containing and the patient's observation of the therapist's countertransference

Clinical Social Work Journal Vol. 21, No. 4, Winter 1993

CONTAINING AND THE PATIENT'S OBSERVATION OF THE THERAPIST'S

COUNTERTRANSFERENCE

Laurence Green, LCSW

ABSTRACT: Projective identification has received much attention for its ability to elucidate certain types of countertransference reactions. However, many severely disturbed patients are unable to benefit from the insight derived from interpretations based on projective identification. For many of these patients, the initial benefit of therapy is based on the containing provided by the therapist tolerating the countertransference rather than insight based on interpretation. Denis Carpy (1989) has written that the patient's observation of the therapist's tolerance of the countertransference helps to build psychic structure in the patient. In this article, the author reviews Carpy's position and then illustrates the value of the patient witnessing the therapist manage his countertransference using the case example of an adolescent in residential treatment.

Many books and articles have been writ ten on countertransference and its use in clinical practice. Much of the writ ing addresses the therapist's abili ty to formulate interpretations based on an understanding of the pat ient through the countertransference. Denis Carpy (1989) has proposed tha t the act of tolerating the countertransference, in itself, is a mutat ive intervention with severely disturbed patients. He believes that the therapist 's countertransference reactions are noticeably perceived by the pat ient and that the patient 's observation of the therapist's management of the countertransference is a key event in the course of the t rea tment that helps contribute to psychic change and the patient 's growth. In this article, I will review Carpy's position and give a case example that i l lustrates the value of the patient witnessing the therapist struggle with his own countertransference. I will begin by

The author would like to thank Robin Emerson, M.S.W. and Timothy England for their supportive and critical review of the manuscript.

375 �9 1993 Human Sciences Press, Inc.

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briefly commenting on the evolution of theories about countertransference and projective identification.

Historically, countertransference was conceived of as an obstruction to treatment. In 1910 Freud wrote, "We have become aware of the 'countertransference' which arises in him [the therapist] as a result of the patient's influence on his unconscious feelings, and we are almost in- clined to insist that he shall recognize this counter-transference in himself and overcome it" (p. 144-145). Freud equated countertransference in the therapist with resistance in the patient. For him, countertransference signified an unconscious conflict that blocked the therapist 's ability to freely understand the patient.

Beginning in the late 1940's, a broader definition of countertransference started to develop. Winnicott (1949), Heimann (1950) Little (1951) and Racker (1953) were among the first to pioneer the broader definition of countertransference. In her concise and resolute article, Paula Heimann defined the new view of countertransference to include all the feelings the therapist experiences in response to the patient. She placed a larger emphasis on what is consciously perceived as opposed to what is unconscious and hidden. She highlighted the counter in countertransference to stress that it is a response to the patient. As a result of the gradual development and acceptance of this perspective, the concept of countertransference changed. It is no longer solely seen as an unconscious conflict which blinds the therapist from seeing the patient clearly. Countertransference is now also thought of as representing a way for the therapist to use his own feelings as a guide to better understand the patient. (For a historical review of countertransference see Slatker, 1987)

One way that countertransference can be used as a guide for the therapist is through the concept of projective identification. Originally, Melanie Klein (1948) described projective identification as a defense, a mental activity that allows the infant to survive overwhelming feelings by fantasizing that the feelings can be put into the care-taking person. Klein conceptualized projective identification as an intrapsychic phenomenon based on fantasy. Later theorists extended the concept to de- scribe an interpersonal process as well as an intrapsychic one (Bion 1959, 1962, Rosenfeld 1964, Grotstein & Malin 1966, Ogden 1979). This process begins with the projector fantasizing that a part of himself is within the other person. The projector then behaves in a way that attempts to induce the recipient to act in accordance with his fantasy. This interactional process induces certain feelings in the recipient by activating his internal objects as a result of the interactional pressure from the projector. Through identification, the projector is then able to stay in contact with those feelings while believing that the intolerable feelings reside outside himself.

