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THE ANALYTIC FRAME, ABSTINENCE AND ACTING OUT

by Robert M. Young

Marion Milner, who coined the phrase ‘analytic frame’, wrote about an analogy between providing boundaries for the analytic situation and a picture frame:

The frame marks off the different kind of reality that is within it from that which is outside it; but a temporal spatial frame also marks off the special kind of reality of a psychoanalytic session. And in psychoanalysis it is the existence of this frame that makes possible the full development of that creative illusion that analysts call the transference. Also the central idea underlying psychoanalytic technique is that it is by means of this illusion that a better adaptation to the world outside is ultimately developed (Milner, 1952, p. 183).

Some years later José Bleger wrote,

Winnicott (1956) defines “setting” as ”the summation of all the details of management.” I suggest... that we should apply the term “psychoanalytic situation” to the totality of the phenomena included in the therapeutic relationship between the analyst and the patient. This situation comprises phenomena which constitute a process that is studies, analysed, and interpreted; but it also includes a frame, that is to say, a “non-process”, in the sense that it is made up of constants within whose bounds the process takes place (Bleger, 1967, p. 511).

There are many elements of the analytic frame. It is a room — a physical setting. It is a set of conventions about how one behaves. It is a state of mind — a mental space. It is all of these at once and something more, something ineffable. It has been described as a facilitating environment and as a container. It needs to be a safe enough place for psychotherapeutic work to occur, a place where the patient can allow herself or himself to speak about things which are too painful or taboo or embarrassing to speak about elsewhere. The essence of the safety of the space is that the patient can project things into the therapist which are contained by the therapist, detoxified and given back in due course in a form which can be used as food for thought.

If I listed all the factors making up the analytic frame, I would still miss out some things and not capture its essence. The things I will spell out are, therefore, examples, designed to set the reader thinking. The point is that the frame should make the analytic space which it bounds a suitable place for analytic work. It should be quiet. No interruptions, phone calls, answering the doorbell. It should not have very personal pictures in sight or other mementoes which reveal personal matters or relationships. It should be pleasant and comfortable. It should, as far as possible, remain the same.

In part, the analytic frame takes the form of a contract about what the patient can expect and what the therapist will and will not do, will or will not allow, what can and cannot be expected. In this sense it includes the ground rules, implicit and explicit, of the analytic relationship’ (Langs and Searles, p. 43), a basic framework, customs and practices which have developed over the history of psychoanalysis and psychotherapy. Their overall purpose is to minimise uncertainty and ambiguity.

There are a number of desiderata about the therapist’s behaviour and demeanour. She should answer the door promptly and begin and end the session on time. Most agree that she should not give out personal details, although some believe that there are occasional circumstances when this may be appropriate. The bill should be presented at the same session every month (i.e., regularly). Sessions should not be changed unless necessary and, when they are changed, maximum notice should be given. Information about breaks or fee changes should be given well in advance. Occasions for differing over sessions, breaks, fees or any matter concerning the frame should be minimised. Bleger stresses that the frame ’should be neither ambiguous nor changeable nor altered’ (p. 518). Langs argues that when the frame is broken a misalliance pathological symbiosis exists between therapist and patient until it is mended and until the break is understood and interpreted (Langs & Searles, pp. 44, 127).

The frame holds something in. It defines a border or limit. Confidentiality is guaranteed, but it is judiciously breached in training cases, when case material is taken to supervision, which is why it is unethical not to mention that one is a trainee. The law also specifies some exceptions to absolute confidentiality — certain criminal acts. Boundary maintenance is another way of conveying what containment means. The patient is being helped to hold himself together, to feel held, neither too tightly nor too loosely, as one holds a baby in distress, imparting a sense of care, taking in and not reprojecting anxiety.

