Efpp - Anastasopoulos, Evangelos Papanicolaou (Eds.) - The Therapist at Work

THE THERAPIST AT WORK
The EFPP Series
Editor-in-Chief: John Tsiantis

Associate Editors: Brian Martindale (Adult Section)
Didier Houzel (Child & Adolescent Section)
Alessandro Bruni (Group Section)
OTHER TITLES IN THE SERIES

• Countertransference in Psychoanalytic Psychotherapy with
Children and Adolescents
• Supervision and Its Vicissitudes
• Psychoanalytic Psychotherapy in Institutional Settings
• Psychoanalytic Psychotherapy of the Severely Disturbed
Adolescent
• Work with Parents: Psychoanalytic Psychotherapy with Children
and Adolescents
• Psychoanalysis and Psychotherapy: The Controversies and the
Future
• Research on Psychoanalytic Psychotherapy with Adults
Personal Factors Affecting
the Analytic Process
Edited by
Dimitris Anastasopoulos
Senior Editor
and
Evagelos Papanicolaou
Foreword by
Paul Williams
published by
KARNAC
for
The European Federation

for Psychoanalytic Psychotherapy
in the Public Health Services
and
The Cyprus Association
for Psychoanalytic Psychotherapy Studies
CONTENTS
ACKNOWLEDGEMENTS vii
EDITORS AND CONTRIBUTORS ix
INTRODUCTION
Dimitris Anastasopoulos xiii
FOREWORD
Paul Williams xxv
CHAPTER ONE
The analyst’s clinical theory and its impact
on the analytic process in psychoanalytic psychotherapy
Joachim Küchenhoff 1
CHAPTER TWO
A different perspective on the therapeutic process:
the impact of the patient on the analyst
Judy L. Kantrowitz 17
v
vi CONTENTS
CHAPTER THREE
Knowing and being known
Christos Ioannidis 43
CHAPTER FOUR
How does psychoanalysis work?
Imre Szecsödy 53
CHAPTER FIVE
Intersubjective phenomena and emotional exchange:
new considerations regarding transference
and countertransference
Gisela Zeller-Steinbrich 63
CHAPTER SIX
Constructing therapeutic alliance:
the psychoanalyst’s influence on the collaborative process
Maria Ponsi 83
CHAPTER SEVEN
The therapist is dreaming:
the effect of the therapist’s dreams on the therapeutic process
Gila Ofer 95
CHAPTER EIGHT
The healing work
of a practising psychoanalyst/psychotherapist
Claude Smadja 109
REFERENCES 129
INDEX 145
ACKNOWLEDGEMENTS
A
s the senior editor of this Monograph, I want to thank
foremost all the contributing authors for kindly accepting
to offer their high-quality papers. I want to express my
gratitude to Dr John Tsiantis for his constant encouragement and
help through the preparation of this book. I am also deeply in-
debted to my colleague and co-editor Dr Evagelos Papanicolaou—
who was also a co-chairman and the soul of the Cyprus Conference
of October 2000—for his persistent help and collaboration.
Of course, this book owes a lot to the Cyprus Association for
Psychoanalytic Psychotherapy Studies and to all my friends and
colleagues there, without whom it would not have been possible to
carry through the preparation of this Monograph.
From this place I also want to thank Karnac publications which,
under new management, are standing by the side of the EFPP and
are continuing the Monograph Series.
Last, but not least, I want to thank Miss P. Nikolaidou, secretary
of HIPP, for her consistent, kind, and effective help in the collection
of the material.
vii
EDITORS AND CONTRIBUTORS
DIMITRIS ANASTASOPOULOS[Greece], MD, is an Adult and Child Psy-

chiatrist working in Athens. He trained in adolescent psychiatry
and psychotherapy at the Tavistock Clinic, London, and is a train-
ing psychotherapist for adult and adolescent psychotherapists in
Greece. He is a member of the Executive Committee of the Hellenic
Association of Child and Adolescent Psychoanalytic Psycho-
therapy (HACAPP). He is vice-chairman of the EFPP.
CHRISTOS IOANNIDIS[United Kingdom], MD, is a psychiatrist and

a member of the Tavistock Society of Psychotherapists and the
Group Analytic Society (London). He worked until recently as
Consultant Psychotherapist in St. Albans Hospital and has now
returned to Greece.
JUDY L. KANTROWITZ [United States] is a Training and Supervising

Analyst at Boston Psychoanalytic Institute and an Associate Profes-
sor at Harvard Medical School (part-time faculty). She is the author
of The Patient’s Impact on the Analyst and of papers on the patient–
analyst match, clinical impasses, supervision, and outcome of psy-
ix
x EDITORS AND CONTRIBUTORS
choanalysis. She is serving her third term on the Editorial Board of

the Journal of the American Psychoanalytic Association.
JOACHIM KÜCHENHOFF [Switzerland], MD, is Professor of Psychiatry

and Psychotherapy at Basel University; he is Chairman of the
Department of Psychotherapy at the Psychiatric University Hospi-
tal Basel; he is supervisor and training analyst at the Psychoana-
lytic Institutes of Heidelberg and Basel and member of the German
Psychoanalytical Association. His main scientific interests include
psychotherapy research, psychoanalytic concepts, interdiscipli-
nary research in philosophy and psychoanalysis, and psychoana-
lytic psychosomatics.
GILA OFER [Israel], PhD, studied English and French literature at the
Hebrew University and then clinical psychology at Tel-Aviv Uni-
versity. She has a private practice in individual and group psycho-
analytic psychotherapy, and currently is an advanced candidate in
psychoanalysis and in group analysis. She is the Chairperson of the
Tel-Aviv Institute of Contemporary Psychoanalysis, a lecturer and
supervisor in the Program of Psychoanalytic Psychotherapy, Bar-
Ilan University, and a lecturer in the School of Social Work, Tel-
Aviv University.
EVAGELOS PAPANICOLAOU [Cyprus], MD, is a psychiatrist working in

Nicosia. He is a trained psychoanalytic psychotherapist and a
founding member of the Cyprus Association for Psychoanalytic
Psychotherapy Studies.
MARIA PONSI [Italy] has been working as a psychiatrist for about

fifteen years in the psychiatric services of the Italian National
Health Service (Mental Hospital, Clinics and Emergency Depart-
ments). Since 1987 she has been only in private practice as a
psychoanalyst (member the Italian Psychoanalytic Society) and
psychotherapist. She is on the European Editorial Board of the
International Journal of Psycho-Analysis.
CLAUDE SMADJA [France] is a Psychoanalyst, an honorary member of

SPP, Medical Director of the Hospital Pierre Marty of the Institute
of Psychosomatics of Paris, and Co-director of Revue Française de
Psychosomatique.
EDITORS AND CONTRIBUTORS xi
IMRE SZECSÖDY [Sweden], MD, PhD, is an Associate Professor and

has been a member of the Swedish Psychoanalytic Society since
1967, a training and supervising analyst, former director of the
Swedish Psychoanalytic Institute, former president of the Swedish
Psychoanalytic Society, and former Vice-President of the European
Psychoanalytic Federation, a member of the EPF Working Party
on Psychoanalytic Education, and a member of the Research Advi-
sory Board of the IPA. He has conducted extensive research into
supervision and the learning process and has long experience of
conducting formal training of supervisors. He has published exten-
sively.
PAUL WILLIAMS [United Kingdom] is a Member of the British Psycho-

analytical Society, a Professor in the School of Community Health
and Social Studies, Anglia Polytechnic University, and Joint Editor-
in-Chief of the International Journal of Psycho-Analysis. He has writ-
ten papers and books principally on borderline and psychotic
conditions and recently was the editor of Terrorism and War: Uncon-
scious Dynamics of Mass Destruction, published by Karnac.
GISELA ZELLER-STEINBRICH [Switzerland] works as a psychotherapist

and psychoanalyst in Basel. She is a lecturer and supervisor in
psychoanalytic training institutes, President of the EFPP Switzer-
land Child & Adolescent Section, Vice-Chairman of the Educa-
tional Board at the Institute of Psychoanalysis in Cologne, and is on
the Council for the CHARTA Postgraduate Studies of Psycho-
therapy Sciences in Switzerland. She has published on different
psychoanalytic topics.
INTRODUCTION
O
ver the last few years there has been an increasing amount
of literature regarding the therapist’s participation in
therapy (apart from references concerning countertrans-
ference). Having gained understanding of countertransference as
an inevitable phenomenon and a therapeutic instrument, perhaps
the next step is connected with the inevitable influence of personal
factors on the development and shaping of the therapeutic relation-
ship. These observations may lead to the formulation of what is
known in psychoanalysis as intersubjectivity theory.
The analyst was initially considered more as an observer of the
patient than as a participant in the therapeutic process. As the
importance and inevitability of countertransference was becoming
more and more accepted, there was a significant shift towards part
played by the analyst, viewing him/her as a subject influenced by
his/her inner world and sharing the analytic process.
I think this process was initiated by the realization of the im-
pact that life events had on the analyst’s psyche and attitude. It
seemed as if there was a request for balance between the so-called
therapeutic neutrality and the knowledge and recognition that the
xiii
xiv INTRODUCTION
analyst is no longer a totally unaffected, immutable mirror before

the patient; between the recognition of the therapist’s personal,
human characteristics and his/her ability not to get emotionally
involved to such an extent that he/she would discharge his/her
own psychic tensions in the patient.
Thus, situations such as pregnancies, deaths of loved ones,
social or natural upheavals or disasters, or illnesses of the therapist
started to become subjects of elaboration as inevitable factors that
somehow affect the therapist and the therapeutic relationship
(Gerson, 1996; Gold, 1999). Once this reality was acknowledged,
the next step was to comprehend that the influence of these factors
was far from destructive. On the contrary, the inability to recognize
them could have a negative impact, in the sense that it would
inevitably lead to a defensive attitude of the therapist and the
development of blind spots and of a certain rigidity in the thera-
peutic process.
Furthermore, I think there was a greater clinical and theoretical
implementation and recognition of the influence on the therapeu-
tic relationship of characteristics of the therapist such as gender,
culture, and ideological and theoretical views and the therapist’s
personality as a whole. Exploring the therapist’s role, we have
now reached a point where we can view the therapist–patient re-
la-tionship as something unitary, non-symmetrical, yet equal even
in terms of unconscious emotional vibrations. This inevitably af-
fects technique, the use of the transference–countertransference as
something unique (Feldman, 1997; McLaughlin, 1991), the formula-
tion of interpretations (Feldman, 1997; Loewald, 1986), the focus of
supervision (Aron, 1999; Berman, 2000), and so on.
Since the multiple experiences concerning personal differences
and personal involvement—which I believe every analyst or psy-
choanalytic therapist has—have been somehow deliberated from a
position of guilt, we have had the opportunity to have a fresh look
and a new elaboration of therapy on a theoretical and technical level
(Goldberg, 1994; Levine, 1994; Schafer, 2000; Viederman, 1991).
This led to articles on the importance of therapist–patient
matching as a request for harmony in unconscious and conscious
communication. In this regard, gender differences, particularities,
style, personality, character, theoretical school, and the like are
taken under consideration as factors involved in the therapeutic
INTRODUCTION xv
approach or choice of therapist. Naturally, all this affects not only

the course but also the outcome of the therapy (Barratt, 1994;
Grossman, 1995; Kantrowitz, 1992, 1993, 1995, 1999; Renik, 1993).
Within this framework, it could be worth wondering what
motivates each therapist in his/her choice of profession with re-
gard to the unconscious elements, in addition to the appealing
elements of the profession. Furthermore, the widely accepted
motto “all therapists are not suitable for all patients”, and vice
versa, comes to mind in the sense that there are areas of maximum
effectiveness and success for each therapist as well as blind spots in
his/her mental life which do not allow him/her to be effective
enough with some kinds of patients or psychopathology.
I think we need to consider what attracts any of us to this
“impossible” profession of analyst or psychoanalytic psychothera-
pist. It may, of course, include a variety of interests such as the
opportunity to offer oneself, to give emotionally, to support those
in need, the attraction of in-depth knowledge, scientific explora-
tion, psychic sharing, and so many other interests—all of which,
however, are included in the role of every clinician. At the same
time, it is an especially binding and demanding profession, one
that requires many years of postgraduate studies. Its satisfactions
are very indirect, and one becomes the recipient of great mental
pain. I think that our daily life as therapists—which we seem to
take very much for granted—contains this mixture of satisfaction
and pain that constitutes a crucial element of our work.
In 1982, the Organization for Promoting Understanding in Soci-
ety (OPUS) held a workshop, partly subsidized by the Society for
Psychotherapy, at the University of London with the participation
of 45 psychotherapists from different societies and skilled consult-
ants experienced in working with group dynamics in the work
environment (from the A.K. Rice Institute in the United States and
the Institute of Human Relations of the Tavistock Clinic in Lon-
don), using psychoanalytic theory along with that of open systems.
The aim was the definition of professional choice and identity in
psychotherapists (Miller et al., 1982). Among other interesting con-
clusions, the following were found: (a) the majority of therapists—
if not all—were dealing with damaged parts of themselves, and, in
consequence, they are curious and eager to help (p. 13); (b) the need
to treat this part of themselves constitutes a positive motive for
xvi INTRODUCTION
psychotherapists, provided that it is utilized in the service of the

patient and not at the patient’s expense (p. 23); and (c) conse-
quently, “it is logic to expect that the therapist will be especially
effective at working with identifiable subsets of patients whose
damage in some way resonates with that of the therapist” (pp. 24–
25).
Based on these observations, which I personally embrace and—
in clinical practice—see them as applying to many younger col-
leagues whose professional development I have had the privilege
to observe, I would like to add a few more thoughts.
Undoubtedly, in order to be attracted to the analyst’s or psy-
choanalytic therapist’s profession, certain qualities are required.
Among others, there is a basic need for an ability to derive pleasure
from thought and especially from thinking about emotions, frustra-
tion tolerance, good contact with one’s personal feelings, and an
aptitude for seeking meaning in depth (in other words, a need for
“epistimophilia”). Since the therapist him/herself is the instrument
as well as the means of therapy, self-knowledge becomes more
important than technique. This is also illustrated by our acknowl-
edging the importance of basing the evaluation and selection of
suitable candidate trainees on their personality characteristics
along with the importance attributed to the therapist’s personal
analysis and individual supervision. I think that if we consider this
issue in terms of the therapeutic process, we could, according to
Levine (1994), discern this process in three parts:
1. the analyst’s application of theory and technique;

2. the analyst’s personally motivated responses to the patient or
the analysis, including the analyst’s transference and counter-
transference;
3. the analyst’s capacity to allow him/herself to participate un-
consciously via feelings, fantasies, and enactments in actualiza-
tion of aspects of the patient’s inner world and internal-object
relationships, as this may be described in the patient’s projec-
tions of “role responsiveness” or the “container” function.
In these three parts, which must co-exist, we can also discern the
extent of personal participation and interchange between therapist
and patient that would be difficult to imagine as being under the
INTRODUCTION xvii
therapist’s total control, especially as far as his/her personal affect-

laden experiences are concerned.
Hopefully, the area of the therapist’s primary damage (or
trauma or conflict) also constitutes the area better explored and
with maximum sensitivity. Of course, it cannot be inferred from
this that the more extensive the damage the wider the range of
capacities available to the therapist, since this is opposed to the
necessity of a stable/healthy-enough psychic structure and endur-
ance that will enable the therapist to interact and contain not only
his/her own psychic suffering but also that of the patient.
I believe that this process never stops—that to some extent
every patient’s therapy results in the therapy of a certain part of the
therapist’s psyche as well, thereby enriching and strengthening the
therapist. In some way, this mutuality of therapeutic willingness is
described by Searles (1975). Klauber (1972) notes that the therapeu-
tic effectiveness of the interpretation offered to the patient also
functions in the analyst’s direction, reducing tension and evoking
emotional and intellectual clearance and transformation. Therapy
is somehow a mutual process, though not of equal weight, meaning
that the patient’s needs weigh much more.
This is especially well-illustrated in severe psychopathologies,
where patients change along with a part of the therapist (Kantro-
witz & Paolitto, 1990). Under normal circumstances, after the ter-
mination of therapy, neither the therapist nor the patient is exactly
the same person, though this is far more striking in the patient and
therefore more easily observable. I think this is what Goldberg
(1994) points out in his article. It is common knowledge that we
need to treat. We need our patients. I have often witnessed thera-
pists under extremely stressful conditions that they have overcome
partly supported by their therapeutic function without this prov-
ing to be at the expense of the quality of their work—rather the
opposite. On the other hand, sometimes one wonders about some
of colleagues how such a good therapist can do so poorly in his/her
personal life. It seems that the psychotherapist’s or psychoanalyst’s
therapeutic function is a privileged area for expressing his/her
good part with particular insight and effectiveness in these areas
that touch upon his/her own painful experiences.
Let us consider the procedure of mutual selection between
therapist and patient—wherever and whenever such a possibility
xviii INTRODUCTION
exists. During this process, one has the chance to observe how
mutual needs and motives can function unconsciously, both from
the very beginning and during the course of therapy (Viederman,
1991). What makes psychoanalytic therapy feasible is perhaps ex-
actly this common place of traumatic experiences. This place be-
comes the “intermediate space” between the therapist and the
patient (subject–object) meant for the creation of the “analytical
third” (Ogden, 1994b) or the “analytic object” (Green, 1975) which
will enable the patient to unfold experiences unconsciously, feeling
that the therapist offers as a space of containment his/her own
experiences that he/she had the chance to know and elaborate at
an earlier stage when transforming him/herself into a therapeutic
instrument. Both subjects are expected to come out of this two-
person encounter having gained certain profits and changes. As far
as the therapist is concerned, each therapy can be a process of
renegotiation and reparation of the therapist’s own psychic dam-
ages, resulting in his/her enrichment with new elements or, in
other words, what Levine (1994) describes as unconscious drawing
of satisfaction from the therapeutic process.
Although a good-enough therapist is capable of working effec-
tively with a wide range of psychopathology, nevertheless the
depth and insight of his/her work may vary, being especially
developed in relation to those patients with whom he/she shares
one or more common areas of psychic conflict, trauma, or damage
(on condition that these have previously been successfully ana-
lysed). Besides, this affects the therapist’s way of dealing with the
patient’s material, the threads the therapist chooses to concentrate
on, or those of them that will stir deeper feelings in the therapist.
The above-mentioned personal thoughts motivated me, along
with my distinguished colleague Evagelos Papanicolaou, to pro-
pose to the EFPP that the Fourth Congress of the EFPP Adults
Section should be “The Psychotherapist’s Influence on the Process
and Outcome of Psychoanalytic Psychotherapy” (held in Cyprus
from 13 to 15 October 2000). The contributions included in this
book grew out of the proceedings of this Congress, with the addi-
tion of Judy Kantrowitz’s and Imre Szecsödy’s chapters as they can
offer something significant to the discussion on the development of
psychoanalytic theory and practice.
INTRODUCTION xix
The opening chapters of this Monograph focus mainly on the

theoretical elaboration of the factors inherent in the therapist that
could affect the process of psychotherapy. Subsequent chapters are
more clinically oriented.
Joachim Küchenhoff, in his extremely interesting and compre-
hensive contribution, explores the levels at which the analyst’s
theoretical basis affects his/her therapeutic function. Küchenhoff
delineates how the theory includes the analyst’s personal philoso-
phy (i.e. the more or less well-formulated ideology that constitutes
the basis of understanding of the various phenomena); general
attitude towards life and therapy; the psychoanalytic background
(or school, we could say); clinical metapsychology; and the con-
scious and unconscious activity of formulation of theoretical con-
structs which encompasses various particular parameters, such as
the subjective capacity for thought, the working out of ideas, or the
capacity for inductive thought. Küchenhoff notes how much the
“data” can be distorted or even created by the therapist’s participa-
tion and elaboration and wonders to what extent this could raise a
demand for a more sophisticated level of theoretical elaboration
and clarification so that the framework could limit the inevitable
distortions. He also reviews the function of interpretation which
itself forms new meanings and situations. He ends by proposing
Derrida’s philosophy of deconstructivism as a framework that
could further promote the elaboration of the psychoanalytic
thought, avoiding theoretical dogmatisms.
In her chapter, Judy Kantrowitz considers the patient’s influ-
ence on the analyst. Kantrowitz is well-known, in particular, for her
work concerning the analyst’s style or the therapist–patient match-
ing and its effect in the therapeutic process. She makes an initial
review of the literature concerning the notion that the analyst him/
herself is subject to some kind of therapeutic alteration during the
analysis; furthermore, she describes a study carried out in two
large samples of analysts in order to explore this issue. The study
compares one group of very experienced analysts with a second
group of analysts who had recently completed their training.
Among other interesting findings, Kantrowitz points out that the
areas of revival of psychic conflict or concern in the analyst are
determined mainly by their coincidence with similar areas in the
xx INTRODUCTION
patient’s mental life. She notes the intensity of countertransference

feelings and the protective factors that help analysts to deal with
and utilize their experiences and enactment in a therapeutic way.
The self-knowledge gained during the analyst’s own analysis as
well as the therapeutic setting itself are included in these protective
factors. Naturally, things are neither simple nor easy, and the
emotional vibrations and reactions are hardly safely contained
within definite limits. The therapeutic experience is a testing ex-
perience for the therapist as well, especially as far as the non-
interpretative elements of the analytic work and relationship are
concerned. Kantrowitz illuminates in a very perceptive way the
entire process of co-formulation and mutual influence and change
during the analytic procedure. In my opinion, her chapter is very
persuasive with regard to the existence of processes of reparation
and maturation in the therapist that perhaps constitute a crucial
unconscious motive in their choice of profession.
In his interesting chapter, Christos Ioannidis explores what is
created in the therapist–patient interaction which he considers to
be the focus of psychoanalytic work. He proceeds to point out that
the analyst constantly reveals him/herself indirectly or directly
and offers him/herself more as a subject than as an object. He
postulates the mutuality of influence during the therapeutic pro-
cess and explores the analyst’s defences and resistances, along with
the various roles that the therapist is evoked to perform based on
his/her personal experience and the relations with his/her internal
objects, under the influence of the phenomena of transference and
countertransference. Ioannidis concludes by arguing that psycho-
analysis has to study further the mutual covering of the two sys-
tems of unconscious which meet each other in psychoanalysis or
psychoanalytic psychotherapy on the grounds of a common con-
scious pursuit.
In his brief yet very dense contribution, Imre Szecsödy under-
lines the need to study the therapist’s subjectivity, which inevitably
filters the entire material of the therapy, leading to a selective
choice and focus. He refers to the importance of the influence
imposed on the therapy by the personality of both participants and
the necessity of the therapist’s being aware of his/her reasons for
engaging in this work as well as the limits of his/her capacity.
Obviously, Szecsödy derives this from his wide experience as a
INTRODUCTION xxi
supervisor and from his work on the mechanisms of learning in

psychoanalytic supervision. Furthermore, he uses Fonagy’s con-
cept of reflective functioning in order to explain the phenomena
created in the therapeutic relationship. Stressing the need for re-
search development in psychoanalysis, he briefly describes a re-
search project that has been developed in order to study the
psychoanalytic process and outcome among psychoanalysts in
Amsterdam, Helsinki, Milan, Oslo, and Stockholm.
Gisela Zeller-Steinbrich’s chapter in some way constitutes a
passage from mainly theoretical to more clinically oriented contri-
butions and, in my opinion, it combines both areas very success-
fully. She initially reviews the conventional ideas concerning
transference–countertransference and therapeutic neutrality in
order to connect them with the acting-out phenomena, and she
poses interesting questions regarding their role and impact on
psychotherapy in relation to the therapist’s participation. Zeller-
Steinbrich goes on to consider the concepts of role responsiveness
introduced by Sandler and projective identification as developed
by contemporary Kleinians. Furthermore, she elaborates the con-
cept of enactment as an interpersonal process, arguing that the
therapist needs to be capable of allowing him/herself to be psychi-
cally affected by the patient’s phantasies and perhaps enact his/her
own phantasy. The author reviews the concepts of transference and
countertransference, postulating that the therapy will not be ef-
fective unless the therapist becomes part of the patient’s problem
in the therapeutic process. She ends her chapter with a creative
synthesis of all the previous points, dealing with the limits of
intersubjectivity and the difficulties and dangers contained for the
therapist and the therapy which are, nevertheless, inevitable as
long as the therapist’s aim is to make the therapeutic relationship
an alive one.
Maria Ponsi deals in her contribution with the concept of thera-
peutic alliance. She points out the main ideas of the intersub-
jectivity theory, such as the participation and interaction in the
relationship, the filtering of the data by the therapist’s subjectivity,
and the construction of the therapeutic process via the mutual
reactions of both participants in the therapy. She refers to the
recognition of the impact that the patient’s phantasies have by
motivating the therapist’s internal objects, so that the therapist is
xxii INTRODUCTION
no longer viewed as an object but, rather, as a subject personally

contributing to the therapeutic relationship. She also notes that
countertransference—if conceptualized in a very broad way—does
not allow one to distinguish what belongs to the therapist as a
person from what belongs to the patient’s transference projections;
therefore, a space provided for the analyst’s subjectivity is re-
quired. Based on the concept of intersubjectivity, the writer views
the therapeutic alliance as a silent cooperative process that enables
both the therapist and the patient to maintain an alive communica-
tion, observing and making corrective interventions indirectly or
non-verbally wherever and whenever needed.
Gila Ofer approaches this issue in her chapter from a far less
discussed point of view—that is, the therapist’s dreams that are
related to the patient. After reviewing the few writings on this
issue, she postulates that these dreams belong to the space created
in the therapist–patient relationship and do not necessarily indi-
cate some kind of defence or concern on the therapist’s part but,
rather, are a sign of intersubjective influence and communication
allowed by a therapist who encourages the therapeutic relation-
ship. I would say that perhaps they are another manifestation of
Racker’s notion of concordant identification or an intersubjective
object created within the therapeutic process. Through the pre-
sented clinical material, Ofer defines these dreams as a product of
resonance between the therapist’s and the patient’s unconscious.
They may indicate a personal involvement of the therapist or
communications of the patient’s inner world, or they may consti-
tute a psychic place common to both of them.
Claude Smadja’s chapter deals with the psychoanalytic thera-
pist’s healing function as the writer experiences and elaborates it
through his rich clinical experience in working with psychosomatic
patients. Smadja focuses on the level of the negative, the absence of
discernible elements of transference, and their inevitable impact on
the experiencing of countertransference feelings by the therapist.
Through a very interesting review of the roots of Freudian theory,
Smadja notes among other points the possible emergence of empty
resistances, which are created via the counter-investment of a
traumatic state of despair and constitute a pure negativism in the
therapy. Since the therapist suffers the impact of such situations,
he/she consequently needs to make appropriate adjustments in
INTRODUCTION xxiii
the technique in order to deal with them. Furthermore, Smadja

presents vivid and rich clinical material from the course of a psy-
chotherapy case. Through this, he describes the experience of the
impact of the patient’s psychopathology on the therapist’s psyche
and the conceptual framework and technique he used in his under-
standing and interventions.
I hope that this unavoidably incomplete presentation outlines
the content of the articles. I also hope that readers will enjoy
studying them as much as I did. Finally, I hope they will gain some
enrichment through sharing the experience of the distinguished
colleagues contributing to this book.
FOREWORD
Paul Williams
T
he EFPP Monograph Series has established itself as an
important source of high-quality psychoanalytic psycho-
therapy material. This volume adds to its growing reputa-
tion with a selection that deals with the analytic relationship from
several perspectives—in particular, the influence of the analyst/
therapist on the evolution of the therapeutic process. This is, of
course, a fundamental issue and one that is hotly debated within
the analytic community. Maria Ponsi succinctly addresses in her
chapter the historical changes of view of the analyst’s influence on
the analytic process. Initially, any such influence was considered
regrettable, then later regarded as a positive technical tool with the
development of the concept of transference. Later again, the dis-
covery of countertransference, with its implications for technique,
deepened the understanding of unconscious communications be-
tween patient and analyst in both directions. In addition, acting out
came to offer a window for understanding failures of symboliza-
tion. Today we see much interest in the impact of the analyst’s
subjectivity based on scrutiny of interactive processes in the con-
sulting-room, but from radically different perspectives and tradi-
tions depending upon which side of the Atlantic one practises. One
xxv
xxvi FOREWORD
could say that there has occurred a progressive shift from one
extreme—analysis of a separate, even isolated mind—towards a
“relational” mind that is not seen to properly exist without its
object-counterpart or outside its subject–object context. This pro-
gressive shift brings with it, however, a risk of extremism in the
opposite direction. For example, how accurate is it to ascribe any
attitude, feeling, or thought arising in the analyst’s mind to the
countertransference? Have we been led to a point where at times
we are stretching concepts beyond their meaning? A tendency to
ascribe to a term anything one likes can render the original term
meaningless. What strikes me as fundamental to the study of the
analyst’s subjectivity and its influence on the therapeutic relation-
ship is the need to research it in all its dimensions with greater
transparency and conceptual clarity. This is no easy task, but no
less necessary for that. There is a need to remove the analyst’s
subjectivity from the twilight zone where it has been abandoned, as
Ponsi suggests. To do this may necessitate a reduction in or greater
circumscription of the concept of countertransference. I hope that
the papers in this monograph will facilitate further thinking on this
important subject.
As I read Dr Anastasopoulos’s Introduction and the chapters I
could not help being struck, as an editor of a psychoanalytic jour-
nal, by the seemingly complex way in which the terms “analyst”
and “therapist” are used, sometimes interchangeably. This is a
reflection of the equally complex relations between psychoanalysis
and psychoanalytic psychotherapy. There is no space to discuss
this vast subject here, but I would like to make one observation that
I hope is constructive. At the International Journal of Psycho-Analysis,
we have long accepted submissions from psychoanalytic psycho-
therapists and have tried to devise reasonable criteria by which
papers are assessed. It is easily possible to imagine the pitfalls such
an exercise entails. Debates over frequency and length of sessions,
the analytic setting, use of the couch, and so on can, without proper
care, descend into vehicles for the articulation of political positions.
Politics is an important part of life, but not at the expense of
knowledge. The frequency of sessions and the nature of the setting
must always remain parameters of scientific importance that our
discipline cannot ignore, whatever our institutional affiliation. At
the same time, respect for cultural differences is also necessary in
FOREWORD xxvii
this area: in France and much of Latin America, for instance,

psychoanalysis is commonly understood to involve three sessions
per week. Elsewhere in Europe and the United States, the situation
is different. Similarly, the interpretation and use of the same theo-
ries and concepts can differ greatly across regions. An anthropo-
logical sensitivity to cultural differences is a prerequisite for
international psychoanalytic dialogue. At the IJPA, a decision was
taken some years ago to assess papers according to the quality of
their argumentation and psychoanalytic content, and this included
psychoanalytic psychotherapy papers. In other words, how logi-
cally argued are the author’s ideas and how compelling is the
demonstration of core psychoanalytic concepts such as the uncon-
scious, transference, countertransference, interpretation, and so
forth? By adopting transparent criteria of assessment (cf. Tuckett,
1998) we try to invoke a climate of serious scientific evaluation that
minimizes the impact of politics. We do not imagine we can do
away with politics, but assertions such as “a psychoanalytic pro-
cess may be absent in a five-times-weekly treatment and present in
a once-weekly treatment” no longer have relevance unless demon-
strable through commonly agreed standards of assessment. It is to
the advantage of all who work in this testing discipline that we
extend and deepen our knowledge of psychic reality in ways that
permit greater scientific exchange, as opposed to factionalism and
ideological bias. Progressive articulation of what does or does not
constitute psychoanalytic thinking is an important key to this: the
EFPP Monographs have a central role to play in the endeavour.
CHAPTER ONE
The analyst’s clinical theory

and its impact on the analytic process
in psychoanalytic psychotherapy
Joachim Küchenhoff
T
he 2000 EFPP Congress in Cyprus was devoted to the im-
portant issue of what the psychoanalytic psychotherapist
contributes to the analytic process. My chapter addresses
the question as to how far the analyst’s theories influence the
course of the therapy. I assume that we would all readily agree that
there is an influence. But it is not at all easy to clarify the ways in
which these influences work.
First, we have to define what we understand by theory—the
first part of my discussion is devoted to that question. Four levels
of theory are introduced:
1. the analyst’s philosophy or Weltanschauung;

