COUNTER-TRANSFERENCE PROBLEMS IN TREATING OBSESSIONALS*
JOSEPH R. BUCHANAN, M.D.!
The term obsessionals as used in this paper refers to the obsessive-compulsive personality type, the clinical features of which have been excellently described by Salzman, (3) and it does not refer to the much rarer obsessive-compulsive neurotic reaction (e.g., hand-washing compulsion). The observations made in this paper were based on a group of obsessional patients with the necessary personality strengths to be deemed suitable for either psychoanalysis or for long-term dynamic psychotherapy focused on character change and subsequent relief from the extremely constricting personality style. The term counter-transference is used here not in the original classical Freudian sense, as reactions of the therapist to the patient based on unresolved infantile conflicts in the therapist, but is used in a broader, more modern sense to refer to a wide range of emotional reactions occurring in the therapist, and which are dependent upon the interaction of all personality variables, both healthy and neurotic, in both parties. These responses are not static, but comprise an evolving set of reactions dependent upon changes that take place in the patient, and to a lesser extent in the therapist, during the therapeutic process. Therefore the possibilities are extremely wide, and no paper can do justice to them. 'Presented at Annual Meeting of the Canadian Psychiatric Association, Banff, Alberta, September 1975 Manuscript received April 1977 I Assistant Professor of Psychiatry, Faculty of Medicine, University of Ottawa and Department of Psychiatry, Ottawa Civic Hospital, Ottawa, Ontario Can. Psychiatr. Assoc. J. Vol, 22 (1977)
This paper contains a small sample of the range of counter-transference reactions identified by a rather obsessional therapist over several years of therapeutic work. One of the most valuable tools available in working with the obsessional is the therapist's own personality, providing he can use this tool skillfully, otherwise therapy is a risky business for both parties. However, the alternative is a falling back exclusively on theory and technique, which makes for an unduly protracted treatment characterized by insight but little behavioural change in patient and, I might add, in therapist. Working with obsessionals can be hard 'on the therapist's narcissism. One must be content with few and far-spaced comments of gratitude, and try to ignore the qualifying comments that accompany them. For example, if after many months of therapy during which your technique is analyzed and all the flaws noted your patient says, "As shrinks go, you have a fairly good sense of humour", one should hold onto the "good sense of humour" part and ignore the qualifiers. During the first phase of treatment as one attempts to deal with the defence of isolation, the stance of the classical, detached, reflecting mirror does not work well. It is vital to be more active and to have the patient actively feel your presence. I have found this role to be personally rather draining. It seems one has to be a combination of (i) Sherlock Holmes, who will not be led off the trail by the numerous red herrings contained in the obsessional's brand of free associating (obsessionals
269
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CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
actually' 'free-associate" in reverse - their associations lead away from relevant emotional issues rather than toward them); (ii) a very durable and resilient teddy bear that the patient can toss around in his seemingly endless power games, and (iii) a sort of prostitute, ready to accept the obsessional's need for you, respecting his delusion that you are there only to provide a service, and not a source of gratification of his dependency needs. That is the last thing he wants to hear from you at this stage! Attempting to fill this role presents the therapist with several emotional hazards: The chronic problem of boredom: Day after day one hears words, words, dry words with all hints of emotion drained from them, pouring out endlessly. As the capacity to listen diminishes the facial muscles become strained in trying to maintain an appearance of serious interest. One further develops the ability to yawn without the patient knowing it. A flight away from the patient into fantasy: Not a creative fantasy which may help you to define where the patient is at during that moment but an autistic one where one slips into thoughts of what else is on the agenda for the day, to family matters, or to anticipation of the hysterical patient who follows and whom you always book after this patient as a "pick-me-up" . Impatience: One thinks "lets get this show on the road". We may attempt to condense the patient's narrative for him. When one suggests "What you seem to be saying is this, ... ", the obsessional may say "Of course, that is what I have been saying all along" , and you then feel stupid for stating the obvious; or he might say' 'No, that is not quite what I meant", and you feel stymied as you know you will never be able to say exactly what he meant. If the therapist's self-esteem at this point needs reinforcing he might commit the next offence, that is, he gets into arguments with his patient. Even as that first verbal stone is thrown at the patient you have that sinking feeling that you have been led into committing a mistake. And you realize the next hazard
Vol. 22, NO.6
