11. Understanding and Resolving Transference Reactions and Resistances



Download 149.35 Kb.
Page1/27
Date22.12.2017
Size149.35 Kb.
  1   2   3   4   5   6   7   8   9   ...   27


11. Understanding and Resolving Transference Reactions and Resistances

The major premise of this chapter is that individuals' transference reactions are determined by their central needs and schemas, a view that is consistent with classical conceptualizations of transference. The classic description of transference by Fenichel (1945) is as follows: In the transference the client "misunderstands the present in terms of the past . . . he 'transfers' his past attitudes to the present" (p. 29). Similarly, Brown and Fromm (1986) define transference as a psychoanalytic term indicating that the client distortedly per- ceives, urealistically feels about, and behaves toward his therapist accordin to the impressions formed about significant figures in childhood. He sees his therapist--who is part of his current world-- through the tinted glasses of the past. (p. 209) We integrate these traditional psychoanalytic notions of transference with social learning theory notions about expectancies. Westen's (1989) conceptualization of transference phenomena is most consistent with that of constructivist self development theory. In referring to transference as person-schema, he writes, To the extent that the manner, appearance, or status of the therapist resembles another person or exemplar of a social category, schemas relevant to that person or category are likely to be activated. (p. 62) Thus, one of our uses of transference in this chapter makes reference to the activation of the client's unconscious schemas about other people in the therapy relationship. Westen's definition of transference as in-
terpersonal expectancies is also in line with our conceptualization. With regard to this concept, he writes, Patients' reactions to the therapist often reflect their expectations about particular kinds of social interaction or interaction in general. The more generalized the expectancy, the more pervasive are likely to be its effects interpersonally, and perhaps the more recalcitrant it will be to change. When stressed, borderline personalities tend to shift into a malevolent object world, in which the interpersonal arena seems filled with victims and victimization. (p. 64) This view of transference is consistent with our view that severely traumatized clients may expect the worst from their therapist, and that the more generalized these expectations (or schemas) are, the more likely they will have a deleterious effect on the therapeutic relationship unless they are understood and ultimately resolved. Finally, Westen refers to the transference of unconscious wishes onto the therapist. This view is consistent with psychodynamic formulations. Here, Westen defines a "wish" as a cognitive-affective structure which includes a cognitive repre- sentation of a desired state and an anticipated affect associated with attainment of that state. (p. 65) We will not address here the theoretical differences between a "wish" and a "need"; rather, we believe that a "wish" is activated when a central need area is also activated, whether consciously or unconsciously. Thus, the client who characteristically wishes to be taken care of, nurtured, or protected by the therapist may be reflecting central needs for dependency, while the client who typically wishes for admiration and validation from the therapist is probably reflecting a central need for esteem. We retain the term transference because we believe it provides a useful framework for understanding clients' responses to therapists. We use the term transference to refer to the client's transfer onto the therapist of the client's expectations about other people or situations related to psychological needs that are central or conflictual for the individual. In a modification of traditional notions about transference, we agree with Lindy (1988) that transference reactions among trauma survivors do not always arise from childhood experiences; rather, they often arise from traumas the person experienced in adolescence, as in the Vietnam veteran, or even in adulthood.

Resistances often reflect important transference phenomena. We in- terpret resistances as arising most often from a perceived, if often unconscious, threat to central aspects of the person, including the subjective experience of self and one's fundamental self-world schemas (or beliefs and expectations about self and others). Although much has been written about the adaptive significance of positive schemas, little is currently understood about the adaptive significance of negative self or other schemas (Taylor & Brown, 1988). As implied in earlier chapters, we believe that disturbed schemas, no matter how maladaptive they may seem, serve defensive functions for the individual, protecting against perceived internal and external dangers. In this sense, we are proposing that disturbed self-world schemas may be analogous to other defenses of the ego as described in psychoanalytic theory (Freud, 1946). We hope that the following discussion will provide a framework for predicting and working with unique transference reactions and resist- ances over the course of therapy with adult trauma survivors.

