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ARTICLES
An Overview
With
Borderline
0.
GLEN
Successful
ence
is critical
common
author
in such
must
constantly
tions
from
aspects
and
patients
that
patient.
conceptual-
their
relationships
of countertransference
behavwr.
be-
from
therapists
own
contribu-
as well as the
evoked
by the
Countertransference
of borderline
the psychotherapy
creation
It follows
that
monitor
en-
A theoretical
as a joint
framework
past
the most
reactions
is also proposed
therapist
of border-
discusses
treatments.
izes countertransference
conceptual
of countertransfer-
to the psychotherapy
The
framework
this
M.D.
countertransference
countered
Patients
GABBARD,
management
line patients.
tween
of Countertransference
in
patients
must
be viewed
as a source
of valuable
diagnostic
and therapeutic
information
and not simply
as interference
with
the therapeutic
process.
telling
me
I dont
care: I see
I know you
watch.
you
have
night.
that
a life
You
s this
Im
out
dont
just
like
you
want
to
there.
care.
quotation
treat
gram
tend
to
Nobody
overwhelm
Received
May
15,
JOURNAL
OF PSHOTHERAPY
of agents,
April
1992.
Kansas
University
Address
reprint
brief
School
AND RESEARCH
papatients
disor-
clinicians
who
treatment
proincludes
individpsychoanalysis,
with any one
or extended
of Medicine,
to Dr. Gabbard,
14,
1992;
Clinic
Topeka,
The
PRACTICE
a long
a borderline
1, 1992; revised
May
From
The
Menninger
requests
I know
be
cares.
the
or
that
conveys,
personality
them.
A comprehensive
for such patients
often
a number
Clinic,
leave.
from
ual
psychotherapy
adjunctive
pharmacotherapy
rest,
at your
It will
tients
therapist
vividly
suffering
from
borderline
der
the
looking
of
hospi-
accepted
and
the
Kansas.
Menninger
Press,
Inc.
COUNTERTRANSFERENCE
talization,
family
group
psychotherapy.
cific form
transference
successful
the
with
to
course
the
potential
patient
and
skillful
management
is only
one
aspect
approach
it constitutes
the
patient
of treatment
both
on which
The
therapy,
of the
and
spe-
treatment,
however,
countercan be a major
impediment
to
therapeutic
efforts.
The treaters
reactions
through
marital
Regardless
of
emotional
pest
or
like
to create
a tem-
havoc
for
therapist.
Although
the
of countertransference
of an overall
treatment
to borderline
personality
the foundation
of the
all other
primitive
sweep
efforts
defenses
disorder,
treatment
pa-
tients,
particularly
splitting
and
projective
identification,
produce
a kaleidoscopic
array
of complex
therapeutic
and chaotic
transferences
setting.
As these varying
in a life-and-death
struggle.2
Some
have even suggested
that counter-
transference
reactions
may
be
the
most
able guide
to making
the diagnosis
derline
personality
disorder.3
These
make
us come
alive
in a specific
heightens
our awareness
rience
of driving
over
narrow
Because
two-lane
they
reli-
of borpatients
way that
much
like the expea mountain
pass on a
road
without
a guard
rail.
are so sensitive
to the therapists
choice
of words
and nonverbal
nuances,
are able to evoke
a sense
of walking
on
shells,
narrow
impact,
their
they
egg-
as if our margin
of error
were
very
indeed.
Yet, in spite of this untoward
they
somehow
therapists4
and
become
inspire
special
to
a surprising
op-
timism
despite
a host of pessimistic
prognostic signs.3
Therapeutic
zeal
rises
like
a
phoenix
from the ashes
of previous
failures.
Borderline
patients
seem to have the peculiar
ability
to inflict
suffering
on their
a specific
therapists.
selves
throughout
and
have
suffered
it is important
to
them
form of sweet
They
themto
BORDERLINE
PATIENTS
therapists
suffer
for them.5
They
mand
that the therapist
abandon
sional
therapeutic
to treat
them
Searles6
has
role: anyone
must
share
in
cautioned
that
simply
not
borderline
applicable
patients.
S
of
E C I F I C
COUNTERTRANSFERENCE
R
Controversy
over
A C
the
1 0
diagnosis
of borderline
personality
disorder
persists
troduction
of this category
years ago. The first systematic
of the disorder
by Grinker
that
borderline
despite
the ininto DSM-III
12
empirical
study
et al.7 suggested
personality
disorder
trum
that ranges
from
the
neurotic.
Kernberg89
argued
line
concept
is really
is a spec-
psychotic
to the
that the border-
a personality
organiza-
tion rather
than a specific
nosological
entity.
A variety
of different
personality
disorders,
including
paranoid,
antisocial,
schizoid,
fantile,
narcissistic,
and cyclothymic,
be subsumed
under
the overarching
ganization.
Gunderson,#{176}
on the
to identify
discriminating
distinguish
borderline
from
other
et al.
