“Yes, Of Course It Hurts When Buds Are Breaking”: Therapist Reactions to an Adolescent Client’s Sexual Material in Psychodynamic Psychotherapy ¨ Helene A. Nissen-Lie and Erik Stanicke University of Oslo This article focuses on the therapist’s emotional reactions to a young female client’s revelations about her fear of being raped that came up in the course of an open-ended psychodynamic psychotherapy. The client suffered from depression and emotional disturbance related to the overwhelming developmental tasks of adolescence, including individuation and psychosexual development. The patient’s fears and nightmares not only raised ethical dilemmas in the therapist regarding how to handle the implications of these revelations but also reactivated the therapist’s own issues from her adolescent period. The fact that the material of the patient found a “hook” (Gabbard, 1995) in the therapist enabled a deeper understanding of the patient that helped resolve her inner conflicts and move on in her development. C 2013 Wiley Periodicals, Inc. J. Clin. Psychol. 70:160–169, 2014. Keywords: therapist emotional reactions; countertransference; adolescent depression; psychodynamic psychotherapy; psychosexual development
Yes, of course it hurts when buds are breaking. Why else would springtime falter? Why would all our ardent longing bind itself in frozen, bitter pallor? After all, the bud was covered all the winter. What new thing is it that bursts and wears? Yes, of course it hurts when buds are breaking, hurts for that which grows and that which bars. (Yes, of Course It Hurts, Karin Boye, translated by David McDuff) The poem “Yes Of Course it Hurts,” by the Swedish poet Karin Boye, is one of Scandinavian poetry’s most beloved. We all recognize the pain of change, including the resistance to letting go and entering new situations, described in such expressive terms by Boye. The poem is often used to depict the developmental crisis of adolescence with all its conflicting forces, sexual awakenings, and challenges of individuation. Working therapeutically with adolescents can be particularly challenging, often evoking strong emotions (e.g., frustration and anxiety) and ambivalence in the therapist (Bonovitz, 2009; Sarles, 1998; Tishby & Vered, 2011). There are many reasons for this, including the fact that adolescent clients are often in therapy not because they wish to be, but because the adults surrounding them tell them they have to be. Thus, adolescent clients are typically more resistant and ambivalent about being in treatment and their trust may be harder to gain. In addition, these clients typically encounter a great intensity of emotions and tensions in their daily lives as they confront conflictual developmental tasks. The therapist needs to be especially flexible in attending to the oscillating needs (i.e., of autonomy and dependence) of clients in this life phase Please address correspondence to: Helene A. Nissen-Lie, Department of Psychology, University of Oslo, P.O. Box 1094 Blindern, 0317 Oslo, Norway. E-mail: [email protected] C 2013 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(2), 160–169 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22067
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(Sarles, 1998; Tishby & Vered, 2011). Moreover, adolescent clients may revive therapists’ memories and emotional struggles from their own childhood or adolescence, thus further intensifying the work (e.g., Bonovitz, 2009). This article will focus on a therapist’s emotional reactions to the sexual feelings, including violent sexual fantasies, of a female client in her early teenage years in the course of an open-ended psychoanalytic psychotherapy. The client suffered from depression and emotional disturbance related to the challenging, and at times overwhelming, developmental tasks she was facing, including individuation, regulation of dependency needs, and the development of a sexual identity. The focus here will be on specific sexual issues that arose during the course of treatment, in particular the girl’s fear of being raped, which in turn stirred up strong emotions in the therapist. It is argued that the therapist’s ability to understand and contain these feelings had implications not only in terms of therapeutic progress and direction but also for some critical ethical decisions. Prior to the presentation of this case, two topics which bind the underlying dynamics of the case and the therapist’s reactions, will be discussed briefly: (a) the psychosocial and psychosexual tasks of adolescence, with a particular emphasis on developing a sexual identity; and (b) the use and management of the therapist’s emotional reactions (countertransference).
Adolescence: A Developmental Crisis? The popular vision of the Chinese sign of “crisis” as containing the symbols for both danger and opportunity could certainly apply as a description of the adolescent phase in normal growth, and even more so in the case of pathological developments in this important transitional life phase. Psychodynamic conceptualizations see adolescence as a developmental period in which the person works through a number of basic and at times conflictual issues related to identity formation, separation-individuation, and psychosexual development (Midgley, Cregeen, Hughes, & Rustin, 2013), and stress the importance of understanding the young client’s pathology in the developmental context in which it occurs (A. Freud, 1966; Midgley et al., 2013). Developing a “sexual body” can be a frightening experience (Laufer & Laufer, 1975) and forming and consolidating a sexual identity is challenging for most young people. Entering puberty can also revive early sexual feelings toward parents (i.e., Oedipal dynamics) and fantasies about the parents’ erotic relationship, and as such can be a startling and confusing experience. This developmental period, however, “presents an opportunity to rework these [earlier] issues in the context of a sexually maturing body and eventually establish a secure young adult sexual and relational identity” (Midgley et al., 2013, p. 70). From the French psychoanalytic tradition, Laplanche (1989) extended Freud’s thinking about the child’s sexual development and challenges. Laplanche’s theory concerns how parents communicate, mostly at an unconscious level, sexual messages to the child, which are difficult to interpret for the child and which can therefore be experienced as traumatic. This perspective suggests that children’s and adolescents’ interaction and communications with their parents can be overwhelmed by (erotic) enigmatic signs and messages that cannot readily be processed at their stage of development. Yet another perspective about the difficulties of the adolescent period—that of Britton (1989)—suggests that the child, and later the adolescent, is a “witness” to the parents’ relationship, including their erotic tensions and desires. Being in a position of a witness, it is suggested, activates not only jealousy but also deepens feelings and fantasies of being rejected and standing outside of something good and creative. With adolescent clients, these issues can come up in the therapy room and require a therapeutic stance that is attentive, open, nonjudgmental and nondefensive toward sexual matters. As mentioned above, therapeutic work with children and adolescents puts the therapist in potentially close contact with his or her own childhood memories and experiences, including sexual ones, and the therapist’s own sexual issues can thus be revived with great intensity. In our view this revival is not a sign of pathology in the therapist or a barrier to therapy, but instead, once understood, can facilitate clinical work (e.g., Bonovitz, 2009). This discussion falls more broadly within the realm of therapists’ countertransference, which is covered next.
