Countertransference and Psychotherapeutic Technique: Teaching Seminars on Psychotherapy of the Boarderline Adult

316 Pages·1986·18.6 MB·English

by  James F. Masterson

Countertransference
and Psychotherapeutic
Technique
Copyrighted Material
Copyrighted Material
Countertransference
and Psychotherapeutic
Technique
Teaching Seminars on Psychotherapy
of the Borderline Adult
By
James F. Masterson, M.D.
BRUNNER/MAZEL,Publishers • NewYork
Copyrighted Material
Library of Congress Cataloging in Publication Data
Masterson, James F.
Countertransference and psychotherapeutic technique.
Includes index.
1. Borderline personality disorder-Treatment
-Study and teaching. 2. Psychotherapy-Study
and teaching. 3. Countertransference (Psychology)
-Study and teaching. 4. Psychotherapist and
patient-Study and teaching. I. Title.
[DNLM: 1. Countertransference (Psychology)
2. Psychotherapy-Methods-Case studies.
3. Personality disorders-Therapy-Case studies.
WM62 M423c]
RC569.5.B67M37 1983 616.85'82 83-3865
ISBN 0-87630-334-3
Copyright© 1983 by James F. Masterson
Published by
BRUNNER/ MAZEL, INC.
19 Union Square
New York, N.Y. 10003
All rights reserved. No part of this book may be reproduced by any process whatsoever, without
the written permission of the copyright owner.
MANUFACTURED IN THE UNITED STATES OF AMERICA
10 9 8 7 6 5
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CONTENTS
Introduction VII
I. VICISSITUDES OF COUNTER TRANSFERENCE
Introduction 5
1. Countertransference: Helplessness 7
2. Countertransference: Overdirectiveness 18
3. Countertransference Controlled; Then Control lost 35
4. Confrontation leads to Abandonment Depression 48
5. Countertransference: Guilt 51
Summary of Part I 57
II. ESTABLISHING A THERAPEUTIC ALLIANCE
Introduction 61
6. Initial Evaluation 63
7. Countertransference: Overdirectiveness 66
8. Countertransference Controlled; Patient Responds 69
9. Patient's Facing Conflict With Mother leads
to A voidance 83
10. Confrontation of Avoidance leads to Basic Conflict 96
11. Reprise: Confrontation, Conflict With Mother, Resistance 106
12. Continued Resistance Based on Feelings of Hopelessness 116
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Countertransference and Psychotherapeutic Technique
VI
13. Confrontations Integrated; Therapeutic Alliance
Established 121
14. Therapeutic Alliance Consolidated; Patient Faces
Conflicts 125
15. Therapist Regresses and Becomes Overdirective 131
16. Therapeutic Alliance Firms; Patient Asserts Self 156
Summary of Part II 164
III. PSYCHOTHERAPY OF LOWER-LEVEL BORDERLINE
Introduction 167
17. Initial Evaluation 169
18. Countertransference: Therapist's Overactivity 181
19. Countertransference Controlled; Patient Faces Depression;
Countertransference Resurfaces 191
20. Countertransference Controlled; Further Working-through 202
21. Further Working-through: Confrontation of Transference
Acting-out Leads to Abandonment Depression 205
22. Working-through (continued): Management of
Hopelessness 212
23. First Therapeutic Crisis: Can the. Patient Do It? 216
24. Working-through: Transference Acting-out Evokes
Countertransference 222
25. Working-through (continued): Patient's Anger Emerges 231
26. Working-through (continued): Improvement, Regression,
More Countertransference 234
27. Second Therapeutic Crisis: Abandonment Panic at Rage 244
28. Psychosis Emerges; Treatment Changed 250
29. Transition From Intensive Analytic to Confrontive
Psychotherapy and Medication 255
30. Reevaluation of Treatment 261
31. Management of Depression 265
32. Psychosis Subsides; Depression Persists 269
Summary of Part III 271
IV. A REPRISE AND A CAUTION
Introduction 275
33. Management of A voidance and Clinging Defenses 277
34. Clinical Evaluation of Sociopathic Personality 287
Conclusion 295
List of Clinical Issues 299
Clinical Therapeutic Issues Index 303
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INTRODUCTION
This book, comprised of edited transcripts of 34 case seminars with a vari
ety of practicing therapists, was written in response to many requests to pro
vide more specific clinical detail on the developmental approach to the psy
chotherapy of the borderline patient. It brings forth and explores a wide
range of immediate, concrete, and practical therapeutic problems not pre
viously emphasized by my more theoretical publications. It is intended to
serve as a guide to all therapists, from the beginner to the more experienced,
in their struggle to refine their therapeutic skill.
In contrast to my prior publications, which focused on the patient, this
