Integrative Psychotherapy Articles
and Transferential Resolution:
Psychotherapy of an Obsession
Richard G. Erskine
Hargaden’s (2001) case study, “There Ain’t No Cure for Love: The Psychotherapy of an Erotic Transference,” provided the clinical material on which to base this discussion of erotic transference as an obsession. Obsessions, repetitive fantasies, rigid behavioral patterns, and habitualized feelings are all maintained because they provide significant psychological functions. Through a relational therapy and phenomenological inquiry the therapist facilitates the client in gaining an awareness of relational needs, appreciating the intrapsychic functions of an obsession, transferring those functions to the therapeutic relationship, and engaging significant others in interpersonal contact. Four examples of psychological function are provided: predictability, identity, continuity, and stability. Various forms of transference are described in terms of relational needs, and the way in which the therapeutic relationship can be useful in the treatment of an obsession is discussed.
Helena Hargaden’s (2001) paper, “There Ain’t No Cure For Love: The Psychotherapy of an Erotic Transference,” is an example of a masterful psychotherapist’s facilitation of an effective in-depth psychotherapy. In her article, Hargaden not only describes a client’s emotional fixations, vivid fantasies, and ensuing transference, but she is also refreshingly forthcoming about her own countertransference. She, too, idealized the client’s love object, found the client’s stories erotically fascinating, and learned to make therapeutic use of both maternal and paternal countertransferential responses.
Although the contemporary psychoanalytic literature includes a number of case studies, written illustrations of clinical material usually rely on composite profiles that present a caricature of the personality or problem described. As a result, we are left to guess about what our colleagues actually do with their clients. Both gestalt therapy and integrative psychotherapy writings provide some examples of verbatim transcripts, but in the psychotherapy literature as a whole, thorough case studies or unedited transcripts of actual therapy sessions are seldom published. The transactional analysis literature also does not adequately reflect the therapeutic struggles, clinical methods, and resolution of therapeutic failures that are part of the daily work of clinical transactional analysts.
Therefore, Hargaden advances our understanding of the clinical process of transference, countertransference, and therapeutic resolution by exposing her work for critical review. This professional dialogue provides us with an opportunity to exchange theoretical concepts, engage in a meaningful discourse about therapeutic process, and arrive at new understandings of clinical involvement.
It is easy to criticize a therapist’s approach when a psychotherapy is restricted by the therapist’s narrow theoretical vision, or it leads to a reinforcement of the client’s script beliefs, or it is handicapped by the therapist’s failure to recognize and resolve therapeutic errors. However, it is difficult to criticize a psychotherapy that honors the client’s natural vulnerabilities,respectfully facilitates the client in dissolving defenses, and results in the client’s transformation and integration of fragmented aspects of the self.
Of course, it is always possible to criticize any approach or method used by a therapist if the colleague or supervisor merely addresses the clinical work from a different theoretical orientation or personal perspective than that used by the therapist. In this article I will share my current professional perspectives in the hope that they will facilitate a lively discussion and expand our collective knowledge of psychotherapy theory and methods. I will emphasize the elaboration of specific psychotherapy concepts as I might in supervision with an experienced psychotherapist: “The aim of supervision with an advanced psychotherapist is the development within the therapist of the ability to integrate multiple theoretical frames of reference and select various treatment plans based on observations and hypotheses about a particular client” (Erskine, 1982/1997b, p. 223).
In actual supervision, an exploration of the psychotherapist’s perspective, discussion of concepts, and further teaching are interwoven in the dialogue. In addition, a responsible collegial critique explores the therapist’s reasoning, validates and/or challenges the therapist’s assumptions, and provides alternative perspectives that enhance professional dialogue and the direction of future clinical work.
It seems to me that Hargaden’s case study is about the successful treatment of an obsession. There certainly is much material in this case study to facilitate discussion of erotic transference, narcissism, aspects of countertransference, and therapeutic methods. Each of these topics could lead to a fascinating and useful discussion. However, I will focus on the psychological functions and relational needs that underlie and are expressed in repetitive fantasizing and the use of the therapeutic relationship in curing obsession.
In this case, the client, Noel, was obsessed with Anna, a woman with whom he was peripherally involved. We can assume from Noel’s consistent fantasizing that Anna served several psychological functions in his life. Hedescribed his Anna as a receptive spirit, as tender hearted, bright, and wise. In fact, it was she who suggested the therapy.