of working with obsessionals a nagging feeling of inadequacy. Patients often have personal qualities which we do not like. One of the qualities of the obsessive which may bother us is his smiling. It is almost diagnostic - a frequent, tight stereotyped smile hiding anxiety and hostility but always conveying a certain air of insincerity, which causes us to hesitate in smiling back. To summarize: the emotional hazards are boredom, escape into fantasy, impatience, argumentative behaviour, dislike and feeling of inadequacy. These emotional reactions, of which the therapist is conscious, do not present the major stumbling block in therapy. Depending on training and experience we should be able to use our feelings of boredom, impatience, irritation, and so on, as a diagnostic tool and say to ourselves, "If he is making me feel this way, why does he have to do it to me" , and we can come to recognize that his interpersonal style has its defensive function, to appreciate that our reactive emotional states may be similar to those states the patient himself experienced with his parents, and we can then focus our energies to help him see how he perpetuates these states within himself. We are likely to do more serious damage by the emotional reactions of which we are not conscious. The most damaging of these is our unconscious sadism - nothing overt, but very subtle, highly disguised and strongly rationalized. Unless we become aware of these tendencies we may perpetuate in our patient those very conditions responsible for his difficulties in the beginning - that is, those disguised, sadistic, frustrating tendencies of the parents that neither parent nor child could appreciate, but which unfortunately victimized them both. We, too, may not appreciate these same tendencies in ourselves but should look for them in two areas: 1) In our use of interpretations, and
2) Checking if we are slow to recognize and support the patient's genuine feelings or whether we are always
October, 1977
COUNTER-TRANSFERENCE PROBLEMS
confusing them with those prompted by his neurotic need for security. 1) One should look for a tendency to make interpretations which are too premature, too much to the point, too accurate, too frequent and those which tend to pin the patient down. An interpretation is essentially an interpersonal exchange via the medium of words. Obsessives perceive words as having magical powers, are extremely sensitive to them, and are very vulnerable to being depreciated by verbal criticism (2). This vulnerability is stimulated every time the therapist speaks. The therapist's latent sadism may find its expression via the unspoken, subtle criticism contained in his interpretations. I have come to suspect any of my interpretative behaviour with the obsessive during the first 6-12 months of therapy and have tried to confine my verbal responses to asking questions beginning with what, when, where, how, but not why; as well as repeatedly suggesting devices the patient may use to profitably work on himself in the session to discover himself. 2) The other problem the obsessional encountered in childhood was a tendency by parents to use verbal interchange to overlook, ignore or otherwise discount the child's true feelings. Consequently, as the adult obsessional in therapy, the patient will also discount them. Furthermore, the therapist's unconscious need to frustrate may find expression in a tendency to withhold his recognition of these true feelings. We may be slow to respond empathic ally in kind to the patient's feeble attempts to feel genuine friendship, caring, remorse, nostalgia, joy, ecstacy, and so on. Our careful air of seriousness, and our preoccupation with technique which make us reluctant to show the patient our spontaneous responses for fear of being out of character, does have a dampening effect on his spontaneity. In other words, if the emotional climate of exchange between doctor and patient is flat and dead, we must be sure it is not due to the invisible wet blanket laid on it by the therapist as he unconsciously frustrates growth and de-
271
velopment of the patient's genuine feelings by his preoccupation with those feelings neurotically generated such as guilt; hostility and anxiety. So far, some counter-transference problems have been described in a general way without taking into consideration the major personality trends in the therapist. These trends (1) do affect the treatment process and do determine which conflicts the patient will have greater or less difficulty coping with. Obviously, one cannot explore many of these. The following three are common patterns that emerge in the doctor-patient relationship and which reflect the interaction of the respective personalities. The obsessional patient and the selfeffacing therapist: Self-effacing people need to be liked and to be helpful; they value close, warm relationships, try to overlook others' shortcomings, are quick to forgive, will consider others' opinions over their own, however they are uneasy with any display of hostility either in themselves, or coming from others. In the early stages of therapy, these therapists have a calming effect on their patients. As they are non-threatening the patient feels he won't be attacked, nevertheless, he is uneasy with the friendliness, which he mistakes for weakness and softness, and he may fear the therapist will be a pushover. Difficulties arise later in therapy and centre around the relationship of anxiety to hostility. In obsessionals, anxiety breeds hostility when he is scared he attacks, usually underhandedly. In the self-effacing the reverse is true - hostile feelings create anxiety. As the patient moves toward tapping his inner conflicts, anxiety mounts, and he defends himself with mounting hostility toward the therapeutic process. The therapist responds with interventions to calm the patient. He may say he understands the hostility, that it is to be expected, that it is O.K. At this point however, the patient would be more reassured by a stance of firmness, as he experiences the therapist as trying to appease him, which raises his contempt for the therapist, which is immediately followed by guilt. The long-term outcome of this interaction may be an
