Pure Contextual Perception [PCP] is the Psycho-Contextual term coined and based on the psychological research of Mathew Dwight Quaschnick of Eagan MN, United States of America. PCP describes the unique experience of a paradoxical mind state theorized as “Thend.” PCP is the physical experience of the psychological state of thend where all states exist simultaneously as both virtual, i.e. psychological; and as actual, the "real" physical world. In their virtual state things have physical appearances as psychological perceptions. In their actual state, as they are physically engaged with the 5 senses things become actualized. ®eality includes everything that is and is not and either has been or will be, whether or not it is observable or even incomprehensible. A still broader definition includes that which has (Past) existed, (Present) exists, or (Future) will exist.
"Eality" is Real Reality
Eality is the paradoxical mind state were physical and mental things exist simultaneously as both virtual, as they may appear or might be imagined and actual, as they do appear or might be actualized. Eality includes everything that is and is not and has been, whether or not it is observable or comprehensible. A still broader definition includes that which has (Past) existed, (Present) exists, or (Future) will exist.
?EALITY of Trauma
Trauma is any event that threatens the integrity of the physical organism or psychic apparatus.
Catastrophic physical trauma is any degree the organism loses its physical integrity that leads to permanent use restrictions in whole or in part and are not recuperable post trauma inducing event.
Catastrophic psychic trauma is any degree the psychic apparatus--i.e. Psyche: ego, id, superego; loses its symbolic integrity that leads to permanent functional restrictions in whole or in part and are not recuperable post trauma inducing event.
What's a symbol, ®?
There is a difference
The fact is that Wittgenstein’s Tractatus Logico-Philosophicus created a functionary truth serum for philosophical realities; however, and through his own admission—nothing was attained or admissible for psychological realities: “What can be said at all can be said clearly, and what we cannot talk about we must pass over in silence.”
(Cartoon credit: Thefirst philosopher.
© 2002 by John Holden)
The truth of this work and all psychological realities: “Silence speaks all the more eloquent than speech and all the more clear is silence in its speech—No longer need your silence slumber, eternally quiescent, but also may it infinitely reverberate.”
This treatise is not meant to have the same type of logical coherence that traditional theoretical works, specifically in the physical sciences, seek to portray and purport to attain, which then lead to the formation of a set of mutually dependent principles that when taken in part or summation direct the individual theoretician to a singular and logical conclusion or system of thought.
Instead this treatise is meant to illuminate the inconsistencies that belie the appearance of logical coherence itself, as only a verbal facsimile or word game. The reality is that with every conclusion or thought systemization there is a remainder or question mark.
This is to say that in every conclusion there is a beginning and that in every system of thought there is something yet “un-thought” and that this is only shear folly to believe conclusively in anything or in a “completed” thought. To believe that everything has been said that can be said or shown all that there is to show.
However, in direct alignment with the main thesis of this work which states that Wittgenstein’s silence is a self-imposed parameter of Logic and not of expression, there is also space for conclusion (this work does conclude—it does end) and for conclusive finalities—it is just the penchant for Logic or Rationality to deem itself the measure of sense and the punisher of irrationality and the nonsensical.
There is a subterranean movement that produces its own offspring, wild and uncontrollable, vibrant and colored—that is not simply non-sense or dismissible as “mere” poetry. Logic has never and will never complete its own circuit because it bases its own foundation on a paradox and antinomy. These are the failures of deductive and inductive reasoning, which never themselves, nor threw any other currently known means, are capable of justifying the deducting premises nor induced conclusions.
The internal antinomy of deductive logic is the completely baseless and assumptive nature of every deductive premise and likewise with induction and its non-extrapolating conclusions that are also only assumable potentials with no verifiable predictive capacity.
And yet Logic, rationality and Reason have maintained a hegemonic deliverance or stranglehold for all knowledge allowed or disallowed. Not only the factual bits and historical minutia but also the ways knowledge is generated, from the scientific method to the Hegelian Dialectic, but also the way it is conveyed or transmitted, priestly classes and ivory towers.
Logic is primarily and firstly about control. The explicit control it exerts is toward Thought as it gives the appearance of gentling guiding and ordering cognition but this same guidance and orderliness does not end with the harmless and beneficent cognitive processes. Logic’s control extends to and implicitly transmigrates to the socius, the economic and political, and is especially pernicious in regard to the lower classes or the segment of the populace whom are without the means of production, the rank and file producers—those without the means—an adequate educational system or the capability—the intellectual/cognitive ability to be educated, to wield the sword of Logic.
Neither, Reason nor Logic, are to be specifically demonized or denigrated, but instead it is the motive of this work to highlight and critique the monopolizing power granted to these forms of information gathering and dispersing. It is neither this works aim to raise as cause célèbre and juxtapose the illogical or nonsensical with Logic, but it is to rather show that there is a very tangible alternative to the time honored celebration of Logic as the only and primary arbiter of experience and expression.
The main purpose of this work is to realign the knowledge-power differential that has existed for centuries as Logic and Reason have been heavily weighted in favor of those who have had the means and capability to access and apply these very specific modes of relating. The relational dynamic that is created by Logic and Reason is twofold: One is to the entity that is Knowledge but also and more so there is the representational function of Knowledge, as channeled through Logic or Reason, as individual is meant to relate to individual and likewise socius to individual and individual to socius. A considerable degree, if not all relational dynamics are filtered through the cognitive lenses of “is it logical,” “are you being reasonable?”
Again this is not to isolate, rehabilitate or champion the cause of nonsense or the illogical, but it is to show the merit and potential in their functions as effective foundational bases for Logic and Reason—as they themselves have never been able to ground themselves in themselves, which is itself, a bit of a paradox or antinomy.
Dynamics of Depression
When you are feeling overwhelmingly negative give yourself a self-infused shot of positivity and then hold yourself accountable for accomplishing the tasks you have given yourself. It can be even better if you do have someone, such as a loved one or a personal therapist, to assist you in your own accountability to start out.
The idea is to write down 10-15 tasks or behaviors that are very positively oriented and then do what ever you can to accomplish each and every one of those tasks DAILY. You can use S.M.A.R.T. a technique for writing achievable goals but the main idea of this exercise is down and dirty--Just do it!
Once you have your list then decide which item is probably the hardest to achieve on a daily basis and make sure you accomplish that one first and foremost. If that item changes daily then change it accordingly.
1) Daily walks (exercise)
2) Daily journaling
3) Spend an hour outside
4) Job hunting 30-45 minutes daily
5) When engaging in negative self talk read/recite positive affirmations
6) Take more time for personal appearance
7) Eat 3 solid meals per day
8) Contact at least one person/friend per day
9) Respond to all personal communications by end of day
10) Daily think of one good thing you can do for yourself that is not already on this list AND do it!
Transference and Counter Transference in Therapy as Mediated by the Intervention of Transference Interpretation
In this paper, the author describes his two practica at Saint Louis Park Junior High School and the Neighborhood Involvement Program. In his literature review, he explores transference and counter transference, its (a) historical antecedents, (b) Lacanian psychoanalysis, and (c) Lacan’s Presentation on Transference. He concludes the paper with a discussion of his areas of competency, strengths and needs for professional development, and future plans.
Table of Contents
Description and Evaluation of the Practicum Sites 5
Practicum I: Saint Louis Park Junior High
Purpose and Staff 5
Role in Individual Therapy 8
Group Therapy 10
Critical Evaluation 11
Ethical and Professional Considerations 12
Practicum II: Neighborhood Involvement Program
Purpose and Staff 13
Role in Individual Therapy 16
Critical Evaluation 19
Ethical and Professional Considerations 19
Transference and Counter Transference in Therapy as Mediated by
the Intervention of Transference Interpretation
Historical Origins of Transference 23
Contemporary Research and Transference Interpretation 27
Lacanian Psychoanalysis 30
Lacan’s “Presentation on Transference” 36
Statement of Competencies, Theoretical Orientation, and Future Plans
Professional Development 40
Abilities and Competencies 40
Theoretical Orientation 42
Strengths and Areas for Growth 46
Future Plans 46
Description and Evaluation of the Practicum Sites
While the master’s degree program for Counseling and Psychological Services at the University of St. Mary’s requires only one practicum experience I benefited from engaging in two separate sites with substantially disparate populations. On September 01, 2009 I began my first practicum experience with Saint Louis Park Junior High School in the capacity of a mental health therapist and student counselor. I have had previous experience working within a public school setting as a teacher’s assistant for special education students. During this period I discovered that working within the school environment and with the population was exceedingly fulfilling. However, as the practicum progressed I began to notice comprehensive failings of which I could not reconcile.
