The nature of the transference is typically controlled through the therapists proper use of

Transference, and its counterpart, countertransference, are among the most fundamental organizing concepts of psychoanalysis. Originally, Freud conceptualized transference as a ‘transferring’ onto the analyst of reactions to the major figures in the patient's early life, primarily the parents. This was first seen as an obstacle to the psychoanalytic work of recovering into consciousness the repressed pathogenic experiences of the childhood past. Subsequently, Freud came to understand transference as an essential vehicle of psychoanalytic work since it represented the reliving of repressed early experiences in the immediacy of the present psychoanalytic situation, which rendered these early experiences more accessible, and therefore more amenable to interpretation. When the whole neurotic symptomatology is expressed in the transference, this is called the transference neurosis. When a psychotic picture manifests itself in the transference, this is called a transference psychosis. When the analyst displays neurotic transference manifestations to the patient, this is called countertransference. As with transference, countertransference was originally seen by Freud as an obstacle to analytic work, but since is time it has also come to be seen as an avenue to understanding the pressure on the analyst from the patient and therefore an opportunity to better understand the psychic processes in the patient.

2.5 An Object Relations Theory Model of the Transference and Countertransference

Modern object relations theory proposes that, in the case of any particular conflict around sexual or aggressive impulses, the conflict is imbedded in an internalized object relation, that is, in a repressed or dissociated representation of the self (‘self representation’) linked with a particular representation of another who is a significant object of desire or hatred (‘object representation’). Such units of self-representation, object representation and the dominant sexual, dependent or aggressive affect linking them are the basic ‘dyadic units,’ whose consolidation will give rise to the tripartite structure. Internalized dyadic relations dominated by sexual and aggressive impulses will constitute the id; internalized dyadic relations of an idealized or prohibitive nature the superego, and those related to developing psychosocial functioning and the preconscious and conscious experience, together with their unconscious, defensive organization against unconscious impulses, the ego. These internalized object relations are activated in the transference with an alternating role distribution, that is, the patient enacts a self representation while projecting the corresponding object representation onto the analyst at times, while at other times projecting his self representation onto the analyst and identifying with the corresponding object representation. The impulse or drive derivative is reflected by a dominant, usually primitive affect disposition linking a particular dyadic object relation; the associated defensive operation is also represented unconsciously by a corresponding dyadic relation between a self representation and an object representation under the dominance of a certain affect state.

The concept of countertransference, originally coined by Freud as the unresolved, reactivated transference dispositions of the analyst is currently defined as the total affective disposition of the analyst in response to the patient and his/her transference, shifting from moment to moment, and providing important data of information to the analyst. The countertransference, thus defined, may be partially derived from unresolved problems of the analyst, but stems as well from the impact of the dominant transference reactions of the patient, from reality aspects of the patient's life, and sometimes from aspects of the analyst's life situation, that are emotionally activated in the context of the transference developments. In general, the stronger the transference regression, the more the transference determines the countertransference; thus the countertransference becomes an important diagnostic tool. The countertransference includes both the analyst's empathic identification with a patient's central subjective experience (‘concordant identification’) and the analyst's identification with the reciprocal object or self representation (‘complementary identification’) unconsciously activated in the patient as part of a certain dyadic unit, and projected onto the analyst (Racker 1957). In other words, the analyst's countertransference implies identification with what the patient cannot tolerate in himself/herself, and must dissociate, project or repress.

At this point, it is important to refer to certain primitive defensive operations that were described by Klein (1952) and her school in the context of the analysis of severe character pathology. Primitive defensive operations are characteristic of patients with severe personality disorders, and emerge in other cases during periods of regression. They include splitting, projective identification, denial, omnipotence, omnipotent control, primitive idealization, and devaluation (contempt). All these primitive defenses center on splitting, i.e., an active dissociation of contradictory ego (or self) experiences as a defense against unconscious intrapsychic conflict. They represent regression to the phase of development (the first two to three years of life) before repression and its related mechanisms mentioned are established.

Primitive defensive operations present important behavioral components that tend to induce behaviors or emotional reactions in the analyst, which, if the analyst manages to ‘contain’ them, permit him to diagnose in himself projected aspects of the patient's experience. Particularly ‘projective identification’ is a process in which: (a) the patient unconsciously projects an intolerable aspect of self experience onto (or ‘into’) the analyst; (b) the analyst unconsciously enacts the corresponding experience (‘complementary identification’); (c) the patient tries to control the analyst, who now is under the effect of this projected behavior; and (d) the patient meanwhile maintains empathy with what is projected. Such complementary identification in the countertransference permits the analyst to identify himself through his own experience with the aspects of the patient's experience communicated by means of projective identification. This information complements what the analyst has discovered about the patient by means of clarification and confrontation, and permits the analyst to integrate all this information in the form of a ‘selected fact’ that constitutes the object of interpretation. Interpretation is thus a complex technique that is very much concerned with the systematic analysis of both transference and countertransference.

