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Moments of Uncertainty in Therapeutic Practice

Moments of Uncertainty in Therapeutic Practice: Interpreting Within the Matrix of Projective Identification, Countertransference, and Enactment

Robert Waska
Copyright Date: 2011
Pages: 272
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  • Book Info
    Moments of Uncertainty in Therapeutic Practice
    Book Description:

    One of therapy's greatest challenges is the moment of transference, when a patient unconsciously transfers emotion or desire to a new and present object-in some cases the therapist. During the course of treatment, a patient's projections and the analyst's struggle to divert them can stress, distort, or contaminate the therapeutic relationship. It may lead to various forms of enactment, in which the therapist unconsciously colludes with the client in interpretation and treatment, or it can lead to projective identification, in which the client imposes negative feelings and behaviors onto the therapist, further interfering with analysis and intervention.

    Drawing on decades of clinical case experience, Robert Waska leads practitioners through the steps of phantasy and transference mechanisms and their ability to increase, oppose, embrace, or neutralize analytic contact. Operating from a psychoanalytic perspective, he explains how to cope professionally with moments of transference and maintain an objective interpretive stance within the ongoing matrix of projective identification, countertransference, and enactment. Each chapter discusses a wide spectrum of cases and clinical situations, describing in detail the processes that invite a playing out of the patient's phantasies and the work required to reestablish balance. Refreshingly candid, Waska recognizes the imperfections of analysis yet reaffirms its potential for greater psychological integration and stability for the patient. He acknowledges the limits and frequent roadblocks of working with difficult patients, such as those who suffer from psychic retreat, paranoid phantasies, and depressive anxieties, yet he indicates an effective path for resetting the clinical moment and redirecting the course for treatment.

    eISBN: 978-0-231-52523-7
    Subjects: Psychology, Sociology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
    (pp. vii-xiv)
    (pp. xv-xviii)
    (pp. 1-8)

    EACH CHAPTER IN this book follows a wide spectrum of cases and clinical situations where patients are provided the best opportunity for health and healing through the establishment of analytic contact. Interpretation is the primary tool that clinicians use to make meaningful contact with the phantasy states and dynamic conflicts each patient suffers with. However, during the course of any treatment, what we say, do, think, and feel can become taxed, distorted, or contaminated by the influences of the patient’s projections and the analyst’s resulting countertransference struggles. This can lead to various forms of enactment, most often in the form...


      (pp. 11-32)

      WHEN DEALING WITH the task of correctly interpreting the patient’s anxiety and core phantasy at the point of greatest urgency, the analyst is often on slippery ground. Despite our best efforts, when interpreting, we are often both colluding with certain defensive or projective mechanisms and helping the patient toward internal growth, integration, and change. Rather than it being a dichotomy—either making correct, timely, and purely therapeutic interpretations or falling into pathological enactments and countertransference boundary violations—the actual clinical reality of interpretive work is more messy and layered.

      This chapter uses extensive material from several psychoanalytic cases to illustrate...

    • 2 SLIPPERY WHEN WET: The Imperfect Art of Interpretation
      (pp. 33-53)

      IT IS RELATIVELY easy to come up with everyday examples of interpretive acting out. When a patient is talking about his or her intense feelings toward the analyst, the analyst and/or the patient may feel so guilty, angry, anxious, or persecuted that they engage in a defensive retreat or reaction. This may take the form of the analyst suddenly shifting from interpreting the negative transference to interpreting genetic material that focuses the patient’s anger at his or her parents instead of at the analyst.

      A supervisee provided an example of another sort of interpretive acting out. The analyst was telling...

    • 3 INTERPRETIVE ACTING OUT: Unavoidable and Sometimes Useful
      (pp. 54-76)

      THERE ARE MANY elements to consider when making an interpretation. One is the immediate transference situation. This is usually the most useful road to take. However, whenever highlighting how the patient appears to be using the analyst or the therapeutic relationship in one particular manner, the analyst is also in danger of missing, ignoring, or minimizing other aspects of the transference that might be as important or even more critical. In other words, one portion of the patient’s core conflict and phantasy life may be exposed while another is more defended or withdrawn. So, often in choosing our interpretive approach,...

      (pp. 77-96)

      BIRD (1972) HAS established that the transference is present in the analytic setting from the beginning. The analyst may or may not be aware of it, but the transference is alive at all times, shaping both the patient’s view of and relationship to the analyst and the analysis. Waska (2004, 2005, 2006) has noted that projective identification is often the core element of many transference states, and thus it is present from the beginning of the treatment up to the last moment of termination. Therefore, there is an important technical interplay between projective identification and analytic contact. The role that...


