Beruflich Dokumente
Kultur Dokumente
Description of Treatment
months because of the patient's plan, which had been made prior to
therapy, to continue her graduate studies in another city. However,
whether or not the patient would be admitted to the program to which
she applied was uncertain.
The initial sessions were taken up with the issue of whether the patient
could trust me and with expressions of futility regarding whether she
could be helped. Why I should be interested in her and how a concrete
symptom could change "just by talking" were frequent themes during the
first couple of months of treatment.
The next phase of therapy dealt mainly with two issues: the continu-
ing experience of her sexual symptom in her ongoing sexual relationships
with men and an exploration of her relationship with her parents,
particularly with her father. The main theme here was the need to be a
"good girl" and to submit to father's wishes in order to continue receiving
his love and approval. I made interpretations linking "submission" to
father and the experience of the sexual act as a "grin and bear it"
submission to the wishes of men. The patient generally accepted the
above interpretations as useful and enlightening but noted that the
sexual symptoms continued "even though I can understand some of the
connections." The patient's behavior continued to be that of enduring
the pain that she experienced during sexual intercourse, without any
protest or without informing her sexual partner of her pain. Indeed, she
felt that it was important that she hide her symptoms from the man lest
he reject her.
The patient spoke mainly about her father and tended to say little
about her mother or her relationship with her. As already noted, the
patient had complete amnesia for her early experiences of abuse and
seemed to experience virtually no connection between the mother who
was the abuser and the current image and description of mother. On a
few occasions, I linked her sexual symptoms to her early experiences of
physical abuse. Just as, early on, defiance of mother had been followed by
punishment and pain, so now, too, the sexual act, experienced as
defiance (that is, it violated father's need to see her as a virgin and a "good
girl"), was followed by pain. In one session, in response to this interpre-
tation, the patient reported the following: very frequently, before sexual
intercourse, the defiant phrase "If they could see me now" occurred to her
in an unbidden, obsessive manner. She made it clear that the "they" in
the phrase were her parents. This association made my interpretation
linking defiance and pain very real and convincing to the patient.
Enactments, Transference, Symptomatic Cure 97
A Critical Event
At this point in the therapy, something occurred that, it turned out, had
an important impact upon the patient and the treatment. As noted, the
patient had total amnesia for the physical abuse by her mother. Refer-
ences to this experience came up frequently during the therapy, but there
were never any accompanying memories and we never went anywhere
with it.
98 Morris Eagle
and "wouldn't last." She also informed me that she and her boyfriend
were due to go away that weekend and she saw that as a kind of test of the
lastingness of her new freedom from her symptom.
The patient returned from the weekend, again elated, and reported
that the symptom had not returned and that sexual intercourse was even
enjoyable. During the remaining few months that therapy continued,
the symptom did not return and the patient began to feel more confident
that her new experience was a secure one. During this time, the major
themes dealt with in therapy were the relationship difficulties with her
boyfriend and the impending termination of the therapy (at this time,
the patient learned that she had been accepted to the program to which
she had applied). With regard to the boyfriend, it became apparent to the
patient that he was highly ambivalent and was looking for a way to end
the relationship. The patient dealt with this issue in a relatively mature
way and observed that her handling of this situation was different from
her past patterns.
Toward the end of therapy, the patient told me what she thought
accounted for the disappearance of her symptom. She said that the
session during which she became enraged at my suggestion that she use
the couch was a "turning point" in the therapy. She informed me that
after she left that session, she kept repeating to herself, "But, he didn't say
anything" (referring to my silence in the face of her anger), and she felt
that she had "overreacted" to my couch suggestion. She related this
"overreaction" to her general pattern with men. Her description of the
value to her of my silence read like a classic psychoanalytic account of the
therapist's neutral stance. It should be clear, however, that this patient
had read nothing of these accounts and was describing her own experi-
ences.
As of the writing of this paper, many years have elapsed since the
termination of therapy, and the patient has kept in touch with me during
this period with an occasional letter. She reports that her symptom has
not reappeared, that she is happily married, and that she feels generally
better and better able to cope with situations that have arisen.