2. his/her general approach to life and to therapy—his/her psy-
choanalytic ideological background;
3. his/her metapsychology—the clinical theory;
4. his/her conscious or preconscious theorizing activity (Barratt,
1994) when engaged in a session with an analysand.
The second part of my discussion deals with Levels 2 and 3: the

analyst’s metapsychological and clinical theories. It will be shown
1
2 JOACHIM KÜCHENHOFF
that psychoanalytic theory—like any scientific theory—is bound to

general epistemological principles, as have been formulated by the
philosophy of science. For example, basic rules have to be consid-
ered as to how a theoretical approach affects the data that are
observed. The epistemological considerations will lead to three
conclusions:
• Neither in psychoanalysis nor in any other science are observa-

tions independent of the theories that set the frame for any
possible observation.
• Thus, different theoretical frames produce different data.
• These different theories may or may not always exclude each
other. It is a task for every therapist but also for psychoanalytic
metapsychology as a science to decide whether a pluralistic
approach—one that takes a variety of theoretical frames to be
equivalent and simultaneously valid—is appropriate and when
theoretical frames cannot be mediated with each other and
therefore cannot be valid at the same time.
Part three of my chapter addresses Level 4, the analyst’s theo-

rizing activity—that is, the (pre-)conscious production of explana-
tory or interpretative theories coming to the analyst’s mind in the
course of the session or in between sessions. This activity is not just
an application of the analyst’s clinical theory or metapsychology in
a concrete clinical situation. Obviously it depends on it, but not
totally: there are other factors influencing the analyst’s theorizing
activity as well, which may be unconscious and may stem from
identificatory processes with his/her training analyst, with his/her
supervisor, with group dynamic processes in the psychoanalytic
peer group, and so forth. And finally, the theorizing activity may
be due to countertransference influences. Thus, an inversion seems
to take place: theory at this level is not only a determining factor
but is itself determined by the psychoanalytic process.
If we take this finding seriously, we have to reflect on a peculiar
interaction of theory and clinical practice in psychoanalysis: first of
all, the very hypothesis of unconscious processes undermines
theory formations that are products of conscious activities. Second,
theory does not always come first—it cannot claim priority over
THE ANALYST ’ S CLINICAL THEORY 3
clinical practice. Theory pre-figures clinical experience but, at the

same time, is subverted by it. The fourth part of this chapter tries to
deal with this special epistemological issue: this subversion of
theory that in itself is a theory needs to be understood. I shall begin
here by returning to the first theoretical level and raising the
question as to which Weltanschauung or philosophy might be ap-
propriate to account for this obvious paradox. I offer an answer by
suggesting that pluralism is not a sufficient epistemological basis
for psychoanalysis. Deconstructivism seems to be more appropri-
ate, because it allows us to conceptualize these theoretical para-
doxes.
Part I
The title of my chapter addresses the “analyst’s theory”—what do

we mean by it? We have been used to differentiate between clinical
theory and metapsychology. Metapsychology is a theory of clinical
theories—that is, it summarizes the principles underlying clinical
theories. These provide the nosological concepts, the therapeutic
rules, and so forth. For example, the concept of defence can be
understood within the metapsychological frame of Freud’s struc-
tural model. As an application of this model, hysteric phenomena
can be understood to be the result of specific defence mechanisms,
conversion and repression; this would be a clinical theory.
As is known, there have been recurring discussions as to
whether metapsychology should be discarded altogether. Instead
of reducing the spectrum, I want to broaden it by adding two
more levels of what theory is in psychoanalysis. On the one side,
at the abstract or general end of the spectrum, there is the level of
the Weltanschauung or anthropology or philosophical basis for psy-
choanalytic theories. We have to consider this level, as the meta-
psychological approaches we use are variable; there is no longer
one unitary metapsychology. So, whatever approach we choose
depends on the general principles we use as theoretical or practical
guidelines in our lives. Whether the psychoanalytic cure is re-
garded as a method by which to confront the subject with the
contingencies of reality, with the unsurmountable limitations of

phantasmatic omnipotence, and with the necessary frustrations
of life, or whether it is seen as a chance to free repressed drives or
affects from repression, this choice of a metapsychological concept
is in itself formed by an ideology or anthropology that most of the
time remains unnoticed. On the other end of the spectrum, there is
the analyst’s theorizing activity—that is, his/her activation of theo-
retical material during a session or—in broader terms—during the
course of a psychotherapy. Under ideal conditions, the four levels
should correspond with each other, each supplementing the other
without producing incompatibilities between the levels. To return
to the example just given: if an analyst has adopted a philosophical
ideology of thoroughgoing liberalism, he/she might be more prone
to choose drive psychology as a metapsychological basis. His/her
clinical awareness will be directed to corresponding clinical mate-
rial—for example, he/she will eagerly notice resistances against
hidden drive impulses and wishes, and his/her theorizing activity
within the sessions will be directed towards the hidden manifesta-
tions of oedipal or anal or oral forces which need to be set free. We
all know that this top-down correspondence of the four theoretical
levels does not work in real practice. We do not give interpreta-
tions in a strictly deductive way. In a therapeutic session, as ana-
lysts we do not concentrate on material best fitting our clinical
theory. And if we do, we do not hesitate to reflect on this somewhat
obsessive-compulsive countertransference approach. If our aware-
ness or responsiveness (Sandler, 1992) is free-floating, our theoriz-
ing activity will lead us to concepts quite remote from our general
convictions. Clinical experience is richer than the theoretical con-
cepts we have; it may stimulate new and spontaneous ad hoc
theories that might be at odds with the prefigured theoretical
notions. I shall return in the last part of the chapter to this impor-
tant issue of a reversed relationship of theory and clinical practice
in psychoanalysis. Up to now, we only need to remember the four
levels of theory and the fact that there might be tensions between
the levels that should not only provoke disturbances but might be
seen as a source of creativity in psychoanalysis.
Part II
Reading Freud’s technical papers, one could have the impression

that psychoanalysts do not need to reflect on their theories in
clinical practice. As theories are products of conscious rational
activities, they should be set aside as best one can because they
interfere with the capability to receive the unconscious dimensions
of the patient’s discourse. The analyst, according to Freud, at-
tempts “to avoid as far as possible reflection and the construction
of conscious expectations” and he should “try not to fix anything
that he heard particularly in his memory” (Freud, 1912e, p. 112).
Bion’s demand that the analyst should listen without memory and
desire seems to foster this argument (Bion, 1967). Nevertheless,
these recommendations cannot be taken as epistemological argu-
ments advocating a “transaudition” (hearing through) of uncon-
scious material in any more or less mystical form. Rather, they are
meant as warnings not to contaminate the free-floating awareness
too early by material that has fixed itself in the analyst’s mind,
preventing further open-minded listening. Instead, psychoanalytic
practice is bound to the epistemological rules valid for each science
or therapeutic theory. It is worth while to remind ourselves of
some of them because they help to clarify how clinical observations
are prefigured by theory.
1. It is an epistemological truism to state that data are not inde-

pendent of the concept by which they are evaluated. There is
not a reality outside our grasp that can be observed by an
independent observer. Theories not only interpret data but
generate them. Having different metapsychologies and clinical
theories at our command, we have to realize that different
theories create different sets of data. According to the approach
we choose, we obtain different analytic processes. No doubt a
Lacanian psychoanalyst listening to the significant words in the
verbal material obtained by free association will influence the
session in another direction compared to the object-relations’
adherent who wonders what part-object representations have
been projected onto him by the patient and what patterns of
unconscious relationship have emerged throughout the session
(cf. Gill, 1997b).
2. What is put into question here is scientific truth as well as

clinical adequacy (cf. Protter, 1988). If our theoretical approach
prefigures the analytic process, it might seem to be difficult to
counter the verdict that psychoanalytic effects are due to sug-
gestion: if the theory chosen by the analyst yields specific data,
this theory obviously serves as an instrument to manipulate the
analysand according to the theoretical presuppositions the ana-
lyst has. Yet epistemology itself can be helpful in answering this
verdict: the influence of the theory on the generation of data is
true for any science, including the natural sciences. That differ-
ent psychoanalytic theories yield different processes is not a
weakness of psychoanalysis as a science but an epistemological
necessity shared by all sciences.
3. Data are constructs: they are—as the word “datum” implies—
given, at hand, they do not exist a priori. They are constructed
by the perspectives chosen beforehand, and even that which is
defined as an object or as a datum is bound to the preliminary
discourse setting the framework for what is to appear and what
is to be beyond it. Therefore, it would be wrong to state that we
have different perspectives of the same data if we compare
different psychoanalytic concepts. Instead, we have to state that
different data are created by different frames. This statement
has implications for the question of what can be regarded as the
truth. If there is not an independent object—an analysand with
unconscious demands irrespective of the analytic process—but
only this patient within this concrete given setting, then it does
not make sense to maintain the option of the one analytic truth.
In fact, there is a variety of more or less valid approaches. And
even this formulation could be misleading: there is no concept
of validity that is independent of the theoretical preconceptions.
Instead, what is valid is due to the needs defined beforehand:
do we aim at supporting the patient pragmatically by our
interpretations? Or do we regard as valid only those interpreta-
tions that have a subjective evidence for the patient? Or is an
interpretation valid only if is able to provoke more material
which has been unconscious so far?
Let me quickly draw a few clinical consequences from these some-

what abstract considerations:
1. Instead of giving up theory, we need more theoretical reflection

as psychoanalysts. If our metapsychological and clinical pre-
conceptions take part in generating the clinical experiences we
have, we need to be aware of them. As they are so influential,
they should become explicit; only then can they be reflected
upon or criticized if necessary. We should train ourselves to
become aware of the implicit theoretical pre-concepts we use. I
return to Bion’s famous prescription to enter the session with-
out memory and desire. Even if we succeed in not thinking of
anything, we still adhere to this very theory—that is, Bion’s
remarkable theory of thinking as the metapsychological back-
ground to our concrete clinical attitude. So it is not only the
content of what we think or what we observe but also our
attitudes which should be questioned as to their background
concepts.
2. If we use competing metapsychological or clinical theories,
each of which influences our clinical awareness, we should feel
an obligation towards theoretical consistency, adequacy, and
actuality. If we make our background theories explicit we
should perform—sit venia verbo—a regular check-up on the
theories we use. Do they contradict each other? Are they up-to-
date? Which of the theories should be dropped, even though it
might have become a good companion to everyday work,
simply because it is no longer in line with present-day develop-
ments of psychoanalytic theory or the results of psychoanalytic
research? I fear we are—as individual therapists as well as a
scientific group—still reluctant to criticize our sets of theories in
this way or even to discard some concepts because they must be
regarded as outdated.1
3. Even so, we will not end up with a unitary metapsychology. I
do not regard such a unity as an ideal option or aim. Instead, we
have to accept, as Strenger (1991) maintains, a theoretical plu-
ralism in psychoanalysis. We have to live with a variety of
theoretical approaches which cannot be reduced further. These
then are, in Nelson Goodman’s sense (1978), different ways of
(psychoanalytic) world-making. Psychoanalytic concepts, seen
from a pluralistic perspective, offer “conceptual frames which
organize phenomena in different ways” (Strenger, 1991, p. 71),
and each frame offers specific and rich clinical perspectives.

Pluralism, as Strenger rightly states, has nothing whatsoever to
do with relativism or scepticism; pluralism does not stem from
a sort of metaphysical resignation that the ideal of a unitary
theory cannot be achieved, either now (Spence, 1982) or ever
(Grünbaum, 1980). It accepts theoretical variety as a fact and
regards it as a source of theoretical enrichment. And it does not
support a dogmatic view that maintains the option of and
privileged access to the one and only truth.
Part III
Up to now, it seems as if psychoanalysis could readily be handled

like any other science in epistemological terms; maybe we would
have to include some hermeneutic rules as well. It seems as if with
the concept of pluralism all epistemological problems have been
solved. Thus we have come to know that there are several psycho-
analytic ways of world-making. We have come to realize that the
analysand’s unconscious notions never appear independently of
the methods by which we address such unconscious experiences.
We have come to accept that there is a mutual enrichment process
going on between theory and clinical experience, the one stimulat-
ing progress in the other.
As pluralistic psychoanalysts we could regard ourselves as
some peculiar sort of epistemological “chameleons”, changing col-
ours whenever we feel the need to do so, having different sets of
explanations and interpretative formulas at hand that can be acti-
vated according to clinical necessities.
Turning now, in the third part of my chapter, to the theorizing
activity of the analyst within the sessions as the most concrete form
of theory formation in psychoanalysis, we have to realize all the
same that this theorizing activity is not only a factor of influence on
the psychoanalytic process. It is itself influenced by several factors,
of which I shall mention only two: namely, extra-analytic influ-
ences and intra-analytic, transference-bound influences.
(1) It was Sandler (1992) who pointed to an important difference

in the formation of the analyst’s theory: he spoke of the public as
opposed to the private face of psychoanalytic theory. What one

admits in public—may that be case conferences, scientific papers,
supervisory sessions, or the like— to doing may be different to
what one actually does in a given therapeutic session. This is
partially so because there are other, more hidden influences on the
theoretical approach that the analyst develops in the session, some
of which may be unconscious and may be detrimental to the
analyst’s analytic capacity when they are not made conscious and
worked through (cf. Grossman, 1995). If an analyst claims himself
to be Lacanian in public debates and if the same analyst has had a
training analyst working according to object-relations theory, he
might in clinical practice be much more object-relationist than he
would be willing to admit. The discrepancies may remain unno-
ticed for a while, especially when unconscious identifications with
the training analyst have not been solved. If the peer group within
a psychoanalytic institute supports ego psychology whereas an
analyst himself does not think it helpful in proper analysis, ego-
supporting strategies may be used all the same, out of fear of not
obeying the unwritten rules of the training institute, while ego
psychology continues to be criticized in a sharp voice.
These examples show that in everyday practical work as psy-
choanalytic psychotherapists, we do not change colour according
to consciously reflected necessities only, but that our colours
change even before we may become aware of it. Granted that our
theories influence the therapeutic process, we should be alert in the
other direction to all the influences on our theorizing activity itself.
If not, these hidden influences will be detrimental inasmuch as
they remain unnoticed.
(2) Let us turn to the intra-analytic influences on the theorizing

activity—that is, the influence of transference and countertrans-
ference on the analyst’s thinking and theorizing capability. Though
it might seem trivial in clinical terms, this influence is most impor-
tant in conceptual terms, as I shall demonstrate shortly. It is a
familiar experience during supervisions: the analyst’s theorizing is
revealed as a defence—maybe the analyst wants to protect him/
herself from drive cathexes in transference by highlighting the
narcissistic pathology all the time. Or the analyst insists in some
form on the patient’s accepting his/her interpretation by repeating
it all the time; this might be due to a countertransference need—the

analyst needs the patient’s approval of everything he/she does,
thus inverting the Bionian containing process: the patient is sum-
moned to contain the analyst’s thought instead of vice versa.
Maybe the analyst’s theorizing can be understood as his/her desire
to be “the one who knows”. This time the analyst is unconsciously
led to replace—speaking in Lacanian terms—the analytic discourse
by a master discourse (“discours du maitre”). In all instances, the
pivotal point is similar: the analyst’s theorizing can be shown to be
an acting out of libidinal or narcissistic desires on the analyst’s side.
Because it is central to the argument I want to make, let us now
consider more closely Bion’s theory of how the analyst gives an
interpretation. As you know, it was Bion’s aim to conceptualize a
psychoanalytic theory of thinking, and this endeavour has stood
the test of time in more than one respect: it is more topical today
than ever. Bion outlined a genuinely psychoanalytic theory of
thinking, and this makes it so important to us. Bion was aware that
psychoanalytically there is no way to conceive of the analyst’s
theorizing or interpreting activities in only rational terms. Accord-
ing to Bion (1962), the act of interpreting is itself a conception; note
the double meaning of the word here. The analyst uses his theory
as a pre-conception, as a form or container, that meets the content
that is being offered by the analysand’s associations, and so forth.
The content becomes contained, the preconception becomes a con-
ception. Thus, something new is generated. Every time an interpre-
tation is given and proves to be fruitful, a kind of analytic child is
generated which will sooner or later live a life of its own (cf. Britton
& Steiner, 1994). Many contemporary psychoanalytic thinkers
stress this constructive, generative capacity; I only mention
Ogden’s notion of the “analytical third” (1994b) and Schafer’s
concept of the interpenetration of thinking between analyst and
analysand (Schafer, 2000). What is important here is that the
Bionian theory amounts to a libidinization of theorizing. The ana-
lyst’s theorizing activity is embedded in a libidinal structure in the
first place.
Now consider the consequences that this beautiful psychoana-
lytic concept of theorizing and interpreting has. Obviously, the
sequence leading from theory to the understanding of a clinical
phenomenon is inverted. Prior to theorizing is the clinical encoun-
ter. Theorizing never is a mere application of a metapsychological

or clinical theory to an individual case. The encounter is richer than
any theory could possibly be. I think that this is the reason why we
like our job: the clinical encounter with another personality has a
creative potential able to enlarge, even change, the preconception
we have. Psychoanalysis is never merely the application of a pre-
formed theory but at the same time a questioning of known clinical
concepts.
Considering, as Bion does, theorizing to be a conception has
another important corollary: the theory the analyst forms is but the
subjective mirror of a shared intersubjective process. Strictly
speaking, there is no solipsistic theorizing activity but only a theo-
rizing process between the partners taking part in the analytic
process, which eventually yields results that can be expressed as
analytic interpretations.
Now let us consider the epistemological consequences for
theory formation in psychoanalysis on the whole. If theory forma-
tion is regarded as a conscious activity that has an undercurrent of
unconscious libidinal encounter, theory itself is questioned psycho-
analytically. As this again is a theory, it can be applied against
itself: the very concept of unconscious motives underlying theories
is a theory built on unconscious motives. In logical terms, an
infinite regression is thus being initiated. But it cannot be used as
an argument against psychoanalysis. Rather, it shows the complex
status of the theory of the unconscious: it is a theory of something
that cannot be covered completely by consciousness while exerting
decisive influences on conscious processes. Reformulated in a more
radical form, psychoanalytic theory maintains that it cannot get
firm hold of its own basis. There cannot be a firm ontological or
epistemological basis for the unconscious, but only one that re-
mains preliminary, incomplete, and so forth. Unconscious experi-
ence is not merely a second, though unnoticed, level of experience
which is parallel to and comparable with conscious experiencing. It
does not follow the conscious notions of time and space. Uncon-
sciousness can merely be reconstructed as a break, a rupture, an
interval, a confusion, a gap in the customary conscious linearity.
The analyst’s theorizing activity mounting in an interpretation is
always late or nachträglich (deferred in action, après coup). It was
Lacan who showed that the ego is always late, that Freud’s formula
stating “where the id was there the ego shall be” must also be
understood in temporal terms.
Part IV
I am aware that my chapter could seem confusing. Have I not told

you first that there is no psychoanalytic experience without a pre-
formed theory as a sort of hermeneutic “prejudice”? Now I have
stated that the analyst’s theorizing activities are themselves de-
pendent on intersubjective unconscious processes taking place in
the course of the analysis. I said an infinite regression has been
initiated. Maybe it is a vicious circle as well: the unconscious
encounter can be perceived only by means of a psychoanalytic
theory, whereas the theory itself is due to unconscious processes.
We could try to evade the circularity by pointing to the differ-
ence in the levels of theory: theory as a perceptual frame is
metapsychology or clinical theory, whereas the theorizing activity
is practical clinical interpersonal encounter. Nevertheless, I do not
think the circularity can thus be escaped from completely. Instead,
I think we have to use some sort of dialectical thinking mediating
between the seemingly contradictory notions. At this point, I come
back to the first level of theory which I have ignored so far—the
philosophical or anthropological background to psychoanalysis.
We can now formulate a demand on this philosophical basis: the
basic philosophical theory underlying metapsychology, clinical
theory and theorizing activity must be one that can reconcile these
contradictions. The contemporary philosophical concept that is
most suited to serve as a metatheory in this sense is, I think,
deconstructivism, in the form in which Jacques Derrida has intro-
duced it into the philosophical debate. It allows us to maintain that,
on one hand, there is no escape from the necessity to have theoreti-
cal frames that form all possible experiences; on the other hand, in
deconstructionist terms, no theory ever satisfactorily covers the
phenomena it wants to explain or show. Deconstructivism has
often been misunderstood. It is not a postmodern theory in the
sense that it advocates an “anything goes” attitude; rather, it pur-
sues the project of modernity and enlightenment. It wants to en-
lighten even those phenomena that up to now have been dark

continents, that lie outside the light, in the shadows, as it were. But
it is convinced that a world without shadows would be nothing
but a global prison trying to control everything and forbidding
questions—it is obvious that in such a world there would indeed
exist a shadow side to this insistence on transparency—that is, the
desire for power and control which it is forbidden to question.
Deconstructivism hints at the shadow sides inherent in any theory.
At the same time, it is not a destructionism. Deconstructivism lays
open the processes and principles by which a structure has been
built. This way the structure may not be destroyed but enriched—
by analysing the details of its constructing principles, something
new—a hitherto unnoticed facet—turns up, adding to the whole
structure’s understanding or allowing for an expansion of the
structure itself. Deconstructivism does not support the notion of
being able to find any final answers to any philosophical issue. It
does not imply that personal history can be understood as arising
from one origin or heading towards one goal. But it tries to recon-
struct some important factors guiding this personal history. In
psychoanalytic terms, a deconstructionistic attitude towards neu-
rosis would be not to hope to find out the original traumatic
incidence one day but, rather, to reveal the ways the experience or
notion of being traumatized has been processed during a lifetime.
A deconstructivistic reading of a given text would try to enlarge
the understanding of this text by reading it from its edges, by
noticing little inconsistencies, not by simply summarizing its main
theses. This approach is quite similar to the psychoanalytic proce-
dure—for example, to reveal the speech’s unconscious content by
analysing the speaker’s slips, as Freud has demonstrated. There-
fore, it is not surprising to find that Derrida has been influenced by
Freudian theories (Derrida, 1967) and that he has always kept a
lively interest in psychoanalysis (see, for example, Derrida, 1980,
1996).
A deconstructivistic approach could be directed to psychoana-
lytic theories themselves. Such an approach would be interested
not only in understanding the theory, but to link this understand-
ing to the exploration of the rest—the inconsistencies, the inherent
limitations in a given clinical theory. It would not assume that a
theory covers all practical possibilities. Instead, it would look for
those unsettled inconsistencies that demand a supplement. It

would never devalue theoretical concepts on the basis of their
limitations but would regard these as necessary. It would reveal
the personal and unconscious effects on theory formation without
claiming thus to have destroyed the theory, but only to have
deconstructed some of its formative influences.
Let me conclude my chapter by formulating some of the conse-
quences that such a deconstructivistic approach would have as a
metatheory to psychoanalysis:
1. In a deconstructionistic perspective, the ambivalence towards

theory in psychoanalysis is but a special example for a more
general problem. Theory is never self-explanatory or self-suffi-
cient. There is always a background to it that cannot easily be
grasped by the theory itself and which is responsible for its
limitations. Psychoanalysis can be used to find out the uncon-
scious dimensions in theory formation, even in psychoanalytic
theories themselves.
2. A deconstructionistic approach to psychoanalysis does not ad-
vocate therapeutic nihilism or conceptual eclecticism. Even
though it does not support the notion that in the psychoanalytic
cure the original trauma can be found and overcome, that the
unconscious experience can be dried out like any Zuyder Zee,
it does not have melancholia or disappointment as its conse-
quences. Rather, it leads to a state of mind in the analyst that
could be described as playfulness, curiosity, or versatility.
3. I assume that deconstructivistic concepts have already influ-
enced psychoanalysts to a greater degree than has been realized
so far. Therefore, I do not think it is surprising that contempo-
rary metapsychological efforts are devoted not so much to the
contents of clinical theories, but to the analytic process and the
creative potential inherent in it. This is why Winnicott (1971) is
still so very popular. His concept of the transitional space has
become a central metaphor to describe the analytic process;
André Green has adopted this metaphor when speaking of the
“éspace aerée”; other analysts have been concerned with similar
metaphors of psychic space—for example, Salamon Resnik
(1995) speaks of mental spaces, and so forth. Others have
further developed Bion’s concept of creativity that is implied in

the model of container–contained; I have already mentioned
Bion’s model of interpretation as a conception. Ogden (1994b)
has spoken of the “analytical third” to show that the analytic
pair—the analyst and analysand—together create something
new. In all instances, the creative potential of the psychoana-
lytic cure is underlined. In deconstructionistic terms, psycho-
analysis deconstructs experience, but by the very process of
analysis itself it sets free a creative potential. There is no need to
separate the reconstructive from the constructive level, the
analytic from the synthetic level; rather, the deconstructive
potential of analysis itself engenders creativity.
4. A deconstructionistic approach reveals that any form of dogma-
tism is the ultimate enemy of psychoanalytic thinking. This is
true for the cure as well as for the institutionalized psychoanaly-
sis. In the cure, psychoanalysis reveals many a hidden facet of
phantasy and experience without ever ending by claiming to
have found out any ultimate truth. On the level of institutionali-
zation, any dogmatic claims have to be deconstructed again
and again. In the deconstructionist perspective, it clearly makes
no sense whatsoever to claim that only a certain setting—say,
a psychoanalysis of four sessions weekly—is psychoanalysis
proper. Instead, one would have to take into account that there
is no—and cannot be a —final form of psychoanalysis, that
there is no original or authentic setting, but only different forms
of setting. And these have limitations—all of them—which
have to be assessed properly. A deconstructivistic approach
does not invite theoretical fuzziness or indifference—on the
contrary! But it is bound to change the dialogue rules within
psychoanalytic societies. It necessarily implies an attitude of
self-scrutiny and self-criticism since no theory is perfect. The
shortcomings of each, including the one that an analyst him/
herself advocates, should be assessed, instead of projecting all
doubts and critical comments onto the other group’s concepts.
Thus, similar to the psychoanalytic cure, the scientific psycho-
analytic dialogue between the different societies could gain in
tolerance, creativity, and friendliness knowing that there is not
one blessed psychoanalytic concept. It is this very fact that
could promote scientific competition as well as psychoanalytic

solidarity.
Note
1. Cf. Green (1975): “I think that one of the main contradictions which the
analyst faces today is the necessity (and the difficulty) of making a body of
interpretations (which derive from the work of Freud and of classical analysis)
co-exist and harmonize with the clinical experience and the theory of the last
twenty years.”
CHAPTER TWO
A different perspective
on the therapeutic process:
the impact of the patient on the analyst
Judy L. Kantrowitz
T
he therapeutic process is considered in this chapter from the
perspective of its impact on the analyst. Analysts undertake
self-scrutiny, focusing on transference and countertrans-
ference reactions, in order to facilitate the treatment of their pa-
tients. However, this self-reflection also serves to continue and
enhance the analyst’s own personal understanding. In the course of
analysing patients, an interactional process develops in which
many of the therapeutic aspects of analysis affect the analyst as
well as the patient. A clinical example is offered later in the chapter
to illustrate this process.
Over the last decade and a half, a shift has occurred in the way
analysts view the analytic process. While many analysts have al-
ways seen analytic work as interactional, for many years there was
a school of thought in the United States that considered psy-
choanalysis an enterprise in which analysts functioned as “blank
screens” on whom patients could project their conflicts. Analysts
First published in the Journal of the American Psychoanalytical Association, 45

(1997): 127–153.
17
18 JUDY L . KANTROWITZ
were thought to be relatively interchangeable, their principal con-

tribution being the offering of interpretations. In this context,
countertransference reactions were seen as intrusions, something to
be analysed by the analyst and controlled, or a reason to go back
into analysis. Countertransference was not regarded as providing
data for exploration, an opportunity for greater understanding of
the patient through greater understanding of what has been evoked
in the analyst in the interaction. Increasingly, analysts have recog-
nized that they are active participants in the process, influencing
and being influenced by what occurs with their patients (Gill, 1982;
Hoffman, 1983). In studying the impact of the patient–analyst
match on the outcome of psychoanalysis (Kantrowitz et al., 1989;
Kantrowitz & Paolitto, 1990), it became apparent that analysts
frequently believe that they, as well as their patients, change during
the process of an analysis. This belief seems consistent with the
current way of thinking, with its greater attention to the impact of
the patient on the analyst’s functioning as a way of providing more
information about the patient (Dorpat, 1974; Dorpat & Miller, 1992;
Gill, 1982; Goldberg, 1979, 1994; Greenberg, 1986; Hoffman, 1992b;
Mitchell, 1993; Modell, 1986; Skolnikoff, 1993; Stolorow & Atwood,
1992; Stolorow, Brandchaft, & Atwood, 1987; Stolorow & Lach-
mann, 1980). Once analysis is viewed as a process influenced by and
impacting on both participants, it would seem expectable that the
analyst, as well as the patient, would be affected by participating in
it. Yet analysts often resist openly discussing and describing such
changes in themselves and how these changes come about. There
are, of course, notable exceptions in which analysts openly describe
their countertransferences and elaborate their self-analytic process
(Calder, 1980; Eifermann, 1987, 1993; Gardner, 1983; Jacobs, 1991;
Kramer, 1959; Margulies, 1993; McLaughlin, 1981, 1988; Natterson
& Friedman, 1995; Poland, 1984; Silber, 1996; Sonnenberg, 1991).
Nonetheless, when analysts discuss the phenomenon of their con-
tinuing personal change among themselves, there seems to be an
uncertainty about how representative or unique their own experi-
ences are.
While only in the last decade has the view of analysis as an
interactional enterprise become a mainstream belief in the United
States, the idea that the practice of analysis has a therapeutic effect
THE IMPACT OF THE PATIENT ON THE ANALYST 19
on the analyst is not new. In response to Glover’s survey (1937),

which investigated analysts’ views on psychoanalytic practice, a
majority of analysts considered the dominant effect of analysis on
the analyst to be therapeutic. It was recognized that the analytic
situation was one in which there was continuous stimulation of
conflict for the analyst; therefore, most analysts assumed that there
would be temporary exacerbations of conflict that would require
self-analytic work. Glover termed this effect “countertransference
therapy”, which occurred for different reasons for different indi-
viduals (p. 179).
In recent years the analyst and his/her role in the analytic
work has become a focus of study (Baudry, 1991; Kantrowitz, 1986,
1992, 1993; Kantrowitz et al., 1989; Kantrowitz & Paolitto, 1990).
Countertransference (Agger, 1993; Jacobs, 1991; McLaughlin, 1981,
1988, 1991; Schwaber, 1992; Spruiell, 1984; Weinshel, 1993) and
enactments (Boesky, 1982; Chused, 1991; Renik, 1993) increasingly
engage analysts’ attention and interest. Hoffman’s social-con-
structivist model (1991, 1992b, 1994) tilts the balance of relative
contribution and participation still further with his emphasis on
analysts as knowing no more than patients and their co-creation of
meaning and understanding.
I am going to discuss the effect of the analytic experience on the
analyst in light of the analytic role and its maintenance. To preserve
this role the analyst must apply a consistent self-scrutiny. Affects,
thoughts, or behaviour provoked by patients require that analysts
continue to find an effective means to rework their own history of
conflict. A concern heard from some analysts is that with this new
emphasis patients lose their place as the proper focus of analytic
attention. Despite this increased interest in the analytic process as
an interactional engagement, however, most analysts retain their
primary focus on the patient’s inner world and use their counter-
transference awareness to monitor themselves in their work. The
shift in emphasis, however, has meant an increased attention to
exploration of the analyst’s process. Particular life events, such as
illness (Abend, 1982, 1986; Dewald, 1982; Engle, 1975; van Dam,
1987) or pregnancy (Beiser, 1984; Friedman, 1993), inevitably stir
transference–countertransference reactions in treatment. These, in
addition to illuminating aspects of the patient’s conflicts, stimulate
analysts to greater self-scrutiny and, thereby, an awareness of

previously unrecognized aspects of themselves. Nonetheless, rela-
tively few analysts have described the reverberating effects their
work has had on them. A notable exception is McLaughlin (1981,
1988, 1991, 1993), who documents how his belief system has been
changed as a consequence of self-discoveries emerging in clinical
work.
Many analysts express a recognition of increased self-aware-
ness growing from their analytic work (Gardner, 1983; Poland,
1984; Spruiell, 1984). Smith (1993) believes that the analyst is
shaped by the nature of the engagement with patients. Whether or
not this shaping is consciously recognized, “the analytic work itself
is for the analyst a source of personal growth and development” (p.
427). Similarly, Goldberg (1994) states, “We do not leave an analy-
sis the same person as we were when we entered” (p. 28). These
statements, however, remain abstract and uncorroborated.
While it is unlikely that an analyst could undertake an analysis
without gaining new intellectual information and personal insight,
it is not inevitable that these new understandings result in psy-
chological shifts. Analysts, like patients, can idealize their own
changes. Nonetheless, if an analyst permits himself to become fully
engaged in the analytic interchange with all its intensity, the prob-
ability that some personal shift will occur is great. The nature and
extent of such changes, however, depend on the interdigitation of
the characteristics and conflicts of the particular patient–analyst
pair.
Studying how analysts perceive changes in themselves over
time allows for a longitudinal view of the impact of the analytic
process on a group of people who have devoted themselves to this
process as their lifework. For most analysts this means that the
psychological issues explored in their personal treatment are not
re-repressed, as they might be following termination, but, rather,
are kept actively alive in their work with patients. As a result, the
analyst has the continuing opportunity to rework these issues on a
potentially deeper level. Every analysis an analyst undertakes is in
this respect potentially a reanalysis for him/herself.
A brief report of a survey
In order to obtain data more extensive than personal anecdotal