Henrich Racker (1968) elaborated upon the interactional aspects of

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countertransference and projective identification. He believed that the therapist's emotional state is constantly being influenced by the patient and provides the therapist with vital information about the patient's self experience and object relationships. Among his many innovative conceptualizations, he described two types of countertransference experiences. He labeled these concordant and complementary identification. Concordant identification refers to the type of countertransference in which the therapist's feelings parallel the patient's feelings. The therapist's affective state is in accord or in sync with the patient's affective state, even when those feelings are out of the conscious awareness of the patient. The therapist feels "this part of me is you" (p. 134). This way of understanding countertransference gives the therapist access to the patient's self experience. Complementary identification refers to the type of countertransference in which the therapist's feelings are aligned with the affective experience of someone significant in the patient's represen- tational world (e.g., the therapist may feel the way the mother or father may have felt). This enables the therapist to understand the patient's internalized object relationships and how they are being enacted in the transference relationship.

Bion (1959, 1962) also elaborated upon the interactional aspects of the therapeutic encounter. In his concept of container/contained, he described how one person can be a receptacle for another person's projections. He elaborated upon the construct of containing by using the model of the mother-infant dyad. When a hungry infant cries, a form of projective communication takes place. If the mother can take in her baby's distress enough to work it over in her mind and respond to her child adequately, the distress becomes an understood experience which can be reintrojected by the infant in a modified form. What is important for the baby is not just the feeding, but the action of feeding imprinted with the mother's understanding. In a similar fashion, the therapist learns to recognize and tolerate the feelings of the patient, metabolizing the anxiety so the patient can reintegrate the feelings in a modified form.

The therapist modifies the patient's distress by illustrating his containing function through the process of interpretation. However, for some severely disturbed patients, successful interpretation of projective identification is not always possible. Patients differ in their capacity to take advantage of interpretation and some patients along the severe bor- derline and psychotic end of the spectrum are unable to use interpretation based on projective identification because these interpretations are experienced as intrusions or assaults.

Rosenfeld (1971) has differentiated between those patients who use projective identification as a communication and those who use it as a defense to deny reality. He suggests that when the patient is using projective identification as a way to communicate with the therapist, the patient will find the interpretation meaningful. But if the patient uses

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it as a way to deny feelings, he will experience the interpretation of his projective efforts as threatening.

Carpy builds upon Rosenfeld's perspective, stating that the patient must have some "vague awareness" (p. 289) of what he has projected to be able to accept the therapist's interpretations. For more disturbed patients, the projective process is more completely split off from awareness and interpretation is counterproductive, because telling these patients something they dare not feel confirms their belief that the intolerable feelings do lie elsewhere and are being thrust into them like foreign objects by an untrustworthy therapist. Carpy proposes that the therapist further tolerate the projective efforts of these patients rather than try to force understanding through interpretation.

Carpy does not mean that the therapist should distance himself or remain unaffected by the patient's projections. Nor does he mean that the therapist should disguise his feelings in order to illustrate his tolerance. He believes that if the therapist acts in these ways the patient will experience him as detached or insincere. Instead, Carpy recommends that the therapist experience the projected feelings but avoid acting them out in any gross manner. He also states that if the therapist is going to work with severely disturbed patients, "it is inevitable that if the projections are fully experienced then the countertransference will be acted out in some partial degree" (p. 289).

Carpy is careful to make the distinction between "partial" acting out and "gross" acting out (p. 285). Partial acting out results in an ob- servable containing function, while gross acting out stems from a failure to contain. He states that partial acting out may come in the form of tone of voice, or the wording of an interpretation. As evidence for the positive effect of partial acting out, he reports a case in which in one session he made interpretations in a slightly irritated tone. As a result, the patient felt she had finally succeeded in getting to Carpy. This indi- cated to the patient that Carpy was actually receiving her projective identificatory efforts and was attempting to manage her struggle. As opposed to partial acting out, gross acting out often comes in the form of forcing an interpretation on a patient which the patient is unable to accept. This type of acting out would be motivated by the therapists' need to relieve himself of the strong feelings that have been triggered in himself. Grinberg (1962) has coined this interaction projective counter- identification.

Some severely disturbed patients initially benefit mostly from the experience of observing the therapist's efforts to provide containing. In the following case example, I will illustrate how the therapist's tolerance of projective identification, at a time when the patient was not yet able to use interpretation, facilitated the treatment process. More specif- ically, I will show how change was promoted through the patient's experience of watching the therapist manage the projective identification.

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CASE

Sean, a 17 year old Caucasian male, was admitted to a residential treatment program with symptoms of depression, paranoia, and refusal to attend school. He had felt suicidal on a daily basis for the past three years. He had made several suicide attempts and had been hospitalized four times in the past two years. Over the past two years, psychiatrists had prescribed several different antidepressant medications without success; with each different prescription and each elevation in dosage, Sean complained that the medication was ineffective.

