Not untypically, those new to the practice of psychoanalytic therapy are hesitant about making transference interpretations. When patients are encouraged to work directly with transference reactions, conflictual issues are identified and the patient's anxiety is heightened. The patient may perceive our behaviour as critical, attacking or intrusive. In these situations, we may find it difficult to be experienced as the bad, persecuting object. The interpersonal strain that is generated when working in the transference sometimes steers us away from taking up the transference implications in the patient's communications. If the patient is angry, it may feel easier to locate his anger elsewhere, for example, in the patient's past, rather than take it up in the transference, thereby allowing us to remain the helpful, caring therapist with whom the patient is not angry. We all like to be liked, especially when we feel we are doing our best to help another person. However, our job is not to be liked, but to be helpful. This often involves being unpopular with our patients given the common resistance to uncovering unconscious motives and desires and given their need to project into us a range of feelings.
Besides a wish to avoid drawing the patient's negative feelings towards ourselves, there are other commonly voiced concerns about working in the transference. Let us look at some of them:
• The transference interpretation overemphasises the significance of the therapist to the patient. Reducing everything the patient says to a ''You really mean me... " type intervention is formulaic and unhelpful. Approached in this manner, working in the transference becomes a parody and may indeed reflect the therapist's need to be at the centre of her patient's affective life. However, used thoughtfully and guided by the overall formulation of the patient's conflicts and the treatment goals, a transference interpretation does not in itself overemphasise the significance of the therapist in the patient's life; it merely acknowledges the fact that the therapist invariably becomes an important figure in the patient's life because the intimacy recreated in psychotherapy elicits intense feelings and phantasies. The therapist avails herself to the patient's projections only so that the patient can work through his conflicts and can eventually re-own his projections.
• By focusing on the patient's negative feelings towards the therapist (i.e. the negative transference), this will somehow preclude a positive experience that will disconfirm the patient's pathogenic assumptions in relationships. Taking up the negative transference is challenging for both patient and therapist. Whether it is helpful to interpret the negative transference early on in the therapy is a moot point. In the absence of a solid enough therapeutic alliance, the exploration of negative feelings towards the therapist may be experienced as too threatening by the patient who may fear the therapist's retaliation for the expression of his hostile feelings. Timing is thus of the essence. A well-timed interpretation of the negative transference can be experienced as very helpful by the patient - the therapist who can bear to hear that the patient hates her is providing the patient with an experience that may implicitly serve to disconfirm negative expectations of others (e.g. ''No one can bear my hatred''). It models a capacity to manage ambivalence without the need to retaliate when on the receiving end of hostile feelings.
In psychodynamically oriented supportive therapy, it is unlikely that the negative transference would be interpreted except where the patient's hostile feelings are undermining the course of therapy. In longer-term therapy, the absence of interpretations of the negative transference would be an indication, however, of avoidance by the therapist. This is because we all harbour ambivalent feelings and it would be unusual if the therapist did not become the focus of the patient's hostility at some stage in the therapy.
• A focus on the transference can divert attention away from the present, conscious concerns of the patient, which also need to be addressed. True enough, a few analytic practitioners are so intent on working in the transference that everything the patient says is reduced to a transference interpretation overshadowing the patient's present concerns. In my experience, this tendency is more prevalent amongst relatively inexperienced therapists than amongst experienced ones. An overemphasis on such interpretations is likely to be experienced by the patient as a failure to hear everything that he is saying, that is, both manifestly and in a displaced fashion. This can feel very alienating and is often counter-therapeutic.
Too great an emphasis on the transference may be associated with a negative outcome (see below) and a weakening of the alliance when the patient's immediate need is to verify and process actual historical events, for example, as with patients who have been traumatised. In such circumstances, it is important to firstly acknowledge what has happened and only then to elaborate the potential transference implications of the story if we consider that the patient will be helped by this.