SELF PSYCHOLOGY CONCEPTUALIZATIONS OF TRANSFERENCE The self-psychology literature contains extensive writit about the transference reactions of clients with disorders of theelf (e.g., Brown & Fromm, 1986; Chessick, 1985; Kohut, 1977). Brown and Fromm (1986) discuss the different transference reactions in persons with nar- cissistic and borderline personality disorders. With regard to the nar- cissistic client, they suggest that a "selfobject" transference emerges in which the client's fragile self-esteem is dependent upon the positive mirroring and admiration of the therapist. When the therapist fails to offer this or there is a failure in empathy, the client's self-esteem plummets, resulting in depression. The borderline transference is char- acterized by boundary diffusion, splitting, panic states, and transient self-fragmentation. Chessick (1985), describing the self-psychology view of resistance, states that resistance arises when the client fears humil- iation, rejection, or another selfobject failure that may fragment the self. Self-psychology theory categorizes severe disorders of the self into narcissistic and borderline disorders. We prefer to assess clients de- scriptively, in terms of the nature and stability of the self schemas and the degree of development of the self capacities. One rationale for this approach is that in trauma victims, symptoms of severe character pa- thology may represent chronic, severe, and unresolved posttrauma ad- aptation (e.g., Briere, 1984; Scurfield, 1985). Furthermore, we believe
that focusing on a personality disorder diagnosis can obscure the central issues involved in chronic forms of PTSD. We also believe that labeling trauma survivors as borderline often reflects the therapist's own coun- tertransference difficulties with "difficult" or "resistive" clients. Finally, we find that our descriptive approach provides clinical information of direct relevance to the therapy process. For these reasons, we prefer to make a complete assessment of each self capacity and ego resource in the context of the individual's unique history and trauma experience. We believe this is a more useful approach to understanding the client's inner world and is ultimately more re- spectful of the trauma survivor. In the following sections, we will describe our own formulations of how the transference reactions and resistances may be manifested in traumatized persons with serious deficits in self capacities.

TRANSFERENCE REACTIONS IN CLIENTS WITH IMPAIRED SELF CAPACITIES

The Therapist as a Threat to Vulnerable Self-esteem Clients with an extremely vulnerable sense of self, as Chessick implies above, have a terrible fear that the therapist, as "selfobject" (someone upon whom the client depends for self-esteem regulation) who will disappoint or humiliate them as others have done in the past. These clients will be highly sensitive to perceived assaults to their sense of self and become depressed or rageful when the therapist fails empath- etically. We believe that, most often, these individuals experience failures in empathy when the therapist makes interpretations, observations, or other statements that are either premature or experienced as an assault on the self. With regard to the issue of interpretation, Chessick (1985) writes Again, there is continuing emphasis on the proper tact, timing, and understanding on the part of the (therapist) of how an inter- pretation is experienced by the patient. (p. 136) We agree with this formulation and suggest that if the client reacts with rage or other negative affects when an interpretation is made, then the interpretation was not truly empathetic, no matter how "cor- rect" the therapist believes it to be. With regard to the "selfobject transference," Brown and Fromm (1986) write,