Sean was first identified as having problems when his kindergarten teacher raised concerns about his isolation and learning difficulties. Sean attended spe- cial education classes throughout public school but always had problems. The family history revealed that Sean's father left when Sean was an infant and he has had no contact with him since then. Sean's mother has a long history of anxiety and depression with one long-term hospitalization when Sean was twelve years old.

Sean began therapy with me after transferring from another residential t reatment program due to his mother's dissatisfaction with his progress in the previous program. ! first met Sean and his mother when they were visiting the facility to determine whether it was a suitable placement. I found Sean to be an irritable and depressed young man who was both angry at his mother and fearful of her. I also had the impression that Sean would benefit from therapy and that I could help him.

Sean was admitted two weeks after I met him and we began sessions three times a week. In the first few sessions, Sean said he did not want to be in the program and that, although he hated the other program, he knew he would hate this one too. He said he knew the program could not help him, no program could, and that he was in this program because his mother wanted to control him. I tried to communicate my understanding by reflecting back how angry he felt. I also commented that he would understandably see me and the program as inca- pable of helping him if we were here as an extension of his mother's control. Sean said that I did not understand him.

In the following few sessions, Sean talked about how he just did not fit in. He said that the people he met gave him dirty looks and that the other teen- agers seemed so strange. I suggested he wished he could be somewhere that felt comfortable to him. He said I did not understand him. Seeing that my comments were not helpful, I next tried to make a connection with Sean by communicating back his feeling that I did not understand. He responded by saying I did not understand, I was of no help, and he wanted to kill himself. A few days later he made some cuts on his wrists with some broken glass.

In contrast to the hope I felt upon first meeting Sean, I became anxious and fearful. I wondered about my ability to help Sean. As these doubts grew, I became increasingly awkward and hesitant in the sessions with Sean. I found myself pausing frequently and making clumsy attempts to reformulate phrases in the middle of speaking. Sean saw me struggle as I tried to find something useful to say, and to my surprise he seemed to sink back in his chair and relax. Notic- ing this interaction, I began to speculate that Sean felt some relief as he watched me wrestle with the feelings he wrestled with everyday.

Over the next several sessions, Sean would often grumble that I did not know what to do. Many sessions he sat silently, not responding to my inquiries or thoughts as to what he might be feeling. In some sessions of silence, he would walk out a few minutes early as if to put an exclamation point on the statement that I was nothing less than an imbecile. Nevertheless, he rarely missed a session and arrived promptly almost every time.

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As I struggled with whether I was helping Sean at all, the milieu staff reported that Sean was interacting with his classmates, making an attempt at doing his school work, and talking less about killing himself. In the fifth month of therapy, Sean began to acknowledge that I was of some value to him. He manifested this by occasionally confirming comments I made. He alsosought me out and spoke with me when he was particularly upset, although generally add- ing that I was useless once we finished speaking.

By the end of the fifth month of therapy I realized Sean was making progress. This gave me a sense of relief. But soon thereafter, Sean's statements of hopelessness returned in full force and I was again faced with the anxious, hopeless, and worthless feelings I had experienced at the beginning of treatment. In one session, I ventured, '~hings are completely hopeless, especially since you have a therapist who doesn't understand you." Sean responded, "I see no reason to come and see you anymore. I think our relationship has come to an end." I believe Sean responded this way because he sensed that my comment was based on my wish to quell his anxiety so I would not have to serve as a container for his feelings. Nevertheless, his reply created the needed effect in me. I was prepared for him to tell me I did not understand, or that he wanted to kill himself, but I was not prepared for him to tell me he wanted to end the therapy. When he said that, it triggered in me the anxiety and doubt I was hoping to avoid. I remember thinking: "If he is going to quit then things really are hopeless." It was at that moment that I started to become inarticulate again and as I did I watched Sean's body move from a rigid posture to a reclined and more relaxed position. It was as if he found a new way to complete the projective identification. And because it was successful, he once again felt I was containing his feelings.