information, a national survey was undertaken. Eleven hundred
questionnaires were sent to psychoanalysts who were members of
the American Psychoanalytic Association. All 550 training and
supervising analysts and a comparable number of graduate ana-
lysts from each institute were selected as the sample. The training-
and supervising-analyst group was selected because they were
presumed to be the most experienced of the analysts.1
The purpose of the survey was to explore (1) whether and to
what extent analysts believe that their analytic work with patients
has led to personal change for themselves; and (2), when analysts
do believe that such change has occurred, (a) what in the patient–
analyst interaction triggered it, (b) what method, if any, the analyst
employed to continue his/ her personal work, and (c) what kind of
change they believe has occurred.
The survey provides three kinds of data: (1) a series of items
that have been checked and therefore allow comparisons among
analysts in relation to gender, age, and institute position; (2) brief
written examples that supplement the more general answers and
provide data that allow comparisons about the kinds of triggers for
self-inquiry, the nature of the process, and the definitions of psy-
chological change among analysts; (3) telephone interviews with a
smaller number of analysts, selected on the basis of the varying
degrees of depth and complexity in these illustrations, which al-
lowed a more intensive examination of the analysts’ process in all
the areas described. A total of 399 analysts responded to the ques-
tionnaire; 206 provided written examples, and 26 from the latter
group were interviewed. (Complete results of this study are pre-
sented in Kantrowitz, 1996.)
The current chapter uses one analyst’s interview to illustrate the
impact of the patient on the analyst. I demonstrate the parallels
between the effect of the therapeutic process on the patient and on
the analyst. I also investigate the nature and extent of the influence
of the analytic process on the analyst to illuminate the contribution
of various factors as agents of change. I hope to show how we can
extend our understanding of how psychological development
builds on analytic work and continues after formal analysis ends.
Studying the effect of patient–analyst match provides a means

to consider the factors that impede or facilitate psychological
growth (Kantrowitz, 1986; Kantrowitz et al., 1989; Kantrowitz &
Paolitto, 1990). Overlapping characteristics or conflicts, a similarity
of values, attitudes, or beliefs in patient and analyst, often result in
“blind spots” that prevent certain areas from receiving analytic
inquiry. Differences along these same dimensions may pose an-
other kind of interference. Too little resonance can result in an
experience of affective distance and a failure of understanding and
communication. Fortunately, when these similarities and differ-
ences become the centre of analytic attention, both participants
may learn a great deal. For the analyst, the recognition of areas of
overlap or tension offers the opportunity to reconsider and poten-
tially rework previously neglected or partially resolved aspects of
the self (Kantrowitz, 1992, 1993, 1995).
What evolves in any analysis, although this is to some extent
shaped by the character and conflicts of the two participants, is not
predetermined but context-dependent. The interaction of the spe-
cific character and conflicts of the two participants will bring out
different aspects in each. Since the patient provides the material
that is to be the focus of the work, it is likely that an analysis
conducted by a skilled analyst with no blind spot in the patient’s
central area of conflict will address the most troublesome areas.
The depth and range of exploration and development in other
arenas, however, will vary depending on the particular patient–
analyst pair. For the analyst, however, the areas of personal conflict
or distress that are revived and explored are dependent more on
the overlap with the particular patient; therefore, some analyses
more than others contribute to the development of further self-
understanding and growth.
It is in the context of countertransference reactions that the
analyst’s participation in the analytic process most parallels the
patient’s. Examples of transference–countertransference engage-
ments therefore provide the best illustrations of the therapeutic
impact of analysis on the analyst.
In the example that follows, an analyst recounts his experience
of self-discovery, the impact his patient has had on him, the rever-
berations of his insights, and his perceptions of the psychological
changes in himself, both professional and personal, that have

emerged as a result of his work with this patient. The analyst
describes how primitive rage and terror in his patient led to similar
experiences in himself. These powerful feelings when unearthed in
the analyst helped him towards a new understanding of his past
and a new sense of security and confidence in himself.
One analyst’s account
The patient was an “intimidating,” “explosive” man of powerful

intellect and temper. The analyst described him as being much
smarter than himself. He treated the analyst with “a narcissistic
indifference” to his state and expressed an explosive rage towards
him. The analyst, after a long period of distancing himself from the
patient’s anger by an “icy” withdrawal, because initially he felt
unable to withstand its intensity, found himself able to allow the
patient’s fury to build without “interrupting or defusing it”. The
analyst knew he had a tendency to “become cold inside” and not
let himself feel in response to fear, and he worked consciously to
not deaden his own response to the patient. When he would start to
feel this “coldness”, he would ask himself why he was having to do
this. The questioning helped him not to withdraw.
Once able to overcome his icy response, he came to feel a rage
and terror in response to his patient’s behaviour that he had “never
knowingly experienced anywhere else”. He found himself going to
the mirror after sessions with this patient and realized later that
he was “struggling to feel if [he] existed in the face of the [patient’s]
total refusal to see and accept [him] in any way as a separate
person”. The analyst was literally checking to see if he was still
whole and still existed; he was experiencing the power of the
patient’s rage as shattering and fragmenting.
The analyst had not had this kind of patient while he was
himself in analysis; the level of intensity was greater than anything
he had previously known. “Most of the initial working through
was done running [jogging] and obsessing and thinking” about
why he was “wasting [his] time with this patient. And working it
out over and over again until it became more powerful and less
fragmenting personally.”
As he became better able to tolerate this experience, he could
begin to think more about what went on in the patient. He came to
understand that this “terror” was what the patient had experienced
growing up. The patient had long used his explosive rage to keep
others away. Now, as he became aware that his analyst was less
“blown away by the rage”, the patient too became less afraid of
“destroying everyone and everything else” and became better able
to stay with his feelings.
The analyst realized that it was only by facing his urge to
disconnect that he could stop himself from “going cold” with the
patient. When he did go cold, he had no idea what was going on for
his patient. Once able to let himself feel the terror, he gradually
found himself able to bring in pieces of his own history. “Whatever
. . . the experience would be filled in with, either a memory, more
genetic material, a kind of fuller understanding of something [he’d]
done all his life, it got filled in mosaic-wise over time.” He came
to the realization that “disconnecting and becoming cold” were
“habitual ways” in which he had dealt with conflicts similar to
those he experienced with this patient. Once he had reached these
understandings about himself, the work with the patient pro-
ceeded without these intense reactions on the analyst’s part. To-
wards the end of this patient’s analysis, the analyst’s father died.
During the first phase of the patient’s termination process, the
work had seemed unremarkable to the analyst, and he was feeling
complacent. Then the patient “began to talk about being very angry
with [him] in a way he hadn’t been”. He talked about the analyst
“not being with him”. At first the analyst listened “relatively com-
placently”. He thought he knew that what was going on was a
repetition of an aspect of the patient’s early experience with his
mother; it was an expected part of the mourning process. But as the
patient “continued to complain rather stridently” and “was filled
with rage”, saying the analyst “just wasn’t with him”, something
about the nature of his complaint “suddenly took on a different
quality. . . . It wasn’t just a repetition; there was something happen-
ing between [them] that made [the analyst] more curious about
what was going on.” He became aware that his complacency was
“kind of peculiar”—he wasn’t feeling empathic at all; it was “no

big deal”. That was not how he usually felt when someone was
terminating. Once he had this recognition, he “literally felt some-
thing lift” inside him, and became “overwhelmed with sadness”.
Until that moment he hadn’t recognized the degree to which he
had been fending off a lot of his own grief about his father’s death
and his own “sadness about this guy’s terminating”. They had
been through an enormous amount together, and he had learned
an enormous amount from him, “so there was this kind of dual
hit”. It struck him that in many ways he had a countertransference
to the patient because the patient’s way of relating was not all that
different from that of the analyst’s father—“so who had the trans-
ference and who had the countertransference at times was a good
question”.
Once the analyst had this realization, without his saying a
word, the patient relaxed and said: “You’re with me now.” There
followed from that a whole series of sessions about a person, very
important to the patient, who emotionally withdrew whenever he
disapproved of the patient.
In the course of describing his reactions and discoveries about
himself through work with this patient, the analyst came to a new
realization. He saw that he had had a father transference to this
patient: “I’m wondering if I have to retract my statement about
never having had this kind of rage before consciously, because
what I was just thinking is that maybe this was some of the rage I
had with my dad, who in my eyes was very powerful and was built
like this guy. He also carried a monumental intellect and there was
no way I could hold a candle to him.” These factors made the
analyst feel like a little boy in the patient’s presence. The analyst
had not consciously been aware of this aspect of his experience
before recounting it in the interview. The link to the experience
with his father when he was a child emerged as a new discovery:
“This is something that has just come to me now. What I’ve become
aware of is just how much of a transference I had to this person.”
The analyst knew that something very important had shifted
for him; after his work with this patient, “a kind of primal terror of
the other is no longer so easily evoked” in him. He feels his sense of
his “own separateness is much firmer now”. He can now “sit with
patients who want to obliterate [him] and not feel obliterated”. He

no longer needs to “disconnect” from this kind of patient in order
to feel intact. He also has “a keener sense” of when feelings of
discomfort are coming from himself and so is less likely to incor-
rectly view these feelings as projected from patients.
Changes also occurred in his intimate relationships. He finds he
has “much more tolerance” for his own affects and “more ability to
reflect on them”. When he was growing up, his “family had been
unexpressive of affect”, except for his explosive father, and “strong
affective displays had been disquieting” to him. He now is “much
less reactive to the emotionality” of members of his adult family.
Subjectively, he feels he can be “more intimate”. His wife notes the
difference and appreciates that he is “less reactive”.
The analyst was aware that analysing this patient had made a
very strong impact on him; this awareness of changes in himself
was what had led him to volunteer to be interviewed. However, it
was only in the process of reporting on these changes that he
connected the experience with this patient to his childhood feelings
in relation to his father.
Discussion
In this transference–countertransference interaction the analyst ex-

perienced his patient’s impact on him. Several parts of a therapeu-
tic process occurred for the analyst as well as the patient. I shall
now trace the process of therapeutic action for this analyst.
Awareness of the analyst’s personal engagement is most often
ushered in by a recognition that a personal conflict has been stirred.
Once the analyst becomes aware of an internal struggle or an area
that requires deeper exploration, the analyst engages in a process
that parallels the patient’s—in both, a disquieting inner experience
needs to be understood. For many analysts, familiar defensive
operations are what first alert them to a need for self-scrutiny. This
analyst first perceives his disequilibrium by the appearance of a
familiar feeling of withdrawnness and becoming “cold”; it warns
him that some old issue is diverting him from his work. This
recognition is sufficient to decrease his defensive response of with-

drawal.
The process of analysing defences is usually the first step un-
dertaken in analytic work with patients, once an atmosphere of
relative safety is established. Sometimes, however, an intense affec-
tive reaction to the analyst comes to the fore more powerfully than
does a recognition of defence. Under these circumstances, instead
of a gradual unfolding, patient and analyst are plunged into an
affective engagement that catches both by surprise. The transfer-
ence, rather than the resistance to the transference, claims centre
stage. The patient has experienced or enacted the very thing in
early development that was most frightening, but has done so
before patient or analyst has enough information to understand
what is occurring. Analysis of defensive retreats must take place at
a later point. Although rarely is the analyst in a position that is
exactly parallel to that of the patient, for this analyst the compara-
bility is greater than usual. He recognizes that his frozen state is a
defence against a potentially overwhelming affective reaction.
Aware of his defensive retreat, he allows himself to be open to his
affective response and finds himself flooded by almost overwhelm-
ing affects he at first does not understand.
Personal analysis should have informed analysts about their
own conflicts and defences. When intense reactions occur in rela-
tion to a patient, analysts have a familiarity with the personal
historical sources that are being re-evoked. Relatively quickly,
memories of related past events or interactions can be brought to
the analyst’s mind. These reflections, along with insight previously
achieved, provide a perspective that prevents the analyst from
being as flooded or confused as the patient is when caught un-
awares by a transference reaction. Recognition of the activation of
familiar defensive reactions also stimulates self-exploration. In this
instance the analyst recognizes as familiar the pattern of his re-
sponses to fear, but not until much later does he discover the early
experience that shaped his fear. Caught in a countertransference
reaction, analysts experience responses to their patients that are
totally discrepant with their expectable analytic selves. They lose
temporarily their position of empathy with the patient’s struggle
and respond instead as if the patient were a threat. This analyst,
once he has relinquished his initial defensive stance, then faces

such a situation, experiencing his countertransference rage and
terror in relation to his patient.
In countertransference reactions or enactments, the analyst’s
cognitive control is diminished. The analyst must then affectively
step back and reflect on what in the interaction has stirred this
response. Stepping back and reflecting are skills the analyst em-
ploys to help the patient gain perspective on what transpires be-
tween them. Here the analyst needs to activate these skills on his
own behalf. To deepen his insight, the analyst uses what he sees
and what he knows about both his patient and himself. In explor-
ing his countertransference, the analyst progressively gathers data:
first from his response to the patient, next from the exploration of
memories from the past, and then from the placement of what is
learned against what he knows about himself and his mode of
relating and working in the present. While the experience is
affectively intense, the process usually remains cognitively con-
trolled.
The recognition of defences and conflicts (or other states of
distress) is a cognitive aspect of analytic work. Insight into the
motives and manifestations of their reactions enables patients and
analysts alike to attain some perspective on themselves. Insights
can both stimulate and consolidate psychic shifts. Perspective
serves to decrease affective flooding and self-criticism. These fac-
tors are likely to modify systems of belief, but they are unlikely do
so in any profound way unless other object-related affective condi-
tions prevail. The containing and consolidating function provided
by communication to an emotionally important person is a crucial
dimension contributing to the power of analytic work.
New integrations can occur in the context of a relationship in
which a person feels safe and understood. Our concept of thera-
peutic alliance is based on this assumption (Greenson, 1965). In
their personal analysis, analysts have not only learned about them-
selves; they have also developed the skills to do analytic work, the
most notable being the ability to associate freely. It is therefore not
so surprising that they would be able to continue their emotional
growth and deepen their understanding of themselves as new and
different situations arise, such as the affect-laden issues with which
their patients confront them.
Analysts are aware of the necessity to establish conditions of

safety for their patients. If their patients are to be free to hate, love,
and fear them, they must be able to trust them enough to do so. The
situation for the analyst again is different. Analysts may well come
to trust their patients, but they expect and, in the context of wishing
an increased freedom of expression for them, welcome the open-
ness and intensity of the affects, both negative and positive, that are
directed towards them. The analyst expects the patient to contain
actions, but not the expression of feelings. In contrast, the analyst
expects to be able to contain both actions and the shape and
intensity with which his/her own feelings are expressed to the
patient. Once less defended, this analyst was initially “blown
away” by his reaction to his patient and believed that his patient
was preconsciously attuned to this fact; however, he did not enact
this response to his patient in any blatant way. Nonetheless, the
analyst’s “coldness”, the suddenness of his “feeling overwhelmed”,
and his unawareness of the connection of his experience of his
patient to childhood events with his father all indicate a relative
loss of control on the analyst’s part. At moments of the analyst’s
countertransference enactments in this case or others, the analyst’s
loss of control may not initially be beneficial to the patient. Under
these circumstances, patients may not feel safe enough to proceed
with their work. Only if the analyst can use the enactment to inform
him/herself about him/herself, his/her patient, and their interac-
tion is the enactment of therapeutic benefit. Ultimately, this analyst
was able to keep the treatment “safe enough” for his patient, though
it took considerable time and self-reflective work before the analyst
felt safe himself.
Caught by intense affective reactions, patients often talk with
others about what they are experiencing in analysis. Often they do
so to dilute the intensity of the analytic work. For the patient, this
may be a resistance to something developing in the transference;
looked at from an adaptive perspective, it may be a way to enable
the patient to remain in analysis without becoming overwhelmed
by its intensity. The relative weighting of defensive and adaptive
aspects undoubtedly varies both for each patient and for each
situation.
It is not surprising that analysts have similar experiences. For
the analyst, too, talking with others may be a way to dilute the
intensity of transference–countertransference interactions and to

gain some perspective on them; at times, however, this may detract
from what might be experienced and learned in the analytic in-
volvement with the patient. When countertransference reactions
are very intense, confiding in a trusted person may be an ongoing
accompaniment to the analytic work. All the analysts interviewed
who offered examples of countertransference as the source of per-
sonal recognitions describe discussing their self-exploration and
discoveries with at least one other person. Most communications of
personal struggle stimulated by analytic work (or by self-discover-
ies attained from it) are initiated to help the analyst contain the
affective reaction, gain perspective on the experience, or provide a
reality check on self-perception.
This analyst reports the containing and sustaining function of
describing his frightening experiences to the two people he be-
lieved knew and understood him best. Finding a means of diluting
his response of feeling “blown away” was essential if he was to
manage his affect. He actively reflected on what was occurring
within him; in addition, he talked with his wife and a close friend.
His patient was not the topic; his reaction and state were what he
described and tried to understand in their presence. They knew
him intimately, and their listening presence meant he was not
alone with his intense affect. Sharing his experience enabled him to
contain it, to reflect more deeply, and to be able, now somewhat
less flooded by what was stirred in him, to refocus his understand-
ing of his patient. Later these same confidants provided confirma-
tion of his own sense of personal change.
Working through issues involves a process of making uncon-
scious experiences conscious, lessening affective charge, and
gradually reintegrating previously unacceptable or disavowed as-
pects of the self. This process occurs in different ways and with
different degrees of intensity and depth for different analysts. The
two steps described so far are (1) the analyst’s private self-reflec-
tions and (2) the sharing of conflict, affect distress, insight, and
work in progress with a colleague or psychologically informed
friend. Some analysts engage only in the first step, and some are
more systematic in these explorations than are others. Some, but
not all, analysts find that the shared exploration of their self-
scrutiny promotes and consolidates their understanding. A third

step occurs in the actual work with the patient. It is likely to occur
simultaneously with one or both of the other methods for attaining
understanding and affect management.
Many of the analysts interviewed describe a process that in-
volves a reverberation between the patient’s and the analyst’s
issues that occurs during the actual analytic work. Since each
analyst has his/her own specific constellation of characterological
and conflictual issues, of which only a particular array will be
stimulated, depending on the nature of the “match” with the pa-
tient, the content that is reworked will vary for each analyst. The
safety of the analytic setting permits a regressive process enabling
usually suppressed or repressed affects and phantasies to become
available for both patient and analyst. The “play” that becomes
possible in the context of such safety creates an opportunity to
rediscover identifications and to become more conscious of their
formation. Then, in relation to a new and different object, shifts in
self- and object representations become possible. Concomitantly,
shifts occur also in defence, in availability or tolerance of affect, and
(more consciously) in attitudes, values, or beliefs.
For this analyst, affect availability/tolerance is worked through
directly in the analysis with his patient. Once the analyst interrupts
his defensive reaction, he experiences powerful and frightening
affects parallel to those the patient is struggling to understand and
master. The analyst not only allows himself to experience intensely
frightening affects but also learns to tolerate and not be “blown
away” by them. This change in the analyst’s capacity is then paral-
leled by the patient’s increased capacity to stay with his affects as
his own rage and terror abate. Both patient and analyst learn more
about each affective state (and what triggers it) in the course of this
exploration of self and other in which they are powerfully engaged.
As the process evolves, rage and terror are experienced alternately
by each participant in relation to the other. Although the analyst
does not detail the process between them, what occurs seems to be
a mutual exploration of what each could tolerate from the other.
This exploration was affectively enacted, not just put into words.
The analyst’s experience in the treatment, if not as powerful as
the patient’s, was close to it. While the patient’s reactions are
re-embedded in their historical context, the analyst’s at this point

are not. For the analyst, it is a “here-and-now” reworking that takes
place.
The psychological changes that attend successful analysis occur
in areas that are embedded in the process. Broadly defined, these
areas are intrapsychic, interpersonal, and work-related. In each of
these areas, shifts in defences, availability and tolerance of affects,
and self- or object representations, as well as more conscious shifts
in attitudes, values, or beliefs, play a role.
To understand the curative aspect of psychoanalysis, it seems
necessary to tease apart two foci of this work. One involves affect
availability and tolerance, the other object relations. The non-inter-
pretative aspects of the analytic work that revolve around these
two variables are experiences of the patient that have many direct
parallels for the analyst.
The analysts in this survey all describe slightly different content
or foci when considering the question of therapeutic action; none-
theless, there is a commonality in their approaches. Most analysts
agree that it is necessary to reengage repeatedly with painful or
disappointing experiences or states from the past and to re-experi-
ence over and over the consequences of unconscious conflicts,
phantasies, defences, and affects in the context of the present rela-
tionship with the analyst. Most, but not all, analysts place a value
on insight; they believe that cognitive clarity, an intellectual appre-
ciation of unconscious determinants, provides increased freedom.
Most, but not all, believe it is important that the patient be able to
articulate these insights. All analysts believe that for analysis to
have an impact, what is learned must be emotionally alive. Most
analysts believe also that reopening painful past experiences re-
quires a regression.
Learning to self-regulate, to tolerate frustration and modulate
affect, is a developmental task most often mastered during the
latency years. It is not infrequent that intellectual precocity inter-
feres with a fuller development of this capacity. The precocious
child, for whom many intellectual tasks are easily and quickly
grasped, is spared the frustrations usually encountered in master-
ing them. As a result of this decreased exposure to enduring
frustration, the skills involved in mastering and containing tension
and intense affects are less developed in such individuals. Analysis
offers these analysands the opportunity to attain these skills (Gedo,

1979; Kohut, 1984). This is accomplished by what Kris (1990) has
called an alliance of self-control and what Modell (1986, 1993) has
referred to as affect retraining. We think of this as the analyst
helping to provide containment for intolerable affect as the patient
comes gradually to tolerate increasingly stronger affects without
fleeing or becoming flooded.
Analysts generally can be assumed to be considerably ahead of
their patients in the acquisition of the capacity for affect availability
and modulation. They have had their own analysis, in which, even
if self-regulation has not been a direct focus of the work, the ex-
perience of frustrated wishes must have been endured. So even if,
in the most idyllic (and unlikely) scenario, life circumstances or
choices have limited the amount of frustration the analyst has had
to withstand, practice with tolerating disappointment and frus-
trated wishes is not entirely lacking. In addition, in the current
analytic situation, the degree of frustration and disappointment
experienced will likely be much greater for the patient than for the
analyst. Although the analyst, like the patient, may experience
disappointment and frustration during the course of their work,
these occurrences are not part of the treatment design; the material
to be the focus of attention is properly the patient’s. All of these
factors contribute to making the analyst’s tolerance of frustration
and affect modulation much less an issue in the analytic setting
than they are for the patient.
In the analysis being discussed, the analyst more deeply experi-
ences the intensity of affective distress than is commonly the case.
The analyst permits himself to regress in this manner in order to
help his patient. He knows that if he maintains his defensive
distancing he will not become flooded—but he will also not be able
to understand or help his patient. He therefore faces and over-
comes his affect inhibition and gives himself over to the process.
He trusts himself enough to take this risk. The patient began
analysis with a transference in which he perceived his analyst as an
enemy to be destroyed. He was the kind of patient Winnicott (1965)
described as ruthlessly aiming to annihilate the analyst and Bird
(1972) described as having wishes to actually, not symbolically,
inflict harm on the analyst. At first it seemed that the patient might
be able to destroy the treatment, if not the analyst himself, because
his analyst backed out. The analyst’s ability to acknowledge his

defences and face himself reversed this outcome. The analyst be-
lieves that the patient had been able to perceive that his analyst had
backed away from him in response to his powerful rage. The
analyst believes also that the patient preconsciously registered
both the analyst’s terror and his ability to withstand it. Once the
analyst no longer retreated, the patient was no longer “blown
away” either, since he could then be less afraid of the effect his rage
might have on the analyst. The patient found, it seems, that the
analyst was neither destroyed nor about to destroy him. The pa-
tient was then able to experience and express feelings other than
rage and to explore and come to understand these affect states.
The analyst, for his part, powerfully revived—though he did
not cognitively register—early childhood experiences of terror and
rage. He reacted and recognized his reactions, but did not know
the origin of his terror. Now a grown man with the physical,
intellectual, and emotional strength he lacked as a child, he was
determined to face and not flee his terror. Why was he willing to do
this? Both professional and personal factors contribute to the an-
swer and in this instance may not be totally separable.
He is committed to helping his patient, a commitment based on
professional ideals. These ideals, of course, are shaped by the
personal values that led to his choice of profession. This analyst has
an ideal of personal honesty and courage that is reflected in his
determination not to withdraw in the face of his experienced terror.
Undoubtedly, based on his later understanding that this experi-
ence was a repetition of early terror and retreat, his determination
also reflects his unconscious need to master this childhood trauma.
The wish to master is a powerful motive in shaping behaviour.
In their transference–countertransference engagements, this
patient–analyst pair struggled with their mutual terror and rage.
The analyst, to be sure, was much more in control of its expression.
Patient and analyst emerged changed from a combination of in-
sight into their defensive manoeuvres and a sense of safety and
trust achieved through having survived their intense emotional
entanglement. The power of the treatment was in their interaction.
In their work, the analyst was overcome by an intense affective
reaction that paralleled the patient’s, and both participants learned
to withstand and ultimately regulate their affective experiences.
The analyst “feels” the familiarity of his affective distress and

reactive pattern of coping, but does not recover its historical con-
text until the interview. He withstands the affective intensity by
focusing on his understanding of personality organization, by rec-
ognizing his defences and their repetitive nature, and by a determi-
nation to master his fear and help his patient master his. Most
important, his sense of increased strength and ability to cope come
from seeing that he is doing so. His increased strength is perceived
by his patient, who is calmed by it. This gradual calming of the
patient further increases the analyst’s sense of strength, effective-
ness, and mastery. He illustrates the idea that changed behaviour
precedes insight.
Increased tolerance of painful affect is not something that oc-
curs outside the context of a relationship. Shifts in affect availabil-
ity and tolerance may precede or follow shifts in self- and object
representations. A change in the analyst’s capacity to tolerate and
modulate intense affect and a change in self-representation are
related. A greater sense of one’s ability to be self-regulating in-
creases a sense of competence and self-esteem. A new integration,
which includes changes in self- and object representations, occurs
after the analyst confronts and struggles with the modulation of his
aggression.
Change in the analyst’s affect availability and tolerance facili-
tated a change in his self- and object representations. Not only was
there a mastery of early terror; there was also an unconscious
reintegration of his sense of himself in relation to his identification
with his father. The analyst, in choosing to become an analyst, has
selected a field of work in which he actively seeks to help others
ease their pain and fear—again suggesting he has selected a career
that supports a mastery of early pain. Unconsciously, this choice
may have also been based on a negative identification with his
representation of his father: he, the analyst, would ease fears by
analysing and mastering them, rather than creating them, as he
believed (unconsciously) his father had created them in him. As the
patient explored the feelings that lay behind his rage, the analyst
was able not only to feel less afraid but also to consciously empa-
thize more with his patient and, unconsciously, with his father.
Once the analyst perceived his patient differently—no longer as
just a terrifying bully—he must also, unconsciously, perceive his
father differently. An interpersonal terror then became understood

as an intrapsychic terror, and paralysing fear was replaced by
anxiety that could be grappled with and understood.
The transference/countertransference is viewed as the dynamic
pivot facilitating psychological change. Psychoanalysts have a
theory of why the affective reliving of dangerous or disappointing
relationships in the context of a new relationship with the analyst
creates the opportunity for psychological change in the patient. We
have theorized that the understanding of past fears and disap-
pointments, through both their re-experience and their interpreta-
tion in relation to the analyst, permits an internal reshaping to
occur. All this is contingent on the analyst’s becoming an emotion-
ally important figure in the patient’s life. While analysts are usually
deeply involved with their patients, we do not assume that a
patient is likely to have the centrality in an analyst’s life that the
analyst has in the patient’s. Indeed, if this should occur in any
sustained way, there are likely to be untoward consequences for
the treatment. However, the degree of personal involvement an
analyst feels with a patient varies with each analytic pair. The more
areas of personal overlap, perhaps especially when these overlaps
are in areas of shared difficulties, the more intense the analyst’s
personal involvement is likely to become.
Under the conditions of this increased emotional engagement,
transference–countertransference interactions are likely to be more
heated and to have a more powerful impact on the two partici-
pants. While it is the patient whose difficulties are the focus, the
analyst becomes a participant in the struggle as the patient’s trans-
ference intensifies. The analyst increasingly feels, not only under-
stands, what the patient has been describing. Sometimes this
affective understanding is in empathic resonance, but sometimes it
is not. Both the position of being “inside” the patient’s experience
and the position of being “outside” in the role of “the other”
provide data about the patient and oneself. Allowing oneself to
actively participate in the affective life of a patient means being
open to one’s own affects, phantasies, hopes, and fears.
Although the asymmetry of the relationship means that the
analyst is by definition in a “safer” position than the patient, the
former, once this emotional openness is permitted, engages in an
emotional risk. Without this emotional risk, no psychological
change can take place. To be truly engaged is to allow oneself to be

vulnerable to another. The relationship benefits the analyst beyond
the cognitive recognition and clarification of personal issues. Once
engaged, the interaction that occurs between patient and analyst
provides the analyst an opportunity to change.
Such engagement is not lightly undertaken. It requires trust in
one’s capacity to withstand the intensity of the patient’s affects and
the intensity of what these phantasies, wishes, and fears evoke in
oneself. The degree of freedom the analyst can permit is dependent
on the extent of this trust and also on the extent to which the analyst
believes the patient can be trusted. The analyst’s spontaneity and
emotional openness are likely to increase the more the analyst
believes in the patient’s capacity to express freely the thoughts,
feelings, and fantasies stimulated by the analyst, the analyst’s
interventions, and the analytic situation. And while it is not the
patient’s obligation to maintain confidentiality in relation to any-
thing learned directly or indirectly about the analyst, or in relation
to what transpires between them, the manner in which the patient
deals with such material undoubtedly affects the analyst’s sense of
safety and freedom in the analytic setting.
If the patient’s psychological change comes about, at least in
part, because what goes on between analyst and patient is different
from what the patient has previously experienced—that is, fright-
ening or disappointing expectations about the other and/or oneself
are not repeated, or if repeated are reworked, re-understood, and
then relived with a different outcome—then something parallel is
likely to occur for the analyst. The patient may become an old/new
object for the analyst in parallel with the analyst’s being an old/
new object for the patient.
If the analyst is really emotionally engaged, and if this engage-
ment is around an area of mutual difficulty, the interaction be-
tween patient and analyst entails a mutual reworking of past
expectations. The analyst not only sees and experiences his pa-
tient’s reliving of these expectations in relation to him, but has
the opportunity to be in both roles and to appreciate affectively,
therefore, the complexity and ambiguity of these experiences. At
one moment the analyst is identified with the patient, as in this
instance the analyst’s countertransference terror and rage become
understood as his patient’s earlier states, at another moment he is
experiencing himself as the perpetrator of this pain. When he

experiences himself as on the “outside”, he sees himself being
represented as causing all this distress. The analytic situation al-
lows him to see and experience both points of view: the patient’s
perspective and the perspective ascribed by the patient to “the
other”. This analyst’s fluctuation between the experience of rage
and terror ultimately facilitates his developing empathy for his
patient and perhaps for himself as a child, which deepened as he
was more fully able to move back and forth between these states.
The analyst’s trial identification with the patient, which enables
the analyst to explore empathically the patient’s difficulties, also
provides a vicarious experience of these issues for the analyst.
When an analyst enters a patient’s world in this way and tries to
understand and grapple with the patient’s experience, if the issues
the patient is struggling with parallel issues for the analyst, the
process that results offers the analyst a chance to work on these
difficulties in a once-removed fashion.
The analyst holds the patient’s construction of self, of the ana-
lyst, and of the analytic relationship and juxtaposes this against
his/ her own perspective on self, the patient, and the relationship.
The analyst does this not to determine which is “true” but, rather,
to understand further each of these different views. The discrepan-
cies are likely to be the areas where important work occurs for both
participants.
What is being played out interpersonally is also intra-
psychically represented; these two perspectives—of patient and of
analyst—are externalizations of intrapsychic representations. What
we see as an interpersonal struggle is also an intrapsychic conflict.
Therefore, as patient and analyst become more empathic, under-
standing, and open to these multiple and at times conflicting points
of view, complexity and ambiguity increase and the sense of con-
flict diminishes. Disowned aspects of the self are able to be reinte-
grated because they are no longer experienced as so frightening;
they are experienced as less dangerous because they are no longer
seen as so black and white. The reintegration creates a new synthe-
sis, with slightly expanded capacities for self-acceptance and the
acceptance of others and their differences.
Self- and object representations shift and consolidate during
the course of working with patients. For this analyst, only in the
termination, which coincided with his father’s death, did he

affectively experience how deeply attached and sad he felt at the
prospect of his patient’s leaving. In parallel, he experienced how
attached he felt to his father and how sad he was at his loss.
This analyst is one for whom sharing his thoughts and feelings,
being open with his intimate experiences, is not a rare occurrence.
He talks freely with his wife and with a close friend. The insight he
attained in the course of the interview may have emerged because
he discussed the patient in greater analytic detail than he might
have with his wife and friend, who were not analysts.
While the analyst does not know me well, we have discussed
some mutual interests previously, and he views me as someone
who would understand, respect, and respond positively to the
ideas and experiences he conveyed. Before the interview he had
had the powerful experience of shifts within himself, but during
our talk they became newly understood in a historical context. It
was in the context of feeling trust and safety in relation to recount-
ing the example that he made the cognitive link between his
experience with his patient and with his father, and recovered the
memory of early terror. While it is reasonable to conceptualize his
response to me as “transferential”, I am not sure that such a con-
ceptualization enhances or is necessary for an appreciation of his
discovery.
In the context of sharing his strong affective experience, the
relational aspect came more into focus for him. What occurred for
this analyst in the interview is not a psychological change—based
on his description, the shift in him had already occurred. What he
achieved in the interview was a deepened understanding of what
had taken place for him and why it had been so emotionally
gripping. This insight will further consolidate the changes that
have occurred, helping the analyst to more fully reintegrate past
experiences with present ones.
The analyst reports that his experience of working with this
patient changed his tolerance for affect, in both his professional and
his personal life. In relation to his work, he no longer finds himself
becoming cold inside, disconnecting, or experiencing primal terror
in response to patients’ rage. He is better able to recognize and own
his discomfort and less likely to assume it is a projective identifica-
tion. In his personal life he is no longer so disquieted by intense
affect and volatility. He finds himself much more comfortable with