272
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unconscious pact between the two to be nice to each other which, in the long run, may have the effect of enabling the patient to have greater respect for his own repressed needs for warmth and closeness, but does delay exploration of his aggressive behaviour toward others inside and outside the treatment situation. The obsessional patient-obsessional therapist interaction: This one should be familiar, and it usually works out very well for two reasons: First, hopefully the therapist is less obsessional than his patient and is equipped with all those positive obsessional attributes he will need in working with this patient, such as diligence, zest for hard work, need for objectivity, and capacity to see things through to their conclusion. Secondly, in his truly reflective and non-ruminative moments he knows and can empathize with the obsessional's dilemma, so he is aware of those special sensitive areas in his patient which he must approach gently. Problems arise only as the therapist's own defences reinforce those of the obsessional. Early phases of therapy go smoothly as the pair speak the same language. Both value words as the key to self-knowledge; if the patient talks long enough the answers will come. As words and ideas are a source of power for both, what emerges later is a prolonged power struggle, not fought openly but as an underground tug-of-war. The therapist usually wins. His own needs for mastery and control have found their solution in a mastery of theory and technique. As the patient's resistances are worked through, he does begin to understand himself. However, since the source of understanding has been the. intellect, the neurotic pride in intellect has not been worked through, and understanding himself is not replaced with knowing himself, and he remains somewhat emotionally constricted. Mutual respect and politeness have been the emotional colour of the relationship rather than passion. Both hasten to "work through" the transference neurosis rather than emotionally grow by lingering in it. The transference phenomenon is a spectre from the past for the patient
Vol. 22, NO.6
to comprehend, rather than a statement of mutual emotional involvement. The obsessional patient and the narcissistic therapist: Treating the obsessional is hard on one's narcissism. We invest considerable pride in our interpretations, this pride is reinforced by other patients who benefit from them, but the obsessional always finds something not quite correct in their wording, timing, or relevance. Hopefully, this eventually has a therapeutic effect on us and helps us to maintain a more modest view of our abilities. However, when the therapist's narcissistic trends are predominant in his personality, one sees a different picture. I use narcissism here in the descriptive sense only as being in love with one's own image. I am referring to people whose selfevaluation is inflated and persistently positive, who are buoyant with energy, charm, aware of their endowments and proud to display them. Free of self-doubts, they tackle any problem without hesitation, yet need endless confirmation of their assets by seeking admiration and devotion from others. With a touch of patronizing concern this therapist is quite tolerant of others' shortcomings, and when the obsessional attacks his interpretations, his selfconfidence is not shaken, as he tolerantly accepts what he feels is the patient's limited ability to grasp the full meaning of the interpretation, and he feels confident that in time the patient will come to appreciate its relevance. The effect on the obsessional may be quite positive. Plagued by self-doubts, it is a ray of hope to meet someone who seems entirely devoid of them. The buoyancy and self-confidence rubs off a bit on the patient. Furthermore, since the therapist's self regard is high he attaches similar regard to any of his work, which in this instance is the patient, who now basks in this reflected self-regard. The effect of this is that fairly early there is diminishment of self-hate in the obsessional and he is able to take risks with himself and to break out of the self-doubting which has lead to inaction. He can more readily risk the anxiety involved in change. One problem which may emerge is
October, 1977
COUNTER-TRANSFERENCE PROBLEMS