volume focuses on the therapist-what he or she hears, reports, thinks, and
feels and how he or she acts. This is reflected in the format, where the thera
pist describes the patient's responses in the therapist's own words. Although
the interaction between patient and therapist cannot be truly separated, as
this volume makes abundantly clear, the patients' reports are used as much
as possible as a vehicle to illustrate the therapist's management; consequent
ly, only limited sections of the patient's entire course of treatment are in
cluded. In addition, the clinical focus of this volume has made the inclusion
of a bibliography unnecessary. For those interested in further study, there
are extensive bibliographies in my other publications, in particular TheNar
cissistic and Borderline Disorders (New York: Brunner I Maze!, 1981 ).
The therapists who took part in these seminars, although otherwise expe
rienced, were not familiar with this developmental approach, which fostered
the inevitable countertransference problems that arise with borderline pa
tients. Countertransference is used here not in the strictly defined sense of
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V111 Countertransference and Psychotherapeutic Technique
those emotions the therapist felt for important persons in his early life that
are transferred onto the patient, but rather as all of those emotional reactions
of the therapist that impede his therapeutic work with the patient.
The seminars contained eight to 12 therapists, one of whom presented
process notes of his or her work for discussion. I did not select cases but dealt
with those presented. The proceedings, one hour and a half in length, were
audiotaped, typed, and edited. I then reviewed and organized the material,
adding whatever commentary or clarification seemed appropriate. All iden
tifying features of both patients and therapists were changed or removed to
protect their anonymity. In some cases, a composite of several patients is pre
sented.
The book has four sections: Although all sections describe countertrans
ference, the first contains five seminars which emphasize the vicissitudes of
countertransference; the second, 11 seminars which illustrate how to estab
lish a therapeutic alliance; the third, 16 seminars which illustrate how to
manage a lower-level borderline patient; and the final section presents two
cases of clinical evaluation, the first as a reprise of the work and the second as
a caution.
Each chapter begins with a list of the specific clinical therapeutic issues
dealt with in that chapter and ends with a summary of my view of what tran
spired. This enables the reader to read the clinical material in the chapter first
to form his or her own opinion, which can then be checked against the sum
mary. In addition, the reader can use the book as a reference source by look
ing up the therapeutic issues listed before each chapter and in the Clinical
Therapeutic Issues Index at the back of the book. For example, if the thera
pist is having difficulty managing his patient's transference acting-out or feel
ings of hopelessness, he I she can look up that therapeutic issue specifically to
see how it is managed.
A regular sequence emerges in the seminars: First, the therapist's counter
transference is identified, along with its effect on both the therapist and the
treatment. The therapist is then taught how to identify and manage the coun
tertransference, thereby restoring the necessary psychotherapeutic objectiv
ity. From this vantage point, the therapist is taught how to make appropriate
clinical observations and how to organize them into a hierarchy according to
the principles of developmental object-relations theory. This tells the thera
pist what specific therapeutic issue now occupies the center stage of treat
ment and how it relates to the patient's underlying intrapsychic structural
problems.
This perspective provides the therapist with hypotheses as to why, when,
and how to intervene, as well as what response to anticipate. This latter al
lows the therapist to assess and evaluate the effect of his interventions so that
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Introduction IX
he may change them, if necessary. This material brings the therapist as close
as is possible by reading a book to the actual supervised work with a border
line patient.
In sum, the book presents a detailed clinical illustration of a comprehen
sive, orderly, consistent, coherent developmental psychotherapeutic ap
proach to the borderline patient.
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