and defending against his attach-
ment to her with the battles he provoked with her.
Despite considerable working-through in these areas,
and a couple of brief sojourns away from home, Mr. I.N.
Patient's Reactions: Principles of Technique 259

remained basically immobile. Here. then. is a brief resume


of a session from this period of his treatment:
Mr. I.N. failed to call his friend to arrange a weekend
away with him. Many excuses followed. He had had the
fantasy that the therapist had a way of spying on him in
the waiting room and was secretly watching him; he knew
that that was absurd and paranoid. He began to complain
about the time of his sessions and said that it was all part
of the therapist's plan to discourage and get rid of him; he
could not believe that another hour was not available.
The therapist suggested that Mr. I.N. had become critical
of him to avoid his feelings of disappointment and guilt
over his inaction and that perhaps he had also anticipated
some comments from himself regarding it. The patient
~id that his therapist must be crazier than he was if he
thought anything like that. He went on with criticisms
and suggestions that the therapist had failed and had not
taught him anything. His previous therapist had done
ridiculous things that were also useless; if a patient fails
to change. it is the therapist's responsibility. not the
patient's. Still. he would not go elsewhere-he would not
give the therapist the satisfaction of leaving; he was not
about to allow him to have any peace.

These are the main points in the relationship and the therapist's
technique of handling it :
1. I shall leave the formulation of the dynamics of this material
to the reader. Mr. I.N. had a serious borderline disturbance in which
denial of inner anxieties and fantasies, externalization, splitting
mechanisms and projections predominated. and he had poor con-
trols over his instinctual drives, especially. for the moment, his
rage.
2. His relationship with his therapist was a blatant expression
and living out of these difficulties; it constituted a type of direct
transference gratification. The therapeutic alliance was deeply
marred by his mistrust of the therapist, his denial of his own prob-
lems. and his blaming and attacking the therapist. The patient was
260 THE PATIENT-THERAPIST RELATIONSHIP

making repeated efforts to create a sadomasochistic or symbiotic


misalliance.
3. These aggressions against the therapist, as far as we can
ascertain from the material, have a number of sources:
(a) A transference from his mother which he nearly believed,
especially in moments of stress or intense emotion. This is typical
of one type of borderline transference in which, at times, the patient
becomes so immersed in his rage and near-delusional beliefs that
the therapist has wronged him, that there is an impairment in his
reality testing and object relationship with the therapist. As is
characteristic in such transferences, Mr. I.N. never quite reached the
point of total or persistent belief in his feelings of persecution and
other distortions; short of that, however, the transference signi-
ficantly affected his behavior toward the therapist, though his
capacity to recover and reconstitute remained intact throughout.
(b) A comparable contribution from the transference onto the
therapist of his rage against his father.
(c) Significant rage against himself, prompted by his sense of
failure and inadequacy (the superego element), which was turned
outward and projected onto the therapist; earlier suicidal threats
demonstrated the danger that Mr. I.N. was struggling so desperately
to defend himself against.
(d) The rage was used to cover up and defend against under-
lying homosexual fantasies towards the therapist. This use of one
type of instinctual-drive derivative to defend against another type
that is more threatening is not unusual in borderline patients.
(e) Direct anger at the therapist for not having helped him
alleviate his major symptoms.
In all, then, we see that the attacks on the therapist derived from
an overdetermined mixture of transferences based on poth genetic
and current displacements, defenses against current unconscious
fantasies and self-directed rage, and direct anger. Further, they were
accompanied by impairments in a wide range of ego functions of
varying complexities, such as judgment, reality testing, object
relationships, the capacity to differentiate his parents-the transfer-
ence objects-from the therapist, and self-boundaries. These trans-
ference manifestations also display primitivization or regression in
instinctual-drive expressions (the blatant and, at times, uncontrolled
Patient's Reactions: Principles of Technique 261

rage) and in superego derivatives (e.g., senselessly harsh and un-


realistic criticisms of the therapist, and a projection of self-criticisms).
These, too, are characteristic of borderline transferences.
4. The patient's energies, for all these reasons, were to a large
extent directed toward verbally attacking, frustrating, and provok-
ing the therapist in the session. While this falls short of physical
attack, it is nevertheless clear that this patient is making an assault
on his therapist. I have not observed circumstances in which a
patient has physically assaulted a therapist, though undoubtedly
this occurs, probably as a result of rage in a more psychotic and
uncontrolled patient whose anger has been exacerbated by a thera-
pist's poor handling of the clinical situation and transference. This
is a kind of acting in, on any level, and a living out that is not insight-
oriented. Once it has become one of the patient's main aims in his
sessions, it must be considered to be a serious disruptive problem.
Notice too, that this type of transference rage has a strikingly
pe.rsonal quality: it is specifically directed at the therapist rather
than at treatment in general. While all resistances disturb the flow
of therapy, this particular type of transference-resistance does so
through assaults on the therapist himself and is therefore difficult
for many therapists to handle. It is a genuinely provocative experi-
ence, which must be managed with skill and tact.
This material offers an opportunity to discuss both the manage-
ment of borderline transferences, and the problem of dealing in
psychotherapy with a patient's past experiences with therapists and
others in the healing professions. Firstly, what means are available
to the therapist in dealing with aggressivized transferences?
1. Identifying the transference object (person) and experiences
with that object-here, those primarily related to Mr. I.N.'S
mother-is only a beginning, and a difficult one. It poses problems
because such patients tend to isolate, repress and deny the impact of
past experiences and even their recollection of them. However, per-
sistent therapeutic work, especially with the patient's defenses, will
permit him to reveal the relevant genetic experiences.
For example, when this patient was repeatedly and in context
confronted with the similarities between his reactions to the thera-
pist and his battles with his mother, and when some of the under-
lying reasons for his rage, and his need to deny its sources in his
262 THE PATIENT-THERAPIST RELATIONSHIP

relationship with his mother, were interpreted, he recalled several


beatings he had received from her at different times in his life, and
an episode where she actually threatened to kill him. This reminds
us again that it is acute traumatic experiences as well as repetitive
hurts that help to create these disturbed transferences, and their
intrapsychic and behavioral consequences.
Thus, in analyzing aggressivized transference reactions, the
therapist begins as always, by identifying the transference object
and experiences. What more is needed?
2. Among the many other areas of work that are required here,
the defensive uses of the transference fantasies and beliefs deserve
prime consideration. These reactions serve as resistances, but do so
in a complex manner, in which not only is the multileveled threat of
the therapist, as he is perceived by the patient, lessened, but also the
related threat of inner awareness is avoided by him. Thus, the rage
is an attempt to support the patient's denial of his inner conflicts,
terrifying fantasies, disappointments, and depressions. It is based
on splitting mechanisms, projections, and externalizations, in addi-
tion to the displacements already noted, which serve to protect the
patient from his awareness of his inner self. All this must be inter-
preted in context, gently and repeatedly.
Thus, in this session, the therapist offered an interpretation that
the patient was using his rage at the therapist to shut out his inner
feelings of disappointment and guilt, and his inner fears; he denied
it. These interpretations must be made and then allowed to pass; the
patient's denials must be tolerated or occasionally further confronted
when associations permit, until he can slowly acknowledge and
mod~fy his defensiveness. This set of defenses is in general desper-
ately adhered to; the patient is able to give them up slowly at best.
At times, Mr. I.N. acknowledged his sense of guilt or one of the
underlying fantasies that he wanted to avoid, and slowly he began
to acknowledge his defensive use of his attacks on the therapist.
While this understanding alternated with persistent denials, over
many months, the latter diminished considerably.
3. Next, we must work on the unconscious fantasies that
account for the persistence of these reactions to the therapist. When
a dream in which Mr. I.N. grabbed hold of a friend's huge penis led
to associations to the therapist that were uncomfortably and quickly
Patient's Reactions: Principles of Technique 263

denied, the therapist could develop the contribution of these homo-


sexual fantasies to his rage. He interpreted the patient's wish to
destroy his power and understanding (an interpretation upward)
and later, to hurt him directly. This led to later dreams and fan-
tasies that made clear Mr. I.N.'S incorporative and castrative wishes
toward the therapist. Other unconscious fantasies, as derivatives
emerged in the material, were also interpreted, and their current
precipitates and genetic roots sought out.
I have already illustrated some aspects of this kind of interpre-
tive work (see p. 238 ff.), which is as complex as the many
unconscious fantasies that underlie such behavior. For another
example, Mr. I.N.'S fantasies of being observed extended to those
of being followed and assaulted by the therapist. Associations were
to his own stalking and attacking behavior, and the initial fan-
tasies were then interpreted as a projection of his own wishes to
harm the therapist. Associations to his parents enabled the therapist
to identify these fantasies as mother and father transference
material as well. A dream of swallowing a huge penis then linked
these projected fantasies to wishes to incorporate the therapist's
powerful phallus; the patient's rages could then once more be seen
as a means of gratifying these impulses, and of avoiding any aware-
ness of them. Wishes to be punished for incestuous fantasies about
his mother emerged next.
Thus, when faced with an aggressivized transference, the thera-
pist must listen to the patient's material with the transference prob-
lem as a main context. In this way, the resistance and communicative
functions of the transference behavior, and its unconscious mean-
ings, can be detected, analyzed, and traced out genetically. Without
resolution of the unconscious sources of these transferences, lasting
modification of them is infeasible.
4. While all of this is being worked through, the therapist is
prepared to deal with the ego dysfunctions reflected in these trans-
ference fantasies and beliefs, and the related superego and id path-
ology. Briefly, he must confront the patient with his poor controls,
distortions, poor reality testing, poor differentiation of objects, and
other aspects of his ego pathology. The excessiveness of his rages
and the undue intensity of the underlying homosexual fantasies
should also be pointed out. The cruelty of his conscience and his
264 THE PATIENT-THERAPIST RELATIONSHIP

unrealistic ideals-the primitive nature of his superego-can also


be noted in context.
In all, the therapist aims to foster the patient's awareness of
these dysfunctions and his endeavors to correct them. These efforts
toward structure building are geared to establish more mature and
stable functioning in the patient. The therapist may refer to the
ways that the patient's behavior endangers his treatment or repre-
sents an effort to seek out actual-inappropriate-punishment from
the therapist.
Thus, in the session reported. the therapist alluded to the sense-
lessness of the patient's attacks. and his failure to listen to him and
to be at all self-reflective; he also assured the patient that he could
never modify his symptoms with such fixed attitudes. In other hours.
Mr. I.N. 's failures to differentiate external reality from his inner
fantasies were brought into focus for him. For example. he
repeatedly described things that he believed that the therapist was
thinking, had done, or wanted to do. and was virtually always in
error with these allusions. Such misperceptions and misconceptions
were often noted to him in an unprovocative way. Similarly. his
repeated losses of control, which led him to panic because he
became disorganized. were pointed out to him, and the cost of these
maladaptations to himself was emphasized.
As material permits. the therapist may gently confront ego
defects and dysfunctions and, if necessary, allude to constructive
alternates, though without telling the patient what to do or how to
do it.
5. Lastly, the therapist must serve once more as a model for
healthy and mature identifications. These are crucial for the kind of
structure building that these patients need. Since they are very
provocative and quite trying, the therapist must have the capacity
to tolerate verbal assault, to point out how inappropriate and sense-
less it is, to understand it, and to analyze its unconscious meanings
and roots. His enduring tolerance and own controls serve to differ-
entiate him from the patient's transference figures and to provide
the patient with new opportunities for inner change. This is not to
suggest. however, that the therapist react with indifference. or that
controlled annoyance at selective moments is not helpful-because
it is. In all. these are delicate matters of technique; in his responses
Patient's Reactions: Principles of Techhique 265

to the patient, the therapist must be consciously in tune with as


much of his feelings as possible, and use them constructively.
In summary, then, aggressivized transference reactions are dealt
with in a variety of ways, depending on the material from the patient
and his behavior. Their presence constitutes a central context for
the therapeutic work: they are a serious disruption of the thera-
peutic alliance, a major resistance and threat to the entire therapy,
and a crucial form of communication from the patient, and must be
slowly modified if treatment is to succeed. The therapist should in
general:
1. Identify the key transference objects, and the past traumatic
experiences and atmosphere that are relevant.
2. Analyze the multitude of defensive and communicative
functions of these transferences, including the unconscious fantasies
on which they are based.
3. Confront the many ego, superego and id dysfunctions
reflected in these transferences, and the disruptive consequences
that they pose for both the patient's life and his therapy.
4. Be tactful, tolerant, and understanding so that he serves as a
model for the patient's ego, superego and id.

Previous Healers
Now let us briefly focus on the technique of dealing with the
patient's previous experiences with those in the healing professions;
such issues in borderline patients will often create special difficulties.
I have already indicated that among the real persons, other than
family members, who influence the anticipatory transference and
reality-based reactions to the therapist, other psychotherapists and
healers (physicians, dentists, etc.) are particularly important. This
is especially true of previous therapists and of physicians who were
involved in an early illness in the patient, or in a catastrophic or
fatal illness in others during the patient's childhood. As we can well
imagine, when the previous therapy has been unsuccessful, this
potential source of transference reactions can be quite disruptive.
In fact, in those patients with whom the previous therapist betrayed
confidentiality or was verbally seductive or assaultive, I have found
that the initial mistrust and wariness are enonnous. This must un-
doubtedly be even more intense when an actual seduction has
266 THE PATIENT-THERAPIST RELATIONSHIP

occurred; without my own data, though, I shall not comment further


on this issue (see Chapters 6 and 22).
The following principles are essential in such cases, and were
applied with Mr. I.N., though with limited initial success since he
was particularly stubborn in fusing his images of people and in
denying the interventions of the therapist, especially during his
defensive rages. At other times, however, he did acknowledge that
differences in technique, reliability, interpretive helpfulness and
patience existed in favor of his second therapist. Eventually, the
distinction became fairly well established, though not entirely.
In principle then:
I. This heritage from previous therapists, especially when
negatively toned (and it may include a traumatic loss-the thera-
pist's moving or dying) is a critical influence on the early transfer-
ence. It should be detected early and analyzed as fully as possible
(see Chapter 23). If not, the therapist tacitly encourages the patient's
detrimental identification of the former therapist with the present
one-it is tantamount to agreeing with his inappropriate fusion of
the two.
2. This exploration of the previous therapist's contribution to
anticipations, fantasies, and beliefs about the present therapist may
also be tied to parental figures where the material permits. The usual
principles of technique apply here; I shall not restate them.
3. The present therapist's behavior and work with the patient
must establish him as actually different from a previously destructive
therapist. If this is not the case, the related interpretations are
entirely unfounded.
4. Where the previous therapist was competent and helpful, and
the termination was not traumatic or arbitrary (e.g., the patient had
resolved his difficulties at the time, or had to move), the positive
anticipations need not be brought into focus, but can become part
of the silent, positively toned background and therapeutic alliance.
Be alert, however, for the emergence of negative fantasies-they are
bound to be there.
5. Later in therapy, when this kind of fusing comes up again,
analysis of it can include limited confrontations regarding the posi-
tive differences between the two therapists, differences that the
patient is denying.
Patient's Reactions: Principles of Technique 267

6. In those situations where other therapists known to the


patient continue to behave destructively, fusions with his own
therapist will reemerge and require reanalysis until the image of the
present therapist has solidified. This should warn us all as therapists,
not to meddle with the treatment of former patients who are being
seen by new therapists-and even the therapy of friends, not to
interfere or criticize in any way, and to behave always with dignity
and responsibility.
7. These problems can only be handled when the patient pro-
vides leads and derivatives of a fairly clear type; forcing such
interventions promotes denial. In the session with Mr. I.N., this
aspect was not central, nor did the material lend itself to a comment
along these lines; the matter was not alluded to. In other sessions,
when the patient, for example, gro~sly distorted the parallels
between the two therapists ("you both gave up on me" or "you both
agreed my mother was to blame"), the therapist pointed out that he,
himself, had certainly not made such comments.
When the patient made slips of the tongue and called his present
therapist by the name of the former one, the maladaptive use of the
confusion and merging, and its unconscious motives, could be
analyzed. Often the fusion was used to depreciate and goad the
present therapist.
A patient's anecdotes about his previous therapy can be used,
but with great caution. The therapist must not set out to fault or
destroy the previous therapist, and he must be careful not to use
these contrasts for self-aggrandizement. Legitimate differences must
be established for healthy identification with the present therapist to
be possible, but the patient will sense and exploit destructive and
narcissistic uses (see also Chapter 23).
Let us now turn to sexualized transferences, a subject which will
enable us to establish further principles of technique that are also
useful with aggressivized transference situations.
Erotized Transferences
Another difficult type of transference reaction is that of the
erotized or sexualized transference. While we can expect to apply
principles to erotized transferences comparable to those that applied
to aggressivized transferences, we will profit by exploring a
268 THE PATIENT-THERAPIST RELATIONSHIP

representative case and refining our techniques for this specific


problem.
In Chapter 20 (pp. 144-45), I referred to several sessions at the
beginning of the therapy with Mrs. I.L. Since I have already defined
the characteristics of this type of transference (Chapter 20), I shall
confine myself here largely to the techniques of dealing with its
manifestations, and discuss only those sexual desires for the thera-
pist that he has not essentially evoked or promoted through his
own behavior and technical errors; this latter situation will be
explored in Chapter 22.
If we now turn to the excerpts from the therapy of Mrs. I.L., we
learn that the therapist, in the sessions before the patient's report of
the dream in which he appeared, had already made a few comments
about her thoughts of fleeing treatment because of her sexual fan-
tasies and anxieties, noting the need to keep these in focus, to
explore them, and not to act impulsively. Similarly, her pressures
for medication, and for direct and immediate answers to her ques-
tions and problems, were taken as opportunities to point out her
need for immediate gratifications, and related to her sexual involve-
ments. The patient began. through these confrontations with her
defective ego functions, to recognize and 3tand apart from these
dimensions of her behavior and personality. and to relate them to
her problems.
Thus. one aspect of handing an erotized transference is to con-
front the patient with the more general ego dysfunctions in which
such erotizing is always embedded. and then to analyze the under-
lying fantasies and genetics. Such ego impairments include:
1. Acting out, poor controls, needs for immediate gratification.
and poor judgment.
2. Demonstrating the suffering that results from these dysfunc-
tions is also important; these can be amply detected in their daily
living.
These confrontations and, later, exploration in depth, of the ego
impairments enable part of the patient's ego or self to stand apart
from these impairments; his total personality is no longer involved
and embedded in them. experiencing them as ego-syntonic. He can
then begin to scrutinize his dysfunctions and stand against his
Patients Reactions: Principles of Technique 269

pathology, seek to modify it and eventually to build more stable ego


functions.
3. As a tool, the therapist uses those manifestations of the
patient's ego difficulties that occur in his relationship with the
therapist, without judging or moralizing, and emphasizing the dis-
advantages to the patient. He must recognize the narcissistic invest-
ment that such patients have in these impulses and handle them
with empathy and tact.
Often, it is helpful with patients who tend to form clinging and
sticky object relationships to "share the transference" in confronting
and interpreting (see above, pp. 235-37). In pointing out the
patient's ego dysfunctions, the therapist should include references,
almost always available, to their manifestations in the patient's
relationships with others; if he does not, he risks placing too much
emphasis on himself, and intensifying the patient's erotization of
the relationship with him. Sharing the transference not only helps
the patient to recognize that the feelings and impulses toward the
therapist are a manifestation of more general life-problems, but
dilutes the intensity of the relationship with the therapist.
This nonverbal aspect is critical, for if the therapist keeps talk-
ing about himself these patients will be overstimulated, regardless
of the nature of his interventions. It is especially with such patients
that the therapist must be certain that the transference is a major
current problem and that the allusions to him in the patient's asso-
ciations are clear before making interventions. With Mrs. I.L., the
session in which the dream of the therapist was reported introduced
specific wishes to have relations with him-the hallmark of the
erotized transference. Such wishes are usually in the service of
other, nonsexual needs, but are experienced as sexual by the patient
and are seriously considered or intended by her. As you would
expect, these patients commonly demand other gratifications that
go beyond the therapeutic domain and boundaries, including
requests for drugs, extra sessions, a lot of talking by the therapist,
and extensions of the hour. The therapist should handle such
demands in a manner comparable to the response to Mrs. I.L. when
she requested medication. These pressures and needs must not be
gratified, but must instead be confronted and analyzed. To do
270 THE PATIENT-THERAPIST RELATIONSHIP

otherwise would reinforce such patterns of behavior and fantasizing,


and undermine their ultimate analysis and renunciation, a mis-
alliance would eventuate.
Since these patients have often been terribly deprived, and have
a strong and persisting narcissistic investment in the gratification of
their needs, frustrating them evokes considerable rage. The patient
feels unloved and even hated; the therapist must be especially
understanding, and, without offering gratifications that go beyond
the boundaries of the therapeutic relationship, must indicate his
appreciation of the hurt and find other appropriate satisfactions for
the patient, lest he terminate therapy in a fury (see also pp. 278-82).
At the same time, the therapist must work with the patient's
superego and id pathology. These patients typically have exceed-
ingly harsh and corrupted superegos, and grandiose self-images;
they are prone to extreme idealizations of others, and unreachable
goals and aspirations. Their instinctual drives are overintense, both
in the sexual and aggressive spheres. Early in treatment, the thera-
pist's tolerance of these difficulties, his empathic responses to them,
and his gradual confrontation of the patient with them are helpful.
Eventually, their genetic roots and the unconscious fantasies on
which they are based will emerge and must be analyzed.

The reader may recall that Mrs. I.L. had said that the
therapist's office seemed like a hotel room to her and that
she felt anxious. She then recalled a series of men who
had tried to, or actually did, seduce her. She felt that she
was expressing a wish for warmth from the therapist in
the dream she had reported. The therapist now inter-
vened.
He pointed out that the patient was looking for more
than warmth-she wanted a relationship without boun-
daries or limits, and that this was in keeping with the way
in which she was flooded by her sexual fantasies. This,
he added, was something that would preclude self-under-
standing, inner change and the resolution of her problems.
She laughed and agreed that she behaved like a princess
whose every wish was to be gratified, and then described
a series of inappropriate sexual encounters and prospects
Patient's Reactions: Principles of Technique 271

that had frightened her. (Notice that here, in response to


the intervention, the patient's sexual openness becomes
ego-alien and a source of danger and anxiety for her.)
She felt good about the session, but asked for an extra
hour in fear of being overwhelmed by her recent anxieties.
When it was pointed out to her that this was again a
request for something extra and special, and that it was
necessary for her to begin to develop her own controls
and capacities to handle her anxieties, she laughingly
agreed, and the hour ended.
In the next session, for the first time, the patient spoke
about her father-a fact that appeared to the therapist as
further confirmation of the validity of his intervention
through the emergence of new and related genetic
material. She described her excessive closeness to him and
his seductiveness with her. They had shared a bedroom
together for a number of years when the patient was very
young. She then went on to describe situations in which
she would lose her temper and manipulate people, and
the therapist confronted her with these tendencies,
attempting again to make them the object of the patient's
scrutiny.
In a session two weeks later, Mrs. I.L. reported several
aspects of her parents' sexual history as described to her
by her mother, and she felt sexually aroused regarding her
therapist. Again, he pointed out that she continued to
sexualize this relationship much as she had done with
others (he detailed examples) and interpreted this defen-
sive use to both avoid, and express in a disguised way,
her memories of her parents and especially her father.
Over the next few sessions. additional genetic
material emerged. The patient in various ways attempted
to deny the therapist's existence in an effort to control
her sexual fantasies about him (a very common defense
against an erotized transference) and this he pointed out
to her. She then reported a dream of touching and look-
ing at nude women. Associations were to early childhood
experiences in her parent's bedroom, which she shared
272 mE PATIENT-THERAPIST RELATIONSHIP

on and off until she was eight years old, when her family
had moved to a larger apartment. These were terrifying
memories for her, and led to recollections of her father's
nudity in the bedroom and elsewhere. As this was elabor-
ated upon, the therapist used the material to demonstrate
that the patient had been overstimulated by her father,
and linked it both to her promiscuity, which had begun
with his illness and the threat of losing him, and to her
unrealistic wishes and expectations about the therapist
himself.
In later sessions, additional genetic roots of the erotic
desires for the therapist unfolded: her mother's rejecting
attitudes, including very early frustrations and hurts;
Mrs. I.L.'S sharing the bedroom with her father during
her mother's hospitalization when the patient was about
four years old; her many fantasies of bodily ugliness and
impairment based, in part, on a depreciated image of her
mother; and specific episodes in which her father was
physically seductive, though it fell short of actual sexual
contact. As each of these clusters of associations emerged,
they were used to give the patient an understanding of
the development of her symptoms and her transference
fantasies; her new perspective led her to see them as
serious problems.
These advances were interlarded with stormy inter-
ludes during which the sexualizing was intensified. These
were most common after Mrs. I.L. felt that the therapist
had been especially understanding and then desired him
intensely, and in her reaction to his pending summer
vacation. However, these responses began to take the
form of fantasies, no longer real expectations or desires.
Crucial factors were explored and understood: her use
of sexuality to hold onto people, to be mothered, to
gratify fantasies of union, for revenge and depreciation,
and to express and gratify wishes on every psychosexual
level; and the development of her corrupted superego,
for example, by her mother's tacit denial of, and per-
mission for, her father's seductiveness, and her father's
Patient's Reactions: Principles of Technique 273
implicit moral looseness and corruptibility as reflected in
his behavior toward her. Many related memories and
unconscious fantasies emerged, centering at first on
primal scene experiences, and fantasies of punishment,
rape, and enslavement.
In a matter of six months, Mrs. I.L. had stopped hav-
ing affairs; these impulses were under control and were
viewed by her as part of her sick past. something she was
no longer capable of. She spoke too of her therapist as
being the first man in her life who did not want in some
way to seduce her; this had helped her realize the inappro-
priateness of her own impulses. She began to control
herself better in all spheres and her anxiety eventually
lessened markedly. Still, much additional therapeutic
work remained to be done; I shall not detail it here.

