Making Transference Interpretations An Applied Example

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In deconstructing a transference interpretation for the purposes of illustrating how to approach its formulation, I cannot recapture the immediacy of the therapeutic interaction, which is a key source of information that guides the intervention. Moreover, transference interpretations are not meant to be formulaic. These guidelines (see Table 7.1) are only intended to provide a possible framework to orient us as we approach making an interpretation. In this respect, Luborsky & Crits-Cristoph's (1998) ''core conflictual relationship theme approach'' (CCRT) is an alternative very helpful source. In this approach, the stories told by patients about their relationships are conceptualised as reflecting a wish (e.g. to be looked after), leading to a response from the other (e.g. rejection) that results in a particular response from the self (e.g. depressive withdrawal). The research carried out suggests that patients display the same CCRT patterns in the stories they recount about significant others as they do in their interactions with their therapist, thus supporting the notion of transference. Effective therapy has been found to be associated with accuracy in interpreting CCRT patterns (Crits-Cristoph et al., 1998).

Working in the transference requires that we attend to the patient's communications at different levels. As we approach a transference interpretation, we remind ourselves that the interpretation aims to link the patient's affect and behaviour with an internalised object relationship that has become actualised in the therapeutic situation. A transference interpretation makes explicit the patient's prototype of a relationship as it is actualised - whether negative or positive - at a given juncture in the session. It can only hope to capture a snapshot of the patient's way of relating at a particular moment. In other words, within a session, there will most probably be multiple transferences, depending on the patient's state of mind as it develops during the session and in response to our interventions.

Table 7.1 General considerations when constructing a transference interpretation

• Ask yourself what is the purpose of the interpretation? How does this relate to the aims of treatment?

• Ask yourself if there is a fit between the thematic content of the interpretation and the overall formulation of the patient's difficulties and the goals of treatment. This is especially important in brief work where it is essential that the interpretations are related to the focal area/conflict that has been agreed upon with the patient.

• Consider what evidence you have for the interpretation. Like any other type of interpretation, a transference interpretation is no more than a working hypothesis.

• Before sharing the interpretation, consider its timing: is the patient ready to hear it? How might it be experienced by him? Are you feeling a pressure to speak and give back a projection to the patient? If so, hold back from verbalising what you think may be going on until you have a clearer understanding of this.

• Especially with patients who are not well versed in psychoanalytic treatment, structure the interpretation by starting with what the patient has said or done (or not said or done) that suggests to you that he may be feeling in a particular way about you.

• Keep the interpretation relatively simple, without too many sub clauses! Including a reference to how you have arrived at the interpretation does not require you to cite chapter and verse.

• When you offer it, the interpretation needs to include clear references to the here-and-now. Especially in brief work, it is helpful to link more systematically the here-and-now experience to parallel relationship patterns in the patient's life.

• Where appropriate, it will be important to acknowledge that the stimulus for the patient's transference perception and reaction may partially come from something you have said or done (or not said or done).

• Too great an emphasis on transference interpretation may be associated with a negative outcome and weakening of the alliance when the patient's immediate need is to verify and process actual historical events (e.g. with patients who have been traumatised).

• If the intensity of the transference relationship is too strong and the patient cannot tolerate it (e.g. if the patient is in a psychotic state and cannot appreciate the as-if quality of the transference), reconstructive interpretations may be indicated as they de-escalate the intensity of the transference. Reconstructive interpretations can be supportive and are especially useful when working in once-weekly psychotherapy with patients with weak ego strength.

As we listen to our patients' narratives, we are listening out for the following:

• Whodoeswhattowhom? This involves identifying perceived intentions (benign and/or malign) towards the self and of the self towards others.

• Who feels what towards whom? This involves identifying the main affects present in the narrative.

• How do we feel as we listen? This involves identifying our countertransference (e.g. do we feel swamped, seduced or excited by the story?)

Once we have formulated a skeleton pattern of actions and affects, we can proceed to consider whether these have any relevance to the here-and-now situation. We rely on our capacity to sustain an internal process of supervision (Casement, 1985) and try to identify the ways in which we may have also contributed to the patient's experience. We thus aim to identify the trigger for the activation of a particular transference reaction - the trigger may be internal (e.g. a conscious or unconscious phantasy) as well as external, that is, an actual event.

A transference interpretation pulls together the above information. Often it does so piecemeal as we may not be able to capture the full picture all at once.7 For example, we may have a clear sense of our countertransference but be less clear about the object relationship that is being played out in the transference. In practice, we build up to a full interpretation that eventually describes to the patient ''What is going on and we explain why we think it is going on'' (Riesenberg-Malcom, 1986: 75).