It was shortly after this interaction that Sean's regression began to fade and he began to make progress once again. Over the next year, similar episodes occurred and I frequently struggled with feelings of worthlessness, anxiety, and hopelessness. Then, after about a year and one-half, Sean started to show signs of tolerating his own feelings. He acknowledged an interpretation that he derived momentary relief from his own feelings when he could stimulate painful feelings in the other students. As a result, he began to develop some empathy for his peers. His merciless teasing of others lessened and he gradually developed a few stable friendships.

In the third year of Sean's treatment, he was free of suicidal ideation, he managed to hold a steady part-time job, and finished enough class work to complete high school. Although Sean's gains were tenuous and he still demonstrated paranoid thinking, his mother agreed to Sean's long-time wish to return home. His mother lived in a different town, so the treatment with me ended and he started therapy with someone else in his own area.

DISCUSSION

Along with the psychotherapy, an important e lement of the t reatment involved the containing Sean received from the residential staff. Throughout the first year Sean was in the group home, the residential care workers, who were under my supervision, often stated tha t they felt f rus t ra ted and devalued when interact ing with Sean. They reported tha t no ma t t e r how much they tr ied to assist him or meet his needs, he

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would always say they were useless. In staff meetings, I served as a container for them by tolerating their frustration, and then explaining that Sean would not be satisfied with them no matter how hard they tried. I suggested they try to tolerate his dissatisfaction with them, keeping in mind that he devalues them to rid himself of intolerable feelings. I additionally reminded them that Sean would not be satisfied with this either, but it would provide support for him by helping him to feel that he, and his feelings, were tolerable.

The supervision enabled the staff to tolerate being with Sean, and kept gross acting out to a minimum (e.g., withdrawing from Sean out of frustration or lecturing him about his complaining). The containing provided by the residential staff reduced Sean's suicidal acting out enabling Sean to stay out of the hospital and allowing the treatment to proceed.

As opposed to the containing I provided for my staff, which occurred via verbal insight, Sean's perception of my containing was not based on interpretation but on his observing me act out the countertransference in small ways. I speculated that this was a possibility in the beginning of treatment, but I became convinced of it after the dramatic shift I recount in which Sean relaxed after I experienced his feelings once again.

The therapeutic value of partial acting out stems from the patient's observation of the therapist struggling with the strong feelings which have been induced in him. The partial acting out signals to the patient that the therapist is in contact with the patient's internal world and attempting to tolerate it. Through this process, the patient learns to tolerate previously intolerable parts of himself. If the patient is unable to perceive any discomfort on the part of the therapist, he may not have a way of knowing that the therapist is tolerating his feelings. In other words, the introjection of the containing function takes place through non-verbal interaction rather than insight through interpretation. Sean's case illustrates this phenomenon. He perceived my struggle as he watched me pause and stammer. This gave him the experience of having someone wrestle with his feelings, which diminished the intensity of his fantasy that these feelings were completely intolerable. Thus, it was not enough for me to recognize his hopelessness and verbalize that to him. Rather, he needed to see m e experience the hopelessness. Only by having witnessed that his feelings were not intolerable could he begin to accept them himself.

Sean regressed in the fifth month of treatment because I was not open to containing his anxiety. He felt rejected when I said, "Things are completely hopeless, especially since you have a therapist who does not understand you," having correctly perceived that my premature attempt to interpret was motivated by a wish to relieve myself of the unwanted feelings. In describing containment, Bion (1959) wrote about a patient

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who felt that his projective identification was refused entry. I believe this aptly describes what led to Sean's regression as well:

The analytic situation built up in my mind a sense of witnessing an extremely early scene. I felt that the patient had witnessed in in- fancy a mother who dutifully responded to the infant's emotional displays. The dutiful response had in it an element of impatient 'I don't know what is the matter with you.' My deduction was that in order to understand what the child wanted the mother should have treated the infant's cry as more than a demand for her presence. From the infant's point of view she should have taken into her, and thus experienced, the fear that the child was dying (1959, p. 104).

As the therapist, I responded to Sean in this "dutiful" way. I responded to him with my verbal presence but not my emotional presence. He im- mediately recognized I was not taking in his anxiety and this caused Sean to redouble his efforts in an at tempt to get me to feel his anxiety and once again provide the needed containing.

Brenman Pick (1985) points out that the therapist is as likely as the patient to wish to avoid the pain of the projected experience. The therapist knows that discomfort, leading to growth, lies ahead; yet, still he hopes for a way to avoid the discomfort involved in this process. But, in actuality, therapeutic change is made possible by the therapist tolerating the discomfort.