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Countertransference Essentially, there are three broad definitions of countertransference (CT). The classical definition by Freud (1910/1959) portrays CT primarily as the therapist’s own “blind spots” that confine the capacity to analyze the patient. Blind spots are understood as the therapist’s unresolved and unconscious conflicts that are reactivated in response to transference. Freud recommended that the therapist resolve these issues to facilitate clinical work with the patient. Freud (1912/1959), however, also reflected a more extensive understanding of CT when he described psychoanalysis as comprising unconscious communications flowing between therapist and patient, which implies that even Freud recognized that CT is a necessary part of treatment. The “totalistic definition” (Gelso & Hayes, 2007), which we are guided by as clinicians, includes the therapist’s whole range of reactions to a patient–encompassing both unconscious and conscious reactions– responses to the patient’s transference, and other phenomena, as well as those pertaining to the therapist’s personal material. Our belief is that even if personal conflicts are central to CT, it is the specific reactivation of those issues in meeting a particular patient that may aid the therapist in understanding patient. This perspective opens up a view on working with one’s CT that is difficult and emotionally straining, yet also highly meaningful and potentially helpful in aiding the therapist in understanding the relational interaction that one is in with the patient. A third definition of CT is labeled the “integrative” definition (Gelso & Hayes, 1998; Hayes, 2004; Hayes & Gelso, 2001). Here, CT is defined as the therapist’s conscious and unconscious reactions to the patient’s transference and other phenomena, but includes only those reactions that stem from the therapist’s unresolved conflicts, making CT less narrow than Freud’s classical definition but more narrow than the totalistic definition. We partly concur with this definition; however, we take issue with the distinction between unresolved and resolved personal conflicts embedded in it. Even if it is a logical distinction, it is often difficult to draw, especially in a clinical situation. We agree with Hayes (2004) in his concern and criticism that the totalistic CT conception risks blaming the patient for the therapist’s problems related to countertransference. The solution to this important problem is, according to Gelso and Hayes (2007), to narrow CT to include only those feelings, thoughts, and behaviors we can be sure stem from areas of personal conflict in the therapist so as to be sure that therapists take responsibility for their own reactions and take measures to manage them. Our sense is that a person’s conflicts can never become completely resolved. Even in areas where a conflict has been sufficiently resolved to make us work effectively as therapists, we think that its resolution is potentially unstable. Any personal conflict in the therapist is always prone to become reactivated in therapeutic work, even when worked on in intensive or in-depth psychotherapy aimed at resolving personal conflicts (such as psychoanalysis). Our own motives are never completely transparent to us and we never gain a total perspective on our own issues. The idea that personal issues can be resolved may lure us into thinking that we know clearly what is going on in ourselves and in the dynamic relationship with the patient. The case we describe below is one in which the therapist’s personal issues were reactivated by the client’s sexual material that emerged in the treatment process. Without this “hook” (Gabbard, 1995) in the therapist, these matters might not have been subject to the intense inner work that guided the therapy in the right direction. We are reminded of a case study by Rosenberger and Hayes (2002) in which the effects of the countertransference reactions of a female psychotherapist were explored. To their surprise, the authors found that when certain topics arose that were related to the therapist’s unresolved issues (which presumably would be experienced as more threatening), the therapist tended to respond by drawing closer to the client and the working alliance and session depth were, in fact, rated as stronger by the client. This was counter to the prediction that the reactivation of conflictual material would impede the process. In retrospect, the authors reasoned that this may have had to do with the fact that the therapist was a woman; while men may be more inclined to withdraw and become avoidant when threatened or anxious, women may draw closer in situations when they feel threatened (Hayes, 2004). We believe that it is also possible that the effects noted in this case might have been caused by the therapist identifying with, even becoming hooked by, the material of the patient
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but managing to work with it, and thereby gaining a deeper understanding of the patient. This interpretation is one we will try to demonstrate in the case study below. The following case illustration is based on the therapeutic experiences of the first author in therapy with a young girl, Stella. The focus of the case illustration is how the therapist’s CT reactions informed the understanding of the delicate sexual issues that the client presented.
Case Illustration Presenting Problem and Client Description Stella, in her early teens, was referred to the outpatient clinic at which the first author works part-time by the school physician because of changes in mood, the apparent beginning of an eating disorder, and social problems at school. Her parents and the girl described the social problems in terms of Stella being left out and rejected by the girls in her class. It turned out she had had suicidal thoughts for a while, had engaged in self-harming by cutting, had been secretly absent from school many days, and was on her way to dropping out. Stella had been isolating herself from friends and activities; she used to be an avid and skilled ballet dancer but had dropped out of it. She was increasingly passive and had seemingly lost most of her interest, energy, and drive, spending most of her days lying in bed, sometimes watching films and TV series, often in a state of apathy. Always having been an even-tempered, smiling, polite, and seemingly happy child and early teenager, she had lately been more temperamental. The discussions between Stella and her parents often focused on her wanting to be by left by herself in her room with minimal contact and interference from her parents. The parents despaired to see their daughter in this state without being able to reach out to her or understand what had caused it. They felt powerless in that nothing they did seemed to make her happier or could convince her to go to school, interact with friends, continue her spare time activities, or stop self-harming and losing weight. They had not found any way to communicate with her and the distance between them grew every day. She had become an enigma to them and in a way also to herself.
Case Formulation The treatment commenced with a thorough psychiatric assessment and some family sessions before we agreed to start individual psychodynamic psychotherapy with Stella. The preliminary goal was to better understand her inner emotional world, her depressed affect, and the basis of her self-destructive behaviors, including symptoms of an eating disorder, self-harming, and strong self-critical thoughts. The psychiatric evaluation found that Stella suffered from clinical depression that met the 10th revision of the International Statistical Classification of Diseases and Related Health Problems criteria of major depression (moderate), with symptoms such as depressed mood, lack of energy, anhedonia, strong negative self-critical thoughts, suicidal ideation, and selfharming (cutting). Semistructured interviews for personality disturbance showed early signs of emotional instability with impulsiveness and avoidant traits. She displayed problems with regulation of affect, impulses, and self-esteem, a low level of reflective functioning (i.e., the ability to mentalize about affective states, thoughts, and intensions in herself and others). She was no doubt also a resourceful young girl: athletic, intelligent, and intellectually curious, with a capacity for empathy with the suffering of others, with a love of young children and animals, and with a good sense of humor, all of which surfaced some time into the treatment process. Both parents and Stella denied traumatic experiences in terms of loss, separation, neglect, or abuse in her early or middle childhood up to the present moment, except the harassment at school. The parents were married and described a stable relationship. Stella was an only child. We formulated goals about Stella getting in touch with her feelings, especially anger and sadness, and becoming more accepting of herself and less prone to self-devaluation and use of self-harming as a way to regulate her feelings and communicate. We also formulated goals about opening up communication between her and her parents, including trying to find ways in which
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her parents could reach out to her in her pain, and ways in which she could communicate more clearly what she needed from them and how she might use them as supports in the developmental tasks ahead. The parents saw a family worker on a regular basis.
Psychodynamic Formulation In addition to the psychiatric assessment, hypotheses about the underlying dynamics (regarding internal conflicts, sense of self and use of defenses) of Stella’s depression and emotional disturbances were formulated (see Goodyer et al., 2011). In particular, this case formulation was guided by a review of the some of the central psychodynamic components in assessing depression proposed by Busch, Rudden, and Shapiro (2004), including narcissistic vulnerability and conflicted anger. At her stage of development, Stella was extremely insecure about who she was and her own self-worth. She let others, especially her peers, decide whether she had any worth and when they started rejecting her, she believed she deserved being left out and treated as “nothing.” She seemed to have a heightened sensitivity to perceived or actual rejections, resulting in a lowered self-esteem, which elicited depressed affect. Because of her fragile sense of self and feeling that she deserved other people’s rejection, instead of expressing her anger or despair to others, she turned it against herself. She disowned her feelings of anger for fear of causing pain to her parents, especially her mother, whom she felt had always been such a good mother and did not “deserve that she was unhappy or angry with her.” This prevented Stella from expressing her needs and engaging in a normal process of individuation and development of autonomy. She seemed to use denial and projection to defend against painful affects, such as anger and sadness, which contributed to her depression because her own inner critical voice was projected onto nearly all other people around her, making the world a hostile, overly critical, and an unwelcoming place in which no one could love her and appreciate her as she was. As for the family dynamics and Stella’s internal representations of them, her father was portrayed as a dominant, aggressive, and authoritarian man, but also one who could be a charismatic and physically caring person. She had, until puberty, been “daddy’s girl.” Stella saw her mother as one who always put everyone else ahead of herself. She was portrayed as rather self-effacing, submissive, and fragile, someone who needed protection from Stella’s aggression and one who could not tolerate strong ambivalent feelings. There were reasons to hypothesize that Stella connected masculinity with dominance and power, and femininity with powerlessness and submissiveness–a stereotypical view that hindered her in developing and embracing her whole self in these adolescent years. Last, Stella had described developing female body characteristics as a frightening experience. She had revealed to her parents that she felt uneasy about being among the first girls in her year to enter puberty. Stella also struggled with her own sexual awakening. She fell in love with a boy during treatment and wanted to “merge” with this boy but stopped herself from developing a relationship with him for fear of rejection. She also convinced herself that she did not deserve him, and that he would be miserable with her as a girlfriend. She also indirectly described ambivalence and confusion regarding her own sexual desires, as will be discussed more below.
Course of Treatment In the beginning of treatment when Stella was in the room with her parents, she was closed off and said little. She looked down most of the time and avoided eye contact with the therapist. One could, however, detect her subtle and nonverbal signs of protest and aggression toward her parents. In response to the therapist’s questions, she usually answered, “I don’t know” and “Yes” and “No,” looking down. The therapist soon realized that Stella needed time on her own to feel a little freer to speak. In her own early therapy sessions, Stella was a little more open with the therapist than when her parents were present; she seemed more expressive, explaining herself in whole sentences about the rejections at school and admitting to the therapist that she had been self-harming much longer than anyone knew. She needed much time and reassurance to open up, and it took a long while before she could make use of the therapeutic relationship.