The most significant factor for this transition was the discovery that the combination of developmental level in cognitive functioning and dearth of life experience of the students highlighted my desire to more deeply intervene therapeutically in those dimensions. This prompted my search for an alternate site. I was successful in gaining another position, more directly in alignment with these desires, at the Neighborhood Involvement Program located in the Uptown area of Minneapolis, MN. I began this portion of my practicum January 04, 2010.
Practicum I: Saint Louis Park Junior High
Purpose and staff. On September 01, 2009 I began my first practicum experience with Saint Louis Park Junior High School in the capacity of a mental health therapist and student counselor. There was one other Saint Mary’s intern who was acting in the same capacity. Randy Zutz, M.A., L.P. was designated as my supervisor. There was not an explicit theoretical orientation that the site was organized around, however, there were elements of Narrative Therapy, Developmental Psychology, and the site was very open to an integrative perspective.
Demographically the junior high’s population was relatively diverse with a total of 594 students between the ages of 12-16 with five main ethnographic groupings: five students of American Indian/Alaskan Native origin, 32 of Asian/Pacific Islander origin, 36 of Hispanic origin, 144 of Black, not of Hispanic origin, and 275 of White, not of Hispanic origin. Further there were three subgroups: 33 students with Limited English Language Proficiency, 78 students in Special Education and 214 students in Free/Reduced Priced Lunch.
The individual and group work mainly revolved around students experiencing difficulties in three general areas of their life: relational, familial, and educational. I worked one-to-one therapeutically with cases that could be labeled with psychiatric diagnoses, including: one case of Panic Attack/Anxiety Disorder, one case of Bulimia, two cases of Autism Spectrum Disorder and one case of Fetal Alcohol Syndrome.
Supervision. Randy Zutz performed two major roles outside of the supervising of master’s level counseling interns. He was both the head student counselor and the “yellow team” dean, 1 of 4 other deans of color-coded teams who supported a sub-group of teachers in daily operations and the management of their students. There is no question as to the dedication Randy Zutz manifested for the student body and, equally, the responsibility he maintained during the supervision of his interns for the semester I retained the site for my practicum. While he remained exceedingly active working with students in every dimension of student life: homework, grades, extracurricular activities, discipline; he was equally able to maintain open lines of communication with his interns.
Supervision mainly consisted of weekly hour-long sessions that provided me with the opportunity to discuss specific student cases that I was either struggling with or experiencing positive movement. One of the more difficult cases was that of “Jill,” name changed to protect anonymity. Jill, a 14-year-old eighth-grade female, was experiencing symptoms that were readily consistent with that of panic and anxiety. Jill, for no apparent conscious reason, would become so overly uncomfortable in a wide range of activities and situations that she would begin to hyperventilate, shake uncontrollably and experience the need to leave the situation or discontinue the activity for fear that the symptoms would overcome her completely leading to a complete loss of control. Jill described to me a very saddening and difficult early childhood event, which quite possibly was either the initial triggering event for her later symptoms or at minimum a contributing factor, the death of her mother in a car accident in which Jill was both witness and directly involved at the age of 7.
Randy Zutz and I both concluded that Jill most assuredly had symptoms of 300.21 Panic Disorder with Agoraphobia. He continued to advise me on this particular case for the next 2.5 months during which I worked with her therapeutically. The main direction from which I managed the case was an empathetic and exploratory perspective. Jill had had a volatile relationship with her father, whom she stated she loved dearly; however, she found it difficult to truly express these feelings directly to him without a cross-sectioning of anger and resentment. The majority of the anger seemed to stem from an infantile demand she harbored against him for contributing to the death of her mother. This was potentially compounded by his inability to have both prevented the accident himself, as he was the driver of the vehicle, but also, in her youthful perception, that he was completely ineffectual in handling the immediate and long term after-effects of the accident.
In addition to the empathetic holding environment mediated by a fairly extensive degree of exploration, Randy Zutz and I believed that the interventions of cognitive restructuring and systematic relaxation from Cognitive Behavior Therapy (CBT) were possible positive directions for Jill. While I did not attempt to directly access the more painful and immediate aspects of the original trauma as a dimension of cognitive restructuring, the accident event did reoccur in Jill’s mentations over multiple sessions; I did target the broader more general correlates (i.e., Dobson & Hamilton, 2009) such as fear and panic occurring during unspecified activities and situations, resentment toward father, and her animosity toward his recently proposed to fiancée.
Additionally, to begin providing, potentially immediate relief or at least proffer the sense to Jill that she can take an active role in reducing the severity of her symptoms I introduced two other CBT interventions: progressive relaxation (Ferguson & Sgambati, 2009) and diaphragmatic breathing (Hazlett-Stevens & Graske, 2009). From self-report, Jill stated that she felt these latter two interventions were of significant benefit to her. She reported an increased ability to maintain her composure during an away-from-home debate competition were she was charged with presenting a theme for debate in front of a rather large crowd. The debate team coach was also stated to have been of immense importance for her own facilitation of a grounded and stable sense of self-being.
Role in individual therapy. As stated above, there was no explicit theoretical orientation for the Junior High site. This was not considered to be a deficit but a potential boon as through my academic career I have chosen to focus on a multitude of counseling perspectives (e.g., Psychoanalytic, Narrative, Rational Emotive Behavior Therapy, Cognitive and many others). The fact that I have had only one master’s level course pertinent to adolescent needs, Child Assessment, did not originally seem to be much of a hindrance. After beginning to see students I commenced researching child development and therapeutic perspectives and interventions (Papalia, Olds, & Feldman, 2007; Shapiro et al., 2006).
Recognizing the limited nature of my academic background in working with adolescents I was bolstered by the fact that I had previously spent one and a half school years working as a paraprofessional with high-school-aged students in a special education program from 2006-2007. This encouraged me in this new pursuit and was of definite benefit as I was able to draw from this previous experience a multitude of positive relational perspectives for dealing with the students themselves and the educational environment in which they we were immersed.
Papalia et al. (2007) was an indispensible reference in my search for entry points into the world in which these students found themselves. The broad overview of adolescent experience outlined within the textbook facilitated a modicum of accuracy as I made attempts at generalizing from the basic developmental level to specific student/client experiences. The basic recognition that adolescents are moving from a prepubescent stage that has strong precursors in their neurological development in which the emotional centers of the temporal lobes are becoming increasingly activated became readily apparent during sessions with the students.
A ninth-grade female of African American heritage was introduced to me early on in my semester with the Junior High. For anonymity her name will be altered to that of “Jane.” This 14-year-old student presented herself with an initially pleasant affect with generally normative interaction and an above average language capacity. She was consistently placed on the honor roll. Upon further interviewing I was surprised to find her very affable; however, when we began talking about her presenting concern, which was that of Bulimia Nervosa, her affect became most assuredly “inappropriate,” (American Psychiatric Association [APA], 2000, p. ) in that she continued to smile with a small degree of laughter.
Jane described the full degree of diagnostically significant criteria for Bulimia Nervosa. After this initial meeting I immediately reported the content of our session to my supervisor and consulted with him as to the next steps that we were required to engage. The client’s mother was contacted. Her father was living out of state and separated from her mother. We decided on a parent-student meeting with both Mr. Zutz and I present to help facilitate the conversation between Jane and her mother. This was also requested from Jane as she informed me that she had made attempts to inform her mother of the issue; however, Jane related that her mother was an avid Christian with the belief that the issue should be placed in the hands of the higher power.
The meeting was held two days from the initial conversation with Jane and was attended by the above-mentioned individuals. Jane’s mother was in fact aware of the problem Jane was having and again was determined that the mother’s faith was the only and last resort. This was what Jane told me she was expecting to hear and that she felt the situation intractable with no possibility of rectification. There was a definite cultural gap between both Jane’s mother and the remaining three members of the meeting. Recognizing that there was limited actionable intervention at this point Mr. Zutz concluded the meeting. The client was referred to me for weekly psychotherapy and to an outpatient clinic for eating disorders.
Group therapy. Group therapy was retained for Anger Management and Grief processing. These sessions were held in two adjoining rooms in the Media Center at the school. The Anger Management group had two separate sections and was gender exclusive, while the Grief group was gender inclusive, with both meeting once per week for approximately 10-12 sessions.
The anger management group individually consisted of 5-12 students, varying from session to session with an average of 6-7 boys in the male group and 8-10 girls in the female group. Both the other intern and I alternated between lead facilitator and co-facilitator. The dynamic we attempted to create within each group was mainly relational and experiential, with the broadly stated intention of allowing open and honest communication for multiple themes relating to anger and explicit acknowledgement that all perspectives were to be validated from all members in either group.