It has been argued by Bleger that the analytic frame is the place where the madness is held so that the therapist and patient can have a space to think and feel about maters felt with a degree of intensity which is painful but still bearable. It keeps overwhelming distress at bay, while allowing something short of that to be thought about. ‘The frame as an institution is the receiver of the psychotic part of the personality, i.e., of the undifferentiated and non-solved parts of the primitive symbiotic links’ (Bleger, 1967, p.518). It contains ‘the most regressive, psychotic part of the patient’ (p. 516). The implication is that when the frame is breached, these forces are likely to be let loose.

Having conveyed some basics, I must now say that there are exceptions to practically everything I have said. For example, the analytic frame is not confined to the room where the therapy is done. It is ideally tacitly in the minds of both therapist and patient all the time. It is there when you open the door or speak on the phone. It is carried with the patient (or not) between sessions: it is internalised. It is conveyed by the therapist’s demeanour, tone of voice, pauses, silences, grunts, the wording of any note or letter which it is appropriate to send to the patient. It is evident in pauses. It is all aspects of analytic space. To maintain the frame is to maintain the analytic relationship. Its essence is containment.

Acting out is breaking the analytic frame. (There is also a concept of ‘acting in’, whereby the transgression occurs inside the therapy room, but I do not find this idea useful and will not employ it.) Acting out is not defined by what the patient does. Rather, it is characterised by the motive — to break the frame. For example, if the therapist and patient meet by chance outside the consulting room, e.g., at a party or at the cinema, the frame has been broken, and it is important to interpret the encounter, but it is possible that no one has acted out. It could be argued that every act which is characterised as acting out could occur for other reasons. If the patient is late, the reason may be a stoppage on public transport or a traffic jam. If the patient is persistently late, she is acting out. There is, however, another level of meaning here. The patient may have a perfectly good story about being late, even including events out of her control, but she may also unconsciously relate to that explanation in a way which involves acting out.

There are many fairly routine examples of acting out: not coming to sessions, unnecessarily phoning the therapist, bringing gifts, not paying the bill or doing so in a way which invalidates the payment (cheque unsigned, wrongly dated, numbers and words not the same, even the payee’s name incorrect), refusing to speak, flooding with speech, coming early, refusing to leave at the end of the session, shouting, screaming, preventing the therapist from speaking, dressing provocatively, acting seductively, lying, bringing inappropriate things to the session (e.g., mobile phone, tape recorder), taking a holiday before or after an analytic break (thus extending the break). I had a patient who was usually on the couch but came into a session and turned the upright chair away and sat down with her back to me. I only wish I had made the interpretation that there was something she could not face. Another stood on the threshold of the therapy room and would not come in. After a long time it occurred to me to say that he wanted me to feel the panic of being on the edge that he felt. He then came in and sat down and began work.

Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not relfective. The patient is acting rather than reflecting. Where acting out is, thought cannot be.

One feature of acting out is that the therapist is usually put under pressure to do something he would not otherwise do — to go after the patient in some way, e.g., to write to the patient or phone, to reveal something, to move, to change a session, to press the patient, to relent about a decision or take a firm line, even to lose his temper.

Many believe that a good therapist is less likely to have patients act out, but I am not so sure. If you want to take account of the purist position in these matters, read the writings of Robert Langs or perhaps Carol Holmes (1998), a follower of his ‘communicative’ approach. It is also true that acting out always has a meaning, just as a dream or a parapraxis does. It conveys a message, and the therapist’s job is to interpret it — to get the message and convey that one has got it. Some say that the patient acts out because he cannot find any other way of conveying that message. As the example of my patient who stood on the threshold of the therapy room shows, the way to deal with acting out is to make the appropriate interpretation, one which hits the spot, reduces the primitive anxiety and allows the patient to re-enter the analytic space on the agreed terms, i.e., that he remain on the couch (or in the chair) and take part in a talking therapy. I did not make the appropriate interpretation to the woman who turned the chair around and sat in it with her back to me, and she left therapy abruptly.