Noel’s Anna was, for him, a psychic entity—an internal image of another, a selfobject (Kohut, 1977)—that provided intelligence, creativity, and profound therapeutic understanding. Hargaden alluded to the psychological functions provided by the illusion of Anna when she described how Noel would bring Anna into the conversation if he ever felt threatened.
Noel’s love and longing for Anna may have reflected a longing for a secure attachment. His attachment to his mother may have been disrupted by both “her betrayal” for using father’s “violence as a way of keeping control of the children” and the implied depression in mother following the stillbirth of his sister just prior to his conception. Noel’s longing for Anna and his recurring fantasies about her provided for him the functions of stability, continuity, identity, and predictability. In healthy development, these psychological functions are provided within the relationship when there is a secure attachment (Erskine, Moursund, & Trautmann, 1999).
Obsessions, recurring fantasies, rigid behavioral patterns, and habitualized feelings are all maintained by an individual because they provide significant psychological functions. In an effective psychotherapy, the functions of the repetitive behavior, feeling, or fantasy must first be identified and appreciated by the client prior to any lasting growth or even change. For change to be lasting, it is essential that the psychological functions imbedded in the obsession, fantasy, or habitualized feeling be transferred into an actual relationship. In the life of a young child, these psychological functions were originally relational in nature.
As a result of relationship failure and the disruption of interpersonal contact, the functions became internalized, defensive, and attached to something intrapsychic, such as obsessive thoughts or feelings, the urge for compulsive behavior, or repetitive fantasy.
Predictability: As an elaboration of a biological imperative, humans have an internal urge to seek structure and predictability (Berne, 1963, 1966). When the urge for relationship isnot satisfied, the failure of the relationship is often compensated for by the individual’s increased attempts to structure experience, that is, to make meaning and predictability (Erskine, 1997c). Hence, repetition, compulsion, obsession, script beliefs, habitualized feelings or behavior patterns, and transference can all be seen as repetitive attempts to structuralize relationship failures.
As described in Hargaden’s case study, Noel’s obsessive fantasizing about Anna provided the psychological function of predictability. With Anna he could long for the secure attachment of a loving relationship with a receptive spirit who was tender hearted, bright, wise, and understanding. Simultaneously, he retained an anticipation of no relationship or perhaps even rejection—a repeat with Anna of the disturbed attachment with mother through fantasizing about Anna. Noel spoke about Anna in therapy, but it seems from the case presentation that he did not speak to her directly. He did not court her or profess his love to her, although he reported in therapy that it was his desire to do so. By not talking with Anna and sharing his feelings with her, he passively created a nonrelationship or, perhaps, in the fantasy, even rejection. But he was, through the fantasy, active and in charge of the prediction of rejection or of the nonrelationship.
Identity: Noel expressed his unique identity in his fantasies about Anna. This identity was of someone who longed for a tender-hearted partner and yet unconsciously knew that he would be scorned—hence the conflict between longing for Anna’s love and not communicating with her. “This is who I am!” is a felt sense that may be more affective and physiological than cognitive, one that often lacks words since the origin of this identity may be lost to awareness. Each fantasy of Anna was a further expression of Noel’s unconscious identity—his life script. This archaic identity is maintained through fantasy rather than the ever-changing identity that occurs in active, spontaneous, authentic relationships. By maintaining a fantasy of Anna, Noel did not risk a new way of being in the world—the continually emerging “who I am” and the ongoing discovering of the other.
Continuity: By fantasizing about Anna, Noel maintained a psychological continuity with thepast. If he had actually courted Anna and professed his love, most likely something dramatic would have happened. She might have responded in a loving way, thereby creating a juxtaposition between his current experience and his emotional memories of longing for an unrequited love. He would probably be filled with fantasies about the love he did not receive as a child. He would hurt again (Erskine, 1993/1997a). Conversely, if Noel had developed a real relationship with Anna, she might not have wanted a loving involvement with him, and that might also have stimulated the emotional memories of the inherent rejection in mother’s use of father’s violence and/or her depression.
Stability: Obsessively fantasizing about what might occur is an attempt to remain psychologically stable and grounded. It is a false sense of living life today, a contact disruption from both the full remembering of the earlier emotional experiences and the pull to a therapeutic, healing regression. The unresolved early emotional experiences are unconsciously expressed in the fantasy. The hurt, rejection, neglect, or abuse may, through fantasy, be projected onto current or future relationships, thereby avoiding a full regression—a kind of being half in and half out.