I shall here summarize the main principles that apply specifically


to erotized transferences:

1. The therapist does not permit himself to be seduced or


aroused by the patient's sexual overtures and fantasies. He explores
and analyzes them as he would any other communication. He is a
model of control and decorum. and is thereby quite different from
the patient's parents, who, as a rule. have been overstimulating and
traumatizing. He not only talks of appropriate boundaries. but
maintains them in reality; no misalliance is generated.
2. The therapist tactfully confronts the patient with the inappro-
priateness of her sexual fantasies toward him, without condemning
them, and does not interfere with their verbal expression for as long
as they continue to exist within the patient. This is essential in
enabling the patient to see that the fantasies are pathological and
maladaptive, and to make them ego-alien for her.
3. As the material of each session permits, he interprets to the
patient the use of these erotic fantasies as a defense or resistance,
and the underlying unconscious fantasies and genetics that motivate
their protective and communicative uses (with their id, ego and
superego elements).
4. At a number of points in these sessions, the therapist
274 TIlE PATIENT-THERAPIST RELATIONSHIP

emphasized the patient's use of her sexual desires and behavior to


achieve nonsexual aims. This is a form of interpreting displace-
ments that plays a vital role in work with erotized transferences (see
Chapter 16). In essence, the therapist must analyze the important
roots of this type of transference in pregenital (pre-oedipal) experi-
ences with, and fantasies about, the patient's mother (and at times,
her father, who may be experienced in these early years in maternal
terms).
Such work serves two main purposes, essential to resolving the
transference: it traces out and makes conscious a critical, repressed
basis that perpetuates and fosters this transference; and it demon-
strates a part of the wide range of nonsexual, maladaptive goals that
are served by the patient's sexual wishes and actions. Thus, we may
recall that with Mrs. I.L., it was the patient's mother who was
involved in the first dream about the therapist, he is often manifestly
in the first dream of such patients, and in a number of ways, fan-
tasies about her mother were related to this patient's erotized
transferences. One example, among many, will serve:

This hour occurred at a time when the patient's


mother was going on a trip. The separation had evoked a
multitude of recollections from Mrs. I.L.'S childhood and
the recall of several family anecdotes from this period.
The material centered upon her mother's severe post-
partum depression after the patient had been born, and
her subsequent general aloofness from the patient. Mrs.
I.L.'S only memories of closeness with her mother centered
upon being in bed with her on mornings when her mother
slept late.
Mrs. I.L. began the hour by complaining about the
therapist's relative silence; it infuriated her. She had
dreamt of shopping with a woman for drapes and spoke
of having no feelings about her mother's trip. Her sexual
desires for the therapist had intensified. In another dream,
she was with a woman-a friend-who had large breasts;
she was in her mother's house and was asked to repair
the holes in the wall of the room where her two younger
brothers had slept, but she refused. She was then being
Patient's Reactions: Principles of Technique 275

pursued by Nazis and escaped to a room where she sat on


a chair with another girlfriend. Her associations had to
do with her rage at her mother for her aloofness. She
recalled a previous dream in which a woman's large
breasts had become a penis: it must all have something
to do with her sexual feelings about the therapist. He
agreed and pointed out that Mrs. I.L. was reacting to her _
mother's absence with sexual fantasies about him; she was
using him to replace her mother.
In subsequent sessions, intense wishes to fuse with
her mother, to nurse again at her breasts, and to fill the
emptiness that she had especially experienced with the
birth of her brothers, unfolded.

The demonstration of the pregenital basis of an erotized trans-


ference and its nonsexual uses extends in to some important added
technical measures. These include demonstrating to the patient that
her erotic fantasies about the therapist, and her tendency to act out
and fantasize sexually, are a primary mode of repair and adaptation,
regardless of the stress. Sexual reactions are, for such patients, some--
thing like a final common pathway for their attempts to resolve
their conflicts. By showing them how these sexual desires restrict
their adaptive flexibility and emerge repetitively regardless of the
stimulus, the therapist devalues and undercuts this avenue of
response (see Chapter 16)-a downgrading of the inappropriate
uses of sexual reactions that is very helpful.
Thus, when Mrs. I.L.'S oldest son was ill, she had fantasies of
intimacy with the therapist. When her mother finally moved away,
she again fantasized about him (this was later in the therapy, at a
point where actllal desires for the therapist and for affairs were no
longer present). When she was upset because someone had belittled
her figure or angered by her husband's momentary insensitivities,
similar transference fantasies emerged. Little by little, the therapist
demonstrated to the patient her pervasive use of sexual fantasies,
for functions as diverse as gaining a fantasied penis, repairing a
multitude of losses, gaining the favor of her mother and father,
merging with an omnipotently idealized mother, and avoiding pain-
ful emerging memories. They appeared indiscriminately, when there
276 THE PATIENT-THERAPIST RELATIONSHIP

was minimal stress and when there was an acute trauma. Awareness
of this fact fostered the patient's repudiation and renunciation of
them.
In principle, then, the therapist should demonstrate the per-
vasive and indiscriminate use of erotizations to the patient in the
transference and in her outside life, devaluing them through demon-
strating the cost and later, through confrontations with less damag-
ing means of coping.
The major pitfalls in handling an erotized transference are the
following:
1. The therapist's failures to detect momentary lapses into
hostility or nonsexual seductiveness on his part. These episodes
prompt acute exacerbations of the erotized transference. Without
an awareness of the true stimulus for these reactions, proper explor-
ation and interpretation is impossible (see Chapter 22).
2. Acceptance of the erotized transference-which is indeed
necessary-but without an appreciation of its inappropriate aspects.
This is an adherence to an old model of therapy and transference
which fails to consider ego dysfunctions and does not estimate how
appropriate-realistic and adaptive-a given intention of the
patient is vis-a-vis the reality circumstances. Erotized transferences
may even be psychotic in nature (see Vol. I, pp. 271-72), and this
dimension, which reflects ego and superego pathology, must be
recognized and worked with. Too often, a therapist is so oriented to
transference content that he misses the pathological aspects of the
transference fantasies and intentions. This greatly interferes with the
vital job of making such wishes ego-alien to the patient and of resolv-
ing them at all. Focus on fantasy content alone generally arouses the
patient rather than resolving the erotization, since in the absence of
allusions to its maladaptive aspects, it is experienced as seductive.
Further, a therapist who responds to such a patient with a comment
that he finds her attractive or would enjoy such an involvement but
cannot do so because she is a patient, offers a sanction, seduction and
an acceptance of her wishes as nonpathological, in effect, creating a
mutually seductive misalliance. Indeed, seductiveness on any level
by the therapist renders the fantasies and wishes of the patient
unanalyzable, since they are a response to a real stimulus, and
Patient's Reactions: Principles of Technique 277

reflect a problem shared, however unconsciously, by the therapist


with the patient.
Failure to recognize that the patient really wants to seduce the
therapist is another common error that leads to many unnecessary
surprises. Certain therapists tend to deny that their patients' fan-
tasies can allude to real intentions directed toward them, and that
not every patient accepts the ground rules and boundaries of therapy
from the outset. The realistically intended and inappropriate aspects
of these wishes must be seen and modified.
3. The therapist may fail to recognize that if he focuses too
much on himself in his selection of interventions, he will promote an
erotized transference, and evoke and contribute to these problems
through narcissistic and seductive misuses of the patient (see Chap-
ter 22).
4. He may fail to deal with the ego dysfunctions and defects
(and superego pathology) reflected in the erotized transference. If
the therapist confines himself to interpretations of the genetics of
the transference, and especially if he uses primarily general rather
than specific interpretations (e.g., "you feel this or that way toward
me, as you once had felt toward your fath~r"), there will be little
diminution of the erotizations. Simply offering insights into specific
unconscious fantasies on which the erotized transference is based
will not in itself resolve these transferences, for they do not go
beyond the interpretation to point up the inappropriate and mal-
adaptive aspects, and thus implicitly sanction the transference. Only
through work with the ego and superego pathology reflected in
these transferences will it be clear to the patient that her fantasies
and wishes are not only embedded in her past history and in her
present overintense needs, but that they are a form of costly mal-
adaptation, which she can and must change if she is no longer to
suffer unduly. The underlying ego and superego malfunctions reflect
significant characterological difficulties, which must be modified
along with the erotization itself. The patient must, therefore, be
offered an opportunity to stand against them and to analyze their
consequences and their origins (see Chapter 22).
5. The therapist may fail to adhere to sound therapeutic prin-
ciples in the face of the threats that such erotic desires offer the
278 mE PATIENT-THERAPIST RELATIONSHIP

therapist. He may use unneccessary parameters as an artificial pro-


tection against the patient and his own erotic or aggressive counter-
transference responses. These patients, who are exquisitely sensitive
to "bad mothering" and to defensive reactions in others (they often
have deeply disturbed and sensitive relationships with their mothers),
will react quite adversely to the nonverbal implications of such
conflict- and anxiety-based manipulations.
Some last notes on this topic:
Therapists must be alert to erotized homosexual transferences,
which are, of course, particularly common in overt or latent homo-
sexuals. Many of these patients are looking to seduce their therapist
rather than analyze their problems, and this major resistance and
wish for a therapeutic misalliance must be worked through and
resolved, along the lines discussed above.
Some patients quickly deny and conceal their erotic desires for
the therapist, and act them out with another person. This acting out
is almost always accompanied by major resistances in therapy and
by what is sometimes erroneously called a "flight into health,"
because the patient seems less anxious and troubled. It would be
more correct to term this a "flight into promiscuity or perversion,"
and it is a major hazard to the therapy. The patient who acts out
in this way achieves a "transference cure" by gratifying his trans.-
ference wishes through displacements. Such patients tend to hold
onto this real adaptation at the expense of painful inner confronta-
tion and possible structural change through therapy.
Lastly, the therapist must not overlook the rich communicative
role such transferences play. Analysis of their defensive use and
use as a means of conveying unconscious fantasies and memories
can, if the therapist is patient and empathic, teach the patient a great
deal about himself.
Narcissistic Transferences
I shall only briefly discuss the complexities of handling trans-
ference manifestations in narcissistic patients (see for example
Balint, 1968; Kernberg, 1970; Kohut. 1971; Boyer and Giovacchini,
1967). All borderline and narcissistic transference reactions necessi-
tate special sensitivities in the therapist; he must be available to the
patient-within the limits of the patient-therapist relationship (see
Patient's Reactions: Principles of Technique 279

Chapters 8, 17, and 20). Initial acceptance of the narcissistic


patient's idealizations and aggrandizements of the therapist is essen-
tial so that patient can relate meaningfully. However, empathic
echoing and mirroring of these transference manifestations, and a
therapeutic stance which accepts the patient's needs as primary and
the therapist's presence as a medium for his gratifications, must
evenutally be followed by analysis. The therapist's surface partici-
pation and interaction is only preparatory; eventually, the transfer-
ence material from the patient will reflect the pathological dimen-
sions of his narcissism, its use as a major defense, and the uncon-
scious fantasies and genetics on which it is based. The maladaptive
aspects must not be overlooked, and the striking narcissistic vulner-
ability which these patients show must be sensitively reworked
many times. The therapist's ability to tune in, to empathize, and to
cognitively recognize the sources of narcissistic hurts, especially
those that stem from his necessary interventions or his inadvertent
insensitivities, is critical to his ability to work with the frequent
regressive reactions of these patients.
To illustrate briefly, let us first recall two earlier vignettes. In
Chapter 20 (pp. 177-78), we reviewed two sessions with Mrs. 1.5.,
who had been narcissistically wounded by her therapist's apparently
necessary inquiry into the delay in paying her fee; she had, indeed,
been unnecessarily delinquent and was largely avoiding this serious
problem in her sessions. In reviewing this material, consider how
you might have dealt with it.
I shall now add the therapist's interventions, which were omitted
from the initial description of these two hours. In the first session,
when Mrs. 1.5. felt that she was hypnotized and merging with the
therapist's walls, and commented that she could not look directly
at the therapist, he pointed out that she was afraid of wanting to
merge with him and related it to her fears that the treatment might
end prematurely.
Mrs. 1.5. responded that her husband often did not make sense
to her, but she had been blind for a long time. Her mother had
called and had been insensitive; the patient had little feeling for her,
though she felt close to her in-laws.
This is rather typical of responses to incomplete interpretations
(see Chapter 19) and reflects the patient's unconscious awareness of
280 mE PATIENT-THERAPIST RELATIONSHIP

the therapist's error (see Chapter 22 and Langs, 1973). When


patients allude at any time in their sessions, though especially after
interventions, to persons who do not make sense, who are blind, and
who are insensitive, the therapist should consider the probability
that these descriptions in some way refer to himself. Narcissistic
patients are especially sensitive to, and easily wounded by, the
slightest insensitivity in the therapist. The therapist here omitted
reference to the immediate and specific precipitate for the patient's
merger fantasies, in his question about the fee. It was insufficient
for him to limit the context of the patient's reaction to the general
one of termination; the specific narcissistic hurts in questioning
Mrs. I.S. about her fee had to be recognized and communicated to
her. She had experienced the question as a narcissistic blow and
probably as a threat that the therapist might terminate her prema-
turely; the merger fantasies were maladaptive efforts to repair this
threatened loss and bypass the patient's latent rage.
I have already described the following hour up to the point at
which the therapist intervened. It was notable for the patient's rage
at the therapist, her suicidal and murderous feelings, and her dream
of the vaginal hemorrhage with associations to a miscarriage.

The therapist intervened here by pointing out that


Mrs. I.S. was reacting to his inquiry about the fee, which
she saw as a disruption in the mothering and caring quali-
ties of his relationship with her, and experienced much
like a rupture in her sense of oneness with him-as if she
had lost a part of herself, as she had with her miscarriage.
He then alluded to her sense of hurt, rage and depression,
and said that it was these feelings that had evoked her
fantasies of merging with his drapes.
Mrs. I.S. then said that she had been able to speak up
in class without anxiety the previous night; she had been
very pleased. She had also read a short story to her
creative writing class; it had been well received-if it had
not, she would have dropped the course. In intercourse
with her husband, his penis did not feel right. Her chil-
dren did not share her interests. She wished she could
look directly at her therapist (she seldom did) ..
Patient's Reactions: Principles of Technique 281

In the next hour, peace was restored for Mrs. and


1.5.,
she reported that for the first time in her life, she had
looked into a mirror while nude and admired her body,
regarding which she had always been so critical.

We see, then, that Mrs. I.5. had regressed toward bodily anxieties
and had viewed the therapist's comments as an implied threat of
separating, creating a danger for her comparable to losing part of
herself in a bloody miscarriage. The unconscious view of the thera-
pist as a fetus inside her-or the reverse-and of termination as a
loss of part of herself, is characteristic of the ways in which these
patients experience their relationship with the therapist, who must
recognize and allude to these aspects of the transference when they
become part of a transference resistance and symptomatic reaction.
The therapist's eventually correct understanding of Mrs. I.5.'S
reaction to him had a typically rapid and dramatic effect. She
responsively referred in the session to her mastery of her exhibi-
tionistic urges, and to being admired and accepted. The positive
feelings evoked by this therapeutic experience culminated in a
sense of acceptance of her bodily self, a crucial gain for this woman,
who had felt degraded because of her unconscious view of femininity
and her own lack of a penis.
In principle, then, with narcissistic patients:

1. The therapist should be initially available in special empathic


and interactive ways that complement the patient's narcissistic needs
within the appropriate limits of a therapeutic relationship.
2. These transferences occur in patients who are narcissistically
vulnerable to the slightest hurts and insensitivities. When they
regress, and especially if they disrupt the therapeutic alliance, the
therapist should search out, among other possible causes, his own
errors.
3. Restoration of an empathic and secure therapeutic atmos-
phere takes precedence over virtually all other therapeutic work.
The therapist must recognize the hurt and the way in which the
patient is experiencing it; he must correct any traumatic aspect of
his stance or any unnecessary trauma he is creating, and offer a full,
well-stated description and interpretation of the entire experience.
282 mE PATIENT-THERAPIST RELATIONSHIP

4. These patients, with their insatiable needs, preoccupation


with self-gratification, and general disregard for the needs of others,
will, from time to time, test the limits of the gratifications available
from the therapist. He must respond flexibly but firmly, with sym-
pathy but without apology; he must not overindulge the patient,
creating a narcissistic misalliance. He must work with both the ego
and superego (ego ideal) dysfunctions, and the narcissistic hurts and
rages evoked by these necessary frustrations.
Some of these principles have also been discussed and illustrated
in Chapter 8, especially in the vignette with Mrs. C.o. (pp. 00-0(0),
who responded with paranoid rage when she found her therapist's
office locked because he arrived after she did-though he was not
late-for his early afternoon hour with her. Here, not only did the
therapist explore the roots of this narcissistic transference in early
insensitivities of the patient's mother and early indulgences by her
father, but he also made sure to arrive earlier for her session, since
he was able to do so. Later, he found a way of leaving his office open
so that she could enter his waiting room, though the door to his
consultation room was locked. In contrast, when this patient asked
the therapist to extend her hour when she was only moderately
upset, he did not do so and comfortably analyzed the consequent
rage and fantasies unneeded deviations deter these patients from
inner mastery.
In all, these are trying patients for many therapists. They tend
to promote very varied feelings: the therapist may see himself as an
omnipotent seer, as a pawn who should gratify the patient's every
whim and need, and as a nonentity solely there to admire the
patient's feats and verbalizations; he may also feel inappropriate
guilt over setting necessary limits that enrage the patient. These
subjective responses are very useful, however, in responding and
interpreting properly to these patients, as long as they are recognized
and relatively well controlled (see Chapter 22).
Psychotic Transferences
I shall not discuss the problem of psychotic transference at any
length, since it would have to be predicated on a discussion of
psychoses that is beyond the purview of this book. I have already
described the phenomenology of this type of transference and shall
Patient's Reactions: Principles of Technique 283

briefly review here the principles with which it can be approached


(see pp. 175-76 for the relevant clinical material).
In doing out-patient psychotherapy, it is essential to maintain a
nonpsychotic therapeutic alliance with the healthy part of the ego
of the psychotic patient, and thereby assure that treatment continues.
One must hope that the relationship and work with the therapist
does not generate a psychotic decompensation, which would necessi-
tate such measures as hospitalization. Briefly, I would emphasize
the following:

1. Prevent the development of psychotic transference reactions


whenever possible.
(a) Therapy with patients with psychotic potential should focus
on the patient's life-problems and not on the relationship with the
therapist whenever possible.
(b) The therapIst should be cautious and as conservative as pos-
sible in responding to the patient's acute decompensations, regres-
sions, or the fragmenting of specific ego functioning. Often, he must
play a real and concrete role in assisting the patient to function at
such times, but he should do so as little as possible and share the
caretaker function with family members as far as he can.
When a patient suffers acute suicidal impUlses, such as those
experienced by Mrs. I.R., and truly wants to die, the therapist may
have to actively foster a wish to live. Or if a patient becomes delu-
sional and it interferes with his functioning, as it did with Mrs. I.Q.,
when she became unable to care for her children, active interven-
tions and at times, manipulating and advising (temporarily taking
over the defective ego functions) may be indicated.
I shall not discuss the technical issues involved in the function
of the therapist as an auxiliary ego, nor those related to the other
problems of whether fostering transference reactions, however psy-
chotic, which might then be analyzed, is preferable to efforts to
diminish the chance of such transferences in out-patient treatment.
My own limited impression is that such transferences disrupt treat-
ment so drastically that their disadvantages far outweigh any pos-
sible advantages. I want simply to emphasize here that, to the
extent that the therapist offers the patient real gratifications that go
beyond the usual therapeutic boundaries, he will become a potential
284 THE PATIENT-THERAPIST RELATIONSHIP

object for fantasies and actual wishes to psychotic patients and that
these extend beyond the usual limits of the patient-therapist dyad.
In these patients, who tend toward delusional and other reality-
impaired fantasies and object relating, deviations in technique, how-
ever necessary, will invite such responses and other ego impairments;
they must be watched for and maximally resolved if they occur.
(c) Do not attempt unnecessarily to break down the patient's
defenses against potential psychotic transferences. Thu~, the thera-
pist does not interpret or confront denials directed against feelings
about him, and displacements to the outside of the transference
fantasies and impulses, unless they become the source of severe
impairments in the therapeutic relationship or in the patient's rela-
tionship with others, or unless they endanger the patient. As we saw
with Mrs. I.R., it was when the therapist found it necessary to con-
front her with her feelings toward him, thereby momentarily pene-
trating her denial in this respect, that the patient became less
suicidal. The price, however, was fragmentation of her capacity to
relate to the therapist, because she turned to more pathological and
disruptive defenses, which, in turn, had been prompted by the
related anxieties.
(d) Maintain special tact and sensitivity in intervening with these
patients, so as not to be provocative or seductive, and do not move
too quickly in the exploration of the material they offer. This
involves a very delicate balance, in which oversensitive and exagger-
ated responses are bound to occur in the patient no matter how hard
the therapist tries not to be disturbing; he should simply try to
minimize these moments.
2. Should psychotic transference responses appear, the therapist
must make them his primary focus and analyze them as quickly as
possible, with emphasis on their resolution. While we must attempt
to understand the genetics, displacements, unconscious fantasies,
and the conflicts related to these transferences. and to interpret them
when possible, we should focus on the immediate precipitate of the
'ransference response (be it within or outside treatment), the mal-
adaptive efforts involved, the unrealistic aspects of the beliefs and
impulses, and the ego dysfunctions and defects.
In essence, the therapist must help the patient reestablish his ties
to reality and his controls over his disruptive regressions. It is
Patient's Reactions: Principles of Technique 285

toward this primary task of maintaining a working relationship with


the patient that therapeutic efforts on all levels converge when such
crises arise.

NONTRANSFERENCE ASPECTS
I shall be especially brief in discussing the technical aspects of
handling the therapeutic alliance and other non transference aspects
of the patient-therapist relationship in psychotherapy, because this
entire subject has been developed in considerable detail throughout
the book and because I shall be focusing on this topic in Chapter 22.
I shall, therefore, confine myself here to a synthesis of the main
principles of technique that have been developed throughout this
discussion (see also Chapters 5, 6, 20 and 23).

1. The therapist should include the status of the working


alliance among the critical dimensions of the therapeutic situation
that he constantly monitors. If it is secure and the therapeutic work
is progressing, there is no need to allude to or explore it.
2. If there is any gross or subtle impairment in the therapeutic
alliance-and these range from minor impediments in the patient's
associations, or passing disturbances in the working relationship, to
attempts by the patient to create misalliances, and gross disturbances
in the joint efforts toward symptom-relief-it must become the
central focus of the therapeutic work. All other aspects should be
secondary unless there is an emergency or an important break-
through. By and large, then, the disturbance in the therapeutic
alliance should serve as the primary therapeutic-and at times,
adaptiv~ontext for listening to the material from the patient;
only rarely and temporarily can other concerns take precedence
contextually.
3. Adhering to sound general principles of technique in dealing
with disturbances in the working alliance, the therapist first recog-
nizes the problem and assesses its sources, either in the patient's
outside life or within his relationship with the therapist. The most
frequent causes of such difficulties lie in the latter area; they range
from the intrusion of transference fantasies and wishes into the
286 THE PATIENT-THERAPIST RELATIONSHIP

therapeutic alliance to the therapist's necessary or technically incor-


rect behavior.
(a) Once the nature of the disturbance in the therapeutic alliance
and precipitates are recognized, the therapist listens and makes as
complete an analysis and working-through as he can of the uncon-
scious fantasies and conflicts, and genetic memories and experiences,
to which this problem is related.
(b) Where disturbances in the working alliance reflect ego and
superego dysfunctions, these should be explored in depth and modi-
fied.
(c) In addition to the exploratory and analytic work with the
patient's material, the therapist must modify and correct any contri-
bution that he has made to the disturbed alliance through his errors
and human failings.

The reader can review the clinical application of these principles


by a restudy of the relevant vignettes (see the Index of Clinical
Material). The maintenance of a strong, secure, and mature working
alliance relies on the therapist's positive stance and skills, and his
ability to detect and analyze any acute or chronic disturbances in
this alliance.
I have discussed the other nontransference dimensions of the
patient-therapist relationship in detail in Chapters 5, 6, and 20. We
shall be considering this area again in Chapter 22.

PITFALLS IN ANALYZING TRANSFERENCE


MANIFESTATIONS
Throughout my discussion of transference reactions, I have pointed
to areas of difficulty, common misconceptions, and possible pit-
falls in the techniques of dealing with such material. Here, I shall
briefly summarize some of the more common problems for the
therapist in this area, and then focus on two general, incorrect styles
of handling transference manifestations that are often seen in thera-
pists: overemphasis of the transference, and its converse.
The most common technical errors made in dealing with trans-
ferences are :
Patient's Reactions: Principles of Technique 287

1. The exploration of transference fantasies in isolation, with-


out a context, and the failure to ascertain the precipitate of the
transference reaction and its adaptive uses.
2. Overemphasis of the realistic aspects of a given transference
reaction to the therapist and relative neglect of the intrapsychic fan-
tasies, conflicts, and especially, the drive-derivatives reflected in the
material.
3. Missing the genetic reference in the patient's associations to a
transference reaction, especially when only a passing allusion is
made to the earlier figure.
4. Failure to recognize the limitations of work with the trans-
ference in psychotherapy. This leads to expectations of being able
to analyze a transference response in depth, rather than piecemeal
as it becomes pertinent; at times, this leads to excessive focus on
transference-related associations when they are no longer the central
problem-the primary adaptive context-for the patient.
5. Failure to deal with ego and superego pathology in transfer-
ence reactions, incorrectly pursuing instead only the content of the
fantasies.
6. Failure to be available to the patient as a meaningful person
onto whom transferences are projected; lack of a sympathetic
understanding of what the patient needs in his relationship with the
therapist. This includes failure of the therapist spontaneously to
conduct himself in ways different from the pathogenic and disrup-
tive behaviors of the patient's earlier objects. This interferes with
both transference development and the modifications of transfer-
ence-related psychopathology through new and more adaptive
identifications with the therapist, and with ego development and
superego muturation.
7. Participation with the patient in misalliances inappropriate
transference gratifications and mutual acting out, consciously or
unconsciously. This interferes with the necessary frustration and
abstinence needed for the analysis of transference reactions.
8. Failure to monitor the transference and therapeutic alliance,
and to foster the exploration of significant disturbances as early as
possible.
9. Overemphasis on every nuance and passing impairment in
the working alliance and on every minor transference reference.
288 THE PATIENT-THERAPIST RELATIONSHIP

10. Failure to interpret transference manifestations as resis-


tances and impediments to the development of the therapy when
they are in fact used in this way by the patient.
11. Failure to trace out the relationship of transference material
to the patient's symptoms and core conflicts when the material
permits.
Now, let us focus on the two extremes, and explore the conse-
quences of each error. Consider this condensed clinical material:

Mr. I.M. was a single Jewish man in his twenties who


was in therapy because of homosexuality and depression;
he had a severe character disorder. After ten months of
therapy, he had become remote and was ruminating in
his sessions, though there were hints of near-conscious
sexual fantasies about his mother. He spoke of moving
closer to his parents. from whom he had been alienated
for some time.
In the next session. Mr. I.M. described functioning
better on his job and feeling generally well. He spoke of
a variety of realistic problems, ranging from plans to take
an apartment with a boyfriend. to recent visits with his
family. The therapist pointed out that he was wandering,
and the patient said that it was because he felt so well.
One of his friends had been helpful to him, but Mr. I.M.
hid what was inside himself. The therapist said that he
was doing so in that session. and the patient ruminated
about what he could be hiding. He had met an old boy-
friend and told him that he was a homosexual. The thera-
pist said that the patient had been talking about closeness
with family members and friends, and suggested that the
reason Mr. I.M. was all over the place in the session was
that he was afraid of closeness with him. the therapist.
The patient said that he could be right, but sometimes he
had those fears and other times he did not. He felt a burn-
ing in his stomach. If he were to admit things, he would
fall down and die-it would be something disgusting. He
thought of how he felt when he had an orgasm.
In the next hour, Mr. I.M. reported that he continued
Patient's Reactions: Principles of Technique 289

to suffer with the stomach pains and was preoccupied


with homosexual fantasies and anxieties. He derided
people who offer pat answers to complicated problems
and spoke of prejudice against the Jewish people.

