Projective Identification And Countertransference

The concepts of projective identification and countertransference represent a major transition in world views, from the modern towards the post-modern position.

The 'modern' world view, to which Klein belongs, holds that therapists are specialists who represent the truth, who have objective knowledge, and a modern mindset to support them. Such therapists believe that 'they are emotionally healthy, objective, and know what is right.'

Intersubjectivity, an approach to psychotherapy based on the work of Stolorow, Attwood, Brandchaft, Orange, and others, is associated with the 'post-modern' perception of the world. Key notions of post-modernism are:

- no objective truth can be found
- relationships are a question of constant negotiation
- everything exists in a context and is relational.

The post-modern view is also interesting in relation to research. The modern worldview suggests that there are specialist researchers who hold special knowledge and who then provide practitioners with that knowledge. Modern psychotherapy approaches are thus theory driven. In contrast, the post-modern view holds that every practitioner should act as a researcher, and that knowledge is better shared without formulating grand theories. Knowledge is more experiential and relates to local context or wisdom.

The Kleinian position

According to the Wikipeda Encyclopedia, projective identification was first introduced in 1946 by Melanie Klein. It refers to a psychological process in which a client projects impulses of intolerable, painful, or unwanted parts of the self onto the therapist, such as a need to be cuddled, or to express rage or sexual feelings. A similar view suggests that therapists may feel a subtle unconscious pressure to act in a certain way or feel "controlled" by the client. Kleinian analysts believe that by influencing the analyst to behave in a particular way, deep-seated and vulnerable material is prevented from coming into the discussion. Therapists with a high level of skills and process awareness usually do not uncritically accept these projections but respond with well-timed and qualified interpretations.

According to Kleinian thought, the scenario described above generally happens out of awareness for both parties involved. The projective identification process is understood to be one of the more primitive defense mechanisms.

Intersubjectivity

The intersubjective approach to psychotherapy rejects the concept of projective identification. Stolorow, Attwood, Brandchaft and Orange re-conceptualised it by suggesting that reality is constantly co-created by the personalities of both therapist and client. Klein's concept suggests that the therapist's observations are objective and the client's transference is seen as coming from a neutral place of what Orange calls "uncontaminated" activity between the therapist and the client (Orange et al., 2001, p. 39). It views transference projections as solely coming from the client's past and present, from his or her psychopathology, and does not consider the possibility that the therapist may also be impacting on the client. According to Orange and her co-authors:

Transference and counter-transference together form an intersubjective system of mutual influence (Stolorow, Brandchaft, and Atwood,1987)[…] The notion of analytic neutrality supports the image of the analyst as a neutral scientist making objective observations about the patient's transferences. Analysts embracing such an objectivist epistemology interpret from a mythological platform with 'a God's eye view' of the true reality that the patient's transference experiences distort (2001, p. 41).

In this view, psychotherapists assess the clients' emotional, physical and mental inner life. Orange holds that: "From an intersubjective […] perspective, the analyst 's perceptions are intrinsically no more true than the patient's. Further, analysts can not directly know the psychic reality of the patient" (2001, p.41) because they see reality through the lens of their personal life experience. Orange (1994) calls this interplay of transference and countertransference "Cotransference." Stolorow, Orange and other intersubjectivists find the Kleininan view on projective identification questionable because:

there is presumed to be not only a projective distortion of the patient's subjective experience of the object, but also a purposefully induced alteration in the external object's actual attitude and behavior towards the patient (Stolorow et al., 2000, p. 112).

These authors view a client's aggression towards a therapist as a product of the disjunction in the therapeutic relationship, a phenomenon described by self-psychologists as empathic error. According to Stolorow (ibid.), aggressive responses from the client:

occur only when the patient's disagreements, assertions, and primary wishes to have his own subjective experiences empathically understood have been consistently unresponded to (Stolorow et al., 2000, p. 114).

We may wonder, of course, whether or not an aggressive assertion has to always be a response to an empathic error, or whether clients do, in fact, project old unconscious, as well as current, feelings onto the therapist.