Persistent acting out indicates a deeper, untouched or unresolved conflict. I have a patient who always comes late and another who used to come very late. The first is indicating an ambivalence about coming at all, so he comes but always late. The other offered two explanations. First, she could not bear the thought of being kept waiting but felt that if she came late, I would always be there and come quickly to the door. The baby would not be left crying, unattended to. She also had low self-esteem and felt she wasn’t a full person and did not have enough to say to fill a whole session, so she came twenty minutes late, believing that she could just about fill three fifths of a session. She offered a different rationalisation every day about what had delayed her, but the coming late stayed the same. Then we changed her session time to one she had before, and thereafter she came on time. It emerged that she had felt displaced and when she got back the original slot, she felt she had been given back her ’own rightful time’.

I have another patient who acts out frequently over money matters. She is highly reactive and storms out and holds out until I make contact and draw her back into coming to her sessions. She comes from a family in which money matters were fraught to the point of involving the law, and she is particularly jumpy about them, often accusing me of holding views about her which are demeaning and of acting in an unfair way. At one time she was so defensive about paying me that she would give me the monthly payment before I gave her the bill. Matters of fees and payment are frequently the occasion for an outburst and sometimes a threat or short-term decision to leave therapy.

Another way of referring to these matters is the concept of abstinence. The therapist is supposed to abstain from doing various things which would perhaps be natural in a social situation. He should not speak to the patient while walking from the door to the therapy room or after the session ends. He should never be gratuitously self-revealing about personal matters and not otherwise unless it is directly contributory to the work and even then very sparingly. He should not offer opinions or advice or make moral judgements about the patient’s material (although tacitly conveying such opinions and judgements seems to me inevitable). Some say he should never ask questions. He should stick to interpreting the unconscious. I think this degree of abstinence is practically impossible to maintain, but it is the goal. This is not the same as saying that the therapist should be cold and too formal, just that she should not chat or exchange opinions. If, as I believe, what we do is to interpret our countertransference, it is essential that this be done in a temperate, civil and level way. To do otherwise is to reproject the patient’s projections and to act out in the countertransference. There are those who believe in a judicious ’expressive use of the countertransference’, in which the patient is carefully told what response she elicits in the therapist. I think this is a dangerous practice, but it has its advocates.

Psychoanalytic psychotherapists are almost all agreed that one should not have social relations with patients. Most agree that the transference never ends and that the patient may need to return, so social relations with ex-patients are also contraindicated. The same taboos apply to physical contact between therapist and patient and ex-patients. I learned about this the hard way. My analyst, an elderly and rather formal man, shook hands with me at the end of each term. I took up this end-of-term gesture when I began my own practice but soon abandoned it. One female patient with a strong sexual transference, who also had severe fertility problems, missed her next three periods. Another, with a particularly intense romantic transference, went straight to a shop from having her hand shaken at the end of her first term of therapy with me, bought a red dress and told the people in the shop that she was having a baby. A supervisee who had been in the habit of hugging a patient gave up this practice under my guidance, and the patient came to feel that this abstinence from physical comforting allowed a greater degree of intimacy in the verbal realm. This supervisee, who was initially unconfident about what she had to offer, also sometimes let sessions run over time, until the patient told her that this made her anxious that the therapist could not handle (contain) her distress. These examples show that abstinence and boundaries are important for the patient and help her to feel safe and contained. This approach is characteristic of orthodox psychoanalytic psychotherapy. Some therapies which have derived their identity by breaking away from some of these forms of abstinence involved various forms of ’the laying on of hands’.

The most important and charged area of abstinence and of potential acting out is that of sexual relations between therapist and patient. There are various estimates of how often this happens. Somewhere between two and ten per cent of male therapists have sexual relations with their patients, and about two or three per cent of female therapists do. The analytic space is an Oedipal space, and the analytic frame keeps incest at bay. The analytic relationship involves continually offering incest and continually declining it in the name of analytic abstinence and the hope of a relationship that transcends or goes beyond incestuous desires. Breaking the analytic frame in this way invariably involves the risk of child abuse and sleeping with patients or ex-patients is precisely that.