The first session of the Anger Management group was opened with a question and answer that revolved around the rights and responsibilities of its members. We asked the students what they felt was of most importance to them in regard to actions, verbiage and responsibility. From the responses we generated a list of essential rights that each member was to be cautious as not to infringe upon in deference to other members’ feelings and sense of safety and wellbeing. This list consisted of: respect for other’s opinions and space, confidentiality, openness, and honesty.
Critical evaluation. The Saint Louis Park Junior High was designated a “blue ribbon” school by the U.S. Department of Education (2010) and as this is an excellent achievement and honor for the school it boded equally well for the relatively smooth integration and operation of the counseling interns. Nearly all teachers and collateral staff members were eager to assist, direct or inquire personally in regard to facilitating the availability of their students for counseling. There were, of course, personnel who were less than open to the eventuality that we as school counselors were compelled to interrupt classes at inopportune moments during the day, but there truly was little we could do to mitigate these interruptions. The other intern and I determined that students receiving “D” grades or less were not to be removed from those classes unless it was a last resort. Neither of us was predisposed to relegating all therapy sessions to periods of physical education, music or art class; however, via upper-administrative demands these periods did in fact became default positions for holding therapy with students.
In relation to fulfilling the needs of the student population, I believe, that the site was in definite concordance with both the students, as there was a high number of individuals of lower socio-economic status (SES) who were in need of our counseling services, and my professional requirements for gaining experience in counseling. With this stated I quickly became aware of the fact that the adolescent population of the school was not going to be my target population upon graduation from my program. This is not to say that I was unable to glean important experiential value from this practicum site; in fact, I was able to more critically determine the population on which I would like to focus my passion for therapy (i.e., adults with a spectrum of clinically significant mental health issues). There is little question as to the benefit I received from the experience at the junior high, and most importantly I discovered that I was interested in working with adults who, while they are experiencing mental health issues, they also have potentially developed a higher level of mental capabilities.
Ethical and professional considerations. Individual therapeutic sessions were conducted in a retrofitted classroom with two counseling areas. The school informed both of us that there was to be installed a floor-to-ceiling divider as soon as possible; however, for the duration of the semester I maintained this site as part of my practicum experience the divider was never installed. Ethically, this made for a rather tenuous experience for me and, self admittedly, the other intern. We were often overlapping with each other as we attempted to counsel students. There appeared to be some ethical implications for this inadequate spatial arrangement, as both the students and our selves could readily overhear the themes and content of the other’s session.
We attempted to remedy such conflicts by taking turns meeting in other areas of the school (e.g., Randy Zutz’s office, and the conference room); however, this was less than ideal as there were often conflicts in acquiring access to these locations due to concurrent occupancy and or physical access was rather difficult to achieve (i.e., multiple and varied efforts to locate appropriate keys to gain access) all of which consumed precious counseling time and appropriated a sense of general disorganization.
Another potentially ethically-related situation arose during the middle portion of the school semester when the other intern and I were informed that we were to begin overseeing a lunch-time program, “The ‘F’ Support Group,” for students failing one or more classes. This duty did not appear compatible or directly relatable to counseling/mental health therapy, as the structure of the group was built around individual students attending during their lunch hour and solely concentrating on completing past homework assignments. The other intern and I were basically relegated to working one-on-one with students for the completion of this incomplete work and the management of a classroom full of students.
Practicum II: Neighborhood Involvement Program
January 04, 2010 was the commencment of the second practicum site. The Neighborhood Involvement Program (NIP) serves the general population of the greater Minneapolis and St. Paul area. The main focus is the support of community members who are under- or uninsured in the areas of dental, medical and mental health.
Purpose and staff. In the area of mental health there are multiple subdivisions, including the two major divisions of the Counseling Center (CC) and the Rape and Sexual Abuse Center (RSAC). Three lisenced doctors of psychiatry conduct on-site service. Unfortunately, as throughout the psychiatric community there is a relatively long wait-list for services, generally stretching out 3 months, minimally. There is a variety of support and therapy groups to which individuals with varying needs have access, including but not limited to: Mixed therapy, Rape and Sexual Abuse, Art Therapy and variously themed, exclusively male or female groups. There is, also located on site, a third division within the counseling program, Therapy Associates, which allows community members access to counseling beyond the heavily requested CC and RSAC. During times of increased volume and need Therapy Associates offers individuals more timely access to mental-health services, albeit at a slightly elevated fee rate, as the program is strictly funded by client contribution. There are various other outreach programs offered by NIP which target youth and elders.
A month-long training orientation was held, consisting of a 3-hour period every Monday and Thursday. We discussed various topics relating to the NIP site and its procedures, but also some significant dimensions of therapy practice in regard to specific populations: GLBT, survivors of sexual trauma both male and female, legal issues for survivors, and work with children. In addition to the educational sessions, NIP held monthly In-Service for therapists that included informational sessions on specific therapeutic perspectives (e.g., Psychodynamic) but also full-length case studies presented by licensed staff members. The adjunct of bi-monthly psychiatric case consults was of inestimable value in that a licensed, practicing psychiatist, Dr. John Heefner, offered all training therapists one hour for the introduction and inquiry into psychopharmalogical issues for their clients.
Role in individual therapy. This practicum site allowed me to work with adults of both genders, ranging in age from their mid-20s to late 60s. The bulk of my client caseload resolved itself around approximately 9-10 once per week, with a small number, between 1 and 2, new clients as older clients moved on for various reasons. I was afforded the opportunity to work with one individual of Vietnamese heritage who was adopted as an infant by a middle-upper- income Caucasian family and raised in the St. Paul area. I worked briefly with two individuals who were self-ascribed homosexually oriented. Through both group and individual supervision I concluded that the brevity of therapy for these individuals could potentially be attributed, in part at least, to the phenomena of transference/countertransference and will be more thoroughly explicated in the remaining sections of this paper.
Following a similar trajectory as the above-noted difficulty incurred in relation to a client’s sexual orientation I was equally confounded during the initial session with the first client I was accorded at NIP. There was a modicum of nervousness I experienced, primarily I suspect, due to my own inexperience; however, there was ample material within the client’s intake paperwork that made this a formidable first client. The client reported to the intake personnel that she had been raped by her husband and that she was still remaining within the household. She also maintained and reported in session that she was able to feel and localize energy being emmited from other people.
I did not then and do not now, during the writing of this paper, attempt to make any value judgements or assertions as to the validity of a client’s personally held belief systems. The question, at hand, is the maladaptivity of the client’s belief system in relation to the goals to which the client is inquiring to achieve through therapy. I mention this client as to the clinical experience she granted me.
This client was experiencing, from my subjective perception, a great deal of psychological, as well as, emotional suffering. During my initial diagnostic inquiry into her presenting problems the client began to reexperience the trauma she incurred during an episode that was interpreted by the client to be her rape by her husband. There was a period of decompensation (i.e., where an individual’s defense mechanisms are summarily bypassed leaving the individual no barriers to external stimuli) during this session which was similar to what I have seen during my work at the Crisis Intervention Unit at North Memorial Hospital. As soon as I recognized the extended distress toward which the client was devolving I intervened with thought-stopping techniques and reality testing. Regardless of the steps I initiated to help her regain a direct connection with objective, here-and-now experience the client was incapable of pursuing further therapy that day and while attempting to be reassigned to another therapist she stated that there must not be any male individuals within the building during her sessions.
While I do not believe that all of my clients were legitimately diagnosable through the matrix of the 2000 fourth edition, text revision, of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) the NIP site and my supervisor made diagnosis a fairly stringent requirement, mainly for educational reasons. There were specific statements proffered during training that the function of diagnosis was regarded to be facilitative for our future interaction with managed healthcare conglomerates. Withstanding, I believe that a majority of the diagnostic criteria for each disorder was fulfilled albeit with the caveat of actual severity (i.e., total impactfullness in relation to overall functioning, as in social, occupational and or educational dimensions); symptoms were typically not significantly expressed as to warrent a full diagnosis. The disorders that I diagnosed during this practicum, in concert with supervisorial input, were: 309.0 Adjustment Disorder with Depressed Mood, 309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood, 300.0 Anxiety Disorder NOS, 296.89 Bipolar II Disorder, 301.83 Borderline Personality Disorder, and 300.4 Dysthymia Disorder.
Supervision. There was an ample amount of supervision during my 10-month internship at NIP. There was one full semester of group supervision acquired from the Univesity of St. Mary’s, which consisted of bi-weekly 2.5-hour sessions. Supervision gained at NIP consisted of weekly hour-long individual supervision and weekly 1.5 hour-long group supervision.
The group supervision at St. Mary’s revolved around dialoguing on case presentation, a variety of counseling themes and therapeutic challanges experienced by all the participants. I found this experience to be of inestemible value. The group facilitator, Jill Flower, PhD., was more than qualified and experienced, as an actively practicing therapist, to lead the group through every situation presented. During these sessions I learned how to actively listen for specific points or challenges that each therapist was dealing with in his or her own practice.