A "field" view of Projective Identification

A psychosomatic view of projective identification conceptualises the experience of a therapist as a resonance of, or transference of, disowned feelings by the client. It can be conceptualised that these disowned feelings form an energetic field in which the therapist participates. Being the more energetically fluid system, the therapist is able to feel in his or her emotional and somatic experience, at times even in observable psychosomatic symptoms, the feelings disowned by the client. This view of projective identification is, as far as I can see, compatible with the relational thinking applied in the intersubjectivity approach to psychotherapy.

In the following case study I present an example of a fictitious client with early experiences of deprivation, who uses fragmentation and disorganisation to regulate his or her affect. Most clients with deprivation experiences, at some point in their therapy blame their therapists for withholding body-contact, love, and attention. In the modern way of thinking outlined above, we would call this transference of feelings, which is the projection of the early deprivation onto the therapist. The client feels, within the therapeutic relationship, these intense feelings and unconsciously projects them onto the therapist. There are a number of ways the therapist can respond to the client's projection: he or she could blame the client for being demanding, could feel guilty, or have doubts or other responses about his or her way of working. All responses may be viewed as expressions of countertransference. In the first case, the therapist rejects the client's needs, whereas in the second one he or she fails to set clear boundaries. A therapist who has sufficient self-awareness will be able to mirror empathically what is going on.

The phenomenon of projective identification, as exemplified in the "field" version, would emerge in the client's inability to identify his or her neediness (Schore, 2003). Unable to consciously sense and express the need for body-contact or nurturing, the client and the therapist both project and introject. This creates a "field" of disowned feelings which, through their close proximity, influences their interaction. Being emotionally receptive, the therapist may have both a psychological and somatic awareness of the client's deep sense of neediness, of his or her 'black hole in the guts.' With a strong awareness of this projective identification process, a therapist will, rather than getting trapped in the field, be able to mirror his or her perception and help the client to find cohesion in him or herself. Therapists may also offer professional bodywork, such as holding, to assist the client in developing a coherent body-oriented self.

While Kleinian therapists would make an interpretation without gratifying the client's needs, Self-psychologists hold the client through empathic verbal attunement. Somatic psychotherapists will also physically hold the client.

My position as a somatic psychotherapist

In my work with clients I integrate the understanding of the psycho-analytical tradition of intersubjectivity (Orange, Atwood, Stolorow, Brandshaft), self-psychology (Kohut, Lee), the neuroscience, (especially Schore), trauma research, (Herman, Rothschild, van der Kolk) and the rich somatic psychotherapy traditions, (Boadella, Conger, Dethlefsen, Dychtwald, Hunter and Struve, Johnson and Grand, Johnson, Keleman, Lowen, Reich, Smith, Staunton and Totten and Edmondson). I use, among other techniques, Gerda Boyesen's Biodynamic Massage in my interaction with clients. I also use my hands to resonate with the client and, when appropriate, to soothe. I use the "field" version of Projective Identification and countertansference (Stolorow and Schore) as a resonating and sensing tool to deepen the understanding of what is happening in the created field. My body is in this context, a resource that assists me with resonating, identifying and empathically responding to the client. This is an experience of joining the client in the intersubjective field that both of us are creating (see Orange et al., 2001).

Current developmental research views projective identification as identical to what Schore calls "maternal receptivity" (2003, p. 60) and recognises that the "infant's states are less cognitively complex and more bodily based and sensory-affective" (2003, p.59).

I meet the developmental needs of my clients with an attuned presence that resonates with them like a mother who is attuned to a distressed child. Developmentally, projective identification is seen by Schore, Stolorow, and Orange as a communication system between mother and child, where the baby reaches out and projects nurturance and relationship behavior onto the mother and she identifies with the needs of the baby and acts on them.

In this process I often experience the natural blurring of boundaries between the client and myself. It is crucial to learn to deal with this phenomenon; otherwise such intense, intimate, hands-on work cannot be done.

This way of working acknowledges that if we meet the clients' needs, they will be enabled to contact deep feelings of grief by receiving something that they never had. If we assist clients with setting their boundaries, they will use the physical contact as a support to face difficult feelings. It is my experience that facilitating a moment-to-moment process that includes physical holding, can help the client organize new resources and a different response to overwhelming feelings. Knowing deep in my being how important it is to be touched, I believe that providing real contact and not just empathic attunement can be also a very spiritual experience.