Martin Bergmann puts some of these points very nicely in his essay on transference love (Bergmann, 1987, ch. 18). He says,

In the analytic situation, the early images are made conscious and thereby deprived of their energising potential. In analysis, the uncovering of the incestuous fixation behind transference love loosens the incestuous ties and prepares the way for a future love free from the need to repeat oedipal triangulation. Under conditions of health the infantile prototypes merely energize the new falling in love while in neurosis they also evoke the incest taboo and needs for new triangulation that repeat the triangle of the oedipal state (p. 220).

With respect to patients who get involved with therapists or ex-therapists, he says that they claim that “‘unlike the rest of humanity I am entitled to disobey the incest taboo, circumventing the work of mourning, and possess my parent sexually. I am entitled to do so because I suffered so much or simply because I am an exception’” (p. 222). Such sexual relations may seem a triumph to the patient, but, as Freud eloquently observed,

If the patient’s advances were returned it would be a great triumph for her, but a complete defeat for the treatment. She would have succeeded in what all patients strive for in analysis — she would have succeeded in acting out, in repeating in real life, what she ought only to have remembered, to have reproduced as psychical material and to have kept within the sphere of psychical events. In the further course of the love-relationship she would bring out all the inhibitions and pathological reactions of her erotic life, without there being any possibility of correcting them; and the distressing episode would end in remorse and a great strengthening of her propensity to repression. The love-relationship in fact destroys the patient’s susceptibility to influence from analytic treatment. A combination of the two would be an impossibility.

It is, therefore, just as disastrous for the analysis if the patient’s craving for love is gratified as if it is suppressed. The course the analyst must pursue is neither of these; it is one for which there is no model in real life. He must take care not to steer away from the transference-love, or to repulse it or to make it distasteful to the patient; but he must just as resolutely withhold any response to it. He must keep firm hold of the transference-love, but treat it as something unreal, as a situation which has to be gone through in the treatment and traced back to its unconscious origins and must assist in bringing all that is most deeply hidden in the patient’s erotic life into her consciousness and therefore under her control. The more plainly the analyst lets it be seen that he is proof against every temptation, the more readily will he be able to extract from the situation its analytic content. The patient, whose sexual repression is of course not yet removed but merely pushed into the background, will then feel safe enough to allow all her preconditions for loving, all the fantasies springing from her sexual desires, all the detailed characteristics of her state of being in love, to come to light; and from these she will open the way to the infantile roots of her love (Freud, 1915, p. 166).

 

From the therapist’s point of view, ‘When the transference relationship becomes a sexual one, it represents symbolically and unconsciously the fulfilment of the wish that the infantile love object will not be given up and that incestuous love can be refound in reality’ (Bergmann, 1987, p. 223). This is a variant on the Pygmalion theme. The analytic relationship works only to the extent that the therapist shows, in Freud’s words quoted above, ‘that he is proof against every temptation’ (Freud, 1915, p. 166). Langs puts this very well when he says that ‘the therapist’s appropriate love is expressed by maintaining the boundaries’ (Langs & Searles, p. 130).

Nevertheless, as I have indicated, alarmingly many therapists do sleep with their patients. If the motives for abstinence are not sufficiently strong, the situation is perfect. There is opportunity in the therapy hour and on the analytic couch. There is no fear of interruption. The patient has placed herself in the therapist’s hands, under his care, trusted to look after her. In their omnipotent and incestuous way of seeing things, what could be a more tender and intimate way of doing so? When the transgression is discovered (usually when the therapist belatedly finds himself), the matter is frequently brought before a professional ethical committee, and the therapist is struck off, suspended and/or required to undergo further therapy. I know of a case where this was done twice with a training therapist and supervisor who took up the practice again and finally had to be permanently removed from the professional organization.

