The verbal squiggle game in treating the seriously disturbed patient.

The psychoanalytic treatment of the seriously disturbed patient depends on working through the countertransference. If the analyst regresses without debilitating anxiety to early levels of psychic development, as does the analysand while reliving his or her early traumatic psychic development, both analyst and analysand may be able to enter states of reverie simultaneously and to communicate with one another in a type of verbal squiggle game. In this variant of Winnicott's written squiggle game, each may easily communicate with the other with quick shifts from the autistic-contiguous, paranoid-schizoid, and depressive positions. During such unusual periods of exquisite understanding, very early pathological experiences can be relived, understood, and repaired.

Countertransference : condensed history and personal view of issues with regressed patients.

Freud's ambivalently negative attitude toward countertransference discouraged systematic study until some psychoanalysts, predominantly Kleinians, began to treat patients with narcissistic neuroses. Recognizing the need to understand the unconscious and conscious contribution of the analyst to the therapeutic process, Heimann, Rosenfeld, Balint, and Racker pioneered in serious study of countertransference. Racker and Boyer found that unresolved countertransference problems contributed significantly to unfavorable responses to psychoanalysis in seriously disturbed patients. Searles, Giovacchini, Ogden, and Volkan have like-wise furthered countertransference research. Following a historical review, the author delineates his personal approach to understanding patients, especially seriously disturbed ones, in terms of the ongoing introjection of patient and analyst of each other's projections. This approach stems from Rosenfeld's initial propositions.

[Rupture of the distal thoracic esophagus by closed trauma]. / Rupture de l'oesophage thoracique distal par traumatisme fermé.

Closed traumatic rupture of the esophagus is uncommon, usually located in the upper third of the esophagus. We report a case occurring in the lower third. This diagnosis must be envisaged when faced with delayed clinical and radiological signs. The prognosis is severe and the therapeutic decisions are controversial.

Roles played by music as revealed during countertransference facilitated transference regression.

Clinical and experimental investigations have demonstrated that music may serve subtle and complex psychological functions, the sounds per se serving more primitive roles than the themes and lyrics. The present study offers data obtained during the psychoanalysis of a musically talented man who had suffered life-threatening croup and asthma until the age of 5 or 6. Regression that was achieved as the result of interpretations based on the analyst's countertransferential responses revealed that the analysand was unable to achieve psychological separation from his mother and that music served predominantly the function of retaining a life-supporting connexion with her. Presumably as the result of a complex elaboration of respiratory and auditory introjection, music came to symbolize the noise of air-flowing through tubes into the steam tents and blood coursing through the umbilical cord, conceptualized as connecting him with his mother and making them permanently interdependent. The early ego defect was overcome through a transference-countertransference interaction that is delineated in detail. Then, the less primitive meanings and psychological uses of musical themes and lyrics were elucidated, again in response to interpretations based on countertransference reactions.

Countertransference and technique in working with the regressed patient: further remarks.

In working with regressed patients, the most effective interpretations are based frequently on information gathered through transference-countertransference interactions, interactions that often depend on the patient's projective and the analyst's introjective identification. A group of regressed analytic patients seek to rid themselves of tension predominantly by evacuating their unconscious fantasies or projecting them into the analyst. A fragment of the analysis of such a patient illustrates how her fantasies could not be adequately contained by the analyst because they revived in him inadequately resolved conflicts from early childhood, conflicts that resembled closely those being relived by the patient. His reacting by falling asleep created an emergency that was resolved by his making an unplanned interpretation that proved to be significantly mutative, a 'turning point'.

Working with a borderline patient.

A summary of the treatment of a borderline patient illustrates (I) that psychoanalytic therapy with such patients is feasible within the framework of the structural hypothesis and (2) that the results of such treatment are influenced materially by the analyst's use of his emotional responses to the patient and her production.

The psychoanalytic impasse.

In the study of impediments to the success of psychoanalysis as a treatment method, the character structure of the analysand has received the most attention. Psychoanalysis has come to be used for the treatment of an ever-widening range of psychopathological states, and the analysts have become confronted with a greater incidence and variety of clinical situations which can develop into therapeutic obstacles. Whether the psychoanalytic impasse will become a therapeutic stepping-stone or an obstacle to treatment often depends upon the emotional response of the therapist and his resultant behavior. Accordingly, there has been a heightened interest in the study of countertransference. Some therapists equate the psychoanalytic treatment of patients with severe character deformations with "wild" analysis and therefore feel needless guilt and anxiety when they attemtp to treat patients who suffer from them; thus they increase the likelihood of their becoming therapeutic obstacles. We have considered the psychoanalytic impasse as an inevitable aspect of the analytic sequence and discussed countertransference reactions in this context. Technical complications resulting from adverse countertransference reactions are examined both in terms of the patient's provocations and responses in the analyst. Among the analyst's responses, three were emphasized: (1) helpless fellings which represent the patient's helplessness and vulnerability; (2) rage reactions; and (3) profound anxiety reactions. The patient's need to construct and environment similar to the early traumatic environment within the analysis can become a very difficult situation for a therapist. The resolution or at least understanding of these interactions becomes equivalent to the lifting of infantile amnesia, a step which has been considered the essence of psychoanalytic resolution. Thus, adverse reactions can become keys to the gaining of fundamental insights, permitting the analytic process to continue its inevitable course.