Reflections on my client

Eve arrived in Australia from Europe when she was 9 months old. On the ocean liner to Australia she became severely dehydrated because her mother did not use the formula correctly. Eve had to spend some weeks in the ship's hospital where her mother visited her. She describes her mother as very disconnected and unavailable.

While growing up she was sexually abused by her father, whom she describes as a tyrant who ruled the family. At the age of four she tried to run away because there was no love in the family. When she was five years old, the family moved to another city where she met her friend Sarah, whom she describes as her only love. Eve and Sarah walked together to school, and she remembers having a lot of fun together. Because her mother did not tell her that Sarah was moving away, she lost her friend without any warning. The mother knew but did not want to deal with Eve's feelings. Eve felt such a sense of betrayal, she lost trust that someone would stay with her and made no new friendships during the remaining school years. Lack of trust and the feeling of isolation are still her central themes.

As a young woman Eve tried to kill herself because she did not feel she could love or be loved. When her suicide attempt failed, she continued the "suicide" symbolically through working as a prostitute. After a few years, Eve moved overseas where she met Deborah who helped her to leave prostitution. They moved to Europe where they lived together for 18 years. Eve experienced Deborah - who had very strong similarities to her parents - as being very cruel. As she had been for her mother, Eve functioned as a self-object for Deborah's narcissistic needs, hoping to find mutuality in the relationship. So far, Eve has not been able to engage in other than dysfunctional intimate relationships. She suffers from bulimia and uses alcohol to cope with her feeling of being overwhelmed.

As Eve's therapist, my experience of projective identification with her has been a very visceral one. I share her experience of hiding away in the bones. I also feel how her tortured and abused body is crying out to be received in an empathic and nurturing way, and I resonate with her lack of trust in people. She still expects that she will be betrayed, this time by me.

Often she comes to sessions not knowing what to share. She then waits for my clues on how to be with me. Knowing that I have to be extremely careful, we often just sit in silence, and, sharing her experience, I mirror to her the difficulty of being together in this space. She shares her disappointment in herself when she drinks and eats too much. Often she feels very alone and wants to escape her internal terror. Eve is gradually becoming aware of her dysfunctional and destructive behavior and thought patterns. There are signs that she is slowly becoming able to organise her drinking and eating more sustainably.

I have introduced her to meditative ways of holding herself by being mindful of her internal world. We practice this in sessions for a little while and occasionally, memories or thoughts arise out of her being.

During the sixth session she talked about the experience when she nearly died on the ship to Australia. She was wondering whether or not her mother was unconsciously trying to kill her because of her own despair. In my body response I tried to attune myself to the distress of this baby. Schore writes:

And so in these exchanges of affect synchrony, as the mother and infant match each other's temporal and affective patterns, each creates an inner psychological state similar to the partner's (2003, p. 114).

As she reflected on this early experience, I felt my intestines getting tense and tortured, and I felt drawn to touching and holding her. My experience of sensing her internally held distress suggests making sense of projective identification in a fundamentally different way. Schore writes:

It is often written that projective identification is an attempt to intentionally control the therapist, but it should be noted that beneath […] is intensive disorganization and insecurity, and not intentionality but hopelessness, helplessness, and a total lack of an organised coping mechanism (2003 p. 87).

I asked Eve what she would have wanted as the little baby. At first she tells me that she doesn't know; then says that the baby wanted to be nurtured and cuddled. (We had talked in an earlier session about the possibility of doing hands-on bodywork and holding). I gave her some options and she chose to be held with me sitting behind her. I made sure that I was comfortable and supported by a wall. She was able to receive me for a few minutes but then I could feel her contract. The feeling "I hate you" emerged, and I encouraged her to express the feeling while looking at me. She briefly experienced that I was able to cope with her strong "negative" feelings but soon had to disconnect. In this moment, she felt "very frozen."

I started to feel numb in my body too and knew in my guts that only meeting her on the tissue level could soothe her in this state of hyper-arousal. At the same time I was in a dilemma because touching her again might create even more dissociation. Yet, deep in my being, I knew that meeting her at the tissue level would be the only way to connect to her. So I decided to bring my struggles into the relationship and let her decide what to do.