This is not a new phenomenon. It has occurred throughout the history of psychoanalysis and psychotherapy, indeed, throughout medicine and the helping professions. Eminent people have been involved — Carl Jung, Sándor Ferenczi, Ernest Jones — and there is a chapter summarizing the history of this matter in Gabbard and Lester’s useful book on Boundaries and Boundary Violations in Psychoanalysis (1995, ch. 5). Other forms of boundary violations abound. An eminent American analyst was discovered to have benefited to the tune of a million dollars from a trust fund of someone with whom he was involved clinically. Freud and Klein analysed their own children of. Freud regularly reported to Jones about the progress of Jones’ lover’s analysis with Freud. In the early days of psychoanalysis some of these violations could be attributed to the teething problems of a new discipline, while more recent indiscretions cannot. It is an ongoing problem, and instances of it occur all the time, so much so that ethical committees exist in every training organisation and many other professional bodies. Since there is a tendency to sweep such matters under the carpet it has become necessary to set up independent bodies so that injured parties can be helped to make complaints and make them stick.

In Sex in the Forbidden Zone (1990), Peter Rutter makes the point that sexual relations should be taboo in any situation where one person is in the care of another, where there are disparities of power (Rutter, p. 26) or where expertise is involved or the conferring of qualifications. Sexual relations in such circumstances are, he says, ‘inherently exploitative of a woman’s trust’ (p. 21).

The forbidden zone is a condition of relationship in which sexual behavior is prohibited because a man holds in trust the intimate, wounded, vulnerable or underdeveloped parts of a woman. The trust derived from the professional role of the man as doctor, therapist, lawyer, clergy, teacher or mentor, and it creates an expectation that whatever parts of herself the woman entrusts to him (her property, body, mind or spirit) must be used solely to advance her interests and will not be used to his advantage, sexual or otherwise.

Under these conditions, sexual behavior is always wrong, no matter who initiates it, no matter how willing the participants say they are. In the forbidden zone the factors of power, trust and dependency remove the possibility of a woman freely giving consent to sexual contact. Put another way, the dynamics of the forbidden zone can render a woman unable to withhold consent. And because the man has the greater power, the responsibility is his to guard the forbidden boundary against sexual contact, no matter how provocative the woman (p. 25).

This taboo includes obvious cases such as doctors, therapists and carers (especially of children, people who are learning disabled or mentally ill), but Rutter also includes teachers, supervisors, dentists, lawyers, architects, bosses, higher ranks. He points out that 96% of cases of exploitation in such situations involve a man as the one having the power and trust, with the woman as the person entrusting herself (p. 20). He estimates that in America about a million women have had their trust violated in this way (p. 36).

Disparities of power and patronage are not compatible with the equality needed for a good and wholesome sexual relationship. This is a stern doctrine and one which is often transgressed. Think of the number of doctors who marry nurses, of patients who marry carers, of couples who first meet in a relationship between professional and client. Some argue that such relations are acceptable after a suitable interval, one which is specified in regulations as, say, six months or two years. I take the view that this may be acceptable in some of the relationships listed above, but I think it is not true of the relationship between a psychotherapist and a patient. As I said above, the transference never ends, so sexual relations will always be unconsciously incestuous.

There is a considerable literature about failures of abstinence between therapists and patients, extending from apparently small matters to sexual relations, and I have included a number of such accounts in the readings listed below. In a number of cases which did not involve sexual intercourse, there was much breaking of boundaries. ’Ann France’ is the pseudonym of an academic who succeeded in bending many boundaries in her work with various therapists. In Consuming Psychotherapy she advocates looser boundaries and more self-revelation on the part of therapists. Some time after writing this book she committed suicide. I edited and published her book and believe that although she was a very disturbed person, more boundary-maintenance on the part of her therapists might have averted this outcome. We will never be sure. (Herman, 1991, has commented on this case.) ’Sarah Ferguson’ is the pseudonym of another patient who, in A Guard Within (1973), gives an account of a therapeutic relationship in which her therapist saw fit to relax a number of boundaries. I am told that this patient also committed suicide. The distinguished psychoanalyst, Margaret Little, (1985) tells a surprising story in which her analyst, Donald Winnicott, regularly transgressed various boundaries when she was severely disturbed. I consider all of these to be cautionary tales: keep the boundaries.