Regression within a sensitive, caring therapeutic relationship is healing and growth producing. It is an opportunity for a reparative experience. Yet people fear the overwhelming flood of emotions often present in regression and therefore use obsessing and other psychological defenses as a desperate attempt to stabilize themselves. However, even in the presence of such defensive, stabilizing maneuvers there is always a pull to healing. Hence, transference and obsessing are expressions of both the repetitive and needed relationship and a defense against a full, vulnerable regression.
It is essential in an in-depth treatment of obsession to assess the origins and intrapsychic functions of the repetitive fantasizing and to validate how those multiple functions help the client to maintain psychological homeostasis. The psychological functions described in this article—predictability, identity, continuity, and stability—are only four of a number of such functions. Many clients who are locked into a life script and use repetitive fantasizing as ameans of maintaining homeostasis may use other psychological functions as well. Compensation, reparation, efficacy, integrity, and triumph are examples of other psychological functions used to maintain obsessions. The psychotherapy of obsessions is complex because of the compounded and continually reinforcing multiple intrapsychic functions. A respectful and patient inquiry into the client’s phenomenological experience is required to learn the unique combination of intrapsychic functions.
Relational Needs and Transference
From a clinical perspective, transference is both an unconscious repetition of the past and an unconscious request in the present for a therapeutically needed relationship (S. Stern, 1994). Transference is the active means whereby the client can communicate his or her past. This includes the neglects, traumas, and needs that were thwarted in the process of growing up, as well as the defenses that were created to compensate for the lack of need fulfillment. In the unaware enactment of childhood experiences there is also an inhibition of full remembering. While this all constitutes a replication of previous relationships, often in coded form, also imbedded in the transference is the therapeutically needed relationship, the desire to achieve the satisfaction of relational needs and intimacy in relationship (Erskine, 1991/1997d).
Perhaps what may be required for a more thorough understanding of script formation and transference is an appreciation of Bowlby’s (1969, 1973, 1980) ideas about early bonding and the necessity of a “secure base,” the psychological significance of disruptions in early attachment, and the psychological attachments that form a visceral and emotional core from which all experiences of relationship emerge.
Hargaden’s sensitivity to both the repeated and needed relationship with Noel is reflected in her saying, “I wanted to fold him in my arms, put him in a carry cot, and bring him away on holiday with us. I also wanted to make a joke out of it, perhaps in the sadistic fashion reflective of his father. Instead, I was able easily to show tenderness toward him and interpret his need for holding and loving without shaming him or acting on it.”
The transference in everyday life that may occur in friendships and love relationships—for example, with one’s children or on the job—also reflects the repetition of emotional experiences of past relationships and the unconscious desire for the other to repair the failures of past relationships. In the case presented by Hargaden, Noel’s transference with Anna, presented in the context of a plausible real relationship, contained numerous and significant transferential idealizations of her attributes. His idealization was so compelling, in fact, that even Hargaden was caught up in the wonders of Anna.
In the first half of the case study, I anticipated that Noel’s love for Anna would be transferred to Hargaden in some erotic form. As I continued to read I was reminded of Kohut’s (1971, 1977) description of idealization as one of the dimensions of pathological narcissism. Although he identified mirroring, twinship, and idealization as the transferential expressions of pathological narcissism, he also attempted to distinguish relational, developmental needs that suffered disruption or rupture from classical transference based on a drive model of psychoanalysis. However, his methods remained psychoanalytic and did not make full use of a relational model of psychotherapy.
There may be evidence to support a diagnosis of narcissism in Noel’s case: he sat provocatively in shorts while describing his sexual exploits with women, his self-centeredness and apparent lack of intimate connection, and his demands of entitlement to his therapist’s schedule. However, as Noel’s story unfolded it became clear that his idealized transference with Anna might reveal much more therapeutically useful material if perceived by the therapist, not from a pathological perspective (narcissism), but rather from the theoretical perspective that his idealized love was an expression of the relational need of a young boy for protection, security, and validation (Erskine, Moursund, & Trautmann, 1999; Erskine & Trautmann, 1996).
If I had been Hargaden’s clinical supervisor during the early phase of Noel’s therapy, we would have talked about Noel’s relational needs and how they were unconsciously revealed through his general demeanor: initiallyin the stories he told about Anna, later in his history with his parents, and, importantly, in Hargaden’s countertransferential response.
