Psychoanalytic Engagement

The interactive dimension of the patient-analyst relationship received considerable attention in the early work of Ferenczi (1916, 1950, 1955) and Rank (1929) and also in the interpersonal literature, particularly in the writings of Sullivan dating from the 1930s. […] Attention to the analytic interaction is also evident in the writing of Lacan (1936, 1952, 1956, 1961), Winnicott (1947, 1963, 1969, 1971), Little (1951, 1957), Fairbairn (1958), Guntrip (1969) and Searles (1965, 1979)

Although these authors differ in terms of their theories of personality […] they agree that the analytic interaction constitutes a transactional field. I believe this has radical implications for a theory of technique.[…] We are forced to expand the traditional view of transference as the analytic “playground” (Freud, 1914) to recognize that transference and countertransference constitute an interlocking unity, and that all of the transactions in the immediate field of experience constitute primary analytic data. […] In the choice of whether to address the immediate transaction, and to what degree, or not to address it at all, the analyst exerts leverage on the way the relationship will evolve. […] 

The analytic transaction, by its very interpersonal nature, provides unique opportunities for new experiences. […] Focusing on the transactions between patient and analyst, and on what goes on affectively between (and within) each of them, as primary analytic data makes it possible to delineate what is being structured interactively in process. Styles and patterns of bonding, expectations, sensitivities and patterns of responsiveness including tendencies to collusion, or to carrying the emotions of the other can begin to be clarified. 

This allows for disavowed experiences to be reclaimed and for exploring the motivations for the prior disavowal in the context of a new sense of choice, competence, and responsibility. Emotionally significant associations to the past and memories of relevant historical material not available before often then begin to become accessible, allowing new perspectives on the past. This in turn, can open the possibility for a necessary and important process of mourning. 

[…] Many authors have also noted that with more disturbed or primitively organized patients the analyst’s active responsiveness may be essential if any kind of therapeutic change is to be achieved.

 […] Winnicott (1947) focused on the importance of knowing that one can evoke the analyst’s hatred so that one can work through one’s own, and of the opportunity to experience that it is possible for the analyst to withstand and survive one’s aggression[…] Winnicott also notes that the opportunity to discover that one has impact, and what that impact is enable the patient to clarify the limits of his or her assumed helplessness as well as his or her assumed omnipotence in relation to the analyst and that the unflappable analyst may be useless when it would have been essential for the patient to know he or she is able to elicit the analyst’s responsiveness. […] I would also add that is also important to be able to explicitly acknowledge and address the interactive subtleties of what transpires affectively between patient and analyst, including the ways they connect and the ways they lose each other in real time and in real ways, as this shifts from moment-to-moment. 

Stern (1983) notes that certain categories of experience “can never even occur unless elicited or maintained by the actions of another and would never exist as a part of known self-experience without another (p.74) What I am stressing is that certain kinds of experiences simply cannot be achieved if the analyst is not affectively engaged and responsive in particular ways.

[...] Bird (1972) writes that there are times when “our not confronting the patient becomes in itself not merely an unfriendly act but a destructive one. By not confronting the patient with the actuality of the patient’s secret, silent obstruction of the analytic process, the analyst himself silently introduces even greater obstructions (p.249)

[...] There are also times when the analyst must take a stand and set limits to protect the relationship and the work from becoming unduly compromised. Nevertheless, I think that is is not just a matter of setting limits. What is also often crucial is demonstrating our commitment to the process and to the relationship despite the patient’s behaviour and despite our own reactions to it. 

[...]For some patients the new experience that the analyst is willing to engage with them even when it is risky and problematic can be profoundly meaningful. The opportunity this can provide to discover that it is possible to touch and be touched in a positive way, even in the context of negative interactions, and that it is possible to move through a toxic interaction and reach a positive outcome, can constitute an experiential kind of insight that throws old assumptions open to question. […] of course it matters how we engage affectively, how we work with what goes on affectively between patient and analyst and whether we deal with this explicitly and constructively.

Bregman-Ehrenberg, D (2012) Psychoanalytic Engagement In L. Aron & A. Harris (Eds.) Relational Psychoanalysis: Evolution of Process vol. 5, pp. 1-8

Transference & Countertransference Positions when working with Survivors of Sexual Abuse: 1) The Unseeing, Uninvolved Parent and The Unseen, Neglected Child.