For the sake of illustration, let us imagine that we have bumped into one of our patients in the street. At that time, we were talking with a friend. We acknowledge the patient discretely but do not engage in any further exchanges with him. Later that same week, the patient arrives late for his session and begins the session voicing ambivalence about the therapy. He says that exercise helps to release his tension and that he thinks that if he made the effort to exercise regularly, that is all he needs. The patient then recounts a long story about a close friend he feels let down by because she has not phoned him for some weeks. As we listen to this, in our mind, we hypothesise that the lateness and the ambivalence about therapy are probably related to the chance encounter during the week and the feelings and phantasies this has stirred up. The eventual interpretation

7It is important to note this as the examples I have given throughout the book may give the misleading impression that we wait until we have formulated a full interpretation before interpreting it and that we arrive at such an interpretation within seconds. Nothing could be further from the painstakingly slow reality of what is involved in understanding another person's unconscious.

will typically contain a reference to the following [I have put in italics the thinking and hypotheses that gradually build up to a full interpretation]:

• How we arrived at the formulation (e.g. ''Today you were late and you tell me that you could not see the point of coming. You then tell me that X has no time for you .. .I think that you are letting me know that...").

• The patient's self-representation (e.g. ''Today you were late and you tell me that you could not see the point of coming. You then tell me that X has no time for you.. .I think that you are letting me know that when you met me in street the other day and saw me talking with another person you felt excluded, as if this was confirmation that I have another life separate from our relationship. Of course, you know that at some level, but at another level I think that my not stopping what I was doing and acknowledging you made you feel like a small child who isn't noticed").

• An object representation (e.g. ''Today you were late and you tell me that you could not see the point of coming. You then tell me that X has no time for you... I think that you are letting me know that when you met me in street the other day and saw me talking with another person you felt excluded, as if this was confirmation that I have another life separate from our relationship. I know you know that at some level, but at another level I think that my not stopping what I was doing and acknowledging you made you feel like a small child who isn't noticed, as if I was neglecting you".)

• A particular affect or anxiety linking the self and object representations (e.g. ''Today you were late and you tell me that you could not see the point of coming. You then tell me that X has no time for you... I think that you are letting me know that when you met me in the street the other day and saw me talking with another person you felt excluded, as if this was confirmation that I have another life separate from our relationship. I know you know that at some level, but at another level I think that my not stopping what I was doing and acknowledging you made you feel like a small child who isn't noticed, as if I was neglecting you. This has left you feeling very angry with me").

• The above interpretation would most probably then be further elaborated during the session by adding an account of the patient's possible conflicts in relation to internal objects along with the associated anxieties and defences put into action to avoid psychic pain (e.g. ''When you feel neglected in this way, it feels so painful that you say to yourself 'I don't need her. I can help myself by exercising more'").

We each develop a particular therapeutic style that influences how we present our interpretations to the patient. The ''how'' to convey our understanding of the transference to a patient - especially one who has not had exposure to psychoanalytic therapy before - is worth considering.

Given that a transference interpretation essentially involves describing a particular object relationship that is active in the patient's mind, I have found it helpful with some patients to present this dynamic as a kind of ''internal conversation". For example, say we formulate that at a given point in a session the patient feels criticised by us and that his way of managing this is to become contemptuous of our interventions. In this scenario, we might share our formulation thus: "I think that when you experience me as critical in your mind, you are no longer talking with someone who is on your side but with someone who is attacking you. The only way you feel you can protect yourself is by putting me down as if you are saying to me 'I don't need you anymore. What you have to offer me is worthless'".

Mark was a man in his late twenties who presented with longstanding interpersonal difficulties starting in adolescence. He had never successfully managed to sustain a long-term intimate relationship. He recounted a difficult family life as he was growing up: his father had suffered from manic depression and his mother appeared to have managed her unhappy marriage by working hard and having affairs. Mark was an only child and recalled spending most of his childhood either playing alone or in the care of other family members whom he felt resented the burden of having to care for him. He described his early experience of being cared for as a kind of "pass the parcel''. Over time, we came to understand the instability of his early life as one of the sources of the obsessionality that was characteristic of his approach to life. Mark liked routines and reacted with anger when these were in any way altered. In therapy he related quite concretely to the physical environment. He liked it if the room was exactly as he had left after his previous session and reacted anxiously and/or angrily if he noticed any changes, however minor.

After one Christmas break he returned to his session and lay on the couch very silently. This was unusual for him and I made a mental note of this. As the minutes ticked by, I began to feel ill at ease with the silence. After five minutes, Mark started to talk: "There is a new picture on your wall outside the room,'' he remarked. "It's an interesting one. I'm not sure what I think of it'', he added. Mark then quickly moved on to telling me about his break. Everything had been fine except that his mother ''as is her wont'', he said acerbically, decided to stage what he had experienced as a very dramatic scene during the Christmas lunch. He berated her for always putting her needs first without a care for anyone else. He said: ''The stupid cow made a quick exit after her performance, saying she was going to visit her elderly aunt''. But Mark ''knew'', he emphasised, that she was only going to go a few houses down the street to the latest man in her life. He said that his father had by then fallen asleep in the armchair, snoring, and he had been left at the dinner table staring at an old print of his birthplace that his mother had given him as a present for Christmas. He concluded by telling me that she should know by now that he did not like coloured prints and that this disregard for his wishes was typical of her.