5 Therapeutic Techniques

The essential techniques taken from psychoanalysis that, in their respective modification, characterize the technique of this psychodynamic psychotherapy, are: interpretation, transference analysis, and technical neutrality.

The technique of interpretation includes the clarification of the patient's subjective experience, the tactful confrontation of those aspects of the patient's nonverbal behavior that are dissociated or split off from his or her subjective experience, the interpretation in the ‘here and now’ of hypothesized unconscious meanings of the patient's total behavior and their implicit conflictual nature, and the interpretation of a hypothesized origin in the patient's past of that unconscious meaning in the here and now.

Transference analysis refers to the clarification, confrontation, and interpretation of unconscious, pathogenic internalized object relations from the past that are typically activated very early in the relationship with the therapist. In simplest terms, the transference reflects the distortion of the initial therapist–patient relationship by the emergence of an unconscious, fantasized relationship from the past that the patient unwittingly or unwillingly enacts in the present treatment situation.

Technical neutrality refers to the therapist's not taking sides regarding the patient's unconscious conflicts, and helping the patient to understand these conflicts by maintaining a neutral position. Therapists, in their total emotional reaction to the patient, that is, their countertransference reaction, may experience powerful feelings and the temptation to react in specific ways in response to the patient's transference challenges. Utilizing their countertransference response to better understand the transference without reacting to it, therapists interpret the meanings of the transference from a position of concerned objectivity, which is the most important application of the therapist's position of technical neutrality.

The therapist's emotional response to patients at times reflects empathy with the patients' central subjective experience (concordant identification in the countertransference), and reflects at other times the therapist's identification with what the patients cannot tolerate in themselves, and are projecting onto the therapist (complementary identification in the countertransference). Both reactions, when the therapist is able to identify and observe them, serve as valuable sources of information.

Countertransference analysis is in fact an essential aspect of this psychotherapy. The countertransference, defined as the total emotional reaction of the therapist to the patient at any particular point in time, needs to be explored fully by the therapist's self-reflective function, controlled in the therapist's firmly staying in role, and utilized as material to be integrated into the therapist's interpretive interventions. Thus, the therapist's ‘metabolism’ of the countertransference as part of the total material of each hour, rather than its communication to the patient, characterizes this psychotherapeutic approach.

The tendency to severe acting out of the transference characteristic of borderline patients has been mentioned already; in addition to its management by the modification of technical neutrality and limit setting in the hours mentioned before, the treatment begins with the setting up of a treatment contract, which includes not only the treatment setting and frame, but also specific, highly individualized conditions for the treatment that derive from life-threatening and potentially treatment-threatening aspects of the patient's psychopathology. Particularly, the establishment of realistic controls and limit setting that protect the patient from suicidal behavior and other destructive or self destructive patterns of behavior are typical objectives of contract setting.

In the course of the treatment, it will become unavoidable to face very primitive traumatic experiences from the past reactivated as traumatic transference episodes in which, unconsciously, the patient may express traumautophilic tendencies in an effort to repeat past traumas in order to overcome them. Primitive fears and fantasies regarding murderous and sexual attacks, primitive hatred, efforts to deny all psychological reality in order to escape from psychic pain are the order of the day in the psychodynamic psychotherapy of these patients.

This internalized object relation, that has transformed the primitive affect of rage into a characterologically anchored, chronic disposition of hatred is activated in the transference with alternating role distribution: the patients' identification, for periods of time, with their victim self while projecting the sadistic persecutor onto the therapist, will be followed, rapidly, in equally extended periods of time, by the projection of their victimized self onto the therapist while the patients identify themselves, unconsciously, with the sadistic perpetrator. Only a systematic interpretation of the patient's unconscious identification with both victim and perpetrator may resolve this pathological constellation and lead to a gradual integration of dissociated or split-off self representation into the patient's normal self. The effects of the traumatic past reside in the patient's internalized object relations; the key to its therapeutic resolution is coming to terms with this double identification.