In this vignette, the therapist introduced therapy several times


and eventually a specific reference to himself, without any definitive
material on which to base his interventions. While one might agree
that his initial confrontations with the patient's rumination was an
appropriate comment in the face of a major resistance, his addi-
tional remarks created pressures on the patient that were unjustified
on the basis of his associations. Rather, the material suggests that
the defenses were directed against the patient's emerging incestuous
fantasies about his mother. The outcome was a regression to
psychosomatic symptoms and ego disorganization with anxiety,
and, in the next hour, an intensification of the patient's homosexual
fantasies and anxieties. The patient also later communicated his
unconscious perception of the therapist as someone who offered pat
answers and as a persecutor. While this latter was strongly related
to his own unconscious fantasies and confi.icts, it was also based on
an accurate perception of the therapist. In fact, most patients,
regardless of their psychopathology, respond to a therapist's
repeated references to himself, without adequate material, by
regressing and developing acute symptoms, rupturing the thera-
peutic alliance, and by having paranoid-like fantasies of being
seduced, pursued or persecuted. The context and derivatives in the
patient's associations connect these reactions to the therapist's
unfounded preoccupation with himself. Acting out, and sometimes
premature termination of the therapy, often follows.
Similarly, regression, disruption in the therapeutic alliance, and
especially acting out will appear when pertinent, conflict-related
transference fantasies and resistances are repeatedly neglected by
the therapist. In such instances, the patient's responses are usually
embedded in derivatives related to insensitive, neglectful, blind per-
sons, who represent the therapist. These reactions are common when
separations or other traumas that are not error-based occur, bt,t
are especially frequent when technical and human errors have
evoked the patient's fantasies about the therapist (see Chapter 22).
290 mE PATIENT-THERAPIST RELATIONSHIP

The following vignette is illustrative; it occurred earlier in the


therapy with this same patient.

After about two months of treatment, Mr. J.M.'S thera-


pist planned to take a one-month vacation. For several
sessions prior to the separation, the patient appeared
depressed and became preoccupied with homosexual fan-
tasies and wishes. In the hour before the break, he spoke
of quitting therapy because he felt uncomfortable with it.
He called an old homosexual friend. and ruminated about
the sexual prowess of young men and about thoughts of
traveling around the country. The therapist said that he
seemed confused about sex, and the patient fell silent and
looked away. He was afraid of becoming a loser and had
allowed a homosexual to pick him up and seduce him; it
was very depressing. He would like a woman to fall into
his lap.

The therapist left without interpreting this patient's erotized


transference, which was being acted out blatantly with others. Upon
his return, the therapist learned that the homosexual acting out had
co~tinued while he was away and that the patient was deeply
depressed. He was also searching for a woman who would under-
stand him; he realized that he was a very dependent person, but no
one really satisfied his needs.
This patient reacted here both to the separation from the thera-
pist and to the latter's failure to understand and interpret the acting
out of his transference fantasies. In response, he felt misunderstood
and depressed, and intensified his acting out as well.
In all, technical errors of all kinds in handling transference
reactions are a frequent cause of the patient's regressions and acting
out, and of disruptions in the therapeutic alliance. When these dis-
turbances occur, this is one critical area of the therapeutic relation-
ship that should be carefully reviewed by the therapist and modified
where indicated.
With these comments, I shall conclude this discussion of the
technical issues in the patient's relationship with the therapist. In
fact, separate discussion of this aspect of the patient-therapist rela-
Patient's Reactions: Principles of Technique 291

tionship is fairly arbitrary, and I have made continuous reference to


the therapist's contributions. I shall now directly consider the thera-
pist's relationship with the patient. In many mays, it is the less
studied and more crucial of the two sides of this dyad.
22 The Therapist's Reactions to the
Patient

There are, to my knowledge, four possible routes in the exploration


of the therapist's relationship with the patient:

1. The therapist's own experiences, behavior and self-observa-


tions, and the outcome of his self-analysis where it has proven to be
viable and productive.
2. The psychoanalyses of therapists, which provide additional,
more profound analytic and self-observations, and access to the
unconscious components of the therapists's relationship with the
patient.
3. Observations by the therapist's supervisor-of the therapist and
of the material from his patients.
4. Observations by the therapist himself of the clinical material
from his patients.

It is these last two relatively neglected sources of data that fall


within the main province of this book and that will be utilized for
the bulk of my discussion of this topic. However, before turning to
these data, I shall briefly discuss the first two sources of information
about therapists; this will enable me to highlight certaIn dimensions
of the relationship with the patient that I might not otherwise com-
ment upon. As background, the following are representative of the

292
Therapist's Reactions to the Patient 293
psychoanalytic literature on this topic: Cohen (1952); Giovacchini
(1972); Gitelson (1952); Kernberg (1965); Little (1951); Money-
Kyrle (1956); Orr (1954); Racker (1968); Reich (1951 and 1960);
Ross and Kapp (1962); Tauber (1954); Tower (1956); Searles (1965);
Weigert (1954); Whitman et. al. (1969); Wile (1972); Winnicott
(1947); and Wolstein (1959).

SUBJECTIVE EXPERIENCES AND SELF-


OBSERVATIONS OF THERAPISTS
The fundamental methodology of this book draws upon clinical
observations of the psychotherapeutic situation, and utilizes the
patient's behavior and associations as the primary source of informa-
tion. Here, however, I want to step beyond these confines to touch
upon the range and kinds of experiences that the therapist may
expect in his interaction with the patient, including both the
appropriate gratifications available to him, and the breadth and
limits of his responses to the patient. I shall also touch upon the
indications that he is having difficulties, be they conceptual mis-
understandings, countertransference problems, or counterfeelings
toward the pati~nt. I shall not only draw upon my own experiences
as I have developed as a psychotherapist over the past 18 years, but
also shall use the reports made to me by colleagues and trainees
during exploratory and informal discussions and in supervisory
sessions. For reasons of confidentiality, observations of therapists
in analysis or psychotherapy with me will not be included here.
I have found that certain "myths" or misbeliefs are prevalent
among my supervisees and colleagues; some of them I had been
taught during my own years of training. I believe that the statement
of these myths can be of considerable heuristic value, not a mere
setting up of straw men for criticism. I do not propose that all
therapists share these misconceptions, or that there are no grains of
truth in them. They are valuable fulcrums for a discussion of this
kind and will help us to recognize and modify ~ome of the denials
that are all too common among therapists. They can aid us to
establish a more accurate and fully dimensional picture of what it is
like to be a psychotherapist (see also Chapter 1).
294 mE PATIENT-mERAPIST RELATIONSHIP

THE MYTH OF THE UNRESPONSIVE ("NEUTRAL" OR


"MIRROR") THERAPIST

There are actually several versions of this myth: that the ideal
therapist is always neutral, in the sense that he is unresponsive to,
or unaffected by, anything that the patient says or does; that it is
entirely inappropriate for the therapist to have any kind of fantasies
or feelings in response to, or about, the patient; or that the therapist
never experiences any sense of threat or anxiety in his work.
These myths, originating with respect to the psychoanalyst (see
Freud, 1912b and Greenson, 1967), are derivatives of a much-
misunderstood concept, that of the psychotherapist's neutrality.
There are realistic and appropriate applications of this important
tenet in psychotherapy, just as there are untenable misuses. In
essence:
1. The patient-therapist relationship is a viable, human inter-
action in which both participants experience a whole range of
thoughts, fantasies and feelings. If this is not the case for the thera-
pist, then we must assume a pathological disturbance on his part.
2. The therapist must limit and control his responses to the
patient so that they are as far as possible nondeviant, realistic, appro-
priate, centered on the needs of the patient, and largely conscious.
(a) I am not suggesting by this that unconscious or primary-
process-dominated, nonpathological and countertransference re..
sponses should not or do not occur in competent therapists; in fact,
these experiences are an inevitable part of the patient-therapist
interaction. But when these reactions are in appropriate, primarily
countertransference-based, and largely related to the therapist's
rather than the patient's needs, they should be detected by the
therapist; they should be short-lived, to some extent made conscious,
and restricted in their effects on his interaction with the patient; and
ultimately, they should be resolved through self-analysis.
(b) The therapist's openness to nonaberrant, primitive and
irrational experiences and fantasies, when they are in keeping with,
and in response to, the material from the patient, is an important
means of understanding the patient and establishing contact with
his more primitive fantasies and basic affects. The therapist must,
Therapist's Reactions to the Patient 295

however, ultimately utilize such feelings rationally and in the service


of the psychotherapy.
Thus, both patient and therapist experience regression and
recovery during sessions. The therapist, however, has a larger
resp0'lsibility to return to the realities of the therapeutic situation
and task, and to communicate in an essentially rational way, than
does the patient.
(c) The therapist's countertransference-dominated reactions (see
pp. 297 if. and 375 if.) may also, when their pathological aspects are
limited and resolvable, be used in the service of the treatment. Thus,
with proper awareness and self-analysis in the context of the on-
going interaction with, and the material from, the patient, the thera-
pist can use his aberrant response to understand the patient and his
unconscious fantasies, and ultimately, to further the therapeutic
work. These reactions can, then, have adaptive as well as mal-
adaptive aspects.
3. It is reasonable and human for a therapist to feel annoyed
when he is provoked, attacked persistently, or frustrated unreason-
ably. On the other hand, anger at inevitable resistances, criticisms,
delays in the progress of therapy, and hostilities from the patient is
inappropriate. These latter are reactions which every therapist
should be able to accept and to analyze with the patient, rather than
responding directly to such frustrations and aggressions. Each
therapist must develop a tolerance for such behavior, and must
draw for himself a fine line between inevitable provocations from
patients and those that are unreasonable and excessive. Yet he must
meet even these undue hostilities primarily with an analytic stance,
although he can legitimately mention that he feels that the patient
is attempting to be inordinately provocative when he intervenes.
Rageful intrusive fantasies, repetitively angry responses, and transla-
tions of his feelings into provocative, counterattacking interventions
are signs of inner difficulties in the therapist. A sense of controlled
hostility or of irrational-but quickly analyzed and mastered-
anger, can be used to recognize the patient's needs, conflicts and un-
conscious fantasies, and especially, his unconscious wishes and
fantasies toward the therapist at the time. Thus, the therapist's self-
awareness of angry feelings and fantasies will alert him to the
296 THE PATIENT-THERAPIST RELATIONSHIP

patient's intention and need to provoke and anger him. He can then
search for the basis for the patient's behavior.
In general, I do not advocate that the therapist share these fan-
tasies and feelings with the patient, except in unusual circumstances
and in a special and careful way. To do otherwise is to burden the
patient unduly with the therapist's problems and pathology (see
pp. 312 ff.). On the other hand, if the patient confronts the therapist
with them, he must not deny, but accept or acknowledge and then
explore, them, primarily in an effort to determine why the patient
has been so antagonistic.
A serious danger with provocative-and often narcissistic-
patients is that of a sadomasochistic misalliance, in which the thera-
pist and patient respectively take either the aggressive or submissive
role, or alternate. This is especially likely to occur if the therapist
is unaware of his feelings of provocation or anger.
4. I would consider only the most innocuous of sexual feelings
and fantasies about a patient as inevitable. A male therapist who
recognizes that a particular female patient is attractive is well
within limits that are appropriate to therapy. If he goes on to
undress her in his imagination (let alone, in reality!) or to touch or
copulate with her in his fantasies, this is an erotized counter-
transference and an inappropriate sexualization of the therapeutic
relationship, and it will inevitably interfere with the therapeutic
alliance. An erotized misalliance is a not uncommon consequence,
and unless it is modified, the entire treatment will be undermined.
In all, the therapist must be aware of a seductive patient's efforts
to arouse him and he must not respond directly to these efforts by
either a similar seductiveness or defensive aggressions. Awareness
of momentary, resolvable erotic countertransference feelings can be
used therapeutically to understand the patient. However, any
unresolved or unconscious seductiveness or aggressiveness in the
therapist will interfere with the therapy.
5. The same principles apply to the therapist's affective
responses to the patient. At times, patients may evoke anxiety,
affection, sympathy, sorrow, or rage. In general, such feelings, when
realistic in light of the communications from the patient and when
limited in intensity and duration, are appropriate; they help the
therapist understand and respond to his patient. Affective reactions
Therapist's Reactions to the Patient 297

which extend beyond such limits-for instance, excessive anxiety


or unduly strong depressive feelings-reflect countertransference
problems.
6. In general, then, all of the pathology that we have recognized
in the patient's relationship with the therapist, with expressions
ranging from fantasies and impulses to direct wishes and intentions,
can be found in the therapist's inappropriate responses to the
patient. When a patient is overaggressive, controlled annoyance is a
realistic response, but murderous fantasies constitute a counter-
transference-based and unrealistic reaction for the therapist. When
a patient is seductive, awareness of this is a controlled or signal
response, but any degree of sexual arousal and fantasizing in the
therapist is a countertransference-based reaction. Further, any
responsive acting in toward the patient or displaced acting out by
the therapist, based on his own unresolved conflicts and fantasies,
must also be seen as a reflection of countertransference problems.
In essence, the therapist is quite alive with thOUghts, fantasies,
and feelings in the therapy situation. He responds to what he sees
and hears. But as far as humanly possible, he strives to keep such
responses appropriate to the patient's needs and in the service of
the therapeutic endeavors, no matter how distorted momentarily.
Lastly, he does not introduce his own fantasies into the therapeutic
relationship and maintains maximal anonymity.

MYTHS ABOUT COUNTERTRANSFERENCES

Two contrasting misconceptions will be discussed briefly here, as


part of the effort to convey a realistic picture of the therapist as he
interacts in the therapeutic situation: the myth of the total destruc-
tiveness of countertransferences, and its converse-the belief that
the therapist can say or do anything as long as he analyzes it. Later
in this chapter, I shall present clinical data from patients to illustrate
the fallacies in them. In essence:
1. Countertransferences are inevitable because:
(a) The therapist has not undergone analysis, and his uncon-
scious fantasies and intrapsvchic conflicts will inevitably be imposed
onto his relationship with the patient, or
(b) The defenses and resolutions of the intrapsychic conflicts of
298 THE PATIENT-THERAPIST RELATIONSHIP

the psychoanalyzed therapist are essentially secondary autonomies


that will sometimes fail.
2. We may briefly define countertransferences as one aspect of
those responses to the patient which, while prompted by some event
within the therapy or in the therapist's real life, are primarily based
on his past significant relationships; basically, they gratify his needs
rather than the patient's therapeutic endeavors. As with the patient's
transferences, we must distinguish these reactions, that are primarily
genetic and conflict-based, from those responses that are realistic
and appropriate to the therapist's role and to the behavior of the
patient. The latter draw upon the therapist's relatively autonomous
and conflict-free functioning and contribute to the mature working
alliance with the patient. They include the therapist's appropriate
listening, intervening, and tolerating, his structuring of the therapy,
and a host of other constructive efforts.
(a) In defining countertransferences, we must keep in mind that
the therapist's responsibilities and role in psychotherapy differ from
those of the patient. We must also recognize the requisite to main-
tain a rational, patient-oriented stance in the face of unconscious
intrusions or momentary irrational lapses.
(b) Countertransference reactions are based on unconscious
fantasies and memories, but their behavioral manifestations may be
confined to fantasy or may extend to verbal and other actions. The
therapist may be entirely unconscious of them, or he may be aware
of them, directly or in some derivative fantasy form. These reactions
may be recurrent and characterological, or acute and episodic; they
may include neurotic symptomology or be confined to attitudes and
actions.
(c) Countertransference reactions unfold primarily in interaction
with the transference and nontransference responses of the patient,
and in response to his communications.
(d) In essence, countertransferences are based on infantile rela-
tionships and wishes, and the defenses directed against such fulfill-
ments.
3. In dealing with countertransference reactions, the primary
goals are:
(a) For the therapist to recognize them when they occur; to
Therapist's Reactions to the Patient 299

limit their extent, frequency, and effects on the treatment; for him
to be aware of their influence on himself and the patient; and for the
therapist to analyze and resolve them by himself as quickly as pos-
sible, without further burdening the patient. The therapist should
not share his problems with the patient nor complicate the thera-
peutic relationship with any exploration of them with the patient
(see pp. 312 ff.).
(b) The therapist must recognize his transference-based reactions
to the patient, and accept them and their consequences without
undue guilt. He can, moreover, adaptively use them to deepen his
understanding of the patient and to further the therapy.
(c) Countertransferences are especially disruptive when the
therapist is not aware of their manifestations and their effects,
whether they are blatantly acted out toward the patient or expressed
more subtly.
(d) There are two main avenues for the conscious realization of
derivatives and expressions of countertransferences: self-awareness
and the material from the patient, which can direct them to the
attention of the unwary therapist (see pp. 312 ff.).
The following self-observations should alert the therapist to
problems within himself (see also Cohen, 1952 and Wile, 1972):
(a) Sexual and aggressive, or otherwise instinctualized, fantasies
toward the patient, either recurrent or rare but intense.
(b) Repetitive dreams about the patient, especially those with-
out elements of renunciation (see Whitman et. aI., 1969).
(c) An ongoing therapy or therapeutic setting and tone which is
aberrant and in difficulty.
(d) Repetitive errors in intervening or in failing to intervene
with the patient.
(e) Chronic dislike or too much liking for the patient; boredom,
disgust, and feelings of frustration with him.
(f) Recurrent anxiety, unease, or guilt when with the patient, or
feelings of hopelessness and depression about him.
(g) Recurrent difficulties in understanding the communications
from the patient.
(h) Difficulty in listening to the patient during sessions and in
remaining alert. A tendency to be preoccupied with personal
300 TIlE PATIENT-TIlERAPIST RELATIONSHIP

thoughts. Shifts in states of consciousness which interfere with the


therapist's autonomous functioning and free-floating attention to
the communications from the patient.
(i) Preoccupation with the patient outside his sessions.
(j) Any tendency to be late or miss sessions with the patient, to
extend or shorten his sessions, or to change his hour more than
rarely.
(k) Any tendency toward quarrelsome or seductive behavior
toward the patient.
(1) Any tendency to use parameters or more subtle deviations
in the therapist's usual technique with the patient.
(m) Any tendency to focus repetitively on deep (so-called "id")
material, reality issues, or any other single area, to the relative
exclusion of other dimensions.
(n) A need to repeat, restate, and defend one's interventions
with the patient.
This is a representative, though incomplete, listing. The therapist
must work through any resistances to remaining alert for such
indicators of countertransference.
4. Once they have occurred, controlled countertransference
responses. and at times even more uncontrolled ones. can be used
constructively in the therapeutic work. as the therapist ultimately
recognizes a deviant response and uses it to understand what the
patient has communicated to evoke it. By becoming aware of the
patient's and his own responses, and the fantaSIes that they express,
the therapist may tune in on aspects of the patient's communications
that he did not previously realize. Further, the constructive working-
through with the patient of such countertransference responses of
the therapist can be a most gratifying and meaningful therapeutic
experience for both parties, though it is fraught with pitfalls (see
also Greenson, 1967, 1971 and 1972, and pp. 312 ff.).
Such responses, when recognized, should usually be briefly
acknowledged to the patient-but only when it is relevant to his
associations. Countertransference effects are a major trauma for
patients; they are, therefore, an adaptive and therapeutic context of
highest priority. Patients virtually always respond to them, primarily
unconsciously (see Langs, 1973), and these reactions are reflected in
their behavior and associations.
Therapist's Reactions to the Patient 301

Thus, once such countertransferences-usually in the form of


errors in intervening, and inappropriate deviations and attitudes-
are acknowledged, the therapist can use the patient's subsequent
associations and responses to the error to reconstruct the true
sequence of events and its meanings for the patient. Frequently
genetic links and adaptive elements to the patient's reactions are
available as well, and a full analysis and working-through of the
experience-often, eventually related to his symptoms-can be
achieved.
In this way, the consequences of many countertransference-based
errors can be minimized and even turned to constructive purposes.
The implications of such a stance are manifold: the therapist
appears to the patient as honest, dedicated, and willing to be truth-
ful about himself-all important traits with which the patient may
then identify. It also serves to restore a proper and healthy thera-
peutic alliance and atmosphere. Unthreatened therapists who can
learn from their mistakes are appreciated and readily forgiven by
their patients for their occasional errors.
Just where a given patient will draw the line-i.e., the point at
which the therapeutic alliance is permanently eroded and the treat-
ment is undermined by unmodified or repetitive counter transfer-
ence behavior-is hard to say. But such a point does indeed exist;
the therapist must not deny this possibility or fail to recognize it if
it should happen with a patient who has been particularly difficult
for him. Referral to a colleague is indicated at such times, but the
therapist should first be certain that he is in an irretrievable jam.
Referrals are traumatic and are to be avoided if possible (see
Chapter 25).
5. There are errors in technique and countertransference prob-
lems which at a single blow can undermine or so distort the thera-
peutic situation that effective therapy could never subsequently
evolve, regardless of how much analysis of the incident follows it.
Similarly, there are chronic countertransference problems, both
blatant and subtle, that have the same result. To cite an extreme
example: once the therapist has sexually seduced a patient, the basic
tone of the therapy and the therapeutic alliance is so modified that
insightful and adaptive inner changes will never occur in the patient,
regardless of how much he attempts to explore and resolve the
302 mE PATIENT-THERAPIST RELATIONSHIP

episode. Such behavior forms a basis for acting-out tendencies,


corrupted identifications, and avoidance of inner change despite
anything that the therapist later says. It serves a multiplicity of
maladaptive functions: transference and countertransference grati-
fications, repetitions of infantile traumas, pregenital wish-fulfill-
ments, and defenses against aggression and bodily anxieties. In
instances of this kind irrevocable misalliances have been created.

There are many shades of countertransference-based disruptive


behavior by the therapist, of its consequences, and of the possibili-
ties for resolution. I shall discuss some relevant data later in this
chapter, and I want simply to emphasize here that such behavior on
any level is, by far, best controlled before it happens. Not always
can it be rectified, and there are very deliCate technical considera-
tions in deciding how and whether the consequences of an episode
can be worked through or referral of the patient is indicated.
In summary, then, countertransference-based responses are an
integral part of the therapist's reactions to the patient; in that sense,
they are inevitable. They should, however, be as limited and con-
trolled as possible; used to understand and work with the patient's
emotional problems; and resolved through self-analysis and then
worked through with the patient without burdening him with the
therapist's problems. Further, it must be recognized that some
countertransference expressions, regardless of how extensively
acknowledged, and subsequently modified and analyzed with the
patient, create disruptions of therapy that leave lasting scars, and,
at times, a permanent impairment in the therapeutic alliance.

MYTHS ABOUT THE THERAPISTS' GRATIFICATIONS


This is a subject that has received attention, and has been clari-
fied and modified, in recent years (see Greenson, 1966); I shall again
be brief.
There are many available and appropriate gratifications for the
therapist in his work; I have touched upon some of them in the first
chapter. Such satisfactions as an adequate income, and a reasonable
pride and sense of accomplishment in one's work, are available,
within limits, to the therapist. These feelings and needs can become
Therapist's Reactions to the Patient 303

excessive and, as reflections of countertransference problems, inter-


fere with the therapeutic alliance. Extreme attitudes toward fees
may lead to greed, difficulties in handling delinquent payments, and
problems in the realistic adjustment of fees (see Chapter 5). On the
other hand, undue generosity or benevolence, which can be seduc-
tive, or can be complex reaction formations against unconscious
hostility, may also prove detrimental to the therapy. Undue pride
and need for reassurances through therapeutic accomplishments can
lead to an exaggerated, ovemarcissistic investment in the patient's
recovery. This can prompt anger with the patient's inevitable res is-
tances and with other obstacles to therapeutic process. The therapist
may then resort to unnecessary manipulations of the patient or other
hostile acts. Such therapists are vulnerable to destructive acting out
by certain patients, who detect this Achilles heel and sabotage the
treatment by frustrating the overzealous therapist.
Other appropriate gratifications in this work include those of
sublimated voyeurism and exploration, that is, when they are con-
trolled and in the service of the treatment, and other well-modulated,
instinctually-related impulses that are also satisfied in an adaptive
and constructive manner. In addition, there are the satisfactions of
getting to know many people and their inner and outer worlds, of
developing one's own skills and working through one's own prob-
lems as a therapist, and of research and discovery on many levels.
A sound therapeutic experience, however difficult, will always
promote extensive growth in a therapist.