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She could also close up and hide her feelings during sessions, pretending everything was fine when it obviously was not. She could be silent for entire sessions and expressed irritation with the therapist for keeping her there, telling her after a while that she would never have come to her unless “she was forced to.” Yet she never missed a session. It was obviously an arduous exercise for Stella to be in therapy, focusing on her emotions toward herself, others, and the therapist, and she started to express this more and more. After a while, when she disagreed with the therapist’s interpretations, she could allow herself to become more expressive about the therapist misinterpreting her, but she could also withdraw into a state of nonsharing and silence. Gradually, Stella became more and more open with the therapist, more trusting that the therapist could be a benevolent figure, someone who could understand her. She often initiated discussions about the boundaries of confidentiality–what she could disclose to the therapist without the therapist’s telling her parents.
Stella Bringing Up Sexual Material in Treatment About one year into the weekly therapy, Stella opened up a whole different topic that had not been touched upon until then. She confessed to the therapist that she had been terrified of men lately, and of meeting men when she was on her own. In one of the following sessions, this came up (presented from the therapist’s, that is the first author’s, point of view): While discussing recent problems at school, Stella suddenly interrupts herself, stating that she has had nightmares every night, nightmares in which she is being raped. She closes off as soon as I begin to explore this by asking her if she could tell me more of what happens in this dream. I also ask if the perpetrator(s) is/are someone she knows. Stella does not answer. I let her leave the subject after saying that it must be very scary to have such nightmares, and that I can understand that it is also scary to talk about it here, when it becomes more vivid and maybe gives rise to a range of different feelings. She seems calmer but refuses to talk more about it. She starts talking about how she feels anxious around strangers on the bus, because they look at her and “they all think she looks weird.” The next time this topic comes up is two sessions later. Stella opens up by saying that lately she has been increasingly frightened, and she describes herself as being “paranoid.” I ask what makes her afraid at the moment, and she says, “Of being raped.” She starts talking about it more freely and how she sees every man as a potential rapist, and she is very anxious in places where she can run into strange men. I wonder if she herself can think of what this means. After a long silence she says, out of the blue, “Dad.” I say, “You think of Dad . . . ” and let her continue. Then she says her father has never been “mean” or “bad” to her and nothing has ever happened in actual life, but what she fears the most is to be raped by him. I wonder if she has any idea why these fears have emerged in her now; she doesn’t know. I wonder how it feels to have these strong fears around her father, and she says it is “terrible” and she cannot say anything about it to him or to Mum because they would misunderstand. She feels very much alone in this situation and I validate that. I say it is good she shared these thoughts with me, and we can perhaps understand more of them together. Stella explains that she does not like the way Dad looks at her sometimes, and a while ago he touched her on her bottom and she felt it was not at all pleasant. She feels he is treating her differently, not only as a daughter but also as a young woman, and that makes her uneasy. I try to find out whether she has experienced any kind of sexual abuse by her father or any other person. She understands what I am getting at and says, “I have never ever experienced what I am so afraid of, that is why I cannot understand these strong feelings.” I feel a little more at ease about interpreting her feelings more in terms of fantasies and confusions related to her sexual awakening and to her relationship with her father (and mother) rather than as a consequence of actual sexual trauma, but I remain unsure about it. After a pause I intervene by saying that at her stage of development and as part of sexual maturation, these feelings can be rather typical and felt by many girls her age. Being the opposite sex, her father is a sort of a template for all boys and men, and that gives rise to her unconsciously (i.e., in her dreams and fears) testing out different scenarios about this relationship and her own sexual feelings, which can be scary and confusing. Stella seems clearly relieved after her disclosure and my response
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to it; she becomes less tense and starts to talk about other things with more ease the rest of the session. The topic did not come up again on her initiative (I always let her take the initiative in our sessions). However, 2 months later, when we were discussing her relationship with her father again, I asked her whether she felt tense or anxious around him or if she still suffered from those nightmares she had talked about earlier. She denied that, and I paused and looked at her and said: “You do not any longer have fears or nightmares about being raped by your father or by other men?” She answered with a clear voice: “No, after you told me it was normal for a girl my age to have such feelings, the fear left me, and has never returned.”
Learning From the Therapist’s CT: Implications From the Case of Stella Stella invoked strong feelings in the therapist from the start. In the beginning she was silent and averted the therapist’s communication—leaving the therapist with feelings of insecurity regarding the possibility of establishing an alliance or of being able to help. When Stella opened up more, there were many areas to work with—suicidal ideation, self-harm, body issues, strong self-critical attitudes, relational problems, and existential issues. The work with Stella, like most work with troubled adolescents, continued to evoke feelings of rejection, doubt, incompetence, and frustration. One can say such feelings are inevitable in clinical work with adolescents (Sarles, 1998; Tishby & Vered, 2011); however, when the work leads to a healthy developmental path being found or resumed, it can be highly meaningful. The work with this patient activated even deeper layers in the therapist when Stella, a year into the therapy, disclosed fantasies of sexual assault and rape. After some careful inquiry by the therapist, Stella confessed that these fantasies were mainly about her father, leaving the therapist for a while confused and worried. What had happened to Stella? Was the disclosure of fantasies and nightmares of rape a way to tell the therapist that she had been a victim of sexual abuse or incest? Was this the answer that could explain the presence of deep psychological suffering and her worrying, loss of functioning, and severe symptoms in the absence of any apparent trauma? Such a resolution might have been tempting for the therapist to grasp, even if its implications would have been demanding as well. Alternatively, were Stella’s fears products of her fantasy and unresolved earlier (Oedipal) conflicts—the fusion of longings and fears, lust and aggression, which can reemerge in the context of a developing mind and body (Midgley et al., 2013)? These possibilities created an ethical dilemma in the therapist. The therapist was faced with a conflict between the therapeutic ideal of empathic listening and of taking responsibility in a possible case of sexual abuse, the latter a course of action that would have risked being both invasive and destructive. This dilemma was amplified by Stella’s preoccupation with the question of confidentiality and her anxiety about the therapist violating it. Complicating the matter, the therapist had her own reasons for struggling with this dilemma. In the therapist’s own relational history, she had experienced strong feelings toward her father. The truth is, Stella’s father reminded her of her own father, which illustrates how the transferencecountertransference matrix in child therapy also involves the child’s parents as well as the child (Anastasopoulous & Tsiantis, 1996). The therapist had herself as a child felt a deep longing for closeness with her father, yet at the same time a fear of his aggression and authority. There had been tensions in her own upbringing, especially in her adolescence, regarding the testing of boundaries and conflicting feelings between longing and fear. The therapist grew up in a family as the middle of three sisters, who often found themselves competing for their father’s attention and favor. Their father, being both highly masculine (and often regretting the lack of a son) and warm and caring at the same time, would often play one against the other, favoring one over the others, causing jealousy and frustration. When Stella revealed her fantasies about being raped by her father, some vital parts of the therapist’s inner world became activated: an awareness of both yearning for closeness and a fear of masculinity, and the complex fusion of fear, aggression, and sexual desire. Thus, it was difficult to determine whether Stella’s own acknowledged fears and anxieties could be therapeutically handled or whether they demanded another type of action. Our working hypothesis is that Stella’s psychological issues were a hook for the therapist’s own issues around Oedipal longings.