6.1 Sexual Misconduct and Boundary Violations

Sexual contact with a patient is unethical. This is one of the least ambiguous sections of the ethical code. It is a tradition that goes back to the Oath of Hippocrates, which speaks of such conduct as ‘mischief’. It is important for psychiatrists because the intimacy of the treatment activates strong feelings and fantasies in the doctor–patient relationship, the discussion of which may be essential to healing. In psychiatry especially, the nature of such feelings the patient may have for the doctor (transferences, i.e., derived from significant relationships in the past and activated in the treatment) and feelings the doctor may have for the patient (countertransferences) receive close scrutiny. They are no less important for other physicians, other therapists, or other professionals. It is sometimes argued that the reason sexual contact is proscribed is because of the power differential, an argument which applies equally to employers and employees, supervisors and supervisees, teachers and students. Most basically, the importance of trust in the therapeutic relationship requires forbearance. As a rule, sexual contact with a patient is proscribed.

Those more legalistically inclined might wonder if erotic feelings might be acted on if the professional relationship were terminated. Transferences endure over time, so the interests of the patient–client could never be served by crossing this boundary. The most recent version of the APA Annotations Applicable to Psychiatry spells this out: ‘Sexual activity with a current or former patient is unethical.’ Other examples of boundary violations, which rest on similar considerations, are business relations with a patient, using the professional relationship for other contacts, or profiting from information gained from the therapeutic relationship.

2.2 Negative Aspects of Collaborative Treatment

2 Contemporary Influence

In contrast with Freud, who gave the impression that psychoanalysis ‘may be likened to Athena's springing forth fully armed from the head of Zeus’ (Eissler 1965), Jung always tried to trace back his ideas to older, universal traditions. His pioneering work was the rediscovery of an uninterrupted chain of psychic manifestations and spiritual traditions from gnosticism through alchemy to the present. His early claim for a constructive, forward-looking meaning in unconscious manifestations led to some changes in early psychoanalytic treatment which are now common in psychotherapy: for instance, the symmetrical setting (instead of the patient lying down), focus on present conditions as responsible for the outbreak of neurosis, and focus on transference and counter-transference as the crucial in changing mental attitude. In addition, Jung's conception of the spiritual nature of psychic life influenced the later transpersonal and humanistic schools of psychotherapy. His concern with spiritual mystical traditions often led to controversial claims that he himself was a mystic, selling false dreams of spiritual redemption. The alleged evidence of a recent recriminatory voice (Noll 1997) has been traced back to an obviously misidentified and misinterpreted document and shown to be fallacious (Shamdasani 1998). Jung emphasized that he had no ‘doctrine’ to offer, but rather some methods of looking at facts, phenomena, and natural laws. His approach to these facts is empirical in the sense of a critical reflection on the nature of all experience which relates to self-experience and the nature of the perceiving psyche.

This view, which valuates the psyche as ‘the mother of all science and arts,’ reveals its special importance in the approach to religious phenomena. The unconscious psyche with its autonomous operators (collective archetypes) reflects the numinous, awful, frightening, and timeless spirit in changing images which correspond to changing religious images from ancient times to the present. In differentiating between religious images and religion itself, Jung pointed to the inner experiences open to everyone independently of every external belief system.

1.1 Data

When studying an individual life, data often pose the central difficulty. The challenges of data can prevent a biographical investigation from exiting the starting gate. Most agree that the single-case study requires a wealth and variety of data, but investigators must typically confront inaccessibility of subjects. To complete the task, psychobiographers often can only consult archival material; the investigator cannot obtain data through interviews or assessments, essentially reducing the project to psychobiography. Given inadequate data, production of psychobiography almost inevitably falls prey to projection and other varieties of countertransference. The consequences of inadequate data partially explain the multiplicity of embarrassing work that plagues the genre.

Biographies that permit creative investigation in vivo typically include clinical cases that suffer from other limitations, most notably a pathological focus. Furthermore, studying a life ideally means conducting an investigation over time, which poses practical difficulties that intimidate all too many. Often, investigators come no closer to the ideal than studying college sophomores over a semester.

Recent developments, however, illustrate that the task of gathering adequate data, although difficult, need no longer derail a biographical project. For example, personologists have outlined guidelines according to which a biographer can extract case data from narrative sources and reveal the underlying order therein. Personologists have also profitably applied coding schemes to analyze the content of narrative material. For example, personologists have devised coding systems that yield quantitative measures of important motives, including intimacy, as well as achievement, power, and affiliation-intimacy, and the broader concerns of identity, intimacy, and generativity. One may also reliably evaluate affect or affective tone through ratings of narrative material.