When I first wrote this paper and tried to account for the dramatic
disappearance of the patient's symptom, I focused on the role of my
100 Morris Eagle
it became too painfiil may have helped to break the chain of submission,
pain, and rage. The boyfriend's actual positive reaction probably also
helped. But neither of these experiences, by itself, led to removal of the
symptom, although they may have prepared the ground and, in interac-
tion with the "critical event," contributed to the eventual disappearance
of the symptom. To use the patient's own words, the "turning point"
came when she could reject my couch suggestion, which to her meant
sexual submission, and find that despite her rage and refusal to comply
with my suggestion, therapy and the therapeutic relationship continued.
In going over my process notes in preparation for this paper, I found
some material that I had missed in my original version of the paper,
material that sheds important light on what preceded the critical session
and on the transference-countertransference interaction between the
patient and myself.
For a period of time, I had noticed the patient's habit of unbuttoning
and buttoning a button of her blouse during the sessions but did not
comment on it. A few weeks prior to the critical session, she unbuttoned
and left unbuttoned two buttons so that the top of her brassiere was
visible. When I did finally comment on this apparently distracted "habit,"
the patient dismissed my observation as "Freudian crap." It is clear to me
now that my suggestion that the patient use the couch was, in part at
least, an unconscious response to her earlier seductive behavior of
unbuttoning her blouse. Thus, to a certain extent, the patient's construal
of my suggestion as a sexual cue was justified. What she was not aware of,
however (and neither was I), was her earlier seductive "invitation" to me
and its link to my suggestion to use the couch. So we have here an
unconscious transference-countertransference "dance" in which the pa-
tient offers a seductive invitation that I accept and act on. These
interactions and communications were taking place without either the
patient's or my conscious awareness of them.
I want to note here parenthetically a shift in my conception (which
parallels a shift on the part of many others in our field) of transference
from the original to the current version of this paper. In the original
version, I understood the patient's enraged reaction to my couch sugges-
tion as a clear case of the patient's transference distortion of me. After all,
was she not reacting to me as if I were her punitive mother or her
compliance-demanding father? Viewing transference, however, as a
more interactional phenomenon in which, as Gill (1982) points out, the
patient elaborates and imbues with personal meanings actual cues pro-
102 Morris Eagle
and without specific and clear insight into what was being enacted. In
this regard, this case is somewhat different from the typical examples
discussed by Weiss and Sampson in which the conscious emergence of
warded off contents is a consequence of test passing and is a critical step
in the achievement of therapeutic improvement. In the present case,
passing of a critical test was followed not by such an intervening step but
directly by disappearance of the presenting symptom.
The patient did achieve a somewhat intellectualized insight into the
way in which the defiance-punishment dynamic characterized her rela-
tionship with mother and father and her sexual relationship with men.
This insight was useful in "making sense" of her symptom, in particular,
in relating it to her lifelong interpersonal patterns. As I have described,
however, the enactment of the core pattern in the therapy, rather than
the patient's insight into that pattern, had the major impact on the
patient's positive therapeutic outcome. Furthermore, as far as I could tell,
the patient never did achieve any significant insight into the degree to
which she was enacting with me her core conflict relationship theme
(Luborsky, 1984).
I understand the patient's improvement as the result of what can be
broadly referred to as a "corrective emotional experience" (Alexander
and French, 1946), but one in which the concept is elaborated and
developed so that it includes the kinds of considerations—such as test
passing, test failing, and unconscious plans—highlighted by Weiss et al.
(1986). That is, quite often (perhaps always), a "corrective emotional
experience" is best understood not simply as the result of a therapist's
responding in a therapeutic and corrective way to a patient—for exam-
ple, in a manner that is different from the patient's "neurotic" expecta-
tions—but rather as the result of a subtle and complex interaction in
which the patient is actively engaging in a variety of activities that elicit
the "corrective" behavior from the therapist.
It seems to me that this case suggests that positive therapeutic outcome
can occur through transference enactments rather than always requiring
direct interpretation and analysis of the transference. Findings consis-
tent with this conclusion have also been reported by Weiss et al. (1986),
who note that emergence of warded off contents and other improved
behavior can occur without interpretation, directly as a consequence of
test passing. Indeed, in the context of control-mastery theory, test
passing and other "corrective emotional experiences" can be understood
as involving implicit interpretations or at least implicit communications.