over-identification with the therapist. In addition, the patient may complete therapy without resolving the transference. Due to the obsessives' high self-imposed standards requiring a very critical self-assessment, he regards any conscious display of grandiosity in himself as improper, so these trends remain unconscious. But with this therapist he can also disown grandiose trends by actively externalizing them to the therapist, where he can support them. This allows for the gratification of the patient's and the therapist's mutual grandiosity. Neither party adequately works through the patient's need to idealize the therapist. The price for the patient may be too high; he would have to accept that much of his self-confidence is really not his own, but is borrowed from the therapist. These three doctor-patient interactions have been described in isolation as distinct static phenomena, which of course they are not. Obviously each therapist, as well as patient has various combinations of selfeffacing, obsessional (perfectionistic), narcissistic trends, as well as other trends. Which trends become manifest in therapy is a function of the various aspects of the therapeutic process as it unfolds. Finally, although working with the obsessional is demanding emotionally, most of the difficulties are confined to the early stages when the patient's defence of isolation is being challenged. It is certainly worth the effort, because later in therapy it is a very gratifying experience to watch your patient grow, and also see him finally free-associate, something neither you nor he thought possible in the beginning. Summary One of the most valuable tools one has in working with the obsessional is the therapist's own personality, providing one
273
can use this tool skillfully. Each doctorpatient relationship is unique and will bring with it its own unique counter-transference problems. Common problems of which we are consciously aware include boredom, escape into fantasy, impatience, argumentative behaviour, dislike and feeling of inadequacy. Hopefully we can utilize these feelings to further our understanding of the patient's dilemma. One problem we should be alert to is our unconscious sadism which may find expression in the nature of our interpretive behaviour. References Horney, Karen: Neurosis and Human Growth. New York: W.W. Norton, pp. 333-365, 1950. 2. Offenkrantz, William, Tobin, Arnold: Psychoanalytic psychotherapy. Arch Gen Psychiatry 30: May, 601, 1974. 3. Salzman, Leon: The Obsessive Personality. New York: W.W. Norton, 1950. I.
Resume La personnalite du therapeute constitue un des outils les plus valables qu'il possede dans le traitement de l' obsessionnel, pourvu qu'il sache l'utiliser avec habilite. Chaque relation docteur-malade est unique et suscitera ses problemes particuliers de contretransfert. Les problemes habituels dont nous sommes conscients comprennent l' ennui, l' evasion dans le fantasme, l'impatience, la critique, l' antipathie et le sentiment d'Incompetence. Ces sentiments, on I'espere, peuvent etre utilises afin d' atteindre une meilleure comprehension du dilemme du malade. Un probleme auquel on doit etre attentif est notre sadisme inconscient qui peut trouver son expression dans la nature de nos interpretations.
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274
JOSEPH R. BUCHANAN, M.D.!
The term obsessionals as used in this paper refers to the obsessive-compulsive personality type, the clinical features of which have been excellently described by Salzman, (3) and it does not refer to the much rarer obsessive-compulsive neurotic reaction (e.g., hand-washing compulsion). The observations made in this paper were based on a group of obsessional patients with the necessary personality strengths to be deemed suitable for either psychoanalysis or for long-term dynamic psychotherapy focused on character change and subsequent relief from the extremely constricting personality style. The term counter-transference is used here not in the original classical Freudian sense, as reactions of the therapist to the patient based on unresolved infantile conflicts in the therapist, but is used in a broader, more modern sense to refer to a wide range of emotional reactions occurring in the therapist, and which are dependent upon the interaction of all personality variables, both healthy and neurotic, in both parties. These responses are not static, but comprise an evolving set of reactions dependent upon changes that take place in the patient, and to a lesser extent in the therapist, during the therapeutic process. Therefore the possibilities are extremely wide, and no paper can do justice to them. 'Presented at Annual Meeting of the Canadian Psychiatric Association, Banff, Alberta, September 1975 Manuscript received April 1977 I Assistant Professor of Psychiatry, Faculty of Medicine, University of Ottawa and Department of Psychiatry, Ottawa Civic Hospital, Ottawa, Ontario Can. Psychiatr. Assoc. J. Vol, 22 (1977)
This paper contains a small sample of the range of counter-transference reactions identified by a rather obsessional therapist over several years of therapeutic work. One of the most valuable tools available in working with the obsessional is the therapist's own personality, providing he can use this tool skillfully, otherwise therapy is a risky business for both parties. However, the alternative is a falling back exclusively on theory and technique, which makes for an unduly protracted treatment characterized by insight but little behavioural change in patient and, I might add, in therapist. Working with obsessionals can be hard 'on the therapist's narcissism. One must be content with few and far-spaced comments of gratitude, and try to ignore the qualifying comments that accompany them. For example, if after many months of therapy during which your technique is analyzed and all the flaws noted your patient says, "As shrinks go, you have a fairly good sense of humour", one should hold onto the "good sense of humour" part and ignore the qualifiers. During the first phase of treatment as one attempts to deal with the defence of isolation, the stance of the classical, detached, reflecting mirror does not work well. It is vital to be more active and to have the patient actively feel your presence. I have found this role to be personally rather draining. It seems one has to be a combination of (i) Sherlock Holmes, who will not be led off the trail by the numerous red herrings contained in the obsessional's brand of free associating (obsessionals