First I empathically agreed that the work we had just done must have been very confronting for her. I told her about my intuition to touch and that I did not want to hurt her. I also suggested that since we were in the dark together, we had to explore what was right for her. When she heard that I didn't want to hurt her she was very touched and started crying. I proposed massaging her shoulders because we had done it before and she had enjoyed it. When she agreed to risk it, I gave her a matter-of-fact gentle membrane massage, which enabled her to relax. As soon as she lay down, her and my peristalsis started and both of us had a big sigh. I knew then that she would be fine.

The next time she came, she told me how sad she had been after the previous session, and that she had had an increased sense of how isolated she is. She felt too scared to reach out and to be intimate. She shared how she creates a boundary through being judgmental. Her experience had been that either her parents were wrong or she was wrong. That made the interaction safe. I listened compassionately.

She then reflected on and talked about the disorganised parts of the baby. She told me that she hated the emerging needs, that they engulf her and that it was dangerous. The adult of here and now wanted to reject this part. To my surprise she wanted to be held again. This time she wanted to try the lying position. We negotiated different ways until she was comfortable with me lying behind her. I gave her the option of how close she wanted to move into me and let her use my body for her self-regulation with me being a self-object for her. Sand says:

If the analyst can not make herself available […] can not receive the patient's indirect, visceral communication, then these dissociated, not me aspects of self that are being communicated will be unconsciously experienced as intolerable to the analyst as well, and the patient will not be able to bring these aspects into the analytic relationship (1997a, p.665)

I relaxed into this contact too; my tissue and right brain enjoyed the impact of feeling her tissue resonating and letting down. Schore says that:

the attuned clinician must instantiate a right brain regulatory strategy that allows him/her to remain in a state of regressive openness and receptivity (2003, p. 95).

After a while she wanted me to massage her back and then a rocking movement came out of the contact. Because in this position I could only reach one side she became scared that the other side could miss out. We turned around and I could feel that the left side was much more tense. After a while she said "I feel that you hate me." I ask her what it is that makes her feel that. "It just must be". I suggested to her to turn around and check my eyes. We again explore what this feeling might mean for her and how it could be connected to her childhood experience. She shared that her mother never expressed any feelings directly, was completely shut down, not present. I invited her to check out how present she felt in our relationship. We lay face-to-face for a while again and I allow her to regulate the connection of the contact. Orbach says:

What is required, however, is to find a way not to be frightened of the hate or the disintegrated or voided bodies of our patients so that we can address their pain. We know that pain diminishes if it has been addressed not sweet talked. The second thing I believe we need to be able to do is to bring our own bodies to the therapeutic encounter: to not leave them out of the relationship (2004, p. 31).

I feel her getting tense as she tells me that the face-to-face contact was becoming too much. She senses that a stronger relationship is developing, and feels the pressure to do something for me but doesn't know what. Again we try to make meaning of that feeling because she was used for such a long time as a self-object for her mother without experiencing mutuality.

She gave me a very firm 'good-bye' cuddle - she held me like a drowning person who was not sure if she could survive. I tried to mirror back hope. In one of the following sessions, while I was holding the back and the front of her heart, she connected to a meditation experience she had on the weekend with her group. She had an image of a half dead baby - burnt, black and barely alive. She picked her up and cradled her without hesitation not disgusted by her but able to hold her and feel her pain. She said that it wasn't nice to feel her, but she did.

Summary and outlook

I hope that this case study provides you with a sense of how I use the concepts of countertransference and projective identification, and of how I use my body, emotions, and intuition to resonate with my clients in a very direct and simple human way. I have shown how I use what I call here the "field" version of projective identification with the awareness of my own somatic and emotional responses as an information tool to meet the client. I have also demonstrated how I work in an empowering way by mirroring clients' experiences, by making suggestions and allowing clients to choose how they want to respond to my interventions. This post-modern approach to therapeutic work allows clients to follow their own path, whereas in the modern approaches clients are generally expected to follow the rules and theoretic frameworks of the therapist.

My aim as a somatic psychotherapist is to enable my clients to feel safe with non-erotic touch, to develop clear emotional boundaries, and to reclaim their bodies. Like many other somatic psychotherapists, I believe that clients need to develop new ways of being embodied and aware of their emotions by having simple touch and social boundaries modeled by the therapist.

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