the emotional expressiveness of his family, much more tolerant of
his own affects, and much more able to experience a sense of
intimacy. His wife has spontaneously corroborated his observa-
tions about his decreased reactivity to the expression of intense
affect.
Although it is not possible to know how deep or far-reaching
the transformations are when analysts report shifts in their atti-
tudes, values, or beliefs, these phenomena have a conscious repre-
sentation; at that level, we can accept that in this instance the
analyst has changed. But whether earlier attitudes, values, or be-
liefs continue to persist unconsciously and influence his reactions
and behaviours in ways he is unaware of cannot be assessed from
this material.
I am not suggesting that when patient and analyst share an area
of difficulty the analytic work will result in identical psychological
changes in each, or even changes in the same general areas. For all
the similarities and overlaps, the differences between the two mean
that each will make use of the work in his/her own way. What a
particular interaction means for the patient, and what he/she
learns from it may be very different from what the analyst learns
from it, even if there was some similarity in their initial construc-
tion of its meaning. In this instance, both patient and analyst
experienced terror and rage. We know that the analyst came to
both master and understand his response in the context of his
personal history. The patient likely has learned something similar,
but he may also have learned something very different, something
more relevant to his particular history and dynamic organization.
In every analytic situation that succeeds, some form of intense
emotional engagement occurs at some time in the analysis. When
the affective intensity is high, as occurs in analytic dyads in whom
mutual erotic transference–countertransference is deeply experi-
enced, or, as in this instance, where the terror and rage of primary
aggression are shared, the mutual change and growth may be very
striking. How much of this the analyst allows to occur in him/
herself would seem to depend not only on similarity of conflict
areas but on similarity of values. This does not mean that the
patient must actually resemble the analyst but only that the analyst
is able to find a place of respect and regard for the patient. Most
analysts report that the longer they work with patients the more
these feelings of regard increase as they come to better understand
what their patients have struggled with and why they have come
to the solutions they have chosen. The more the analyst comes to
know and respect the patient, the more the analyst trusts the
patient and is able unconsciously to move closer and to be more
open and vulnerable. I am not suggesting that this is expressed in
the content of what the analyst says, though at times it may; rather,
I am alluding to something nonverbal that is communicated in
subtle ways. This is an area of our work that deserves further
consideration.
In our attempts to elucidate the nature of therapeutic action, it
becomes clear that many factors play a role, though their relative
importance remains to be determined. The recent emphasis on the
experience of analysts during analysis has allowed us to begin
documenting how the analytic process affects both participants, to
the extent they open themselves to it.
Note
1. Many experienced analysts have chosen not to become training and

supervising analysts.
CHAPTER THREE
Knowing and being known
Christos Ioannidis
I am accustoming myself to the idea of regarding every sexual

act as a process in which four persons are involved.
Sigmund Freud, Letter to Wilhelm Fliess, 1899
T
his chapter addresses an often acknowledged and equally
often overlooked aspect of the psychoanalytic encounter. It
is not uncommon to hear comments about how differently
individual analysts respond to the same material, of the impor-
tance of the “match” between analyst and patient, or of the so-
called degree of unresolved pathology in the analyst. The implied
point of reference in these statements is, it seems, an idealized
condition that the analyst should be striving for—that is, a state of
being neutral, “tabula rasa”, mirror-like. There is no hesitance in
recognizing the frequent falling short of this imperative, but the
instruction to persist striving for it remains, it seems, impervious to
this reality.
An expanded version of this article appeared in Psychoanalytic Psycho-

therapy, 16 (No. 3, 2002).
43
44 CHRISTOS IOANNIDIS
It is my aim here to claim that the notion of an analyst striving

for neutrality is epistemologically untenable and that the more the
participation aspect of the participant observer is underestimated
or looked at for the sole purpose of taking it out of the equation, the
more it will be driven underground and be given free rein in the
realm of the unconscious. Ideals of abstinence and objectivity may
end up promoting what is no more than an illusion that then runs
the risk of encouraging tunnel vision. Paraphrasing the well-known
systems-theory dictum that says “one cannot not communicate”, it
is essential that one recognizes the fact that the analyst’s personal
presence cannot but affect and influence both the patient and the
process. Consequently, the subject matter of any analysis is not
exclusively the patient’s unconscious or psychic constitution, the
patient’s projections and other defence mechanisms, the patient’s
trauma and distress, or the patient’s developmental arrest but the
relating that gets engendered in the room. Whereas the long-term
aim of an analysis in the form of a search for the patient’s inner truth
remains unaltered, the subject matter of the day-to-day focus must
needs be the understanding of the here-and-now encounter, under
very special circumstances of two subjects one of whom has delib-
erately and consciously chosen to “wear a mask” (Kennedy, 1998)
and another who has consciously, at least, accepted that this will
be the case. Just as we now recognize that internal objects or internal
representations are not simply internalized distortions of parental
figures but internalizations of structures of relating that by now act
as procedural templates outside the realm of subjective experience
(Sandler, 1998), so, too, the focus of analysis is not the internal world
of one, but what gets created through the interaction of the internal
worlds of two (Ogden, 1994a).
Theoretical background
In 1915 Freud talks about a communication that takes place be-

tween the patient’s and the analyst’s unconscious in the realm
outside awareness. It is a clear acknowledgement of the fact that
the analyst is unconsciously communicating to the patient as well
the reverse. How else could it be? It would be a betrayal of our very
KNOWING AND BEING KNOWN 45
own theory if we were to claim that the analyst, who only a few
months or years ago as a patient him/herself was transferring,
making full use of unconscious defence mechanisms, was employ-
ing projective identification, and so forth, would somehow cease to
do that the moment he switches from using a couch to using a
chair. Reality must surely be closer to Searles’s (1978) courageous
remark that one’s own analysis does not decrease the gamut of
emotions, but enables them instead to come into a better harmony,
a better balance, so that no single emotional attitude predominates
over the others.
The propensity, and indeed ability, that patients have to read
the unconscious of the analyst and to monitor variations that reveal
aspects of the analyst he/she may not be aware of him/herself,
raises three fundamental issues that we can no longer afford to
evade.
(1) The fallacy of the impenetrability of the mask. The analyst is con-
stantly revealing him/herself. Commencing from simple overt
characteristics like his/her appearance, voice and use of language,
social skills, the aesthetics of his/her space, and other inevitable
choices he/she has made, and so forth, all the way to more subtle
indicators—such as at which point he/she chooses to interpret
(Renik, 1993), what he/she selects to interpret, in the transference
or outside it, what conceptual model he/she employs, how consist-
ently it is adhered to, and if a shift occurs, when does he/she do
so—are all highly significant (Klauber, 1986). They are also in full
deployment for the patient to observe and incorporate into his/her
experience of who this person he/she is having an analysis with is.
Sandler (1976) describes the analyst’s free-floating behavioural re-
sponsiveness as acting under motivational forces that may not yet
be cognitively understood by the analyst.
Anna Freud’s classic definition of neutrality as the ability to
maintain equidistance from the ego, the id, and the superego has
often been misinterpreted as referring solely to the patient. As
early as 1957 Racker made the following statement: “The truth is
that [the analytic situation] is an interaction between two personali-
ties, in both of which the ego is under pressure from the id, the
superego, and the external world; each personality has its internal
and external dependencies, anxieties and pathological defences . . .
and each of these [two] personalities responds to every event of

the analytic situation” (p. 132). It may be important at this point
to consider that it is equally vital for the analyst to maintain
equidistance from his/her own three psychic structures. To fail to
maintain this equidistance, claiming that the analyst’s conscious
comments and conscious perceptions of reality is all there is, and to
hold an attitude that assumes the analyst’s conscious reality is the
norm against which the patient’s reality has to be compared and
modified, is to veer heavily on the side of the ego and betray the
equidistance.
When Renik (1993) talks about the self-idealization of the ana-
lyst that results from the belief in the possibility of the analyst
transcending his subjectivity, I suspect that he is referring to the
failure to maintain this vital equidistance. This failure may lead to
coercion and, as Brenman Pick (1985) has pointed out, “when the
split-off emotionality of the analyst returns, it will do so with all the
risks of acting out”. To imagine that the split-off emotionality won’t
return, she emphasizes, is contrary to the very theories we hold in
relation to mental life.
A crucial element of the psychoanalytic encounter is the experi-
ence of being understood/recognized by another (or the lack of it).
Given that a purely intellectual understanding is neither possible
nor desirable nor indeed has any meaning, it is the affective impact
that one concentrates on—that is, how the patient affects the person
of the analyst. Searles (1978) calls the need to force the analyst to
admit that the patient is having an emotional effect on him, the
“source of one’s strongest resistance”. An analyst who does not
permit his own subjectivity to be recognized is one who offers to be
experienced as an object rather than a subject (Benjamin, 1988).
Such skewed relating cannot but have consequences.
(2) The patient’s perception of the analyst (i.e. the transference) not as a
distortion in quality but as a distortion in degree. The way the analyst is
experienced by the patient is in the realm of the transference. We
have it on the highest authority (Freud), however, that the patient
uses attributes of the analyst as pegs to hang his/her own distor-
tions/internal phantasies as transferential elements on. It is prover-
bially difficult to separate between what belongs to the analyst and
what to the patient, and since many theoreticians have advocated
the view that the patient’s perception of the analyst is to be treated

technically the same—irrespective of whether it is veridical or
transferential—this ambiguity and paradox will forever form part
of the conceptualization. It is a short but pivotal step from this
fluidity to the attribution of the total situation to the patient’s
initiative, albeit unconscious, and to disown the analyst’s contribu-
tion. There exist two possible positions to take: one that stays with
the uncertainty, and the other that takes this short step towards
certainty. The latter position sees the patient as the instigator of the
emotional atmosphere in the analytic process and the analyst as the
sensitive recipient of the communications (and/or projections)
who then responds either in the grip of the transference (counter-
transference enactment) or analytically even if after a long period
of “not knowing”. If, on the other hand, one chooses not to attribute
the emerging matrix solely to the patient’s doing, then one is left
with a much more complex and unnerving set-up. This set-up
would of necessity expand our definition of the psychoanalytic
encounter to incorporate the bidirectionality of the above de-
scribed dynamic. Together with (a) the patient as instigator and the
analyst as respondent, one would have to consider (b) the analyst
as instigator and the patient as respondent, and the subject matter
of the analysis would then be the recognition and interpretation of
the intermingling of these concurrent dimensions. Tarachow (1962)
makes a similar point when he underscores “the basic urge both
patient and therapist have to mutual acting out”. Loewald (1986)
has courageously put forward the view that there are just as good
reasons for calling the patient’s experience countertransference in
order to emphasize the responsivity to the analyst, as there are to
call the analyst’s experience transference in order to emphasize the
extent to which he is the initiator of interactional sequences. Other
theorists would see the patient acting as a therapist to the analyst
(Searles, 1978), or monitoring the analyst’s countertransference,
and the free associations as being no more than commentaries on
that (Langs, 1978).
(3) The essence of what is being communicated by the analyst—that is,

the analyst’s needs, be they instinctual or defensive. The issue of the
person of the analyst is enormous and there is no way a chapter like
this could do justice to the complexity it entails. Consequently, I
shall simply confine myself to a brief and incomplete survey of

some areas of concern:
• It is noted that there is a tendency to avoid transference inter-

pretations—a counter-resistance to making them—because
such interventions draw the full impact of the patient’s libido
onto the analyst and thus put the analyst’s relationship to his/
her own unconscious impulses to test. It is also noted that the
reluctance to interpret the transference may be influenced by a
wish in the analyst not to know. Conversely, the insistence on or
exclusivity of transference interpretation may be indicative of
feelings of grandiosity and self-importance or narcissistic
longings for idealization—phantasies of having become the
centre of the patient’s emotional life.
• Given that the analyst has his/her own object needs and given
the continuous investment he/she makes on the patient and the
analytic process, the patient inevitably becomes a kind of love
object for the analyst. Fear of losing the object, fear of losing the
object’s love, and having to deal with abandonment and loneli-
ness may unconsciously promote the tendency to overcome this
through the use of the patient in some way and most particu-
larly through fostering dependence.
• It is important to remember the fear of incompetence in the
analyst, the fear of failure, fear of craziness, frustration of the
sublimated instinctual forces, and so on, which may all subtly
lead to the tendency to attribute phenomena to “transference
projections” of the patient and/or deny the analyst’s own
anxieties through the use of interpretations. The analyst’s nar-
cissistic vulnerability, plus the necessity to always doubt and
constantly question the validity of his/her understanding, puts
the analyst in a position where a patient’s criticism, contempt,
or devaluation may deeply wound the analyst and provoke
either a wish to counter-attack in an attempt to re-establish
authority or a retreat to a stony withholding silence. The patient
may, on the other hand, for his/her own reasons willingly
collude and comply because he/she clearly senses the analyst’s
unease.
• There is mention of the ever-present sadomasochistic elements
in the psychoanalytic process. That is, the interpretation as a

depriving act that imposes separation and loss, the temptation
to exercise control, be all knowing, and expect that the patient
surrender his/her defences against painful ideas and feelings.
The failure to gratify, and the expectation to put up with non-
gratification, also fall into that area of experience.
• The principal temptation the analyst finds him/herself strug-
gling with is to be parental, to play the role of mother, or to see
the patient as an early aspect of the analyst’s self. Just as
prevalent is the conviction that through care and attention the
analyst will provide a better (and hence curative) experience to
the patient than the one the patient’s own parents provided.
• It is acknowledged that fear of collusion/seduction with the
patient or of being caught up in an “overvalued idea” may
result in a reaction-formation rigidity, which makes communi-
cation very problematic.
• Equally, idealization of the analyst’s ability to be objective can
foster complacency and sow blind spots—that is, failure to
recognize that an interpretation is a kind of imposition of the
analyst’s own truth and is being heavily influenced by uncon-
scious countertransference feelings. In other words, it is a form
of behavioural enactment. Elements of coercion and suggest-
ibility may end up being denied rather than examined.
• The analyst’s own unconscious guilt for the harm done to his/
her internal objects and the severity of his/her own superego
undoubtedly plays a vital role.
• The patient may be experienced as the internal damaged object
of the analyst’s unconscious phantasy and the object of his/her
reparative drive. If this reparative drive is thwarted (i.e.
incomprehension), unconscious guilt and anxiety may increase,
further limiting understanding. There is great temptation at this
point to offer to the patient love (reassurance) as an ostensible
reaction formation or resort to hostility/dismissal, both of
which are defences against the analyst’s emerging depression.
All in all, the concern is around how the analyst may be prepared
to deal with his/her own unconscious gratifications and limita-
tions in view of the inevitable encounter during the psychoanalytic
process, with his own frightening and unwanted feelings, espe-

cially when the patient corresponds too closely to not-understood
aspects of the analyst’s own self. The analytic situation, one should
not forget, is a compromise formation for both a wish for intimacy
and a defence against it for the analyst, thus providing a quasi-
mastery of powerful affects brought on by close and direct relation-
ships with other people (Greenson, 1967). Despite such complexity,
which represents only a proportion of what happens in an analysis,
the paradigm of unidirectionality has survived. There must be
powerful forces that keep it afloat, and it may be that we shall need
to fully understand them first before we get a clearer and more
systematic understanding of all the conscious and unconscious
fields overlapping in the consulting-room. No one could be more
succinct than the non-analyst Vygotsky (1988) when he writes: “A
true and complex understanding of another’s thought becomes
possible only when we discover its real, affective-volitional basis
. . . when we reveal the most secret internal plane of verbal think-
ing—its motivation” (p. 282).
Concluding remarks
In his attempts to tackle the issue of subjectivity in the psycho-

analytic situation, Bollas (1987) encourages the analyst to think of
him/herself as “the other patient”, and goes on to say that the “the
clinician must find a way to make his subjective states of mind
available to the patient and to himself . . . even when he doesn’t
know what these states mean” (p. 203). This borders on the contro-
versial debate on disclosure that has plagued psychoanalysis since
Ferenczi’s experiments. Much has been written on this issue, but it
may in the end turn out to be a pseudo-dilemma, in that as far as
the essential core is concerned, the patient already knows. The
patient is constantly taking in, consciously or unconsciously, defi-
nite perceptions regarding the analyst as a real person, overall and
at any given moment. Just as the analyst often listens to the mood
beyond the words, so too, we have to concede, does the patient
(Brenman Pick, 1985). How that is then elaborated within the total
transference situation is an inevitable second step and may belong

mainly to the patient.
The dilemma of disclosure is a direct consequence of the
epistemologically untenable notion that the pursuit of truth (K) can
be engaged in without concurrent L or H (Bion’s frequently misap-
prehended comment regarding memory or desire)—a very preva-
lent premise that has repeatedly been refuted over the years.
Simply put, does being a neutral analyst mean that he/she is cold
and with no feelings (Segal, 1978)? If disclosure is then not the
issue, the task one is left with will be the prevention of possible
undue impingement onto a situation that is mutually created by
two subjects in the common pursuit of truth. The shift of focus from
the patient’s internal world and its realization in the analytic space,
to the interaction between two subjects (mutual but not symmetrical)
that has been so elegantly portrayed by Ogden (1994b) as “the
analytical third”, invites a re-conceptualization of our day-to-day
understanding of what happens in an analysis.
The familiar image of the figure/ground employed by some
psychoanalytic authors (Benjamin, 1988; Bion, 1961; Hoffman,
1983) to describe the analytic situation does indeed convey quite
convincingly the live paradox of the bidirectionality entailed in
any analysis. Failing to see that the patient transfers the precon-
ception onto or into parts of the analyst that permit or at times
promote this mating in order for the transference realization to be
established is tantamount to advocating that the attributes of the
container can be disregarded when examining the containment
process. If this is inconceivable for the mother–baby dyad, it is
equally inconceivable for the analytic dyad. Our complex concept
of countertransference has sometimes been thought of in what
appears like defensive ways. Initially it was defined as something
to be avoided or to be grown out of because it comes from the
analyst. In the last few decades, however, it has been understood
as something valuable because inevitable and to be made use of.
Peculiarly though, theory has gone to the other extreme, and now
countertransference is frequently misunderstood as a state evoked
in us exclusively by the patient (so it is a communication by the
patient about his/her internal world) and saying nothing about
analysts as agents who have their own unconscious world perme-
ating subliminally the conscious countertransferential thoughts

and feelings.
It seems to me that as philosophical and infant-research theories
converge in their understanding of the human encounter, psycho-
analysis with its unique focus on unconscious processes cannot but
tend towards this point of convergence and redefine its field of
vision as that very particular and certainly asymmetrical area of
overlap of two unconscious systems in a common conscious pur-
suit. The study of this phenomenon—which is the subject matter of
analysis—cannot but be the study of the meeting of the two indi-
vidual systems and not the vicissitudes of only one. This latter view
seems to claim that the one unconscious system overwhelms the
analytic situation totally and that the analyst’s unconscious has
already reached consciousness and is therefore not truly present in
the interaction. Can such a view be defensible still?
CHAPTER FOUR
How does psychoanalysis work?
Imre Szecsödy
T
he goal of psychoanalysis is complex; this cannot be more
clearly defined or made explicit than as an aspiration on the
part of the analysand and the analyst to promote autonomy,
knowledge, emancipation, and health and to liberate the indi-
vidual from some limitations and suffering. How do they reach
their goals in psychoanalysis? What happens within and through
the interaction between the analysand and the analyst? What does
it signify that patients may feel equally understood by analysts
belonging to different schools of thought, despite their divergent
and often conflicting views of what is relevant and correct? What is
specific? Is the analysis a process of acquired learning or a new
beginning due to the analysand’s relation to the analyst? What is
curative? Are the factors that vary and distinguish between differ-
ent schools non-specific or specific?
In the analytic situation we try to reach dyad-specific knowl-
edge, which must be differentiated from accumulated knowledge
where the goal is to create general formulations. Engrossed in
clinical material we try, often impressionistically, to identify vari-
ous elements in the process and to elucidate what it is that changes,
and how and why. The problem is that our subjectivity remains
53
54 IMRE SZECSÖDY
tacit, not systematically tested and checked, and that the choice of
material can easily be guided by latent bias with fixed ideas and
expectations. Meaning is created through the mutual relations that
arise between representations. Juxtaposing two representations
opens the door to reflection, making change possible. We under-
stand others—their thoughts, feelings, behaviour, and percep-
tions—by trying to give meaning to, “make sense of”, their
opinions, by using our own viewpoints as a source of fantasy.
Fantasy allows us to create an inner view of feelings, convictions,
and goals (which we do not necessarily share) so that we can
understand the conduct of others.
The psychoanalytic process arises in a mutual interaction be-
tween analysand and analyst. Both the analysand’s and the ana-
lyst’s personalities and expectations, their conceptions of the
world, their attitudes about themselves and others, and their char-
acteristic ways of organizing and working through information
contribute to the progress of the analysis and to how the process of
change develops. Ideally, the relation may bear the stamp of the
analyst’s attitude, distinguished by his/her interest, vigilance, and
reliability. It calls for the analyst’s constant attention to how he/she
is affected by and affects this specific relationship that is founded
on an illusory and real exclusiveness. Within a limited and chosen
time, the analyst extends his/her particular ability to remain open
to whatever may pass between the analysand and him/herself, and
between him/herself and the analysand. It is an exclusive relation-
ship, also, in the sense that it gives temporary (during the course of
the session) precedence to the symbolic meanings of events, with-
out, however, denying the actual reality that exists both within and
outside the consulting-room. It is an exclusive relationship, be-
cause it is simultaneously constant and questioned, striving to
establish reliability while at the same time allowing and affirming
ambiguity. The analyst’s attention should encompass an effort to
examine the motives for his/her commitment and the limits of his/
her ability.
It is highly important to understand how psychoanalytic com-
petence is developed and maintained. Psychoanalytic training was
institutionalized 1922 at the Berlin Congress. It was built on the
tripartite model: personal analysis as the basis, to get in touch with
HOW DOES PSYCHOANALYSIS WORK ? 55
the method as well as with the influence of the unconscious on

everyday as well as professional life; didactic training, to learn the
theory; and supervision, to integrate the experience and theory
with the candidate’s personality. It may be of service to remember
that as soon training becomes organized it poses trainer and train-
ees with the problem of what the content of a training programme
should be, whom to select for such training and according to what
kinds of principles, and last but not least, what the most productive
teaching methods might be. Different psychoanalytic schools differ
in how discoveries about the unconscious are organized and conse-
quently of what needs to be done for the contribution of the past to
present experience to be fully explained and assimilated. Conse-
quently there are differences in the criteria for the definition of the
good-enough analysis. There are many different opinions about
how to select candidates, organize the curriculum, and the length
of training, and confrontations about training are often heated and
divergent, as well as repetitive (Szecsödy, 1999; Watillon, 1993).
Nevertheless, the majority of discussants stress the complexities of
training for the “impossible profession of psychoanalysts” and the
ambiguous position of the training analyst, and they emphasize
that there are hard-to-find scientific or objective criteria for selec-
tion and evaluation.
The supervisory situation should provide conditions in which
learning can develop. To achieve such conditions is not easy and
can be complicated by the trainee as well as by the supervisor. The
position of the trainee is both difficult and ambiguous (Szecsödy,
1997). The ability to think over the interaction with his/her analy-
sand—who may arouse strong feelings and sometimes cause be-
wilderment—demands that the supervisor be able to create and
maintain a platform for the supervisee that leaves room for reflec-
tion. Anxiety, pain, shame, and excessive guilt block learning.
Mental pain may lead to disorganization, where the ability to stay
open for new impressions is extremely limited. The experience
may lead to a loss of self-esteem, causing feelings of shame. The
supervisor must respect the supervisee’s extremely complex iden-
tity and allow for the fact that adult candidates may be at different
stages professionally. Being trusted, being viewed with thoughtful
curiosity, being greeted with respect and insight into the fact that
56 IMRE SZECSÖDY
closeness and distance are needed in different ways at different

phases of development—all this is important for the creation of
confidence in one’s own ability to learn and change.
It is often claimed that the tripartite system of psychoanalytic
education is the best available, yet we know that it produces a kind
of a theological seminar and a trade-school atmosphere that
spawns practitioners and not scholars or researchers and that it
often stifles creativity and questioning. Systematic studies con-
ducted about psychoanalytic training are scarce, and we need to
devote more attention to making explicit our educational goals and
the rationale behind them. We have to investigate our training
practices in two ways. We should try to collect information from
and/or within any and/or each institute that could be transformed
into a comprehensive picture of the training model of the insti-
tute—as it is perceived, understood, and used by those who partici-
pate in it. To be able to comprehend the model of training, we have
to know what underlying ideas shaped it, what theoretical, ideo-
logical, educational, cultural, and historical aspects did and do
influence the stated as well as latent goals, and the structure and
performance of training in its details as well as in the whole. It
should be asked: are our educational modes indoctrinating, or do
they free the epistemological search? These are very complex ques-
tions, and to collect data poses serious methodological problems.
Nevertheless, these kinds of studies have to be conducted as they
could help us to reflect and think, instead of sticking to our internal
conflicts and continuing the fight between those who wish to
preserve the old methods and those who urge for a change.
Empirical research has just begun to focus on the process of
change in psychoanalysis (Galatzer-Levy, Bachrach, Skolnikoff, &
Waldron, 2000; Shapiro & Emde, 1995). Nevertheless, systematic
research and empirical research does encounter resistance within
the psychoanalytic community (Schachter & Luborsky, 1998). So is
the ever-recurring argument against the presence of a third in the
highly confidential situation that has to govern psychoanalytic
practice. In my opinion, we do need to reconsider what we mean
by confidentiality and we do need to become more open to allow
for the presence of the third as an observer if we wish to study what
goes on between analyst and analysand. I agree with Gill that:
Confidentiality is meaningful only in terms of what it means to

the two participants. The working alliance is ultimately based
upon trust, and trust is ultimately based—assuming the patient
is not one who is incapable of trust—upon the analyst’s dem-
onstration to the patient in the course of their work together
that he is in fact trustworthy. That is to say the analyst has both
the capacity and the intent to put the patient’s welfare fore-
most. Trust is neither guaranteed by the formal criterion of
confidentiality, nor destroyed by its absence, any more than an
analytic situation is guaranteed by the formal criteria of fre-
quency of interviews, recumbent posture, etc., nor destroyed
by their absence. [Gill et al., 1968, p. 237]
A study of the process and outcome

of psychoanalyses
During the first summer school on research organized by the

Research Committee of the International Psychoanalytical Associa-
tion in 1995, a group was established with psychoanalysts from
Amsterdam, Helsinki, Milan, Oslo, and Stockholm (the AHMOS
study group), receiving encouragement, support, and consultation
from the faculty. We started a joint venture to study psychoanalytic
treatment, pursuing the psychoanalytic process and outcome with
a minimum level of common design and identical methods and
instruments.
We did agree to the following assumptions: the aim of psycho-
analytic treatment is to establish a specific relationship within a
specific frame, in which the patient can gain insight—into his/her
consciously and unconsciously enacted experiences, expectations,
wishes, and fears—that can lead to better control and balance of
emotional life and to the reduction of complaints joined with
improvement of functioning in daily life. The medium for change is
the specific relationship established between analysand and ana-
lyst within the secure frame of the analytic setting. Psychoanalysis
is supposed to have an influence on how the individual is able to
relate to and integrate emotional experiences through a develop-
ment of the capacity to tolerate mental frustration and pain.
58 IMRE SZECSÖDY
Furthermore, we had to decide on a construct that at least

theoretically could be seen as related to the changes one hopes to
achieve in psychoanalysis. We found this in the capacity for “reflec-
tive functioning”, as proposed by Fonagy and co-workers (1995).
This is related to the development of the mentalizing function. For
the study of reflective functioning, the multi-centre project agreed
upon the use of the Adult Attachment Interview (AAI) (George,
Kaplan, & Main, 1996). This is an hour-long, semi-structured inter-
view focusing on the description and evaluation of early attach-
ment relationships and attachment-related experiences. The
interview includes features of both a highly structured or “ques-
tionnaire” interview format and the more clinical interview. It asks
participants both to provide several general overall evaluations of
their experiences and to illustrate those evaluations with a descrip-
tion of specific biographical episodes. The interview is transcribed
verbatim and is scored according to the reflective-functioning
manual.
Reflective function is the operationalization of the psycho-
logical function, which is frequently referred to as mentalizing
(Fonagy, 1997). It contains both a self-reflective and an interper-
sonal component that ideally provide the individual with a well-
developed capacity to distinguish inner from outer reality, pretend
from “real” modes of functioning, intrapersonal mental and emo-
tional processes from interpersonal communications. Mentalizing
capacity is about seeing and understanding oneself, and individu-
als around one, in terms of mental states (feelings, beliefs, inten-
tions, desires) and, further, about the capacity to reason about one’s
own and others’ behaviour in terms of such mental states, through
a process normally termed as “reflection”. The robustness of this
capacity determines not just the nature of psychic reality of the
individual, but also the quality and coherence of the reflective part
of the self, which we believe to be at the core of the self-structure
(Fonagy & Target, 1997).
Mentalization is important: first, it enables the individual to see
people’s action as meaningful through the attribution of thoughts
and feelings, so that their actions become predictable, which in
turn reduces dependency on others. Second, it allows for recogni-
tion of the fact that someone is behaving as if things are a particular
way does not mean that things are like that. Third, without a clear
representation of the mental state of the other, communication

must be profoundly limited. Finally, mentalization can help an
individual to achieve deeper experiences with others and, ulti-
mately, a life experienced as more meaningful. One can assume
that it is the successful connecting of internal and external that
allows beliefs to be endowed with meaning, which is emotionally
alive and manageable. A partial failure to achieve this integration
can lead to neurotic states; in more profound and pervasive failures
of integration, reality may be experienced as emotionally meaning-
less, other people and the self are related to as things, and the
relating itself occurs at a very concrete level. In the extreme, indi-
viduals may inhibit or decouple their tendency to treat themselves
or others as motivated by mental states, resulting in a personality
organization sometimes denoted as borderline (Fonagy et al., 1995).
Psychoanalysis is supposed to have an influence on how the
individual is able to relate to and integrate emotional experiences
through a development of the capacity to tolerate mental frustra-
tion and pain. Reflective functioning can indicate the degree of
ability for relating to and integrating conflicting emotional experi-
ences. The manner and the degree in which this function changes
during psychoanalysis could then be a process-related outcome meas-
ure of psychic change during psychoanalysis.
A central question is, of course, the relationship between pro-
cess and outcome. Modelling research on what has been criticized
as the “drug metaphor”—the belief that there exists a causal rela-
tionship between certain aspects of the process and outcome—was
not attractive, considering the complexity of the psychoanalytic
conception of process (Stiles et al., 1995). A tentative design was
thus created, which has a structure, that gives allowances for
considerable variation among the participating centres, such as
timing (when to start to implement the different parts of the
project), to focus on different aspects, to add specific instruments,
and to integrate research and quality assurance.
A further aim was to construct research approaches that gener-
ate a multi-window view on the process and/or the interaction
between the analyst and the patient. We are interested in whether
it is possible to detect positive and/or negative critical moments,
variables, or developments in the process and to see how funda-
mental changes take place and to find out to what extent these are
60 IMRE SZECSÖDY
characteristic and specific for the psychoanalytic process under

study.
One way to collect process data was to use the Psychoanalytic
Process Rating Scale (PPRS), designed by the group in Amsterdam
as an elaboration of the Session Rating Scale of the Anna Freud
Centre for Children and Adolescents in London. Through the PPRS
one can collect the subjective opinions of the analysts, regarding
the presence and/or absence and the sort of their interventions
concerning more than 200 items The subsequent filled-out PPRS
(completed with the help of a detailed instruction manual) pro-
duces a picture of the ongoing process, in a form that is a compro-
mise between a naive descriptive and a more theoretical clinical
kind of reporting that is systematized and standardized. These
items are divided into three sections and concern:
1. General attitude: time keeping, missed sessions, quality of