Kernbergs
related
Axis
classic
psychoanalytic
#{149}
WINTER
borderline
1993
Abend
about
of bor-
posed
that
would
disorder
II conditions.
by documenting
treatment
sought
that
personality
their
hand,
criteria
in-
all could
ego or-
raised
serious
questions
diagnostic
understanding
derline
patients
ful psychoanalytic
with
other
have
NUMBER
attenin the
Theraob-
to the psychotherapy
lives,
#{149}
traditional
jective
role vis-#{224}-visthe borderline
patient
are at risk of projectively
disavowing
their own
conflicts
and anxieties
and using
the patient
as a container
to receive
them.
The classical
notion
of the therapist
as blank
screen
is
their
who attempts
their
misery.
the
on traditional
conflict
theory.
sented
yet another
point
of
VOLUME
seem
to dethe profes-
analytic
posture
of evenly
suspended
tion is neither
viable
nor appropriate
psychotherapy
of borderline
patients.
pists who attempt
to assume
a detached,
in the
configu-
rations
of self- and object-representations
parade
before
the therapist,
they are further
complicated
by accompanying
affective
states
that are unusually
intense
and raw, often
inducing
in therapists
a feeling
that they are
trapped
clinicians
AND
patients
based
Adler2
view. He
could
best
preprobe
GABBARD
understood
as suffering
condition
Specifically,
sence
could
sence
rather
this
from
describing
aspects
of the psychotherapeutic
process,
attempts
to hold rigidly
to a dichotomous
view that prescribes
a
given
form of therapeutic
modality
to
specific diagnostic
entities
is neither
theoretically
sustainable
nor clinically
practical.
the therapist
needs to maintain
a position
of flexibility
and adaptability,
allowing
the selection
of available
techniques
from the range of psychotherapeutic
interventions
to deal with
the
problems
presented.
(p. 121)
a deficit-based
than
intrapsychic
condition
involved
of a holding-soothing
sustain
them
emotionally
of their
psychotherapists.
conflict.
the ab-
introject
that
in the abOther
clini-
..
cians
influenced
maintained
that
by self
psychology34
borderline
symptomatology
results
from breakdowns
in the empathic
latedness
between
therapist
and patient
should
therefore
be
reconceptualized
entity
that is definable
a relationship.
This controversy
only
of the
tion
that
context
of
The
diagnosis
is mir-
controversy
regardMany (though
not
differences
commodated
as an
in the
about
rored
in a corresponding
ing the optimal
treatment.
all)
reand
can
be ac-
by embracing
Meissners5
no-
borderline
diagnosis
the
of opinion
is
essentially
a spectrum
of conditions
that are
psychodynamically
related.
At the high end
of the spectrum
are patients
who have notable ego
the
are
can undergo
psychoanlittle
modification.
At
cause
require
of prominent
ego
more
supportive
From
a clinical
spectrum
construct.
wide
tion.
and
with
strengths
treatment
alytic
weaknesses
approaches.
perspective,
who
be-
and
who
however,
in their
normal,
clinical
neurotic,
must
assume
to
and
a flexible
wherein
fro
continuum
along
the
according
moment.
point
and
has
to the
psy-
interventions
shift
expressive-supportive
to the
at a particular
of view
approach
their
patients
Meissner5
offered
following
observation:
this
JOURNAL
OF PSHOTHERAPY
of
depending
particular
upon
where
on
patient
stands.
univocal
spectrum
is important
countertransfer-
keep
in mind
that
the
may vary considerably
serves:
Countertransference
borderline
conditions
this
continuum
a
ob-
in relation
is therefore
not
phenomenon
of levels and
but rather
intensities
ence/countertransference
to
an
involves
of transfer-
interactions
that
Feelings
patients
have
an
uncanny
ability
to tune in to the
ities and exploit
them
therapists
vulnerabilin a manner
that in-
duces
guilt.
feelings
development
such a way
therapist.
apist
At the very
patient
cusations
they
attempt
professing
the
may
and
caring
that
of
moment
accuse
may
have
been
patient.
feelings
found
the
out.
in
the
ther-
disappear,
therapist
the
create
therapists
their
lack
would
the
of disliking
common
will behave
exasperate
when
patient
of not
Such
in
ac-
therapists
Under
may reproach
of professionalism
such
themand
to make
amends
to their patients
by
undying
devotion.
The
patients
accusatory
charges
may
row of the therapists
PRACTICE
is that a patient
as to infuriate
and
is wishing
conditions
selves
for
of a spectrum
discussions
must
reactions
the
needs
shares
the
in
ence,
one
therapists
for
presentaand psy-
chotic
transferences
in the same
patient
in
the course
of one therapeutic
hour.6
A corollary
of this observation
is that
therapists
chotherapy,
concept
because,
the
must be regarded
as a metaphorical
Borderline
patients
are known
fluctuations
One can see
AND
RESEARCH
strike
10
COUNTERTRANSFERENCE
and
create
a form
transference4
of physiological
that
sympathetic
heart,
a dry
involves
discharge,
mouth,
and
Another
common
counter-
The
manifestations
of
such
as a pounding
trembling
limbs.
scenario
relatively
and
intact
seem
is that
progresses.
at the beginning
to unravel
as
Searles6
has
suggested
the
of treattherapy
that
origins
such
BORDERLINE
of
expressions
tional9
result
therapist
begins
to feel responsible
for apparent clinical
deterioration
in the course
of
psychotherapy.