We have found that there are eight relational positions, expressed within the four relational matrices, alternatively enacted by therapist and survivor in the transference and countertransference that repeatedly recur in psychoanalytic work with adult survivors of sexual abuse (p.167)

The Unseeing, Uninvolved Parent and The Unseen, Neglected Child

Whenever a child is sexually abused, someone’s eyes are closed […] One aspect of the internalized world of the adult survivor, then, is a relationship between a neglectful, unavailable parent and an unseen, neglected child.[..]. Within the transference-countertransference, the patient enacts either side or both sides of the relational matrix sequentially, while the therapist protectively identifies with and enacts the complementary role. 

Manifestations of this paradigm are varied.

A) At times the patient identifies with her parent and enacts the latter’s coldness, unavailability and rejection in the therapy sessions. The patient may be profoundly withholding, remaining silent for long periods, or she may respond minimally to queries or overtures from the clinician. When identified with the uninvolved parent, the patient may appear bored, disdainful, narcissistically preoccupied, hostile to the interpersonal engagement sought by the clinician. During these periods of identification with the neglectful parent, the patient treats her own vulnerability, emotional needs and affect states with the same cold neglect that she heaps on the therapist.[…] The clinician frequently countertransferentially takes on the role of the patient’s disowned self- representation of a neglected, unseen child. The therapist experiences herself as unwanted, unimportant, and utterly bereft of vital connection with the patient. The clinician may begin working very hard to reach the patient and when these efforts fail, as they once did for the child struggling to make contact with her parent, the therapist sequentially may feel frustrated, inadequate, enraged, and ultimately depressed. 

B)   In another enactment, the patient identifies with herself as a child and responds to the clinician as she once did, at least initially, to her parent. Here, the patient denies her own needs and feelings in order to care for the therapist. Certain that the only way to obtain emotional supplies from the clinician is to tend to latter’s perceived needs, the patient is solicitous of and, at least superficially, compliant with the therapist and the demands of the therapeutic situation. Associations may appear to flow freely, but, in fact, the patient “protects” the clinician from her deepest pain, rage and bereavement. She also is quite likely to “protect” the therapist from the memories of her abuse, much as she once shielded her parent from the reality of the sexual victimizations. During this period the therapist may collude with the relational matrix being enacted by not seeing the “false self” (Winnicott, 1960) aspects of the patient’s presentation. If this transference-countertransference configuration extends for some time, the patient is likely to become enraged at once again not being truly seen or heard. As she did when she was a child, the patient may split off rageful responses in order to maintain a tenuous attachment to the therapist/parent. Instead of expressing them in session, the patient may act out her rage in extra-therapeutic relationships or by engaging in self-destructive behaviours such as cutting, substance abuse, or promiscuous sex or she may become increasingly depressed. Within this relational matrix at play, the therapist may feel bored, annoyed, increasingly angry as she senses that the treatment is mired in apparent superficiality. […] 

C)  Finally, an overt to the therapist transference as an unseeing, uninvolved parent may develop, which the patient experiences the clinician as neglectful. Sometimes, the patient angrily and repetitively berates the therapist for somehow “missing” her; for not noticing, hearing, correctly interpreting, remembering feelings, behaviours, facts, dreams, memories the patient considers crucial. Here it seems that nothing the therapist does or does not do is “right” In this case the therapist is once again identified with a hostile parent who expected to be cared for by the child and who berated the patient for her ineptness in meeting the adult’s needs perfectly. […] Countertransferentially, the therapist, much to her or his chagrin may enact stupidity, forgetfulness, inadequacy. It is with such a patient that therapists uncharacteristically double-book a session, miss an “obvious” connection among associations or forget dream material. The clinician, again identified with spit-off aspects of the child feels panicky, stupid, frozen, and inadequate. She may begin to dread sessions with the patient. Once again it is important for the therapist to use the countertransference experience to gradually help make explicit the split-off terror of the patient and to refrain from self-protectively emotionally abandoning the survivor.

 The relational matrix of the uninvolved parent/neglected child is frequently the first transference-countertransference paradigm to emerge in the treatment.

Davies, J. & Frawley, M (1994) Treating the Adult Survivor of Sexual Abuse: A Psychoanalytic Perspective, United States of America: Basic Books