269
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CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
actually' 'free-associate" in reverse - their associations lead away from relevant emotional issues rather than toward them); (ii) a very durable and resilient teddy bear that the patient can toss around in his seemingly endless power games, and (iii) a sort of prostitute, ready to accept the obsessional's need for you, respecting his delusion that you are there only to provide a service, and not a source of gratification of his dependency needs. That is the last thing he wants to hear from you at this stage! Attempting to fill this role presents the therapist with several emotional hazards: The chronic problem of boredom: Day after day one hears words, words, dry words with all hints of emotion drained from them, pouring out endlessly. As the capacity to listen diminishes the facial muscles become strained in trying to maintain an appearance of serious interest. One further develops the ability to yawn without the patient knowing it. A flight away from the patient into fantasy: Not a creative fantasy which may help you to define where the patient is at during that moment but an autistic one where one slips into thoughts of what else is on the agenda for the day, to family matters, or to anticipation of the hysterical patient who follows and whom you always book after this patient as a "pick-me-up" . Impatience: One thinks "lets get this show on the road". We may attempt to condense the patient's narrative for him. When one suggests "What you seem to be saying is this, ... ", the obsessional may say "Of course, that is what I have been saying all along" , and you then feel stupid for stating the obvious; or he might say' 'No, that is not quite what I meant", and you feel stymied as you know you will never be able to say exactly what he meant. If the therapist's self-esteem at this point needs reinforcing he might commit the next offence, that is, he gets into arguments with his patient. Even as that first verbal stone is thrown at the patient you have that sinking feeling that you have been led into committing a mistake. And you realize the next hazard
Vol. 22, NO.6
of working with obsessionals a nagging feeling of inadequacy. Patients often have personal qualities which we do not like. One of the qualities of the obsessive which may bother us is his smiling. It is almost diagnostic - a frequent, tight stereotyped smile hiding anxiety and hostility but always conveying a certain air of insincerity, which causes us to hesitate in smiling back. To summarize: the emotional hazards are boredom, escape into fantasy, impatience, argumentative behaviour, dislike and feeling of inadequacy. These emotional reactions, of which the therapist is conscious, do not present the major stumbling block in therapy. Depending on training and experience we should be able to use our feelings of boredom, impatience, irritation, and so on, as a diagnostic tool and say to ourselves, "If he is making me feel this way, why does he have to do it to me" , and we can come to recognize that his interpersonal style has its defensive function, to appreciate that our reactive emotional states may be similar to those states the patient himself experienced with his parents, and we can then focus our energies to help him see how he perpetuates these states within himself. We are likely to do more serious damage by the emotional reactions of which we are not conscious. The most damaging of these is our unconscious sadism - nothing overt, but very subtle, highly disguised and strongly rationalized. Unless we become aware of these tendencies we may perpetuate in our patient those very conditions responsible for his difficulties in the beginning - that is, those disguised, sadistic, frustrating tendencies of the parents that neither parent nor child could appreciate, but which unfortunately victimized them both. We, too, may not appreciate these same tendencies in ourselves but should look for them in two areas: 1) In our use of interpretations, and
2) Checking if we are slow to recognize and support the patient's genuine feelings or whether we are always
October, 1977
COUNTER-TRANSFERENCE PROBLEMS
confusing them with those prompted by his neurotic need for security. 1) One should look for a tendency to make interpretations which are too premature, too much to the point, too accurate, too frequent and those which tend to pin the patient down. An interpretation is essentially an interpersonal exchange via the medium of words. Obsessives perceive words as having magical powers, are extremely sensitive to them, and are very vulnerable to being depreciated by verbal criticism (2). This vulnerability is stimulated every time the therapist speaks. The therapist's latent sadism may find its expression via the unspoken, subtle criticism contained in his interpretations. I have come to suspect any of my interpretative behaviour with the obsessive during the first 6-12 months of therapy and have tried to confine my verbal responses to asking questions beginning with what, when, where, how, but not why; as well as repeatedly suggesting devices the patient may use to profitably work on himself in the session to discover himself. 