Using countertransference: analytic contact, projective identification, and transference phantasy states.Am J Psychother. 2008; 62(4):333-51.AJ
The influence of projective identification is an integral aspect of most psychoanalytic treatments, not only with patients who are more disturbed, but also with individuals are higher functioning and have neuroses. Projective identification involves both internal relational phantasies of self and object as well as external interactions with the environment. Both elements shape the transference. Continuous projections distort the ego's image of the object, causing introjections that bring increased guilt, anxiety, and envy onto the ego, creating even more radical projections. Consequently, the countertransference is repeatedly stimulated in an evolving or devolving manner (Clarkin, Yeomans, Kernberg, 2006). The case material has illustrated the constant interplay among projective identification, transference, and countertransference as well as the utility of countertransference in making the most helpful interpretations. The concept of analytic contact (Waska, 2006; Waska 2007) was noted as the vehicle of optimal psychological transformation. Rather than an emphasis on frequency, diagnosis, use of couch, or mode of termination, the focus is more on the clinical situation and the moment-to-moment work on internal conflict, unconscious phantasy, destructive defenses, analysis of the transference and extratransference anxieties, and the gradual integration of core object relational experiences. Regarding a more clinical rather than theoretical definition of psychoanalysis, Sandler (1988) states that what truly defines a treatment as psychoanalytic is the analyst's attitudes towards his patient, his willingness to contain and make the effort to patiently understand the patient's unconscious conflicts and reactions to internal phantasy states, the humane detachment and lack of judgment, and the maintenance of a comfortable and safe setting in which the transference can unfold. This definition is certainly similar to the elements of analytic contact. Use of the countertransference is crucial in finding a path into the patient's projective identification processes, which in themselves often hold the core phantasy states with which the patient most struggles. These phantasies shape his experience of the analyst and the world around him. Melanie Klein thought that phantasy was an essential aspect of the mind from birth onwards, with love, hate, and the quest for knowledge being innate, yet influenced by external events that then recast the phantasy and the patient's reaction and perception of those external situations (Spillus, 2007). Klein's belief that phantasy is the bedrock of human experience has led the Kleinian school to conceptualize the transference as being constant and all pervasive, and therefore, not something that arises at only selected times in the treatment. There is no differentiation between the transference and the working alliance. If the analyst is consistently on the alert for manifestations of the transference, he or she may be able to help the patient identify and work through phantasy conflicts. However, the transference, through a constant phenomenon, may elude the analyst for many reasons. Projective identification dynamics are often the culprit because transference phantasies are hidden, discharged, communicated, acted out, camouflaged, or traded off in projective identification interactions with the analyst. It is here that the countertransference, a likewise constant element in the treatment setting, can be most useful in relocating the transference phantasies. The analyst can begin to explore them, rather than be a part of the patient's denial, destructive acting out, or gratifications. As the countertransference is better understood, the analyst can begin to more properly contain, translate, and ultimately interpret the core phantasy states to help the patient feel more in control of them. It is this ongoing emphasis in working within the transference/projective identification/countertransference matrix that gradually brings clarity to the analyst who can share that knowledge as an interpretive proposal. Then, the patient may use it to build greater psychological freedom, emotional stability, and personal choice.