Many borderline
patients
appear
ment
AND
this
proneness
of aggression
or secondary
is that therapists
apist may
disclosure,
extend
defer
fee
whatsoever,
ual
behavior
or engage
with
the
to the point
of madness.
that some
therapists
will
sation
because
patients
dured.
Suicide
threats
pists
to
justify
transgressions,
often
they had not deviated
guilty
that
the
more
provide
greater
fascination
or more
neurotic
areas
Rescue
psychotic
than
the
of the ego.
Fantasies
primitive
be
constitu-
patient
in physical
patient.
of professional
because
of the
as a victim
tices,
ther-
who
or sex-
In some
cases,
boundaries
is
perception
of the
is entitled
to compen-
the
and
the session,
engage
in selfpayment
or not charge
any
ing a parental
He has noted
aspects
healthier
to
or intimidated
by the patients
volatility
potential
to explode.
To ward off the patients
anger,
the
this violation
rationalized
feel
may
guilt feelings
by therapists
may be related
to
unconscious
empathy
with the patients
child
self-representation,
who felt guilty about
drivfigure
also
PATIENTS
measures
has en-
she
patient
would
have
another
source
committed
sui-
17
Intimately
related
to guilt
feelings
evocation
of rescue
fantasies
in the
This
aspect
of the countertransference
volves
more
than
simply
are the
therapist.
in-
therapeutic
zeal.
It
also reflects
a perception
that the patient
is
essentially
helpless.
Therapists
often
feel that
they must do things
for the patient.
Borderline
patients
often
present
themselves
as
Dickensian
orphaned
waifs4 who
need
the
therapist
ther
to
parent
to serve
as a good
mother
up for the bad
or
responsible
for victimizing
Transgressions
The
third
ference
of specific
follows
the
child.
Boundaries
form
reaction
absent
of
Professional
frame
ing.79
or fa-
make
countertrans-
naturally
patients
from
from
the
are notorious
the therapeutic
Still
gressions
relates
to
ment.
Many borderline
are
always
that
They
leads
are
known
to frequent
to have
a short
expressions
VOLUME
NUMBER
#{149}
of being
abandoned
sources
of nurturance
their parents,
lovers,
demonstrate
their
sincere
concern.
these
demands
may
escalate
to
phone
calls, a rendezvous
outside
Because
late-night
the ther-
apy, and
borderline
who treat
as well as
ference
sexual
liaisons,
patients
have
need
pitfalls
A common
therapy
#{149}
WINTER
to understand
and
countertrans-
Hatred
phenomenon
of borderline
1993
therapists
an ethical
thoroughly.23
Rage
fuse
of rage.
verge
trans-
form
of entitlement
resulting
in demands
to
be treated
as exceptions
to the usual
procedures.
the
issue
patients
pists.2122
Some
patients
interpret
any
communication
from
the therapist-except
unconditional
love-as
having
an implicit
threat
of rejection.2
These
patients
demands
for reassurance
that one really
cares
a clinical
to ill-advised
boundary
crosspatients
may feel a specific
on
by significant
port,
typically
of boundary
the
patients
in the
is their
psychoalley-
11
GABBARD
tension
ating
by
feelings
into
has
termed
Whereas
evacuating
or
the therapist:
a lavoratoric
neurotic
patients
superego
constellations
borderline
patients
primitive
dumping
tend
into
project
to
therapist,
the
sick
or
bad
self in a primitive
split-off
form.92526
Volkan26
has described
the feeling
of being
choked
by the externalization
of such primitive and negatively
charged
affects
and introjects.
One
can
hardly
avoid
feeling
rage,
hatred,
and
resentment
lead
being
calls
and
extraordinary
unceasing
to profound
feelings
Helplessness
and
can
of seething
mands
are
these
patients
contemptuous
rather
can shift
transferences
from
form
hanced
of
tients
countertransference
by the expertise
at
exploiting
ing out
identifying
and
their
de-
gratified,
is further
borderline
vulnerable
withdrawal
enpa-
areas
are
postures
devaluing
of the therapist
attacks,
but
face the
petence
feelings
of helplessness
are prominent.
Anxiety
and
often
in the throes
underneath
and
tioned
thing
ment,
and
misidentify
Regardless
this
anxiety
of what
borderline
therapist
therapists
often
up to the
efforts.
clinical
are
many
else
THE
As the
moved
concept
to center
and
varied.