Countertransference has traditionally been viewed as the psychotherapist’s unfinished business from the past (Racker, 1968). However, from a relational therapy perspective, countertransference refers to the feelings, images, fantasies, and reactions that a psychologically healthy therapist has as a unique reaction to the unconscious communication of a particular client (Bollas, 1979).
As her supervisor, I would have encouraged Hargaden to be sensitive to her own emotions and fantasies as a possible glimpse at perceiving Noel’s relational needs. I would have continually raised questions about her feelings and fantasies as an identification with Noel’s unconscious communication regarding his traumas, relational needs, and the psychological functions of his obsessions. Hargaden’s “countertransference” reaction of also idealizing Anna may have been an indication of how profoundly Noel needed protection from a stable, consistent, and effectively protective other. Her caring feelings toward him and her nonjudgmental response set the stage for responding to Noel’s need for security. She liked him and valued him, a necessary condition for attunement to affect, developmental level of functioning, and relational needs.
Attunement to the need for security involves the therapist being sensitive to the importance of this particular need and conducting himself or herself both emotionally and behaviorally in a way that provides security in the relationship. This includes respectful transactions that are nonshaming as well as an honoring and preserving of the individual’s vulnerability. It involves the experience within the client that his or her variety of needs and feelings are human and natural. Security is a sense of simultaneously being vulnerable and in harmony with another. In my imagined supervision of Hargaden, the security aspects of the therapy with Noel would receive only a little attention since this is an area in which Hargaden seems so sensitive.
Early in the work I would also have focused on the unconscious communication of the need for protection as revealed in Noel’s idealizationof Anna. Idealization is the expression of a search for protection—the protection in early childhood from the emotional and physical impingement of bigger people. When manifested in psychotherapy, such idealization is the unconscious search for protection from a controlling and humiliating introjected Parent ego state and the resulting intrapsychic conflict. It may also represent the search for protection in the form of containment of an escalation of affect or fantasy or a secure setting of limits. Just as young children look to grown-ups for guidance and protection, so, too, was Noel searching for someone who could be strong, responsible, and protective. He most likely searched for the kind of protection that his mother failed to provide when she allowed his father to beat him.
Additionally, the consistency, dependability, and reliability of a stable mother was probably lost if mother was depressed following the death of Noel’s sister. D. N. Stern (1985) writes of the importance of the mother’s affect of vitality to the baby’s emerging sense of self. If such maternal vitality is absent, as is often the case when mother is depressed, the result is an emotional abandonment, a lack of security and protection. Noel turned to an illusion to receive a sense of vitality and protection. Noel’s description of Anna as strong, passionate, and feminine was not a description of himself, as Hargaden surmised, but a description of what was not provided in Noel’s relationship with his mother and therefore was therapeutically needed in the psychotherapy relationship. I think that an essential therapeutic element was Hargaden’s providing Noel with her attunement, involvement, and protection.
Hargaden’s refusal to be seduced by Noel into a friendship or erotic relationship was also a necessary therapeutic response. He needed to be in the presence of someone who was stable, dependable and reliable; a friendship would not have provided the necessary protection. Hargaden’s insistence on the structure of the therapeutic relationship provided the protection that allowed Noel to remember.
As Hargaden responded to Noel’s need for validation, he was correspondingly more able to feel her provision of stability, dependability, and protection. Conversely, whenever shefailed to validate Noel, he would bring Anna into the conversation as an illustration of both validation and protection. Since Hargaden is skillful at validating and affirming, in supervision I would not spend much time discussing various therapeutic responses to the need for validation. Rather, we would examine the inevitable therapeutic failure to provide perfect validation and the necessary repairs that reestablish contact-in-relationship (Erskine, Moursund, & Trautmann, 1999). (For a valuable discussion of the concept of “Failures in the Therapeutic Relationship: Inevitable and Necessary?” see Guistolise ).
Hargaden’s failures to validate or affirm Noel’s sense of being significant in the relationship stimulated his fixated early childhood need to depend on a stable other person while receiving security, validation, and protection. Bringing Anna into the conversation at such points served as an unconscious example of how to do it right. Noel’s need to feel confirmed by the personal experience of another was responded to by Hargaden’s shared delight in a similar sense of humor, art, literature and political sensitivity, and perhaps also by her enchantment with Anna. Had Hargaden responded more behaviorally to Noel’s demand for a shared experience, such as meeting socially or even telling him of her sexual fantasies, she would have overemphasized this need (perhaps acting out a need of her own) and missed the central importance of providing both validation and protection to a client whose Child ego states were active and vulnerable.