THE MYTH OF TOTAL EQUALITY BETWEEN THE PATIENT


AND THERAPIST
This myth, which is especially prevalent in psychotherapy as
compared to psychoanalysis, stems from the unarguable fact that
both participants in therapy are human beings. From this, it is
erroneously deduced that they are to be considered and treated as
equals in many or all ways, since the goal of treatment is that the
patient become a mature individual on the level achieved by the
therapist. The therapist must always help his patient to maintain his
dignity and must observe his rights, but it does not follow either as
a matter of fact or of good technique that they are equal in every
304 TIlE PATIENT-THERAPIST RELATIONSHIP

way. The therapeutic relationship is both a "tilted" or unequal one


in the service of therapeutic goals (see Greenacre, 1954) and one in
which the two parties have decidedly different roles, responsibilities,
assets and liabilities. A clear understanding of these roles is neces-
sary to the development of a therapist's stance.
In essence, the therapist must offer correct understanding. com-
petence. and appropriate interventions (see Chapters 1 and 8). He
is the skilled clinician who assists the patient in resolving his
emotional problems. The patient. on his part recognizes his prob-
lems. and agrees to engage the therapist's services and to participate
in therapy according to the ground rules established by him. The
therapist is the helper; the patient is to be helped. The latter is not
demeaned by the recognition that his needs for the therapist differ
from the latter's needs for him. There is, therefore. a necessary
inequality; without it. the therapist could not aid the patient.
The prerogatives of each, and the limits of their behavior and
verbalizations. must differ. The therapist can and should speak only
when he feels it is indicated in the interests of the patient, or he
may constructively choose to be silent. The patient. on the other
hand. is committed to say everything that comes to his mind, and
his silence is often destructive or pathological. The therapist should
not reveal any of his incidental thoughts. fantasies, or feelings; to do
so would confuse the patient, shift the focus of treatment away from
his problems. contaminate the therapeutic relationship, and create
misalliances, seriously impairing the opportunities for constructive
and lasting inner change. The therapist's verbalizations should not
be personal or idiosyncratic. nor should they be self-revealing,
except for the inevitable indirect revelations reflected in his style,
timing and choice of interventions. The patient is. of therapeutic
necessity, obliged to reveal everything about himself that he can.
Otherwise he would gain little or nothing (see also Chapter 6). In
all. the patient must reveal and explore his problems; the therapist
should not burden the patient with his. Practically speaking, too.
the therapist, assuming that he exercises his prerogative with utmost
responsibility and consideration for the patient, can select vacation
times and miss sessions whenever he feels it is vital and necessary.
while the patient is far more restricted in this regard (see Chapters
5 and 6).
Therapist's Reactions to the Patient 305

It should be clear that these differences are not a degradation of


the patient and must not be so used. They are instead the necessary
differentials that make treatment possible and successful. Feelings
of injustice and gUilt in either party must, therefore, be analyzed
and worked through.

THE MYTH OF THE THERAPIST'S OMNIPOTENCE AND ITS


CONVERSE
The precise and realistic extent of the therapist's responsibilities
to and for the patient and his effect on the patient's life are difficult
to delineate exactly. Distortions in this area and some general
guidelines can, however, be defined :
1. The therapist is, most certainly, not omnipotent, nor can he
be solely responsible for the life course of the patient and the course
of therapy. Other factors in the patient's life and outside relation-
ships also determine its course and the outcome of the therapeutic
experience. The patient's character structure, his ways of respond-
ing. and his own decisions and choices contribute significantly to
these eventualities, whatever the outside stimuli.
2. On the other hand, the therapist's relationship with the
patient is unique. It is specially cathected by the patient and exerts
a powerful influence on him, and entails distinct, though limited,
responsibilities that the therapist may never deny.
3. The therapist must accept responsibility for detecting and
exploring disruptive behavior and symptoms as effectively as pos-
sible, and for intervening strongly and with concern in crises. He
must conduct himself and the therapy in a dignified manner that
does not provoke the patient into generating symptoms or behavior
destructive to himself or others. Because of the special investment
that every patient has in his relationship with the therapist, this last
responsibility is particularly important, for the therapist can so
easily evoke such reactions and patients are so vulnerable to them.
A delicate balance of responsibilities exists here: the patient must
always share responsibility for his behavior at such moments, and
take the primary responsibility for his own re'iponses to any trauma,
but the therapist must neither under- nor overestimate his significant
contribution to them, to his own and the patient's misfortune.
306 THE PATIENT-THERAPIST RELATIONSHIP

In essence. then. the therapist assumes the responsibility to


minimize his countertransference reactions and his negative effects
on the patient. recognizes his special and powerful relationship with
him. acknowledges his many other responsibilities and the real ways
in which he influences the patient's life. and does his best to help
him. On the other hand. the patient must recognize his own respon-
sibility for his behavior and his reactions to life situations and to
the therapist. The therapist's errors are not licences for the patient's
pathological regressions or destructive acting out. nor are they per-
mission for senseless attacks on the therapist. Both parties share
responsibilities. though the therapist has a special quota.

THE MYTH OF THE TOTAL ISOLATION BETWEEN THE


THERAPIST'S EXTERNAL LIFE AND HIS PRACTICE
There is a tendency to ignore the effects of the therapist's
external life on his work with patients. effects that anyone who has
experienced an acutely traumatic life-situation must well appreciate.
If a therapist is faced with chronic life problems. or fails to find
adequate external channels of gratification through outside rela-
tionships or interests. athletics. or hobbies. he may tend to listen to
the material from the patient in a biased way and to intervene in a
manner related to his own needs and fantasies. These problems also
create pressures in him to seek nontherapeutic gratifications from
his patients. thereby impairing or destroying the therapeutic alliance.
Self-awareness will amply illustrate the conscious and uncon-
scious effects of these factors on the therapist. The goal is. of course.
to be in tune with such effects and their influence on one's work. and
to keep them well under control.

THE MYTH OF THE THERAPIST'S OFFICE AS A PLACE


OF FANTASY
Many therapists deny that their patients could and. at times. do
have real intentions toward them-and expectations from therapy
that extend beyond the wish for symptom-relief through inner
change. Some therapists may do so because they do not seek to
gratify extratherapeutic needs in the relationship and have difficulty
recognizing that this may not be the case with the patient. Others
Therapist's Reactions to the Patient 307

deny such pressure and desires in their patients in order to deny or


sanction their own inappropriate counter-needs. In actuality, the
patient may begin therapy with many inappropriate needs for the
therapist; the therapist should not do so with the patient.
Patients may have many deviant motives: they may begin
therapy with conscious or unconscious intentions to seduce the
therapist, make a fool of him, destroy his image, find sanction for
their own inner corruption and pathology, and even use him as a
tool against others. These are not to be condemned by the therapist,
but are to be detected, explored and analyzed so that the wish to
get well through inner change can prevail. However, if their reality
is ignored, effective intervening by the therapist is impossible and
a therapeutic misalliance will be created (see Chapter 23).
Should the therapist have inappropriate designs on his patients,
he must not deny them, but recognize them as a real countertrans-
ference problem and resolve it. Psychotherapy is a difficult endeavor
in which the search for unconscious fantasies and memories plays a
crucial role, but in which many hard realities and temptations to
deviate also exist and must be dealt with. It is no exception to the
rules of life; out of them, its own special rules emerge.

THE MYTH OF THE EFFECTIVE, UNANALYZED


PSYCHOTHERAPIST
Can a person, even a gifted one, carry out reasonably effective
psychotherapy of any kind without having undergone analysis or
intensive psychotherapy? I believe the affirmative answer to this is
a myth; it denies the reality of the therapist's unanalyzed conflicts
and pathology, and the role that these play, as expressed in be--
havioral derivatives of fantasies, in therapy. I shall not belabor this
point nor expand upon it. I have never met or supervised such a
therapist, and it was, in fact, only my work with therapists who
themselves adhered to such beliefs that led me to recognize its
prevalence.
Effective psychotherapy is a hazardous undertaking, to which
the therapist's problems can contribute major roadblocks or total
failure. The resolution of his own inner difficulties has extra-
ordinarily positive and beneficial effects on his work as a therapist.
308 THE PATIENT-THERAPIST RELATIONSHIP

In conclusion, I want to emphasize that the therapeutic setting


is one that involves conflicted and conflict-free areas of the per-
sonality of both parties; it is to be hoped that the balance is quite
different in each. Further, it is well to be realistic about the thera-
peutic situation and the range of the therapist's experiences while
he is participating in it. A closer study of these dimensions will
enhance our work in many ways.

THE,PSYCHOANALYSIS OF
PSYCHOTHERAPISTS
This is potentially a very rich source of information regarding
the therapist's professional experience, and might be of great assis-
tance in understanding the constructive aspects of his work, as well
as his problems and countertransferences. But there are obvious
difficulties inherent in collecting and reporting such data, notably
the problem of confidentiality, and the subject requires a thorough-
going and extended analysis that is beyond the scope of this book.
I shall therefore move directly to the subject of iatrogenic syn-
dromes-the reflection of the therapist's errors in the material from
the patient-with but one comment: as a consequence of my own
self-observations, supported by discussions with others, I believe
that behind virtually every technical error lies a countertransference
problem. Exceptions, of course, exist, especially in untrained and
relatively inexperienced therapists, but it is my impression that
conflict-related unconscious factors play a significant role in the
selection and timing of all errors and unneeded deviations in tech-
nique. This is a matter well worth further study.

THE REFLECTION OF THE THERAPIST'S


ERRORS IN THE MATERIAL FROM THE
PATIENT: IATROGENIC SYNDROMES
[NTRODUCTION

The therapist-evoked syndromes that I shall discuss here were


predicted and observed in patients in psychotherapy. They all
Therapist's Reactions to the Patient 309

belong to a category that I have termed "iatrogenic" to emphasize


the often overlooked and crucial contribution of the therapist's
technical and human errors to the patient's reactions. In no way is
this meant to imply that the therapist is solely responsible for such
syndromes; as we shall see, the patient contributes a significant
share. However, the role of the therapist in triggering these responses
affords them certain characteristics in common and a special place
in the therapist's work in psychotherapy. Further, the patient is
particularly vulnerable in this area and is prone to react pervasively
to such incidents, often with serious disruptions of the therapeutic
alliance. My goal is to establish the attributes through which such
syndromes can be recognized, and then to develop the principles of
technique necessary for dealing with them (see also Greenson, 1967,
1971, and 1972, and Langs, 1973).
This is a sensitive and delicate issue, and I believe it useful,
therefore, explicitly to state some basic impressions and tenets as a
framework for the specific clinical studies that follow. Essentially:
1. Adverse reactions and regressions during therapy may occur
in the patient in two contexts: occurrences in the patient's external
life, and events in treatment.
(a) Traumatic experiences in his life may disturb the patient
and evoke regressive responses within or outside the therapy situa-
tion. In general, though, such events cause temporary and readily
managed regressive episodes, and do not lead to a major disruption
in the therapeutic alliance.
(b) Within therapy, we must first distinguish those regressive
pressures that are inherent in the therapeutic setting and ongoing
therapeutic work. While these are considerably less powerful in
psychotherapy than those seen in psychoanalysis, their effects should
not be underestimated, especially with patients with severe character
disorders or borderline syndromes. With any patient, however, the
tactful and careful modification of pathological defenses, the
scrutiny of painful memories and fantasies, the experience of neces-
sary separations from the therapist, and at times the presentation
of painful confrontations and interpretations, may evoke regressive
reactions. Again, these experiences generally do not seriously disrupt
the therapeutic alliance and they prove to be relatively limited to
manageable episodes.
310 THE PATIENT-THERAPIST RELATIONSHIP

(c) The therapist's human and technical errors constitute a


second major source of regressions and adverse reactions that are
derived from the therapeutic relationship. Indeed, in my super-
visory experiences, such errors are the single largest cause of nega-
tive and adverse reactions in patients during therapy. These regres-
sions are often difficult to resolve and cause major disturbances in
the therapeutic alliance, especially when they go undetected and
unanalyzed. As we shall soon recognize, it follows from this finding
that the appearance of regressions in the patient and disruptions in
the therapeutic alliance should alert the therapist first to reassess
his interventions-or failures to intervene-his general attitude
toward the patient, and other aspects of his therapeutic stance for
countertransference difficulties.
Again, these statements do not imply the therapist's total
responsibility; the patient's behavior and reactions remain his own
affair. But I believe that the available data speak clearly: the thera-
pist has a special and understandable power to evoke adverse reac-
tions in the patient, and he must be alert to any such behavior on
his part, and be prepared to deal with its repercussions. The thera-
pist is neither omnipotent nor blameless in what happens with his
patient.
2. A sensitive consideration of the patient's plight when faced
with attitudinal traumas, hurtful incidents, technical errors, mis-
understandings, and human failings in the therapist will also help
orient us to what will follow. When the therapist is both the trau-
matizer and the supposed therapeutic ally of the patient, we have a
difficult situation. The patient is generally unprepared for such
experiences, and is hard-pressed to deal with them himself. Yet,
consciously or unconsciously-and usually it is the latter-he is
aware of the therapist's role in the disturbance and will inevitably be
conflicted about turning to him for help with his problem. Mistrust,
defensiveness, anger, feelings of betrayal, and uncertainty are bound
to prevail, and all of these responses will contribute to disturbances
in the therapeutic alliance. In fact, it is no coincidence that the first
syndrome of this kind that I ever identified (see pp. 341-43) was an
iatrogenic paranoid-like group of symptoms: paranoid elements
exist in the matrix of every therapist-evoked regression in the patient.
(a) The patient will almost never directly confront the therapist
Therapist's Reactions to the Patient 311

with his sense of hurt and the basis for it. It is, therefore, essential
for the therapist to discover it through his SUbjective awareness or
from an understanding of the material from the patient, especially
his indirect-disguised and derivative-communications.
(b) It follows that the major problem in such situations~xcept
for extreme traumas-is not so much the initial error made by the
therapist, as his failure to recognize and subsequently to deal with
it. This often leads to the repetition of such mistakes and to a com-
plete misunderstanding of the nature of, and basis for, the patient's
regression; all of this compounds the initial hurt. These spirals of
accumulated traumas from the therapist create major hazards for
the therapy.
3. The patient's contribution to these syndromes will stem from
his character structure; the nature of his pathology, intrapsychic
conflicts. unconscious fantasies, defenses, etc.; his past experiences
and relationships; and his ongoing transference, nontransference,
and working relationship with the therapist. His particular sensi-
tivity to the specific trauma from the therapist and his propensity to
act out or maintain controls will also be factors, as will the extent
to which he is prone to evoke such errors from the therapist where
this is a factor.
The data upon which I base my discussion of these areas were
obtained almost entirely from supervisory work. The supervisee
presented his sessions with the patient to me from notes written
during or immediately after the hour, and always did so sequentially.
After some months of preliminary observations, I began to predict
the occurrence of regression from the material presented to me, with
something like 90-95% accuracy. In the later stages of this work, I
also predicted the nature of the specific regression, because the two
main factors involved became clear: the nature of the error by the
therapist and the character structure and pathology of the patient.
The borderline status of many of these patients may well have con-
tributed to their consistent and quite blatant responses to hurts and
errors, whether subtle or major ones, but observations with less
disturbed patients demonstrated that we are dealing here with an
almost universal tendency to react extensively to such traumas. The
therapist's contribution proved to be the crucial day residue and
context for the patient's reactions.
312 THE PATIENT-THERAPIST RELATIONSHIP

Thus, the data for this section are composed of predicted regres-
sions and disruptions of therapy anticipated in supervision. Con-
firmation was in the form of consensual agreement between the
presenting therapist and myself as supervisor. Incidentally, there
were almost no situations where regressions occurred that were not
predicted. I could detect no special influence of the supervision on
these syndromes; as a rule, the regression was well under way
before the material was presented to me. One last point: as I have
said elsewhere (see the Preface and Chapters 18 and 19); the
methodology presented here is understood to be no more than an
effort to observe systematically and to predict crudely; more careful
validation of these findings is necessary .
.1 have divided the iatrogenic syndromes into major-those that
are blatant and acute, and minor ones-those that are more subtle
and insidious. They can also be classified by the nature of the
patient's response-which, as one might expect, is drawn from the
full range of psychopathological syndromes, or according to the
nature of the therapist's error--drawn from a range of possible mis-
interventions, deviations, seductions, aggressions, psychopathology,
and sharing of defenses. From this material, which will also include
a study of technical errors that were properly worked through, we
will derive the principles of technique for handling such situations.

MAJOR IATROGENIC SYNDROMES


Iatrogenic Depressions and Suicide Attempts
Because of the serious nature of these responses, I shall begin
with three vignettes; fortunately, I have not observed an actual
suicide and shall confine myself to less drastic outcomes.

Mrs. E.J. was a woman separated from her husband,


with two children, who sought treatment at a clinic
because of her marital difficulties and episodes of depres-
sion. She had been in therapy for five months when her
therapist took an extended vacation. She had missed two
sessions before the therapist left, blaming her sitter's
inability to take care of her children. She then came in for
the hour just before the therapist was to leave.
Therapist's Reactions to the Patient 313

In that session, she first noted that it was currently the


anniversary of the time when she had left her husband a
couple of years earlier. She then spoke of an affair that
she was having that was entirely sexual for her. Her regu-
lar boyfriend, Nick, killed her dreams of him and made
her feel inadequate; he was everything and everyone to
her-she had no one else. She might go back to her old
apartment (which was out of town) for the Christmas
holidays, which fell in the following week. She hurt others
and felt no guilt-was that normal? The therapist said
that Mrs. E.J. tended to feel guilty and responsible for
things even though they were not her fault. The patient
responded that she did that with her children; she felt sad
when Nick did not live up to her expectations. She was
like her father-she needed to be needed. The only one
who ever satisfied her sexually was a physician for whom
she had briefly worked. At her wedding, she looked beau-
tiful and her father ignored her. The therapist spoke of
the patient's need for approval and the patient ended the
hour by saying that she had to find the answers for her-
self.

Since this session set the tone for what followed, let us briefly
discuss it. I was consulted about this therapy some weeks later and
made these comments:
1. The context here is unmistakably the therapist's pending
vacation. This is reflected in the many derivatives related to separ-
ations and to not being needed, in the theme of hurting others, and
in the maladaptive fantasied repair of the loss by sexual involve-
ment and the return to her old apartment. A good deal of her anger
at the therapist and disappointment in her <the therapist was a
woman) is displaced onto the patient herself and onto her boyfriend,
and communicated and worked over through the patient's relation-
ship with him.
2. The therapist's failure to deal with the patient's reaction to
her vacation is unconsciously recognized by the patient, who finally
said sadly that she would have to find her own answers.
3. This hour is the culmination of a series of sessions in which
314 THE PATIENT-THERAPIST RELATIONSHIP

the therapist felt confused, had been advised that the patient's
reactions to her leaving were not important or relevant to the thera-
peutic work, had felt conflicted about leaving the patient in limbo
since she had been very depressed, and had avoided-along with the
patient-the entire topic since it had first been introduced. All this
was bound to set the stage for a depression-related regressive reaction
in the patient.

Upon the therapist's return, the patient described her


trip with Nick to her old apartment. Her husband had
sculpted a likeness of their daughter; the patient had
cried over his sense of hurt. With Nick, she and her chil-
dren had been like a family; she was afraid of losing him
and had clung to him desperately. She spoke too of being
cut off from her family, of her children being a burden
to her, and of a girlfriend she could confide in, except
that she had vicious dogs. She felt allright with her thera-
pist; a girlfriend was getting married and moving away.
The patient missed the next hour because her sitter
was ill and, in calling the therapist, said that she wanted
to terminate her treatment. At the therapist's suggestion,
she came in for her next session and blamed the cost of
therapy, which was actually minimal, and other hard-
ships for her decision. The therapist offered to reduce her
fee, and the patient spoke of a clinic to which she had taken
her children, where the doctor had been rude, too busy,
and indifferent. She then spoke of her fears that Nick
would leave her. She felt degraded at work and thought
of quitting her job. The therapist acknowledged her
various problems, but emphasized that her thoughts of
leaving treatment pointed to anger with her for her vaca-
tion. The patient acknowledged a lifelong problem with
separation, but denied any anger with the therapist.
It must be noted that the patient knew that her
therapy would be terminated the coming June-less than
six months hence. Briefly, to go on with the clinical
material, the patient continued her treatment and spoke
in the next hour of feeling hopeless and misunderstood
Therapist's Reactions to the Patient 315

by Nick who tried to help, but could not-it was all so


temporary. She asked him whether, if she had leukemia.
he would give her pills to end her life and he said he
would; she appreciated this. She wanted to go away and
die; her children did not really have a mother; they would
be better off without her. Nick had talked to her all night
and she had felt better. The therapist said that the patient
felt that no one, including herself, could help her, and
the patient agreed.
In the next few sessions, depressive and suicidal fan-
tasies continued to be reported. She quarreled from time
to time with Nick; his interest in another girl enraged her.
This led Mrs. E.J. to recollections of friends who had been
hurt by crazy. destructive psychotherapists. The therapist
continued mainly and generally to point out the patient's
feelings of being misunderstood by her. The situation with
Nick improved and when references to things being im-
permanent again appeared, the therapist spoke of Mrs.
E.J.'S concerns about her being left again by her in June.
The patient acknowledged that she was worried about
termination, and spoke of how frightened her children
were when left alone. She then recalled a series of painful
separations that had occurred during her childhood and
later life.
It was at this point, saying that she felt hopeless that
things might ever work out with Nick. that Mrs. E.J. made
a serious suicide attempt with tranquilizers and sleeping
pills. She was hospitalized briefly and missed several
sessions after her discharge. saying on the telephone that
she felt fine. In the next few sessions, she described the
events that led up to the suicide attempt and immediately
went on to suggest that when her therapy ended, the
therapist see Nick. She traced her suicidal effort to being
treated like an animal at another clinic and to the per-
sonnel there, who did nothing for her. The therapist
attempted to demonstrate the patient's anger at her for
her vacation and plans to terminate treatment, but Mrs.
E.J. began to miss most of her sessions. Eventually, she
316 THE PATIENT-THERAPIST RELATIONSHIP

likened her relationship to the therapist to being faced


with leukemia in her child, and watching her slowly die;
she felt completely helpless. She began to seek out old
boyfriends and even her former physician-employer, and
abruptly stopped her therapy because of a new job that
conflicted with her therapy hours, refusing alternative
times offered to her.

It has been necessary to present this vignette at length so that


we might be clear about the therapist's role in this patient's suicide
attempt. Often, other factors may be involved in acute regressions
in patients and we must place them into perspective with the contri-
bution of the therapist. For our purposes here, I would note the
following:
1. The therapist-evoked factors in this suicide attempt are
reflected in:
(a) The therapist's vacation, which was not countertransference-
based, and her plan to terminate Mrs. E.J.'S therapy at the end of a
year, which was in keeping with clinic policy. Such forced termina-
tions are extremely traumatic for all patients, since their needs are
entirely disregarded (see Chapter 25).
(b) The therapist's poor technical handling of her vacation,
creating a situation in which mutual avoidance and denial of its
importance to the patient prevailed. This added to the patient's
sense of abandonment, of not being understood, and despair.
(c) The therapist's weak and largely general efforts to deal with
the patient's feelings once she did come to handle them. Her inter-
ventions had a self-effacing quality; they offered no positive under-
standing, nor a positive figure for the patient to rely on. The
patient's specific feelings and fantasies of being abused and mis-
treated were missed, adding to her rage and sense of aloneness.
It was in this atmosphere of mutual confusion, marked by the
therapist's failure to be available as a good object, and her inability
to help the patient work through her intrapsychic conflicts as they
were evoked by these experiences, that the suicide attempt occurred;
soon after, the therapy was abruptly and prematurely terminated.
2. Here, outside events contributed relatively little: the situa-
tion with Nick had improved, and there was no evidence of a trau-
Therapist's Reactions to the Patient 317

matic incident with him. The material from the patient suggests that
many of her feelings and fantasies toward the therapist were being
lived out or experienced consciously with Nick as a displacement.
3. The patient's contributions to the suicide attempt included:
(a) Her tendencies to feel hopeless and depressed, and not to
express her rage directly toward others, but rather through self-
effacing and self-harmful behavior. Other clinical material indicated
that both of her parents were provocative and intolerant of her
responsive anger. The patient's transference to the therapist showed
elements of this interaction with her parents.
(b) Her great sensitivity to separation, the roots of which are
not available in the data.
(c) Her tendency toward sadomasochistic relationships and
fantasies. The therapist appears to have inadvertently participated
in a sadomasochistic misalliance with Mrs. E.J., thereby intensifying
these fantasies and responses.
4. The major role played by the therapist in these events is
documented by the following:
(a) The sequence of sessions and associations, which center upon
fantasies and conflicts related to the therapist, and to being aban-
doned, hurt, and treated insensitively by her.
(b) The repeated predictions of depression-related acting out
made in supervision when the therapist failed to deal adequately
with those issues. The possibility of a suicide attempt was fore-
shadowed in many of the patient's associations and in her behavior.
(c) The coalescing of the patient's associations after the suicide
attempt onto the therapist and especially onto the anticipated, pain-
ful termination of the therapy the coming June-as predicted.
(d) The missed sessions and other indications of a sadomaso-
chistically tinged therapeutic misalliance, which culminated in the
patient's premature termination of her therapy.
5. As to technique:
(a) When unavoidable traumas to the patient, such as vacations
and necessary but premature terminations of therapy, occur or are
anticipated, they must be a central context for the analytic work in
the treatment situation whenever the patient's associations indicate
their importance to him. These reactions must be explored sym-
pathetically, and ultimately dealt with through specific interpreta-
318 TIlE PATIENT-TIlERAPIST RELATIONSHIP

tions. In this way, the therapist can modify his image as a hurtful
figure and restore a more unimpaired working alliance.
(b) Similarly, when interventions are missed or are inadequate.
and the therapeutic alliance is in difficulty, the therapist must
endeavor to reassess his work with the patient and modify it
accordingly. As we can see, in this instance the material from the
patient abounded in allusions to the therapist's failures to under-
stand and help her. These must be detected by the therapist and
used to reorient him.
(c) After a suicide attempt, intensive therapeutic work with the
basis for this behavior is indicated. Tracing out its specific roots in
the material from the patient and interpreting its specific meanings
is essential. The therapist must work not only with the patient's
general feelings of hopelessness and despair, but also with her
murderous rage-here, at the therapist-and must reach into the
specific fantasies and genetics involved. He must confront and
explore the wishes for revenge and the ego dysfunctions reflected in
the suicidal behavior. The therapist's work with Mrs. E.]. fell far
short of this, and as a result, the patient terminated her therapy in
what appears to have been a final show of anger, denial, and active
compensation for the past and intended hurts from the therapist-
an identification with the aggressor. What began as a therapist-
evoked suicide attempt ended as an iatrogenic premature termination
of the therapy (see Chapter 25).
Let us now move on to another suicide attempt in which the
therapist played a significant role.