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Complicating these dynamics even further was the fact that the therapist had been going through a long-term psychoanalytic psychotherapy in which she had worked intensely with Oedipal issues in the transference dynamics with a male psychoanalyst. Yet these issues were not resolved in a finalized way, as indeed we believe that they cannot be. When these issues were stirred up in working therapeutically with Stella, they had to be worked through again. However, we believe that precisely because the therapist had worked with these issues in personal therapy, she was more able to maintain an accepting and nonjudgmental attitude toward Stella’s revelations, and less prone to act out the anxiety or shock in treating the case as one of potential child sexual abuse or incest. In this way, the case demonstrates to us how the reactivation of a therapist’s early conflicts may actually benefit the client. Here, the therapist was better able to align with the patient in her feelings and fantasies—quite difficult, taboo-laden feelings that understandably caused anxiety, shame, and confusion. We should note that the reactivation of a therapist’s own personal issues is not beneficial in itself. Rather, the therapist was sufficiently aware of the roots of her response to the material brought forth by the client because she had worked with similar issues in her personal treatment process. Without this level of insight, the course of treatment might have been different. One might argue that the therapist diverted from the typical analytic attitude of exploration with her “normalizing” intervention. That is, by utilizing a psychoeducational (i.e., normalizing) intervention (albeit with a psychoanalytic flavor), the therapist might have been acting out her own wish to consider the case as one of internally generated (Oedipal) fantasies, rather than a case of child sexual abuse, to feel more normal about herself. Notwithstanding this, the effect of the intervention was beneficial and lasting; the patient experienced relief, probably because the explanation and normalization reduced her shame and confusion and made her more accepting of herself. Arguably, though, the therapeutic process might have been even more beneficial if the therapist had maintained her analytic stance. Doing so might have enabled the client to find her own way, which, in turn, might have promoted her development of autonomy. The answer to the riddle of what Stella’s symptoms actually reflected was not known to the therapist, as it rarely is. Based on the effect of the therapist’s intervention, it seems the therapist was on the right track; the patient’s fears and nightmares were not indicative of actual experiences with rape or incest. If they were, the patient would hardly have felt so relieved and improved. When the therapist does not know the meaning of a patient’s communications and the dynamic between them, she is in need of “negative capability,” a term first coined by the English poet, John Keats (1817): “when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason” (see also Bion, 1970, p. 125, and Strømme, 2010). This is a vital capacity that we believe develops through experience and, more important, through personal therapy. In the following months, the therapist strove to tolerate the uncertainties by letting the patient take the lead in her process of discovery, trying not to interfere with this process to satisfy her own needs to settle the case and reduce her own inner turmoil. When it came up months later, Stella painlessly informed the therapist that she no longer experienced fears or nightmares of being raped by her father. This was at least temporarily settled for the client. Later on during treatment, Stella did commit to a boyfriend and had her first sexual experience with him. She described this as a pleasant experience. In the work with this patient, the therapist found a number of things helpful. She attended regular psychodynamically oriented supervision in which this particular case figured prominently in the months after Stella’s disclosures of her fears of rape. In these sessions, the feelings evoked in the therapist were closely attended to. Through this, the therapist became aware of how Stella’s father reminded her of her own father, and she got in touch with her own conflicts from adolescence. Additionally, the dilemma of whether to take action in a case of possible sexual abuse or incest versus interpreting the patient’s fears as internally generated fantasies—and keeping these competing hypotheses active for a period of time—was discussed. Theory suggesting that Stella’s fear might be understood in terms of the complexities of psychosexual development in adolescence, including challenges relating to triangulation and the frightening fusions of fear and desire, helped the therapist gain perspective to tolerate her anxiety (St¨anicke, 2012).
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In addition, we believe that some of the capacities that Gelso and colleagues (Gelso & Hayes, 2007; Hayes, Gelso, & Hummel, 2011) have suggested are critical for therapists’ effective management of countertransference–including empathy, anxiety management, and conceptualization ability—were vital in this case, facilitating the therapist’s ability to get in touch with the roots of her feelings evoked in this case, tolerate doubt and maintain a “wait and see” stance, and understand the patient at a deeper level.
Conclusion This article has presented a case study of therapist reactions evoked in adolescent psychotherapy with a young female client. The client suffered emotional disturbances related to the challenging and sometimes overwhelming developmental tasks of adolescence, including individuation and psychosexual development. One of the apparent breakthroughs in the treatment process was when the patient disclosed strong fears and nightmares about being raped by men in general and her father in particular, which raised ethical dilemmas in the therapist regarding how to handle the implications of these revelations and, at the same time, reactivated the therapists’ own issues from her adolescent period. Getting in touch with these personal issues—which had been worked on in intense psychoanalytic psychotherapy—was a significant aspect of the therapeutic process. The inner work of understanding the patient at her level of fantasy and tolerating the uncertainty for a period of time in the work with the patient seemed to have been critical for the relief of symptoms in the patient. Furthermore, the fact that the material of the patient found a hook (Gabbard, 1995) in the therapist enabled a deeper understanding of the patient that helped resolve her inner conflicts and move on in her development. We believe this case suggests that, as therapists, we can work well with patients stirring up our own material and conflicts, which are never completely resolved, and gain a deeper connection with our clients, even in such delicate matters as frightening sexual and violent fantasies in adolescence. In this particular case, it was as if the therapist, during what was a critical moment in treatment, communicated the following words to her young client (borrowed again from the Boye poem cited earlier): “Yes, of course it hurts when buds are breaking, hurts for that which grows and that which bars.” The client could continue her journey into summer.
Selected References and Reading Recommendations Anastasopoulous, D., & Tsiantis, J. (1996). Countertransference issues in psychoanalytic psychotherapy with children and adolescents: A brief review. In J. Tsiantis, J. A. M. Anastasopoulous, & B. Martindale (Eds.), Counterttransference in psychoanalytic psychotherapy with children and adolescents (pp. 1–11). Madison: International Universities Press. Bion, W. R. (1970). Attention and interpretation. London: Karnac Books. Bonovitz, C. (2009). Countertransference in child psychoanalytic psychotherapy: The emergence of the analyst’s childhood. Psychoanalytic Psychology, 26, 235–245. Boye, K. (1935). “Yes, of course it hurts.” Poem translated into English by David McDuff (2005), Karin Boye. Complete poems. Bloodaxe Books. Britton, R. (1989). The missing link: Parental sexuality in the Oedipus complex. In J. Steiner (Ed.), The Oedipus complex today: Clinical implications (pp. 83–101). London: Karnac Books. Busch, F., Rudden, M., & Shapiro, T. (2004). Psychodynamic treatment of depression. Washington: American Psychiatric Publishing. Freud, A. (1966). Normality and pathology in childhood: Assessments of development. London: Karnac Books. Freud, S. (1910/1959). The future prospects of psychoanalytic therapy. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11). London: Hogarth Press. Freud, S. (1912/1959). Papers on technique. The dynamics of transference. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11). London: Hogarth Press.
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Gabbard, G. O. (1995). Countertransference: The emerging common ground. The International Journal of Psychoanalysis, 76, 475–485. Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship: Theory, research and practice. New York: John Wiley & Sons. Gelso, C. J., & Hayes, J. A. (2007). Countertransference and the therapist’s Inner experience: Perils and possibilities, Mahwah, NJ: Lawrence Erlbaum. Goodyer, I. M., Tsancheva, S., Byford, S., Dubicka, B., Hill, J., Kelvin, R. . . . Fonagy, P. (2011). Improving mood with psychoanalytic and cognitive therapies (IMPACT): A pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: Study protocol for a randomised controlled trial. Trials, 12–175. doi:10.1186/1745-6215-12-175 Hayes, J. A. (2004). The inner world of the psychotherapist: A program of research on countertransference. Psychotherapy Research, 14, 21–36. Hayes, J. A., & Gelso, C. J. (2001). Clinical implications of research on countertransference: Science informing practice. Journal of Clinical Psychology, 57, 1041–1051. Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy, 48, 88–97. Laplanche, J. (1989). New foundations for psychoanalysis. Oxford: Blackwell. Laufer, M., & Laufer, E. (1975). Adolescent disturbance and breakdown. Harmondsworth (London): Penguin. Midgley, N., Cregeen, S., Hughes, C., & Rustin, M. (2013). Psychodynamic psychotherapy as treatment for depression in adolescence. Child and Adolescent Psychiatric Clinics of North America, 22, 67–82. Rosenberger, E. W., & Hayes, J. A. (2002). Therapist as subject: A review of the empirical countertransference literature. Journal of Counseling and Development, 80, 264–270. Sarles, R. M. (1998). Individual psychotherapy with adolescents. In. H. S. Gurman & R. M. Sarles (Eds.), Handbook of child and adolescent outpatient, day treatment and community psychiatry (pp. 259–264). Philadelphia: Brunner Mazel. St¨anicke, L. I. (2012). Relasjonelle utfordringer i en ungdomsterapi – sett i lys av noen psykodynamiske grunnbegreper [Relational challenges in adolescent psychotherapy – in light of some psychodynamic concepts]. Mellanrummet [Nordic Journal of Child and Adolescent Psychotherapy] 26, 22–35. Strømme, H. (2010). Confronting helplessness. A study of psychology students’ acquisition of dynamic psychotherapeutic competence. (Unpublished doctoral dissertation). University of Oslo, Oslo, Norway. Tishby, O., & Vered, M. (2011). Counter transference in the treatment of adolescents and its manifestations in the therapist-patient relationship. Psychotherapy Research, 21, 621–630.