Enactments, Transference, Symptomatic Cure 105
"Transference Cure"
"Misalliance Cure"
avoidance on the part of both patient and therapist. Although the con-
cept of "misalliance cure" may, in principle, have some important and
defensible meaning, I suspect that it would be extremely difficult to secure
reliable identifications of its presence. Also, the concept of "misalliance
cure," particularly when it is applied too liberally, implies that there is a
correct psychoanalytic or psychotherapeutic technique and that any de-
viation from it carries the risk of leading to this false kind of cure. It also
implies that we know enough not only to make clear distinctions between
a genuine and a false cure but also to specify the kinds of therapeutic
interventions that lead to one or the other type of cure. Only if one is very
certain regarding what constitutes the "correct" kind of intervention can
one feel very confident about what constitutes a "deviation." Also, I
strongly suspect that most therapeutic situations are sufficiently complex
so that they include all sorts of subtle "deviations" and interactions of the
kind I have described in this paper (see Jacobs, 1986).
The very idea of "deviations" (resulting in "misalliance cures") often
seems to involve the application or perhaps imposition of principles
derived from "classical" psychoanalytic technique to all forms of
psychodynamic psychotherapy. Interventions that may constitute a
"deviation" or "misalliance cure" in the "classical" psychoanalytic context
(and I am not at all sure that it is uniformly justified even in that context)
do not necessarily do so in the context of psychodynamic psychotherapy.
In short, although they may, at times, point to important phenomena,
both concepts of "transference cure" and "misalliance cure" often imply a
degree of precision and of knowledge about what goes on and what is
supposed to go on in the therapeutic process that is simply not warranted
by the facts.
Finally and ironically, what is known about the therapeutic process
suggests that what some see as a "transference cure" may well be one of
the more effective ingredients in therapeutic outcome. That is, the
patient's experience of the therapist as helpful and supportive is one of
the treatment process variables that are significantly related to positive
therapeutic outcome (e.g., Luborsky et al., 1988).
Conceptions of Transference
(Note that this is very different from the picture painted by classical
psychoanalytic theory in which successful treatment is characterized by
the patient's relinquishment of hitherto intractable infantile wishes; e.g.,
see Waelder, 1960.)
I noted earlier Luborsky et al.'s (1988) finding regarding the relation-
ship between positive outcome and the patient's experience of the
therapist as helpful and supportive. If one combines that finding with the
above findings on changes in negative and positive responses from other
and self, one can hypothesize that a critical factor in effecting changes in
the expected response from the other is the therapist's supportive and
accepting response to the patient's expression of his or her needs and
wishes. Thus, successful treatment need result not in relinquishment of
needs and wishes but rather in a greater expectation and confidence that
one's needs and wishes will be responded to positively by the other.3
This may not apply to all needs and wishes expressed in treatment—
some, indeed, may need to be relinquished. In the present context,
however, the point to be made is that transference reactions do not
consist solely in attempts to gratify instinctual wishes but also consist in
attempts to evoke from the therapist constructive responses to one's
wishes and needs, to disconfirm pathogenic beliefs, and to master
anxieties and conflicts.
In coming to the end of this paper, I want to turn to the issue of the role
of analysis of the transference in therapeutic outcome. Interpretations of
the transference have been held by many to be more primary and more
3
It is important to point out here that Luborsky et al. (1988) do not distinguish between
inappropriate infantile wishes and age-appropriate wishes (e.g., wish to be accepted) and
that the latter kinds of wishes seem most frequently represented in the relationship
episodes discussed by Luborsky and his colleagues. Furthermore, my impression is that
most of the wishes discussed by Luborsky in his CCRT method are conscious (or at least
preconscious) rather than unconscious.
Enactments, Transference, Symptomatic Cure 109
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Mitchell, S. A. (1988), Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard
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Stone, M. H. (1982), Turning points in psychotherapy. In: Curative Factors in Dynamic
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