Mrs. E.Y. was a young woman with a severe character


disorder who had been repeatedly separated from her
husband and reunited with him. Their marriage was
characterized by constant battles, the patient's refusal
to have relations with her husband, and her frequent
degradation by him through such practices as his mastur-
bating himself and ejaculating onto her face. There were
violent battles and in addition, the patient herself often
beat her only son when he misbehaved. She had felt
intensely depressed and been withdrawn, but an affair
Therapist's Reactions to the Patient 319

with her husband's closest friend enabled her to feel better


about herself.
During the first few months of her treatment, she had
revealed a traumatic early history: her parents had been
divorced when she was in her latency, and she had lived
with her remarried father who then died of a suspected
suicide, leaving her with a much-disliked stepmother. Her
father had been openly seductive toward her, and she
herself was promiscuous in her early teens. Corruption of
this kind was prominent in her family; she had discovered
her mother with other men and her paternal grandfather
had made overt sexual overtures toward her.
At the point in therapy to be described here, Mrs. E.Y.
was very depressed and thinking seriously of initiating
divorce proceedings, while her husband very strongly
wanted a chance at salvaging their marriage. As part of
his efforts at reconciliation, he called the therapist and
asked to see him. The therapist said that he would discuss
this request with the patient and brought it up with her
toward the end of the following session. The patient said
coldly that she had no objection to such an interview; the
therapist then called the husband back and saw him before
the next session with the patient.
In the session with the husband, the latter essentially
made a strong appeal to the therapist for his help in
preserving his marriage and in showing his wife why this
was the wisest course for her to follow. He also added that
the therapist had better let her know that if she had one
more affair, he was through with her. The therapist was
generally noncommittal.
Mrs. E.Y. began her next hour by describing the
details of a new job that she had obtained and said that
it was going well. After a while, the therapist interrupted
her and summarized his interview with her husband in all
its details. Mrs. E.Y. then immediately recalled a dream
from the previous night. (Though not informed by the
therapist, she had already known from her husband when
320 THE PATIENT-THERAPIST RELATIONSInP

his interview with the therapist was to take place: the


patient .had the dream after that meeting had been
consummated.)
She had dreamt that she was underground somewhere,
with her friend Helen, whose husband had cut off her
hair when he found out that she had been having an
affair; Helen was also the patient's name. Her friend told
the patient that they were being chased, but then the
patient was alone. She was chased by several men and ran
away to a ferris wheel; she was in an amusement park.
She got on the ferris wheel to escape and went around and
around, fearing to get off. Suddenly, some device in the
seat tried to eject her-to force her out of the seat. She
awoke frightened.
Asked to associate, she said that she felt alone without
her husband, that she had had nightmares like this one as
a child, and that she had awakened before the dream with
the thought that her son had come into the room. The
underground room was like a basement or a subway
without tracks. She fell silent and seemed quite de-
pressed.
The therapist pointed out that her mood had
changed, and that perhaps this was related to his having
seen her husband, an interview she had avoided asking
him about. The patient said that she did not think that
this was it, but it could be. She then fell silent again for a
couple of minutes. The therapist repeated his speculations
as the hour ended.
The patient missed the next hour without calling; in
the following session, she blamed her son's illness for the
oversight. In that session, she said that she had not
wanted to continue her therapy and came in only because
her husband badgered her. She then ruminated about her
son's illness and appeared depressed. Alluding to a
telephone call from her grandfather, she spoke about how
he had betrayed her as a child after she had trusted him:
She said that she had not been sleeping and that she hated
herself.
Therapist's Reactions to the Patient 321

In the following two sessions, Mrs. E.Y. was relatively


uncommunicative and asked a series of questions about
the clinic procedures, tests, and forms that she had filled
out before starting treatment with the therapist. Because
she had seen a worm in the street, she described her fear
of them and of snakes; as a child she had once dug up
and cut up a worm, and then had become frightened and
had run to her mother.
The therapist now tried to emphasize her feelings of
betrayal in his seeing her husband, and spoke of her anger
at him as well. He said that he felt that his well-intentioned
interview with her husband had turned out to have had
disruptive effects on the patient and her therapy, and
acknowledged his error. The patient did not respond
directly to any of these comments and remained remote
and depressed.
The following week, the therapist received a call from
her husband that Mrs. E.Y. had made a suicide attempt
with sleeping pills, and that she had recovered on her
own, but had decided not to return to therapy. He then
mailed a note that the patient had left for the therapist to
the effect that she could not go on as she was and that it
was better for her to leave everyone.
The patient later returned to therapy, which continued
in a stormy manner until termination three months later,
when the therapist left the area. It emerged that, at the
time of the suicide attempt, the patient's husband had
learned of her affair with his friend and had forgiven her.
The patient's associations suggested a fantasy that the
therapist had betrayed this secret to her husband in the
interview with him. In this last period of therapy, the
patient's reactions to the forced termination were very
disruptive and included considerable rage, missed sessions
and, ultimately, an aloof detachment and reintegration.

Let us now attempt to formulate what happened with Mrs. E.Y.


and how the situation might have been handled. My main ideas here
are these:
322 THE PATIENT-THERAPIST RELATIONSHIP

1. This vignette illustrates once again that supposedly simple


supportive measures in psychotherapy are often unhelpful to the
patient, and also may be disruptive and disas~rous in their outcome
(see Chapter 16). The therapist naively thought that seeing Mrs.
E.Y.'S husband would help clarify the marital situation and enable
him to understand the patient's conflicts better. He completely
ignored the possible risks and unconscious meanings that such an
interview would have for this mistrustful woman, and did not
consider either the probable erotic or erotized transferences in this
patient or her past history of betrayals by close family members. He
compounded this denial of unconscious and genetic factors with a
failure to give the patient an opportunity to explore her feelings about
such an int.erview, and perhaps then to communicate negative re-
actions, and reveal her hidden rage and suspiciousness at such a
prospect. He was thus unable to hear her direct, conscious
responses and the indirect, associative responses through which her
unconscious fantasies could be detected. Both the failure to allow
time for exploration and analysis, and the interview itself, evoked a
disastrous response.
Note that the patient's simple permission under these circum-
stances is like a direct agreement to an intervention; it is only the
beginning of the patient's reactions. It may conceal a multitude of
fantasies that could be detected from the derivatives in the patient's
subsequent associations. Here, Mrs. E.Y. may have agreed to the
interview with her husband out of fear of him or of the therapist.
Or her acquiescence may represent a submission to the therapist that
is related to a wish to be hurt and betrayed, from guilt or some other
motive. We would need more material to be entirely clear on this
point; let me simply emphasize that a patient's agreement cannot
be taken at face value-it must be analyzed. The response may con-
ceal rage, wishes for punishment, and anticipations, both feared
and desired, of betrayal and desertion. If no opportunity is afforded
to the patient to express those feelings in advance, acting out of the
representations of these fantasies, both directly toward the therapist
and toward others, will follow. The therapist himself has un-
consciously set the stage for this by behaving in just such a manner
himself-acting without exploring first. Therapists who operate
without investigating unconscious fantasies, intrapsychic conflicts,
Therapist's Reactions to the Patient 323

and genetic material, and who also think of "support" in naive ways
that ignore the responsive stirrings within their patients, will repeated-
ly commit errors of this kind and evoke iatrogenic symptoms in
patients.
2. The material here unmistakably supports the thesis that the
therapist's decision to see the husband, his failure to explore the
patient's response, and the actual interview precipitated the initial
depression and regression in this patient, and contributed to the
suicide attempt that followed.
(a) The therapeutic relationship had been characterized by many
provocations and re si stances in Mrs. E.Y.; it had a strikingly sado-
masochistic tone to it. The therapist had made previous errors with
her and had felt some degree of annoyance. It is typical for lesser
hurts and disruptive experiences with the therapist to culminate in an
acute response such as Mrs. E.Y.'S suicide attempt. Such extreme
disruptions almost always are the result of multiple ongoing counter-
transference problems in the therapist, of a poorly established or
weakened therapeutic alliance or a misalliance, and of many un-
resolved and unanalyzed transference feelings and fantasies in the
patient, evoked by both the therapist and others.
(b) On the basis of minimal data about the patient and her past
and current circumstances and experiences (this was a case presented
to me outside my usual supervisory work), I predicted that the
interview with the husband would evoke a serious regression and
seriously disrupt the therapeutic alliance, though I could not
determine the form of the patient's response other than to expect it
would be sadomasochistic (destructive) in form and that the patient
would feel betrayed by the therapist in view of her past experiences
with her parents and grandfather, and would react accordingly.
She would undoubtedly feel that the therapist was taking her
husband's side in their dispute about the divorce, and it seemed
likely that she would also unconsciously see the interview with the
husband as an invitation to him to be voyeur of the erotic trans-
ference and to gratify himself homosexually with the therapist.
(c) The dream and other associations clearly fitted this formu-
lation. The suicide note left for the therapist indicated the impor-
tance of the unconscious-and possibly conscious-link between
the attempt at suicide and the relationship with the therapist.
324 THE PATIENT-THERAPIST RELATIONSHIP

(d) Immediately after the interview with the husband, the patient
acted out by missing a session without calling him; she also made
efforts to leave therapy.
(e) The stormy termination period that followed the suicide
attempt indicated that the pending forced termination itself was
another factor in the patient's disturbed behavior. This aspect had
been neglected by the therapist, although it is alluded to indirectly
in the patient's dream of being forcibly ejected, and in many other
associations.
3. This iatrogenic syndrome had both reality-based and trans-
ference elements:
(a) There are realistic precipitates in the behavior of the therapist
with the husband and in the pending termination. Although the hurt
was not intentional, or deliberately hostile or seductive, it did evoke
powerful unconscious motives and fantasies in both the therapist and
the patient. We do not know why the therapist decided to see the
husband; his unconscious motives could range from fears of being
too close to his patient, anger with her and a real wish to hurt and
betray her, his own need for a chaperone or a homosexual defense or
partner, and even to an unconscious wish to be rid of her. Thus, Mrs.
E.Y.'S response may have been based, in part, on a correct, though
probably unconscious, understanding of these hidden fantasies and
intentions in her therapist (see Langs, 1973). The day residue-the
therapist's secret interview with the husband about the patient-was
all too well calculated to evoke images and fantasies of betrayal,
mistrust, harm, and a preference by the therapist for the husband.
This realistic precipitate does reflect a lack of sensitivity in the
therapist to this patient's present needs, as well as her character,
emotional problems, and past experiences; something which she
probably sensed. As a final contribution, this therapist had been
taught to see the spouses of patients upon request, though he may
have misused this unfortunate teaching.
The additional trauma of the forced termination and its poor
handling has been discussed in connection with the previous
vignette, so I will not elaborate upon it here (see also Chapter 25).
In the main, the helpless rage it evoked was acted out in the suicide
attempt and in the patient's disruptions of the treatment ..
Therapist's Reactions to the Patient 325

(b) On Mrs. E.Y.'S side, there are other determinants in her


response not attributable to the therapist's actions and the meanings
she gave to them. Her ego functioning in particular may have been
so impaired that the similarity in behavior between the therapist
and her parents, grandfather and husband created difficulties for
her in distinguishing differences in underlying motives to the extent
that they did exist (the therapist did not consciously wish to betray
or seduce this patient).
Ego dysfunctions undoubtedly contributed to Mrs. E.Y.'S defensive
denials of feelings about the interview with her husband, a common
defense in the face of the helplessness patients experience when hurt
by their therapists. Her impulsive suicide attempt also reflected poor
controls and strong tendencies to act out; other impairments are not
documented here, but undoubtedly were present.
Another factor in fixing Mrs. E.Y.'S perception of the therapist as
attacking and betraying may have been the powerful masochistic
wishes and conflicts that led her to agree to the interview. Her guilt
and need to suffer would, in turn, unconsciously reinforce her image
of the therapist once he saw her husband, and her further reaction
to him.
Genetically, the patient's actual past experiences with her family
members, and the intrapsychic conflicts and fantasies they evoked,
determined the transference dimension of her response. .Her
depressive tendencies (there was no previous history of a suicide
attempt, however) and her tenuous life situation also contributed.
Thus, we see that there are many intrapsychic responses within
the patient that account for her intense and relatively unmodifiable
response to what the therapist did. On the other hand, its evocation
by a therapist's error contributed to their fixity, since, in some ways,
the therapist was thereby lost as a helpful object. It often takes long
and perceptive work to restore such a therapist's helpful image.
Lastly, the pending termination, compounded by the loss of her
lover, made the anticipated unavailability of the therapist especially
painful for her. The forced termination was undoubtedly experienced
by this patient, who was traumatized and sensitized by many early
childhood separations and betrayals, both in terms of its realistically
hurtful qualities and in transference terms, as another parental
326 THE PATIENT-THERAPIST RELATIONSHIP

deception and abandonment. Her previous difficulties in dealing


with such issues contributed to her present ones.
(c) The transference elements can be briefly summarized now.
The secretive behavior of the therapist and the pending termination
were linked to the patient's fantasies about her mother, with reactive
homicidal impUlses. Note the reference to the unfaithful girlfriend
who was punished for her betrayal; her mother had deserted her
children for other men. The therapist becomes her unfaithful mother
and is also identified with her sexually uncontrolled and aggressive
father and grandfather-the allusion to men chasing her in her
dream. A very strong need to escape the dangerous therapist, linked
to terrifying experiences with, and fantasies about, these early
figures in her life, emerges rather clearly, as does the patient's need
for revenge. Further, there is a very primitive feeling of rejection-
her being mechanically pushed out of the seat and into danger-which
is determined largely by the pending forced termination. The direct
associations to her grandfather'S betrayals and to cutting up the
worm (the therapist?), with consequent terror of her aggression, are
supportive of these formulations. The image of a cold and inhuman
mother-therapist allowing no sense of safe harbor seems to stand out.
(d) We must recognize that the discovery by the patient's hus-
band of her affair evoked guilt, rage and despair. However, my
impression is that such outside crises will not lead to suicide
attempts and drastic disturbances in the therapeutic alliance if the
therapist has offered the patient a sound relationship without acute
traumas.
The patient's acting out by missing a session and attempting
suicide was therefore invited in part by the therapist's actions. It
also reflected the patient's desperate need for active-though
destructive-mastery. Further, Mrs. E. Y. tended to have poor controls
over her impulses. This was, however, her first suicide attempt;
without further material, we are left with speCUlations, though we
must be impressed with the enormity of her behavior.
In brief, we may wonder if she had felt despair that not even her
therapist could be trusted; or had her action expressed a search for
fantasied union with her dead father? What her husband had told
her of the interview we do not know. Murderous aggression was
turned against herself, clearly deflected from, and used against, the
Therapist's Reactions to the Patient 327

therapist. Paranoid elements are hinted at in her questioning about


clinic procedures; in depressed patients, this suggests a masochistic
relationship with a parental figure (see Bak, 1946). Lastly, it is of
interest that her husband and she were, it appeared, at least
momentarily united through her act and the therapist was excluded;
the patient took over control of the situation and directed the
pairings and exclusions in this triad. Self-destructive efforts mal-
adaptively to find a substitute for the therapist may also have been a
factor.
4. My main points about technique are:
(a) The therapist-evoked responses that occur as a result of
errors of this kind are best prevented by proper technique, in which
the therapist considers unconscious and intrapsychic factors and the
patient's genetic background, and in which he permits full ex-
ploration in advance of any such parameter or deviation in usual
technique-though such moves are best avoided.
(b) If an error is inadvertently committed, the therapist must
recognize it as quickly as possible. At first, subjectively sensing that
he has erred or deviated, and that something is not quite right, will
lead him to reassess his work. In addition, the therapist must be
alerted by any observation of disruptions in the therapeutic alliance,
regressions of all kinds in the patient, acting out-especially with
elements directed against the therapy-and by the specific clues
offered in the content of the material from the patient. One of the
main findings that emerges from the observations being presented
here is that these disturbances most often serve as unconscious com-
munications from the patient that the therapist has erred, and that
his countertransferences are evoking major difficulties in the patient
and his treatment. The therapist must learn to recognize such regres-
sions, symptoms and acting out in his patients as indicators of
problems within himself as a therapist and in his techniques.
(c) Once identified and formulated, the error should generally be
acknowledged to the patient in an appropriate therapeutic context,
candidly and briefly, and without undue self-exposure. If the patient
seems too narcissistically fragile, this can be bypassed. Mrs. E.Y.'S
therapist, unfortunately, did this much too late in the sequence of
events and at a time when the patient was especially vulnerable.
The earlier this is done, when indicated, the more likely it is that the
328 THE PATIENT-THERAPIST. RELATIONSHIP

problem can be worked through. In addition to frankly admitting


that he has erred, the therapist may want to assure the patient quickly
that he is exploring the basis for the error within himself. He should
go no further in revealing himself, lest he unduly disturb and burden
the patient.
(d) Once this is done, the therapist can then deal with any of the
ways that the patient may have arranged and evoked his erroneous
response, though only if this is in clear evidence and not in order to
blame the patient for the therapist's error or to deny his own
responsibilities. The patient's role in instigating countertransference-
based errors is often quite significant, however; there is an active
interaction between the two parties in psychotherapy. To illustrate,
there is evidence in her flat consent to the interview that Mrs. E.Y.
had promoted her own downfall.
Lastly, the therapist must analyze how the patient is reacting to
his error-the patient's realistic and unrealistic responses-and to
his admission of it. He must do so from the material from the patient;
the therapist here failed to use Mrs. E.Y.'S dream and associations,
and the later references to her grandfather and the worm, to interpret
some of the specific meanings of his interview with the husband to
her. This work must take precedence over everything else except for
emergencies; and the interpretations must be firm, clear, accurate,
and specific.
(e) In interpreting the behavior and fantasies that occur in
response to an error, the therapist must clearly distinguish the
realistic from the unrealistic. Mrs. E.Y. had a realistic reason to feel
betrayed, exposed, mistrustful, and misunderstood. On the other
hand, to react to the therapist's well-intended error by missing a
session and attempting suicide suggests extreme and irrational
fantasies.
Both the real and fantasied meanings of the precipitating error
for the patient must be identified and analyzed. In the situation with
Mrs. E.Y., the therapist did not do so specifically and consistently,
nor did he interpret the acting out and point out the cost to the
patient. These further errors, undoubtedly a reflection of the thera-
pist's lack of training and his countertransferences,must have
promoted the continuing regression and disruptions in the damaged
therapeutic alliance, and ultimately the suicide attempt by the patient.
Therapist's Reactions to the Patient 329

(f) Such episodes are among the most threatening and disturbing
for a therapist. He must comfortably analyze his own error within
himself and without involving the patient, doing so with an
appropriate realization of the degree of his own responsibility. He
must avoid the temptation to blame either the patient or himself. He
especially must not feel angry with the patient either for involving
him in a countertransference reaction if this has occurred, or for
merely being part of a situation that has evoked narcissistic hurts
for him. The honest, constructive exploration and working-through
of experiences of this kind can, most fortunately, be among the most
gratifying of all therapeutic endeavors. For the patient, the
realization that the therapist, whom he has feared as destructive or
identified with negative aspects of his parents, can honestly admit his
errors and change his ways, that he does not blame or attack the
patient for the latter's responses to the error, however regressive they
were, and that the therapist is truly different from past figures, fosters
renewed trust, constructive identifications and considerable ego
maturation. For the therapist, his ability to convert a disruptive
clinical situation into a positive one is also ego-enhancing and
growth-promoting.
(g) Earlier in this chapter I discussed some of the technical
problems that forced termination presents and I shall return to this
topic again in Chapter 25. It is a situation that requires the utmost
sensitivity and therapeutic skill, and vigorous analytic work with the
patient. As we have seen, in depressed, masochistic patients, such an
experience can precipitate disastrous, self-destructive behavior. Only
good clinical work can anticipate and prevent such an outcome; it
is a time for the therapist to be especially careful to avoid a major
error or trauma to the patient.
At this point, I want to emphasize that the major determinants
of iatrogenic syndromes and the forms they take appear to be:

1. The countertransference problems of the therapist and the


nature of his acute error, including all of their real, conscious and
unconscious meanings to him, and the real and fantasied meanings they
have for the patient.
2. The nature of the patient's realistic and transference relationship
to the therapist. This includes the nature of his actual experiences with
330 THE PATIENT-THERAPIST RELATIONSHIP

past figures and the patient's repressed fantasies and conflicts about
them.
3. The conscious and unconscious meanings of the therapist's
specific error to the patient, in terms of his current and past life, and
the affects and conflicts it evokes for him.
4. The repertoire of the patient's responses to disturbances of this
kind. Here the patient's ego functioning, superego reactions, and
predominant instinctual drives are all crucial, as is his character
structure and pathology.

In all, the outcome is based on an interaction between the


behavior and intrapsychic fantasies of the therapist and those of
the patient on every possible level.
With these basic principles for the comprehension of iatrogenic
syndromes firmly in mind, let us briefly look at one last major,
depressive, therapist-evoked syndrome.

Mr. J.N. was a young man with a borderline syndrome


and a history of transvestitism (especially of wearing his
mother's clothes), fears of becoming an overt homosexual,
difficulties in relating to women, depression, and prob-
lems with his ambition, and his work, so that he seldom
kept a job for more than a few months. He began therapy
because of mounting homosexually-related anxieties and
nightmares, and was quite guarded and ruminative from
the start. Treatment quickly became a battle in which the
therapist's aggressive and poorly timed confrontations,
and his attempts to interpret prematurely with little
material from the patient, were countered by the patient's
direct anger and cursing, disbelief, provocative remarks,
and acting out, especially through absences from sessions.
Under direct pressure from the therapist to mobilize him-
self and get a job, Mr. J.N. begrudgingly did so, but at the
same time became more provocative in the sessions, missed
a number of them, and came to others late or high on
marijuana.
Unable to explore this acting out, feeling that the
patient did not accept his interventions, tired of the
Therapist's Reactions to the Patient 331

constant battles, and with the general feeling both that


the patient at last seemed to have arranged a steady job
and that they were getting nowhere in the therapy, the
therapist decided to shift to a strictly reality-oriented and
"supportive" role; he therefore suggested to the patient
that they reduce the sessions from twice to once weekly.
He gave his reasons much as above, emphasizing that the
patient did not seem ready to accept more intensiye
treatment and that continuing once weekly would never-
theless help him stabilize the gains he had made. The
patient readily agreed to the change, openly admitting
that he did not like the two sessions each week and
stating that he preferred something less stringent.

A retrospective review of the sessions prior to this decision


brought out clues to at least one factor in the patient's behavior in
therapy that had been missed. He had been unable to get an erection
with his girlfriend, though he later was potent in a tempestuous
affair with the girlfriend of one of his close male friends. Associations
at this time, and the intensification of his destructive behavior in the
sessions, suggested that the patient was in the throes of an intensely
erotized homosexual transference and in a homosexual panic. The
homosexual wishes and fantasies (and we do not know their specific
content) were being defended against by the flights into drugs and
absences, and through the battles with the therapist-the use of
aggression as a defense. This transference had two main determi-
nants: the patient's perverse character structure and pathology, and
the therapist's aggressive asaults; there was an antitherapeutic
sadomasochistic alliance between the two of them. Further, both the
therapist and patient had agreed to ignore the homosexual anxieties
and fantasies, and shared the defenses of repression, denial,
aggressive concealment, and mutual acting out by decreasing the
sessions and thereby creating an unanalyzed, artificial distance
between them. This tactic was rationalized as "supportive" and
therefore accepted by both parties, though in effect it constituted an
avoidance-based misalliance. What followed is enlightening.

As therapists, we know all too well how life's realities


332 TIlE PATIENT-TIlERAPIST RELATIONSHIP

can contribute a vehicle through which many of the


patient's responses and unconscious fantasies are ex-
pressed, and this happened here. Soon after the actual de-
crease in the frequency of the sessions, a male friend of the
patient, who had been in therapy very briefly, committed
suicide. Mr. J.N. had reason to suspect-correcdy-that
the friend's therapist and his own therapist were col-
leagues. The patient denied suicidal thoughts himself, but
ruminated at length about why it had happened. He took
long trips to see old acquaintances, in order to discuss his
friend's death in detail with them, and spent hours with
one friend who saw the suicide as a beautiful act.
At this point, I followed several sessions with this
patient. He began one hour by stating that the therapist
must be relieved to see him (projecting his own suicidal
concerns ?), and went on to themes related to the lack of
real concern for others in so many people, and to being
rejected himself by some friends and family members. He
criticized his dead friend's therapist as cold and insensitive;
he had failed to understand (Mr. J.N. was probably un-
consciously in tune with the problems of both therapists).
If he were a therapist, Mr. J.N. thought, he would be dead
by now.
In the next hour, he began by criticizing the thera-
pist's office layout and spoke again of how people do not
understand their fellow men, sounding quite depressed,
and using a number of psychotherapists as examples of
this problem. He went on a date with the dead man's
former fiancee and spoke of fears of being at her mercy;
she made him feel desperate. If she had satisfied his friend's
needs and opened her legs to him, the boyfriend would not
have died. She rejected the patient and he knew how his
dead friend felt: she was a dangerous woman and he was
not going to see her again. He felt quite depressed.

I shall pause to formulate matters to this point rather briefly. In


this material, we see evidence of the patient's identification with the
dead man, and his projection of his own suicidal fantasies and
Therapist's Reactions to the Patient 333

impulses onto him and perhaps onto the therapist in the form of
concern. The present therapist is unconsciously represented in this
material both by the friend's therapist and his fiancee-the killers.
The basis for this view of the therapist is twofold: first, the therapist's
overdefensive, unfeeling, and imperceptive reduction in the sessions
and his basic failure to understand the patient; and second, the
patient's unconscious homosexual fantasies about the therapist,
which in part had evoked the therapist's error and were also a
response to the error itself. These repressed fantasies included notions
of murderous and destructive rage, and of being murdered himself.
None of this was dealt with by the therapist-a matter I shall discuss
later.

In the next hour, Mr. I.N. began by criticizing the


therapist's coldness and then spoke of how the dead man's
mother reacted as if he had not killed himself (the thera-
pist's and, in part, his own denial?); his own mother would
go crazy if he killed himself-or maybe she too would not
react at all (note the patient's dread of his own instinctual
drives). After other thoughts from the patient about
loveless, cold people, the therapist said that he wondered
if the patient's preoccupation with his friend's suicide was
related to the decrease in sessions. (The therapist himself
did not believe that this was so; he had spoken out only
after several supervisory sessions and resented doing so.)
The patient became acutely confused and angry, and felt
condemned for discussing the suicide. He said that they
had lessened the sessions because the therapist felt they
were getting nowhere and he had been getting too tense.
In the next hour, Mr. I.N. discussed the referral of
another friend to a colleague of the therapist. While
denying doubts and rage about therapy, his associations
were filled with veiled references to fury, criticisms, dis-
illusionment, and depression. In this hour, the therapist
waited until the final minutes to cancel the next session
because he had to be away for the day.