JOURNAL
At the
choanalytic
transformation
OF PStHOTHERAPY
not
in their
OF
ence
placed
as a disruptive
obstacle
has
by a view of countertransference
ened
interest
relationship
enactments
ological
replaced
has
psy-
discourse,
it has undergone
in meaning.
Countertransfer-
Accompanying
most
are simply
failing
of countertransference
stage in contemporary
if not
on in the
they
or are
Finally,
throughout
feeling
that
NATURE
standing.
almost
always
The sources
of
that
task
runs
the
COUNTERTRANSFERENCES
essential,
source
this
in how
serves
of past
search
for
by careful
by-moment
is going
that
from
have
valuable,
incom-
patient
men-
anxiety.
anxiety
arises
overt
of such
the sur-
in many
treatment
of guilt and respon-
countertransference
an overriding
the treatment
pointDefen-
Terror
patients
anxious.
belonging
shift
been
of
reas a
under-
is height-
the patient-therapist
as a forum
for
experiences.
the buried
attention
reverberations
and
treatment,
make
the
feelings
in the therapist
instead.
or fusion
may be ex-
by the borderline
worries.
The previously
concern
and cause
or abruptly
creates
that awareness
by constantly
weaknesses
to the therapist.
siveness
as residing
of merger
induced
such
incompetent,
about
it. This
of
may
to them
A feeling
sibility
amplifies
idealizing
to
in the twinkling
unskilled,
anything
patients
dealso
con-
therapists
is ever
present
and the sense
resent-
than
lead
suicide
processes,
Worthlessness
frustrated
patients
may
to
by
ment.
Borderline
patients
tend to devalue
therapists
efforts.2
Also,
when
their
borderline
in
used
treatment
the
boundaries
tremely
unsettling
to the therapist
in such
situations.
A common
response
is to distance
oneself
from the patient
and become
aloof.27
The
anxiety
that
the patient
will commit
patient.
Being
held hostage
or driven
to distraction
phone
mands
when
about
to feel a primal
terror
related
to the concern
that they will be swallowed
up by their patient
and annihilated.
In psychotic
transferences,
project
the
level,
fusion
what Rosenfeld24
transference.
re-
between
therapist
patient.28
Freuds
original
definition
of countertransference
was narrowly
focused
on the
analysts
transference
to the patient.
In other
words,
countertransference
involved
feelings
PRACTICE
AND
RESEARCH
12
COUNTERTRANSFERENCE
that belonged
displaced
onto
to the analysts
past but were
the patient
in the same
way
needed
broader
form
to be construed
analyst
experiences
plicit
in Heimanns
tertransference
was
empathic
(i.e., the
link between
therapist
therapist
identifies
with
subjective
affective
state
or
has
the
focused
recipient
in-
tification.
Whereas
and patient
the patients
self-representa-
the
effected
largely
interpersonal
tient.
Projective
patients,
this
discussion,
mechanisms
takes
the
pa-
and
I will
by border-
importance
for
elaborate
on
it
below.
One
about
implication
of this
shift
countertransference
analysts
conflicts
tainer
patient
those
internal
transference
object
in thinking
is
Racker viewed
this complemenas an instance
in which
the
by the
con-
that
used
on crucial
the therapist.
tary
reaction
activated
remains
therapist
produces
to conform
to the
These
changes
are
analysts
response
to the
great
deal of information
were
concept
through
powerfully
coercive
pressure
exerted
by the paidentification,
as one of the
defense
line
of
on changes
in
projective
iden-
or affect
tient
projects
into
the
changes
in the therapist
nature
of that projection.
tions).
Complementary
countertransferences
involve
identifications
with an internal
object-representation
of the patient
that has
been projectively
disavowed
and attributed
to
own
concept
Although
controversial,
there
is a general
that
the split-off
self-representation,
central
an
PATIENTS
as used
by Klein
infantasy
rather
than an
the modern
usage
to a great
extent
of the patients
object-representation,
Concordant
involving
those
the original
concept
volved
an intrapsychic
interpersonal
coercion,
the
that
BORDERLINE
of interest
in the Kleinian
identification.69253
in a
the feelings
the analyst
experiences
are
duced
by the patients
behavior.
Racker3
divided
such
patient-induced
reactions
into concordant
and complemenare
pouring
projective
highly
sensus
toward
the patient.
Imunderstanding
of counthe notion
that some
of
tary
countertransferences.
countertransferences
AND
patient
about
that
world.
Moreover,
entails
first serving
to receive
and
then
projections.
projected
studying
Sandler45
the
provides
the patients
counteras a con-
aspects
of the
the contents
of
suggested
that
patients
projections.
Grinberg32
took this notion
one
step further
with
the concept
of
projective
coun teridentification,
in which
the analysts
supplemented
the analyst
introjects
object-representation
from
the patient.
determines
what
complementary
role
is
being
coerced
by the patients
words
and
behavior.