I know of a number of therapists and analysts who believe that friendship between themselves and ex-patients is appropriate. In all of the instances which I know enough about to feel entitled to express an opinion, I am sure that the relationship has had a baleful effect on the ex-patient’s subsequent life. One analyst makes a point of keeping in touch with ex-patients, of becoming friends with them and having them bring their dreams to him. My view is that these people remain in orbit around this analyst to the detriment of their autonomous development and, in a surprising number of cases, to the detriment of their marital or partner relationships. Something similar occurs in patronage networks between therapists and their patients or former patients. I have seen a detailed account of patronage relationships in several of the big American psychoanalytic societies, and it is striking how the patients of some training analysts prosper in the organizational roles in those institutes and become training analysts in their turn. Something similar can be said of the wives of some senior training analysts: they seem to become training analysts before some unrelated colleagues It may be merit; it may be nepotism. My view is that if you are someone’s therapist or analyst you had better not have any other relationship with them, and if you are someone’s partner, you had better not be involved in assessing his or her merit for preferment in a supposedly meritocratic organization.

I hope it is clear that the analytic frame, its maintenance and breaks in it and acting out are topics which closely interdigitate, and that there is an ongoing relationship among these matters throughout therapy and ever after, as long as ye both shall live.

REFERENCES

Bergmann, Martin S. (1986) ‘Transference Love and Love in Real life’, Int. J. Psychoanal. Psychother. 11: 27-45; reprinted in his The Anatomy of Loving. Columbia, 1987, pp. 213-28.

Bleger, José (1967) ‘Psychoanalysis of the Psycho-analytic Frame’, Internat. J. Psycho-anal. 48: 511-519.

Ferguson, Sarah (1973) A Guard Within. Chatto & Windus; reprinted Harmondsworth: Penguin, 1976.

France, Ann (1988) Consuming Psychotherapy. Free Association Books.

Freud, Sigmund (1915) ’Observations on Transference-Love (Further Recommendations on the Technique of Psychoanalysis III)’, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, 24 vols. Hogarth, 1953-73. vol. 12, pp. 159-71.

Gabbard, Glen O. and Lester, Eva P. Boundaries and Boundary Violations in Psychoanalysis. N. Y.: Basic Books.

Herman, Nini (1991) ‘Prodromal States of Suicide: Thoughts on the Death of Ann France’, Free Assns. (no. 22) 2: 249-58.

Langs, Robert and Searles, Harold (1980) Intrapsychic and Interpersonal Dimensions of Treatment: A Clinical Dialogue. Aronson.

Little, Margaret (1985) ‘Winnicott Working in Areas where Psychotic Anxieties Predominate’, Free Assns. no. 3: 9-42.

Milner, Marion (1952) ‘Aspects of Symbolism and Comprehension of the Not-Self’, Internat. J. Psycho-anal. 33: 181-85; reprinted in expanded form in Milner (1987), pp. 83-113.

______ (1952a) ’The Framed Gap’, in Milner (1987),, pp 79-82.

______ (1987) The Suppressed Madness of Sane Men: Forty-four Years of Exploring Psychoanalysis. Routledge

Rutter, Peter (1990) Sex in the Forbidden Zone. Unwin.

Winnicott, Donald W. (1956) ‘Clinical Varieties of Transference’, in Through Paediatrics to Psychoanalysis. Hogarth, 1975, pp. 295-99.

READINGS

On the analytic frame the best single source is:

**Blejer, J. (1967) ‘Psychoanalysis of the Psycho-analytic Frame’, Internat. J. Psycho-anal. 48: 511-519.

There is an introductory volume:

Gray, Anne (1994) An Introduction to the Therapeutic Frame. Routledge pb.

Standard sources are:

Stone, L. (1961) The Analytic Situation. Internat. Univ. Press.