It is difficult for me to confine my comments to the iatrogenic


334 THE PATIENT-THERAPIST RELATIONSHIP

syndrome here. Since such syndromes evolve from countless


variations of poor technique and their underlying countertrans-
ference basis, we must identify these aspects clearly so that we can
avoid such misinterventions ourselves. My main comments are:
1. The decrease of sessions is a serious matter which can be
justified only as a last resort, if ever (see Chapter 5). It is a blow to
insight-oriented work, a frustration and hurt to the patient, a sudden
loss for him which threatens total abandonment, and almost always
an acting out by the therapist. It invites maladaptive, reparative act-
ing out and iatrogenic regression and syndromes. We can only
suspect uncontrolled aggressions and possible homosexual anxieties
in Mr. ].N.'S therapist. These possibilities are supported by his
sudden cancellation of a session without providing any opportunity
for the patient to respond to it and work it through. In any case,
analysis of resistances is the proper technique of psychotherapy;
surrendering to them or sharing them with the patient by reducing the
sessions is antitherapeutic and creates, if accepted by the patient, a
misalliance that will not lead to change within him.
2. The patient unconsciously saw the decrease in sessions as an
insensitive abandonment and attack upon him, despite his conscious
denials. The original transference figures and experiences are not
clear from the material, though one reference to his mother's lack
of concern toward her. However, this is a relatively realistic appraisal
of the therapist, regardless of the contribution of transference fan-
tasies-an unconscious perception of the therapist's errors. The
situation is probably to some extent an actual repetition of the
traumatic past; less so, an inappropriate projection from that past.
3. The patient's suicidal feelings are a response to the therapist's
rejection, and the past hurts it unconsciously reinforced. They are a
product of the ongoing hostile transference, the sadomasochistic
misalliance, and of the decreased sessions. They are also a response
to the therapist's failure to help the patient explore his reactions to
the decrease in sessions-a further insensitivity.
The suicidal fantasies are intrapsychicaUy determined by the
patient's pathology, character, and past history as well. His rage
over these narcissistic hurts, his guilt about this rage and about his
homosexual fantasies, and his predisposition to depression and self-
hate-factors we know very little about-are relevant here.
Therapist's Reactions to the Patient 335

4. The recurrent associations to the therapist indicate that fan-


tasies about him and responses to his behavior are crucial to Mr.
J.N.'S reactions to his friend's suicide. While fears of his own therapist
would undoubtedly emerge in any case after such an event, the
associations point to the decrease of the sessions as the nodal reality
on which the patient based his mistrust of his therapist.
5. The principles of technique previously discussed apply here
too:
(a) Acknowledging the error, and here, correcting it. It is crucial
that a therapist modify an error where he can in reality do so. If he
does not, talking about it is hollow and inconsistent. Mr. J.N. should
have been offered two weekly sessions again and his responses then
analyzed.
(b) Vigorous exploration and analysis of the trauma from the
therapist and clear interpretation of the patient's reactions to it.
This would include first, analysis of the defenses used by the patient
to support his denial of the hurt and rage involved (e.g., rationaliza-
tions and displacements), and second, of the patient's specific un-
conscious fantasies (e.g., of being attacked or provoked to suicidal
feelings). This must take precedence in the therapy so that a healthy
therapeutic alliance is reinstated.
(c) Strong efforts by the therapist to modify and control his own
aggressive behavior and homosexual anxieties with this patient.
Without inner change on his part, the sadomasochistic misalliance
cannot be modified.
(d) In this situation, the disadvantages for the patient of de-
creasing the sessions, of failing to analyze, and of acting out should
be detailed. The sense of hopelessness and hurt which the patient
felt can be used to motivate him to face himself and change. Above
all, if the therapist gains proper understanding of, and adequate
controls over, his countertransferences, he can reestablish a secure
working alliance and restore the potential for therapeutic success.
Facing and exploring the homosexual problem with tact and efforts
toward insight in the sessions when relevant would also help both the
therapist and patient.
Whether the therapeutic alliance was permanently damaged by
this therapist's behavior is a moot point. If no further progress was
made with this patient, especially in the light of his suicidal
336 THE PATIENT-THERAPIST RELATIONSHIP

preoccupation, referral to another therapist would be indicated.


It is now clear, I believe, that major iatrogenic depressions have
certain common features:

1. The climate of an ongoing, sadomasochistic misalliance between


the patient and therapist. Further, a failure of basic trust in the thera-
pist and some degree of mutual acting out between the two parties.
2. A critical contribution from separation issues in the therapeutic
interaction.
3. An acute, therapist-evoked trauma in the form of a desertion
(though it could be some other type of hurt), which was subsequently
poorly understood and worked with by the therapist.
4. A struggle within the patient to master and avenge the hurt in
the face of helpless rage and feelings of abandonment.
5. A patient with a previous history of self-harmful behavior,
which was therefore a common mode of maladaptation for him. None
of the patients in these vignettes had, however, previously attempted
suicide.
Iatrogenic Masochism
I shall confine myself to one illustration of this syndrome.

Mr. 1.0. had been in psychotherapy for a year with an


aggressive, overactive and overcritical therapist who did
not understand him and mistreated him; images of his
unconscious awareness of this interaction were abundant
in his associations. He was a young man with a borderline
syndrome who had dropped out of college in an acutely
confused state, and had settled for a menial job and a
degraded girlfriend, whom he ill-treated and with whom
he preferred anal intercourse.
After several supervisory discussions at this point in
the treatment, the therapist began to sit back and let the
patient talk. Mr. 1.0. almost immediately commented on
his great relief about the change in the therapist. Then,
over the next few sessions, it emerged that the patient
had reacted to the therapist's recent vacation with con-
siderable hidden rage, and fantasies of raping and impreg-
Therapist's Reactions to the Patient 887

nating women-acting this out, in part, by not using


contraception with his girlfriend. He described masturba-
tory rape fantasies and linked them to seeing his mother
nude as a child. He then called to cancel a session and
when the therapist said on the telephone that he would be
charged for it, he came in but was angry with the therapist.
After the call, he had masturbated, fantasizing anal inter-
course. He recalled that his father would grab his penis
when he found that he (the patient) had had wet dreams.
As he described this material, he bantered with the
therapist, who kept telling the patient he was trying to
provoke and attack him. He went on to recall enemas
from his mother and how his father took his temperature
rectally as a child. The therapist continued to avoid the
content of these associations and made challenging and
provocative comments, repetitively conveying his impres-
sion that the patient wanted him to choose the topic for
the session or finding something else to carp about.
Before the next session, the patient tried to change his
long-standing hour because his boss had complained about
the lost work time. The patient was angered when the
therapist could not comply and the therapist said that he
would work on it, though he felt that the patient was
overreacting and was trying to get out of treatment. The
patient felt that the therapist was putting words into his
mouth; he attacked the therapist because he was Jewish
(the patient was Protestant). As the two bickered back and
forth, the therapist ended the session. The patient correctly
pointed out that there was still ten minutes left and the
therapist apologized. Mr. 1.0. told the therapist to get the
notes that he took during sessions in order and when
the therapist pointed out his anger, he said that it did
not matter and maybe he would just not come to this
particular hour again until the therapist could change
the time.
In the next session, Mr. 1.0. ruminated about not being
able to get a new job and denied the therapist's obser-
vation that he seemed remote, saying that he really wanted
338 THE PATIENT-THERAPIST RELATIONSHIP

to reach out to him. He continued to obsess and denied


any feelings regarding the early dismissal when the
therapist referred to it.
The therapist began the next hour a minute or so late.
The patient ruminated throughout the session and the
therapist again dismissed him early. The patient left and
then promptly returned; the therapist again apologized.
In the discussion of the error, the therapist pointed out
that Mr. J.O. was in error about the time the hour began.
The patient said that he somehow was reminded of the
way his father drilled him in his school work during his
childhood.
In the next hour, the patient felt like terminating, but
did not. His father wanted him to move out of the house
and the patient wanted the therapist to see his parents. In
the following session, the patient described in detail how
he masturbated while he defecated, and then smeared the
feces on his body.

I shall stop the description here, adding only that there followed
considerable acting out and many threats to leave therapy, which
were not carried out. I want to emphasize these points:
1. The material demonstrates the excessive interventions and
real provocations of an angry, aggressive therapist. His verbal
hostilities culminated in acting out, which showed poor controls and
suggested an intense need to attack the patient. We may speculate
that this behavior was based on the therapist's countertransference
problems, which seemed to relate to intense homosexual and
castration anxieties, and other fears about his relationship with this
patient and the fantasies expressed by him. Last, note that the
sources of the iatrogenic syndrome here are both ongoing, charac-
terological difficulties within the therapist, that culminate in acute
incidents of acting out, and repeated failures to understand the
patient.
2. Early in supervision, I asked why this patient continued in
therapy since he was primarily being badgered and not learning
anything about himself. This is a question of considerable. im-
Therapist's Reactions to the Patient 839

portance: many patients continue in therapies of this kind for long


periods of time.
The material presented here seems to offer us several answers.
For one, the patient's masochism, be it feminine wishes, needs for
punishment, or a sort of victory over the therapist in provoking
senseless attacks by him, is gratified in this kind of treatment setting
and atmosphere. Patients continue to participate in a sadomasochistic
therapeutic misalliance to enjoy the passive feminine and aggressive
gratifications involved, and to defend themselves against the deeper
homosexual and castrative anxieties that plague them. Further,
through the mutual acting out of separation problems, these anxieties
become central and again serve to conceal the pateint's deeper fears
regarding his bodily integrity. Through the sadomasochistic inter-
action, both parties maintain a protective distance from each other.
Therefore, through his countertransference behavior, the therapist
directs the patient to restrict his communications and explorations
to areas that are less threatening to both, and that are largely pre-
genital. Further, the therapist's ineptness and his hostilities provide
a negative kind of reassurance for the patient, who unconsciously
senses them and feels superior to him. The mutual acting out also
justifies the continuation of the patient's neurosis. No constructive,
inner change can occur; instead, the patient's neurotic patterns are
repeated and maintained with the therapist.
3. The therapist's sadism is complemented by the patient's
masochism. The response to the countertransference takes the form
of transference fantasies and behavior determined in part by past
experiences and the current character of the patient, and in part by
the nature of the therapist's difficulties and errors.
(a) The therapist's behavior is, in reality, a new version of the
behavior of the patient's father.
(b) The patient responded to the therapist's attacks with latent
homosexual fantasies that are reality-evoked, as well as based on a
father transference, and undoubtedly on a passive mother trans-
ference as well. Thus, Mr. J.O. recalled his father taking his tempera-
ture rectally and grabbing his penis, and his mother giving enemas.
The therapist's real aggressions evoked a submissive, feminine
response and an erotized or erotic transference; it is not clear how
340 THE PATIENT-THERAPIST RELATIONSHIP

real the patient's masochistic wishes are, though the very fact that he
continues in this therapy indicates that strong needs to be abused by
the therapist are being gratified. There is also a definitive sado-
masochistic interaction here with real, though inappropriate,
gratification for both parties.
(c) The response of the patient culminated in the recollection of
masturbation during defecation and fecal smearing. This is both a
reflection of the patient's psychopathology and an apt, unconscious
portrayal of aspects of the therapeutic situation. The sexual
gratification inherent in the interplay with the therapist is apparent.
(d) Defensively, the patient became the aggressor in some of his
fantasies and with his girlfriend. He penetrated her anally, much as he
unconsciously fantasized that the therapist was doing to him with his
permission. He also attempted to attack the therapist directly in
various ways.
4. In regard to technique:
(a) The therapist must detect his countertransference problem
here, analyze and resolve it. Without such inner changes on his part,
this therapy cannot progress.
(b) He must be conscious both of the behavioral interplay with
';
the patient, and of his own and the patient's unconscious fantasies.
It is the therapist who must identify in his own behavior the pre-
cipitates of the patient's behavior and fantasies, and who must then
analyze the nature of the patient's responsive fantasies; and further,
he must interpret them to the patient. Remember, however, that such
interpretations lose all strength if not offered in the context of a
behavioral change by the therapist. To be effective, he must control
his countertransference behavior, or it undermines his verbal efforts.
A healthy therapeutic alliance and positive therapeutic atmosphere
must be created on all levels.
(c) The therapist must acknowledge his provocations and indicate
to the patient that he is working them out. However, any additional
comments are contraindicated since they would court anxiety in this
patient, who needs an intact therapist.
(d) If the therapist cannot resolve these difficulties, he should refer
the patient to another therapist.
It is clear by now that there are as many iatrogenic syndromes as
there are psychiatric syndromes. I shall briefly describe several of the
Therapist's Reactions to the Patient 341

more common ones so that we may be in a position to discuss


identification of them from the patient's material.

Iatrogenic Paranoid-Like Syndromes; Impairments in Trust


Iatrogenic paranoia-a descriptive term-is a syndrome in
which the patient becomes mistrustful of the therapist, feels that the
latter is trying to harm him, attacks or criticizes the therapist, and
behaves mistrustfully and aggressively with others-all on the basis
of a correct unconscious, and more rarely conscious, perception of
the therapist's behavior toward him. This syndrome, which repre-
sents a failure in the therapeutic alliance with emphasis on the loss of
basic trust in the therapist, is usually a response to direct (usually
verbal), inappropriate, repetitive aggressions or seductions against
the patient. The paranoid-like reaction may include some partial
distortions on the patient's part or, more often, be an essentially
correct appraisal of the therapist, which the latter erroneously
assesses as distorted. In any case, there is a kernel of truth in this
paranoid reaction. Further, most iatrogenic syndromes include
elements of mistrust of the therapist in the patient's reactions.

Miss I.P. was in therapy for depression and con-


fusion about her future; she could not settle into a job or a
stable social situation. Her therapist tended to be very
nasty, suspicious of her, and argumentative. When her
father took seriously ill, the therapist reacted without
sympathy, and continued to berate the patient, telling her
that she was angry with him, though her associations did
not support this idea. He kept suggesting that she had
feelings under the surface and was hiding them. The
patient became anxious, felt that the walls were moving,
and imagined tearing a cigarette to shreds. She felt that
nothing was being accomplished and that the therapist
must hate her; she cried. Her mother tried to weaken her
and she wanted her to stop, she said.

The therapist felt that the patient had become paranoid about
him. A more correct assessment would indicate that this patient was
correctly alluding to her therapist's aggression against her and that
342 THE PATIENT-mERAPIST RELATIONSHIP

the label of "paranoid" was a misnomer. More correctly, this is an


iatrogenic anxiety reaction, depression, and paranoid-like response
that is, in fact, based on a correct assessment of the therapeutic
situation and the therapist, though it may be distorted on a deeper
level. The repetition of the patient's actually destructive relationship
with her mother is also evident; the patient's reaction is primarily a
genetically-founded realistic one, which parallels that to her mother,
rather than a primarily transference response. Not every feeling of
mistrust and hurt regarding the therapist in a patient is unfounded;
it may be quite appropriate to the situation.

Mr. 1.Q. was a depressed and suspicious man who was


in treatment with an angry therapist who repetitively
attacked him. As termination, set by clinic rules,
approached (see Chapter 25), the patient began to engage
the therapist in petty quarrels. He finally became openly
furious with the therapist, accused him of hating him and
of not helping him (both were essentially true), and went
to the director of the clinic for a new therapist.

Here again, we cannot call this reaction a paranoid one in the


usual sense of a projective response; there is too much validity in it.
Often, this type of response culminates in a premature termination
of therapy. The patients who respond in this way need not previously
have shown prominent paranoid features, though they may have.
Much depends on the extent to which the therapist is behaving
traumatically.
One problem in defining these iatrogenic paranoid-like syndromes
lies with our present concepts of paranoid reactions. Undoubtedly
we are learning to recognize that there is, as a rule, a kernel of truth
in all such pathology (Niederland, 1959 and Freud, 1937). Thus,
patients who respond to aggressions from their therapists with
paranoid-like responses range from those who are predisposed to
such fantasies and pathology, and respond in this way to minimal,
nonverbal hurts, to those who are not so inclined, but are being
treated with blatant destructiveness. In interpreting these responses,
it is essential that the therapist be capable of ascertaining their true
sources and nature. When these fantasies are in keeping with reality,
Therapist's Reactions to the Patient 343

this must be acknowledged and modified by the therapist; on the


other hand, when the reality precipitate is minimal or distorted by
the patient's inner fantasies, and the paranoid fantasies are based
essentially on the patient's own conscious and repressed fantasies and
conflicts, these can be analyzed on that basis.

Mr. J.R. was in therapy with a somewhat forceful


therapist, who did not analyze his mounting anxiety and
unconscious fears of being damaged in treatment, based,
in turn, on fears of betrayal and exposure because the
patient was employed by the clinic in which he was being
treated. Dreams of being cut in the groin, of dying while
performing, and of being attacked by vicious animals, all
in the context of his anxieties about therapy, went un-
heeded. The patient left treatment abuptly.

This patient's fantasies have a paranoid tinge which goes beyond


the realities of the therapist's aggressions and the inevitable fears of
being treated in a clinic where one works. But much of the response
was evoked by the therapist's failures to make correct interventions,
especially specific interpretations. The outcome was an iatrogenically-
evoked termination.

Iatrogenic Obsessive Reactions


Mr. J.S. was a patient with a borderline syndrome and
obsessive defenses whose therapist had been on vacation.
When he returned, the patient described how he had barely
functioned in school and at home while the therapist was
away, and how he felt that he had been floating along and
apathetic. The therapist did not allow the material to
develop or permit clues to the patient's fantasies to emerge,
but quickly began to ruminate and generalize with the
patient about his not functioning, his isolating himself,
his school and social problems, and his shutting out the
therapist. The patient responded with even greater
detachment and rumination. (The therapist's contribution
to the patient's obsessing was unmistakable, and was noted
in supervision; the two w.ere sharing this defense.)
344 THE PATIENT-THERAPIST RELATIONSmp

In the next hour, Mr. J.S. spoke of having seen a


television play in which the patient and the psychiatrist
were ridiculously mechanically interacting in a meaning-
less way-it was just a back-and-forth comedy.

I shall emphasize these points:


1. Countertransference problems evoke in patients reactions
that run the gamut from isolated realistic and transference-influenced
fantasies and specific defensive responses to complex symptom
formations, acting out, and regressions.
2. Patients are capable of sensing, consciously and especially
unconsciously, the nature of the therapist's countertransference
problems, and of communicating this awareness to the therapist (see
Langs, 1973). By and large, they do so indirectly.
(a) One goal in treatment and in dealing with these errors is to
make the unconscious perceptions conscious for the patient.
(b) A second goal is to use the associations in the material from
the patient as indicators of the therapist's problems. The therapist can
thereby help the patient analyze and work through his responses to
them.
3. In supervision, the therapist had complained about this
patient's obsessiveness. Yet, when the former refrained from facili-
tating and sharing these defenses, the patient was far more lively,
reported quite a few dreams and associated to them, and com-
municated far more meaningfully.
Lesser Iatrogenic Depressions
I have already described Miss J.P.'s depressive response to her
therapist's hostility and lack of concern for her (p. 341), and there are
numerous other vignettes in which therapist-evoked depressions have
been described. Beyond the feelings of despair and hopelessness that
occur in patients in response to an aggressive and imperceptive
therapist, there are other roots and meanings to these depressive
reactions.

Miss J.T., a young woman with a mixed character


disorder, was in treatment with a therapist who was both
seductive and hostile. At a time of considerable difficulty
Therapist's Reactions to the Patient 345

with her boyfriend, her therapist kept interrupting her


flow of talk with provocative comments. In the session
that followed, Miss J.T. described an intense depression,
with anger at herself for being unfeeling, nasty, stupid,
and worthless with her boyfriend and her parents.

In this instance, the patient had put herself in the therapist's place
as a means of representing her unconscious perceptions of him, and
then condemned herself in a manner intended for him. Her rage
at the therapist was, in effect, turned against herself. This is a very
common response to the errors of therapists; many patients are
fearful of direct aggressions and criticisms toward their therapists
and berate themselves instead. In fact, when patients become
especially self-critical, the therapist should look for possible errors
and hurts to the patient that stem from himself, among other factors.

Iatrogenic Erotic and Erotized "Transferences"


and Iatrogenic Acting Out
Iatrogenic provocations of erotic and erotized transference
reactions are another very common phen-omenon in therapies con-
ducted by countertransference-dominated psychotherapists; they
should be considered whenever sexual fantasies and desires for the
therapist come up. Such reactions may be a response to a hostile
therapist, whose behavior evokes sexualized longings for closeness
out of the patient's frustrations and rage at not being able to create a
rapport with him; and they may arise as a defense against the fury
directed toward him. They may also be the response to a therapist who
is seductive on some level, and they intensify when he fails to recog-
nize his contribution to the erotic reaction. Such realistic and trans-
ference-related reactions often culminate in acting out through
affairs or termination of treatment.

Mrs. J.U. was a young woman with a severe character


disorder, separated from her husband, and having
considerable difficulty tolerating the loneliness involved
and in handling the problems of her two children. She was
tempted to allow her husband, who had been openly
346 THE PATIENT-THERAPIST RELATIONSHIP

unfaithful and was disruptive with her and their children,


to return; she also was seeing another man who was
married and had many unfavorable traits. She was
struggling with thoughts of having an affair with him.
Each time the patient began to talk about these
problems in her psychotherapy, the therapist told her that
he felt that she was really referring to him and to treat-
ment, and that she was struggling with desires to get closer
to him or with wishes to leave treatment. The patient was
angered and told him that all he ever wanted to do was to
talk about himself. She began to express sexual fantasies
about, and wishes for, the therapist. These went un-
explored and the patient's associations did not bring out
any genetic aspects to them. In this bind, the patient acted
out and abruptly got involved in an impulsive affair with
the married man who had been calling her. In the session
in which she reported this, she described this dream: she is
at work and cannot reach the clinic-she cannot reach the
therapist; she is then with her father, yelling at her son. No
direct associations to the dream were given or asked for.

This is a common form of countertransference seductiveness and


also a typical response to it on the part of the patient. Therapists who
insist on trying to relate themselves to everything that the patient
discusses, and who erroneously do this in the name of "working with
the transference," are putting pressure on the patient to think about
themselves, fantasize about them, and desire them-all in a
therapeutic situation where only frustration can prevail. This is far
different from working in context with spontaneous transference
fantasies and realistic reactions to the therapist. Nor should this
insistence on focusing on the therapist in the sessions be confused
with the silent monitoring of the patient's associations for trans-
ference implications-something every therapist should do. Excessive
focus, and even totally unjustified focus, by the therapist on himself
are, if we take our clues from this patient's response, based on un-
resolved seductive fantasies in the therapist. There must be a sound
basis for any interpretation of transference or other material related
Therapist's Reactions to the Patient 347

to the therapist. When this is not the case, the patient will rightfully
feel teased, provoked and seduced, and he will react.
Another common response to seductiveness by a therapist of the
opposite sex is a defensive flight into homosexual fantasies or
behavior, again varying with the nature of the therapist's act, and
the pathology and ego functioning of the patient. I have used the
model of a male therapist with a female patient because it is the one
I have observed most often; these problems obviously can occur with
any pairing of sexes in the therapist and patient.

Violations of the Therapeutic Boundaries by the Therapist


There is a special form of countertransference behavior that goes
beyond errors in what the therapist says and does not say, and beyond
the usual limits of the therapist's role; it entails behavior toward the
patient that is directly aggressive or seductive. The principle that the
therapist should remain as anonymous as possible, and not reveal his
personal life or fantasies to his patients, is relevant here, as is the need
to avoid unnecessary parameters.
I have already alluded to patients' reactions to their therapist's
uncorrected lateness (see Chapter 5) and even to the rectified early
dismissal of a patient. These behavioral errors are on a continuum
with those I shall discuss here, where the therapist does something
even more radical or self-revealing, and more intentionally erroneous.

Mrs. J.V., a woman in her thirties with a borderline


syndrome, was in therapy with a very provocative and
angry therapist. She had a long-standing depression and
a very poor, embattled marriage. One day, she called her
therapist to cancel her session, saying that she was sick
and in bed. The therapist heard her out, hung up the
telephone and decided to call her physician, whom he
knew, in order to be sure that she was not lying. He
learned that she was indeed telling the truth. He told the
patient of his investigation in the next session and she was
not particularly perturbed by, his action. In the next hour,
however, she described how she found a way to live with
her husband-by recognizing that he really was nothing
348 THE PATIENT-THERAPIST RELATIONSHIP

more than a destructive, provocative fool and that she


certainly was a far better person than he.

Mrs. J.V.'S statement reflects her justified appraisal of her


therapist. It offers another indication why patients stay with de-
structive therapists who provide them momentary relief through such
drastic and unfavorable comparisons. This is a form of "counter-
transference cure;" these symptom alleviations are based on the
therapist's errors and countertransferences (see pp. 353 ff.) and are
generally temporary. In this instance, the "cure by comparison" did
not last very long and the patient soon turned to attack her therapist,
her husband and herself again.
The following vignette is also pertinent to the boundaries of the
relationship between the therapist and the patient, because it high-
lights important aspects of the topic rather than because it involves a
major error by the therapist.

MR. J.W. was a young man in psychotherapy for a de-


pression and perversions-wearing his mother's clothes
and isolated homosexual experiences. The therapist, as a
rule, met him in the clinic waiting room and escorted him
to the office. Before one session, they found, to the thera-
pist's surprise, that a new air conditioner was being
installed in his office. The therapist remarked that he was
being replaced by an air conditioner and that they would
have to find a different office. In the session, the patient
said first that it was the first time that the therapist seemed
human, and that he had been fighting the therapist without
knowing why. He ruminated about his family and his
adolescence, and finally focused on his overt sexual fan-
tasies toward his mother's women-friends during his teens.
He began the next session by reporting a dream.
(I shall pause in presenting the vignette much as I did in
supervising this case, because it proved possible to
predict the patient's manifest dream, by considering the
most likely day residue (context) for it and the derivatives
that were emerging toward the end of the previous hour.)
To return to the vignette:
Therapist's Reactions to the Patient 349

In the dream, the patient and his brother were together.


His brother was a girl and the patient was having inter-
course with him. Associations were to the fact that it was
not really a sexual dream, just a way of being close, and to
the patient's fears of being homosexual, though he was not
one overtly. He then recalled a repetitive dream of inter-
course with his mother. He spoke of his excitement in first
attending college and of his fears that his father would die
and spoil it. He then described early incidents of wearing
his mother's clothes.