sessions, physical behaviour, affective moods, defences, resist-
ance.
2. Conscious and unconscious content concerning the body, self-
esteem, object relations, sexuality, and aggression; also further
questions about schoolwork, employment, current life events,
gender and age issues, as well as treatment parameters.
3. The form of transference themes, analyst’s feelings, styles of
interventions, and reactions to interventions, and analyst’s feel-
ings in the gross.
The analyst fills out this questionnaire monthly, and the hope is
that this, together with three-monthly clinical summaries, will
create in a systematized and standardized manner a picture of the
profile of the analytic process as seen by the analyst. The PPRS is
now used by the groups in Amsterdam, Milan, and Stockholm.
Furthermore, there seemed to be a common interest in conduct-
ing regular interviews with the analysand during ongoing analysis.
These are carried out using specially designed interviews: (a) the
Therapist Attachment Transference Interview (TATI, which is an
application of the AAI with the focus on the way one is reflecting
about the attachment on the analyst/therapist) with the aim of
measuring the reflective function of the analysand during the pro-
cess; (b) the Analysand Experience of the Process (AEP) developed

in Oslo, the aim of which is to give information of the analysand’s
ongoing experience of his/her analytic process. In Oslo, a number
of ongoing analyses are also tape-recorded, with the aim of de-
tailed process analysis.
In addition, at several centres the analyst is interviewed regu-
larly. These interviews are conducted before the beginning of
analysis, yearly during treatment, and at termination. Questions
focus on what impressions/considerations influenced the analyst
to offer psychoanalysis to this very patient; what does she/he think
about the patient’s problems, expectations, primary relations, ac-
tual relations, feelings, and attitude towards the analyst; and what
the analyst’s ideas and expectations were about entering this study.
At the yearly interviews, the analysts is asked to talk about the
main features, themes, problems, interventions of the past year;
his/her thoughts about patient’s expectations and feeling about
analysis and the analyst; and what influence the study might have
on the process and analytic work. At termination, the specific focus
is on motives and circumstances for termination, about the pa-
tient’s and analyst’s expectations and feelings about the process
and outcome and towards each other. These interviews are tape-
recorded and studied qualitatively, according to the grounded-
theory model.
In summary
One of our main interests was to gather material for the study of
the “specificity” of psychoanalytic treatment: to find ways to “open
windows” into the process and to get information about the inter-
action and how the interaction is experienced/interpreted by the
participants—the patient and the analyst. One important asset of
the project is to compare information received using different
methods: interviewing, filling-out periodic rating scales, writing
clinical summaries, as well as, at some centres, tape-recordings
sessions. To have co-ordinated co-operation between several cen-
tres also give a greater freedom of working with different numbers
62 IMRE SZECSÖDY
of ongoing analyses. We do also expect and hope that as more and

more analysts become engaged in research, within, connected, or
parallel with their clinical work, the more we can become a disci-
pline that does not have to rely on past authority, but one that is
completely committed to the reflection of its own nature and struc-
ture. Only in this way will we be able to keep psychoanalysis as a
theoretical system and as a treatment method alive in the future.
CHAPTER FIVE
Intersubjective phenomena
and emotional exchange:
new considerations regarding
transference and countertransference
Gisela Zeller-Steinbrich
“Only, when the analyst is drawn into this world, will the
analysand and the analyst be able to find their way around it.”
J. Lear, 1999
“The analyst is assigned a part and is expected to join the

play.”
R. S. White, 1992
“The person watching sees more than the person joining in the
game.”
Wilhelm Busch
Preliminary remarks
D
uring my psychoanalytic training, I experienced some-
thing that remained firmly imprinted on my mind right
up to this present day. One of my supervising analysts
commented on a case study about a therapy for an adolescent,
which I had presented emotionally modulated, with the words,
63
64 GISELA ZELLER - STEINBRICH
“You are highly involved.” I was angry at the critical undertone of

these words, and summoned up the courage to reply, “One is
always involved, it’s just a matter of what one makes of this
involvement.” This also emphasized a request of mine to my super-
visor not to assess me in a critical, distant way but to discover with
me and come to understand what actually takes place in the trans-
ference–countertransference relationship.
It was at this point that I started to concern myself with this
theme. The interconnection of transference and countertrans-
ference processes still constitutes the most exciting area for me
in both psychoanalytic-therapeutic and control-analytic work (cf.
Zeller-Steinbrich, 1995, 2000). I would like to present to you an
intermediate report on my theoretical considerations and clinical
experience.
The problem
Psychoanalytic concepts are not something that have been defined

once and for all. They are like empty vessels, which are re-filled
each time we treat a new case, as well as each time a discussion
takes place in the psychoanalytic community. “In psychoanalysis,
as in all other disciplines, there never has been, and never will be,
a final word on any topic” (Schafer, 1999, p. 75). Freud did not leave
us a real definition of countertransference. He felt it “inappropriate
to crush the unity of emotional life for the sake of a definition”
(Freud, 1940b [1938], p. 146). For Nerenz (1997), however, it is
appropriate to assume that Freud had imagined that a counter-
transference, which is “waiting in readiness” as it were (Freud,
1915a), could only take effect after the analyst’s unconscious feeling
had been specifically influenced by the patient. This constitutes an
example of the attribution of a psychic creation to others that have
preceded it in time. As far as I see it, Freud did not, however,
formulate “the communicative moment of a direct relationship
between transference and countertransference” (Nerenz, 1997, p.
147).
The analyst who does not get involved, and who simply reflects
back the conflicts and the patient’s transference dynamics, was
INTERSUBJECTIVE PHENOMENA AND EMOTIONAL EXCHANGE 65
long regarded as the psychoanalytic ideal. The fact that child

analysts and the psychoanalysts of seriously ill people were unable
to avoid becoming interactionally and emotionally involved did
not lead to this ideal being abandoned; instead, the status for these
particular fields of psychoanalytic work was questioned (Zeller-
Steinbrich, 2000).
I shall be looking at this aspect of the influence and involvement
of the psychoanalyst in the psychoanalytic process. First of all, I
shall show which conceptualizations to date already touch on this
aspect of the psychoanalytic relationship. Working on from this, I
shall develop a number of questions and discuss more recent
approaches to answering these questions.
Conventional ideas
on transference and countertransference
In his studies on hysteria, Freud makes mention for the first time of
a frequent “indeed, in some analyses, regular occurrence” (Freud,
1895d, p. 244), which he calls transference to the doctor, and at-
tributes it to an “incorrect link”: a prohibited wish, which has been
actualized in the treatment, is linked to the person of the doctor
without recalling the original situation and the original object of
the wish. The embarrassment that followed the wish in the original
case and led to “repression” of the prohibited wish similarly occurs
once more. Only the object of the wish has changed, according to
Freud, this being on account of an “association compulsion”. Freud
borrowed this concept from general psychology at the time and did
not elaborate any further on how the association compulsion comes
about in the case of transference (Steimer-Krause, 1996).
I shall return to this later to show how this process can be
understood from the present-day point of view.
During transference, the current object—the psychoanalyst—is
not uninvolved. Feelings are induced
1. that can correspond to the analysand’s state of mind;

2. where the analyst can experience the emotional state of mind of
the original object;
3. where the relationship between the subject and the “old” object
can be mirrored in the psychoanalytic relationship—for exam-
ple, to be acted out in an interaction scene (one cannot do
nothing: verbalizations, interpretations, asking questions, or
keeping silence are the analyst’s activities of communication in
an interactive scene—the question is whether or not the interac-
tion takes place on a symbolic level.)
When viewed in this way, countertransference provides the key

to transference.1
Gill (1984) goes one stage further. In accordance with the
patient’s selective attention, which will be a function of his/her
individual biography and pathology, the patient chooses those
parts of the analyst that he/she can use for transference purposes.
Viewed in this way, transference always holds a certain plausibility
in the nature and behaviour of the analyst. It would then no longer
be an incorrect link, as Freud saw it, but a successful one which can
dock on to the analyst. The patient “understands” the analyst in the
manner to which the patient is accustomed. Research into psycho-
analytic psychotherapy also provides evidence of the decisive
curative importance of subjective commitment on the part of the
psychoanalyst. Technical neutrality and insight contribute less to
the therapeutic success of (low-frequency) psychoanalytic psycho-
therapies than mastery, support, openness, and friendliness
(Sandell, 1999). Results such as these have contributed towards an
increasing significance being attached to the subjective factor.
Whereas it was earlier assumed that the psychoanalyst interprets
the transference as a relatively uninvolved, “neutral”, or “objec-
tive” observer, the involvement of the psychoanalyst in the trans-
ference–countertransference process is now undisputed. The
question is thus no longer whether the therapist actively partici-
pates him/herself but, rather, how he/she is legitimated to do this
against the background of his/her psychoanalytic treatment tech-
nique.
So far, phenomena of this type have been observed from several
different angles, not always with a theoretical bearing on each
other and without adopting a uniform approach.
This is the question of acting out and co-acting out, of actualiza-
tion, of the concept of enactment which has played a role in the
Anglo-American literature in particular, and of the concept of

projective identification from the Kleinian school.
“Agieren und Mitagieren”:

acting out and co-acting out
Freud assumed that the patient, instead of remembering (which
would have been better and more accessible), repeats the past and
experiences it once again. In terms of the analytic situation, there-
fore, acting out is transference behaviour.
Anna Freud had described the “classical” idea of acting out
in such a way that “Agieren” is given a certain “Spielraum” (sic!)
(room, scope for play) within the limits of the analytic rules, both in
the transference and for purposes of interpreting the transference.
It threatens the continuation of the analytic therapy if it cannot
be restricted to the sphere of the psychic (this side of motility) and
the analytic situation (i.e. the transference) (A. Freud, 1968, p. 2456,
cited in Klüwer, 1995, p. 50).
Narrowing down the concept, the term finally came to be used
above all for inappropriate, impulse-driven, and destructive be-
haviour. In short: “Since psychoanalysis is a ‘talking cure’ carried
out in a state of reflection, acting out is anti-therapeutic” (Rycroft,
1995, p. 2).
As a supervising analyst, I often had to make clear to the
candidates that, what they were doing with their patients, and
what they couldn’t stop themselves from doing (e.g. giving an
answer to an adult, holding back a child) in some cases was very
much therapeutic psychoanalysis even if they rejected it as un-
analytic on the basis of their own training analysis and textbooks.
Experience has shown that scenes of more or less co-acting out
take place in psychoanalytic therapies at times, when the affective
tension of the analyst increases to such an extent that the mainte-
nance of evenly hovering attention is abandoned and the psycho-
therapist is drawn into the patient’s conflict. In the same way as
the countertransference reaction has to be delimited from the
therapist’s own transference, it is also necessary for the action
dialogue that is taking place to be uncovered in analytic terms and
to be understood as part of the patient’s conflict. If this uncovering
does not eliminate the therapist’s own involvement, then it is

probably a conflict-type transference on the part of the therapist
that is at play here rather than a countertransference reaction to
the patient.
It goes without saying that different analysts can arrive at
different interpretations of the same material, just as the emotion-
ally tinted and hence “subjective” action of the analyst will come
through in any interpretation—however minimal. I thus assume
that even with a cautious and purely interpretative approach to
work, in which the evenly hovering attention2 is retained, the
subjectivity of the analyst will unavoidably come through. I shall
come back to this later on. To return to the concept of acting out
and co-acting out: in this perception, the action component in the
transference and countertransference is rehabilitated. Klüwer es-
tablishes that “Mitagieren” —that is, co-acting out—“is an unavoid-
able phenomenon in the psychoanalytic treatment process in the
same way as countertransference” (Klüwer, 1983, p. 829). The co-
acting out of the therapist is no longer regarded as resistance
against becoming aware of unconscious contents but as a source of
information.
Klüwer thus logically speaks of an “action dialogue” that comes
about between the patient and the analyst. This view comes very
close to the concept of the “scene” that was developed by
Argelander (1970) and Lorenzer (1973, 1983).3
In therapy, a verbalized transference offer often is followed by
the actualization of the transference, with an increasing tendency
by the patient to act, and a tendency on the part of the analyst to
assume the complementary role and set up an action dialogue. The
verbal dialogue plane can be attained again by developing an
understanding and an insight into the unconscious meaning of the
action dialogue, with the staged transference subject-matter being
wound up and the next-deeper transference subject-matter
configuring itself (cf. Klüwer, 1983, p. 839).
Actualization and role-responsiveness

Sandler supplements evenly hovering attention with evenly hover-
ing role-responsiveness. The relationship with the analyst should
become so real that the patient can experience the analyst fulfilling
his/her expectations. The transference wish is expressed in the
analysand’s behaviour. “The transference would thus represent an
attempt on the part of the patient to establish, on his initiative, an
interaction, a mutual relationship, between himself and the ana-
lyst” and thus “to actualise these roles in disguised form” (Sandler,
1976, p. 300)
Actualization is the intention—motivated by a wish or the
pressure, tension, or active urge—to convert this wish into reality,
although the actual implementation does not necessarily have to
take place. Even if Sandler does not refer to the concept of acting
out, actualization designates the inner process that goes with acting
out (Klüwer, 1995, p. 54).4
Transference that is not translated into motoric action also
incorporates an unconscious intention to act, imparted not least by
the primary emotions and their “propositional structure” (Krause,
1990). According to this, emotions are the means by which relation-
ships are regulated. Simply spoken, the emotion makes a proposi-
tion: for example, I away from you (anxiety), you away from me
(anger), you out of me (disgust), you back to me (grief). I shall return
to this later
The concept of projective identification

When dealing with severe psychic disorders, the concept of projec-
tive identification took on an increasing significance from the treat-
ment angle—this being due in particular to the followers of Klein.
Here, the psychoanalyst was naturally involved, but in a way that
looked objective, insofar as the impression was given that the
analyst was being “forced” to reconstruct the patient’s transference
through his/her own countertransference—“his internal reaction
to the analysand”—that is, to react in the manner that the patient
had encountered in his/her earlier experiences (Bollas, 1987, p.
210).
This, in turn, permits the conclusion that all the analyst’s inter-
nal reactions mirror what the patient has experienced, and the
therapist, with the perception of his/her inner life, is the quasi-
objective observer.
More recently, increasing questions have been posed about the

involvement of the analyst. The analytic relationship is regarded as
a creative process in which the analyst and the analysand undergo
change. In relations analysis (Bauriedl, 1980) this is considered as a
matter of course in practical treatment: “The change starts in the
therapist” (Herberth & Maurer, 1997). Thomä recently noted that
the one-sided attention paid to intrapsychic conflicts led to the loss
of an interactional, interpersonal understanding of therapy and
transference (Thomä, 1999, p. 832).
In the conventional understanding of projective identification,
which I have already referred to above, the patient is the creator of
the countertransference reaction and the therapist is only “forced”
to react in this and no other way. Viewed in this manner, therefore,
the therapist does not participate on his/her own account at all—it
is all an affair of the patient, and the analyst makes no contribution
other than to observe from outside. I regard this as an inadequate
approach and will now expound my own considerations.
An enlarged understanding of enactment
In the Anglo-American countries, the active contribution of the

analyst has been discussed using the concept of enactment. The
“necessity of participation and enactment as part of the transfer-
ence relationship” is assumed here (Kirshner, 1998, p. 424). The
analyst’s contribution to countertransference enactment is seen
here as that of the “sensitive, responsive listener”, whose reactions
are stimulated, and who can observe them and use them for inter-
pretation purposes.
The analyst identifies enactment through close analysis of the
moment-to-moment interplay of language, psychic movement,
emotional expression, associative content, and already-established
dynamic context. Enactment is regarded as:
a vehicle for always keeping alive the questions:

• What is going on here right now?
• What am I being told indirectly or being shown concern-
ing the patient’s way of experiencing this moment in the

analytic relationship or of trying to structure it?
• How might I be stimulating or supporting this perform-
ance? [Schafer, 1999, p. 77]
Although this concept of enactment does not mention interaction

or acting, it comes near to my understanding of emotional and
action dialogue, which I would like to illustrate with a practical
example:
A borderline young boy during his analytic treatment literally

feels like running away. He cannot stay in the therapy-room for
fear of his own aggression, and he runs agitatedly around the
entire office. I go after him and explain that I cannot conduct
therapy throughout the whole house but that I do want to
conduct therapy with him. Then I tell him that, time and again,
he is not sure whether I really want him to stay here and keep
him in therapy and that he keeps wanting to try it out. He
replies: “You’re just doing it for the money!” “There are other
ways I can earn money, you know. But you are important to me
and I want to do this work here with you.” He kneels on the sofa
in the waiting-room with his back to me and gazes towards the
outside. “What do you suggest? Should I lock you in the play-
room? I don’t want to lock you in but perhaps it would help
you.” He still says nothing. I say, “I don’t want to lock you in
because that seems rather violent to me, and I think that you
were locked in by yourself when you were younger. If you were
very young now and if I was your mother, I would pick you up
on my arm and carry you into the therapy-room.” The tension
in the patient’s body relaxes, he slips down deeper into the sofa,
stays in this position for a while and then turns around so that
I can see his face. I say once again, now looking regretfully in his
face, “If you were a very young child, aged two years or so, then
I would take you on my arm and carry you back.” Once again,
he slips down further and lies relaxed on the sofa. He can’t
come back into the therapy-room but, with my encouragement,
does adhere to the allotted time. Last of all he complains: “But
it’s going to rain now.” With this he is showing, that, on a
deeper level, not his staying with me but the separation and the
separation aggression is the problem. Me: “You are well-

equipped, you’ve brought what you need with your cap and
hood and, if necessary, I have an umbrella that I can lend you.”
He gathers hope and sits on the chair in the hall. “Now I’ll tell
you something.” Slurring his speech, he reports on an event that
triggered immense shame and on slanderous attacks at school.
“I haven’t hit anyone, but what should I do? What should I do
so that I don’t hit anyone?” The true situation is very difficult.
Sadness and helplessness take over from my feeling of being
unable to cope and my initial anger at this patient, who is
making it so difficult for me and repeatedly disrupts the thera-
peutic setting. I do not act out the anger defiantly, or with the
aid of therapeutic superego norms (not leaving the playroom
would have meant letting him down), but can find access to my
wish for a relationship in his direction and thus take up his
hidden, unconscious wishes for a relationship and display these
on his behalf. Where his educators react with anger and rejec-
tion like normal people, I gained access to the underlying disap-
pointment, helplessness, and sadness. I made great concessions
towards the patient here, overstepping my own frame and
limit. He demanded these concessions like a very small child
and by repeating the negative experience of relationships he
had had in his early childhood.5
Six months later, after my holidays, he is able to show his
separation aggression and disappointment verbally, by saying
he now only wanted to come once a week. Taking a glass jar
into which he pours vinegar and baking powder, so that it starts
to foam and the cork flies out under the pressure, he illustrates
on a symbolic level how he himself sometimes flies around like
the cork on account of aggressive stress. Now I don’t have to
run after him in real life any more and am thus able to under-
stand the symbolic meaning. He smiles as I give my interpreta-
tion, and we speak of his tendency to annoy others so much that
he is sent out (excluded from school), or runs away himself in
anticipation, as he often did during therapy and like his father
did, who ran away after the onset of schizophrenia (when the
patient was early in his second year) and who has lived abroad
ever since.
After this, the patient sits on the floor and plays artistic games
with soap bubbles, deriving great enjoyment from letting them
float around and predicting which ones will burst first. Just one
is given a sharp tap so that it bursts: “You’re hitting it before it
disappears.” He laughs. He now begins to understand my inter-
pretation of his psychic mechanisms and the symbolic meaning
of his acting. He has my full admiration and bears with this
delightful situation until the hour is up. At the end, I have just
a small penance imposed on me: I have to tidy up, he says,
which was, in this hour, not a big deal.
Transference for this patient is not a fantasy he could talk about at

this stage of the therapy and of his psychic development. Instead,
the patient is enacting a conflictual relationship with the analyst, as
a repetition of the relationship with the primary object . He estab-
lishes a situation where the object—the analyst—by means of pro-
jective identification becomes somebody dangerous and represents
the negative emotions that the patient is not capable to mentalize,
decode, and control in himself.
As we know, these processes are typical for patients suffering
from so-called early disorders.
The role of the analyst, in my opinion, is not only to be there as
a container, but to use his/her knowledge about the patient to
understand the maladaptations and misleaded emotions to create a
new relational situation that comes closer to the personal truth of
the patient—namely, the original relational wishes and affective
tendencies and their malformation, which led to the affective
symptoms.
Even in situations when there is no acting out and co-acting out,
but when a patient on a neurotic level is talking about his/her
transference fantasies, the transference reaction is bound to the
capacity of the analyst to get mentally and emotionally affected by
those fantasies, whenever they do become productive in the thera-
peutic process. Maybe, we could think of it in the sense of an
enactment in the fantasy, but it still would be an enactment as
White defines it: “the vivid re-experience of a childhood role
played out on the stage of the analyst’s consulting-room. The
analyst is assigned a part and is expected to join the play. Both
parties lose their sense of distance and get swept up into the verbal
and non-verbal interactions; both contribute intrapsychic dynam-
ics to the shape of the interaction” (White, 1992, p. 339). This
experience in real-life terms requires the transference resistance to
be staged. Only then is transformation of the countertransference
and transference possible.
Enactments should thus increasingly be understood as inter-
personal processes (Chused, 1991). Then they are coming close to
the above-mentioned scene concept and action dialogue, without
relating to these.
Developmental psychological conceptualization

of transference and countertransference
In order to clarify the question as to how transference and counter-

transference come about, I would like to engage in a brief digres-
sion to clarify the concept of mental representation in the manner
in which it has come to be understood more recently.
Zelnick and Buchholz (1991) define self- and object representa-
tion in the sense of unconscious interactive organizational struc-
ture. These representations are shaped in the dyadic exchange.
They can originate from perceptions, sensations, and emotions. In
advanced development they are more the result of symbolic think-
ing. Representations “not only store our past experience but also
guide our perception and influence our experience of our external
and internal worlds” (Fonagy et al., 1993).
The analytic observer is constructing in the here-and-now situ-
ation of the psychoanalytic context and dialogue one version of the
representational world of the analysand and its constructive prin-
ciples. I want to point out that the observing function itself is
a constructing function. What we say, what we see, is only one
possible version. In my infant-observation course, I usually do
something unexpected of me, and then I ask the students what they
observed. Once I stood up, walked through the auditorium, and
shook hands with one of the students. The emotional state of the
students constructed different scenes. Did they see friendliness or
sudden and frightening activity? One, startled, seeing me “going
straight up” to somebody, had the fearful thought: I hope she

doesn’t come up to me. Another was amused and curiously
watched the “strange performance”. A third felt a composed inter-
est and saw me welcome somebody in a friendly manner.
How do transference and countertransference take place?

The role of emotions and emotional exchange
Back in the eighteenth century, Fontenelle was already using a

number of wonderful seafaring metaphors to compare feelings
with the wind, observing it as the movens of the soul, and estab-
lished that a complete lull in the wind was what seafarers feared
most (cf. Blumenberg, 1979). The same is probably true of us
psychoanalysts too. The fact that emotions are driving forces
(emovere) is nothing new in psychological terms. The fact that the
emotions also have an action structure inherent in them, however,
is a rather new part of the psychoanalytic-theory edifice, stating
that the primary emotions are the announcement of actions
(Krause, 1990; Moser, 1989). These actions are structured with a
subject, an object, and a desired interaction between the two, as I
mentioned earlier.
If we work on the basis of the enormous importance of early
relationships, attaching central importance to the bonding motiva-
tion, then it is clear that relationship wishes can be deciphered
from emotions: interruptive or geared to change (anger), or pro-
moting and motivating (pleasure). This means that the movement
is not a purely intrapsychic movement. Emotions can much more
readily be defined as “instructions for relationship movements”;
they regulate object relationships (Steimer-Krause, 1996, p. 94).
If we follow Stern, then the contents of the wishes, relative to
the object, change in the course of development from the “self-
regulating other” to ever more complex forms of relationship
(Stern, 1995). The relationship wishes that have been attained are
symbolized and form implicitly available structures for relation-
ships. These relationship structures are transferred.
The tendency to form a certain kind of relationship is thus tied
to the attempt to re-create or avoid specific emotional states as well
as to the unconscious attempt to trigger certain emotions in the

other person. If dysregulations occur in primary relationships, then
this leads to a breaking apart of intrapsychic and interactive emo-
tions. If relationship wishes remain unfulfilled in full or in part,
then the desired and internally symbolized relationship quality
will undergo a change, together with the emotions that are experi-
enced. In other words, the inner emotions are characterized by past
experience (restricted and qualified by defences), while the emo-
tions that are displayed and control the relationship are governed
by the newly learned (less satisfactory, less appropriate) relation-
ship model. Emotions, therefore, are used to suppress relationship
wishes and to restrict the amount of potential intersubjectivity that
can be shared with others. My young patient, for example, at first
did not dare to show his wishes for being admired and instead
showed anger and disappointment.
How can the emotional exchange during treatment now be
pictured?
The therapist first experiences what the patient is unable to
experience. (In the example given, fear of losing a relationship,
helplessness, sadness.) Only as the next step can the patient inter-
nalize this and adopt a different attitude to what he/she have
experienced in respect of the different relationship episodes de-
scribed, and undergo a change. The patient can then try out the
new experience that has been gained in therapy in everyday life
and internalize this.
It is essential that the therapist does not reproduce the patho-
genic patterns, in the sense of an uncomprehended repetition, and
does not identify with the patient’s defence. If everything goes
well, then these scenes, in which primarily involved feelings are
exchanged, will have a different and better outcome than in the
past.
In other words, the analyst must first experience or admit those
emotions within himself that the analysand is keeping in his un-
conscious, but must then react in a different way from the patient’s
everyday environment and handle the offer of transference in a
different manner from what is expected. The patient will then be
able to see his/her own contribution to the everyday pattern and
modify his/her part in the interaction. New, changed relationship
patterns in the working-through phase will then lead to a change in

structure.
I believe that there is much truth in the idea that the therapy
will only have an effect when the analyst has become part of the
problem. Productive countertransference, role responsiveness, and
projective identification all have their full justification in terms of
their significance for an understanding of the patient. At the same
time, it is necessary for the analyst to repeatedly adopt the view-
point of the observer and analyst (Zeller-Steinbrich, 1998). What is
necessary is to move between emotional involvedness, with the
perception of affective signals, and observation, which is what
permits empathy in the first place.
A major portion of “transactional empathy” (Emde, 1990, p.
892) might be unconscious. It is brought into the treatment by the
patient, yet also by the psychoanalyst. This unconscious or implicit
relationship knowledge enables the therapist to take multiple roles
of self and other at the same time and to transform the experience
even as this is done.
The boundaries of intersubjectivity
Does one person’s unconscious react through the impact of an-

other’s unconscious? Freud was of the opinion that this process
certainly merited deeper investigation. After Freud, and right up to
the present day, however, the impression has been maintained
that, taking Freud’s assumption, it is possible to derive justification
for an unmethodical, perhaps even arbitrary, process in which the
analyst somehow knows what is occupying the patient without
having to account more accurately to him/herself for his/her cog-
nitive process. This is mystified in the metaphor of “hearing with
the third ear” (Reik, 1966), when this metaphor is taken as a matter
of fact, as if an understanding between one unconscious and an-
other unconscious would be plausible at all times.
Greater attention is focused on the subjectivity of the analyst
today; this is due not least to the efforts of the “relational theorists”
(cf. Gill, 1983), who viewed the subjectivity of the analyst as a
central factor and attempted to overcome the limitations inherent

in the concept of the blank screen and the anonymity of the analyst.
The fact that both the analyst and the analysand play a part in
countertransference cannot, however, mean that the patient is an
equal-ranking interpreter of the analyst’s experience (Renik, 1995).
And this certainly does not mean a relaunch of Ferenczi’s mutual
analysis. There should be no doubting the fact that the patient is
more involved than the analyst and that the latter bears responsi-
bility for shaping the therapeutic process and the therapeutic rela-
tionship.
Emotional exchange and acting dialogues take place during a
psychoanalytic therapy in which the analytic frame is respected
and which is conducted in appreciable privation and abstinence.
Usually the “answer” of the analyst will not have to overstep the
limits of the setting. It has nothing to do with an acting out of the
countertransference, where the analyst acts according to his/her
own countertransference feelings, satisfying the patient’s needs in
order to relieve his/her own emotional pressure. As long as the
analytic situation itself would not have been endangered in my
case vignette, I surely would not have gone after the boy. This was
an effort to reach him analytically, while he was running out not for
the first time and thus jeopardizing the analytic relationship. Thus,
it was also a chance to keep in contact with the inner world of the
analysand and with my countertransference reactions, whereas my
staying alone in the room would have meant leaving him angry
and alone like mother did, a scene with the risk of deep injury and
total loss. It would have also meant the inhibition of the develop-
ment of the transference–countertransference scene, in order to
avoid a more difficult situation with more unbearable counter-
transference feelings—“like” the primary objects of the analysand
in the past. (Those internalized interactive scenes are always sub-
ject to change by fantasy activity, by control and defence mecha-
nisms, and by dominant emotions. They are never plain “copies” of
the reality.)
This co-acting out always should be or should become as soon
as possible an instrument of analytic understanding and knowl-
edge. We always have to care about the frame and to watch over
the analytic situation, which should not become a “normal” every-
day situation or experience. It is a dialectic proportion of emotion-

ally taking part and of keeping a more distant observing position.
One danger is to repeat in an unconscious way the traumatizing
situation in the role of the traumatizing original object or to step
outside the role of the analytic observer so far that one cannot get
back to it. The other is to inhibit the transference process, not to
reach and understand emotionally the acting of the analysand.
That might leave the analysand alone and hopeless. As I take it,
situations of emotional exchange and action dialogue that include
such a “dramatic” acting of the analyst are restricted to scarce key
scenes. Here the patient experiences that he is not a standard
patient, treated by a standard technique, but an individual analy-
sand with the capacity to induce meaningful changes in his/her
analyst. On the other hand, with more neurotic analysands, the
involvement in an infantile scene may be kept within the standard
setting and then shown through our verbal interventions and inter-
pretations. Speaking or keeping silent is acting too.
I mentioned Anna Freud, who spoke of the “playground” of
transference, and my early analytic experience of the inevitable
involvement in the roles the analysand is proposing to us. They are
by no means only projections of the inner world on the analyst but
are scenes in which the analyst plays his/her part, if ever he/she
wants to understand deeply. We are inside the game, a game that is
built up from the multitude of impressions by which the analysand
has organized his/her representational world. We have to enter
this world to experience in which particular way we are “caught
up”. On the other hand, we always have to reach the analytic
position again, and the person watching sees more than the person
taking part. Only then can the analysand become aware of his/her
patterns, unconscious defence and needs, and ways to create or to
find in creative neurotic ways his/her former frustrating objects in
today’s reality.
At the outset I established that, to a certain extent, every inter-
pretation, every attitude, every choice of technique already consti-
tutes an expression of the analyst’s subjectivity in itself. We always
convey something of our personality, whether we wish to or not, or
are aware of this or not. This makes it all the more important for us
to make exceedingly well-thought-out use of real statements about
ourselves and about the therapeutic relationship as viewed by the

analyst. Furthermore, the analyst must take into account that his/
her subjective experience may be defensive as well.
It is presumably a matter of leaving the “field” as little influ-
enced as possible and, at the same time, of not assuming that this
could be achieved through anonymity or “abstinence” as a “com-
mandment” or “rule” in the sense of the mirror metaphor. It is
essential to keep the therapeutic space open as a space that pro-
vides opportunities for the patient. The transference relationship
docks onto true responsive elements in the analyst’s personality
and comes up against its limits when the analyst has to defend
himself. An ability and readiness to admit negative and positive
transference and not to nip them in the bud presupposes a readi-
ness to become annoyed about the patient during therapy and also
to experience pleasure about him/her. This readiness can be
present to a greater or lesser extent and is sometimes rather weak
in candidates or in “weary” or even burnt-out colleagues.
We are inclined to speak about theories rather than about emo-
tions. I still experience a tendency for therapists to ward off posi-
tive affective reactions in particular. There is obviously a fear of
emotional reaction here, which is placed under taboo as constitut-
ing gratification. It could be assumed that psychoanalytic super-
ego-fear is at play here. Some are afraid of violating the principle of
abstinence through an emotional response, while others fear the
“spectre of the unfeeling, inhumane analyst” (Heimann, 1960, p.
151). There is no “abstinence rule” with Freud, however. Freud
speaks of the “principle of abstinence” to make it clear that resist-
ance to transference and countertransference should not be allayed
through surrogates but should be analysed (cf. Nerenz, 1997, p.
151) And analysis is ultimately still possible, even if the analyst
becomes emotionally involved. But it is only the inner participation
of the analyst him/herself that will make a therapeutic relationship
into a living relationship, and I am convinced that only living
therapeutic relationships are healing and effective.
The section on intrapsychic representations has shown that it is
not a matter of curtailing the significance of intrapsychic processes
in favour of an interpersonal view of things. Instead, the patient
learns something about his/her intrapsychic world by means of
his/her own participation in an intersubjective process that he/she