Gabbard, Glen O. and Lester, Eva P. (1995) Boundaries and Boundary Violations in Psychoanalysis. N. Y.: Basic.

Langs, R. (1977) 'Psychoanalytic Situation: The Framework', in B. Wolman, ed., International Encyclopedia of Psychiatry, Psychology, Psychoanalysis, and Neurology. Aesculapius, pp. 220-22.

More accessible is his paperback:

*Langs, R. (1992) A Clinical Workbook for Psychotherapists. Karnac. See index entry: ‘ground rules’ [frame].

Langs writes a lot about this matter in his weighty tomes on theory and technique. I prefer to follow the continuing thread about this topic running through

** Langs, R. and Searles, H. (1980) Intrapsychic and Interpersonal Dimensions of Treatment: A Clinical Dialogue. Aronson. See index for specific passages, but the whole book is a feast, not least because of their contrasting characters and styles.

A disciple of Langs has written a clear, accessible account of these issues

Holmes, Carol (1998) There Is No Such Thing as a Therapist: An Introduction to the Therapeutic Process. Karnac

For a succinct account, have a look at the comprehensive volume:

*Etchegoyen, R. H. (1991) The Fundamentals of Psychoanalytic Technique. Karnac, chs. 36-38, 43, 52-54 on the analytic situation and setting, container/contained and acting out.

There is a useful chapter in

Thomä, H. and Cachelë, H. (1987) 'Rules', in Psychoanalytic Practice, Vol. 1, Springer-Verlag/ Aronson pb, pp. 215-52.

See index entries on 'frame', 'boundaries', and 'space, analytic' in

Casement, P. (1985) On Learning from the Patient. Routledge.

______ (1991) Further Learning from the Patient: The Analytic Space and Process. Routledge.

The concept of the analytic frame broadens out and has been written about by a number of interesting people. Have a look at

Milner, Marion (1987) The Suppressed Madness of Sane Men. Routledge - see index re: framed gap, boundaries.

Davies Madeleine and Wallbridge, David (1981) Boundary and Space. Karnac.

Perhaps the most general approach to the topic is W. R. Bion’s concept of containment. A good place to begin with this is

**Hinshelwood, R.. D. (1991) ‘Containing’, in A Dictionary of Kleinian Thought, revised ed. Free Association Books, pp. 246-53.

On acting out, start with

*Laplanche, J. and Pontalis, J.-B. (1983) The Language of Psychoanalysis. Hogarth; reprinted Maresfield.

There is a useful introduction in

Sandler, J. et al. (1979) The Patient and the Analyst. Maresfield, ch. 9.

On the subtler debates about acting out, see

Boesky, D. (1982) 'Acting Out: A Reconsideration of the Concept', Internat. J. Psycho-anal. 63: 39-55.

Gaddini, E. (1982) 'Acting Out in the Psychoanalytic Session', ibid.

63: 57-64.

There is a symposium on acting out, with several articles, commentaries and a discussion in volume 49 (1968) of Internat. J. Psycho-anal.

The discussions I have found most helpful are in Etchegoyen, op. cit., chs. 52-54.

The literature on transference and transference love is central to these issues. See:

*Freud, S. (1915) ‘Observations on Transference Love’, S. E. 12: 157-71.

The best overall source on this issue is:

Racker, H. (1968) Transference and Countertransference. Hogarth; reprinted Maresfield pb, 1982.

See also:

*Bergmann, M. S. (1986) ‘Transference Love and Love in Real life’, Int. J. Psychoanal. Psychother. 11: 27-45; reprinted in his The Anatomy of Loving. Columbia pb, 1987, pp. 213-28.

Young, R. M. (1994) ‘Analytic Space: Countertransference’, ch. 4 of Mental Space (Process Press pb), pp. 53-72.

On abstinence and its vicissitudes (or therapists acting out), see

Rutter, P. (1990) Sex in the Forbidden Zone. Unwin.