Yes, of course it hurts when buds are breaking. Why else would springtime falter? Why would all our ardent longing bind itself in frozen, bitter pallor? After all, the bud was covered all the winter. What new thing is it that bursts and wears? Yes, of course it hurts when buds are breaking, hurts for that which grows and that which bars. (Yes, of Course It Hurts, Karin Boye, translated by David McDuff) The poem “Yes Of Course it Hurts,” by the Swedish poet Karin Boye, is one of Scandinavian poetry’s most beloved. We all recognize the pain of change, including the resistance to letting go and entering new situations, described in such expressive terms by Boye. The poem is often used to depict the developmental crisis of adolescence with all its conflicting forces, sexual awakenings, and challenges of individuation. Working therapeutically with adolescents can be particularly challenging, often evoking strong emotions (e.g., frustration and anxiety) and ambivalence in the therapist (Bonovitz, 2009; Sarles, 1998; Tishby & Vered, 2011). There are many reasons for this, including the fact that adolescent clients are often in therapy not because they wish to be, but because the adults surrounding them tell them they have to be. Thus, adolescent clients are typically more resistant and ambivalent about being in treatment and their trust may be harder to gain. In addition, these clients typically encounter a great intensity of emotions and tensions in their daily lives as they confront conflictual developmental tasks. The therapist needs to be especially flexible in attending to the oscillating needs (i.e., of autonomy and dependence) of clients in this life phase Please address correspondence to: Helene A. Nissen-Lie, Department of Psychology, University of Oslo, P.O. Box 1094 Blindern, 0317 Oslo, Norway. E-mail: [email protected] C 2013 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(2), 160–169 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22067
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(Sarles, 1998; Tishby & Vered, 2011). Moreover, adolescent clients may revive therapists’ memories and emotional struggles from their own childhood or adolescence, thus further intensifying the work (e.g., Bonovitz, 2009). This article will focus on a therapist’s emotional reactions to the sexual feelings, including violent sexual fantasies, of a female client in her early teenage years in the course of an open-ended psychoanalytic psychotherapy. The client suffered from depression and emotional disturbance related to the challenging, and at times overwhelming, developmental tasks she was facing, including individuation, regulation of dependency needs, and the development of a sexual identity. The focus here will be on specific sexual issues that arose during the course of treatment, in particular the girl’s fear of being raped, which in turn stirred up strong emotions in the therapist. It is argued that the therapist’s ability to understand and contain these feelings had implications not only in terms of therapeutic progress and direction but also for some critical ethical decisions. Prior to the presentation of this case, two topics which bind the underlying dynamics of the case and the therapist’s reactions, will be discussed briefly: (a) the psychosocial and psychosexual tasks of adolescence, with a particular emphasis on developing a sexual identity; and (b) the use and management of the therapist’s emotional reactions (countertransference).
Adolescence: A Developmental Crisis? The popular vision of the Chinese sign of “crisis” as containing the symbols for both danger and opportunity could certainly apply as a description of the adolescent phase in normal growth, and even more so in the case of pathological developments in this important transitional life phase. Psychodynamic conceptualizations see adolescence as a developmental period in which the person works through a number of basic and at times conflictual issues related to identity formation, separation-individuation, and psychosexual development (Midgley, Cregeen, Hughes, & Rustin, 2013), and stress the importance of understanding the young client’s pathology in the developmental context in which it occurs (A. Freud, 1966; Midgley et al., 2013). Developing a “sexual body” can be a frightening experience (Laufer & Laufer, 1975) and forming and consolidating a sexual identity is challenging for most young people. Entering puberty can also revive early sexual feelings toward parents (i.e., Oedipal dynamics) and fantasies about the parents’ erotic relationship, and as such can be a startling and confusing experience. This developmental period, however, “presents an opportunity to rework these [earlier] issues in the context of a sexually maturing body and eventually establish a secure young adult sexual and relational identity” (Midgley et al., 2013, p. 70). From the French psychoanalytic tradition, Laplanche (1989) extended Freud’s thinking about the child’s sexual development and challenges. Laplanche’s theory concerns how parents communicate, mostly at an unconscious level, sexual messages to the child, which are difficult to interpret for the child and which can therefore be experienced as traumatic. This perspective suggests that children’s and adolescents’ interaction and communications with their parents can be overwhelmed by (erotic) enigmatic signs and messages that cannot readily be processed at their stage of development. Yet another perspective about the difficulties of the adolescent period—that of Britton (1989)—suggests that the child, and later the adolescent, is a “witness” to the parents’ relationship, including their erotic tensions and desires. Being in a position of a witness, it is suggested, activates not only jealousy but also deepens feelings and fantasies of being rejected and standing outside of something good and creative. With adolescent clients, these issues can come up in the therapy room and require a therapeutic stance that is attentive, open, nonjudgmental and nondefensive toward sexual matters. As mentioned above, therapeutic work with children and adolescents puts the therapist in potentially close contact with his or her own childhood memories and experiences, including sexual ones, and the therapist’s own sexual issues can thus be revived with great intensity. In our view this revival is not a sign of pathology in the therapist or a barrier to therapy, but instead, once understood, can facilitate clinical work (e.g., Bonovitz, 2009). This discussion falls more broadly within the realm of therapists’ countertransference, which is covered next.
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Countertransference Essentially, there are three broad definitions of countertransference (CT). The classical definition by Freud (1910/1959) portrays CT primarily as the therapist’s own “blind spots” that confine the capacity to analyze the patient. Blind spots are understood as the therapist’s unresolved and unconscious conflicts that are reactivated in response to transference. Freud recommended that the therapist resolve these issues to facilitate clinical work with the patient. Freud (1912/1959), however, also reflected a more extensive understanding of CT when he described psychoanalysis as comprising unconscious communications flowing between therapist and patient, which implies that even Freud recognized that CT is a necessary part of treatment. The “totalistic definition” (Gelso & Hayes, 2007), which we are guided by as clinicians, includes the therapist’s whole range of reactions to a patient–encompassing both unconscious and conscious reactions– responses to the patient’s transference, and other phenomena, as well as those pertaining to the therapist’s personal material. Our belief is that even if personal conflicts are central to CT, it is the specific reactivation of those issues in meeting a particular patient that may aid the therapist in understanding patient. This perspective opens up a view on working with one’s CT that is difficult and emotionally straining, yet also highly meaningful and potentially helpful in aiding the therapist in understanding the relational interaction that one is in with the patient. A third definition of CT is labeled the “integrative” definition (Gelso & Hayes, 1998; Hayes, 2004; Hayes & Gelso, 2001). Here, CT is defined as the therapist’s conscious and unconscious reactions to the patient’s transference and other phenomena, but includes only those reactions that stem from the therapist’s unresolved conflicts, making CT less narrow than Freud’s classical definition but more narrow than the totalistic definition. We partly concur with this definition; however, we take issue with the distinction between unresolved and resolved personal conflicts embedded in it. Even if it is a logical distinction, it is often difficult to draw, especially in a clinical situation. We agree with Hayes (2004) in his concern and criticism that the totalistic CT conception risks blaming the patient for the therapist’s problems related to countertransference. The solution to this important problem is, according to Gelso and Hayes (2007), to narrow CT to include only those feelings, thoughts, and behaviors we can be sure stem from areas of personal conflict in the therapist so as to be sure that therapists take responsibility for their own reactions and take measures to manage them. Our sense is that a person’s conflicts can never become completely resolved. Even in areas where a conflict has been sufficiently resolved to make us work effectively as therapists, we think that its resolution is potentially unstable. Any personal conflict in the therapist is always prone to become reactivated in therapeutic work, even when worked on in intensive or in-depth psychotherapy aimed at resolving personal conflicts (such as psychoanalysis). Our own motives are never completely transparent to us and we never gain a total perspective on our own issues. The idea that personal issues can be resolved may lure us into thinking that we know clearly what is going on in ourselves and in the dynamic relationship with the patient. The case we describe below is one in which the therapist’s personal issues were reactivated by the client’s sexual material that emerged in the treatment process. Without this “hook” (Gabbard, 1995) in the therapist, these matters might not have been subject to the intense inner work that guided the therapy in the right direction. We are reminded of a case study by Rosenberger and Hayes (2002) in which the effects of the countertransference reactions of a female psychotherapist were explored. To their surprise, the authors found that when certain topics arose that were related to the therapist’s unresolved issues (which presumably would be experienced as more threatening), the therapist tended to respond by drawing closer to the client and the working alliance and session depth were, in fact, rated as stronger by the client. This was counter to the prediction that the reactivation of conflictual material would impede the process. In retrospect, the authors reasoned that this may have had to do with the fact that the therapist was a woman; while men may be more inclined to withdraw and become avoidant when threatened or anxious, women may draw closer in situations when they feel threatened (Hayes, 2004). We believe that it is also possible that the effects noted in this case might have been caused by the therapist identifying with, even becoming hooked by, the material of the patient
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but managing to work with it, and thereby gaining a deeper understanding of the patient. This interpretation is one we will try to demonstrate in the case study below. The following case illustration is based on the therapeutic experiences of the first author in therapy with a young girl, Stella. The focus of the case illustration is how the therapist’s CT reactions informed the understanding of the delicate sexual issues that the client presented.
