Anti Depression Guide

Uncertainty and Countertransference
Robert L.  Tyson, M.D.  3/85

    There are, of course, many ways by which uncertainty may affect the psychoanalytic interaction between analyst and analysand.  The nature and quality of that interaction determines whether or not it is a psychoanalytic one, or some other variety, and it ultimately also determines whether it is a process which proceeds, or one which becomes arrested.  I will examine some clinical examples of how the analyst’s uncertainty can affect the analytic process through the countertransference, but first I will establish working definitions of countertransference and of uncertainty.

    As psychoanalysts all know, any interaction, and especially the psychoanalytic one, is profoundly influenced by the mental representations of past relationships, experiences, fantasies, hopes, wishes, fears, disappointments and humiliations.  It is now becoming more generally accepted by analysts that any focus on the internal aspects of the psychoanalytic process must take account of the countertransference, however that may be defined.  For the purposes of this discussion, I will use a broad definition of countertransference to refer to all the analysts’ responses to a particular patient, including the patient’s transference, and any other aspect or behavior of the patient, whether or not these responses result in an interference with the analytic work.

     However, this definition does exclude ignorance; that is, the analyst’s ignorance or lack of experience may affect analytic technique so as to interfere with the analytic process in just the same way and with the same result as an analytic impediment which takes origin in the analyst’s unanalyzed conflicts stimulated by the patient’s material.  

    The analyst’s inner uncertainty to which I refer is a combination of cognitive uncertainty with indecision, elements which were distinguished by Rangell (1971, p.  439) with admirable precision.  Rangell said that uncertainty exists when there are inadequate or unsatisfactory results from cognitive efforts to reach a conclusion; that indecision appears when the ego cannot commit itself to action, either because of uncertainty due to cognitive or other insufficiencies, or, I would suggest, due to other insufficiencies because of the gap between the patient’s level of expression in the transference, and the analyst’s level of uncertainty in the countertransference.  It is also in the area of indecision, Rangell pointed out, that the ego is affected by a sense of responsibility, and here the influences from the superego make themselves felt.  Doubt was defined by Rangell as the affective state accompanying uncertainty and indecision. 

    I would like to illustrate some of these points beginning with a vignette from the analysis of a nine year old girl who was brought because of extensive inhibitions in her social and family relationships, her academic work, and throughout all her activities.  It went so far that the family noticed she would attempt to cut meat at dinner using only the blunt side of the knife.  Well along in the analysis I received a phone call from the mother to inform me that the parents were considering discontinuing treatment following an incident at a dinner party the evening before.  This quite proper daughter of an English aristocratic family had announced for all the guests to hear, that Dr.  Tyson talks about penises. 

    In the luxury of retrospect, I could separate several countertransference interfaces each permeated by the amalgam of uncertainty and indecision I have described.  While it may well be true that ignorance and lack of experience made a significant contribution to this situation as undoubtedly it does to some extent in all psychoanalytic work, ignorance cannot be analyzed so I will not consider it further. 

    The first reaction of which I became aware in myself was in response to the evident aggression in my patient’s acting out.  While I was cognizant of the resistance involved, her behavior was like using the sharp edge of the knife, and therefore expressing the hostility she was at the same time defending against.  I felt intense uncertainty about which aspect to interpret to her first ? her need to defend against the analytic work, or the aggressive content which was so clearly being expressed.  It was no problem to know what to say or how to interpret it in the transference, only whether to do one or the other, and I was convinced that saying nothing was out of the question. 

     It would be necessary, I knew, to tell her that her mother had called and that her parents wanted to stop the analysis.  Knowing them as I did, it was certain they had announced this to her.  The second countertransference interface of uncertainty was in relation to the parents with whom it was now necessary to arrange a meeting.  I would have to reconcile my experience of the parents with the image of them I had built up in the course of the anaytic work.  The depressed mother had wanted her daughter to have treatment instead of being sent away to boarding school, and she made what were for her Herculean efforts to convince the reluctant father that analysis was preferable to exile and banishment.  I now felt uncertain about how to interpret these events to the parents in such a way that they would be willing to allow their daughter to continue in analysis with me, a person who not only was talking about forbidden subjects but who was a foreigner as well.  I began to think about Ernest Jones who was briefly put in jail in London early in his career for talking to a little girl about her sexual experiences, and he wasn’t even a foreigner.  I was concerned about the issue of confidentiality and undecided about how much to explain to the parents, always intolerant of their children’s aggression, let alone the topic of sexual anatomy. 

    The third countertransference interface was with myself, as between my “work superego” (Shafer) and its ideal analyst representation, on the one hand, and my current assessment of my actual analytic technique, on the other hand.  In other words, how did we get into this situation, and had I gone too far, too soon with my patient, precipitating her abrupt acting out of resistance?

    To summarize, I have presented a clinical example with inner uncertainty manifested in three interfaces of countertransference ? one with the patient, one with the patient’s objects, as I came to know about them from her, and one with my own work ego ideal.  In each instance one can see the uncertainty in Rangell’s sense deriving from insufficient information, indecision from several sources including in particular the influence of the sense of responsibility and the gap between patient in transference and analyst in countertransference, and the affect of doubt which accompanies them all. 

    In a more complete presentation, other examples from patients at other developmental levels would be used in an effort to find similarities and differences in uncertainty manifested in countertransference responses with patients of different ages.  The technical means of handling these countertransference responses then would be more clearly seen in a developmental perspective.  With the single example given here, very briefly one can say that the usual simple recommendation of self?analysis becomes more complicated.  The task of self?analysis is difficult enough, but its importance and complexity is dramatically emphasised when countertransference is considered in terms of the analyst’s reaction to the patient, to the patient’s objects, and to the analyst’s work ego ideal.