The implications of this vignette are apparent. Just a minor re-


laxation of the boundaries between the therapist and his patient
evoked in the patient intense incestuous (mother) and homosexual
(brother) transference fantasies on an unconscious level, and trans-
ference rage (father) as well. The therapist's seemingly innocuous
remark was experienced as a frank seduction by this patient, who
was, of course, very strongly inclined to sexualize relationships. Em-
pirically, even minor deviations in technique have major reper-
cussions.
I do not mean to imply that this therapist's social remark was
necessarily a reflection of a countertransference problem, though it
may have been. On the surface, an occasional offhand comment to the
patient is not out of line. However, I did not follow this case closely
and have no data about the ongoing patient-therapist relationship.
The main point is that if the therapist had been aware that such a
remark can evoke intense sexual and incestuous fantasies in some
patients, and if he had been alerted by the material toward the be-
ginning and end of the session that followed, he might have inquired
further into the patient's reaction to his comment in that hour. Then,
with that added material, he might possibly have made an interpre-
tation of the fantasies that his remarks had stirred up in the patient,
and pointed out how easily he was stimulated in this way, referring
to his ego pathology. This might well have helped the patient to
control his subsequent response, which in turn merited a correct
assessment of the context and interpretation (see Weiss, 1973).
The therapist's main errors, then, were in not exploring the extra-
therapeutic interlude with the patient in the session which immediately
850 THE PATIENT-THERAPIST RELATIONSHIP

followed it, and in not interpreting the material of the next hour
in that context. Had he done so, he most certainly could have pointed
out to the patient how readily he sexualized relationships in his search
for closeness and how deeply he feared it (interpreting upward). The
therapist had not made a gross error here, and I would not recom-
mend any apology or admission of error, but would focus on the
patient's inordinate reaction.

We see a similar response in Mr. J.x., a young man who


was struggling with homosexual fantasies and impulses,
when his therapist attempted to work with a dream that
seemed important (it referred to being drugged by the
therapist), but that he had missed in a previous session. In
the later hour, the patient could not remember the dream,
so the therapist decided to tell it to him in lieu of working
with the apparent resistance. In the next hour, the patient
reported an upsurge of homosexual masturbatory fan-
tasies and impulses; there was no other apparent
precipitating factor; the patient had felt seduced.

One last brief vignette, which alludes more to a technical error


than to an infringement of boundaries, will be included here because
it highlights again how the therapist's failure to maintain the ground
rules of therapy can evoke strong unconscious responses in a patient.

Mr. J.Y. was in therapy for depression and recurrent


problems in meeting people in the course of his work; he
tended to do poorly in business. He had a moderate charac-
terological disturbance.
In one session early in his treatment, he spoke of his
anxiety and fears of not being able to function because of
his partner's several recent and pending brief vacations,
and described in some detail his distress over a cousin who
seemed to be dying of cancer. At the end of the session, he
asked the therapist if they would meet at the next regularly
scheduled appointment time since it was to fall on Labor
Day, and the therapist said that he had forgotten to
mention it, but there would be no session that day.
Therapist's Reactions to the Patient 351

The patient began the next hour by saying he did not


think the therapist would be there, and elaborated upon
that fantasy. He said that his customers had no regard
for him, and often did not keep their appointments and
forgot to cancel them. He then spoke of the way the
Germans mishandled the tragedy of the Israelis who were
killed by the Arabs at the Olympic Games.

I shall not add any further material from this session. The
therapist did not recognize the context of this material, and did not
interpret it as a response to his own neglect and failure to tell the
patient of the coming holiday. I must emphasize that patients can be
far more sensitive to errors by the therapist (here, his failure to men-
tion the holiday) than to a necessary separation from him (the holiday
itself). It was the former trauma out of which the patient developed
his unconscious fantasies and his anxieties.
These vignettes reintroduce the issue of the therapist's main-
tenance of adequate boundaries and limits in his relationship with
the patient. Using good common sense and sound therapeutic tenets,
we may state these principles here (see also Chapter 6):

1. The consequences of these trivial boundary infractions by


therapists indicate that patients are especially sensitive to such incidents.
2. These vignettes imply that more flagrant infringements of the
boundaries, such as the revelation of the therapist's life, opinions and
fantasies, will evoke even more intense and disruptive responses in
patients. From all we have learned, these disturbances in the thera-
peutic alliance will probably culminate in detrimental acting out,
other iatrogenic regressions and symptom-formations, and often
enough, in termination of the therapy.
3. These infractions are experienced as incestuous seductions and
aggressions, and as a reflection of the therapist's poor controls and
incompetence. The patient's response is based on these unconscious
perceptions, and is very often ultimately a self-destructive violation
of some boundary within or outside therapy. In addition, the therapy
is also threatened by the reactive longings and fantasies that such
behavior in the therapist evokes in the patient; they range from wishes
for sexual fusions to rage at being tempted and used.
352 THE PATIENT-THERAPIST RELATIONSHIP

In this connection, the reader may review the vignette of Mr. I.C.
(Chapter 6, Vo!. I, pp. 188-91). There, the presence of a young lady
in his chair as he arrived late for his hour prompted unanalyzed fan-
tasies of betrayal and seduction. The patient then directly violated a
confidentiality at work and later acted out perversely. These reactions
were directly traceable to the inadvertent, but unexplored, intrusion
of a third party into the patient-therapist relationship.
In conclusion, I want to reemphasize the need to maintain the
appropriate boundaries of the therapeutic relationship and to avoid
deviations in technique. Unneeded parameters invite and sanction
acting out and regressions of all kinds in the patient, and these
reactions will be apparent in his subsequent communications and
behavior.

4. In regard to technique:
(a) Maintain a constant awareness of the appropriate limits of
the therapeutic relationship.
(b) Do not violate these boundaries, though obviously the thera-
pist may be forced to do so in a dire emergency (e.g., preventing a
suicide or a direct physical attack; see Chapter 6); most other
deviations will prove to be largely countertransference-based.
(c) The therapist should be immediately aware of inadvertent
infractions of the boundaries by either party. If not, clues and deri-
vatives in the patient's material should lead him to a review, especially
of recent behavior with the patient, for possible infractions.
(d) Once it is recognized, acknowledge the infraction in an
appropriate context and analyze the .patient's reaction to it as
reflected in the material from him. Often, the patient will attempt to
use the error to foster resistances and to sanction his own acting out,
or to justify an attack on, or seduction of, the therapist, verbally or
otherwise. The therapist must not, in his anxiety and guilt, fail to
analyze such defensive and pathological exploitations of his error.
In addition, such infringements may serve as a stimulus for intense
therapist-evoked but transference-related reactions, which, if under-
stood fully by the therapist, can be analyzed to produce considerable
insight and inner change in the patient. As always, anxieties, conflicts,
unconscious fantasies, and genetic-memory material evoked in the
patient by the therapist's behavior are important.
Therapist's Reactions to the Patient 353

Before my concluding comments on countertransference problems


and the technique of handling them, I want briefly to discuss the
topic of countertransference "cures."

So-called Countertransference "Cures"


I have already discussed briefly the concept of so-called
"transference cures" (Chapter 20) and will allude to "flights into
health" later on (see Chapter 23). I have suggested that these
phenomena are probably not cures in the sense of lasting, adaptive
inner change, and that very often there is a significant contribution
from countertransference problems in such outcomes (see Barchilon,
1958).

Mrs. J.Z. was in twice-weekly psychotherapy for a


depression prompted by a separation from her husband.
They had both been unfaithful and both tended to act out.
In her sessions, she revealed a rather traumatic childhood,
which included overt incestuous sexual experiences with
both her brother and her father, and a poor relationship
with her mother. The treatment itself was focused primarily
on realities, such as her uncertainties about the married
man with whom she was currently involved sexually. She
was unable to mobilize herself to get a job, which would
enable her to be divorced, and tended to keep to herself.
There were many repetitive and ruminative sessions in
which both the patient and the therapist kept close to the
surface and shared a variety of obsessive defenses; there
were no interpretations or confrontations of these defenses
and no investigation of the occasional derivatives hinting
at deeper and serious conflicts and related unconscious
fantasies. After seven months of this, the patient
suddenly decided to get a job, and did so. Later material,
not detected or explored by the therapist, made it clear
that the anticipation of a termination, necessitated by
clinic rules a few months hence, was an important factor
in this decision; the therapist had set a one-year limit to
therapy at the outset.
Despite the likelihood that her hours could be shifted,
354 THE PATIENT-THERAPIST RELATIONSHIP

the patient requested that they cut down to one session


weekly because of her job, and the therapist agreed without
analyzing it-a new level of mutual acting out. The
patient missed the next session, which was to be her first
on a weekly basis, blaming a minor illness in her daughter
for the absence. In the next couple of sessions, she des-
cribed her job and her functioning in glowing terms,
moved closer to a divorce, established a relationship with
a new boyfriend, and spoke of feeling ready to terminate
her therapy. Careful listening indicated that there were
many questionable aspects to her relationship with the
boyfriend, but on the surface all doubts were denied.
Any sense of distress was blamed on her husband, whom
she now definitely planned to divorce.

If we pause here, how would we assess this patient's improvement


and what would we do, as the therapist, at this juncture?
There were two factors which prompted this seeming improve-
ment:
1. The complex misalliance and defenses shared between the
therapist and patient-ruminating, denying unconscious fantasies
and even hints at realistic problems, and acting out through a
premature decrease in the frequency of sessions. Thus, counter-
transference and transference problems and fantasies, both well
concealed for the moment, evoked this "cure."
2. The anticipated termination, which we might call the clinic's
countertransference problem, prompted the need for "self-cure" in
this patient and she attempted to live it out (see Chapter 25). For
her, such a termination was a blatant rejection and hurt, though the
clinic policy was based on the need to serve many in the community.
Incidentally, this kind of defensive flight into "health" is ex-
tremely common in patients under these circumstances. Both
patients who made suicide attempts that were, at least, in part
therapist-evoked-Mrs. E.Y. and Mrs. E.J.-acted out counter-
transference "cures" after the attempt. Mrs. E.Y. made two subse-
quent minor suicide attempts and then returned for a final two
months of therapy, during which she denied any serious need for
the therapist and mobilized her weakened resources finally to leave
Therapist's Reactions to the Patient 355

her husband. Mrs. E.J. terminated her treatment soon after her
suicidal attempt in an episode of prolonged elation and denial,
supported by her family who had finally rallied to her side. In neither
of these patients was there any evidence of inner, positive structural
change; fragile defenses and acting out seemed to prevail. Similar
responses also occur when therapists go on vacation, especially
when the separation reaction is not analyzed (see Chapter 20).
Unconsciously, the first and most general meaning of a patient's
reaction to such a separation is something like this: "Go-leave
me-I don't need you-I don't care." It is a denial of dependency in
the face of utter helplessness to modify the loss, and always has
specific current and genetic meanings for a particular patient.
This represents then, both a countertransference "cure" based on
the therapist's defenses, errors, and fantasies and on the dictates of
clinic policy, as well as a corresponding transference "cure" based
on the patient's reaction to these errors and to the anticipated
termination. It is also a "self-cure." It in no way follows upon
insight and working-through in treatment and is not based on the
resolution of intrapsychic conflicts and resultant inner change. Such
a "cure" or behavioral change is usually quite fragile, and much too
dependent upon the patient's spiteful denial of any need for the
therapist. In all likelihood, it will not be sustained in the face of new
traumas and pressures in the patient's life, though it may occasion-
ally be reinforced by new rewards and prove relatively stable. At
best, it is a risky matter; at worst, it is a fragile facade of denials.
In a patient with the type of history and character structure present
in Mrs. J.Z., we must suspect the worst.
There was, however, still time to test the strength of Mrs. J.z.'s
"cure." It was recommended in supervision that the therapist con-
front and, if possible, interpret the patient's resistances, so that
whatever lay beneath them would emerge; we would then see how
stable this patient's symptom alleviation would prove to be.

In the next session, Mrs. J.Z. ruminated about a


pleasant evening that she had spent alone in the city,
refusing a pick-up by a man in a restaurant. She was
considering breaking up with her new boyfriend and
reviewed again at length her thoughts about getting
356 THE PATIENT-THERAPIST RELATIONSHIP

divorced. The therapist pointed out that Mrs. J.Z. kept


repeating the same thing, as if to keep him at a distance,
and she avoided whatever really bothered her. She said
that in fact, what was on her mind was the question of
what she could be avoiding. Well, she went on, she had
had an anxiety attack that morning and had had a dream
(one of the few to be reported in her treatment): it was
her birthday party. There was a big cake with her name on
it and her mother was trying to cut a piece of this cake.
Her husband was there and she wanted him to tell her
mother: do not touch it. He said that he did not care; let
her do as she pleased. In a second dream, she was with a
professor, a Dr. Siegel, and was showing him a book done
by herself and one of her sons. Dr. Siegel said that she
had ruined her son.
Mrs. J.Z. linked the doctor to her therapist and spoke
of feeling rejected by her boyfriend. The therapist con-
nected this latter feeling to his reducing the frequency of
the sessions and the patient said that she had not thought
of it, but in the dream, she now remembered that Dr.
Siegel said that she could come back once if she
wanted to.
In the next session, amidst concern about her children,
she reported dreaming that her father wanted her to go
to bed with him; at first she was going to say yes, but
then she realized it would be sick and she refused him.
Associations were sparse, and were to a promiscuous
man whom she had dated and whom she had seen recently
and refused sexually.

Here is a good illustration of a correct confrontation with a


defense and a confirmatory response (see Chapter 18). With a
momentary resolution of the therapist's countertransference prob-
lems reflected in his sharing the patient's defenses of obsessing and
denying, and pretending that all was well, he was able to make a
correct intervention-and thereby also to let the patient know that
he no longer was willing to settle for pretense.
Therapist's Reactions to the Patient 357

Immediately, the patient revealed a previously concealed anxiety


attack and upsetting dreams which she had not been reporting. In
them, we can detect many transference fantasies and specific hints at
an incestuous father transference that was also being concealed. The
"cure" was indeed a facade and a defense, and possibly based on an
unconscious idealized and erotized transference.
I shall leave it mainly to the reader to detect the rich latent
content of this material, merely noting the reference to Mrs. J.z.'s
husband's remark in her dream ("I don't care, let her do as she
pleases.") and also the allusion to the ruined child; these are certainly
a partially correct unconscious reading of the relationship between
the patient and therapist. The dream of the patient's father, which
followed, suggests that she kept her distance from the therapist as a
defense against an erotized transference. Subsequent work with
these underlying problems helped to solidify this patient's adjust-
ment.
I have already described other countertransference "cures" (see
the Index of Clinical Material). Many of them are reactions to hostile
and seductive therapists in which denial, acting out, and "self-
cures" through precipitous marriages, flights to drugs or deviant
groups, or escape into perversion or deviant behavior prevail. These
are strongly rationalized and defended, and often cannot be modified,
especially by an unwary therapist. They are best prevented. The
extent to which they reflect an acting out of the therapist's own
fantasies cannot be assessed from the data available to me; it merits
separate study.
In essence, then, countertransference "cures" are apparent
symptomatic or behavioral improvements that do not follow upon
insight and working-through, but are a response to problems
within the therapist that have been translated into errors and omis-
sions with the patient. They must be considered whenever there is
seeming improvement without insight, when there is a fragile-
appearing "flight into health," and when a countertransference
response to the patient has been recognized by the therapist either
through self-awareness or in following the material from the patient.
Let us turn directly to this last issue.
358 THE PATIENT-THERAPIST RELATIONSHIP

THE RECOGNITION OF THERAPIST-EvOKED


SYNDROMES

Types of Hostile Countertransference Expressions


For purposes of recognition, I shall begin with a rather basic
categorization of hostile countertransference expressions from
therapists, including those I have observed most often; no list can
be entirely complete. Such expressions may take the form of:

1. Open carping, nastiness, anger and hostility


2. Sarcasm and teasing
3. Provocative, rationalized, unneeded deviations in technique
4. Cajoling and challenging the patient; pressured questioning
5. Insisting that the intervention is correct or repeating it
6. Interrupting the patient, and talking too often and too soon
7. Inappropriately doubting and not believing the patient
8. Making premature and especially too deep interpretations
9. Projecting the therapist's own fantasies and aggressions onto the
patient
10. Manipulating and controlling the patient; shifting hours more
than rarely
11. Unnecessarily frustrating the patient
12. The aggressive and hostile use of self-revelations
13. Failing to intervene when indicated, especially when the patient is
acting out destructively or regressing
14. Other expressions of hostility, actively and passively expressed,
including physically hitting the patient
Common Responses in Patients to Hostile Countertransferences
The main reactions of patients to hostile behavior by the
therapist are:
1. Attacking and criticizing the therapist and therapy, and disruptions
of the therapeutic alliance
2. Erotic and erotized-reparative-reactions toward the therapist
3. Wanting to leave, or actually leaving, therapy
4. By displacement, hostilities and seductions toward others; including
anger turned against the patient himself, which leads to
Therapist's Reactions to the Patient 359

5. Self-depreciation and depression


6. Other forms of acting out and acting in
7. Suicidal fantasies and behavior
8. Intensification of symptoms and other regressions
Now, let us develop a comparable compendium of seductive
countertransference expressions.
Types of Seductive Countertransference Expressions
1. Titillating and seductive comments, such as references to the
patient's apparel, attractiveness, and the like
2. Seductive, unneeded deviations in technique
3. Excessive interest in, and questioning about, the patient's sexual
behavior and fantasies, often to the relative neglect of other material,
and without proper context
4. Overemphasis on the erotic transference and on sexual interpre-
tations, often without sufficient work with the ego and superego elements
involved
5. Undue focus on the patient's feelings toward, and fantasies about,
the therapist
6. The acceptance of the patient's sexual fantasies about the therapist
without analysis and resolution
7. The conscious and unconscious sanction or failure to explore sexual
acting out by the patient
8. The utilization of erotic self-revelations, however minor, to stimulate
the patient and arouse his interest in the therapist personally
9. Other subtle and not so subtle forms of seductiveness, including
touching the patient or making direct sexual overtures

Common Responses to Seductive Countertransference Behavior


1. Sexual acting out, often strongly rationalized, and ranging from
affairs to precipitous marriages
2. More subtle displacements of sexual desires for the therapist onto
others
3. Erotic fantasies about the therapist and erotized "transference"
wishes for actual sexual contact with him
4. Flights into homosexual fantasies and behavior when the patient and
therapist are of opposite sexes, and into heterosexual fantasies and
behavior when they are the of same sex
360 THE PATIENT-THERAPIST RELATIONSHIP

S. Hostile reactions and rage against the therapist or others


6. Depression, self-accusations, guilt, and suicidal fantasies and
attempts
7. Other disruptions of therapy and the therapeutic alliance, including
termination
8. Regressions and exacerbations of symptoms

From this condensed summary, we can see that any disruption in


therapy, and any regression or episode of acting out by the patient,
should lead the therapist to question what is prompting it. There are
two main possibilities: some event or trauma in the patient's life,
and something in the therapy. The former can be readily detected
from the patient's material and through recognition of the traumatic
potential of various incidents, hurts, and anniversaries, which must
then be explored with the patient when regressions follow them.
The latter-experiences directly involving therapy-may be of two
kinds: either events and interventions not based on countertrans-
ference or those reflecting such problems. The former may be readily
detected in vacations, painful but clearly necessary confrontations
and interpretations, modifications of pathological defenses, and
similar unavoidable moments when the patient is bound to feel
vulnerable. Such regressions do not, by and large, seriously threaten
or disrupt therapy and the unfolding of meaningful material from
the patient. Reactions to countertransferences can be detected first
by subjective awareness in a sensitive therapist, and secondly, from
the material from the patient. They evoke intense disruptions in the
therapy and within the patient, and when such regressions occur,
the therapist must immediately investigate for countertransference
problems. He listens for clues in the patient's material, and reassesses
his behavior, interventions and inner feelings. A crucial step toward
resolving such difficulties is simply a therapist's preparedness for
their possible appearance in the reactions of patients. Counter-
transference expressions are inevitable; their detection is the critical
issue, since their modification and analysis will generally be welcomed
by the patient and lead to an ultimate strengthening of the thera-
peutic alliance.
Therapist's Reactions to the Patient 361

Other Aspects of Countertransference Problems


This outline may be supplemented by the following observations:
1. Interpretation of the defenses involved in a countertransfer-
ence "cure" will often lead to a collapse of the facade. Without such
efforts, it may culminate in acting out and premature termination.
2. Even a subtle sharing of defenses and pathological fantasies-
misalliances-between the therapist and patient undermines therapy.
3. Patients with emotional conflicts and problems similar to
those in the therapist are particularly likely to evoke countertrans-
ference responses in him, as are those who are especially similar to
his own parents and siblings.
4. Deviations in usual technique are among the most common
precipitates of iatrogenic reactions; flexibility within firm limits
should prevail.
5. With the exception of brief acknowledgement of technical
errors, self-revelations by the therapist to the patient reflect counter-
transference problems (see also Chapters I and 6):
(a) The therapist functions as an expert and healer, and should
not step out of this role.
(b) The therapist maintains proper boundaries in his relation-
ship with the patient, as an effective, healthy, and noncorrupt model
for identification, and as one means of ensuring the absence of
seductiveness or hostility toward the patient.
(c) The therapist's anonymity permits the patient to work in as
uncontaminated a field as possible, so that it is the latter's pathology
and not that of the therapist, that emerges. This also fosters the
fullest range of possible transference reactions and projections onto
the therapist; these then primarily reflect the patient's conflicts and
fantasies, and not those of the therapist.
(d) Such boundaries deprive the patient of a major defense and
resistance, namely, that of blaming the therapist for disturbances in
the treatment and for the patient's own pathology_
(e) This provides an optional level of frustration, which, in turn,
aids the patient in expressing his intrapsychic fantasies and conflicts
in verbal derivatives rather than in action, such as that related to
transference gratifications and misalliances.
(f) The fact that such infractions undoubtedly reflect erotized
362 THE PATIENT-THERAPIST RELATIONSHIP

and aggressivized countertransferences is confirmed by patients'


disruptive and regressive responses-iatrogenic syndromes.
I shall not belabor these points, but shall now summarize the
principles for dealing with countertransferences when they affect the
therapy, and the constructive and adaptive utilization of the thera-
pist's fantasies, countertransference-based or not, in the patient's
therapy.

THE TECHNICAL HANDLING OF THERAPIST-EVOKED


REACTIONS IN PATIENTS
I have discussed the techniques we use in dealing with the patient's
reactions to countertransference problems throughout this chapter
(see also Chapters 5 and 6). I shall here collate the main points:

1. Good technique always begins with proper listening and recog-


nition of significant manifest and latent content. Here we may apply
these basic principles to the therapist's own reactions to, and fan-
tasies about, the patient.
(a) Any disruption in the therapeutic alliance and in treatment
calls for a scrutiny of possible countertransference problems.
(b) Constant monitoring of the patient's material for fantasies
about, and realistic perceptions of, the therapist is essential. When
the context of the material and the sequence of associations point to
latent content related to the therapist, he must consider such fan-
tasies as though they were mirroring aspects of his behavior and
unconscious fantasies, rather than view them solely as the
patient's projections and irrational fantasies. The content of the
patient's associations is, therefore, to be considered on one level as
a reflection of the therapist's unconscious fantasies and behavior, as
unconsciously perceived-often correctly-by the patient.
For example, recurrent dreams of being seduced, exposed,
attacked, penetrated, harmed, or tortured may very well allude to
countertransference expressions from the therapist, and go beyond
the patient's own anxieties, conflicts, and fantasies. Ignoring such
leads will perpetuate the problem when it exists (see Langs, 1973).
(c) The therapist's awareness of deviant fantasies, unusual verbal-
izations or behavior, errors, and anything different or recurrently
Therapist's Reactions to the Patient 363

aberrant in his responses to the patient is a vital clue to his own


recognition of countertransference difficulties. Especially when he
responds out of character or makes an exception in a therapeutic
situation, however seemingly innocuous or necessary it may appear,
he should explore himself for countertransferences, and watch the
patient's material for reactions and clues. This self-monitoring is
most fruitful if the therapist has achieved a stable, consistent and
relatively countertransference-free level of therapeutic work. Such
a baseline is essential if deviations are to be meaningful indicators of
problems. Otherwise, countertransference manifestations are so
inherent in the therapist's work and in his character that they are
relatively unrecognizable to him. There is a great need for self-
awareness and a full resolution of the therapist's own problems.
2. Once the countertransference problem is recognized it must be
resolved:
(a) Recurrent countertransference behavior must be controlled
and analyzed. Acute, single episodes should be analyzed and worked
through to avoid repetitions. All this is the responsibility of the
therapist and the patient should not be burdened with it in any
way.
(b) The reaction of the patient should be allowed to unfold, yet
analyzed before any acting out or acute regression takes place.
(c) In exploring the countertransference-evoked reaction, the
therapist should, briefly and as simply as possible, generally acknow-
ledge his error. At times, it is also helpful to indicate that he is work-
ing on the basis for the error within himself, as a model of the search
for self-understanding and resolution, but he should not divulge any
details of what he has discovered.
This "self-cure" or change in the therapist is essential if the error,
and its effects on the patient, are to be analyzed and resolved. If the
therapist himself has not changed, the patient will not alter his
reactions and fantasies, and he will have a basis for the continuation
of his maladaptive responses.
(d) With the error identified as the day residue or context, the
patient's response is then delineated and interpreted in terms of his
underlying conflicts, fantasies and genetics. At such times, this
problem takes precedence over all other topics and therapeutic
contexts, except, of course, for emergencies-which would probably
364 THE PATIENT-THERAPIST RELATIONSHIP

be related to it anyhow. The patient's response is always treated as


his responsibility; the therapist's behavior is not seen as a license to
act out or regress. Nor should the therapist's realistic, controlled
sense of responsibility lead him to take the ultimate responsibility for
the patient's behavior or open him to psychological blackmail by the
patient. Many patients will attempt to misuse the therapist's error as
sanction for disruptive behavior on their part or as a defensive
rationalization for an aspect of their own pathology. Such efforts must
be detected, analyzed and not gratified. The correct stance traverses
a fine line: neither undue guilt and responsibility, nor undue denial
of the therapist's provocative role.
3. Such an honest analysis of the patient's reactions to a thera-
pist's error usually has two results: constructive growth and inner
change for both; and a tendency for the patient, despite this effective
work, to attempt to use the incident for defense and resistance when
under new stresses. At such times, further focus on the error will
usually lead to previously unreported fantasies and genetic material
enabling additional working-through.
4. There are two cautions:
(a) That the therapist not allude too often to his own errors and
to the patient's feeling that he has been misunderstood. Unless he
confines such work to major episodes and specific fantasies, he may
be seen as ineffectual and self-effacing; the therapeutic alliance will
suffer.
(b) That the therapist recognize those situations where the
patient attempts to use the error to disrupt therapy or maintain
neurotic symptoms.