This influence
from the British
school
of
Winnicott,33
a reaction,
feeling,
or
that
comes
entirely
in his classic
paper
tertransference
hate,
spoke
form
of countertransference
analyst
manner
sistent
reacted
the patient.
patient
persons
This
the
According
patients
might
hate in other
the
to
patient
evoked
by the
across
all people
past.
shift
a specific
to this schema,
about
in
in
patient
that was
who interacted
consistently
people
that
than
on coun-
of an objective
in which
the
the
thinking
induce
reflect
conwith
certain
feelings
of
more
about
analysts
led
or other
to
VOLUME
an
out-
NUMBER!
#{149}
ness
involving
object
Atlantic
the
free-floating
attention
by a free-floating
a form
relations
theory
and has had
classical
overview
nique,
tion
has traveled
a significant
originating
of understanding
has now become
WINTER
1993
that
across
impact
school,
the
on
cre-
interest
in concepts
such
enactment.4#{176}
In a recent
of countertransference
Abend5
acknowledged
countertransference
#{149}
of introspection
or ego-psychological
ating
considerable
as interaction
and
must
be
responsive-
with
Klein
can
and
that
that
the
techno-
the
analysts
be a crucial
source
the patients
inner
universally
accepted.
world
As part
13
GABBARD
of this acceptance,
of the analyst
have
the self-analytic
activities
come
to be regarded
as a
systematic
effort
at collecting
data
about
ones
analysand.
The analyst
must be particularly attuned
to subtle
or not-so-subtle
forms
and patient
vary according
to the severity
of
the psychopathology.
In general,
projective
identification
or objective
countertransferences occur with sicker patients,
such as those
suffering
from
of acting
in, whereby
the patients
internal
object
relationships
are enacted
in the clinical setting
between
patient
and analyst.
In
der, whereas
tertransferences
speaking
many
of enactments,
An
analyst
catches
ing
reacts
himself
regains
Chused
to his
in
his analytic
himself
and
the
the
so
to
and
patient,
speak,
in observ-
increases
his
understanding
of the unconscious
fantasies and conflicts
in the patient
and himself
which
(p.
616)
have
Borderline
enactments
affect
and
resentations
apist.
assume
prompted
patients,
him
ference
reactions
patient.
must
be
In my
thought
are
simply
evoke
erroneous
countertransaspects
neurotic
patients.
tertransference
Although
reactions
with
are overwhelming
in
not neglect
more
elusive
that also occur
throughof psychopathology.
out that even aspects
of
sciously
determined
and therapist.
This
modernization
through
the sheer
power
of the
the primitive
self- and object-repthat are projected
into the ther-
However,
it would
be
that all of a therapists
or
coun
disorcounwith
the standard
analytic
or therapeutic
posture,
such
as neutrality
or silence,
can become
involved
in subtle
enactments
that are uncon-
to action.
in particular,
healthier
personality
narrow
or subjective
are more
prominent
borderline
patients
intensity,
we must
forms
of enactment
out
the
spectrum
Jacobs49
has pointed
patient-but
act,
stance,
notes:
borderline
the
to
of the
view,
countertransference
of as a joint
creation,
in
by issues
of
in both
the
countertransference
has led some
that the term
has been
so greatly
as to lose its specificity.
Natterson,53
ample,
makes
countertransference
a differentiation
and the
patient
concept
of
to believe
expanded
for ex-
therapists
between
own
subjectivity.
He prefers
the language
of intersubjectivity
because
the therapist
initiates
as
well as reacts.
It is my view, however,
that in
which
both
the therapists
past conflicts
and
the patients
projected
aspects
create
specific
patterns
of interaction
within
the therapeutic
actual
practice
the interactions
between
therapist and patient
are so inextricably
bound
up
with one another
that what is initiative
and
process.
Indeed,
a central
feature
of the
therapists
role with such patients
is to engage
in an introspective
process
that attempts
to
what is reactive
dissect.
Meissner5
differentiate
those
of
or
ones
own
the patient.2M
order
within
to find the
ourselves.
points
within
to the fact
the session
mentary
sources
The therapist,
intrapsychic
in an effort
the patient
If one
transference
that
the
patient
This
contributions
Bollas52
that there
are
and therefore
of free
notes:
we must
process
from
In
association
then,
must
maintain
focus and an interpersonal
the
premise
is ajoint
creation,
relative
contributions
JOURNAL
that
it
In his view,
therapist
should
experiences
be construed
(p. 202).
to the
assigned
both
regarded
counter-
also follows
of therapist
OF PSIHOTHERAPY
role
to impossible
argued
definition
ference.
that
patient
an
focus
be next
has also
limited
He proposed
ence to the
more
may
to
for a narrower
of countertrans-
not
all reactions
that
the
toward
the patient
as countertransference.
only
and
the analysts
the analysts
by the
as countertransference.
patient
transferreaction
should
be
In this con-
ceptualization,
reactions
that
involve
the
therapeutic
alliance
and the real
relationship
(outside
of technique)
between
therapist
and
patient
are
not
necessarily
countertransferential.