The fact that each participant was acting in a different capacity and at differing sites was also a boon, adding depth and color, which allowed me to reflect on the disparate challanges each site presented to the therapist working there. My ability to then have a supervisory outlet that was not connected to the actual site I was working at was sorely missed upon the completion of this semester-long course. It afforded me an unbiased and positively non-associated space in which to express my personal frustrations with working at NIP. Some of these frustrations will be discussed further in the Ethical Issues section below.
The individual supervision received at NIP was conducted with Jennie Yngsdahl, MA LP. Overall I was exceedingly satisfied with the level of professionalism, care, and accountability she offered. I felt very at ease with her in discussing client cases, my personal reactions to clinical work and with any difficulties that I may have been experiencing. She was open, actively interested and very constructive in her responses and advice for the possible directions I could take with my clients.
Further elaboration into the mechanics and subject matter related to my individual supervision can be exhibited in my experience with my group supervision at NIP and a personal hardship which I experienced contemporaneously with the start date at NIP. Group supervision was led by Max Hines, PhD.
The structure of this group was similar to that of the supervision received at St. Mary’s; however, there was a distinct progression that accompanied each session. The group commenced with a mindfulness exercise, which consisted of one member prearranging either a guided meditation, poetry reading, yogic exercise or some such similar relaxation-based intervention.
This was then followed with a brief check-in of which each participant was afforded the opportunity to discuss any exciting events in the previous week, personal or professional. We were then tasked to delineate any particular difficulties we were experiencing with any clinical cases that would subsequently be presented before the group or any potential therapy-related themes that we may be struggling with or interested in. Following the check-in was then the presentation of such themes or case studies revolving around client difficulties.
While the initial session of this group appeared to progress with great ease and alacrity the following and remaining sessions progressively became more frustrating and distressing. There was a level of anxiety I experienced with the commencement, for that matter, with the nearing of the commencement of each session that followed. Supervision with Jennie Yngsdahl was of immense benefit to me in attempting to negotiate the feelings and nearing utter dispondence with which I was associating these weekly group sessions. Her caring nature and overly empathetic response to my difficulty allowed me the space to express my frustrations and further consolidated my reactions to the group and particularly the group leader.
Without expending too much time and space to the explication of this troubling dimension of my internship, I will relate however, that there appeared to be a degree of transference and counter-transference between myself and Dr. Hines. This situation can be further expanded with the revelation that I was informed by multiple sources that I was not the sole complaintant in relation to Dr. Hines and similar difficulties incurred.
Critical evaluation. As referenced above with the distinguished honors received by my first practicum site, Saint Louis Park Junior High; my second practicum at the Neighborhood Involvement Program has itself a fairly time honored history: During the mid 1960s individuals living near the Lake of the Isles began organizing volunteer programs for youth and elders. This led to the incorporation of the organization and the employment of a director, the only paid staff person. The organization established itself in a permanent location in the 70s which brought about the opening of RSAC and in 1985 NIP moved to its present three-story location in the heart of Uptown.
Placing my first practicum in contradistinction to the second I find equal benefit in both; however, the latter was supremely more in line with my ultimate goals as a mental-health professional. The direct one-on-one contact with clients placed me in the parallel position of being a sole proprietor, the much-welcomed experience that could then be translated into a personal private practice in individual mental-health therapy. NIP granted me the freedom and personal responsibility of controlling the grand majority of the operational aspects in working with clients. I was required to contact, interview and ascertain the viability of each and every client, albeit with the supervision of an experienced therapist, but the onus was relegated to me in its entirety, in regards to the actual facilitation of a therapeutic practice. This was something for which I had projected, from the beginning of my studies, as the penultimate goal in gaining a master’s degree in the field of mental-health therapy.
Ethical and professional considerations. The level of professionalism that I experienced at NIP was above my expectations. I experienced some difficulty in only one area-- that of group supervision, while in every other area I was exceedingly appreciative of the thoroughness by which NIP conducted its services. The three main areas that I believe are critical in performing well at a practicum site were accomplished in many ways: client contact, supervision and client paperwork.
The condition of the site’s therapy rooms was always: clean, uncluttered and aesthetically pleasing, both visually and without auditory distraction. They were conducive to the facilitation of the client’s sense of privacy with white noise machines directly outside of the therapy room door and or light music playing in overhead external speakers in the hallways. There were very rare occasions when external noise interrupted sessions, or knocks or accidental door openings during a session. Both at the commencement and near termination of the practicum, all therapists experienced difficulty in gaining open space for conducting therapy, as the outgoing practicum therapists were still providing services, virtually doubling the amount of space needed. However, this was a relatively short window and was only encountered a handful of times.
As discussed above the individual supervision I received was of exceptional quality; while, combining the group supervision and the required supervision courses at St. Mary’s, supervision as a whole became, at times, exceedingly overwhelming and slightly tedious. The group supervision as led by Dr. Hines, while I have cited some difficulty with it, was beneficial in many ways. The level of knowledge and relative experience of the participants, being that we were all therapists in training, I considered above average; however, for reasons not completely determined I was unable to fully explore my theoretical perspectives and conceptualization of client cases.
There was no concerted effort to dismiss my psycho-analytically oriented perspective; however, and for whatever reason—which remains undeterminable, there was a lack of responsiveness to my conceptualizations and hence, therapeutic direction from which I was approaching my clients. It must be noted that I did not incur this resistance in any other area of my supervisory experience, in neither of my individual supervisory practicum dyads nor in my two St. Mary’s course required supervision groups.
Again, in contradistinction with my initial practicum site where there was virtually no oversight or direction in regard to client case notes nor any systematic structure for tabulating client backgrounds or determining confidentiality via specific forms, the paperwork at NIP was exceptional in its cogency and global reach for covering all of these areas.
There is little doubt as to the most benefit I received from incurring a double practicum experience. The combination of working with the two disparate age ranges, and the realization that the adult population was and will be the main focus of my professional career is inestimable.
I was able to learn a great deal from both sites in regard to my personal preferences for engaging in mental-health therapy and the integration of those experiences with my overall academic background will continue to make its presence known affectively, as a base and foundation, for the remainder of my professional career.
Throughout the duration of both practicum experiences I was continuously interested in the “how and why” of the manifestation of the therapeutic dynamic. How is it that individuals, whom I have never encountered previously, are going to freely open up their vulnerabilities and begin speaking about intimate pains and frustrations? Why will these individuals knowingly breach their silence and grant access to these susceptibilities? Finally, what psychic mechanisms are going to either facilitate or restrict these fragile openings?
These questions spurred my interest in determining what psychology as a broad academic field and psychoanalysis as an actionable and distinct perspective parallel to that field had to say about these critical themes. I was led to the dynamical concepts of transference/counter-transference and the intervention of transference interpretations, the activating element within the former conceptual duality, for these answers. They will be the heart of my literature review which will follow this section directly.
Transference and Counter Transference in Therapy
as Mediated by the Intervention of Transference Interpretation
The concept of transference is considered one of the most active ingredients within psychotherapy (Connolly et al., 1996; Freud, 1912/1990; Hoglend, 2004, 2006; Strachey, 1934/199). Therefore, the concept is potentially of indisputable importance in developing a well-rounded perspective for the performance of effective psychotherapy. The concept is one of the earliest (Cooper, 1987), most continuously referenced and while, widely accepted (Cooper, 1987) (Gabbard, 2006), it remains equally controversial and disputed (Gill, 1980) within the field of psychotherapy. Due to its critical influence upon the effective treatment of psychopathology and its countervailing polyvalence, ubiquity, and disputation this portion of the paper will be a modest attempt at firstly, formulating a general working conceptualization of the term that includes both historical as well as current thinking and secondly, an explication of the interventional capacities of the concept as found in “transference interpretations” which are considered to be one of the most active ingredients within the more broad dynamical aspects that is the transference.
Historical Origins of Transference
Sigmund Freud (1912) concluded, in his seminal paper on the transference, that “it is impossible to destroy anyone in absentia or in effigie” (p. 35). This is a graphical illustration of the exacting power granted the therapist when utilizing the transference. Strachey (1934) further promoted the explication of the statement when he discussed the therapeutic action within psychotherapy is a moving past the mere intellectualization of the client’s problem to a point where client and problem meet.
While Strachey (1934/1999) remains slightly dated and overtly psychoanalytic (i.e., primarily focusing on libidinal exigency), he went on to delimit the progress of therapy to that of the overcoming of “resistances” between the client and therapist (i.e., the transference) which, ultimately is between the client’s own ego and superego. This resistance is overcome via the therapist’s act of subsuming the client’s superego position in the “here and now” of the therapeutic session, which leads to the dampening of the savage, primitive ferocity that the previously unmediated superego foisted upon the client. As the client is allowed to experience the therapist’s non-critical and non-condemning undistorted superego, the client healthfully introjects elements of that adaptive and healthy superego. Hoglend (2004) contemporized and practically situated Strachey’s (1934) dynamical conceptualization of psychopathology; it will be discussed below.