    • 5 KLEINIAN COUPLE’S TREATMENT: A Complicated Case
      (pp. 99-121)

      THIS CHAPTER INVESTIGATES how a Kleinian psychoanalyst works with couples. The number of individual patients in classical psychoanalysis, as defined by the use of the couch and the frequency of sessions, has declined dramatically in the last forty years. Research within the psychoanalytic community finds the typical analyst spending the majority of his or her clinical time treating couples, families, and low-frequency individuals. Given this contemporary profile of private practice, it is important to understand the technical issues involved in treating our actual caseloads. At the same time, it is valuable to study the more complex and difficult cases in...

      (pp. 122-144)

      MOST ANALYSTS ENCOUNTER a wide variety of patients in their private practice, and many of these individuals present complicated and difficult transference situations. Projective identification is often the primary vehicle in which persecutory and primitive depressive phantasies play out in the interpersonal and intrapsychic realm of the transference. With the more regressed and defensive patient, there can be chaotic and confusing moments in which acting out by both patient and analyst is common. The analyst can easily stumble within the countertransference, falling into a mutual object-relational enactment. The tool of analytic interpretation is most crucial with these difficult patients. Interpretation...


      (pp. 147-161)

      Danny was a middle-aged man I saw individually after several initial consultations with him and his wife. After a twenty-year marriage and several children, she announced she was leaving him. She explained that she had never been physically attracted to Danny, but since they “got along so well” she thought that aspect of the relationship “might emerge later or that it might not be so important in the scope of things.” After five years of marriage, she said she “was completely turned off and had zero interest in ever having sex” with him again. “She told me she was fed...

      (pp. 162-183)

      IN PSYCHOANALYTIC PRACTICE, we encounter a variety of patients who operate at different levels of anxiety or desire in regards to their objects. Some patients seem to have an extremely strong conviction, not just a resistance, about their objects, including the analyst. This conviction is an internal status quo that they have created and now must live by. It is their “law of the jungle”: they have staked out a certain defined, known, and controllable vision of self and object, which they use to defend themselves against even more unbearable paranoid and/or depressive phantasies.

      Of these patients, some want to...

    • 9 TWO VARIETIES OF PSYCHIC RETREAT: The Struggle with Combined Paranoid and Depressive Conflicts
      (pp. 184-204)

      A NUMBER OF patients in psychoanalytic practice seem to share similar phantasies regarding the desperate longing for a loving object as well as the dread of being rejected by that same object. Hoping to please the object as a way to being loved is a large factor in their life, but equally important in their internal experience is the counterphantasy of always disappointing the object, leading to feelings of primitive loss, abandonment, and persecution. The desire to be pleased or praised by the object followed by the fear of being disappointed or ignored is also common. These complex conflicts involve...

    • 10 TRAPPED IN AN EMOTIONAL FOXHOLE: Coping with Paranoid and Depressive Conflicts
      (pp. 205-222)

      MANY OF OUR more difficult cases (Hinshellwood 1989) are embedded between the paranoid-schizoid position (Klein 1946) and the depressive position (Klein 1935, 1940) and rely on complex defensive systems or pathological organizations (Steiner 1987) to ward off a sense of fragmentation and severe guilt. Their fragile psychological structure depends on a rigid adherence to various self-defeating defensive systems (Segal 1972), defensive organizations (O’Shaughnessy 1981), or narcissistic organizations (Rosenfeld 1964). To maintain a sense of control and safety for themselves and their objects, these patients cocoon themselves into these rigid systems of pathological defense. Some of the time, they are successful...

    (pp. 223-232)

    REGARDING ENACTMENTS, KATZ (1998, 1140) states, “Attention to these unintended but meaningful and often elaborately developed characteristics of the treatment process furthers our understanding of the therapeutic action of psychoanalysis. The process of integrating the enacted with the verbal dimension of treatment enables the analysand to achieve higher levels of psychic organization.” This is an example of the general acceptance we now find in the psychoanalytic literature for this clinical phenomenon. It also shows the shared acknowledgment in the field of the potential therapeutic value in understanding the clinical meaning behind it.

    The concept of enactment and countertransference acting out...

    (pp. 233-238)
  11. INDEX
    (pp. 239-248)