Again,
this distinction
may be extremely
difficult
to tease out in the
PRACTICE
AND
RESEARCH
14
COUNTERTRANSFERENCE
heat
of the
derline
affective
storms
by bor-
patient
that
I have
been
advocating
great responsibility
on therapists
themselves
whose
own
as both
clinicians
issues
enter
into
arena.6255253
Self-analysis,
mount
importance
in
countertransference.
served,
My view.
. .
tegration
ment
into
an
of
self-analysis
R 0
J E C T
model
delineated
rein-
the
projector
with
transcends
feels
the
the
for projective
1)
movethat
of
that
or union
recipient
simple
pur-
pose of defense.
As Scharff42
has eloquently
summarized,
four
distinct
purposes
can
Defense:
to
unwanted
one
(p. 339).
T
by the
form.
projection.
This
o bof
is a systematic
the psychoanalytical
exiled
function:
stressed
of oneness
of the
PATIENTS
of them
in modified
also
sense
is of paramanaging
Indeed,
Bollas54
is that contemplation
countertransference
Ogden
here
to see
and patients
the therapeutic
then,
effectively
BORDERLINE
to a reintrojection
patients
in psychotherapy.
The
conceptualization
of countertrans-
ference
places
the
generated
AND
I V E
distance
part
else,
2)
or
understood
cipient
to experience
own,
3)
with
a recipient
the
make
the
re-
of feelings
like
Object-relatedness:
to
separate
projection
the
in some-
pressing
a set
teract
receive
from
it alive
to
by
ones
to
oneself
to keep
Communication:
oneself
be
identification:
in-
enough
yet
undifferen-
IDENTIFICATION
tiated
enough
tion
In light of the
tive identification
borderline
central
importance
of projecthe psychotherapy
of
in
patients
and
in the
term,
I view
the
concept
cal
conceptualiza-
of projective
for
To
begin
with,
be regarded
aspect
avowed
someone
2.
3.
of the
in
be
the
the
sense
of
psychologi-
transformed
by
projection
the
after
recipient,
mother-infant
or
for
as
its
occurs
relationship,
patient-therapist
in
rela-
29)
(p.
This
model
of projective
identification
ries with it a spirit of therapeutic
optimism.
with
identification
than
simply
is projectively
dis-
placing
it in
therapists
patients,
a
else.
interpersonal
the other
to
mispercepthe
Pathway
by
tionship.
the
self
exerts
coerces
foster
the
marriage,
develop-
by unconsciously
The projector
pressure
that
change:
modification
defense
mechanism
of borderline
patients.
OgdenTM
has defined
it as a three-step
procedure
in which
the following
events
occur:
1.An
4)
some
identi-
understanding
projective
as more
and
allow
to
reintrojecting
ments
in the psychotherapy
of patients
borderline
personality
disorder.
should
occur
oneness,
tion of countertransference
as I have defined
it, a more
careful
consideration
may be helpful in clarifying
my use of this term.
Despite
the controversy
over confusing
usages
of the
fication
as essential
transference-countertransference
to
to
person
to experience
or unconsciously
with what has been
projected.
The recipient
of the projection
therapeutic
situation)
processes
contains
the projected
contents
VOLUME
can bear
they offer
tients
transform
containment
and
jections
affects
and
therapists
Some
the
the
jected,
arguing
the definition
projections
of their
hope
of helping
pa-
their internal
modification
in
countertransference.
critics
of this
the
the
third
Kernberg8
gard
identification
projective
crucible
of
the
have
ob-
has broadened
original
intent
step
involving
preferred
to
re-
as a primitive
identify
defense
tolerable
(in the
and
leading
pathy
with
the
projected
contents,
attempting
to control
the object,
and unconsciously
inducing
the object
to play the role
of what is projected
in the actual
interaction
#{149}
NUMBER!
WINTER
#{149}
mechanism
aspects
world
through
of those
pro-
model374
that Ogden38
beyond
Kleins
by including
reintrojection.
carIf
1993
involving
projecting
of the self, maintaining
inem-
15
GABBARD
between
the
projector
and
the
recipient.
ment
Sandler4
also objected
to extending
the
projective
identification
concept
to include
the therapeutic
actions
of containment,
detoxification,
and
modification
as described
Ogden.TM
However,
Sandlers45
responsiveness
is very much
the first two
with my view
creation
steps
of Ogdens
of countertransference
of patient
Very
often
analyst,
science
blind
and
concept
therapist.
He
the irrational
response
which
his professional
leads him to see entirely
spot
of his
own,
may
by
notion
of role
in keeping
with
process.