However, and in direct relation to my initial interest at the outset of my practica, first is the question of how does an individual come to formulate the material that will lead to transferential enactments within the therapeutic dyad? In the above referenced paper, Freud (1912) outlined in a focused yet schematic and perfunctory sense the basic dynamical core underpinnings of just those aspects within the transference. He recognized the limited nature of his article and referenced a more extensive presentation; however, he asserted his belief that it is pertinent to lay out the core ingredients due to both the prominent conceptual and functional importance of the idea within psychoanalytic treatment.
He based the intrapsychic and dynamical foundation of the transference on the broad and ambiguous term of a stereotype plate which he later assimilated to the term originally introduced by Carl Jung (as cited in Freud, 1912), the imago. Freud hypothesized that there is a causal connection between an individual’s “innate disposition and the influences brought to bear on him during his early years” (Freud, 1912, p. 29) which in turn, potentiates the stereotype plate. This plate consists of the individual’s historical, intersubjective experiences related to other people and acts upon the individual’s impulses. These impulses, according to Freud (1912), are primarily libidinal (i.e., sexual) in nature but also include other instinctual capacities for food, shelter, and so forth. These stereotype plates guide, positively or negatively, individuals in navigating their psychic life.
The capacity for an individual to appropriately direct these impulses relies on the historical markers that, reciprocally, are also a part of the plates themselves. A major component of therapy consists in the individual becoming conscious of the unconscious correlation between his or her impulses and these stereotype plates (Freud, 1912; Gill, 1976; Hoglend, 2004). Contemporary terminology for stereotype plate can be, I believe, translated into object-relation within the psychoanalytic theory of Object-Relations, as “the subject’s mode of relation to his world” (Laplanche & Pontalis, 1973, p. 277).
However, the essential point mediating healthy versus unhealthy behavior, according to Freud (1912), depends upon the psychic developmental level of the individual. Freud’s hypothesis was that a mature psyche directs impulses outward towards reality and is consciously manipulable, therefore, more readily satisfied. A developmentally healthy individual’s psyche has the ability to cathect with positive or fulfilling love objects, therefore, satisfaction of the individual’s impulses.
Freud (1912) again referencing a Jungian term introversion, established the basis for the dynamically and pathologically immature process of cathexis, a “certain amount of psychical energy is attached to an idea […]” (Laplanche & Pontalis, 1973, p. 62) which is the “invariable and indispensible precondition of every onset of psychoneurosis” (p. 30). Introversion is opposed to the healthy development of the libido in that impulses are turned inwards towards fantasy or worse simply left unconscious; therefore, they remain less malleable and more readily susceptible to frustration—ergo, unsatisfied impulses.
The extrapolation of an unhealthy or maladaptive stereotype plate and its unconscious impact upon the psychic life of the individual can be readily explored via a brief anonymous case example from my practicum experience. Amanda (name changed), a 27-year-old female, presented with concerns revolving around anxiety, relational difficulties involving both her contemporaneously current partner (she has subsequently broke off relations) and the entirety of her nuclear family, which consists of a biological mother and father and one brother. During the inquiry phase of therapy this client related multiple dysfunctional interactional correlates; such as excessive argumentation, physical and verbal abuse originating from the time of her childhood, approximately at 13 years. The grand majority of these relational dysfunctions were consistently related back to that time and in regard to her father. This pattern of dysfunctional interaction was then apparently re-inscribed with two of her most significant boyfriends, the first lasting 2 and the second, 7 years.
The task of psychoanalysis therefore is to retrace the lack within the developmental pathway of these infantile imagos, as they express themselves via a patterned symptomology, or complex. The transference, according to Freud (1912), is to be found within these complexes. The subject-matter or complexive material that make up the symptoms are transferred onto the therapist in the transference and can be identified in a stoppage, parapraxsis, inaudible mumbling or inconsistency within the dialogue (Freud, 1912, p. 31).
Strachey (1934), following the same line of reasoning as Freud (1912) described two broad groups of transference: positive and negative, and two subgroups within the negative which were the affectionate or friendly and the erotic (Gill & Muslin, 1975, p. 784) which the latter normally remained unconscious and therefore became a major resistance as it could not be admitted to. This setback was discovered to be circumvented in the realization that the transference itself could be overcome by its own analysis. Strachey (1934) stated that by “inducing the ego to abandon its resistance” (p. 69) to the conscious acceptance of the erotic or unconscious material, the transference would be broken. Strachey himself acknowledged the apparent circularity of this argument as the “neurotic’s vicious circle” (p.73).
Contemporary Research & Transference Interpretation
Hoglend (2004) distinguished between two main types of psychoanalytic interpretation: (a) transference interpretation which consists of the therapist referencing the ongoing relationship within the therapeutic dyad, and (b) extra-transference interpretation which references interpersonal patterns or conflicts in the contemporary relationships of the client and are extraneous to the immediate relational dynamic of the dyad.
While Hoglend (2008) gave two examples of these definitions, I would like to propose a personal clinical example, as it was proffered during a session: “I see that there appears to be a pattern developing between us, in what seems to be your consistent deference to my authority—this happens most often when you break off in mid-sentence and cast your gaze in my direction in a searching sort of way.” This transference interpretation, subsequently elicited here-and-now feelings of frustration and a mild sense of anger from the client (Hoglend, 2008), which act as a resistance to therapeutic movement (Davanloo, 1995b). The here-and-now immediacy of the transference interpretation is theorized as enacting the most significant movement toward therapeutic change (Gill, 1980), and with the enlistment of this resistance to the transference I needed to be aware that I could have mobilized it positively in relation to the therapeutic alliance (Davanloo, 1995b).
As stated above, this type of intervention has the potential of eliciting both a sense of frustration as it taps into a client’s underlying experience of anger. The session was nearing a close at this time and evoked a response of global uncertainty from the client as to the purposeful nature of therapy. I performed a degree of psycho-education as to the tension that can arise during therapy and in regard to the dynamic between each of us.
Again, Hoglend (2004) posited an extra-transference interpretation by slight modification of his original example. I believe that I could add: “Does this dynamic of seeking validation or an answer from someone, recall to you, anyone in your life?” which may suffice to broaden the original transference interpretation to that of an extra-transference interpretation. This near exact additional phrasing was utilized during a subsequent session with the same client and elicited an opposing amount of sadness and tearfulness rather than the combative, defensive response of the sole transference interpretation.
This raises the question of timing in regard to the application of transference interpretations and the viability of such an intervention early on in therapy. Gill and Muslin (1976) argued that the early use of this intervention is adequately grounded in multiple original Freudian sources and that it is a key element in the fostering of therapeutic rapport. While other authors (i.e., Gobbard, 2006; Hoglend, 2008) referenced the widely accepted negative outcomes of early transference interpretation which are thought to provoke anxiety in the client, they were in support of the potential overarching benefits of such an early intervention and described it as globally beneficial.
Tellides et al. (2008) maintained slightly alternative findings. While not explicitly researching transference interpretations, they analyzed the early dynamic of transference itself and in relation to high-functioning clients. The researchers utilized the “Core Conflictual Relationship Themes” (CCRT) assessment for critically analyzing the patterns expressed by the client participants of the study: 22 in total, 17 female and 5 male, who were students enrolled in a counseling course. Briefly the CCRT is used to analyze three main components of a client’s relational capacity: Wishes, needs or intentions (W), response of others to client (RO), and subject’s or client’s response to the other (RS); which parallels the transferiential dynamic in highly similar ways. Their data indicated that clients tended to exhibit control issues within early narratives related to transference; either toward the therapist explicitly or indirectly via stories about external relationships.
Hoglend et al. (2006) also conducted an experimental study in which they researched the effectiveness of transference interpretations on 100 patients separated into two groups; there were 52 participants with an Axis I diagnosis of either, depression or anxiety, while 48 other patients met criteria for Axis II diagnoses. The group receiving 1 year of dynamic psychotherapy with transference interpretations had a total of 52 participants, with one dropping out of the study; the other group (n=48) received the same type of therapy but without the transference interpretations.