Case Illustration Presenting Problem and Client Description Stella, in her early teens, was referred to the outpatient clinic at which the first author works part-time by the school physician because of changes in mood, the apparent beginning of an eating disorder, and social problems at school. Her parents and the girl described the social problems in terms of Stella being left out and rejected by the girls in her class. It turned out she had had suicidal thoughts for a while, had engaged in self-harming by cutting, had been secretly absent from school many days, and was on her way to dropping out. Stella had been isolating herself from friends and activities; she used to be an avid and skilled ballet dancer but had dropped out of it. She was increasingly passive and had seemingly lost most of her interest, energy, and drive, spending most of her days lying in bed, sometimes watching films and TV series, often in a state of apathy. Always having been an even-tempered, smiling, polite, and seemingly happy child and early teenager, she had lately been more temperamental. The discussions between Stella and her parents often focused on her wanting to be by left by herself in her room with minimal contact and interference from her parents. The parents despaired to see their daughter in this state without being able to reach out to her or understand what had caused it. They felt powerless in that nothing they did seemed to make her happier or could convince her to go to school, interact with friends, continue her spare time activities, or stop self-harming and losing weight. They had not found any way to communicate with her and the distance between them grew every day. She had become an enigma to them and in a way also to herself.
Case Formulation The treatment commenced with a thorough psychiatric assessment and some family sessions before we agreed to start individual psychodynamic psychotherapy with Stella. The preliminary goal was to better understand her inner emotional world, her depressed affect, and the basis of her self-destructive behaviors, including symptoms of an eating disorder, self-harming, and strong self-critical thoughts. The psychiatric evaluation found that Stella suffered from clinical depression that met the 10th revision of the International Statistical Classification of Diseases and Related Health Problems criteria of major depression (moderate), with symptoms such as depressed mood, lack of energy, anhedonia, strong negative self-critical thoughts, suicidal ideation, and selfharming (cutting). Semistructured interviews for personality disturbance showed early signs of emotional instability with impulsiveness and avoidant traits. She displayed problems with regulation of affect, impulses, and self-esteem, a low level of reflective functioning (i.e., the ability to mentalize about affective states, thoughts, and intensions in herself and others). She was no doubt also a resourceful young girl: athletic, intelligent, and intellectually curious, with a capacity for empathy with the suffering of others, with a love of young children and animals, and with a good sense of humor, all of which surfaced some time into the treatment process. Both parents and Stella denied traumatic experiences in terms of loss, separation, neglect, or abuse in her early or middle childhood up to the present moment, except the harassment at school. The parents were married and described a stable relationship. Stella was an only child. We formulated goals about Stella getting in touch with her feelings, especially anger and sadness, and becoming more accepting of herself and less prone to self-devaluation and use of self-harming as a way to regulate her feelings and communicate. We also formulated goals about opening up communication between her and her parents, including trying to find ways in which
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her parents could reach out to her in her pain, and ways in which she could communicate more clearly what she needed from them and how she might use them as supports in the developmental tasks ahead. The parents saw a family worker on a regular basis.
Psychodynamic Formulation In addition to the psychiatric assessment, hypotheses about the underlying dynamics (regarding internal conflicts, sense of self and use of defenses) of Stella’s depression and emotional disturbances were formulated (see Goodyer et al., 2011). In particular, this case formulation was guided by a review of the some of the central psychodynamic components in assessing depression proposed by Busch, Rudden, and Shapiro (2004), including narcissistic vulnerability and conflicted anger. At her stage of development, Stella was extremely insecure about who she was and her own self-worth. She let others, especially her peers, decide whether she had any worth and when they started rejecting her, she believed she deserved being left out and treated as “nothing.” She seemed to have a heightened sensitivity to perceived or actual rejections, resulting in a lowered self-esteem, which elicited depressed affect. Because of her fragile sense of self and feeling that she deserved other people’s rejection, instead of expressing her anger or despair to others, she turned it against herself. She disowned her feelings of anger for fear of causing pain to her parents, especially her mother, whom she felt had always been such a good mother and did not “deserve that she was unhappy or angry with her.” This prevented Stella from expressing her needs and engaging in a normal process of individuation and development of autonomy. She seemed to use denial and projection to defend against painful affects, such as anger and sadness, which contributed to her depression because her own inner critical voice was projected onto nearly all other people around her, making the world a hostile, overly critical, and an unwelcoming place in which no one could love her and appreciate her as she was. As for the family dynamics and Stella’s internal representations of them, her father was portrayed as a dominant, aggressive, and authoritarian man, but also one who could be a charismatic and physically caring person. She had, until puberty, been “daddy’s girl.” Stella saw her mother as one who always put everyone else ahead of herself. She was portrayed as rather self-effacing, submissive, and fragile, someone who needed protection from Stella’s aggression and one who could not tolerate strong ambivalent feelings. There were reasons to hypothesize that Stella connected masculinity with dominance and power, and femininity with powerlessness and submissiveness–a stereotypical view that hindered her in developing and embracing her whole self in these adolescent years. Last, Stella had described developing female body characteristics as a frightening experience. She had revealed to her parents that she felt uneasy about being among the first girls in her year to enter puberty. Stella also struggled with her own sexual awakening. She fell in love with a boy during treatment and wanted to “merge” with this boy but stopped herself from developing a relationship with him for fear of rejection. She also convinced herself that she did not deserve him, and that he would be miserable with her as a girlfriend. She also indirectly described ambivalence and confusion regarding her own sexual desires, as will be discussed more below.
Course of Treatment In the beginning of treatment when Stella was in the room with her parents, she was closed off and said little. She looked down most of the time and avoided eye contact with the therapist. One could, however, detect her subtle and nonverbal signs of protest and aggression toward her parents. In response to the therapist’s questions, she usually answered, “I don’t know” and “Yes” and “No,” looking down. The therapist soon realized that Stella needed time on her own to feel a little freer to speak. In her own early therapy sessions, Stella was a little more open with the therapist than when her parents were present; she seemed more expressive, explaining herself in whole sentences about the rejections at school and admitting to the therapist that she had been self-harming much longer than anyone knew. She needed much time and reassurance to open up, and it took a long while before she could make use of the therapeutic relationship.
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She could also close up and hide her feelings during sessions, pretending everything was fine when it obviously was not. She could be silent for entire sessions and expressed irritation with the therapist for keeping her there, telling her after a while that she would never have come to her unless “she was forced to.” Yet she never missed a session. It was obviously an arduous exercise for Stella to be in therapy, focusing on her emotions toward herself, others, and the therapist, and she started to express this more and more. After a while, when she disagreed with the therapist’s interpretations, she could allow herself to become more expressive about the therapist misinterpreting her, but she could also withdraw into a state of nonsharing and silence. Gradually, Stella became more and more open with the therapist, more trusting that the therapist could be a benevolent figure, someone who could understand her. She often initiated discussions about the boundaries of confidentiality–what she could disclose to the therapist without the therapist’s telling her parents.