has helped to shape.
It is a matter of opening up space for a living emotional ex-
change, of admitting living emotional movement. If this is avoided
through professional warding-off (mirror ideal), then psychoanaly-
sis confirms the old reproaches put forward by its critics to the
effect that it has problems with fully experienced contact. At the
same time, we are giving away our key psychoanalytic opportuni-
ties, which lie precisely in not just opening up space but in conduct-
ing an analysis in this space. And this means progressing towards
the meaning of things with the patient and extending his indi-
vidual freedom away from predetermined, emotionally character-
ized relationship patterns, while always observing the limits.
Notes
1
The conceptual distinction between the unconscious process of counter-
transference and the conscious or preconscious derivatives has hence remained
unclear up to the present day (cf. Nerenz, 1997). It must be constantly recalled
that manifest countertransference does not offer ready access to the patient’s
unconscious at all times.
2
This is a close translation of Freud’s “gleichschwebende Aufmerksamkeit”. I
avoid the term “free-floating attention”, because our attention never can be
really “free” (cf. Zeller-Steinbrich, 1998).
3
In early child development, dialogic interactional scenes precede verbal
exchange (Bruner, 1983). The action dialogue thus could be regarded as a
necessary regression phenomenon. According to the niveau of the psychic
structure, the “action” of the analysand will tend to be more or less pronounced
or dramatic.
4
Klüwer pays homage to the old ideal still, when he writes, “Defined in
narrow terms, interpretation is the refusal of action in the sense of action or re-
action. This is the point where the picture of the ‘mirror’ is appropriate, since
the interpretation is restricted to the verbalization of hidden meanings that
have become accessible to the analyst from what the patient has verbalised,
thereby ensuring that the interpretation remains neutral. Interpretation is the
verbalised reflection of what the patient has revealed. Interpretation itself does
not involve any intention to act” (Klüwer, 1983, p. 837).
5
Early in his second year he once was sent away from his angry mother,
who felt disturbed by his demands in an activity with her other child. He
strolled to the kitchen, where his father was preparing tea. But his father let him
slip from his shoulders, and the little boy severely burnt his arm in the boiling
water. Shortly after, the father became schizophrenic and left the family for
ever.
CHAPTER SIX
Constructing therapeutic alliance:

the psychoanalyst’s influence
on the collaborative process
Maria Ponsi
The analyst’s influence on the analytic process
T
here is a phenomenon that repeatedly occurs in the history
of psychoanalysis: some aspect that initially was considered
regrettable, awkward, and inconvenient eventually turns
out to be worthy of attention and study, to the point that its
meaning is reversed—from negative variable to be removed, it
comes to be considered a positive technical tool. The first of these
obstacles transformed into instruments was transference. Then
there was countertransference. Then acting out underwent a simi-
lar evolution. (See Ponsi & Filippini, 1996; Filippini & Ponsi, 1993.)
And now it is the turn of the analyst’s subjectivity.
Until not very long ago it was held that any aspect concerning
the analyst’s person ought to be carefully hidden from the patient.
The analyst was supposed to be anonymous, in addition to being
abstinent and neutral (Gill, 1987, 1991, 1994, 1997a; Hoffman, 1983,
1991, 1992a, 1992b, 1994, 1998). Today, many maintain that it is not
possible, or even desirable, for such an ideal to be realized, because
the analyst is an active participant in the analytic process and
83
84 MARIA PONSI
because the patient is able to perceive—consciously and pre-

consciously no less than unconsciously—elements concerning the
analyst’s subjectivity (Aron, 1991, 1996; Jacobs, 1991, 1993, 1997;
Levine, 1994; Renik, 1993, 1998; Slochower, 1996).
However anonymous, neutral, and detached the analyst may
be, his/her subjectivity—that is, his/her affects, mentality, expres-
siveness, and culture—will come into the analytic situation. As-
pects of the analyst’s personality affect his/her way both of
listening to the patient and of conveying understanding of the
unconscious through interpretations. “Interpretation is a bi-per-
sonal and reciprocal communication process, a mutual meaning-
making process”, says Aron, which is not to be understood only as
“an explanation of one who knows interpreting to one who does
not know . . . but also as the individual’s unique, personal expres-
siveness . . . as a creative expression of [the analyst’s] conception of
some aspect of the patient”: interpretation is as personal and sub-
jective as the pianist’s interpretation of a sonata, or an actor’s
interpretation of a role (Aron, 1996, p. 94).
Though, in the abundant literature on this subject, terms such as
“subjectivity” and “intersubjectivity” are used in a slightly differ-
ent way, there are some common basic ideas: the idea that it is not
possible to understand the mind outside its relational matrix; the
idea that clinical data are brought about by interaction between
analyst and patient; the idea that the analyst gains access to the
patient’s psychology through his/her own subjectivity; the idea
that the therapeutic process is constructed beginning from mutual
reactions involving both participants.
The attack on the myth of the analyst as anonymous and neutral
comes mainly from the United States, where liberation from the
theoretical and technical canons of ego psychology has come to be
something like a movement (in this connection Green, 1997, 1998,
has spoken of “intersubjective protest”). The contemporary infla-
tion of writings about “subjectivity” of the analysts and “intersub-
jectivity” of the analytic process bears witness to the “interpersonal-
ization” process of North-American psychoanalysis in the last few
decades (Blum, 1998; Dunn, 1995; Kennedy, 1997; Kernberg, 1997;
Lichtenberg, Lachmann, & Fosshage, 1996; Ogden, 1994a, 1994b;
Spezzano, 1997; Stolorow & Atwood, 1992, 1997; Stolorow, Atwood,
& Brandchaft, 1994).
CONSTRUCTING THERAPEUTIC ALLIANCE 85
What has occurred in Europe in the same period?

Since the postwar period in European psychoanalysis, object rela-
tions theory has, though with different nuances, been a common
cultural background, whereas in North America ego psychology
has been dominant for decades. Hence, interest in interactive pro-
cesses stemmed from different traditions (Baranger & Baranger,
1969; Greenberg, 1995; Hurst, 1995; Katz, 1998; Nissim Momigliano
& Robutti, 1992; Ponsi, 1997, 1999; Ponsi & Filippini, 1996;
Turillazzi Manfredi, 1994; Turillazzi Manfredi & Ponsi, 1999).
In this trend towards interaction, a central role has been played
by the concept of projective identification. This phenomenon—
which in its first formulation by Melanie Klein was conceived as
belonging to the patient, while acting simultaneously on the ana-
lyst’s mind—has eventually taken on a more bi-personal character
(Feldman, 1994; Sandler, 1976, 1988, 1996; Schwaber, 1995; Spillius,
1994).
A similar process of “bi-personalization” has at the same time
concerned the concept of countertransference. Initially connoting
the obstacles to transference analysis caused by the analyst’s unre-
solved conflicts, this concept has begun to be used to refer to the
way split objects of the patient’s internal world are projected and
represented in the analyst’s mind (Gabbard, 1995).
This is why in Europe the model—typical of classical, original,
psychoanalysis—of the analyst as a “blank screen” has had a
shorter life than in the United States. According to the concept of
countertransference prevailing in Europe, the analyst reacts to the
patient’s transference by means of an activation of his/her internal
objects—that is, by involving his/her personal characteristics. This
means that the patient’s phantasies and affects do not simply come
up against the analyst as an object, or as a mirror, but also as a
subject who brings a personal contribution to this relationship.
From a European perspective, the first question we ask our-
selves when faced with the intersubjectivist trend is the following:
Why should we speak about subjectivity if we already have a
well-constructed concept like countertransference? Isn’t it un-
necessary to insist so much on the analyst’s subjectivity when
for a long time we have known that he participates with all his
person in the task of understanding the patient, that he must
86 MARIA PONSI
take into account all his own reactions while listening, under-
standing and interpreting? For a long time we have considered
countertransference as a probe for investigating the uncon-
scious, as a basic, most useful, tool for following the patient’s
transference movements. So, what is new in the proposal of the
analyst’s subjectivity? [Turillazzi Manfredi & Ponsi, 1999, p.
702.]
I think we could share the intersubjective perspective, yet for

different reasons. Our point of departure was to discard the limit-
ing meaning of the concept of countertransference and to consider
it a resource rather than an obstacle. After this first phase an op-
posite trend developed: the concept of countertransference began
to be given a very broad meaning, according to which everything
the analyst said or felt was ascribed to the patient’s transference. As
a consequence, it was no longer possible to distinguish what be-
longed to the analyst (personality, culture, attitudes) from what
belonged to the patient (transference projections).
To ascribe any attitude, feeling, or thought arising in the ana-
lyst’s mind to the countertransference has led to a mistake that is
only too common in our discipline: that of trying to stretch con-
cepts beyond the meaning they can reasonably have or to stow into
a term everything we like.
Therefore, I think for us, too, it might be useful—conceptually
no less than clinically—to recognize that there is a place for the
analyst’s subjectivity and remove it from the twilight zone where it
has been abandoned. This implies making a parallel reduction in
the concept of countertransference.
Constructing the collaborative process
It follows from the general relational trend peculiar to many con-

temporary psychoanalytic schools that nowadays factors relating
to the analyst’s subjectivity are no longer minimized or left in
obscurity. The shift from “isolated mind” towards “relational
mind”, from the patient’s psychic activity towards interaction in
the analytic dyad, goes hand in hand with the dissolution of the
central organizing paradigm of classical psychoanalysis: drive

theory (Greenberg & Mitchell, 1983; Mitchell, 1988, 1997).
In the classical drive-model perspective, the patient transfers
derivatives of drive thrusts onto the analyst; the latter’s job is to
recognize these psychic movements and interpret their nature and
mechanisms. In this paradigm, the analyst’s role is consistent with
its basic premise: the drive directs affects and wishes, and the
analyst is only the point of discharge of these drives—that is, the
object to which projections are addressed. The analyst’s task is to
keep as neutral and detached as possible, in order not to alter with
his/her own feelings and reactions the patient’s original affects
and representations—namely, in order not to affect the transfer-
ence. The technical rule of anonymity and neutrality is consistent
with this theoretical presupposition.
While the drive paradigm was crumbling and, parallel to it, a
relational paradigm was being established, the way of conceiving
the analyst’s function became more complex: the analyst was no
longer seen as a neutral and passive object receiving the patient’s
projected affects, but as an active participant in the interaction.
It is within this framework—in which the analytic process is
conceptualized as a co-construction by the analyst and the patient
together—that I shall now go on to examine a specific area of the
analytic relationship: the collaboration between patient and ana-
lyst.
After a short historical review of the concept of therapeutic
alliance, I address the subject of constructing a collaborative pro-
cess and then I give a clinical illustration of the therapist’s involve-
ment in it.
Therapeutic alliance
In 1934 Sterba described what happens to the analysand’s ego
during a transference interpretation: on one side, the analyst ex-
periences inside the transference, and, on the other side, he/she
distances him/herself from it—that is, the analyst observes him/
herself emotionally involved in this particular relationship.
Sterba’s description of the ego splitting into an “experiencing ego”
88 MARIA PONSI
and an “observing ego” was taken again and broadened twenty

years later by authors who elaborated the concept of therapeutic
alliance.
In the 1950s and 1960s, Zetzel (1956, 1965) and Greenson (1965;
Greenson & Wexler, 1969) pointed out that patients with an ego
weakness are able to develop a proper analytic process and carry
out an analysis only if their capacity, which is often impaired, of
taking in interpretations and working them through is very care-
fully fostered. The capacity to maintain a collaborative relationship
with the analyst was termed “therapeutic alliance”. By this expres-
sion it was meant to highlight the agreement—or, the alliance—
uniting analyst and patient in their common fight against
resistances and for the conquest of unconscious.
Around this concept, a heated debate developed. Many held
that emphasis on therapeutic alliance might warrant non-analytic
interventions—that is, active support, reassurance, or even sugges-
tion. Resistances, they said, ought to be interpreted, not overcome
through suggestion. This way there would be the risk of giving the
patient an emotional corrective experience instead of an analysis of
his/her conflicts and lead psychoanalysis out of its specific
tracks—that is, towards transference manipulation and suggestive
therapy.
On the whole, criticisms of the concept of therapeutic alliance
concerned both its theoretical assumptions and its implications for
technique: the advocates of the therapeutic alliance, who draw on
the conflict-free part of the ego, have been accused of playing down
the role of transference, of practising non-interpretative tech-
niques, and of assigning greater therapeutic value to relational
factors than to insight.
In substance, the controversy about therapeutic alliance is a
replay of old disagreements between those who considered inter-
pretation the focus of psychoanalytic therapy and those who, in the
wake of Ferenczi, gave at least equal weight to the relational factor
and, more precisely, to the healing action of the affective relation-
ship between analyst and analysand (Hanly, 1994; Horvitz et al.,
1996; Meissner, 1996; Wallerstein, 1995).
In the last decade, interest in the concept of therapeutic alliance
has faded. It could be said that this concept is mainly American, as
is the debate that has developed around it. Outside the United
States, where models other than ego psychology prevail, the con-
cept of therapeutic alliance is hardly taken into consideration: on
the contrary, it is considered irrelevant and useless. Nor—even
though it is a diadic concept referring to a relational dimension—
has it found a significant place in the contemporary relational trend
of psychoanalysis.
Collaborative process
W. W. Meissner—the author of a monumental and comprehensive
treatise on the therapeutic alliance—maintains that it “made a
distinctive contribution to the analytic process, that it is an essential
dimension of the therapeutic relation, and particularly that it pro-
vides the matrix within which therapeutic effects are wrought”
(Meissner, 1996, p. vii).
I agree with this statement. Yet it is difficult to insert the term
“therapeutic alliance” in the conceptual framework of contempo-
rary psychoanalysis. The concept of an analytic treatment carried
out as a war against unconscious resistances, in need of an alliance
to overcome conflict, refers to the drive model and in general to an
approach that ignores theoretical and technical perspective of ob-
ject relations. This conceptual framework is anachronistic and
hardly compatible with prevailing models, such as object-relations
theory, attachment theory, self psychology, and constructivist and
intersubjectivist approaches.
For this reason, I am going to leave on one side the idea that
patient and analyst are allies fighting together a war, and speak
instead about the collaborative relationship and the collaborative
process. I do not mean to identify a new theoretical and clinical
entity but simply to address the interactive processes in which
collaboration is negotiated in a selective way.
However, in addition to preferring the term “collaboration” to
“alliance”, I regard the classical concept of “therapeutic alliance” as
having represented in psychoanalytic thought the need for the
analyst to maintain contact with those aspects of the patient that
are most autonomous and mature and potentially capable of intro-
spection. These parts must not necessarily be identified with the
adult, mature, realistic and objective ego. Collaborative parts can
90 MARIA PONSI
also be organized in a rather primitive way, and it is the analyst’s

job to be able to keep in touch with them—that is, to find the
communicative and interactive level that can drive the analytic
process forward.
A primitive level of collaboration is often observed at the begin-
ning of treatment, when a “narcissistic alliance” (as Meissner says)
takes place, whose roots lie in basic trust—that is, in the primary
relationship with the caregiver based on empathy and intuition.
Thanks to this bond, the patient is able to accept the regression
imposed by the psychoanalytic situation.
In many cases, this evolution does not take place: a real analytic
process stops because of pseudo-alliances, because the patient re-
quires a silent holding, or because the patient rejects and attacks
the rules of the setting.
Stable instability—such a typical feature of borderline pathol-
ogy—also affects the relationship with the analyst. It often occurs,
even during the same session, that the borderline patient shifts
from active, self-reflective, and collaborative behaviour to an atti-
tude that at best is passive and uninterested and at worst is devalu-
ing and hostile. There may be steps forward, but steps backward
are just as likely. Often the shift from a collaborative interaction to
a detached and hostile attitude happens suddenly: the very same
patient who has seemingly proved to be able to achieve a therapeu-
tic splitting of the ego suddenly loses this psychic shaping and
again seems to be able to maintain only a very primitive bond with
the analyst based on massive projective mechanisms or on merging
with a soothing object.
In its more mature form, the collaborative process develops
silently in the implicit background that supports the analyst’s and
the analysand’s communications: it corresponds to the classical set-
up in which the patient observes the setting rules creatively, freely
associates, and is capable of insight and working through. In its
immature forms—that is, when the patient does not make use of
the analyst’s interventions—fostering the collaborative relation-
ship comes to the foreground. In these cases, the collaborative
process does not develop gradually and straightforwardly. Mature
and immature collaborative interactions alternate. The idea of a
collaborative process developing gradually—from simple to com-
plex, from primitive to advanced—fits the normal neurotic patient

better than the borderline one.
When the collaborative relationship shifts from mature to
primitive form (and also the other way round), the range of com-
municative means the analyst has to resort to is larger. He/she
must think up particular communicative forms in order to restore
the patient’s capacity to make use (in the Winnicottian sense of
“object usage”) of the analytic function. The analyst must be aware
of the type of collaboration the patient is able to accomplish at any
particular time—the analyst must be able to respond in a flexible
way, to change gear, as it were (Ponsi, 2000).
A non-verbal tool for monitoring and constructing

the therapeutic alliance: a clinical illustration
The following clinical illustration concerns a young woman, Ruth,

in her twenties, with a borderline personality organization
(Kernberg et al., 1989) characterized by self-devaluation and de-
pressive feelings alternating with paranoid ideas and outbursts
of rage.
After an initial phase in which variations of setting and tech-
niques had taken place, the treatment stabilized on three sessions
per week, face to face, with a prevalence of expressive interven-
tions over supportive ones.
I shall focus on a particular communicative channel through
which the collaborative relationship might be monitored and con-
structed: non-verbal interaction— more precisely in this case, eye
contact.
During sessions Ruth alternates two types of behaviour: kind,

docile, compliant, and collaborative and tough, desperate, rude,
and angry. While in the latter condition, she is totally impervi-
ous to any kind of intervention from me and her trustful and
communicative attitude is replaced by a behaviour of the oppo-
site type: she becomes tenaciously silent and often annoyed and
openly hostile.
92 MARIA PONSI
Two object relationships correspond to these opposite behav-

iours. In the phase of compliance and submissiveness towards
me, she appears to be magically merged with an omnipotent
good object by whom she feels protected, whereas in the sub-
sequent phase she is possessed by a desperate rage against
a persecutory object she deems unable to give her what she
wants. In this phase of angry disappointment she wants to
interrupt the treatment, and the analytic process comes to a
standstill. Since I realize that the patient is unable to understand
my words, and often even to listen to them, I resort to paying
more and more attention to the non-verbal side of our commu-
nication—in particular, to our eye contact.
When Ruth stubbornly looks down, she is inaccessible to any
contact, entrenched behind the autistic wall of her paranoid
defence, whereas when she raises her eyes a number of object
relationships come into being, depending on her way of looking
at me.
She gives me many types of looks: there is a piercing, intensely
moved, gaze, with bright eyes; there is a puzzled, questioning
look; there is a confused and half-asleep gaze; there is a furtive
glance, escaping and seeking refuge in her autistic shell; there is
a playful, conspiratorial glance; there is a frightened look, a
hateful look, a resigned look. At times, she looks at me blinking
repeatedly as if the air were stinging her eyes or as if there were
a strong, blinding, light.
The impact on me of such a diversified range of looks, cor-
responding to Ruth’s different self states, is to make me tune
into them while listening and while speaking as well. They are
the most important source of information for understanding
the kind of object relationship in the transference, which is the
developmental level I am dealing with.
It often occurs, for instance, that I start to speak to “Ruth-
hanging-on-my-words”—that is, to Ruth looking at me with a
trustful and childish smile—and shortly afterwards I see her
eyes becoming absent and dull. Stopping and cautiously inquir-
ing, I learn that a particular word I have used has produced a
breakdown of contact and a withdrawal into her autistic shell.
Had I gone on speaking, her withdrawal would have been

greater and my interpretation would have been stopped by her
paranoid defences. By leaving aside the interpretation and try-
ing to identify the word that upset her, I let myself be guided by
her look so as to remain attuned to her developmental level. The
whole sequence takes place on a double track—on a verbal level
and on a visual level—the latter serving as a sign of the patient’s
capacity to collaborate in the analytic work so that I can adjust
my words to the level of the ego’s functioning.
In this clinical case it has been the continuous exchange of looks

that has had a major role in monitoring the level of the ego capable
of self-observation. By this means, it has been possible to keep
together and to coordinate scattered parts of the patient’s self and
to give a minimum of stability to the patient’s self-observing capac-
ity. By co-constructing something like a fabric or a network as a
background to our verbal communication, a sort of visual frame of
ego support has been established: this has performed the function
of a continuous sensory container providing stability and safety to
carry on the interpretative work.
In this case, collaborative interactions have been focused on
a single communicative channel—the visual one, parallel to the
verbal one—rather than being contained in the pragmatic aspect of
language, as usually occurs in most psychoanalytic treatments
(Canestri, 1994; Ponsi, 1997, 2000; Makari & Shapiro, 1993; Tuckett,
1983).
Whether the collaborative relationship is fostered by explicit
intervention from the therapist or is regulated by non-verbal inter-
action or by various pragmatic linguistic devices of his/her dis-
course, its task consists in widening and deepening the analytic
function of the patient—a function that develops in two directions:
towards deepening his/her introspective capacities (that is, to put
it differently: towards developing his/her observing ego) and to-
wards getting better in touch with his/her unconscious mental
areas (that is, towards developing the ability to freely associate).
CHAPTER SEVEN
The therapist is dreaming:

the effect of the therapist’s dreams
on the therapeutic process
Gila Ofer
D
reams have multiple functions and are looked at from
different angles according to different theories. A dream
may be “a royal road to the knowledge of the uncon-
scious” (Freud, 1900a); a representation of the self and of inner
dramas; a way of communication of emotions and unbearable
feelings, dreadful events, the “unthought known”; or a mode of
organizing data via metaphors, images, and symbols. Patient’s
dreams have been given a central place in psychotherapy and
psychoanalysis. Much less discussed is the importance of the ana-
lyst’s dreams relating to his/her patients. The aim of this chapter is
to explore and reflect upon a therapist’s dreams and their functions
in the therapeutic process. It is suggested that a therapist’s dreams
related to his/her patients have developmental and organizing
functions. Thus, on the one hand, they reflect different stages in the
therapist’s development. On the other hand, they can cast light on
the patient’s psychic life, on his/her patterns of relating to others
and others relating to him/her, and can further facilitate communi-
cation between therapist and patient.
In this chapter, I first present the model of dreams that I follow
in my work. I then relate to what has been written until now on the
95
96 GILA OFER
subject of analysts’ dreams about their patients. Next, I consider

my idea about the functions of patient-related dreams, and, last, I
illustrate with clinical examples my idea about the functions of this
kind of dream.
In general, I follow Fosshage’s ideas about the organization
model of dreams. Fosshage proposes a revised psychoanalytic
model of dreams based on changes occurring within psychoanaly-
sis and on rapid eye movement (REM) and dream-content research
(Fosshage, 1997). He refers to his model as the organization model of
dreams, because the core process and function of dreaming is to
organize data. As a primary process, it uses visual and other sens-
ory images with intense affective colouration in serving an overall
integrative and synthetic function. Based on the reconceptualiza-
tion of primary process, the principal mode of dream mentation,
Fosshage proposes that the supraordinate function of dreams is the
development, maintenance, and, when necessary, restoration of
psychic processes.
The developmental, organizational, and regulatory processes
that Fosshage posits are all viewed as directly (manifestly) observ-
able in dreams. He refers to the dream content. He does not
maintain a differentiation between latent and manifest content,
because he does not assume a transforming or disguising process
in dream mentation. He does not consider that images are chosen
for the purpose of disguise and are therefore transformed into
other images. Instead, he feels that the dreamer selects images for
their evocative power and actual usefulness in imagistic thinking.
Dreams reveal the dreamer’s immediate concerns through af-
fects, metaphors, and themes. Dream images need to be assessed
clinically for what they reveal metaphorically and thematically, not
for what they conceal. Dream images are appreciated for their
communicative value within the structure of the dream drama.
Over the years of doing psychoanalytic psychotherapy, talking
with colleagues, and supervising other colleagues, I became inter-
ested in dreams, relating to their patients, of analysts and thera-
pists. I myself remember quite a few that relate to my own patients.
I also had many supervisees telling me their dreams about their
patients. However, to my surprise, this kind of dream has received
little attention in the psychoanalytic literature. To my knowledge,
there have been only five direct communications on the subject in
THE THERAPIST IS DREAMING 97
English-language journals (Lester, Jodain, & Robertson, 1989;

Robertson & Yack, 1993; Spero Halevi, 1984; Whitman, Kramer, &
Balbridge, 1969; Zwiebel, 1985), and an equally small number of
explicit references to this type of dream. Among those papers
reporting and discussing a therapist’s dream that relate directly to
his patient, one is analysing the author’s dream, one is a survey,
and the rest of them are discussing supervisees dreams. The au-
thors of these papers refer to this kind of dream as a countertrans-
ference dream.
By calling these dreams “countertransference dreams”, the em-
phasis is on the therapist’s reaction to transference aroused in the
patient, providing new insights on either the therapist’s or the
patient’s mental life. Less emphasis is given to the intersubjective
space in the therapeutic process.
On trying to understand the paucity of writing about this sub-
ject, I looked into a related subject: communications about patients’
dreams of their analysts. Kavanagh (1994) writes that the over-
whelming tendency in the existing literature about this kind of
dream has been to view dreams about the analyst, undisguised, as
indicating a problem. It could be either a problem in the therapeu-
tic process or an extreme pathology in the patient or the analyst.
Hence, he believes it to be striking that there is a paucity of articles
concerning a phenomenon that empirical studies have shown to
occur so frequently.
If the case is so for patients dreaming about their analysts, what
could be expected when we write about our dreams that relate to
our patients? Most analysts still feel uneasy when it comes to
revealing their personal reactions to their patients. They fear that
this must inevitably lead to some consideration of their own con-
tinuing unconscious conflicts. Moreover, it would be too hazard-
ous for them to report a dream that could be interpreted as
pointing to a pathological condition or as devaluing their profes-
sional skills and ability. Blum (1996) has stated that “the analyst’s
exposure of his technique (and I might add here his dreams) might be
too self-revealing, too involved with issues of discretion and confession,
voyeurism, exhibitionism, and criticism”.
In a survey led by Lester, Jodain, and Robertson (1989), both
senior analysts and candidates in roughly equal proportions have
reported countertransference dreams (CTDs). The authors report
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that CTDs are common, whether one is a candidate or an experi-

enced analyst. In addition, their findings support the concept of a
resonance between the patient’s and the analyst’s unconscious at
all stages of analytic work. Countertransference dreams signal this
resonance in all of its affective intensity and conflicted nature.
Lester reports two main conditions that prevail in the trans-
ference–countertransference dynamic when these analysts had a
CTD.
1. Their patients were in the grip of what the authors described as

an “instinctualized” transference (either erotic or aggressive).
2. The analysts were at somewhat of a loss to understand their
patients.
These findings tallied with other works on CTDs that proposed a

link between the occurrence of this type of dream and “problematic
and conflict-laden” stages of the analyses. An interesting finding
was significant differences in the manifest content of CTDs re-
ported by male and female analysts. Male analysts reported more
on erotic/sexual content, whereas female analysts had a higher
frequency of dreams in the manifest content of which the analy-
sand intrudes on the analyst’s private space. Lester explains these
differences in the light of object-relations and wish-fulfilment theo-
ries.
Myers (1986) characterizes these dreams as being of inestimable
importance in helping the analyst resolve countertransference re-
sponses. Robertson and Yack (1993) sees such dreams as both a
signal of the analyst’s resistance and an unconscious attempt at its
resolution. It is not only an intrusion into the closed system of the
dreamer but also a positive challenge, representing a new opening
to the outside world, increasing the range of potential problem-
solving and need-gratifying opportunities. When the analyst be-
comes aware of the various meanings of the dream, the CTD
becomes a potentially vital source of information with which to
unlock a therapeutic impasse and unfold the transference–counter-
transference. Yet, when Robertson reports a case of a CTD, he
reports a candidate’s dream in supervision and argues that of all
manifestations of candidates’ countertransference that occur in a
supervisory process, CTD is one of the most useful in promoting

cognitive and experiential learning. The CTD of Robertson’s super-
visee had forced her to abandon her defensive inertia in the thera-
peutic process and enabled the candidate to find her way out of an
acute therapeutic impasse with her patient.
The implication here is that this kind of a dream is fine for
beginners but not so for more experienced analysts. Implied also is
that these preconditions for CTDs might hint at the frightening loss
of analytic competence. This might cause analysts to refrain from
discussing their own CTDs.
Note that the most renowned dream in psychoanalysis is a
countertransference dream, namely, the Irma dream, or what is
called the specimen dream of psychoanalysis. The Irma dream was
initially a secret dream, which represented the initiation of a self-
analytic and supervisory process. Freud had the dream in 1895 and
published it only in 1900. It remains the most interpreted dream of
all time. It is “enshrined in psychoanalytic history and idealized as
the first dream to be interpreted and then reinterpreted by succes-
sive generations of psychoanalytic scholars and students” (Blum,
1996, p. 515) (Erikson, 1954, Schur, 1966, and Hartman, 1983, are
just a few other writers who have analysed the dream).
In his dream, recounted in The Interpretation of Dreams (1900a),
Freud meets Irma at a ball; she complains about some physical
symptoms after receiving an injection. He wants to check her
mouth, and she shows some recalcitrance. Then, when she opens
her mouth properly, he can see some white patches and grey scabs.
He calls some of his friends, all of them doctors, and they each
confirm his suspicion. His friend Otto has given her an injection,
and Freud in his dream says, “Injections of that sort ought not to be
made so thoughtlessly . . . and probably the syringe has been not so
clean.”
Blum (1996), in his meticulous and exquisite reinterpretation of
the Irma dream, asserts that the day of the Irma dream represented
a milestone in the development of the new science and a nodal
point in Freud’s personal metamorphosis from neurologist to psy-
choanalyst. This is clearly a dream by a therapist about a patient
reported—or rather not reported—to a senior, supervisory col-
league. The Irma dream may be designated CTD about the patient
100 GILA OFER
as well as a dream about the supervisor. The Irma dream was

intimately connected with Freud’s “transference” relationship to
Wilhelm Fliess, who operated on Emma/Irma’s (Freud’s patient)
nose in order to alleviate some of her symptoms, which were
connected in the doctor’s view to masturbation. Emma almost died
because of Fliess’s operation and because he left a piece of gauze in
her nose. The dream was a turning point in Freud’s relationship to
Fliess. Freud had to face reality after this dream. Freud was very
careful not to tell this dream to Fliess. The rising de-idealizing,
discord, distrust, and inherent disillusionment with Fliess could be
decisively dated to the Irma dream. It was a patient-related dream,
which signalled a change of “identity” for Freud.
I choose to call these kind of dreams patient-related dreams
(PRDs) rather than CTDs. By this, I aim at emphasizing the fact that
these dreams belong in the space created in the therapeutic en-
counter between patient and therapist. They do not merely reveal
the defensive attitude of the therapist on a particular area of a
patient’s mental life; nor are they merely a reaction of the therapist
to transference aroused in the patient. Perhaps all open-minded
and sensitive therapists should be able to dream for their patients.
Just as a mother must dream her infant, so must the analyst dream
for himself and for his patient (Grotstein, 2000).
I would like to explore PRDs from two developmental perspec-
tives (and possibly there are more perspectives to look at):
1. The time of appearance of such dreams: at what points in the

analyst’s professional life can these dreams come to the surface?
I look at this without pathologizing the phenomenon. I suggest
that it happens at intersections of two separate developmental
roads taken by the analyst and the patients that he/she treats
along the years. When there is a conjunction in the intersub-
jective field between analyst and patient, the intensity of affects
is augmented and primary processes are more likely to occur
abundantly. (Primary process, according to Fosshage, I remind
you, is a mode of mentation that uses visual and other sensory
images with intense affective colouration in serving an overall
integrative and synthetic function.) Both patient and analyst are
engaged in this kind of process. However, it is the analyst that is
dreaming, that has first to go through a change. From this perspec-
tive, it is interesting to look at the sequence of PRDs of each

analyst along the years and to learn from this sequence about
the professional (and also personal) development of each indi-
vidual analyst.
2. A second perspective is related to a specific function of such
dreams. I would like to suggest here that PRDs, when suffi-
ciently worked through (and sometimes just by appearing), can
shed a new light on the therapeutic process, on the way the
analyst experiences the patient and him/herself in the process.
They can bring about what I call “flipping the page” in the
narrative of therapy: from a romantic identification with the
other, to a realistic participant observer.
To illustrate my ideas, I have chosen to bring three PRDs that I had

in different periods of my professional career with three different
patients.
(a) Twenty-two years ago, I was working in a mental hospital

trying to manage my anxieties, on coming into real contact with
psychotic patients who are so sensitive as to read me before I
can read myself. I also had to respond to so many responsibili-
ties, and I did all this by pretending I was managing. Although
I felt somewhat anxious, I managed to deny some of the emo-
tional difficulties. Supervision was very partial in that hospital.
The experience was very difficult and shaking; it was a move-
ment between total helplessness and omnipotent hopes, with
not enough regulatory work done within.
A new patient came to the ward. He was young, bright, and had
just finished his degree at university. He was plump in appear-
ance and had a sort of baby face. He looked very naive. How-
ever, he was psychotic with manic and megalomaniac thinking
and defences. He acted as if he could conquer the world with
mathematics (a field in which he was outstanding). To me he
seemed a baby who was in someone else’s body. I wanted to
work with him, but he was assigned as a patient to another
psychiatrist. I watched him in the ward from a distance. Very
often we would talk in the ward, and I felt that I could treat him
better than the psychiatrist did (and this was also an omnipotent
102 GILA OFER
thought!). The patient’s mental condition did not improve for