• Working in the transference encourages regression that is damaging for the more severely disturbed patient. It is the case that transference interpretations are not indicated with all patient groups and maybe more difficult to manage with particular patients. For example, those patients who are dominated by persecutory and sadistic phantasies cannot maintain an ongoing internal or external relationship with the therapist. Such patients may use extensive projection, denial or splitting to dilute and destroy evidence of an attachment, and they are often unaware of any feelings or thoughts about their relationship to the therapist. In such cases, working in the transference will involve holding in our minds, without interpreting out loud, the different unconscious phantasies in the matrix of the patient's self-to-object representations until the patient's own state of mind is receptive to taking some responsibility for his effect on us. These are instances when Steiner's distinction between patient-centred and therapist-centred interpretations is helpful (see Chapter 5). The therapist-centred interpretation allows for an exploration of the patient's view of the therapist's mind, for instance, "You are concerned that I am sitting here in judgement of you today". A patient-centred interpretation would, on the other hand, suggest to the patient that he is projecting into us his own critical self.
With psychotic patients, it is not advisable to work in the transference unless under expert supervision. This is because the transference relies on the patient's capacity to appreciate the "as-if" quality of the transference, creating an ''illusion that is experienced simultaneously as real and not real'' (Ogden, 1986: 239). Psychotic patients lose this capacity in the grip of psychosis, though they may regain it at other points.
All of the above criticisms are worthy of note as they helpfully remind us that making a transference interpretation is a powerful intervention that needs to be carefully evaluated. Nevertheless, clinical experience repeatedly suggests that a well-timed and accurate transference interpretation can be very helpful in bringing to the fore core patterns of relationships that assist the patient towards change. Although transference analysis is at the very centre of psychoanalytic work, this should not lead us to neglect other types of interpretations. A transference interpretation is but one of several kinds of interventions at our disposal. Analytic sessions call upon us to make a variety of interventions, with a possible skewing towards transference interpretations, depending on our theoretical allegiances. However, as anyone who has had personal therapy will know, most therapists say far more that would be classified as ''extra-transference'' than the published case material suggests.
Approaching critically the use of transference interpretation is important since this intervention has become overvalued in some analytic circles as the main pathway to change. Although the most mutative transference interpretations are widely considered to be those related to the person of the therapist, there is no evidence that this is so since even supportive therapy, and other types of therapy that do not interpret the transference, have been shown to be effective. Indeed, Stewart (1990) also draws attention to the importance of transference interpretations towards other people in the patient's life. Although such interpretations, along with historical reconstruction, may be used defensively to avoid the present situation, this is by no means always the case. As Blum (1994) warns, a focus on the here-and-now can also function as a defence against the disturbing ''there-and-then''.
Reconstructive interpretations are an important part of technique. An interpretation based on historical reconstruction may help to bring coherence. For example, those patients who are insecurely attached may have a powerful phantasy of caregivers as unable to soothe and of themselves as somehow unmanageable. This experience is dominant in the transference relationship. For such patients, closeness may be, paradoxically, only experienced through an angry outburst. Such intensity is psychically vital because in its absence the anxiety is that those close to you might not respond. In therapy, the aim with such patients is to create structures that enable them to contain affect. Holmes (1998) refers to this as the process of ''making stories'', whereby the therapist helps the patient to make sense and meaning out of early experiences that have not been emotionally processed. With such patients, transference interpretation may not be the main focus of the therapeutic work, whereas reconstructive interpretations may be very helpful.
Having cautioned against an idealisation of transference interpretation over and above other kinds of interpretations, we can now consider the ways in which these interpretations are helpful, mutative interventions.
• Transference dynamics are live and more immediate and hence verifiable in the here-and-now than the patient's report of past experiences or relationships outside of the therapy. The material we work with in therapy is of two kinds: the actual stories and events recounted to us by the patient and the live experience with the patient in the consulting room. What the patient tells us has happened to him is subject to the distortions of memory. So, whilst this is a valuable source of information about what troubles the patient and how he manages his life, the information is of necessity once removed. By contrast, the relationship that develops with the therapist provides a more immediate experience of some of the conflicts that occur outside the therapeutic relationship. It allows us to make these conflicts explicit to the patient as they are happening in the room, thus providing raw material to reflect on with the patient.