Through projective identification, the patient creates a bridge between himself and the therapist to rid himself of intolerable feelings. However, the patient constructs a one-way bridge, and the therapist 's task is to help the patient construct a two-way bridge, making a return trip of his feelings possible. When this process occurs, the patient is then able to start building the internal bridges necessary to reintegrate previously split off parts of himself.

In parenting, the mother contains the infant's projected distress and modifies the distress so it can be reintrojected in a detoxified form. As Carpy describes, the infant is provided with a containing experience by receiving slight indications that his mother is being affected by his feelings and responding in a way that shows that the infant's feelings are tolerable.

In more highly organized patients, indications of containing are experienced through interpretation. In more primitively organized patients, containing is experienced by the observation of partial acting out. Therefore, partial acting out is not only inevitable but a necessary part of psychotherapy with some severely disturbed patients, because these severely disturbed patients are more sensitive to the non-verbal interaction, as are infants, than the actual words one uses. Thus, partial acting out is a non-verbal therapeutic communication.

Since the days when Freud recommended that the therapist should conduct psychoanalytic t reatment like "the surgeon who puts aside all

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his own feelings," (1912, p. 115) psychoanalytic practitioners have de- bated the place their own feelings should play in psychotherapy. In more recent years, the broadened view of countertransference has been widely acknowledged, recognizing that the therapist's feelings provide valuable information about the patient. In the same spirit that led psychoanalytic practitioners to accept their own humanness and use it to their advantage, counter-reactions, such as partial acting out, should also be studied for their meaning and recognized for their potential to facilitate therapeutic change. This will lead to a more comprehensive understanding of the curative factors in psychoanalytic psychotherapy with severely disturbed patients.

REFERENCES

Bion, W.R. (1959). Attacks on linking. International Journal of Psychoanalysis, 40: 308-315. Reprinted in Second thoughts. London: Heinemann, 1967, pp. 93-109.

Bion, W.R. (1962). Learning from experience. London: Heinemann. Brenman Pick, I. (1985). Working through in the countertransference. International Jour-

nal of Psychoanalysis. 66: 157-166. Carpy, D. (1989). Tolerating the countertransference: A mutative process. International

Journal of Psychoanalysis. 70: 287-294. Freud, S. (1910). The future prospects of psychoanalytic therapy. Standard Edition. (11:

141-t51). London: Hogarth Press. Freud, S. (1912). Recommendations for physicians on the psychoanalytic method of treat-

ment. Standard Edition (12: 111-120). London: Hogarth Press. Grinberg, L. (1962). On a specific aspect of counter-transference due to the patient's pro-

jective identification. International Journal of Psychoanalysis. 43: 436-440. Heimann, P. (1950). On counter-transference. International Journey of Psychoanalysis. 31:

81-84. Klein, M. (1946). Notes on some schizoid mechanisms. International Journey of Psycho-

analysis., 27. Reprinted in The writings of Melanie Klein 3. Hogarth, 1975. pp. 1-24. Little, M. (1951). Counter-transference and the patient's response to it. International Jour-

ney of Psychoanalysis, 32:32-40. Malin, A. and Grotstein, J. (1966). Projective identification the therapeutic process. Inter-

national Journey of Psychoanalysis, 47: 26-31. Ogden, T. (1979). On projective identification. International Journey of Psychoanalysis, 60:

357-73. Racker, H. (1953). A contribution to the problem of counter-transference. International

Journey of Psychoanalysis, 34: 313-324. Racker, H. (1968). Transference and countertransference. New York: International Uni-

versity Press. Rosenfeld, H.A. (1971). Contribution to the psychopathology of psychotic states: The im-

portance of projective identification in the ego structure and the object relations of the psychotic patient. In Problems of psychosis, ed. P. Doucet and C. Laurin. Amsterdam: Excerpta Medica pp. 115-128; republished (1988) in Bott Spillius, ed. Melanie Klein today: Development in theory and practice, Volume 1, Mainly Theory, pp. 239-255.

Slatker, E. (1987). Countertransference. Northvale, New Jersey: Aronson. Winnicott, D.W. (1949) Hate in the counter-transference. International Journey of Psycho-

analysis, 30: 69-74.

Laurence Green, M.S.W. 10350 Santa Monica Blvd., #310 Los Angeles, CA 90024

containing and the patient's observation of the therapist's countertransference

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