a long time. He became more and more psychotic. He received
a huge amount of antipsychotic drugs, but nothing helped.
After a certain time, his psychiatrist had to leave the ward. I was
very happy to replace him as the patient’s therapist. I felt that
with me as his therapist, things would improve. I felt I could
understand him. He was talking about kingdoms and kings
who could change the world, and I felt I could change him. We
shared omnipotent feelings, only I kept them secretly.
We met twice a week inside the ward. As much as I liked to
hear him when we were outside the therapy-room, I was pretty
bored by him when we were together in the therapeutic session.
Pretty soon, he became so “normal”, with no sense of humour
and talk about the food, the nurses, and the everyday dull
routine in the ward. I almost regretted having him as a patient.
And then I had a short dream:
In my dream I was walking with him in the backyard of the hospital
without talking. The view was very beautiful and serene. We came to
a nice corner where there was a table and two chairs. We sat down and
started talking. The way we were talking was through telephones. But
it was very strange since there were many cables connecting the two
telephones. Actually there was no way we could hear one another since
the cables were so many and so entangled. The more I tried to listen,
the more cables and knots there were. I could not do anything about it.
When I looked up I could see the patient and we could almost touch,
but when we tried to talk again, there was no way we could hear or
understand each other. I felt so bewildered.
The dream was simple and revealing. I could talk about it for a
long time in my personal analysis and in supervision. It was a
period when I was fascinated with psychotic thinking and
symbolism. I was beginning to work in a mental hospital. It was
very intense and unsettling. Like many beginners in the field, I
was oscillating between omnipotent wishes of healing patients
and despair in not being able to do anything. Sometimes I felt
I could easily connect with the patients and “lead” them to
health; at other times, I felt totally impotent, lonely, and a
failure as a psychologist. I projected my impotent feelings on

the nurses in the ward, blaming them and the physical condi-
tions for all difficulties in therapies.
Having dreamt this dream, I came to realize how tormenting it
was for my patient to live everyday life and to adjust to the
growing demands made on him by life. He was flying away
into an omnipotent beautiful world where he could avoid the
burden of growing up, of coming to terms with his human
limitations (he was an extremely bright young man but could
hardly face daily demands and routine). It brought me back into
a reality where I had to face my limitations but also the fact that
I could use other modalities to connect with the patient. I could
no longer delve into fantasies of either totally identifying with
or saving the other.
(b) A second dream I would like to bring here was about a 25-
year-old patient, very skinny and delicate looking, who came
into treatment suffering from extreme conditions of high blood
pressure, difficulties in her relationship with her husband, and
anxieties related to her 2-year-old daughter. I saw her in an
outpatient clinic. She was quite regressed in therapy, and I met
her twice, sometimes three times, a week.
In my dream, she came to my house and knocked on my door. I let her
in and she went into my bed. I covered her and, after a few minutes, I
saw that she had peed in my bed. I was very angry at her peeing in my
bed.
I thought about the regression that was so apparent in this
dream. But I also had an immediate association to the dream: I
had a friend who very often came to visit me in my apartment
with her 3-year-old daughter. Very often, when they came to
me, the child would take a big stick and run around my apart-
ment, hitting out in every direction. The mother would not do
anything, and I felt very uneasy and worried about furniture
and objects in my room. Only later did I realize how intrusive
this was and that I felt it as an aggressive attack on me. It took
me some time until I dared to tell my friend anything. After all,
the aggression was so disguised by a child’s behaviour . . .
104 GILA OFER
So, for me, it was the first time to admit the aggression that was
prevalent in this patient, aggression that was also augmented in
her regressive state. I had to shed my Polyanna-like perspective
on this patient: she was not only the victim of her insensitive
husband and impossible daughter. She had her passive-aggres-
sive way of getting to them. She also had her own way of
making me angry. I tried to avoid my aggression towards her,
and so I denied her own aggression and identified with her
helplessness. Only after realizing this through the dream could
I go with her into the complexity of her relationship with me
and with other people. Later we found how this was connected
to her past in her relationship with her parents.
(c) The third dream I would like to report occurred a few

years ago. In my dream I was in my bedroom with two men. The
three of us were going to bed together, but one of the men had pyjamas
with the sign of skull and bones on his chest.
I woke up. I could not understand the dream. I could associate
to a few themes I was interested in at the time, such as gender,
mind and body, sexuality, and perversion. I could identify the
two men: one was a man who was very sensitive but also
ambitious, curious, intellectual. The other was a builder who
was undertaking some construction work in my house, always
postponing his work, not a very honest man, and hard to find at
home. I could associate further to some issue in my life, connect
it to a traumatic past event, but nothing felt like it was really
there.
In the morning I started to work with my patients. When the
third patient came, she started to talk about her husband, and I
felt dizziness in my head the moment she started to talk, know-
ing that I had dreamt about what she was going to say.
She was a young woman who was married to a bisexual man
and had a child from him. Her former therapist, who referred
her to me, said that she had problems with her femininity and
that this was the reason for marrying a bisexual man.
At the time she married him she knew about his sexual orienta-
tion, but they were very attached to one another and had an
agreement that he will give up his attraction to men. Appar-

ently, the patient was a highly functioning woman, a successful
lawyer. She was very charming, nice looking, and intense in her
reactions. She seemed to be very composed when she first came.
However, very soon I could realize her symbiotic needs. Her
husband, though, had started a process of separation (following
an intense therapy) and became more aware of his homosexual
tendency. He actually had a love affair with a male friend that
ended only because the other man left the country. He started to
look for other men, mainly in the form of short acquaintances,
and most of the time concealed from his wife his search for
homosexual ties. They had a sexual relationship, but she finally
realized that he was in fact a homosexual. The pain was im-
mense for her. However, they still decided not to separate. They
stopped their couple therapy and continued individual
therapy.
At the time I had the dream, the issues discussed by my patient
in therapy were mainly childhood deprivation in the neigh-
bourhood where she had grown up, her relationship with her
parents and siblings, and the complexity of raising her child
when there is double career in the family. She hardly referred to
the presence of homosexual relationships in her life.
On the morning after I had the dream, the patient was telling
me how her husband is going to Independence Park (a famous
park in Israel which is a hangout and meeting place for homo-
sexuals) to look for young men and how insulted she was by
this. I was alarmed. We were talking about her history, about
her feelings, about her children, but this woman’s life was also
in danger! While her husband was having short encounters
without protecting himself, he was putting himself and his wife
in possible danger of contracting AIDS. She and I together went
on in the process of splitting mind and body and denying the
fateful dangers, including possible deaths that were inherent
to the situation. Again, the dream brought reality back into
therapy. No more a romantic but a distant look at this situation
where seduction, intellectualization, and the flare of striving
towards individuality cover concealed threats, deadly aspects,
and dangers.
106 GILA OFER
Over the years, if we look at our dreams relating to our patients, we

can see the different issues that were dealt with at different points
in our personal and professional development. Each dream repre-
sents an important issue with which we, as analysts, have to deal as
persons and as professionals.
The three dreams I brought here relate to different patients in
different periods in my professional career. Each of them reflects a
developmental shift. In the first, there is a turning point from an
omnipotent view of the therapist role to a more limited one. In the
second, there is an acceptance of aggression in the patient and at
the same time in the therapist. In the third, there is a push towards
a more complex look and acceptance of gender and sexual issues—
the multiple facets of the relationship between life and death.
Our profession is a continuous search into ourselves, into our
identity, as well as being with our patients in their own search for
their own selves, identity, and meaning. On certain conjunctions of
emotions, traumas, feelings, and experiences, we have our dreams
related to our patients/partners. We have dreams that illuminate
some difficulty within us as well as within our patients.
Loewald (1980) writes that the resonance between the patient’s
and the analyst’s unconscious underlies any genuine psychoana-
lytic understanding and forms the point of departure for empathic
verbal interpretations of the material perceived, heard, and articu-
lated in the hour. At each point in our life, there are many overlap-
ping threads of development that coexist. In each of our patients
we might meet a counterpart to one of these threads. However,
when there are two principal threads or themes that meet in a
crossroad, chances are that we can react more intensely to the
patient and can collude at a certain point to disregard certain
aspects that should be dealt with. A dream relating to the other,
met in the therapeutic session, met within us, might occur. This is
why a patient-related dream is often referred to as a countertrans-
ference dream.
However, it is more than that. A dream about the analyst’s
patient belongs in that space which is created between patient and
analyst. In this “analytical third” created by the therapeutic dyad
(Ogden, 1994b), the analyst dreams his/her patient. One wonders,
as Grotstein (2000) says, who wrote the dream? Who produced it?
Who arranged the narrative? One could say that the patient is the
other within the analyst as well as the analyst being the other
within the patient. As such, the dream belongs to both.
Thus, PRDs, as can be seen in the examples here, can bring
about moments of creative breakthrough in therapy. The profound
shift in the analyst’s experience of the patient is important to
the ongoing re-creation of patients’ identities. Those are crucial
moments that involve a change in perspective, a realistic look at
the patient, without fear of becoming dull and restrictive. This,
after all, would prevent therapist and patient from drowning in a
romantic, maybe exotic, yet dangerous denial. The challenge, then,
is still there: continuing the journey, with enough freedom and
creativity, yet without losing sight of the real.
CHAPTER EIGHT
The healing work of a practising

psychoanalyst/psychotherapist
Claude Smadja
Psychoanalysis stands firstly for the investigation of psychic

processes which otherwise are barely accessible; secondly for a
method of treatment of neurotic disorders based on this inves-
tigation; thirdly, for a series of psychological concepts acquired
by this means which gradually form a new scientific discipline.
[Freud, 1923b]
T
he above definition of psychoanalysis put forward by Freud
in 1923 introduces the Paris Institute of Psychoanalysts’
programme of training and scientific activities and is taken
up again in the presentation of this chapter. This set of proposals
contains at one and the same time a very high degree both of
openness and of internal cohesion. Let us examine this quotation
from Freud carefully.
Psychoanalysis is defined according to three phenomenal regis-
ters. The first concerns a methodological innovation in the scientific
field; it is a new method of exploring the unconscious processes.
This is what is meant by referring to processes inaccessible by any
method.
109
110 CLAUDE SMADJA
The second register concerns a therapeutic modality for neu-

rotic disorders; it is, therefore, a kind of psychotherapy, as it uses
psychic tools. We know of new technologies in medicine that were
first invented to explore organic activities and then were used for
therapeutic ends—coelioscopy or coronography are ordinary, con-
temporary examples of this. This analogy with medico-surgical
techniques is in line with Freud’s thinking.
The third register concerns the establishment of a new theoreti-
cal corpus. What is remarkable about the form in which Freud
presents his definition is that it is in stages—we go from one
phenomenal level to another—integrated—each higher level inte-
grates the preceding ones—and, at the same time, linked. The three
levels are coordinated and related to the others: the therapeutic
method is based on the investigation; the theoretical corpus is
based on the experience gained from this new therapy in current
practice.
What I believe we need to retain from this reading of Freud’s
text is the imperative need of an identity in the work of the
psychoanalyst. This imperative obliges every practising psycho-
analyst to maintain an internal coherence throughout and in spite
of the variety of the situations that confront him/her in his/her
work. This apparent contradiction between coherence on the one
hand and variety on the other can be also found in the form of
technical variations and analytic processes.
Throughout his work, Freud ceaselessly encountered technical
difficulties which led him to reformulate the rules of conduct of the
analytic process and to pose new questions, which often remained
unanswered. The first rules were established from the experience
acquired from the psychoanalysis of hysteria and of classic psy-
choneuroses. After the First World War, in a text written in 1918
and presented to the Fifth Psychoanalytical Congress in Budapest
in September of that year, Freud envisaged “Lines of Advance in
Psycho-Analytic Therapy” (1919a [1918]). This text was written as a
result of pressure from the new psycho-pathological forms appear-
ing in the field of the psychoanalyst’s work. The war neurosis, the
seriousness of some neurotic disorders, the diffusion of psychoana-
lytic therapy, and its inscription in the domain of public health led
Freud to envisage technical modifications and to broaden the activ-
ity of the psychoanalyst in the new climate. Thus, he wrote in this
HEALING WORK 111
paper: “We are obliged to operate in an entirely different way due

to the fact that each day we are more aware that the various forms
of illness treated by us can not be cured by the same single tech-
nique.” Starting from the example of the treatment of serious
phobias, Freud was led to use preliminary techniques that, accord-
ing to him, were a necessary first stage before the patient was ready
for psychoanalytic therapy. This notion of preliminary techniques
entails the idea that non-recognition or denial by the psychoanalyst
of certain forms of mental function can lead to premature interrup-
tion of psychoanalytic treatment or to interminable analysis. The
ability of a psychoanalyst to adapt to new psychic situations, dis-
tant from the neurotic terms of reference, becomes one of the main
issues in psychoanalytic training. These technical variations, recog-
nized early and taken into account by Freud and metaphorically
expressed in the image of a combination of the pure gold of analy-
sis and the lead of direct suggestion, do not divert him from the
thread of the conduct of the psychoanalytic process. Thus, Freud, a
little further on, writes: “Whatever the form of this popular psycho-
therapy and its elements, the most important and active parts will
remain those taken from strict psychoanalysis stripped of all bias.”
Strict psychoanalysis represents a neurotic hard core from which,
from the unconscious processes, can be extracted the mechanism of
repression, the transferential investments, and the oedipal organi-
zation of sexuality. Today, on the basis of clinical experience gath-
ered over the years, we should add to this hard core the evaluation
of the quality of narcissism, as well as that of masochism and the
processes of internal disintegration. In addition, work concerning
non-neurotic organizations, and particularly psychosomatic obser-
vations, have sufficiently underlined the role of the economic fac-
tor for an increasing number of patients. In this respect, the
psychoanalyst should take into consideration the behaviour and
the somatizations in the general economic state of his/her patients.
These different elements in the evaluation of the psychic function-
ing should be approached at every point in the course of the
analysis as much in their positive valence of presence as in their
negative valence of absence. It is the way of listening to the nega-
tive in its different degrees of organization and disorganization
that marks the specific quality of the psychoanalyst (more and
more today) and the choice of language used to the patient. Thus,
112 CLAUDE SMADJA
for example, although a patient may not be able to develop trans-

ferential investments towards his/her psychoanalyst, he/she still
remains within the realm of analytic work. The pinpointing, on the
level of the negative, of the lack of transferential movement, and
the inevitable effects of this on the countertransference personal
experience of the analyst, can direct the work of thinking of the
psychoanalyst and to help him/her choose a technical modality
likely to generate a new dynamic in the psychic functioning of the
patient.
Finally, in spite of any technical variation used by the psycho-
analyst, a variation justified by the necessity to adapt him/herself
to a modality of mental functioning removed from the neurotic
modality, it is the psychoanalyst’s work specifically in his/her
ability to listen and choice of language that guarantees both the
installation and the maintenance of the analytic process.
The healing process
From Freud onwards, every psychoanalyst has encountered dif-

ficulties in the course of the analytic process. Although Freud
adequately codified this process which has became the mainstay
of psychoanalytic therapy, the questions posed to psychoanalysts
even today relate to the obstacles to the psychoanalytic process
and, consequently, to the therapeutic effects of psychoanalysis. It
was about the notion of resistance that Freud envisaged this ques-
tioning, as much to consider the smooth course of the analytic
process as to recognize its limitations, which in turn justify techni-
cal variations.
In the 1923 quotation above, in which Freud defines psychoa-
nalysis, the notion of the analytic process correlates directly to the
notion of the healing process. This first mention of psychoanalytic
healing is linked to the notion of transference. Freud underlines
here the two valences of transference: resistance and driving force
of change—that is to say, the healing process during the psycho-
analytic treatment. The role of transference and its analysis form
the basis for one of the definitions of the healing process in the form
HEALING WORK 113
of the resolution of the transference neurosis. In 1934, Strachey

based his notion of mutational interpretation on this. According to
him, this interpretation “should be put to the patient to the point of
urgency” (Strachey, 1934, p. 150) in relation to events acted, lived
through, and repeated in the course of the transference neurosis
and the recalling of events of infantile neurosis.
The second mention of psychoanalytic healing was formulated
by Freud when he developed the notion of the healing work. This
notion of work, coming from Freud, makes us think of the dream
work, but here it is a question of the contrary, which, unlike the
dream work, involves two protagonists: the fully awake patient
and the psychoanalyst. The healing process, according to Freud, is
linked to the analysis of resistances. This analysis evolves in two
stages, which are interconnected. The first stage is the recognition
of resistances, which the psychoanalyst transmits to the patient.
The second stage is that of going beyond the resistances to their
resolution, which releases the therapeutic effects aimed for by the
psychoanalysis. In this second stage, it is a question of overcoming
resistances, conquering resistance by means of continuous, pro-
longed, and reviewed endeavour. It will be noted that in Freud’s
text the notion of psychoanalytic healing is linked both to proce-
dure and to work. The notion of procedure contains the idea of a
gradation in temporality; this means that therapeutic effects come
in the course of time and through time. As for the notion of work,
this implies a force, a constraint, against which patient and psycho-
analyst should unite in order to achieve the psychic transforma-
tions that confirm that the healing process is active. It is in this
respect that the importance is shown of Freud’s advice on the
psychoanalyst’s qualities of perseverance and patience in the
course of his practice.
These two distinct phases in the analysis of resistances corre-
spond, in fact, to historic moments in the history of psychoanalytic
technique. Psychoanalysis was the art of interpretation, with its
analysis of hysteria and classic psychoneuroses, together with the
analysis of dreams. It was a case of revealing the hidden meaning
concealed by the patient’s symptoms or his/her conscious repre-
sentation. This interpretation of the latent meaning of an obvious
content could only be achieved once the unconscious resistance
114 CLAUDE SMADJA
had been identified, recognized, and transmitted to the patient.

Then Freud and the first analysts recognized that this interpreta-
tion procedure was incomplete and insufficient. It had become
clear that there was an impediment to the resolution of resistances.
Freud soon identified this negative factor as relating to the phenom-
enon of repetition. In 1914, Freud studied the relationships between
remembering and repetition and showed how the process of re-
membering, specific to the associative work of the patient, is
thwarted by the phenomenon of repetition. On a technical level, it
appeared then that the slow and painstaking building up of repeti-
tion constituted a preliminary and necessary stage leading to the
beginning of remembering. Remembering is, to a certain extent,
triggered off by the resolution of resistance. This is what Freud
called the interpretative working out of resistance, the Durcharbeiten of
“working-through” (Freud, 1914g).
Repetition, identified after 1920 as a fundamental factor of
drives, constitutes the main obstacle to analytic processes (Freud,
1920g). It is necessary to understand that the notion of resistance
changes dimension here. It was first conceived as clinical evidence
of a barrier separating the unconscious content from a precon-
scious–conscious content and, at the same time, as evidence of the
continued repression separating an unconscious system from a
preconscious–conscious system. It henceforward became the
means of revealing the defensive mechanisms of the ego in its relation-
ship on the one hand with the impulsive system and on the other
with other psychic agencies. Traditionally, what legitimizes the
status of resistance is the energy expended continually by the ego
to maintain its repressions in the face of the constant thrust of
drive. Resistance is therefore based on a counter-investment that
is opposed to a set of unconscious repressed representations. This
type of resistance can be qualified as full resistance. Moving from the
idea of resistance to that of counter-investment on which it is
based, a wider view of the ego with the whole variety of its
defensive attitudes is reached. It is this theoretical orientation that
led Freud to envisage the relationship between resistance and the
modifications of the ego caused by the need for defence.
In the addenda of Inhibitions, Symptoms and Anxiety (1926d
[1925]), Freud foresaw that resistance of the ego alone was not
HEALING WORK 115
enough to account for the clinical facts encountered. He was there-

fore led to describe five types of resistance: three of them concern
the ego, one the id, and the last the superego. The resistance of the
ego concerns the classic repression resistance, the resistance linked
to the transference, which is distinguished from the first type by its
possibly new and reinforced effects of repression resistance, and
the resistance linked to the secondary benefits of illness. The resist-
ance of the unconscious or resistance of the id is what had been
identified as the heart of the working-through process. It is linked
to the phenomenon of compulsive repetition and, in the course of
psychoanalysis, imposes on both the patient and the analyst the
interpretative elaboration of resistances. The resistance of the su-
perego is related to the unconscious guilt feeling or need for
punishment and is revealed by a negative therapeutic reaction
(Freud, 1926d [1925]).
The aim of the healing work has, after all, been displaced. It is
no longer a question of merely overcoming resistances in the ego
but of modifying the ego, as it has become an agent of resistance
through the defensive forms it has taken on during its develop-
ment. It was in 1937, in one of his last (written) works, “Analysis
Terminable and Interminable”, that Freud pursued this dilemma
further. The accumulation of experiences in the field of analytic
practice and the encounter by analysts with patients showing clini-
cal and psychopathological forms intractable if not resistant to all
psychic change led Freud to stress once more the economic factor.
Among the determinants that more or less hamper the healing
process, Freud particularly highlights external traumas, the inten-
sity of the drives, and the defensive modifications of the ego either
inherited or acquired in the course of development. These are
installed precociously and cause the ego to adopt vicious attitudes
that then remain. Thus, it is the ego itself in its defensive config-
uration which becomes a resistance “against the revelation of
resistances”. In fact, it is the analytic process and its associated
healing work that have become the object of the ego’s resistance.
The initial healing work was organized according to relatively
simple metapsychological data. The resistance of the self/ego pre-
supposed the existence of a counter-investment situated in the
preconscious system. The counter-invested representations were
116 CLAUDE SMADJA
situated in the unconscious system. The conflict dynamically op-

posed sexual drives and the drives originating in the ego. As for the
economic factors, an alliance with the psychoanalyst could be relied
upon to beat and overcome the resistance of the patient. After 1920,
because of the introduction of the second theory of drives and the
second topography, relationships within the psychic apparatus
were completely changed. As a result, certain types of resistance,
qualified as of a different type, were revealed in the clinic without
it being possible to locate them precisely. Freud attempted a de-
scription of them that today seems to evoke the non-neurotic func-
tioning of the ego. The adhesiveness of the libido underlines the fixity
of the link to the object and is to be found in certain forms of the
psychic organization of the personality. The exhaustion of plasticity
translates the relative failure of the libidinal investment and evokes
the operational functioning of the ego and its attendant loss of
libido, which is as much narcissistic as objective and which is
accompanied and revealed in the form of an essential depression.
As for the negative therapeutic reaction, it is dependent on a moral
masochistic factor as the patient clings on to the suffering caused by
his/her illness and fights any cure. These new variants of resistance
of the ego all presuppose a psychic functioning dominated to a
greater or lesser extent by defusion of drives. The defused libido has
the effect of increasing the tension of excitation within the psychic
apparatus at the same time as the link to the object grows. For its
part, the defused death instinct has the effect of increasing the
effects of disintegration of the internal links and disorganization
within the psychic apparatus, while at the same time contributing
to the disturbance of the somatic functioning. It is to be understood
that, faced with patients having psychic non-neurotic disorders—a
true illness of the ego—the psychoanalyst in his/her healing work
should adapt his/her technique while firmly bearing in mind the
level of disintegration within the drive apparatus and the quality
and organization of the psychic defences of the patient. In these new
circumstances, resistance is very often based on counter-investment
that no longer counter-invests repressed representative contents in
a functioning and dynamic unconscious; it only counter-invests a
state of traumatic helplessness. These types of resistance can be
qualified as empty resistances; they are pure negativity.
HEALING WORK 117
To sum up, in Freud are to be found three types of technical

operation that specify the work of psychoanalytic healing:
1. The recognition of an unconscious resistance and the interpre-

tation of it presented to the patient.
2. The interpretative elaboration of types of resistance principally
based on the analysis of transference.
These two operations aim particularly to remove secondary repres-

sion.
3. The correction in the course of the analysis of the process of

primary repression.
This third operation attempts to modify the ego in its defensive

organization. It introduces a new notion, that of correction, which
can be related to reparation. By bringing a technical status to this
correction of primary repression, Freud sought to alleviate the
negative effects of the insufficiency of the precocious processes of
counter-arousal which obliged the ego to set itself up in an aberrant
defensive mode. As a result, the rigorously therapeutic dimension in
psychoanalytic healing is conferred on the corrective method mod-
elled on substitutive or reparatory medical or surgical treatment.
Thus it seems that, for Freud, a period of therapy justified by
certain types of resistance opposed by the patient as a result of the
specific quality of his/her mental functioning and the defensive
organization of his/her ego formed an integral part of the analytic
process and, as a result, of the healing process. This period of
therapy cannot therefore be detached or distinguished from the
analytic process of which it is fully one of the determinants.
The concept of technical variations opposable to the analytic
process seem therefore to misconstrue the Freudian conception of
the healing work. Only the weight of a psychoanalytic ideal based on
a more or less high degree of denial in the community appears to
justify the concept of opposition between technical variation and
analytic process. Finally, it is essential for the psychoanalyst both to
know the patient at every moment of the cure and to adjust his/her
language according to the knowledge he/she has of the mental
118 CLAUDE SMADJA
organization of the patient, in order to keep alive the dynamism of

the analytic process and to avoid any risk of interruption.
Technical preliminaries to the analysability

of patients suffering from somatic disturbances
Marc was 35 years old. He came to the Institute of Psychosomatics

as the result of discovering he had a myeloid splenomegaly. It was
a chronic, progressive disturbance concerning the hematopoietic
system, characterized by the fibrous transformation of the bone
marrow. Its severity was due to the degree of non-differentiation of
the blood cells and to the extent of compensatory splenomegaly.
Usually it is an illness found in an older person. Its diagnosis was
tremendously traumatic, especially when linked to a life expect-
ancy of some ten years given him by his doctor. This traumatic
event intensified, at several years’ distance, a traumatic event of a
different kind, which had been relatively ignored from a psychic
point of view. Four years before, in fact, his father had died of
prostate cancer. Marc had then developed, almost immediately,
precardiac and epigastric pains, which were both persistent and
lasting; no medical examination over the years had discovered any
organic aetiology. The pains were, in all probability, manifestations
of an anxiety neurosis, to which the patient had in any case been
relatively susceptible in the past, although to a lesser degree, and
which had formed the background to his somatic disorder.
Marc was married with two young children, a daughter of 6
years and a son of 4. He was handsome, with a confident manner.
He was a school inspector and, by training, a history and geogra-
phy teacher. He entered the consulting-room with a quick, firm
step and sat down as if he were the consultant rather than the
consultee. He spoke as if he were giving a lecture, in a magisterial
manner and a high tone of voice. He always seemed to need to
forge ahead. His speech was organized, always rational. His eyes
never left mine. When his talking stopped and there seemed to be
a pause, I felt that he was in a situation of great psychic difficulty.
His anxiety was immediately perceptible, although it was not
HEALING WORK 119
expressed. He searched for a gesture, a mime, or a word from me to

set him going again. He seemed quite ready to be interrupted.
The somatic event represented by Marc’s illness was the result
of disruption of his psychosomatic equilibrium and of its usual
psychic mechanisms. As a result of the development of a traumatic
state rather than a traumatic neurosis, these mechanisms had been
massively intensified and directed into a defensive fight with the
purpose of avoiding the unleashing of a state of internal distress,
at the expense of a specific deformation of his ego. These psychic
conditions seemed to me to define the basis of an evident neurosis
to which my patient responded from the point of view of his
fundamental organization. His urgent and pressing need for nar-
cissistic “completeness”; the excessive dimension of all kinds of
excitation with immediate satisfaction or anxious disintegration
the only alternative; the poor capacity for psychic restraint; the
importance given to the material nature of objects; and the lack of
passive psychic attitudes—all these confirmed my opinion of the
current narcissistic organization of Marc’s mental state. In effect,
we could say that because of a special situation, as much in the past
as in the present, his process of control had superseded the process
of symbolization. Or, in other words, we could say that the self-
calming systems had superseded the representational systems.
As soon as the diagnosis of his illness had been confirmed, Marc
took a series of steps designed to deny the reality of it and to
control the catastrophic effects of it on his psychic life. He used to
work at this twenty hours a day. He gave the name “path to health”
or “path to a cure/healing” to this therapeutic process. This com-
prised participating in a group of psychological therapy sessions,
in the adoption of new restrictive attitudes to diet and exercise, and
in the daily application of techniques called techniques of visuali-
zation. It was in the context of this project and to complete his
therapeutic procedure that he came to the Institute of Psychoso-
matics to begin psychotherapy. His idea was that certain events in
his life, and in particular in his recent life, had caused the onset
of his illness and that recognizing these events could help to cure
him. He then referred himself to me to help him in this project. In
fact, in his manifest demand, he was appealing to a technician
of psychism. Thus, the start of the treatment was marked, on the
120 CLAUDE SMADJA
patient’s side, by the pressure to capture me in his processes of

control and denial of reality.
On a practical level, we agreed to meet once a week (face to face
for a 45-minute session) at the Institute of Psychosomatics.
The work of one session

during the second year of treatment
Marc went off for three weeks to an African country on a profes-
sional visit. The session reported here was the first on his return,
after the interruption to his treatment. In the course of the sessions
before his departure, Marc had been very anxious about his health
and afraid that his illness would be made worse by his travels. He
reproached his doctors for their light-hearted attitude to the vacci-
nations he had to have because of his African destination. In fact,
all the doctors consulted had reassured him and had permitted him
to make that journey. His anxiety had quite another internal cause,
about which he said nothing. By travelling to a distant foreign
country, he was separating himself from the familiar objects of his
environment, and especially from his analyst. I felt that behind the
reproaches to the doctors who had let him leave “light-heartedly”
was a reproach aimed at me. At the same time, the journey repre-
sented a narcissistic gain for Marc.
Here is the session: Marc sat down. “My stay in Africa was
gruelling. Throughout the three weeks, I was racked with anxiety
about falling ill. What marked this period was my permanent
vigilance, I could not relax.” He spoke about the food, the African
way of life, his numerous trips. “However, I did not fall ill. When I
returned to France, on the other hand, I found myself in a psychic
state of confusion. I had spells of dizziness for several days which
gradually wore off. I noticed that my wife had borne my absence
well and had realized that if I disappeared, she would be able to
cope alone with my children.” Marc paused for a moment before
carrying on.
This first fragment of speech contained the following traumatic
content: Marc reported to me his wife’s remarks according to
which, if he disappeared, “she would be able to cope alone with my
HEALING WORK 121
children.” This traumatic pronouncement was to form the focus of

the session by reason of its affective density, of the psychic work it
imposed on me, and of the condensation of the past and present
psychic history of the patient it represented. It was to return again
at another point in this session, thus confirming the motor force of
its traumatic traces.
Marc did not express any affect nor add any comments to his
remarks. His eyes remained fixed on me. I perceived, for a fleeting
moment, a strong emotional tension on his face, which was frozen
and immobile. I received the full force of this statement carrying a
death wish and assessed the brutality and crudeness of it. My first
move was to identify with his helplessness, and I perceived in
myself an increase in empathy towards him and in hostility to-
wards his wife. Everything happened as if I had felt the need to
protect him from a catastrophe, to envelop him with my presence.
The question of what to say to him arose. In reality, the traumatic
nature of his pronouncement and its impact on me could have made
me act at that precise moment. But any action would have had to be
more soothing than symbolizing on the mental functioning of the
patient as well as on mine. I was aware of his usual control mecha-
nisms, and a direct comment on my part on this pronouncement
might have caused him to collapse uncontrollably. I felt the need for
that traumatic affect to be contained by binding representations
before it was named and talked about. I chose to say nothing.
Two associations of ideas came to me. The first was a remark
Pierre Marty had the habit of calling to mind, concerning the
attitude of a psychoanalyst towards his somatic patients: he would
speak of the caution of a mine-clearing expert (or chimney-
sweeper) to describe his attitude (Marty, 1980). The second was a
development of Michael Fain’s in Le désir de l’interprète [The Desire
of the Interpreter] on the subject of the containing function of
certain condensations used for control and against any displace-
ment (Fain, 1982). Any move here might have caused an explosion
of excitation.
The affect missing from his speech, arising from his wife’s
remarks, confronted Marc with his own death. I made the associa-
tion with two fragments of information drawn from previous ses-
sions. The first was the expression of his anxiety-panic at the
122 CLAUDE SMADJA
thought of not being there as a father when his children were

adolescents. The second was the memory of his father’s death; he
had spoken little about this to me spontaneously, and the telling of
it had caused intense psychic pain.
Identification with the dead father, full of ambivalent feelings
and an unelaborated oedipal guilt feeling, seemed to underlie his
traumatic experience.
Thus, while Marc’s speech culminated in that traumatic pro-
nouncement and he was preparing to carry on talking in a
progredient—psychically gradually escalating—way, I had an as-
sociation of ideas made possible by an attitude of psychic passivity.
He went on: “I recognized my extreme vigilance concerning my
illness and that my whole life was filled with measures taken for
my path to health. I wondered if I should not let everything drop
and begin to live more serenely.”
I interjected a “Yes . . .” of support and encouragement for him
to continue.
This second fragment of speech was both directly linked to the
preceding traumatic pronouncement and presented a depressive
tone; at the same time, it brought with it a psychic move intended
for his analyst. His desire to let everything drop was a direct
response to the death wish expressed by his wife. It seemed useless
and premature to point out the connection to him. At the same
time, recalling his recognition of his vigilance with regard to his
care for his health was a reference to the work we were doing
together. By underlining with a banal word my presence and my
interest in his mental process, I put myself forward as an analytic
object, leaving him the control of his words. This attitude pro-
longed my first move to identify with his helplessness, emphasized
above, and brought to mind the maternal function of the therapist
spoken of by Marty (1980).
Still without expressing any affect, Marc launched into a recital
of the evolution of his illness, from the medical point of view. “For
a year my full blood-count picture has been stable, especially my
platelet count. All that is linked to the work I am doing.” He
recalled the course of group psychology sessions, his new attitude
to his diet, and his visualizations.
I noticed that at no point did he mention the work we were
doing together, which we had begun eighteen months previously.
HEALING WORK 123
“On my visit to my haematologist in January, he was very