Applying each of the aforementioned techniques, Nasby and Read (1997) reported an integrative case study of the solo circumnavigator, Dodge Morgan. In addition, the investigators applied concomitant time series analysis (CTSA) to the quantitative measures of motives, broader concerns, and affect as well as performance measures of daily progress. CTSA permitted detection, modeling, and removal of statistical artifacts (long-term trends, cycles, and serial dependencies) from each variable over time. Once decomposed, accurate calculation of cross-correlation functions that assessed synchronous and lagged relations between variables occurred, which permitted valid statistical tests of hypotheses about the circumnavigator's functioning throughout the life-defining event of the voyage.

Similarly, Simonton (1998) investigated ‘Mad’ King George of England, first performing content analyses of the historical record to obtain quantitative measures of stress and health, and then decomposing each series before finally calculating the cross-correlations (synchronous and lagged) between the multiple indices of stress and health. Of considerable importance, the ‘historiometric’ approach illustrates that a biographer can often derive quantitative indices from the qualitative or narrative sources of information that dominate historical records, and then apply sophisticated statistical techniques, including but not restricted to CTSA, to test explicit hypotheses about historical figures.

3 Its Problematic

Psychohistorical research is uniquely demanding of its practitioners because of its concern with subjective phenomena that are rarely if ever directly recorded. To understand a piece of the human past psychohistorically, researchers must first master the relevant facts at least as thoroughly as the practitioners of any other mode of inquiry. But much more, they must become immersed in those facts, make them vicariously their own, and feel out their inner determinants by dint of this imaginative identification with their original experience. The method is strikingly like the one promoted by Henri Bergson under the name of ‘intuition’: to study a subject intellectually from the outside until one enters into it subjectively through a core insight around which everything known about it will then fall into place. Such intimate, personal self-projection into a historic subject is trebly problematic. For one thing, it presupposes a basic equivalence of mental and emotional constitution as between researchers and their human subjects, however remote those subjects may be from them historically, and even if they are groups rather than individuals like themselves. For another, researchers' identification with their subject must be thoroughgoing, yet unless they can also sustain some critical awareness outside of that identification the insights gained through it will be lost. And for a third, pieces of the researchers' own mental underworld may slip unnoticed into their reading of a subject. This danger, often called ‘countertransference’ by loose analogy with psychoanalysts projecting into their patients, is the risk most cautioned against by psychohistorians themselves. Actually, an affinity in researchers for their subject's inner experience can, on the positive side, sensitize or alert them to connections and meanings they might otherwise miss. Besides, a purely projective finding will not stand up in any case inasmuch as it will fail to fit all the evidence, let alone satisfy anyone apart from the researchers themselves.

Researchers will feel the rightness of their inner grasp of a subject when it not only pulls together all the relevant facts at their disposal, but points the way to unsuspected additional corroborative evidence. Yet the discovery of such new evidence, however suggestive, is in itself no proof that their inner grasp of their subject is universally valid. Because of the very nature of psychohistorical explanation, to validate a psychohistorical thesis takes more than just a wealth of corroborative material, even if the thesis itself is what turned up key pieces of that material. To pass muster, a psychohistorical thesis must also carry subjective conviction, beyond the researchers themselves, with others willing and able to put themselves in the subject's place in their turn and see whether the proposed unconscious source of the thought or action at issue checks out subjectively with them too.

This second, subjective criterion of verification means in brief that a psychohistorical thesis must be emotionally as well as intellectually compelling. Consequently it can rely on no pregiven theory for support. Yet however direct its appeal, its need for subjective on top of objective verification demands too much effort, not to add goodwill, of critics accustomed instead to merely material and logical criteria of validation. As a substitute test of validity I therefore propose that, in psychohistory as in any science, a thesis is confirmed if, first of all, the known evidence all runs its way, if moreover it could potentially be refuted by new evidence, and if finally any piece of what it purports to explain cannot very well be explained otherwise. To take a simple example of this last stipulation from my own thesis that Hitler was traumatized by his mother's iodoform poisoning during her terminal cancer treatment: why else did he put it to his generals in late 1944 that his Ardennes offensive had caught the Allies off guard because they believed he was dead already ‘or at all odds am down with cancer somewhere and can't live any more or drink any more’ except that deadly iodoform poisoning induces a burning thirst together with an inability to drink? (Binion 1976, p. 143).

2 History of Concepts of the Therapist–Patient Relationship

Modern views of the therapist–patient relationship can be traced directly to Freud's writings. Freud considered the therapist–patient relationship to be a unique laboratory for observing aspects of patient's personalities that may have relevance to the patient's symptoms or psychopathology. Moreover, he utilized the relationship to effect change in the patient (see Psychoanalysis in Clinical Psychology and Psychoanalysis: Overview).