Patients
and
Although
therapist
over, she
that
an import-
reintrojection
of negative
Scharff42
shares
engage
places
that
patient
I am
and
in a mutual
process.
greater
emphasis
on
identification
therapist
who
The therapist
broadened
the
projective
identification
she stresses
that the
trojective
Morethe in-
component
of
the
receives
aspects
of the patient.
may respond
in a concordant
or complementary
manner,
according
to
Rackers3
distinction,
but Scharff
also notes
that introjective
identification
is determined
be
may
believed
element
of projective
identipatients
observation
that
nor patient
is destroyed
by
projection
said:
in part
respond
the
view of
endorsing,
usefully
regarded
as a compromise
formation
between
his own tendencies
and
his reflexive
acceptance
of the role which
the patient
is forcing
on him. (p. 46)
feature
Boyer
affects.
and
as joint
of the
conas a
sometimes
process.
ant therapeutic
fication
is the
neither
therapist
experi-
what
words,
by the therapists
own
in an identificatory
is projected
by the
some
projections
good
enced
fit, whereas
as alien and
propensity
manner
to
with
patient.
In other
may
represent
a
others
discarded.
may be
Finally,
experiScharff
ence
the depositing
of aspects
of themselves
in the therapist
as forging
a powerful
link
observes
that
patient/projector
the reintrojective
may promote
between
containment
made
slight
by the therapist/recipient
modifications
that
can
be
cepted
the limits
capac-
the
two members
of the
dyad,
giving
them
the illusion
of influence
over the therapist.
Often
the power
of this control
is
recognized
only
after
the therapist
has responded
in the specific
manner
that has been
unconsciously
projective
by the
Therapists
programmed
identification.
patients
of bor-
derline
patients
must
transference
enactments
accept
are
that counterinevitable.
By
rigorously
therapists
internal
regroup
responses,
and process
what
monitoring
can at least
has happened
with
the patient
construed
in the
Ogden.TM
patients
such
has written
that
of what has been
In fact,
reintrojection
the
distorted
patients
change.
with
he
projective
manner
also
projection
of the patients
be pathological,
is returned
form
anxiety
Certainly
by the
if the
has
ac-
however,
in
if
a completely
that
does
not
modify
the
or lead
to psychological
in nontherapeutic
settings
the aspects
that are projected
are routinely
crammed
back
down
the patients
throat
rather
than
contained
or modified,
often
following
enactments.
Boyer55
has
also
identification
broadly
within
ity to change.
This can
process
change
of
the
pro-
considerably
panded
sumes
containment
should
be
affect.
The
and modification
noted
that close
transference
JOURNAL
contain-
OF PSItHOTHERAPY
PRACTICE
that
AND
RESEARCH
goals.
(It
parents,
resentation
therapists
and
aswhich
apeutic
in the way they contain
what
has
been
projected
into them
even though
a formal psychotherapy
process
is not involved.)
The joint-creation
model
of counter-
the
spouses,
are
friends,
ex-
jected
into the therapist
is a neglected
aspect
of the process.
For example,
when
they project hostility
into
their
therapists,
these
patients
may benefit
from
the detoxification
of the affect and associated
self- or object-repthrough
lovers,
intensified
model
of projective
identification
a therapeutic
context
in
I believe
also be ther-
is most
apposite
16
COUNTERTRANSFERENCE
for the
depends
psychotherapy
heavily
on
projective
Ogden,TM
of borderline
expanded
the
identification
Boyer,
Scharff,42
crucial
importance,
keep in mind
the
as
and
however,
metaphorical
exchange
of mental
contents.
ing mystical
about
projective
When
patients
coerce
us into
iors
or
they
have
feelings
that
into
repressed
as troops
be called
into
service
described
others.
by
It is of
jective
identification,
els have been used
with
entrenched
what
have
simply
or split-off
aspects
far from the front
specific
of
may
forms
of
pattern
THE
ROLE
Francis
Bacon
ories are better
the most
some
parallel
OF
once
than
to theory
emphasizes
are perhaps
most
gling
with intense
ings.
They
bring
aspect
counterpart
by unconsciously
role of the child
themselves
for
time.
intense
transferhas noted
that
involves
conthe psychotherapist
One dimension
the application
of theory
to the clinical
situation is that it also is applying
balm
to soothe
the therapists
anxiety.
ory
Nevertheless,
as absolute
Theories
are
only
countertransference,
as valuable
as their
I have borrowed
from
in my conceptualization
and
specifically
VOLUME
clinical
object
of
of pro-
active
trauma
model
analyst;
the
the
the affect
is
it is simply
patient.
Rhine57
from
approached
projective
a self psychological
per-
to be used
by the
need
for the
to the pamust
allow
patient
for
psy-
The therapists
selfobject
allowing
mirroring,
ideal-
ization,
and twinship
in the patients
ences.
Adler
and Rhine
described
a
patient
who insisted
that her therapist
tion as a selfobject
by accepting
her
tions and projections.
They pointed
transfercase of a
funcprovocaout that
the containing
and
jective
identification
modifying
aspect
of proconverges
with
self-
object
therapist
in
to be
functioning
understands
used
by the
tient verbalize
them.