2) The other problem the obsessional encountered in childhood was a tendency by parents to use verbal interchange to overlook, ignore or otherwise discount the child's true feelings. Consequently, as the adult obsessional in therapy, the patient will also discount them. Furthermore, the therapist's unconscious need to frustrate may find expression in a tendency to withhold his recognition of these true feelings. We may be slow to respond empathic ally in kind to the patient's feeble attempts to feel genuine friendship, caring, remorse, nostalgia, joy, ecstacy, and so on. Our careful air of seriousness, and our preoccupation with technique which make us reluctant to show the patient our spontaneous responses for fear of being out of character, does have a dampening effect on his spontaneity. In other words, if the emotional climate of exchange between doctor and patient is flat and dead, we must be sure it is not due to the invisible wet blanket laid on it by the therapist as he unconsciously frustrates growth and de-
271
velopment of the patient's genuine feelings by his preoccupation with those feelings neurotically generated such as guilt; hostility and anxiety. So far, some counter-transference problems have been described in a general way without taking into consideration the major personality trends in the therapist. These trends (1) do affect the treatment process and do determine which conflicts the patient will have greater or less difficulty coping with. Obviously, one cannot explore many of these. The following three are common patterns that emerge in the doctor-patient relationship and which reflect the interaction of the respective personalities. The obsessional patient and the selfeffacing therapist: Self-effacing people need to be liked and to be helpful; they value close, warm relationships, try to overlook others' shortcomings, are quick to forgive, will consider others' opinions over their own, however they are uneasy with any display of hostility either in themselves, or coming from others. In the early stages of therapy, these therapists have a calming effect on their patients. As they are non-threatening the patient feels he won't be attacked, nevertheless, he is uneasy with the friendliness, which he mistakes for weakness and softness, and he may fear the therapist will be a pushover. Difficulties arise later in therapy and centre around the relationship of anxiety to hostility. In obsessionals, anxiety breeds hostility when he is scared he attacks, usually underhandedly. In the self-effacing the reverse is true - hostile feelings create anxiety. As the patient moves toward tapping his inner conflicts, anxiety mounts, and he defends himself with mounting hostility toward the therapeutic process. The therapist responds with interventions to calm the patient. He may say he understands the hostility, that it is to be expected, that it is O.K. At this point however, the patient would be more reassured by a stance of firmness, as he experiences the therapist as trying to appease him, which raises his contempt for the therapist, which is immediately followed by guilt. The long-term outcome of this interaction may be an
272
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
unconscious pact between the two to be nice to each other which, in the long run, may have the effect of enabling the patient to have greater respect for his own repressed needs for warmth and closeness, but does delay exploration of his aggressive behaviour toward others inside and outside the treatment situation. The obsessional patient-obsessional therapist interaction: This one should be familiar, and it usually works out very well for two reasons: First, hopefully the therapist is less obsessional than his patient and is equipped with all those positive obsessional attributes he will need in working with this patient, such as diligence, zest for hard work, need for objectivity, and capacity to see things through to their conclusion. Secondly, in his truly reflective and non-ruminative moments he knows and can empathize with the obsessional's dilemma, so he is aware of those special sensitive areas in his patient which he must approach gently. Problems arise only as the therapist's own defences reinforce those of the obsessional. Early phases of therapy go smoothly as the pair speak the same language. Both value words as the key to self-knowledge; if the patient talks long enough the answers will come. As words and ideas are a source of power for both, what emerges later is a prolonged power struggle, not fought openly but as an underground tug-of-war. The therapist usually wins. His own needs for mastery and control have found their solution in a mastery of theory and technique. As the patient's resistances are worked through, he does begin to understand himself. However, since the source of understanding has been the. intellect, the neurotic pride in intellect has not been worked through, and understanding himself is not replaced with knowing himself, and he remains somewhat emotionally constricted. Mutual respect and politeness have been the emotional colour of the relationship rather than passion. Both hasten to "work through" the transference neurosis rather than emotionally grow by lingering in it. The transference phenomenon is a spectre from the past for the patient
Vol. 22, NO.6