Freud described several components of the therapist–patient relationship. In terms of the patient's contributions to the relationship, Freud (1958) described both positive and negative transference reactions. Transference refers to the expectations, desires, thoughts, and feelings that are ‘transferred’ from a previous relationship on to a new relationship (e.g., the therapist). Positive transference was further divided into the reality-based ‘friendly and affectionate aspects of the transference which are admissible to consciousness and which are the vehicle of success’ (Freud 1958) vs. other positive feelings and perceptions (e.g., sexual feelings, strong dependency) that were not reality-based, originating instead from the patient's unconscious linking of the therapist with significant past relationships. Similarly, negative transference included negative feelings and perceptions that originated from past relationships and were not evident in the therapist–patient relationship. Finally, Freud acknowledged that distortions in the therapist–patient relationship might result from the therapist unconsciously linking the patient to significant people in the therapist's past (‘countertransference’) (see Transference in Psychoanalysis).

While the reality-based friendly feelings motivated a patient to stay in treatment and engage in therapeutic work, distorted positive and negative transference reactions served as the basis for the therapist's technical interventions. By illustrating these distortions to the patient, previously unconscious conflicts became conscious and such insight lead to patient improvements.

A number of subsequent psychodynamic theorists expanded upon Freud's discussion of the therapeutic relationship. The term 'ego alliance was used by Sterba (1934) to refer to the patient's capacity to work with the therapist in treatment, alternating between experiencing and observing. Subsequently, Greenson (1965) described this capacity as the ‘working alliance,’ and theorized that it stemmed from the patient's mature ego functioning in conjunction with an identification with the work orientation of the therapist. Zetzel (1956) discussed the patient's attachment to the therapist (labeling it the ‘therapeutic alliance’), and postulated that it originated from positive aspects of the mother–child relationship.

Because the analysis of transference became the defining feature of many approaches to psychodynamically-oriented psychotherapy, a relatively large literature has developed on this aspect of the therapist–patient relationship. Esman (1990) has collected a sample of influential papers on transference that illustrate the perspectives of a range of psychoanalytic writers including Freud, Klein, Winnicott, Gill, Kohut, Kernberg, Lacan, and others.

Although there are historical disagreements about whether the positive aspects of the therapist–patient relationship represent patient distortions or realistic appraisals of the treatment situation, the writings of Bordin (1979) served to mark the beginning of consensus on the importance of the reality-based, collaborative therapist–patient relationship (the ‘alliance’). This is not to say that other schools of psychotherapy had been silent on the importance of the therapist–patient relationship. In many ways, client-centered psychotherapy, developed by Rogers, can be seen as an approach that relied exclusively on a positive therapist–patient relationship for inducing change (see Person-centered Psychotherapy). Unlike the psychodynamic emphasis on reactions of the patient to the therapist, Rogers' (1951) focus was on the therapist's contribution to the relationship. Rogers claimed that if certain ‘facilitative conditions’ (therapist empathy, genuineness, and unconditional positive regard) were provided to a patient, the patient's natural tendencies for growth and healing would be activated.

The behavioral school of psychotherapy, however, has often been characterized as minimizing the role of the therapist–patient relationship. This school of therapy describes behavior change in terms of principles of learning (i.e., classical or operant conditioning; social learning theory), with no focus on the context in which therapy takes place—i.e., the therapist–patient relationship. Practicing behavior therapists came to realize that this was an oversimplification. Goldfried and Davison (1976), for example, devoted an entire chapter of their book on clinical behavior therapy to the therapist–patient relationship, describing how behavior therapists can use the therapeutic relationship to directly sample aspects of the patient's problematic behavior (see Behavior Therapy: Psychological Perspectives). Moreover, a positive relationship was seen as crucial to facilitating favorable patient expectations for change and receptiveness to the behavioral approach, enlisting patient's active cooperation in treatment, and motivating the patient to attempt new behaviors outside of therapy.

Beck's cognitive therapy approach has long acknowledged that the therapist–patient relationship was important to successful outcome, but it was largely considered a ‘given,’ with only brief explicit attention to the relationship in the original writings on cognitive therapy as a treatment for depression (Beck et al. 1979) (see Cognitive Therapy). However, as cognitive therapy expanded its scope to the treatment of other disorders, especially personality disorders, the therapist–patient relationship has come into focus increasingly as a key element of the process of treatment (Newman 1998).