Establishing a transference
By Christina Biedermann
In my work at the Austen Riggs Center, and in the reflections of my colleagues in a series of 12 papers published in the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, I have encountered patients for whom establishing a usable transference is complicated by intrapsychic, familial, social, and iatrogenic factors. These patients likely make up a significant subset of those labeled "treatment resistant," as treatment relying on transference takes for granted the patient's, and the therapist's, ability to organize, tolerate, and maintain a transference. Unreflectively, the label "treatment resistant" positions the problem in the patient, rather than in treatment relationships and interventions. In this essay, I will reconsider these patients, their needs, and the needs of therapists working with them; furthermore, I will suggest team-based milieu treatment as one means of addressing the factors contributing to disorganized, intolerable, or otherwise unusable transferences. For these patients, milieu treatment, wherein the patient is surrounded by potential transference objects and known across time and contexts, and the treatment is provided by a team, may be a useful precursor to outpatient treatment, providing a space within which to organize, tolerate, maintain, and, ultimately, establish a usable transference.
As a group, patients labeled "treatment resistant" generally carry multiple diagnoses, have a history of self-destructive behaviors, and have tried multiple psychotherapies and medications without lasting positive effect. The therapists working with them often feel beleaguered, concerned about risk management, and very much alone. Of the patients admitted to the Austen Riggs Center, a psychodynamic residential treatment center in Stockbridge, Massachusetts, where "treatment resistant" patients are often referred, patients have an average of six diagnoses upon admission, and 40% have made near-lethal suicide attempts. On the psychological testing that is part of the six-week evaluation, many show evidence of relatively primitive character organization and often subtle, but significant, vulnerability to psychotic processes. My colleagues have offered several perspectives on the intrapsychic, interpersonal, familial, and social dynamics frequently found in these patients' life histories, some of which are also evident in their outpatient treatments. Briefly, these include unbearable negative affect (Plakun, 2006), its contribution to enactments (Kayatekin & Plakun, 2009), failure to recognize the Third (Muller, 2007), the intergenerational transmission of trauma (Fromm, 2006), and group and social dynamics that promote displacement and silence (Elmendorf & Parish, 2007).
A common consequence of these factors is that the transference cannot be organized, maintained, and tolerated in the service of treatment. Though one's theoretical perspective shapes how to understand the etiology and mechanics of such difficulty, the outcome is somewhat the same. Whether to avoid intrapsychic conflict, ward off fragmentation, protect a relationship with an internal object, or maintain a familial tie, strong affects and affectively laden bits of transference are threatening. Patients organized at a borderline level might split off parts of experience, self, objects, self-objects, or self in relation to objects, whereas patients organized at a more psychotic level might not have the temporal, linguistic, or somatic boundaries sufficient to ground them in themselves and in relationships in a usable way over time. As transference, depending on one's perspective, is some mixture of affect, experience of self, experience of other, and experience of self in relation to other, these dispersals complicate its organization. And, when organized, transference's "as if" space is consistently vulnerable to collapse. To protect themselves and others, these patients may lodge bits of transference, whether conceptualized as one transference split among multiple objects, or multiple distinct transferences, onto members of treatment teams without the resources or conceptual framework to understand and integrate them. A prescribing doctor, for example, and the medications prescribed may be used as a container for feelings that seem too threatening to bring to a therapist. (The field of psychodynamic psychopharmacology goes further in exploring the multiple ways patients use medications, prescribers, and the team of a psychotherapist and prescriber as transference objects. For an introduction see Mintz & Belnap  and Mintz ).
Milieu treatment provides a broader net within which to catch these dispersed bits of transference and hold the therapy dyad. Across time and context, patients are surrounded by a variety of persons in differentiated roles. If the role-related thoughts and feelings of the staff working with the patient are considered relevant data, much can be learned about the range of the patient's functioning and the gestalt of his or her intrapsychic and interpersonal worlds (Shapiro & Carr, 1987). Depending on one's perspective, treatment team members might evoke different dimensions of a single transference or multiple, distinct transferences. Furthermore, each member of the treatment team has countertransference reactions that might deepen a formulation, aid in understanding an impasse, or focus a treatment intervention (Shapiro & Carr, 1987).
For the clinician, the milieu provides a holding environment, too, one particularly helpful for work with patients presenting with disorganized or intolerable transferences. The treatment team within the milieu provides grounding in the face of overwhelming negative affect, containment in times of crisis, and perspective no one person could develop alone (Krikorian & Fowler, 2008). It catches and integrates dispersed transference(s) and maximizes the space for them by concretely grounding the therapy dyad in a larger system. At any given time, therapists are under pressure to abide by established standards of care and to practice risk management, particularly with patients engaging in self-destructive behaviors; a treatment team and system organized from this perspective helps negotiate these tensions so that ultimately the task of meaning-making can remain paramount (Charles, 2008).
When reconsidering "treatment resistant" patients as those who might struggle to organize, maintain, tolerate, and, ultimately, establish a usable transference, one must ask whether the treatment might be contributing to the resistance. Might, for example, it be helpful to reconceptualize the focus of treatment, at least initially, as establishing a usable transference? This could include identifying the factors underlying its partiality or instability, as well as working to integrate it. As I suggest, milieu treatment is one forum for doing so, though certainly outpatient treatment teams and systems might also reconsider the treatment task and the ways they integrate available resources to meet it.
Charles, M. (2008). A view from Riggs: Treatment resistance and patient authority, VIII. Standards of care and patient autonomy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 547, 560.
Elmendorf, D., & Parish, M. (2007). A view from Riggs: Treatment resistance and patient authority, V. Silencing the messenger: The social dynamics of treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 3, 375, 392.
Fromm, M. G. (2006). A view from Riggs: Treatment resistance and patient authority, II. Transmission of trauma and treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 34, 445, 459.
Kayatekin, M. S., & Plakun, E. M. (2009). A view from Riggs: Treatment resistance and patient authority, X: From acting out to enactment in treatment resistant disorders. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 37, 365, 381.
Krikorian, S. E., & Fowler, J. C. (2008). A view from Riggs: Treatment resistance and patient authority, VII. A Team approach to treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 353, 373.
Mintz, D. (2002). Meaning and medication in the care of treatment-resistant patients. American Journal of Psychotherapy, 56(3), 322, 337.
Mintz, D., & Belnap, B. (2006). A view from Riggs: Treatment resistance and patient authority, III. What is psychodynamic psychopharmacology? An approach to pharmacologic treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 34, 581, 601.
Muller, J. P. (2007). A view from Riggs: Treatment resistance and patient authority, IV: Why the pair needs the third. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35, 221, 241.
Plakun, E. M. (2006). A view from Riggs: Treatment resistance and patient authority, I. A Psychodynamic perspective on treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 34, 349, 366.
Shapiro, E., & Carr, W. (1987). Disguised countertransference in institutions. Psychiatry, 50, 72, 82.
About the Author
Dr. Christina Biedermann is a clinical psychologist practicing psychotherapy and psychological testing at the Austen Riggs Center. She has lectured on Posttraumatic Stress Disorder, the intergenerational transmission of trauma, psychological and neuropsychological testing, and is engaged in research using psychological assessment to identify risk factors for suicidality. She is a contributing editor of DIVISION/Review and maintains a private practice with war veterans.