As a construct, transference interpretations (Hoglend et al., 2006) consisted of five specific techniques: (a) the therapist was to make direct reference to the therapeutic dyad, (b) the therapist was to stimulate discussion of thoughts and feelings about therapy and the therapist, which was to include any negative repercussions, (c) the therapist was to stimulate conversation about how client interprets how therapist may feel about him or her, (d) the therapist was charged with direct linking of self to dynamic, conflictual elements of therapy, and (e) the therapist offered an interpretation of repetitive interpersonal patterns. The researchers were unable to differentiate effects between the groups (Hoglend, 2006, pp. 1742 & 1743). They did report a positive correlation between transference interpretations and participants with low object relations, which is counter to the mainstream in clinical thought.
As an explanatory mode the above cited research articles have hopefully imparted a general sense of the what some of the major thinkers in psychotherapy believe the transference to be and how it dynamically manifests, both (a) intrapsychically, within the client’s own psyche, as an imago or stereoplate, and (b) intersubjectively, between the client and therapist, as the technical intervention of the transference interpretation. However I am of the firm belief that without an explanatory structure (i.e., a psychotherapeutic theoretical perspective), the modes, or wheels, are without an engine—therefore they are lifeless or without movement, psychoanalytically speaking, without drive. There are two major theoretical perspectives that I researched and applied during my time at NIP: Lacanian psychoanalysis and Short-term Dynamic Psychotherapy (STDP). While each modality is a highly specified theory with broad theoretical differences I understand the infeasibility of fully explicating either approach; however, I do wish to relate a general synopsis of the Lacanian theory along with some of its major concepts, while highlighting and juxtaposing the more personally influential aspects of STDP that theory.
To commence with a brief, general encapsulation of what Lacanian psychoanalysis is, at its most basic level, will take the most explanatory effect with what is probably the most famous statement of Jacques Lacan:
The unconscious is constituted by the effects of speech on the subject, it is the dimension in which the subject is determined in the development of the effects of speech, consequently the unconscious is structured like a language. (Lacan, 1964/1998, p. 149)
Personally, I have consistently struggled with the terminology, grammatical structure and general obscurity of references that Lacan impels upon his readers in regard to his writing style and its content; however, I have equally, if not increasingly, been rewarded for my effort and determination insomuch as that I have accrued a dutiful capacity for the useful application of his theorizations.
The above quotation, potentially obscure, even arcane, at first passing is for me, rather, an apt exegesis of a concept that forces its reality upon every therapist at every moment of every therapeutic interaction. It was culled from the edited transcripts of the eleventh year-long seminar Lacan presented in 1964, entitled: “The Four Fundamental Concepts of Psychoanalysis,” those being: the unconscious, the transference, repetition and the drive. From my reading, Lacan is essentially instating a position for therapists in relation to their client’s own problems or STDP terminologically, their psychoneurotic constellation of disturbances (Davanloo, 1995a).
When Lacan (1966/2006) positions the clients of psychotherapy in relation to the “the effects of speech” it grants the therapist immediate recourse to one of the most illusive elements of therapy, the unconscious, the site of the symptoms and therefore the gateway to the expression of the clients’ difficulties (i.e., from this position the therapist can allow the clients to verbalize or emotionally express their pain), “the ortho-dramatization of the patient’s subjectivity” (Lacan, 2006, p. 184) and is considered to be a “triumph of the treatment if he [the therapist] can bring it about that something that the patient wishes to discharge in action is disposed of through the work of remembering [e.g. verbalizing via their own “subjectivity”]” (Freud, 1924/1958, cited in Lacan, 1966/2006, p. 153).
The delicate question of situating one’s self, as a therapist, within the transference may be somewhat mitigated by the application of Lacan’s (1966/2006) tripartite meta-psychological structuration of the psyche. As an overarching schema his conceptualization grants a therapist a foundational viewpoint for understanding the most basic motive forces underlying the client’s psyche (i.e., whether he/she knows it or not: “what does my client wish or desire?” ).
Lacan (1966/2006) attributed three main categorical structures to the psyche: Psychosis, Perversion and Neurosis, with three subcategories underneath Neurosis: Obsession, Hysteria and Phobia. This section is a brief outline of only two of the neurotic subcategories: obsession and hysteria, and their relation to the concomitant transferential issues presented before and to be presented in the pages that follow. (These are the two categories most likely encountered in the therapeutic setting, with hysteria the more common of the two.)
Fink (1997) historicized the development of both subcategories with a limited retelling of Freud’s failed attempt to psychosexually distinguish them as they relate to a “primal scene” (p. 117). Each subcategory attributes and describes a specific and desperate psychic reaction by the individual in relation to the initial experience of separation from a caregiver: Obsessives, “guilt and aversion;” hysterics, “disgust or revulsion” (Fink, 1997, p. 117)
Fink (1997) maintained that Freud was never able to complete this Herculean endeavor, yet Lacan (1966/2006) relegated it to himself as a first-order task. He was not blind to the limitations of conceptualizing clients via deeper structures as he admitted the adverse potentiality for therapists misattributing traits, which are sometimes cross-categorical; that is, a therapist may prematurely designate one structure over another as the symptomology for neither is mutually exclusive. However, he was adamant of the equally valid utility granted the therapist within the transference by these categories when cautiously and judiciously applied.
It is important to acknowledge that both of these subcategories are highly variegated, complex notions of which Lacan (1966/2006) spent an entire 50+ year career fully developing and differentiating. I believe that a brief detailing of some of the more salient points will allow the reader to fully recognize the importance and validity for structuring the client’s psyche in such a manner (i.e., within the transference).
Lacan (1966/2006) was influenced by three main fields of human knowledge: Linguistics, Structuralism and Logic. He adopted the latter of the three fields, Logic, as a method for formally symbolizing the subject/object intra-psychic action he presumed to encounter during clinical interactions with his patients. The matheme is understood to represent a “most basic form, [...that of] the relationship between the subject and the object: (S <> a)” (cited in Fink, 1997, p. 118). The matheme for hysteria is (a <> A) and obsession (S <> a); and they are meant to act as quick mental reference points for the therapist. Both categories of hysteria and obsession, as they are expressed through the symptoms of a person with neurosis, “can be understood as strategies for keeping one’s desire alive.” (Fink, 1997 p. 51)
The matheme for each subcategory is a “fundamental fantasy” from which the clients base their basic longings and relationship to external objects and people (Fink, 1995). The lower case “a” stands for an object, including objectified other people who are within the clients’ sphere of influence. The upper case “A” represents the symbolic “Other” that comes into existence via the client’s capacity to linguistically represent other people. Finally the upper case “S” stands for the clients themselves as a subject. Again there are multiple variations and intricacies just in the full explication of these two symbolizations; however, the focus of this paper is only on a brief description, which now will be followed by the pertinence of these formulations in relation to the transference.
The compounding variables of age, sex, gender, maturity level, cognitive capacity, previous traumatic history, and so forth, all of which are unique for, and remain of utmost importance to any given client, are given a basic structure, in the matheme, from which the therapist is then able to disentangle the sure massiveness of these various and variegated components. The utility of employing a concentrated formula that explicates the basic intrapsychic relational matrix of clients grants the therapist a movement into the clients’ unconscious: “Why are they doing this?” It gives the therapist a vaulted position from which all of the disparate machinations of the clients can be readily associated and related back to a coherent whole—this coincidentally, also, has the potential for keeping the desires of the clients alive, as the matheme, as was stated above, is meant to parallel the clients’ own strategy for keeping themselves in desirousness—but in regard to therapy, specifically for the continuance of therapy, all can attest to this oft encountered difficulty, when motivation for such, seems to be waning.
Russell, a 63-year-old Caucasian male, whose name has been altered to protect anonymity, presented with longstanding unemployability, the longest and most recent period lasting over 5 years to present. While the client’s chief concern related to this recent track of unemployment the secondary concerns of depression, pervasive disinterest and virtual total loss of motivation in nearly all areas of his life, seemed to me of critical importance. It must be restated that the matheme does not have hard and fast, distinct diagnostic criteria for which it is then guaranteed to be accurately applicable for a specific individual once those criteria are met; alternatively, the therapist is charged with following the dynamical pace for which the clients explicate themselves in relation to their presenting (not to mention their unconscious wishes) concerns (Fink, 1997). This is accomplished in the “here and now” of the therapeutic session and within the dynamic between the client and therapist as established in and with the prolongation and deepening of the transference—as described above.
Russell was fairly straightforward in situating his neurotic structure within the category of obsessive, ergo the matheme of (S <> a). From the initial session, in which Russell described to me the main elements of his current life circumstances, I was immediately aware of the superfluity my presence seemed to take on in relation to Russell. This is potentially an explicit manifestation of the main question that people with obsessive behaviors default to: “Am I dead or alive?” (Fink, 1997, p. 161). Russell’s primary mode of relating to me was via an ample exhibition of his fixation on his stories—all of them revolving around inanimate objects (e.g., his motorcycle, trinkets found at yard sales, and various broken technical instruments he gathered with the intention of fixing, yet, never has). Russell, of course did acknowledge my presence, while even maintaining a moderate amount of eye contact as he discussed, at length, his current constellation of problems (“a,” objects); however, he did so without much interest in my feedback, or acknowledgement; that is with limited intersubjective communications. Fink stated that this is a prototypical feature of individuals with obsessive symptoms in their relation to themselves, to their sense of being, as it is largely mediated by “being in thinking” (1997, p. 161).