• The transference interpretation allows the therapist to make use of the emotional immediacy of the therapeutic relationship to counter intellectual resistances. Some patients are very adept at telling stories, yet struggle with expressing affect. Working in the transference can help bypass intellectual resistances by seizing the emotional immediacy of the way the patient relates to the therapist. It is the live interaction with the therapist that facilitates the eventual reconstructions of primitive anxieties and defences (Roys, 1999). The immediacy of the interventions based on this more direct source of information can have a very profound, and often moving, effect on the patient.
• The transference interpretation facilitates an increase in interpersonal intimacy by allowing the therapist to demonstrate attunement to the patient's current experience. A well-timed and accurate transference interpretation is perhaps one of the most powerful expressions of the therapist's empathy as it shows the patient that he has been heard at various levels, not only in terms of what once happened, but also in terms of what is happening. For those patients who have not had the experience of being with another person who reflects back to them what is only indirectly implied in their communications, a transference interpretation can be experienced as containing and transformative.
• The transference interpretation allows the therapist to address the patient's defences against intimacy as they emerge in the therapeutic relationship and so contributes to a strengthening of the alliance. We all recognise that patients turn up for their sessions but this does not necessarily mean that they want to be there. The transference interpretation squarely focuses on the reasons why the patient may want to avoid the therapeutic relationship by trying to reflect on the anxieties it generates. At its best, this kind of interpretation helps the patient to move on from a resistance. However, a word of caution in this respect: it is precisely the patients who are most resistant who invite transference interpretations in the hope that this will resolve the therapeutic impasse. Such a focus may backfire as the patient may feel hounded by the transference focus on his resistance and may terminate treatment. In other words, too great a focus on the transference may compound resistance if the patient ends up feeling ''got at''. As Greenson (1967) helpfully noted, our interventions need to be sensitive to the fact that the patient may need to ''run away'' from insight. A transference interpretation should ideally further and/or deepen the patient's exploration of his conflicts. There will be times when the transference implications are evident to us, but it will not be timely to interpret them.
As I have repeatedly suggested, a transference interpretation is but one of several kinds of interpretations available to us. We thus always have to consider whether there may be particular reasons for not opting for a transference interpretation. If we do opt for this type of intervention, then we have another important consideration to make. As we saw in Chapter 5, an interpretation is only as good as its timing. Although Freud's early injunction to interpret only after the establishment of a positive early relationship is too rigid, as a transference interpretation with a very hostile patient in an initial session may contain the patient, we always have to be mindful of the current state of the therapeutic relationship before we interpret. Timing requires us to see things from the patient's point of view. Sometimes transference interpretations can acquire an unhelpful ''return to sender'' quality. To interpret prematurely that the patient is projecting something into us that he wishes to disavow in himself may simply leave the patient feeling that we cannot bear his projection (Mitriani, 2001). In this kind of situation we help the patient by allowing him to locate his bad objects in us for some time. This may be especially important for patients who would otherwise feel internally persecuted if they did not rid themselves of ''bad'' aspects of the self. Through bearing the split-off aspect of the patient's self and not returning it to the patient prematurely under pressure of our own need to be seen to be a ''good'' therapist, we may allow for a helpful transference of the bad internal objects. Sometimes we need to allow the transference to intensify, even if this feels uncomfortable and refrain from interpreting it as soon as we identify it.
• Through a transference interpretation the therapist models a way of handling negative perceptions. Many transference interpretations highlight the patient's negative perception and experience of the therapist. In making an interpretation that acknowledges such feelings and phantasies the therapist implicitly conveys to the patient that it is possible to reflect on such feelings without fearing being destroyed by them. The clarification of the distortions in the patient's experience of the therapist may contribute to a strengthening of the therapeutic alliance by allowing the patient to see the therapist as a potentially helpful person rather than the persecutory figure she may have come to represent in the transference.
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