Stella Bringing Up Sexual Material in Treatment About one year into the weekly therapy, Stella opened up a whole different topic that had not been touched upon until then. She confessed to the therapist that she had been terrified of men lately, and of meeting men when she was on her own. In one of the following sessions, this came up (presented from the therapist’s, that is the first author’s, point of view): While discussing recent problems at school, Stella suddenly interrupts herself, stating that she has had nightmares every night, nightmares in which she is being raped. She closes off as soon as I begin to explore this by asking her if she could tell me more of what happens in this dream. I also ask if the perpetrator(s) is/are someone she knows. Stella does not answer. I let her leave the subject after saying that it must be very scary to have such nightmares, and that I can understand that it is also scary to talk about it here, when it becomes more vivid and maybe gives rise to a range of different feelings. She seems calmer but refuses to talk more about it. She starts talking about how she feels anxious around strangers on the bus, because they look at her and “they all think she looks weird.” The next time this topic comes up is two sessions later. Stella opens up by saying that lately she has been increasingly frightened, and she describes herself as being “paranoid.” I ask what makes her afraid at the moment, and she says, “Of being raped.” She starts talking about it more freely and how she sees every man as a potential rapist, and she is very anxious in places where she can run into strange men. I wonder if she herself can think of what this means. After a long silence she says, out of the blue, “Dad.” I say, “You think of Dad . . . ” and let her continue. Then she says her father has never been “mean” or “bad” to her and nothing has ever happened in actual life, but what she fears the most is to be raped by him. I wonder if she has any idea why these fears have emerged in her now; she doesn’t know. I wonder how it feels to have these strong fears around her father, and she says it is “terrible” and she cannot say anything about it to him or to Mum because they would misunderstand. She feels very much alone in this situation and I validate that. I say it is good she shared these thoughts with me, and we can perhaps understand more of them together. Stella explains that she does not like the way Dad looks at her sometimes, and a while ago he touched her on her bottom and she felt it was not at all pleasant. She feels he is treating her differently, not only as a daughter but also as a young woman, and that makes her uneasy. I try to find out whether she has experienced any kind of sexual abuse by her father or any other person. She understands what I am getting at and says, “I have never ever experienced what I am so afraid of, that is why I cannot understand these strong feelings.” I feel a little more at ease about interpreting her feelings more in terms of fantasies and confusions related to her sexual awakening and to her relationship with her father (and mother) rather than as a consequence of actual sexual trauma, but I remain unsure about it. After a pause I intervene by saying that at her stage of development and as part of sexual maturation, these feelings can be rather typical and felt by many girls her age. Being the opposite sex, her father is a sort of a template for all boys and men, and that gives rise to her unconsciously (i.e., in her dreams and fears) testing out different scenarios about this relationship and her own sexual feelings, which can be scary and confusing. Stella seems clearly relieved after her disclosure and my response
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to it; she becomes less tense and starts to talk about other things with more ease the rest of the session. The topic did not come up again on her initiative (I always let her take the initiative in our sessions). However, 2 months later, when we were discussing her relationship with her father again, I asked her whether she felt tense or anxious around him or if she still suffered from those nightmares she had talked about earlier. She denied that, and I paused and looked at her and said: “You do not any longer have fears or nightmares about being raped by your father or by other men?” She answered with a clear voice: “No, after you told me it was normal for a girl my age to have such feelings, the fear left me, and has never returned.”
Learning From the Therapist’s CT: Implications From the Case of Stella Stella invoked strong feelings in the therapist from the start. In the beginning she was silent and averted the therapist’s communication—leaving the therapist with feelings of insecurity regarding the possibility of establishing an alliance or of being able to help. When Stella opened up more, there were many areas to work with—suicidal ideation, self-harm, body issues, strong self-critical attitudes, relational problems, and existential issues. The work with Stella, like most work with troubled adolescents, continued to evoke feelings of rejection, doubt, incompetence, and frustration. One can say such feelings are inevitable in clinical work with adolescents (Sarles, 1998; Tishby & Vered, 2011); however, when the work leads to a healthy developmental path being found or resumed, it can be highly meaningful. The work with this patient activated even deeper layers in the therapist when Stella, a year into the therapy, disclosed fantasies of sexual assault and rape. After some careful inquiry by the therapist, Stella confessed that these fantasies were mainly about her father, leaving the therapist for a while confused and worried. What had happened to Stella? Was the disclosure of fantasies and nightmares of rape a way to tell the therapist that she had been a victim of sexual abuse or incest? Was this the answer that could explain the presence of deep psychological suffering and her worrying, loss of functioning, and severe symptoms in the absence of any apparent trauma? Such a resolution might have been tempting for the therapist to grasp, even if its implications would have been demanding as well. Alternatively, were Stella’s fears products of her fantasy and unresolved earlier (Oedipal) conflicts—the fusion of longings and fears, lust and aggression, which can reemerge in the context of a developing mind and body (Midgley et al., 2013)? These possibilities created an ethical dilemma in the therapist. The therapist was faced with a conflict between the therapeutic ideal of empathic listening and of taking responsibility in a possible case of sexual abuse, the latter a course of action that would have risked being both invasive and destructive. This dilemma was amplified by Stella’s preoccupation with the question of confidentiality and her anxiety about the therapist violating it. Complicating the matter, the therapist had her own reasons for struggling with this dilemma. In the therapist’s own relational history, she had experienced strong feelings toward her father. The truth is, Stella’s father reminded her of her own father, which illustrates how the transferencecountertransference matrix in child therapy also involves the child’s parents as well as the child (Anastasopoulous & Tsiantis, 1996). The therapist had herself as a child felt a deep longing for closeness with her father, yet at the same time a fear of his aggression and authority. There had been tensions in her own upbringing, especially in her adolescence, regarding the testing of boundaries and conflicting feelings between longing and fear. The therapist grew up in a family as the middle of three sisters, who often found themselves competing for their father’s attention and favor. Their father, being both highly masculine (and often regretting the lack of a son) and warm and caring at the same time, would often play one against the other, favoring one over the others, causing jealousy and frustration. When Stella revealed her fantasies about being raped by her father, some vital parts of the therapist’s inner world became activated: an awareness of both yearning for closeness and a fear of masculinity, and the complex fusion of fear, aggression, and sexual desire. Thus, it was difficult to determine whether Stella’s own acknowledged fears and anxieties could be therapeutically handled or whether they demanded another type of action. Our working hypothesis is that Stella’s psychological issues were a hook for the therapist’s own issues around Oedipal longings.