Recognizing these two layers, there are many others I do not have space to describe, while positioning me in relation to Russell as he sees me, as an object: “a,” further allows me to structure my approach and strategy for asking him questions. The obsessive matheme, (S <> a), indicates that I do not exist for Russell as a subject and therefore he does not readily see me as capable of inspiring or motivating him and his desire. This structuration, however, then gives me the insight that I must, in the transference, both, create the environment that “becomes the site of an enactment of the subject’s [Russell’s] relation to the object” (Fink, 1997, p. 58). This is accomplished according to Fink similarly as Freud enacted “the role of the father as cause of the Rat Man’s desire” (1997, p. 59).
Lisa, name changed, was a 27-year-old Caucasian female presenting with panic and anxiety symptoms that had recently taken on agoraphobic severity. Also from the initial session with Lisa there were explicit references to the matheme: (a <> A) of a person with hysteria. The left side of the formula, the subject’s position, is occupied by the object “a” symbol and not the subject, “S,” which would be Lisa, herself. The right side of the formula, the other’s position, is occupied by the barred other and symbolizes the other as Lisa’s object of desire. The “bar” that crosses out the “A” symbolizes that language has divided that individual that becomes Lisa’s object of desire.
To quickly flesh this out, all throughout the duration of therapy Lisa placed me into this position, and in contradistinction to Russell, by mobilizing her desire, drive and motivation for therapy as a means of receiving praise and adoration from me. In, fact there is a countervailing conceptualization that transforms the obsessive’s relation to the other as pure object to that of the hysteric’s, know as hysterization; this allows the obsessive to mobilize his or her own desire and is said to be one stage on the way to alleviation of his or her symptoms. (Fink, 1997, p.131)
Lacan’s “Presentation on Transference”
Lacan (1966/2006) wrote a beautiful philosophical dissertation on the dynamic and effects of unacknowledged countertransferencial content, bordering on, in my mind, the poetic:
In other words, transference is nothing real in the subject if not the appearance, at a moment of stagnation in the analytic dialectic, of the permanent modes according to which she constitutes her objects. (p. 184)
Invoking a basic terminology, Lacan (1966/2006) is stating that the transference is most thoroughly expressed at the moments when there are stoppages or break-offs in the dialogue between client and therapist and that this is the expression of the stereotype plates, or “permanent modes” the client mobilizes in his or her attempts to relate with others. In Lacan’s Presentation on Transference (1966/2006) he is attempting to situate the transference in relation to Freud’s case study of Dora (1905/1963) and “to define in terms of pure dialectic the transference,” which can be understood as the dynamic between Freud and Dora.
First dialectical development: The determination that there is a starting point, a foundational “truth,” whether subjectively experienced or factually verifiable, that the client is capable of articulating, in dialectical terminology the thesis. In this case the thesis is the well expanded narrative made by Dora about her father’s relationship with a mistress, Frau K. Dora also reveals that her father actively participated in offering Dora in exchange to Herr K, the husband of Frau K, so that Dora’s father could then have Herr K with impunity.
1st Thesis: Dora’s narrative
Antithesis (stoppage): Dora’s unwillingness to divulge
Synthesis: Dora is jealous
First dialectical reversal (or stoppage): Freud initiates a request of Dora that she self reflect as to her involvement in the situation. Dialectically, the antithesis: Why is Dora doing the logical opposite by “stopping” the secret from coming into the open? The synthesis, the combination of thesis with antithesis, is revealed in the following second developmental truth in an underlying “truth” or motivation for Dora’s antithetical behavior.
Second dialectical development of truth: This truth is uncovered by synthesizing the thesis: Dora’s displeasure, which manifests as conversion symptoms, within the “love quadrille,” and the antithesis, that Dora is purposefully vouchsafing the secret; therefore the second development is Dora displaying a significant amount of jealousy toward the affair, which again leads Freud/Lacan to the second thesis.
2nd Thesis: Dora is jealous
Antithesis (stoppage): Dora has affection for Frau K.
Synthesis: Dora admits of attraction to Frau K.
Second dialectical reversal: The previous synthesis produces a relational dynamic between the four primary characters in the case and highlights the jealousy Dora expresses as the new, second thesis. However, this reveals that Dora is not explicitly interested in her father, but instead is interested in her rival, Frau K, for her father’s adoration and affections. This becomes the antithesis and is validated in the third development of truth.
Third development of truth: The synthesis of the second thesis: the jealousy toward her father, with the second antithesis: the actual affection for Frau K. is made dialectically apparent in Dora’s admission of a homosexual attraction to Frau K. This is the point of breakdown in the treatment of Dora. Freud was incapable of continuing the work impartially, and according to Lacan’s (1966/2006) perspective, this is due to Freud’s inability to reconcile his own personal homosexual tendencies.
3rd Thesis: Dora admits of attraction to Frau K.
Antithesis: Freud unable to control personal homosexual feelings
Synthesis: Breakdown in therapy due to unanalyzed countertransferential feelings
Herein lay the stoppage that Lacan (1966/2006) accrued to the concept of transference/counter-transference. Freud’s personal object relations to homosexual individuals, a counter-transferential reaction, breaks down the fluid pursuit of Dora’s true object of desire, Frau K—considered by Lacan (1966/2006) to be so, only, as a “body of mystery” (p. ), a surrogate of sorts for her own body that she has not yet fully come to realize or introject, and the reason for Dora’s stoppage: she is projecting onto her love object, Frau K., but due to the transaction’s homosexual nature Freud produced a stoppage of his own: one of a countertransferential nature.
When assessing the potential importance that the transference takes on during therapy, there is the added relation of how does a therapist operationalize and enact, in the here-and-now of the therapeutic dyad, the ensconced patterns that contribute to the client’s constellation of problems? I believe that the above-detailed accounts, via case studies, in combination with the exegesis of Lacan’s (1966/2006) conceptualization of the transference, countertransference and his mathemes for structuring the client’s psyche, have the dynamical and added potential to act as a schematic structure for any therapist, who can then overlay this schema upon nearly every one of his or her clients.
Statement of Competencies, Theoretical Orientation, and Future Plans
The practicum experience for the trainee therapist is a daunting phase. Regardless of the excitement and prospect for benefit there still remains a degree of pressurization that lends itself to the initial meeting of a client face-to-face. With no intermediary, except the knowledge one has garnered via the preceding academic phase of training, the experience has the potential to generate an ample amount of stress. However, the confluence of these two essential elements, the lived practice of therapy and the folding of academic theory into that experience, is the ultimate goal for the new therapist and once attained can be termed, their praxis. The purpose of this portion of the integration paper is to detail and, therein, deduce an archival narrative of my practical attempt at fulfilling this goal.
Abilities and Competencies
The Neighborhood Involvement Program (NIP) provided me serviceable areas within the counseling field in two critical areas: Assessment and Individual Therapy. NIP, also, allotted me the opportunity to work with a wide range of populations: Adult women, chemically dependent, students, gays/lesbians, trauma histories, adult men, people with disabilities and minorities. I was also introduced to a variegated cross-section of DSM-IV diagnosable clientele. While there was no specific theoretical orientation at the site, nor was there a specific subset of techniques that therapists were trained in or expected to be utilized, my individual supervision was primarily structured around a psychodynamic and relational perspective and my group supervision, a family systems, relational and existential perspective.
In the area of assessment, as an NIP therapist, I was required to perform initial diagnostic inquiries with each new client via an Individual Intake Summary. This aspect of therapy was reminiscent of Arnold Lazarus’s multi-modal therapeutic concept of the “B.A.S.I.C. I.D.” The intake summary, similarly, was an aid in exploring the general complications and life history of the client. Just as with Lazarus’s blueprint for strategizing with the client to formulate a general direction in regard to treatment, the intake summary was a brief template for evaluating progress; psychoeducationally there is a mutual benefit for both the client and therapist, and inclusive so as to allow the client an immediate introduction to the therapeutic process (Lazarus, 1981, p. 22).
The practice of individual therapy was the primary focus at the NIP site. The basic process for starting therapy with clientele at the site was the transmission of an initial client telephone intake form to a respective therapist. The telephone intake form functioned as a brief reference aid so the therapist would have some insight into the presenting problem of the client upon making first contact to establish a mutually conducive appointment for starting therapy.