At least for a while, (the therapist) must be the always available mother, who thinks so highly of her child and admires the child so much that the patient can begin to develop solid self-confidence. (p. 212) In working with trauma survivors with extremely undeveloped self capacities, we are generally cautious about making any interpretations, but rather focus on maintaining a calm, stable, soothing therapeutic stance while providing a safe and supportive "holding environment" (Winnicott, 1965). During the early phase of the work with such in- dividuals, we avoid being too active or delving into areas that may be too paiful for the client, but rather let the client's material guide the proce. If the client experiences a failure in empathy, the therapist nonffefensively apologizes for the error and empathetically seeks to uncierstand how the error was experienced by the client. In relation to trauma survivors, one must be very cautious about how one responds to material related to the client's sense of inner damage or unworthiness. Prematurely offering reassurances can be a failure in empathy; rather, tuning in to the feelings underlying these painful self schemas must precede any interpretations about their meaning. The Therapist as "Container" for Intolerable Affects Parson (1988) writes about the importance of the therapist being a "container" for the terrible affects the client experiences. Often, clients with severely impaired affect tolerance will unconsciously test in a number of ways the therapist's ability to contain the affect. One common way is by experiencing affective overload, such as intense rageful states, in the presence of the therapist. Another way might be for the client, early in therapy, to pour out horrible details of the trauma which are often associated with shame and self-loathing. The client will be reading the therapist's reactions very carefully to ascertain whether the therapist can tolerate these emotions or whether there is any indication, however subtle, of shock, dismay, or disgust. Lindy's (1988) articulate description of this process is as follows: [The veteran] tests his therapist's mettle; his capacity to survive the trauma when it breaks through. The therapist must not cower when horror reveals itself. (p. 225) It takes a great deal of self-awareness and working with one's own countertransference issues to pass these tests, as overwhelming affects and exposure to material that is horrific can temporarily overtax the
therapist's own self capacities. Again, it is critical to respond to these states in a calm, gentle, soothing way, through one's tone of voice and nonverbal demeanor. At times it is useful to address the client's un- derlying fears by saying something like, Perhaps you are wondering whether I will be able to understanci and tolerate these terribly painful feelings, and memories, or whether I, as other people have, will be repelleci or overwhelmed by them. With regard to rage states, we often respond by tuning in to the underlying affects of hurt and vulnerability, by responding with such statements, "I imagine you have been badly hurt, betrayed, disappointed, to feel so much anger." Finally, the therapist should be aware that it will often take a long time for the client to internalize the therapist's empathy and develop trust that the therapist, and eventually the client, will be able to absorb and transform the intolerable affects. In a discussion of these issues, Lindy (1988) makes the important point that setting a slow, careful pace is often essential to managing affect overload. In this regard, he writes, The veteran, perhaps with more foresight than his therapist, knows that trauma is always close to the surface. He scans his therapist to assess the leadership skills he possesses, his ability to set out a careful course, to proceed cautiously. (p. 225) The issues of pacing and timing are clearly complex and cannot be fully elaborated here. However, we will say that one important way of regulating this process is to be very alert to any signs that one is going too fast. Even if a client pours out traumatic material with little prompting, this does not mean that he or she will not become frightened by the meanings or overwhelmed by the affect associated with these disclosures. This is particularly true if this occurs early in therapy, but may also hold true at later stages in therapy. One way to monitor this process is to allow time at the end of such a session to explore fully how the client felt anci what it meant to him or her to have made such a disclosure, how the client perceived the therapist's response, what the client imagines s/he might experience after leaving the therapist's office, and how the client might soothe or nuture himself or herself later. It is also helpful to let the client know that s/he and the therapist can work together to regulate the pacing of the uncovering process.

The Therapist as Soothing Other Individuals who are unable to tolerate affects, to self-soothe, and to tolerate being alone become very dependent on the therapist to supply

these self capacities or they may act out in ways that pose difficult case management issues. This may be expressed by calling the therapist frequently outside of the therapy hour or going into panic states during the therapist's vacations. The other troubling aspect of working with clients with serious self deficits is that they will often attempt to self- soothe through excessive drug or alcohol use, hypersexuality, or other self-destructive behaviors. Most often, these clients come from backgrounds of severe and sadistic child abuse or they may have been massively traumatized in Vietnam _. or other cultural or social arenas. It is most likely that persons with strong dependency needs will adopt the former pattern, calling the therapist frequently, while those with stronger needs for independence are more likely to act out destructively, failing to call the therapist unless in an imminent life-threatening situation. In either case, if such behavior is frequent or extreme, the therapist may feel drained, worn out, or angry at the client. If these feelings are not monitored closely and discussed in supervision, the therapist is at risk for acting out by "forgetting" the therapy hour, being late, failing to return the client's phone calls, and so forth. On a more subtle level, the therapist may tune out during therapy sessions with these individuals. The therapist may also suffer somatic reactions, as in the case of Jeb described by Lindy (1988). Lindy reported developing a severe headache after receiving a telephone message from Jeb, at whom he was unconsciously very angry. We do not pose any simple solutions to these difficult clinical issues; clearly, such individuals will require long-term therapy in order to develop the capacity to internalize the empathetic therapist. These issues were addressed in Chapter 7. However, there are some responses that have been helpful in the short run as these self capacities are developing. We generally feel it is appropriate to gratify the client's wishes for merger by responding to telephone calls and being available, within limits, during times of crisis. This is particularly true when an alliance is being built and the client is testing whether the therapist will be there for him or her. Our approach to these crisis calls is to make them as brief as possible, while conveying the following messages: "I'm still here; I understand how much pain you are in; let's find a way for you to calm yourself until we meet again; what do you need now in order to feel safe, calm, in control?" With some very damaged clients, such as persons with MPD, we have provided transitional objects, such as a book or the therapist's business card with the next appointment date written on
itmsomething that will encourage object constancy; the ability to rec- ognize that the therapist is still alive and present internally. It is important, however, that the therapist set sufficient limits on outside contact to avoid feeling so drained that she or he experiences annoyance, anger, resentment, boredom, or exhaustion. The therapist might say something like, I understand how difficult it is for you when you experience these painful states and how important it is for you to feel in contact with me. However, I too need my time alone so that I can be rested and present when we are together. I want to be there for you when you need me but I also believe that you have the internal strength to calm yourself when you are alone. How do you feel about working together to discover a way to do that? Clearly, it is important to monitor the client's reactions closely, exploring any feelings of anger or rejection. Finally, it is also important for the therapist to state that s/he does want to be contacted in potentially life-threatening emergencies. With persons who are reluctant to call until they are in dire straits, it is important to explore the meanings of calling and to convey concern for the client's well-being. Gradually, as the relationship solidifies, we will gently broach the issue of the outside calls and explore ways that the person can calm and soothe himself or herself without the therapist's direct involvement.