Even while sharing one’s personal experience in response to the client’s current relational needs, it is essential that the therapist remain mindful of the fixated relational needs of a traumatized child. The fixated archaic needs are either acted out in the transference or are expressed in fantasy. The unconscious behavior and/or fantasized expression of these needs demands an appropriate therapeutic response, one that may focus on providing either security, validation, protection, or initiation while also responding to the need to feel confirmed by the personal experience of another.
Noel attempted to have an impact on Hargaden by making demands for extra sessions during holidays and to meet some place otherthan the established therapy room. Certainly he had the need to make an impact on another person, but in the way he expressed this, his need for protection could have been overlooked if the psychotherapist allowed the relationship to become social. Any child who has been neglected, rejected, and/or physically abused will have an intense need, later in life, to make an impact—to demand in some form or another “attend to me,” “be sensitive to me,” “don’t hurt me.” Often this need is acted out in the form of entitlement and/or takes subverted forms that overshadow other equally important needs (e.g., security, protection, self-definition, etc.); such was the case with Noel’s request that he and Hargaden meet socially.
Hargaden demonstrated that she received the impact of Noel’s presence and personal story when she initiated her interpretation about the psychological effects of Noel’s dead sister and the depressing effect it had on his mother. Interpretation is psychologically transmuting (Kohut, 1977), not necessarily in its accuracy, but in demonstrating to the client that the therapist is stirred to think about him or her, that the therapist is taking the client’s story seriously, and that the therapist is invested in the client’s welfare. The accuracy of the interpretation may not be what is therapeutically important. A partially accurate interpretation leaves room for the client to correct the therapist, thereby creating an opportunity to make further impact. However, interpretations that accurately reflect a client’s need or experience express an attunement and involvement that builds and strengthens the therapeutic relationship.
Noel’s need to express love was evident in his affection for Anna—the Anna who in fantasy provided both validation and protection. Noel’s current need to express love was manifested in the establishment of a mature active involvement with an available partner.
I have enjoyed studying Hargaden’s case presentation and appreciate her highly professional therapeutic acumen. However, in theory I disagree with one of her comments: “In not getting the need met with me, Noel became frustrated enough to break through his fantasy and attempt to get his needs met in a morerealistic way.” I have a different perspective: It is precisely because Noel had both his archaic and current relational needs therapeutically responded to by Hargaden that he could become involved with another woman. Because of Hargaden’s attunement and involvement, Noel was able to transfer the psychological functions of predictability, identity, continuity, and stability into the therapeutic relationship and therefore establish a secure base from which to pursue a mature relationship.
Noel’s obsession with Anna provided a pseudosatisfaction of his relational needs while alluding to significant relational failures in his childhood. The fantasies of Anna served to unconsciously reveal what was therapeutically needed: a receptive spirit, a tender heart, a person bright and wise. This was Noel’s unconscious description of the therapeutically needed relationship that he brought to Hargaden. In providing Noel with therapeutic consistency, ethical responsibility, and dependable nurturing, the therapeutic relationship offered him an opportunity to relax his defenses, receive therapeutic responses to both archaic and current relational needs, and transfer the psychological functions imbedded in the obsession into the therapeutic relationship. Thus Hargaden’s psychotherapy with Noel provided a protective, secure foundation for building a healthy mature relationship with another person. His healing was in the therapeutic relationship with Hargaden.
Richard G. Erskine, Ph.D., is the training director at the Institute for Integrative Psychotherapy in New York and visiting professor of psychotherapy, University of Derby, United Kingdom. Please send reprint requests to him at 500 East 85th St., New York, New York, 10028, U.S.A. Email and website: IntegrativeTherapy.com .
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The author thanks the members of the Wednesday morning supervision group at the Institute for Integrative Psychotherapy, New York, and the members of the Seminar on the Treatment of Obsession sponsored by the Vancouver Institute for Integrative Psychotherapy, Vancouver, British Columbia, Canada. Their comments were valuable in the development and refinement of an integrative psychotherapy theory and treatment of obsession and repetitive fantasizing.
This article was first published in the Transactional Analysis Journal, Vol. 31, No. 4, pp. 220-226. Reprinted with permission of the ITAA