to comprehend, rather than a statement of mutual emotional involvement. The obsessional patient and the narcissistic therapist: Treating the obsessional is hard on one's narcissism. We invest considerable pride in our interpretations, this pride is reinforced by other patients who benefit from them, but the obsessional always finds something not quite correct in their wording, timing, or relevance. Hopefully, this eventually has a therapeutic effect on us and helps us to maintain a more modest view of our abilities. However, when the therapist's narcissistic trends are predominant in his personality, one sees a different picture. I use narcissism here in the descriptive sense only as being in love with one's own image. I am referring to people whose selfevaluation is inflated and persistently positive, who are buoyant with energy, charm, aware of their endowments and proud to display them. Free of self-doubts, they tackle any problem without hesitation, yet need endless confirmation of their assets by seeking admiration and devotion from others. With a touch of patronizing concern this therapist is quite tolerant of others' shortcomings, and when the obsessional attacks his interpretations, his selfconfidence is not shaken, as he tolerantly accepts what he feels is the patient's limited ability to grasp the full meaning of the interpretation, and he feels confident that in time the patient will come to appreciate its relevance. The effect on the obsessional may be quite positive. Plagued by self-doubts, it is a ray of hope to meet someone who seems entirely devoid of them. The buoyancy and self-confidence rubs off a bit on the patient. Furthermore, since the therapist's self regard is high he attaches similar regard to any of his work, which in this instance is the patient, who now basks in this reflected self-regard. The effect of this is that fairly early there is diminishment of self-hate in the obsessional and he is able to take risks with himself and to break out of the self-doubting which has lead to inaction. He can more readily risk the anxiety involved in change. One problem which may emerge is
October, 1977
COUNTER-TRANSFERENCE PROBLEMS
over-identification with the therapist. In addition, the patient may complete therapy without resolving the transference. Due to the obsessives' high self-imposed standards requiring a very critical self-assessment, he regards any conscious display of grandiosity in himself as improper, so these trends remain unconscious. But with this therapist he can also disown grandiose trends by actively externalizing them to the therapist, where he can support them. This allows for the gratification of the patient's and the therapist's mutual grandiosity. Neither party adequately works through the patient's need to idealize the therapist. The price for the patient may be too high; he would have to accept that much of his self-confidence is really not his own, but is borrowed from the therapist. These three doctor-patient interactions have been described in isolation as distinct static phenomena, which of course they are not. Obviously each therapist, as well as patient has various combinations of selfeffacing, obsessional (perfectionistic), narcissistic trends, as well as other trends. Which trends become manifest in therapy is a function of the various aspects of the therapeutic process as it unfolds. Finally, although working with the obsessional is demanding emotionally, most of the difficulties are confined to the early stages when the patient's defence of isolation is being challenged. It is certainly worth the effort, because later in therapy it is a very gratifying experience to watch your patient grow, and also see him finally free-associate, something neither you nor he thought possible in the beginning. Summary One of the most valuable tools one has in working with the obsessional is the therapist's own personality, providing one
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can use this tool skillfully. Each doctorpatient relationship is unique and will bring with it its own unique counter-transference problems. Common problems of which we are consciously aware include boredom, escape into fantasy, impatience, argumentative behaviour, dislike and feeling of inadequacy. Hopefully we can utilize these feelings to further our understanding of the patient's dilemma. One problem we should be alert to is our unconscious sadism which may find expression in the nature of our interpretive behaviour. References Horney, Karen: Neurosis and Human Growth. New York: W.W. Norton, pp. 333-365, 1950. 2. Offenkrantz, William, Tobin, Arnold: Psychoanalytic psychotherapy. Arch Gen Psychiatry 30: May, 601, 1974. 3. Salzman, Leon: The Obsessive Personality. New York: W.W. Norton, 1950. I.
Resume La personnalite du therapeute constitue un des outils les plus valables qu'il possede dans le traitement de l' obsessionnel, pourvu qu'il sache l'utiliser avec habilite. Chaque relation docteur-malade est unique et suscitera ses problemes particuliers de contretransfert. Les problemes habituels dont nous sommes conscients comprennent l' ennui, l' evasion dans le fantasme, l'impatience, la critique, l' antipathie et le sentiment d'Incompetence. Ces sentiments, on I'espere, peuvent etre utilises afin d' atteindre une meilleure comprehension du dilemme du malade. Un probleme auquel on doit etre attentif est notre sadisme inconscient qui peut trouver son expression dans la nature de nos interpretations.
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