TRANSFERENCE ISSUES RELATED TO CENTRAL PSYCHOLOGICAL NEEDS AND SCHEMAS

Transferences Related to Disruptions in Safety Vietnam veterans are often acutely aware of the safety of the ther- apeutic relationship as well as of the physical environment. Lindy (1988) describes one transference theme among Vietnam veterans as ubiquitous danger-preoccupation with any aspects of the physical setting of the office or the environs which might indicate that a perimeter had been breached and that the veteran or doctor was in imminent danger of losing his life. (p. 242) Lindy proceeds to articulate the central dynamics surrounding trans- ference reactions related to safety concerns: An unusual and striking experience for many of us was to discover the nearly universal importance of the physical setting of our

offices and surroundings to these veteran patients. We were un- accustomed to seeing transference reactions being so physically attached to this particular element in the therapeutic frame, but we quickly learned to expect a series of questions and concerns related to space: Where were the doctor's chair and the patient's chair with respect to exits? What was the road to the therapist's office like? How dangerous was it? What unfamiliar or unexpected cue might indicate a change in environment, turning it from friendly to hostile? (p. 236) In one of the cases presented in Lindy's (1988) Casebook, a veteran became agitated when the furniture in the office was rearranged so that passageway to the door was blocked. The therapist, understanding that the client's concerns about being blocked might relate to a specific trauma, was able to guide the client back to a central trauma in Vietnam. We imagine that most therapists who work with Vietnam veterans are sensitive to these issues and allow the veteran to position himself or herself in order to maximize his or her sense of security. This may involve rearranging the seating so that the veteran can sit against a wall and have free access to the door. We have learned that many veterans are reluctant to go to the local vet center after hours because it is located in a dangerous part of the city. Fortunately, our own rural-suburban setting is perceived as much safer, although some have expressed concerns about the security system after hours. This theme may also emerge for rape or other crime victims who were assaulted at night or in a parking lot. For persons whose safety needs have been disrupted, the therapist must be sensitive to understanding these themes as they emerge in response to the physical environment. With regard to safety issues within the therapeutic relationship, we have observed some common themes among persons for whom dis- turbed safety schemas are central. We describe these in the following sections.




Share with your friends:
  1   2   3   4   5   6   7   8   9   ...   27


The database is protected by copyright ©psyessay.org 2017
send message

    Main page
mental health
health sciences
gandhi university
Rajiv gandhi
Chapter introduction
multiple choice
research methods
south africa
language acquisition
Relationship between
qualitative research
literature review
Curriculum vitae
early childhood
relationship between
Masaryk university
nervous system
Course title
young people
Multiple choice
bangalore karnataka
state university
Original article
academic performance
essay plans
social psychology
psychology chapter
Front matter
United states
Research proposal
sciences bangalore
Mental health
compassion publications
workplace bullying
publications sorted
comparative study
chapter outline
mental illness
Course outline
decision making
sciences karnataka
working memory
Literature review
clinical psychology
college students
systematic review
problem solving
research proposal
human rights
Learning objectives
karnataka proforma