To arrive at an interpretation, I progressively work through a series of stages in my own mind:

• Step 1: Identifying the themes: Mark gives me a vivid picture of a desultory Christmas lunch. He relates a story in which he is left stranded at the dinner table staring at the present his mother gave him - a picture that Mark says his mother should have known he would not like - whilst he knows that she has gone off to see her lover. There are two dominant themes: one is the experience of his mother not keeping him in mind enough to know his preferences and a related theme of being supplanted by a rival, that is, mother's lover - another version of not being the most important one in his mother's mind.

• Step 2: Identifying the trigger: Internalised object relationships are triggered by the patient's idiosyncratic perception of an external event. Working in the transference involves approaching Mark's narrative not only as an expression of his feelings about what happened over Christmas but also as the manifestation, in the transference, of a very specific internalised object relationship. The activation of this object relationship is reinforced by two events associated specifically with the therapy. The story about the print that Mark had not liked and that his mother, according to him, should know that he would not like makes me think about the meaning of the new painting I have introduced since the break. I hypothesise that the vacation break and the change to the physical frame are fuelling a hostile transference towards me.

• Step 3: Noting the countertransference: I am aware of a number of emotional reactions as Mark speaks. I feel reprimanded for being a selfish mother/therapistwho has not kept him in mind. This feeling helps me to connect with the possible meaning of the two triggers identified above. I speculate that the appearance of the new picture in my corridor is evidence to Mark that during the break I have been meeting my own needs, leaving him alone, whilst I engage with my interests and other people in my life as symbolically represented by the new picture. Mark's narrative suggests to me that I have become identified in his mind with a version of a mother who abandons him at the dinner table whilst she visits her lover, just as I left him for the break and engaged with my personal life, which excludes him.

• Step 4: Identifying the patient's self-representation: Mark seems to be positioning himself in the narrative as the neglected and rejected little boy who is supplanted by a rival in his mother's affections. This hypothesis is informed not only by all the above considerations but it is also based on Marks' description of his father asleep, snoring. This description conjures up in me an image of an ineffectual man who does not represent in Mark's mind a potent man who can sustain his wife's interest. In light of this, I speculate that Mark is identified with a castrated father and he feels that he is not exciting enough to sustain my interest during the break.

• Step 5: Identifying the object representation: The focus of the narrative is on Mark's mother. She is depicted as selfish and insensitive to his needs and preferences. This suggests to me that Mark internally relates to an object that is selfish, who prioritises her needs over his and, importantly, who does not know his mind, that is, as Mark tells me, his mother should have known that he does not like coloured prints. I hear this as him saying to me in the transference that as his therapist I should have known that he does not like change in the physical environment of the consulting room and that he finds the break difficult. I hypothesise that my new print is evidence that I have a life separate from him, and more specifically, that it symbolises the existence of a rival - my partner - in his phantasy.

• Step 6: Identifying the dominant affect: Mark is giving voice to a number of affects. He is angry and contemptuous towards his mother (e.g. ''She's a stupid cow''). I speculate that this is a defence against his feelings of abandonment and an experience of himself as not exciting or potent enough to sustain his mother's interest. Though this may be right, these affects are not the most immediate and therefore would only be interpreted at a later stage, depending on how Mark reacts to the first interpretation focusing on his anger.

• Step 7: Formulating the interpretation: This needs to take all of the above into account and might look something like this: ''Christmas at home was difficult and I am aware that it was difficult for you to get going in the session today. I think you are also perhaps letting me know that you found the break difficult. It's as if the new picture in my hallway becomes painful evidence in your mind that I have other interests that invade your place in my mind. In my absence you quickly feel as if I am rushing off to see another man whom I prefer to you, leaving you alone with a print that I should know is not to your taste. I think that this makes you feel very angry with me.''

In making this kind of interpretation, I am trying to help Mark identify how he positions himself in relation to his objects. Whether my interpretation is helpful will depend on whether Mark ''runs with it'', that is, whether it leads to an elaboration of the patterns I identify in the interpretation and their associated affects and whether it extends to helping him perceive his interactions with others in light of this pattern.

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  • Ginger
    How to make transference interpretations?
    8 years ago
  • jonathan
    How to make an interpretation in therapy?
    8 years ago
  • leah
    How to make psychoanalytic interpretations?
    7 years ago

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