Bates, C. M. and Brodsky, A. M. (1989) Sex in the Therapy Hour: A Case of Professional Incest. Guilford.

Russell, Janice (1993) Out of Bounds: Sexual Exploitation in Counselling and Therapy. Sage pb.

Ciardiello, Jean (1996) ‘Therapist-Patient Sexual Contact’, Psychoanal. Rev. 83: 761-75.

For personal accounts of failure to maintain boundaries, see

Hill, J. (1993) ‘Am I a Kleinian? Is Anyone?’, Brit. J. Psychother. 9: 463-75 - a candid account of three Kleinian analysts’ very idiosyncratic behaviour about boundaries.

Fox, R. P. (1984) ‘The Principle of Abstinence Reconsidered’, Internat. J. Psycho-Anal. 11: 227-35

*Little, M. (1985) 'Winnicott Working in Areas where Psychotic Anxieties Predominate', Free Assns. 3: 9-42 — where Winnicott does.

Carotenuto, A. (1984) A Secret Symmetry: Sabina Spielrein between Jung and Freud. Routledge — about one of Jung's patients who fell in love with him.

Masson, J. (1991) Final Analysis. Harper Collins — in which the notorious apostate describes a training analysis with practically no boundaries.

There are well-known accounts of rule-breaking which the authors believed to be beneficial:

*Coltart, N. (1986) '"Slouching towards Bethlehem"... or Thinking the Unthinkable in Psychoanalysis', in G. Kohon, ed., The British School of Psychoanalysis: The Independent Tradition. Free Association Books, pp. 185-99; reprinted in her collection, Slouching Toward Bethlehem... Free Association Books pb, 1992, pp. 1-14.

Symington, N. (1986) 'The Analyst's Act of Freedom as Agent of Therapeutic Change', in Kohon, Gregorio, The British School of Psychoanalysis: The Independent Tradidion. Free Associarion Books, 1986, pp. 253-70.

There is a useful brief discussion of these issues about self-revelation and 'expressive uses of the countertransference' in

Rayner, E. (1990) The Independent Mind in British Psychoanalysis. Free Association Books, pp. 289-96.

On boundaries in the analytic and post-analytic relationship, see

Blomfield, O. H. D. (1985) ‘Psychoanalytic Supervision — An Overview’, Internat. Rev. Psycho-anal. 12: 401-9

Crick, P (1991) ‘Good Supervision: On the Experience of Being Supervised’, Psychoanal. Psychother. 5: 235-45.

Limintani, A. (1989) ‘The Training Analyst and the Difficulties Associated with Psychoanalytic Training’, in Between Freud and Klein: The Psychoanalytic Quest for Knowledge and Truth. Free Association Books, 1989, pp. 73-87.

Norman, H. F. et al. (1976) ‘The Fate of the Transference Neurosis after Termination of a Satisfactory Analysis’, J. Amer. Psychoanal. Assn. 24: 471-98

Wallerstein, R. S., ed. (1981) Becoming a Psychoanalyst: A Study of Psychoanalytic Supervision. N. Y.: International Universities Press.

*Schachter, J. (1990) ‘Post-Termination Patient-Analyst Contact: I. Analyst’s Attitudes and Experience, II. Impact on Patients’, Internat. J. Psycho-anal. 71: 475-86.

*Schachter, J. (1992) ‘Concepts of Termination and Post-Termination Patient-Analyst Contact’, Internat. J. Psycho-anal. 73: 137-54.

Grinberg, L. (1990) ‘Theoretical and Clinical Aspects of Supervision’, Part Four of The Goals of Psychoanalysis: Identification, Identity and Supervision. Karnac, pp. 289-369.

Peddar, J. R. (1986) ’Reflections on the Theory and Practice of Supervision’, Psychoanal. Psychother. 2: 1-12.

Copyright: The Author

Address for correspondence: 26 Freegrove Road, London N7 9RQ

robert@rmy1.demon.co.uk


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