surprised that my platelet count had returned to normal and
thought that my splenomegaly was in regression, but this was not
the case. He revised my life expectancy. Although he was not in
favour of psychology, he still recognized that this evolution might
be linked to the work I was doing in my analysis. But, for the last
three weeks, I have been confused with this journey and the prob-
lem of vaccinations, and my platelet count has gone up again.”
I noticed again that he did not stress the fact that he had
interrupted his treatment for three weeks.
“I abandoned my treatment during my stay. I have to admit
that the effort I make has some results.”
I replied in this way: “In fact your vigilance as regards your
health care has the paradoxical effect of keeping your illness
present in your everyday life.”
“Yes, that is quite true. I wonder how I can continue my treat-
ment and make more space for life.”
This material was marked by a change in the affective tone of
the patient. Whereas I had been able to perceive in him (at the
beginning of the session) an anxious and subdepressive tension, I
found him more and more euphoric. This change was no doubt
linked to the cushioning effects of my psychoanalytic attitude,
which allowed him to resume the conduct of his usual psychic
mechanisms and to control his traumatic affects. Moreover, the
tentative move to transference, which had appeared in the frag-
ment of his speech earlier, was clearly confirmed here. The patient
brought up the improvement in his somatic state by enumerating
all the protagonists in his therapy, apart from his analyst. In fact, he
spoke of his analyst in a negative way—he was situated elsewhere.
The unconscious enrolment of his analyst seemed probable. The
hypothesis could be advanced that this evolution was linked to
my absent presence, with its underlying associative regredient—
psychically gradually declining—work and urging Marc to find
mechanisms of hysterical identification (Hollande, 1973).
My intervention showed him nothing of this transference. On
the contrary, I was trying to preserve that unconscious little island,
to allow him to evolve and to support himself with a representation
of things, the source of symbolization. Bearing in mind his fragility,
it was premature to make any interpretation. My intervention was
124 CLAUDE SMADJA
on another level, nearer to his consciousness. It took up a signifying

factor that he had mentioned several times from the beginning of
the session—his vigilance with regard to his health care—and
sought to show him that, beyond his logical comprehension, there
were also unconscious representational goals that had the effect of
installing his illness. In fact, I suggested that he should recognize in
himself an erotogenic zone of a hypochondriac nature and intro-
duced a passive erotic dimension into his logical speech and his
progredient system.
Marc’s response to my intervention was interesting to the ex-
tent that it showed the modifications brought to a problem ex-
pressed at the beginning of the session; these modifications had
been filtered during this second stage of the erotic life-enhancing
dimension suggested by my intervention. Thus, the statement
where he wondered if he should let everything drop in order to
live more serenely became, after transformation: “How shall I
continue to look after myself and yet make a bigger space for
living?” This second statement was the opposite of the first by the
double acceptance of a real need (to take care of himself) and an
erotic need (to live).
Marc went on: “I wanted to tell you something else. In Africa I
was scared of the weight of tradition. I am going to relate an event
I experienced which made me think at the same time as it dis-
tressed me. With a group of about twenty people we travelled from
one town to another, about 600 km apart. The conditions during the
journey were dreadful, and we broke down several times. The local
state of mind tended towards resignation and fatalism. I could not
bear that. I had to do something, and I took things in hand.” He
remembered a scene in Lawrence of Arabia which he had seen the
day before on television. In that scene, a Bedouin falls in the desert
and is abandoned by his companions. Lawrence turned back to
save the man, thus going against the fatalistic belief: “That was
written.” He then made the link between what he had just remem-
bered and the preceding sequence: “It is the same with my illness—
I need to be active and I cannot stay doing nothing. Simply, in that
case it puts pressure on my wife.” Marc stops himself.
This material marks a change in direction in the movement of
his speech, introduced by the words: “I wanted to tell you some-
thing else.” Its logical continuity is momentarily broken. This
HEALING WORK 125
shows evidence of leaving latent the preceding material. I noticed

that the associative detour of my patient led him to speak about his
wife again. At this second stage, however, his wife is included in
the associative network, which links her to his illness and to his
passivity–activity problem. I wondered about the link between the
preceding material ascribed to latency and the current associative
material. My intervention had encouraged him to recognize a
certain erotic passivity in himself. During the movement that fol-
lowed, Marc restarted his need to be active. It seemed that calling
this passivity to mind triggered off a psychic move. With his wife
being mentioned again, the initial traumatic statement returned. I
could not yet clearly formulate the links between the problem of
Marc’s passivity–activity, his wife, and the traumatic statement at
the beginning of the session, but I felt the need and the opportunity
to probe in this direction in the second stage.
I intervened and said: “You brought up your wife’s remarks
again just now. What effect did that have on you?”
“It is my children who affect me most. If I disappear, my
children will be destitute. I have always thought that my wife was
fragile and that I needed to be there to take care of family affairs.
That gave me a powerful motive to look after myself.”
With this new material, the session opened up other levels of
significance. First of all, at this second stage, Marc was able to
express his affects about his wife’s traumatic remarks. His identifi-
cation with his own bereft children brought to mind a memory he
had reported to me during a session; when he was 13 years old, he
saw himself alone on a deserted road on his way to enrol in a new
school. His parents were not there with him. He had to deal alone
with his affairs. This memory seemed to be evidence of an at-
tempted masochistic representation of his life. The second part of
the material could be viewed as the product of the sessions and of
his own internal processes. The initial traumatic statement takes on
a new significance here, linked to the passivity–activity problem
brought out in the preceding material. It appeared clearly that
Marc found it intolerable that his wife no longer needed him and
that she felt strong enough to take care of her children. It was this
reality that was the object of the patient’s vigorous denial; his
wife’s remarks had the opposite effect. In fact, he was motivated by
a desire to look after his wife rather than himself.
126 CLAUDE SMADJA
Many associations came to mind, all of which concerned his

relationship as a boy with his mother; these relationships aimed at
making him a complementary phallus of his mother. As the elder
son in a family of two boys, he had been a good son to his mother,
just as he had been a good pupil, then a good teacher, a good
inspector, and, no doubt, the good patient he aspired to be with me.
Drawing on this objectal maternal model, a product of his
childhood psychic history intervened to draw him along this
regredient associative way. I chose a mode of intervention that
introduced a certain complicity between him and me. This com-
plicity was linked to the work we had done together which implied
the existence of a common area of associations.
I said to him: “Does that not remind you of anything?”
“Yes, of course, I am thinking about my parents. I always had to
look after my own affairs very early on because of their weakness.”
He stopped again.
I noticed that he did not differentiate between his two parents.
Besides, it became clearer and clearer to me that his hyperactivity
was a procedure for denying the castration anxiety of his mother.
She represented a defence mechanism in the service of the object,
annexed by the object. This hyperactivity included necessarily a
denial of reality and a deformation of his ego. The danger came,
therefore, from the introduction of an erotic passivity that threat-
ened the narcissistic organization of the patient.
For a certain time, psychic work had been operating in me that
would find an outlet in the formulation of a new intervention for
the patient. This work came from my perception of a fundamental
defect in Marc’s subjectality. I kept latent his first train of associa-
tion after the initial traumatic statement: if his wife could look after
the children alone, he could then let everything drop. In this
second movement of the session, he connects, through associations,
his hyperactivity and his motivation to take care of himself, with
the necessity of a castrated representation of his wife. In both cases,
it was the object that dictated the subject’s moves towards life or
death—to exist with and for him, or to disappear without him.
I intervened and said to him: “In effect, either your wife is as
weak as your parents and you are motivated to take care of your-
self, or you recognize her strength and you might as well let
everything drop.”
HEALING WORK 127
Marc immediately makes the association with a memory: “I do

not know why, but the competitive examination I took to become
an inspector has just come to mind. I was one-hundred per cent
motivated. I was sure to pass. For my mother, it was the height of
ambition/recognition.” A pause, then: “I always need a challenge
in order to live. I tell myself that this illness is the same thing. But
then, perhaps I am forcing myself to remain ill in order to live. And
after the illness, what else will there be?”
This last sequence showed, in succession, a memory immedi-
ately invoked in response to my intervention—which had the
status of an association of ideas through which Marc showed me
the power he was capable of developing to ensure the denial of
the castration anxiety of his mother, to which, at the same time, he
confirmed his narcissistic link—then, a movement to reflection on
his own mental state, probably supported by the work we were
doing together.
The evolution of Marc’s work is characterized by two events.
The first is the progressive relaxation of his regime of therapeutic
measures, which led him to holding on only to the essential—that
is to say, to the regular medical supervision prescribed by is doctor.
Little by little he abandoned his physical and dietary measures and
his daily visualizations. He lived to forget that he was ill, to the
extent that he experienced no symptoms and that his biological
constants stabilized. He even thought for a time of stopping his
treatment, as he said he had regained all his former psychic facul-
ties and his vitality. The second event was a hint of a cancer phobia.
From the beginning of his illness, he had daily, through his visual-
izations, imagined his illness as a cancer and had fought it victori-
ously. More recently, he had no longer felt able to bear that image,
which aroused a feeling of anxiety and which made him take
avoidance measures.
I have gathered together several technical points that have
arisen from the work I have reported.
The first point I wanted to make is of a countertransferential
nature. I realized that, for several months, the sessions with Marc
had caused a state of psychic fatigue in me that I could not manage
to shake off. The explanation of a state of an actual neurosis
sparked off by the effects of the mental functioning of my patient
on my own psyche constituted a first approach to the problem. I
128 CLAUDE SMADJA
was frustrated not to have been able to maintain a floating atten-

tion towards my patient. The always logical and rational nature of
what he said, together with the resolutely progredient orientation
of his mental processes seemed to stop me drifting into reverie/
day-dreaming. I finally understood that my fatigue was the result
of a struggle between my desire for the psychic regression neces-
sary for an attitude of floating attention and a force coming from
the patient that blocked all regredient movement as much in him as
in me. My fatigue disappeared, and I could settle into a state of
psychic passivity. It is from that moment that I noted in my patient
a gradual relaxation of his psychic systems, with a progredient
polarity. Thus, when confronted with patients such as these, the
fundamental attitude of psychic passivity needed by any psycho-
analyst did not seem to be given to me. The attitude was hampered
by the effects of specific factors of these patients’ own mental
functioning on those of the psychoanalyst.
Second, it seemed necessary to me when confronted with such
patients to preserve what could be the essence of a neurotic func-
tion, or more generally of functioning “as at first topography”. The
conduct and work of psychoanalysis should aim at the setting up
and deployment of a dynamic unconscious, the only guarantee of
later authentic interpretative work.
Third, interventions should aim to widen the scope of a pa-
tient’s representations. In other terms, it should be a question, as
Marty said, of encouraging the patient’s preconscious, to broaden,
to diversify, and to conflictualize.
Fourth, the approach of a traumatic state so frequent in such
patients presupposed to my mind the preliminary work of the
setting up of a framework of representations that allows for the
linking and control of immobilized affects and representations;
otherwise the patient is in danger of collapse.
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INDEX
A.K. Rice Institute, xv analysability, of patients with somatic

AAI (Adult Attachment Interview), disturbances, 118–128
58, 60 Analysand Experience of the Process,
Abend, S., 19 61
abstinence, 44, 78, 83 analysis (passim):
rule, fear of violating, 80 discussion of with others, 29–30
acting out, 10, 46, 66–69, 73, 78, 83 good-enough, 55
mutual, 47 interminable, 111
action dialogue, 67, 68, 71, 74, 79, 81 therapeutic effect of, on analyst, 19
actualization, 68–69 analyst:
Adult Attachment Interview (AAI), affective tension of, 67
58, 60 approval of, by patient, 10
affect: as choice of profession, 35
modulation, 33 dreams, 95–107
tolerance for, 39 ideological background of, 1
affective distress, 35 insecurity of, 48
in analyst, 33–34 needs of, 47–50
affective life of patient, participating as “other patient”, 50
in, 36–37 –patient match, 18, 22 43
affective reaction, 27 patient’s perception of, 46–47
affective understanding, 36 personal change in, 25–26, 30
affects, frightening, experiencing, 31 personal philosophy of, xix
Agger, E. M., 19 philosophy of, 1
Agieren, 67–68 preconscious theorizing activity of,
alliance of self-control, 33 1
145
146 INDEX
analyst (continued): Berman, E., xiv

principal temptation of, 49 Bion, W. R., 5, 7, 10, 11, 15, 51
psychic fatigue in, 127 bi-personalization, 85
self-idealization of, 46 Bird, B., 33
sharing with others, 39 blank screen, analyst as, 17, 85
subjective commitment, curative blind spots, xv, 22, 49
importance of, 66 development of, xiv
survey of changes in, 21–23 Blum, H. P., 84, 97, 102, 103
theorizing of, 9 Blumenberg, H., 75
unconscious gratifications/ Boesky, D., 19
limitations in, 49–50 Bollas, C., 50, 69
unconscious guilt in, 49 borderline:
unresolved pathology in, 43 pathology, 90
withdrawal/coldness, 23, 24, 29 personality organization, 59, 91
see also therapist Brandchaft, B., 18, 84
“analytical third”, xviii, 10, 15, 51, 106 Brenman Pick, I., 46, 50
analytic child, 10 Britton, R., 10
analytic competence, fear of loss of, 99 Bruner, J., 81
analytic material, 68 Buchholz, E., 74
different responses to, 43 C
analytic process: Calder, K. T., 18
analyst’s influence on, 83–86 Canestri, J., 93
co-constructed, 87 change:
rules of conduct of, 110–112 medium for, 57
shared, xiii process of, empirical research on,
Anastasopoulos, D., xiii–xxiii 56
Anna Freud Centre for Children and Chused, J. F., 19, 74
Adolescents, 60 clinical theory, of analyst, 1–16
Argelander, H., 68 co-acting out, 67–68, 73, 78
Aron, L., xiv, 84 cognitive control, analyst’s, 28
association compulsion, 65 coldness, 39, 51
attention: fear of, 80
free-floating, 4, 5, 45, 81, 128 collaborative process, constructing,
evenly hovering, 67–68 86–91
one-sided, 70 collusion/seduction, fear of, 49
selective, patient’s, 66 communication, unconscious and
Atwood, G. E., 18, 84 conscious, xiv
awareness, free-floating, 4, 5 complacency, in analyst, 24–25
B concordant identification, xxii
Bachrach, H., 56 confidentiality, 56–57
Balbridge, B. J., 97 container–contained, 15, 51
Baranger, M., 85 containing process, inverted, 10
Baranger, W., 85 countertransference, xiii, xvi, 2, 4, 17–
Barratt, B., xv, 1 19, 22, 25, 27–30, 49, 66–70,
Baudry, F., 19 74, 85
Bauriedl, T., 70 acting out, 78
Beiser, H., 19 dream see CTD
Benjamin, J., 46, 68 Freud on, 64
INDEX 147
influence of on thinking/ psychology, 9, 84, 85, 89

theorizing, 9–10 Eifermann, R. R., 18
intensity of, xx Emde, R. N., 56, 77
as key to transference, 66 emotional dialogue, 71
monitoring of, by patient, 47 emotional engagement, 37
patient as creator of, 70 intense, 40
productive, 77 emotional reaction, fear of, 80
as resource rather than obstacle, 86 emotional risk, 36
responses, resolving, 98 emotional vibrations, unconscious,
terror/rage, 37 xiv
transferential movement, lack of, emotional withdrawal, 25
112 emotions, as regulators of object
value of, 51 relationships, 75
see also transference empathic resonance, 36
CTD (countertransference dream), 97– empathy, 38
100, 106 lack of, 25
failure to understand patient, 98 loss of, 27
unlocking therapeutic impasse, 98 transactional, 77
enactment, xxi
data, as constructs, 6 case study, 71–73
deconstructivism, xix, 3, 12, 13 concept of, 70–74
deconstructivistic approach, to Engle, G. L., 19
psychoanalytic theories, 13– Erikson, E., 99
16 evenly hovering attention see attention
defences, analysing, 27 F
Derrida, J., xix, 12, 13 Fain, M., 121
Dewald, P. A., 19 Feldman, M., xiv, 85
dialogue plane, verbal, 68 Ferenczi, S., 78, 88
disclosure, dilemma of, 50–51 Filippini, S., 83, 85
Dorpat, T., 18 Fliess, W., 100
dream(s): Fonagy, P., xxi, 58, 59, 74
analyst’s, fear of reporting, 97 Fosshage, J. L., 84, 96, 100
countertransference (CTD), 97–100, free-floating attention see attention
106 Freud, A., 45, 67, 72, 79, 84
Irma (Freud), 99–100 Freud, S., 3, 5, 11, 13, 16, 43, 64–67, 77,
organization model of, 96 80, 81, 95
patient-related (PRD), 100–107 communication outside awareness,
patients’, about analysts, 97 44
in supervision, 98 on countertransference, 64
drives, defusion of, 116 Irma dream, 99–100
drive theory, 87 theory, roots of, 109–118
Dunn, J., 84 on transference, 46, 65
E Friedman, M., 19
early disorders, 73 Friedman, R., 18
economic factor, 111, 115, 116 frustration, learning to tolerate, 32–34
ego, 115, 116
experiencing/observing, 87 Gabbard, G. O., 85
defensive mechanisms of, 114 Galatzer-Levy, R. M., 56
148 INDEX
Gardner, R., 18, 20 function of, xix

Gedo, J., 33 as imposition of analyst’s own
George, C., 58 truth, 49
Gerson, B., xiv Irma dream, 99
Gill, M. M., 5, 18, 56, 57, 66, 77, 83 mutational, 113
Glover, E., 19 repetition of, 9
Gold, J., xiv resonance, 106
Goldberg, A., xiv, xvii, 18, 20 subjective, 68
Goodman, N., 7 therapeutic effectiveness, mutual,
Green, A., xviii, 14, 16, 84 xvii
Greenberg, J., 18, 85, 87 transference, 48
Greenson, R. R., 28, 50, 88 of unconscious resistance, 117
Grossman, W., xv, 9 validity of, 6
Grotstein, J., 100, 106 intersubjective perspective, 86
Grünbaum, A., 8 intersubjectivist trends, in Europe vs.
U.S., 84–86
Hanly, C., 88 intersubjectivity, xiii, xxi, xxii, 76, 84
Hartman, F., 99 boundaries of, 77–81
healing function, xxii limits of, xxi
healing process, 112–118 intrapsychic representations,
Heimann, P., 80 externalizations of, 38
Herberth, F., 70 Ioannidis, C., xx, 43–52
Hoffman, I. Z., 18, 19, 51, 83 Irma dream (Freud), 99–100
Hollande, C., 123 J
Horvitz, L., 88 Jacobs, T., 18, 19, 84
Hurst, D. M., 85 Jodain, R. M., 97
I K
id, 115 Kantrowitz, J. L., xv, xvii, xviii, xix,
ideal, psychoanalytic, 65 17–41
identificatory processes, 2 Kaplan, N., 58
infantile neurosis, 113 Katz, G. A., 85
insight, 32 Kavanagh, G., 97
Institute of Human Relations, Kennedy, R., 44, 84
Tavistock Clinic, xv Kernberg, O. F., 84, 91
Institute of Psychosomatics, 118, 119, Kirshner, L. A., 70
120 Klauber, J., xvii, 45
internal disintegration, 111 Klein, M., 69
International Psychoanalytical Klüwer, R., 67–69, 81
Association, Research knowledge, dyad-specific, 53
Committee of, 57 Kohut, H., 33
interpretation(s), 4, 11, 16, 18, 36, 47, Kramer, M., 18, 97
66, 70, 79, 87, 88, 114 Krause, R., 69, 75
and analyst’s personality, 84 Kris, A. O., 33
Bion’s theory of, 10, 15 Küchenhoff, J., xix, 1–16
case study examples, 72, 73, 93, 123 L
as a depriving act, 49 Lacan, J., 11
formulation of, xiv Lachmann, F. M., 18, 84
fruitful, 10 Langs, R., 47
INDEX 149
Lester, E. P., 97, 98 89, 92, 98

Levine, H. B., xiv, xvi, xviii, 84 objects, split, 85
libido, adhesiveness of, 116 Ofer, G., xxii, 95–107
Lichtenberg, J. D., 84 Ogden, T. H., xviii, 10, 15, 44, 51, 84,
Loewald, H. W., xiv, 47, 106 106
Lorenzer, A., 68 omnipotence, 4
Luborsky, L., 56 Organization for Promoting
Understanding in Society, xv
Main, M., 58
Makari, G., 93 painful affect, tolerance of, 34–36
Margulies, A., 18 Paolitto, F., xvii, 18, 19, 22
Marty, P., 121, 122, 128 Papanicolaou, E., xviii
mask: parapraxese, 13
fallacy of impenetrability of, 45–46 Paris Institute of Psychoanalysts, 109
wearing, 44 patient (passim):
masochism, 111 affective life of, participating in,
Maurer, J., 70 36–37
McLaughlin, J., xiv, 18, 19, 20 –analyst match, 18, 22, 43
meaning, co-creation of, 19 impact of on analyst, 17–41
Meissner, W. W., 88–90 as internal damaged object of
mentalization, 58–59 analyst, 49–50
metapsychology, 1–3, 7, 12 as love object for analyst, 48
clinical, xix -related dream (PRD), 100–107
Miller, E., xv with somatic disturbances,
Miller, M., 18 analysability, 118–128
Mitagieren, 67, 68 personal analysis, 27–28
Mitchell, S., 18, 87 personal conflict, in analyst, 22
Modell, A., 18, 33 plasticity, exhaustion of, 116
Moser, U., 75 pluralism, 3
mourning process., 24 Poland, W., 18, 20
mutual analysis, 78 Ponsi, M., xxi–xxii, 83–93
mutual difficulty, 37 PRD (patient-related dream), 100–107
Myers, W., 98 case studies, 101–106
N preconception, 6, 7, 10, 11, 51
Nachträglichkeit, 11 preconscious, 1, 29, 34, 81, 84, 114, 115,
narcissism, 111 128
“narcissistic alliance”, 90 primary aggression, shared, 40
Natterson, J., 18 primary emotions, “propositional
negative therapeutic reaction, 115, 116 structure” of, 69
negativity, 116 primary repression, correction of, 117
Nerenz, K., 64, 80, 81 process and outcome, relationship
neutrality, therapeutic, xiii, xxi, 44, 45, between, 59
66, 83, 84 projective identification, xxi, 39, 45,
Nissim Momigliano, L. E., 85 73, 77, 85
non-verbal interaction, 91–93 concept of, 69–70
O Protter, B., 6
objectivity, idealization of, 49 psychic change, measure of, 59
object relations, xvi, 5, 9, 32, 60, 75, 85, psychic conditions, shared, xviii
150 INDEX
psychic fatigue, in analyst, 127 reparation, 117

psychic functioning, evaluation of, repetition, 114–115
111 compulsive, 115
psychic passivity, 122 representations:
psychic structures, equidistance from, repressed, 114
46 self- and object, 74
psychoanalysis (passim): repression, 65
goals in, 53–55 resistance(s), 112–115
study of process and outcome, 57– analysis of, 113
61 in analyst, 98
theoretical pluralism in, 7–8 empty, xxii, 116
psychoanalytic competence, Resnik, S., 14
development of, 54–56 resonance, lack of, 22
psychoanalytic education, tripartite Robertson, B. M., 97, 98, 99
system of, stifling of Robutti, A., 85
creativity, 56 role-responsiveness, xxi, 68–69
psychoanalytic encounter, bi- Rycroft, C., 67
directionality of, 47
psychoanalytic healing, work of, 117 sadness, overwhelming, 25
psychoanalytic practice, safety, conditions of, 29
epistemological rules of, 5–6 Sandell, R., 66
psychoanalytic process: Sandler, J., xxi, 4, 8, 44, 45, 68, 69, 85
extra- and intra-analytic influences Schachter, J., 56
on, 8–10 Schafer, R., xiv, 10, 64, 71
sadomasochistic elements in, 49 Schur, M., 99
Psychoanalytic Process Rating Scale Schwaber, E. A., 19, 85
(PPRS), 60 Searles, H., xvii, 45, 46, 47
psychoanalytic theories: Segal, H., 51
basis for, 3–4 selection, mutual, xvii
public and private faces of, 8–9 self-analysis, 18, 19, 99
psychoanalytic training, tripartite self-awareness, increased, 20
model of, 54–56 self-discovery, experience of, 22
psychoanalytic treatment: self-exploration, 27
aim of, 57 self-knowledge, xvi, xx
“specificity” of, 61 self-monitoring, by analyst, 19
psychological growth, factors self-observing capacity, in patient, 93
affecting, 22 self-regulation, 33
R self-scrutiny, 20
Racker, H., xxii, 45 shared exploration of, 30
rage, 24, 31, 34 Shapiro, T., 56, 93
induced in analyst, 23 Silber, A., 18
patient’s, 23 Skolnikoff, A., 18, 56
“reflective functioning”, 58, 59 Slochower, J., 84
Reik, T., 77 Smadja, C., xxii–xxiii, 109–128
relational theorists, 77 Smith, H. F., 20
relations analysis, 70 Society for Psychotherapy, UCL, xv
remembering, 114 Sonnenberg, S. M., 18
Renik, O., xv, 19, 45, 46, 78, 84 Spence, D., 8
INDEX 151
Spero Halevi, M., 97 –patient:

Spezzano, C., 84 interaction, xx
Spillius, E. B., 85 matching, xix
Spruiell, V., 19, 20 primary damage to, xvii
stable instability, 90 qualities required for, xvi
Steimer-Krause, E., 65, 75 therapeutic functioning of, xvii
Steiner, J., 10 see also analyst
Sterba, R., 87 Therapist Attachment Transference
Stern, D. N., 75 Interview (TATI), 60
Stiles, W. B., 59 therapy (passim):
Stolorow, R. D., 18, 84 as mutual process, xvii
Strachey, J., 113 preliminary techniques in, 111
Strenger, C., 7, 8 thinking, interpenetration of, 10
subjectivity, of therapist, xx Thomä, H., 70
suggestive therapy, 88 training practices, 56
superego, 115 “transactional empathy”, 77
supervision, 55, 55–56 transference, xvi, 17, 29, 36, 45–48, 51,
focus of, xiv 60, 76, 83, 85–87, 123
survey, of changes in analysts, 21–23 actualization of, 68
Szecsödy, I., xviii, xx, 53–62 affective engagement, 27
T analyst’s, 25
Tarachow, S., 47 annihilation of analyst, 33–34
Target, M., 58 behaviour, acting out as, 67
termination, 24 –countertransference, xiv, xvi, xx, 9,
theoretical constructs, conscious and 17, 19, 22, 26, 63, 64
unconscious, xix action component of, 68
theorizing: conventional ideas about, xxi,
influence of unconscious processes 65–70
on, 11–14 developmental psychological
libidinization of, 10 conceptualization, 74–75
preconscious, 1 erotic, 40
therapeutic action, content or foci of, interactions, intense, 30, 34, 36
32 process, involvement of analyst
therapeutic alliance, xxi, xxii, 87–89 in, 66
case study, 91–93 resistance to, 80
constructing, 83–93 role of emotions and emotional
therapeutic neutrality, xiii, xxi, 44, 45, exchange, 75–77
66, 83, 84 scene, development of, 78
therapeutic process, effect of unfolding of, 98
therapist’s dreams on, 95–107 effect of on theorizing, 8, 9
rigidity in, xiv fantasies, 73
unconscious drawing of feelings induced in analysis, 65
satisfaction from, xviii Freud, 65, 100
therapeutic relationship, development instinctualized, 98
of, xiii interpretations, avoidance of, 48
therapist (passim): intersubjectivity and emotional
good-enough, xviii exchange, 63–70
motivation to become, xv, xx linked to resistance, 74, 80, 115
152 INDEX
transference (continued): unconscious feelings, analyst’s, 64

manipulation, 88 unconscious guilt, in analyst, 49
neurosis, 113 unconscious processes, influence of
offer, verbalized, 68 on theorizing, 11–14
“playground of”, 79 unconscious resistances, 89
process, inhibition of, 79
in psychoanalytic healing, 112 van Dam, H., 19
of therapist, conflict-type, 68 verbal dialogue plane, 68
therapist’s reaction to, 97 Viederman, M., xiv, xviii
wish, 69 Vygotsky, L., 50
transitional space, 14 W
trust, 37, 57 Waldron, S., 56
Tuckett, D., 93 Wallerstein, R. S., 88
Turillazzi Manfredi, S., 85, 86 Watillon, A., 55
Weinshel, E., 19
unconscious, xviii, xx, xxii, 2, 5–14, 32, Wexler, M., 88
76–79, 88, White, R. S., 63, 73, 74
analyst’s: Whitman, R. M., 97
object representations, 35 Williams, P., xxv–xxvii
and patient’s, communication Winnicott, D. W., 14, 33
between, 44–52 withdrawal/coldness, 24, 29
resonance of with patient’s, 98, work, notion of, 113
106 working-through, 114, 115
dynamic, 128
and PPRS, 60 Yack, M. E., 97, 98
theory of, 11, 109–118
and training, 55 Zeller-Steinbrich, xxi, G., 63–81
and transference, 68, 69 Zelnick, L. M., 74
and working through, 30 Zetzel, E., 88
unconscious conflicts, in analyst, 97 Zwiebel, R., 97

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THE THERAPIST AT WORK

The EFPP Series

Editor-in-Chief: John Tsiantis

OTHER TITLES IN THE SERIES

The European Federation

DIMITRIS ANASTASOPOULOS[Greece], MD, is an Adult and Child Psy-

CHRISTOS IOANNIDIS[United Kingdom], MD, is a psychiatrist and

JUDY L. KANTROWITZ [United States] is a Training and Supervising

choanalysis. She is serving her third term on the Editorial Board of

JOACHIM KÜCHENHOFF [Switzerland], MD, is Professor of Psychiatry

EVAGELOS PAPANICOLAOU [Cyprus], MD, is a psychiatrist working in

MARIA PONSI [Italy] has been working as a psychiatrist for about

CLAUDE SMADJA [France] is a Psychoanalyst, an honorary member of

IMRE SZECSÖDY [Sweden], MD, PhD, is an Associate Professor and

PAUL WILLIAMS [United Kingdom] is a Member of the British Psycho-

GISELA ZELLER-STEINBRICH [Switzerland] works as a psychotherapist

analyst is no longer a totally unaffected, immutable mirror before

approach or choice of therapist. Naturally, all this affects not only

psychotherapists, provided that it is utilized in the service of the

1. the analyst’s application of theory and technique;

therapist’s total control, especially as far as his/her personal affect-

The opening chapters of this Monograph focus mainly on the

patient’s mental life. She notes the intensity of countertransference

supervisor and from his work on the mechanisms of learning in

no longer viewed as an object but, rather, as a subject personally

the technique in order to deal with them. Furthermore, Smadja

this area: in France and much of Latin America, for instance,

The analyst’s clinical theory

1. the analyst’s philosophy or Weltanschauung;

The second part of my discussion deals with Levels 2 and 3: the

that psychoanalytic theory—like any scientific theory—is bound to

• Neither in psychoanalysis nor in any other science are observa-

Part three of my chapter addresses Level 4, the analyst’s theo-

clinical practice. Theory pre-figures clinical experience but, at the

The title of my chapter addresses the “analyst’s theory”—what do

contingencies of reality, with the unsurmountable limitations of

Reading Freud’s technical papers, one could have the impression

1. It is an epistemological truism to state that data are not inde-

2. What is put into question here is scientific truth as well as

Let me quickly draw a few clinical consequences from these some-

1. Instead of giving up theory, we need more theoretical reflection

and each frame offers specific and rich clinical perspectives.

Up to now, it seems as if psychoanalysis could readily be handled

(1) It was Sandler (1992) who pointed to an important difference

opposed to the private face of psychoanalytic theory. What one

(2) Let us turn to the intra-analytic influences on the theorizing

it all the time; this might be due to a countertransference need—the

ter. Theorizing never is a mere application of a metapsychological

I am aware that my chapter could seem confusing. Have I not told

lighten even those phenomena that up to now have been dark

those unsettled inconsistencies that demand a supplement. It

1. In a deconstructionistic perspective, the ambivalence towards

further developed Bion’s concept of creativity that is implied in

could promote scientific competition as well as psychoanalytic

First published in the Journal of the American Psychoanalytical Association, 45

were thought to be relatively interchangeable, their principal con-

on the analyst is not new. In response to Glover’s survey (1937),

analysts to greater self-scrutiny and, thereby, an awareness of