Here is a brief illustration:


Mr. K.D. had been in therapy for six months because of
homosexual problems and a moderate character disorder.
His therapist had been on vacation, and he had responded
with an upsurge of homosexual acting out, which had
expressed fantasies of undoing the separation and revenge
on the therapist. The associations that revealed specific
derivatives of these fantasies and the basis for the acting
out went uninterpreted. The patient then reported that he
had taken a job that would require a training period of
Therapist's Reactions to the Patient 365

two weeks out of town. The job was an apparent advance


for the patient, but the therapist-without supportive
associations-quickly interpreted the interruption as a
vengeful flight from treatment. The patient responded by
justifying the step.
In the next hour, Mr. K.D. was furious with the thera-
pist for having said that his leaving was an escape from
therapy. He went on to recall his first homsexualliaison as
a teenager, with a peer whom he later exposed to others
as a homosexual. He described himself as searching for
an ideal lover ; people hated him because he was fat.
In the next hour, he recalled dreams of wars in which
he was impotent. Reluctantly, he described an impulsive
homosexual pick-up with a young boy whom he pene-
trated an ally-like a Dr. Jekyll. He used to worry that
God would strike him dead for such behavior. It was a
step backward for his treatment. The therapist interpreted
this episode as an expression of the patient's rage regard-
ing his recent vacation and his comments about Mr. K.D.'S
business plans. The patient responded that the therapist's
assumption that he did not want therapy had infuriated
him; he had felt like saying "Fuck you!"

Here, the therapist's technical error was an unsupported criticism


of the patient and an unwarranted, hurtful intervention. It evoked
rageful homosexual fantasies and homosexual acting out-iatrogenic
homosexuality. The interpretation of this behavior could have been
more specific in its content and should have been made in the first
session described, in order to forestall acting out by this impulsive
patient. However, such an interpretation would not be complete
without reference to the patient's misuse of the therapist's error to
justify his maladaptive behavior. Thus, the therapist's accusation
was defensively used by Mr. K.D. to account for his behavior, and
as a cover for his more irrational responses to the therapist's vaca-
tion. This self-harmful misuse of the therapist's acknowledged error
should have been pointed out. In principle, whenever a patient
attempts to rationalize, justify or excuse his pathological behavior
or fantasies by alluding directly or indirectly to the therapist's errors
366 THE PATIENT-THERAPIST RELATIONSHIP

or human failings, the latter must nondefensively confront and


interpret this behavior.
Now let us turn to two vignettes where single countertransference
problems occurred, were recognized, and were worked through
properly (see also the Index of Clinical Material):

Mr. K.A. was a young man with a severe passive-


resistant character disorder who sought therapy for de-
pressions and poor work at college. He had been in therapy
for a brief period the year before his present treatment,
and had been with a therapist who had worked in a clinic
where his father, who was an attorney, served on the Board
of Directors. The latter had himself been in some kind of
therapy, and often discussed and interpreted his son's
problems directly to him.
In his current treatment, at an entirely separate
clinic and without any involvement on the father's
part, the patient was extremely guarded, often silent for
long periods, and very wary of any intervention, however
cautiously made. There was little progress, though he
continued to come to therapy. Efforts to link this mistrust
to his previous therapeutic experience and to the pryings
of his father were met with a nod, but led nowhere.
In one session, the therapist received a telephone call
related to a research project in which he was participating.
The caller urgently needed the name and address of another
participant; the therapist gave the information and hung
up.
The patient, who had been ruminating about some
minor problems at school, paused a moment and then
went on for a while with his trivia. The therapist was quite
aware of his conflict over mentioning a name in front of a
patient, and that this was an unusual thing for him to do.
The situation had appeared too urgent to wait-or was it,
he wondered? In the absence of any manifest or latent
meaningful associations from the patient, he asked Mr.
K.A. what the conversation had brought to his mind.
The patient at first said, "Nothing." He then paused
Therapist's Reactions to the Patient 367

and added that he guessed that he had wondered who had


called and who it was that the therapist had mentioned.
He paused again; the therapist asked if Mr. K.A. had
thought that he had named a patient. The patient immedi-
ately said that he had. The therapist then clarified the
situation: the name was not that of a patient-he would
never under any circumstances violate such a confiden-
tiality-but a co-worker, and the information was urgently
needed or he would not have mentioned even him. The
incident may have evoked mistrust in the patient, he
added, but it did give him (the therapist) a chance to
clarify his stance on such matters.
The patient began to talk fluently for the first time in
his treatment: he had been uncomfortable being seen at
the clinic where his father was active. The latter had actually
been involved in his son's first therapy and discussed his
sessions with the therapist at this clinic; confidences had
been violated repeatedly. In addition, his father, in his own
work, had often violated the confidences of his clients; this
behavior was now detailed by Mr. K.A.
In subsequent sessions, the patient felt quite relaxed,
was very verbal, began to report dreams and fantasies,
and to work with his problems in a more productive way.

This is a remarkable vignette with a striking outcome. There are


a few points I want to make:
1. The therapist's self-awareness about the unusual aspect of his
behavior was crucial in detecting this countertransference problem.
He recognized it and changed his stance immediately.
2. The therapist later analyzed his behavior and in discussing it
with me (not with the patient), felt that he was motivated by some
annoyance at the patient's secretiveness. He also wondered if there
was something constructive in his unconscious infraction, which was
actually relatively minor and not a violation of a confidentiality. If
it had been the latter, we must wonder if the therapist could ever have
resolved the problems it would have evoked in this patient.
The therapist wondered if he unconsciously sensed that it would
take an actual provocation to get this patient to open up. Perhaps,
368 THE PATIENT-THERAPIST RELATIONSHIP

but I caution the reader against consciously or unconsciously pro-


voking patients in this way. The next time it might prove permanently
disruptive; these are delicate matters.
3. The acknowledgement and clarification of the error established
this therapist as truly different from the patient's previous therapist
and father, whom he rightfully mistrusted. A major resistance and its
underlying basis was then quickly worked through for the moment.
I suspect that it was both the reassurance of the therapist's ability to
keep confidences, and his obvious honesty and self-awareness that
evoked the patient's consequent trust. This patient obviously needed
a concrete experience with which he could establish such differentia-
tions.
Consider now this vignette:

Mrs. K.B. was a married woman with three sons who


was in psychotherapy because of several recent and dis-
tressing affairs; she had a moderate narcissistic character
disorder. She had developed a strongly erotized trans-
ference to her therapist, with conscious seductive wishes
based, in part, on earlier seductions by her father, Much
of this was worked through and resolved in the first
months of her therapy.
In a session soon after the therapist's summer vaca-
tion, the patient was discussing her seductiveness with her
son and the anxieties it seemed to be evoking in him. When
the therapist confirmed this with material from previous
sessions, Mrs. K.B. went on to describe a conversation
with a friend who knew the therapist: The friend teased
her about where the therapist had vacationed and with
facts she knew about his family-not telling her the infor-
mation, however. The patient pleaded and the two went
back and forth playfully. The therapist smiled as he list-
ened. The patient said that she was angry that the therapist
would not see any of her sons, and went on to link her
involvement with them to her father's seductiveness with
her. She had dreamt of being in a mental hospital and
seeing the therapist undressed. Finally, she mentioned an
ungratifying sexual experience with her husband that week.
Therapist's Reactions to the Patient 369

In the next hour, the patient reported dreaming of the


therapist, who was nude on a toilet in a courtyard. Some-
one was discussing how many children he had. The court-
yard was associated with her father. In the session, she
focused on her problems in establishing adequate bound-
aries with one of her sons, with whom there had been some
sexual byplay. She had realized how seductive she had
been with him and had begun to take measures to control
it. She felt that the dream had something to do with the
previous session.
Rather than relate the "transference" fantasies to the
separation, which probably, indeed, was a secondary
factor, the therapist connected the patient's dream to his
having smiled in the previous session. He pointed out that
just this slight indication of amusement or pleasure, which
he recognized as inappropriate, was enough to stimulate
her manifest dream. He then linked this response to her
relationship with her sons, demonstrating to her how
sensitive people are to the slightest hint of seductiveness
and how she had been involved in mutual, unconscious,
seductive byplay with them.
The patient simply repeated much of what the thera-
pist had said. She then described sexual fantasies about
her sons and rape fantasies she had imagined that week.
She felt guilty, but was trying to change things. She liked
the therapist, and felt he understood her.

I have used this vignette in which the confirmation of the thera-


pist's intervention was rather indirect because it illustrates some
important points:
1. With highly sensitive patients, such as those prone to erotized
transferences or narcissistic disturbances, a very slight indication of
excessive involvement is sufficient to evoke strong responses. The
therapist must therefore be quite in tune with any such reaction on
his part, lest the patient's reaction snowball.
2. In this instance, the therapist was aware that he had experi-
enced some undue pleasure in the patient's pursuit of him. He was,
therefore, prepared for the dream that followed. The problem with
370 THE PATIENT-THERAPIST RELATIONSHIP

boundaries was clearly his and the patient had vividly portrayed
how such reactions are experienced on deeper levels by patients with
this kind of pathology. In her unconscious fantasies. the therapist
had exposed himself to her seductively, as her father had in his own
ways, and much as she had to her own sons. He had participated
in a mutual acting out and transference-countertransference grati-
fication, and if therapy was to continue on a sound basis, this had
to be corrected.
3. In this instance, the therapist's self-awareness and inner
change, and the patient's material and the unconscious fantasies
and perceptions reflected in it, both pointed to the countertransfer-
ence problem. The therapist's smile had evoked the sequence; the
patient's personality determined the form of her response. Whether
more subtle ongoing seductiveness by the therapist could have con-
tributed to this sequence is a moot question.
4. The countertransference reaction was handled rather straight-
forwardly, and in keeping with the principles established in this
section. Without the therapist's corrective self-awareness and inter-
ventions, a secret and corrupted therapeutic misalliance would have
been established as part of his relationship with this patient. Given
her sensitivity to such ties, the result could have been an undermining
of the therapy and a return to the erotized "transference" at the
therapist's invitation. The vignette shows how even minor counter-
transference responses can evoke major reactions in patients.
What if the therapist had missed this countertransference problem
and its consequences? He might well have repeated it. Would this
impair or totally undermine the treatment? What might happen?
This leads us to an important, virtually unexplored issue: the indi-
cations for referral of a patient to another therapist, especially when
the therapist has unresolved countertransference problems. (I shall
discuss other aspects of this problem in Chapter 25; see also
Greenson, 1967.)

REFERRALS OF PATIENTS BECAUSE OF UNRESOLVED


COUNTERTRANSFERENCE PROBLEMS
This is among the most difficult and unexplored issues in all of
psychotherapy. Because of the difficulties in collecting definitive
Therapist's Reactions to the Patient 371

relevant material, I have very little clearcut data on which to base


my discussion. I shall, however, use the vignettes available to me
as a starting point for a brief discussion of some guidelines and
principles.
I have not myself, nor has any therapist that I have supervised,
found a clinical situation where the patient's therapist had decided
that an unresolved problem within himself made it virtually impos-
sible for him to work with and help the patient, and referred the
patient to another therapist. I have, on the other hand, observed all
too many therapies in which repetitive countertransference problems
were so prominent that virtually no effective insight was offered to
the patient in an entire year or more, and major, pathological mis-
alliances predominated. The therapists involved had difficulty in
acknowledging their own problems, and the consequences for the
patient and the therapy. This makes recognition of the indications
for referrals on this basis an exceedingly difficult matter. Yet we can
develop some leads and extend our understanding of therapeutic
situations in which the patient's reactions point toward unresolved
problems in the therapist and referral should be considered.
I shall begin with several instances in which the patient, rather
than the therapist, made a switch in therapists. I do not mean to
imply that this is a reliable criterion of difficulties in the therapist. It
mayor may not reflect countertransference problems, though it
most often does; contrariwise, the fact that a patient remains in
treatment does not in any way negate significant countertransference
problems in the therapist-there are all too many "unholy" mis-
alliances between therapists and patients.
In the cases that I will cite, the patient's response occurred after
I had, as a supervisor, repeatedly detected major errors by, and
appararent countertransference difficulties in, the therapist. In these
instances, the patient left therapy rather than find neurotic gratifi-
cation in the therapist's pathologically motivated interventions.
Most of the time this was, as we shall see, out of fear of the therapist,
though occasionally it was from recognition that help and under-
standing simply were not forthcoming.
I have already described one such dramatic flight from psycho-
therapy, in the case of Miss I.H., (pp. 131 ff.), and we may recall
372 THE PATIENT-THERAPIST RELATIONSHIP

that she sought further therapy from another therapist. The reader
may wish to review this material as well as that of Mr. J.R. (p.
343), who directly asked to be referred to another therapist. To these
examples, I shall briefly add the following:

Mrs. K.C. was a young woman with a severe character


disorder, who was depressed and confused about her
marital situation; she was separated from her husband,
but uncertain whether to obtain a divorce. In her sessions
with her therapist, the latter repeatedly missed material
related to her unconscious fantasies, especially those that
reflected intensely castrative and envious feelings toward
her husband. Genetic material related to similar feelings
toward a younger brother and her father was also missed.
Instead, the therapist repeatedly intervened about reality
issues in a hostile, provocative, and teasing manner. On
the surface, it was apparent that he was angry with the
patient and unable to resolve it. He finally informed me,
as his supervisor, that he was about to be divorced him-
self and was having great difficulty separating his feelings
about his wife from those about this patient. Mrs. K.C.
left treatment at this point, feeling that she was getting
nowhere with her problems.

Patients who leave therapy give us a number of clues to the


referral problem. Since patients take flight from therapy for many
reasons (see also Chapter 25), I shall restrict my observations here
to premature terminations where the supervisor of the case-or the
therapist himself-observed before the termination repeated errors
and other indications of clearcut countertransferences.
1. If we review such therapeutic situations, we find that patients
unconsciously perceive the therapist's countertransference on many
levels. These usually unconscious awarenesses will always be reflected
in their associations and be expressed in derivative form (see Langs,
1973). Such material, along with self-awareness, can serve as initial
warnings of special difficulties with a particular patient.
2. By and large, it is when the countertransferences are repetitive
and resolved that patients often will leave therapy.
Therapist's Reactions to the Patient 373

3. Empirically, very few patients leave a therapist whose counter-


transferences are interfering in a major way with the development of
insight and are creating a pathological misalliance. Many patients
find gratification of their own infantile, neurotic wishes in the infan-
tile-neurotic beh'avior of their therapists. They continue indefinitely,
though of course without resolution of their neurotic problems; a
static and interminable treatment situation prevails. Among such
misalliances, those of a mutually seductive or sadomasochistic
nature (therapist attacking patient, or at times, the reverse) are rather
prominent. I have described many such misalliances already (see
The Index of Clinical Material) and remind the reader especially
of Mr. J.O. (pp. 336-38), who admired his attacking therapist, with
whom he could identify in order to deny his own fears, and justifiably
attack in return and even feel superior.
4. It follows that the therapist must constantly reassess the
status and progress of each therapy, as well as his relationship with
each patient. I have attempted to define indicators by which he can
recognize pathological therapeutic alliances and stalemated therapies
that are gratifying the neurotic needs of both the patient and the
therapist. Threats from the patient to leave treatment always call
for prime consideration of countertransferences.
5. The greatest problem in these situations is that of blind spots in
the therapist's awareness of a major countertransference difficulty.
I have observed such repetitive difficulties and the failure to recognize
them; proper monitoring of one's therapeutic work and inner feel-
ings can minimize these difficulties.
6. In these countertransference-based stalemates or misalliances,
it is best for the therapist to discover and resolve his countertrans-
ference difficulties, rather than to refer the patient. The point at
which the situation must be viewed as hopeless is difficult to define
(see below); however, such referrals are always traumatic and leave
scars-they should be made only when no other recourse is
possible.
7. There are many therapists who work at a level of general
competence, but get into unresolved difficulties with a particular
patient-as did Mrs. K.C.'S therapist. The patient usually is identified
with a person in the therapist's present or past life who is the source
of marked conflict or anxieties. These problems are usually more
374 THE PATIENT-THERAPIST RELATIONSHIP

readily sensed, and here, too, it is best if the therapist can then
analyze and work through such difficulties on his own.
8. There are in some instances immediate indications for referral
of a patient. Any attempt by the therapist at physical or open verbal
seduction or attack is the most obvious. Others to be considered
include conscious, unresolved sexual wishes toward a patient or
anger, rage, and dislike; awareness of repetitive errors and difficulties
with the patient's material; and an inability to alter a disturbed
therapuetic misalliance with the patient-e.g., repetitive arguments
or mutual seductiveness. In addition, a therapist's repetitive, sanc-
tions or promotions of corrupt behavior and acting out on the part
of the patient, or even a single such dramatic and conscious act,
constitute serious technical errors, and should lead to consideration
of referral. Here, much depends on the therapist's ability to change
himself and his stance, and to help the patient truly resolve the mis-
alliance involved. In all of these situations, there may be an unre-
solved countertransference problem that undermines any possible
lasting insight and constructive inner change in the patient.
Beyond these open and blatantly unresolved indications for
referral are those that are more subtle, though just as crucial, and
those of which the therapist may be unconscious, though I hope
that he can detect them in the various ways presented here. Any
persistent countertransference that gratifies the patient's neurosis or
undermines the therapeutic alliance and process may call for referral
of the patient. The final decision that the situation is unresolvable
or that the therapy has been irreparably contaminated demands
much honest thought; the therapist must neither act too quickly
nor deny that his sanctions and pathological behavior may have
rendered the patient essentially untreatable by him. Continued work
with the patient will often direct the decision; if the error-constella-
tion has been properly resolved and analyzed and the therapeutic
work becomes productive, referral is generally unnecessary.
9. When a therapy is stalemated or not going well, some thera-
pists refer their patients to another therapist for consultation. Others
seek consultation on their own. I shall comment briefly.
I have no experience with the former, but see many complications
for the therapy in it, and little chance that the patient could ade-
quately and usefully define the difficulties in the therapy to another
Therapist's Reactions to the Patient 375

therapist. On the other hand, my experience as a supervisor has shown


me that presentation in sequence of process notes will, in one or two
supervisory sessions with a skillful supervisor, almost always lead
to identification of the source of the problem. From there, it becomes
the responsibility of the therapist to determine the extent of the
damage to the therapy and whether it is reparable. Review with an
uninvolved supervisor can help here. Thus, I prefer consultation by
the therapist to consultation by the patient, and feel that it does less
damage to the therapy.

THE CONSTRUCTIVE UTILIZATION OF THE THERAPIST'S


SELF-AW ARENESSES
I shall conclude this chapter with a brief discussion of the
therapist's constructive utilization of self-awarenesses-be it of
technical errors, countertransference fantasies or behavior, or fan-
tasies appropriate to the therapy. Fantasies and feelings toward the
patient are inevitable. They range from appropriate reactions or
minor annoyances, boredom and distractions, to less appropriate-
countertransference-based-resentments and erotic fantasies. What-
ever the emotion or response, it should be used to understand the
patient. Even with essentially idiosyncratic, primarily countertrans-
ference-based fantasies in which the inner needs of the therapist
prevail, there is always a reality stimulus; other reactions may be
quite appropriate to the reality of the situation with the patient.
Thus, self-awareness always contains a clue to the fantasies, con-
flicts, and bahavior of the patient-the kernel of truth.
For example, resentment in the therapist suggests provocation
and anger in the patient; and boredom suggests obsessive defenses
and needs to be distant from the therapist. The therapist should use
these fantasies and inner experiences to understand the patient, not
by revealing his own thoughts and feelings, but by using them as
guides to the latent content of the patient's associations. In essence,
everything within the realm of the therapist's subjective awareness
can be utilized in the therapy, especially if his· own conflicts are not
disruptive and are fairly well worked out.
Remember too that awareness of one's own feelings and fantasies
-experiencing the patient-is one instrument through which the
376 THE PATIENT-THERAPIST RELATIONSHIP

therapist understands the communications directed toward him. It


is also among the reliable ways in which the therapist assesses the
patient's associations, especially those about himself.
Countertransference is certainly one of the most problematic
yet inevitable aspects of psychotherapy. Reasonably controlled,
these responses, when understood by the therapist, can be a vital
part of growth for both participants in the therapeutic process. There
are those who believe that the interaction of countertransferences
with transferences forms the unconscious core of the therapeutic
relationship, and this is undoubtedly so. Mastered, it is part of the
vital forces that lead to insight, inner change and maturation in the
patient, and in the therapist; unmastered, it undermines the entire
therapy.
VIII

THE PHASES OF

PSYCHOTHERAPY
23 The Opening Phase

In many ways, the opening phase of psychotherapy is an extension


of the initial session; the problems to which the therapist must be
particularly alert are elaborations of those already discussed in the
Part 2 of Volume I, The Initial Contact with the Patient.
I would define the opening phase of therapy as that period of
treatment, however long (and it may range from a week to many
months), during which the patient's emotional problems and need
for treatment are being defined, and a firm and positive therapuetic
alliance is being established. This phase continues as long as there
are major doubts about the patient's motives for seeking treatment
and willingness to explore his problems, and about the establish-
ment of a lasting alliance. I do not propose a clear distinction
between this phase and the middle phase of therapy, in which the
main focus is on the analysis of the patient's emotional problems;
clearly the two overlap. But while long-term therapy is in doubt or
the therapist-patient relationship not firmly established, it is best
to consider the patient to be in the initial phase of therapy; the
issues of that phase will predominate, and should continue to be the
main focus of the therapist's interventions.

379
380 THE PHASES OF PSYCHOTHERAPY

THE MAIN THERAPEUTIC PROBLEMS


Let us begin with some clinical material:

Mr. K.E., a young married man, arrived for his first


session five minutes late and began by saying that he did
not want to come to the consultation, but that his wife
had urged him to do it because she felt that he had sexual
problems. He and his wife fought constantly because she
nagged a lot, though, he added, he might also be con-
tributing to the battles. She was stupid, insincere and a
phony; he would ask her to leave him after some of the
quarrels, but she would not. He preferred oral sex and she
fought it; she became annoyed when he went to the
bathroom after relations.
The therapist mostly listened and then established the
ground rules for the therapy. The patient wanted to know
the conditions under which he would not be responsible
for a missed session and the therapist said that it would
be when they agreed in advance that his excuse was
important.
In the next hour, Mr. K.E. first asked if he could change
his hour or arrange two consecutive hours on the same
day, because of new pressures in his job. The therapist
could not shift the sessions. The patient then spoke at
length of his financial problems, angrily blaming his wife's
poor budgeting. The therapist eventually asked if he was
concerned about his fee. which had been set by other
clinic personnel, and the patient said that" he was: it was
set higher than he had been told initially, but he expected
a rebate. Asked if money was a problem for him, he went
on with a long list of financial injustices, including many
parking tickets, which he had never paid. He then des-
cribed problems with his fellow workers in which he
became angry and held grudges, but blamed them for his
difficulties. He again questioned the time of the sessions
and how therapy would work.
In the next two meetings, he expressed more doubts
The Opening Phase 381

about treatment and raised further questions about


whether he could make the sessions; for the rest of the
time, he continued to focus on the way others mistreated
him. A car accident led to the cancellation of the next
hour, and in the following week, the patient called to
terminate; he refused the therapist's invitation to talk
over this decision with him.

This vignette graphically illustrates just how brief and hazardous


the opening phase of therapy may be. There is little doubt that most
patients who leave treatment prematurely do so in the initial weeks.
Obviously, the therapist knows the least about the patient in these
first sessions, and yet he is faced with the greatest risk of premature
flight from treatment at this time. What can he do to lessen these
difficulties? In answering this, I shall make constructive criticisms
of Mr. K.E.'S therapist:
1. The therapist must recognize the hazards that exist and realize
that in every opening phase-without exception-there are very
real dangers that the patient will leave therapy. Anxieties about
treatment, resistances, and impairments in the therapeutic alliance
are usually at their height at the beginning of treatment, and often
a good deal of the basis for these hesitations and uncertainties in the
patient is unconscious or consciously concealed by him (see pp.
393 ff.).
2. From this, it follows that even in the very first session the
therapist must be alert to any clue to such resistances, fears of therapy
or thoughts of leaving (see Chapter 4). He must especially attempt to
identify patients who are likely to leave treatment prematurely (see
pp. 398 ff.).
In contrast to Mr. K.E.'S therapist, one must be prepared to
intervene and confront these resistances, and to interpret the under-
lying anxieties, conflicts, and fantasies to the extent that the material
from the patient permits. In discussing this tenet with him, Mr.
K.E.'S therapist said that he was waiting for the patient's patterns and
fantasies to emerge. We now see (and this was predicted) that if the
therapist delays his interventions with patients who are clearly
doubtful about therapy and ready to leave (Mr. K.E.'S first words
were: "I don't want to be here!"), he will most certainly lose the
382 THE PHASES OF PSYCHOTHERAPY

patient. Actually, one must be especially alert to such resistances and


use all of his resources as a therapist to understand and interpret
them.
3. In the opening phase of therapy, the main goal of establish-
ing a sound and firm therapeutic alliance and commitment to therapy
is pursued through:
(a) Existence of a proper therapeutic atmosphere and stance on
the therapist's part.
(b) Establishing a working relationship with the patient; silently
and actively indicating to the patient how therapy is carried on, and
the safety of, and freedom to communicate in, the therapeutic
situation.
(c) Defining and demonstrating the patient's problems and his
need for treatment.
(d) Detecting and analyzing early anxieties about, and resistances
to, therapy, including pathological-deviant-motives for seeking
therapy; these must be brought into focus and resolved (see pp.
390 ff.).
(e) Demonstrating to the patient the therapist's skills and ability
to be helpful; establishing trust and a sense of competency.
The general resolution of these tasks marks the entry into the
middle phase of therapy.
4. Problems with the therapeutic alliance and resistances against
treatment are of course present throughout therapy as actual or
potential issues, and the therapist must constantly be alert to deal
with'them whenever they arise. However, in the opening phase, these
problems are central and especially dangerous, and the therapist's
interventions should also focus on them. It is imperative to recog-
nize that the relative importance of the issues with which the therapist
is prepared to deal at different moments in therapy varies. Proper
timing and effective therapeutic work depend upon the therapist's
anticipation of this order of importance, complemented by his
preparedness to deal with acute crises or other foci of interest at any
given moment.
In the opening phase,