The first appointment charged the client with completing a fairly extensive battery of paperwork, ranging from personal demographics to permission for audio/visual recording authorizations, to that of confidentiality, informed consent and HIPAA. The informational recording processes at NIP appeared to be professionally detailed enough and rigorously extensive so as to maintain ample data for the smooth operation and conduction of therapy.
The maintenance of case notes was a mandated priority at NIP and all of the therapists’ client files were subject to routine examination via their individual supervisor with random inspections via the site’s program director, Shannon Schmidt. The learned skill of annotating accurate, descriptive and concise case notes was consistently emphasized and exercised throughout the practicum. While I was most familiar with the procedural notation of P.A.I.R. (Problem, Assessment, Intervention, and Response) formally instituted at the Crisis Intervention Program in North Memorial Medical Center, Robbinsdale, MN of which I have maintained a mental health assistant position for nearing 3 years, I quickly deduced the limiting scope of such a model outside a strictly psychiatric, behaviorally focused perspective.
The therapeutic work that I was performing at NIP was much more varied. In contradistinction to the hospital, which primarily resolved patient behavior to psychopharmacological and reinforcement/punishment schedules, clients at NIP were not primarily concerned with discrete behavioral maladaptions, but more systemically broad narratives that required notation to be equally expansive and colorful to accurately contain and reconstruct the experiential and subjective aspects of the client. This penchant for a narrative form of note taking is, obviously, influenced by my psychodynamic, narrative therapy theoretical perspective, of which, I engaged my clients during therapy.
At the outset of this, the third section, of the paper I referenced the dual operation of combining the knowledge garnered through the academic phase of the counseling program with that of its active implementation in the experiential pursuit of performing individual therapy and that this could be termed, praxis. I believe that through my exceptionally beneficial practice at NIP, and lesser so in my difficult experience at the Saint Louis Junior High, I have been able to progress toward this end with exciting precision and positive gain.
This subsection, Theoretical Orientation, is the academic pole that lies in opposition to the pragmatic, active experience of actually working with clientele and must be folded back into experience of the practica. Structurally speaking, from the perspective of Saint Mary’s University, I am aware that traditionally this section is to fall within the third part of the integration paper; however, I have seen it more fit to include my theoretical orientation, which again is highly influenced by Lacanian Psychoanalysis and Short-term Dynamic Psychotherapy, in part two, the Literature Review section. My theory is intimately connected to its actual pragmatic operationalization and therefore is more readily assimilated and actuated if I place it in relation to the theme of my literature review—itself, a major dynamical aspect of therapy: Transference and countertransference, as relatable to the intervention of transference interpretations.
Strengths and Areas for Growth
Self-assessing the positive and negative abilities of one’s own skill-set from within the field of counseling and psychological services, while granting myself this exercise in self-reflection there remains the invitablility of subjective bias. However, the pedogoical aspect far outreaches any personal coloration that may insinuate itself into the argument. Overall, as a nascent therapist, I believe that I have progressed in a fairly rapid and systematic fashion to a point where I consider myself to be an above average therapist with adequate competencies in nearly all the major areas in regard to individual counseling.
In an attempt to mitigate the potential effects of subjective bias and its interference, I will be following in a schematic sense the outline of St. Mary’s “Practicum Student Evaluation Form: End of semester II” that Jennie Yngsdahl filled out and both she and I discussed upon the completion of my practicum at NIP. The four main categories of “therapeutic skills, assessment skills, professional relationships, and diversity competence” will be further explicated in relation to the form’s generally sterile numerological qualification of ability.
The category of therapeutic skills encompasses a wide range of qualities that I will scale down to a manageable subset that prioritizes the most salient and impactful. I have consistent and accurate recollections of making “active listening” a focal point in both my contemporary therapeutic interventions, but also, since the first time I was introduced to the concept in my high school days. There remains and I continually build upon this historical foundation for this skill, which, I believe is one of my most important personal orientations in developing and strengthening rapport with the client.
Following along these lines then would be the equally important skill of rapport and relationship building. This skill has been distinguished as one of the core active ingredients that helps facilitate therapeutic change above and beyond the diversity of theoretical perspectives. I believe that there is a confluence of skills that combine to enliven and energize the interaction between client and therapist. For me these include as major components, but is not limited to: active listening and empathy.
As an illustration of such a confluence and a further explication of the slight deficiency I attribute to myself in the skill of empathetic response, I will discuss briefly two separate client experiences. The first is, John, name altered for confedentiality, a Caucasian male client in his late 30s who systematically presented with a constricted affect, low self-esteem, low grade depression and a pattern of seeking out validation and direction from me, the therapist. Active listening, rapport and empathy are all elementally interconnected within the full expression of each skill in its apparent separation, individuality.
John maintained a consistent pattern of deference to me as a source of direction for the loss of direction that he would find himself in a loss of words. This would happen multiple times per session. Via my capacity to listen in an active and perceptive fashion I was able to redirect and key into specific material that overlayed John’s pattern of trailing off and losing his ability to maintain a dialogue. We developed multiple metaphors that inscribed and highlighted the latent content (i.e., the client simply wanted to “play” and move through the “stagnated water pools” of his emotion, in relation to the manifest content), (i.e., “I rarely talk to old friends, ‘out of sight, out of mind) which was related back to playing the childhood game of hide-and-seek.’”
The “stagnant water” was metaphorized as him staying or remaining in the “hidden” position waiting for his friends to seek him out. We discussed that one of the main dynamics of this childhood game is the potentiality that when one hides that child has to be aware that if hidden so well there is no recourse of being found and that child then must “peek-out” or make small insinuating clatter in order for the interest and search to be maintained by the seeker.
My perception and subsequent empathetic response to his building sense of loss and separation was, in my mind, a major contributer to the emotional release that he thereafter experienced. The rapport, therapeutic alliance, was also greatly enhanced as we moved forward from that session. The client, previously was consistently late and confrontational; however, following this enactment the client redoubled his efforts to arrive on time and pursue the contemplation of themes discussed within therapy, outside of therapy.
In contradistinction to this impactful and positive utilization of the skill of empathetic response I believe that my work with another client, Arron, name altered for confidentiality, a Caucasian male in his late 20s is illustrative of my inexperience as a therapist. Arron presented with a low grade and persistent depressive state. His symptom constellation also included low levels of energy, apathy in regard to career goals however he wanted to “want” to achieve and change his current position in life. I diagnosed him with 300.4 Dysthymic Disorder.
I received and sought out, an ample amount of supervision in regard to Arron’s case. He maintained relative consistency in his weekly sessions that lasted for over 5 months. There were breaks in therapy; mainly for events that were foreseen, as there were only 1-2 sessions Arron was unable to give 24 hours notice of cancellation. While the therapeutic rapport with Arron was quite high, he was motivated during sessions to express himself, I believe that I was unable to tap into his underlying insecurities and pain due my active stance to therapy.
Jenny Yngsdahl advised me to attempt a more feelings-grounded stance from which I could then create a holding environment that may then eventually and naturally elicit an emotional response from Arron. He was potentially holding onto a great degree of shame and self-denegration of which I was unable to access because of my activity as it translated into performance anxiety—only adding to the painful feelings of shame and further recriminations onto his self-concept. My inability to empathize with his postion potentially disturbed the progress of treatment so much that Arron eventually called me saying that he was literally in a state of near “terror” in relation to coming to see me for his next session. I realize that there are further extenuating circumstances within his core neurotic pathology that were beginning to present themselves to Arron’s consciousness; however, I was unable to truly connect with that and alie his fears so that therapy could continue. This was by far the most extreme outcome I experienced in relation to a client’s reactions to my practice as a therapist. However, given my preference for therapeutic approaches that require complex analysis, I will continue to seek moderate to significant supervision depending on the case.
The vast array of therapeutic modalities and my research into the complex theorizations therein will remain a prominent feature in relation to both my career goals and as a continuance of the praxis that I have often referred to within this paper. My work for North Memorial Medical Center has granted me an inestemible opportunity to work with a population, while severely pathologized are not so different from the general population (if at all) but are simply extreme expressions of the charactorlogical and behavioral realities we all experience, and very few other training therapists have had such good fortune to experience.
Amongst others, I am currently negotiating potential opportunities for advancement within the hospital, but have a very strong desire to set out as a sole proprietor, or in conjunction with a couple like minded therapists, to open my own practice. There will be a definite sabatical of sorts from the structure and regimentation of traditional academia; however, I will be in continual contact, nearing full immersion, with my favorite theorists of Psychoanalysis, including those of my undergraduate degree in Cultural Studies and Comparative Literature, all the while biding my time, contemplating my next move, bolstering my praxis in readiness for an advanced “assult,” if you will, upon the ivory tower.
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