Different
same
are
situations
and tolerates
patient
and
where
the
helps
the
need
the
feelings
rather
than acting
theories,
the authors
essentially
clinical
issues.
Most
therapists
struggling
use
on
sug-
with
multiple
pa-
the
mod-
els.M6162
Rigid
adherence
to only one theoretical
frame
when
the clinical
data do not fit
utility. Although
relations
theory
and
growth.
include
gested,
of
In Porders
into
the
spective.
Kohut5#{176} stressed
the
therapist
to serve
as a selfobject
tient.
In other
words,
therapists
chological
functions
thehere
between
casting
the analyst
in
while the patient
assumes
by the
in
that theoretical
models
useful
when
one is strugcountertransference
feelorder
to the
chaos
of
discomfort
deal of the
induced
of
THEORY
overwhelming
affect
and
ence
distortions.
Friedman56
the practice
of psychotherapy
siderable
a good
bizarre
of relatedness
Adler
identification
that
Projective
identification,
in
is an identification
with
the
is a chronic
repetition
of an
view,
that
sense
of self. We all have sadists
and murderers lurking
in our depths
as well as saints and
heroes.
Considerable
insight
is gained
in conceptualizing
the psychotherapeutic
process
as involving
two patients
rather
than
one,
has
modclini-
perspective.
Porders
aggressor
parental
role.
not projected
the patient
ourselves.6
other
theoretical
to explain
the same
There
is nothidentification.
specific
behav-
battle
need
to be fought.
We all possess
myriad self-representations
that
are integrated
into a more
or less continuously
experienced
understanding
PATIENTS
that therapists
nature
of the
us, they
when
BORDERLINE
cal phenomena.
Porder4#{176} shares
OgdensTM
view that projective
identification
is not simply a defense
mechanism.
However,
he explains
it from a traditional
ego-psychological
correspond
projected
stimulated
ourselvesjust
patients
model
of
AND
#{149}
NUMBER!
the theory
contemporary
is an unfortunate
practice
that
phenomenon
privileges
in
theory
over clinical
observation.
misused
to rationalize
acting
out.23 One can
Theory
can also
countertransference
use self psychology
rationalize
of idealization
#{149}
WINTER
enjoyment
1993
be
to
by a pa-
17
GABBARD
tient.
Similarly,
one
encouragement
can
to
misuse
schools:
forming
Kernbergs9
confront
and
interpret
the negative
transference
early on in the therapy to justify
expressions
of anger
at the patient.
Bollas63
has
stressed
that
modern
analysts
must
1. Boyer
LB:
Master
edited
Jason
understand
a variety
1990,
2. Kernberg
OF,
Psychodynamic
the
Seizer
MA,
Psychotherapy
and
Solomon
Press,
4. Gabbard
GO:
1987,
5. Giovacchini
Koenigsberg
HW,
of Borderline
Therapy
Jason
Aronson,
JS:
patient,
Concepts
et
al:
Pa-
Clinical
im-
Treatment,
MF, Lang
treatment
vol 1, edited
JA. Hillsdale,
of the
special
II:
and
HF:
7. Grinker
by
NJ,
RRJr,
Werble
Techniques
of
in PsychoanNew
Borderline
1986
B, Drye
Behavioral
JG:
Washington,
11. Abend
tients:
New York,Jason
Borderline
DC,
SM,
American
Porder
MS,
Psychoanalytic
RC:
The
Borderline
New
ment.
New
13. Brandchaft
an
tient:
1987,
14. Terman
praisal
pp
103-1
15. Meissner
Its Treatconcept:
concept:
suggestions,
Pa-
Psychody-
a critical
in The
MF, Lang
pp 61-71
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anal
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in the
by
NJ,
Border-
OF PStHOTHERAPY
1991;
personality
disorder,
and patient-therapist
Psychiatry
1989;
sex:
146:597-602
Patients
involved
isavictim
profile
in sexual
possible?
JL, Perry
in borderline
1989;
bound-
medicolegal
misconduct
Psychiatric
JC,
van
der
personality
Kolk Bk
disorder.
Childhood
AmJ
Psy-
146:490-495
of the
1975;
sex
21:651-655
borderline
syndrome:
and
psychic
personality.
IntJ
Psycho-
56:163-177
23. Chessick
RD: Intensive
Psychotherapy
line Patient.
New York,Jason
Aronson,
of the
1977
24. Rosenfeld
H: Impasse
tic and Anti-therapeutic
TherapeuPsychoanalytic
and Interpretation:
Factors
in the
of Psychotic,
Borderline,
London,
Tavistock,
1987
Patient:
Emerging
namics,
Solomon
and Treatment,
MF, LangJA.
and
countertransference
patient,
in The
Concepts
Border-
Neurotic
in the
Borderline
in Diagnosis,
Psychody-
vol 2, edited
by GrotsteinJS,
Hillsdale,
NJ, Analytic
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