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Complicating these dynamics even further was the fact that the therapist had been going through a long-term psychoanalytic psychotherapy in which she had worked intensely with Oedipal issues in the transference dynamics with a male psychoanalyst. Yet these issues were not resolved in a finalized way, as indeed we believe that they cannot be. When these issues were stirred up in working therapeutically with Stella, they had to be worked through again. However, we believe that precisely because the therapist had worked with these issues in personal therapy, she was more able to maintain an accepting and nonjudgmental attitude toward Stella’s revelations, and less prone to act out the anxiety or shock in treating the case as one of potential child sexual abuse or incest. In this way, the case demonstrates to us how the reactivation of a therapist’s early conflicts may actually benefit the client. Here, the therapist was better able to align with the patient in her feelings and fantasies—quite difficult, taboo-laden feelings that understandably caused anxiety, shame, and confusion. We should note that the reactivation of a therapist’s own personal issues is not beneficial in itself. Rather, the therapist was sufficiently aware of the roots of her response to the material brought forth by the client because she had worked with similar issues in her personal treatment process. Without this level of insight, the course of treatment might have been different. One might argue that the therapist diverted from the typical analytic attitude of exploration with her “normalizing” intervention. That is, by utilizing a psychoeducational (i.e., normalizing) intervention (albeit with a psychoanalytic flavor), the therapist might have been acting out her own wish to consider the case as one of internally generated (Oedipal) fantasies, rather than a case of child sexual abuse, to feel more normal about herself. Notwithstanding this, the effect of the intervention was beneficial and lasting; the patient experienced relief, probably because the explanation and normalization reduced her shame and confusion and made her more accepting of herself. Arguably, though, the therapeutic process might have been even more beneficial if the therapist had maintained her analytic stance. Doing so might have enabled the client to find her own way, which, in turn, might have promoted her development of autonomy. The answer to the riddle of what Stella’s symptoms actually reflected was not known to the therapist, as it rarely is. Based on the effect of the therapist’s intervention, it seems the therapist was on the right track; the patient’s fears and nightmares were not indicative of actual experiences with rape or incest. If they were, the patient would hardly have felt so relieved and improved. When the therapist does not know the meaning of a patient’s communications and the dynamic between them, she is in need of “negative capability,” a term first coined by the English poet, John Keats (1817): “when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason” (see also Bion, 1970, p. 125, and Strømme, 2010). This is a vital capacity that we believe develops through experience and, more important, through personal therapy. In the following months, the therapist strove to tolerate the uncertainties by letting the patient take the lead in her process of discovery, trying not to interfere with this process to satisfy her own needs to settle the case and reduce her own inner turmoil. When it came up months later, Stella painlessly informed the therapist that she no longer experienced fears or nightmares of being raped by her father. This was at least temporarily settled for the client. Later on during treatment, Stella did commit to a boyfriend and had her first sexual experience with him. She described this as a pleasant experience. In the work with this patient, the therapist found a number of things helpful. She attended regular psychodynamically oriented supervision in which this particular case figured prominently in the months after Stella’s disclosures of her fears of rape. In these sessions, the feelings evoked in the therapist were closely attended to. Through this, the therapist became aware of how Stella’s father reminded her of her own father, and she got in touch with her own conflicts from adolescence. Additionally, the dilemma of whether to take action in a case of possible sexual abuse or incest versus interpreting the patient’s fears as internally generated fantasies—and keeping these competing hypotheses active for a period of time—was discussed. Theory suggesting that Stella’s fear might be understood in terms of the complexities of psychosexual development in adolescence, including challenges relating to triangulation and the frightening fusions of fear and desire, helped the therapist gain perspective to tolerate her anxiety (St¨anicke, 2012).
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In addition, we believe that some of the capacities that Gelso and colleagues (Gelso & Hayes, 2007; Hayes, Gelso, & Hummel, 2011) have suggested are critical for therapists’ effective management of countertransference–including empathy, anxiety management, and conceptualization ability—were vital in this case, facilitating the therapist’s ability to get in touch with the roots of her feelings evoked in this case, tolerate doubt and maintain a “wait and see” stance, and understand the patient at a deeper level.
Conclusion This article has presented a case study of therapist reactions evoked in adolescent psychotherapy with a young female client. The client suffered emotional disturbances related to the challenging and sometimes overwhelming developmental tasks of adolescence, including individuation and psychosexual development. One of the apparent breakthroughs in the treatment process was when the patient disclosed strong fears and nightmares about being raped by men in general and her father in particular, which raised ethical dilemmas in the therapist regarding how to handle the implications of these revelations and, at the same time, reactivated the therapists’ own issues from her adolescent period. Getting in touch with these personal issues—which had been worked on in intense psychoanalytic psychotherapy—was a significant aspect of the therapeutic process. The inner work of understanding the patient at her level of fantasy and tolerating the uncertainty for a period of time in the work with the patient seemed to have been critical for the relief of symptoms in the patient. Furthermore, the fact that the material of the patient found a hook (Gabbard, 1995) in the therapist enabled a deeper understanding of the patient that helped resolve her inner conflicts and move on in her development. We believe this case suggests that, as therapists, we can work well with patients stirring up our own material and conflicts, which are never completely resolved, and gain a deeper connection with our clients, even in such delicate matters as frightening sexual and violent fantasies in adolescence. In this particular case, it was as if the therapist, during what was a critical moment in treatment, communicated the following words to her young client (borrowed again from the Boye poem cited earlier): “Yes, of course it hurts when buds are breaking, hurts for that which grows and that which bars.” The client could continue her journey into summer.
Selected References and Reading Recommendations Anastasopoulous, D., & Tsiantis, J. (1996). Countertransference issues in psychoanalytic psychotherapy with children and adolescents: A brief review. In J. Tsiantis, J. A. M. Anastasopoulous, & B. Martindale (Eds.), Counterttransference in psychoanalytic psychotherapy with children and adolescents (pp. 1–11). Madison: International Universities Press. Bion, W. R. (1970). Attention and interpretation. London: Karnac Books. Bonovitz, C. (2009). Countertransference in child psychoanalytic psychotherapy: The emergence of the analyst’s childhood. Psychoanalytic Psychology, 26, 235–245. Boye, K. (1935). “Yes, of course it hurts.” Poem translated into English by David McDuff (2005), Karin Boye. Complete poems. Bloodaxe Books. Britton, R. (1989). The missing link: Parental sexuality in the Oedipus complex. In J. Steiner (Ed.), The Oedipus complex today: Clinical implications (pp. 83–101). London: Karnac Books. Busch, F., Rudden, M., & Shapiro, T. (2004). Psychodynamic treatment of depression. Washington: American Psychiatric Publishing. Freud, A. (1966). Normality and pathology in childhood: Assessments of development. London: Karnac Books. Freud, S. (1910/1959). The future prospects of psychoanalytic therapy. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11). London: Hogarth Press. Freud, S. (1912/1959). Papers on technique. The dynamics of transference. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11). London: Hogarth Press.
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Gabbard, G. O. (1995). Countertransference: The emerging common ground. The International Journal of Psychoanalysis, 76, 475–485. Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship: Theory, research and practice. New York: John Wiley & Sons. Gelso, C. J., & Hayes, J. A. (2007). Countertransference and the therapist’s Inner experience: Perils and possibilities, Mahwah, NJ: Lawrence Erlbaum. Goodyer, I. M., Tsancheva, S., Byford, S., Dubicka, B., Hill, J., Kelvin, R. . . . Fonagy, P. (2011). Improving mood with psychoanalytic and cognitive therapies (IMPACT): A pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: Study protocol for a randomised controlled trial. Trials, 12–175. doi:10.1186/1745-6215-12-175 Hayes, J. A. (2004). The inner world of the psychotherapist: A program of research on countertransference. Psychotherapy Research, 14, 21–36. Hayes, J. A., & Gelso, C. J. (2001). Clinical implications of research on countertransference: Science informing practice. Journal of Clinical Psychology, 57, 1041–1051. Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy, 48, 88–97. Laplanche, J. (1989). New foundations for psychoanalysis. Oxford: Blackwell. Laufer, M., & Laufer, E. (1975). Adolescent disturbance and breakdown. Harmondsworth (London): Penguin. Midgley, N., Cregeen, S., Hughes, C., & Rustin, M. (2013). Psychodynamic psychotherapy as treatment for depression in adolescence. Child and Adolescent Psychiatric Clinics of North America, 22, 67–82. Rosenberger, E. W., & Hayes, J. A. (2002). Therapist as subject: A review of the empirical countertransference literature. Journal of Counseling and Development, 80, 264–270. Sarles, R. M. (1998). Individual psychotherapy with adolescents. In. H. S. Gurman & R. M. Sarles (Eds.), Handbook of child and adolescent outpatient, day treatment and community psychiatry (pp. 259–264). Philadelphia: Brunner Mazel. St¨anicke, L. I. (2012). Relasjonelle utfordringer i en ungdomsterapi – sett i lys av noen psykodynamiske grunnbegreper [Relational challenges in adolescent psychotherapy – in light of some psychodynamic concepts]. Mellanrummet [Nordic Journal of Child and Adolescent Psychotherapy] 26, 22–35. Strømme, H. (2010). Confronting helplessness. A study of psychology students’ acquisition of dynamic psychotherapeutic competence. (Unpublished doctoral dissertation). University of Oslo, Oslo, Norway. Tishby, O., & Vered, M. (2011). Counter transference in the treatment of adolescents and its manifestations in the therapist-patient relationship. Psychotherapy Research, 21, 621–630.
