A Relational Perspective on Enactments, Boundary Violations and Self Disclosure

Jacobs (1986) was one of the first to use the term enactment in an analytic context. He conceptualised enactment as a subtle interlocking of the transference and countertransference that operates outside of conscious awareness, often through nonverbal means. More recently, he suggests that the root of enactments lies in mutually regulating and self-regulating behaviours (Jacobs, 2005). Enactments may also be understood in terms of Sandler’s (1976) theory of role-responsiveness . Elaborating on Sandler’s theory, Gabbard (1996) contends that countertransference enactments represent a joint creation that involves contributions from both the therapist and the patient. Whereas the patient may actualise an internal scenario within the therapeutic relationship, resulting in the therapist playing a role scripted by the patient’s internal world, the dimensions of the role enacted by the therapist will be coloured by their own subjectivity. This reflects the fact that therapists bring their own wishes, needs and desires to the therapeutic situation, as well as their own traumatic histories

On discussing countertransference enactments, Mitchell (1993) compares a relational/intersubjective model to that employed by Freud (1905e) in his brief analysis of Dora. Mitchell (1993) argues that Freud’s focus on intrapsychic neurotic conflict invalidated Dora’s subjective experience of trauma and abuse, and perpetuated, in the countertransference, her victimisation by the men in her life. Thus, Mitchell (1997) cautions us to guard against enacting or re-enacting in the transference/countertransference matrix aspects of the patient’s original traumatic experience or abusive relationships by blaming, victimising or, indeed, seducing him or her. Seductive behaviour by the therapist may include a countertransferential wish to rescue or parent the patient, thereby encouraging a regressive dependency (Herman, 1992; Blum, 1994). Mitchell (1997) emphasises that awareness of countertransference tendencies of these kinds requires continual self-reflective responsiveness to the material being presented.

Although we may well heed Mitchell’s (1997) cautionary words about being drawn into enactments with our patients, as doing so is likely to interfere with the development of a good working relationship, Davies and Frawley (1994) argue that traumatic transference/countertransference enactments are inevitable. Evolving out of their work with adult survivors of childhood sexual abuse, the authors delineate eight positions, as expressed within four relational matrices. In a similar way to Sandler’s (1976) theory of role-responsiveness, these positions, roles or self-states may alternately be enacted by the therapist and patient in the transference/countertransference matrix. They include the uninvolved non-abusing parent and the neglected child; the sadistic abuser and the helpless, impotently enraged victim; the idealised, omnipotent rescuer and the entitled child who demands to be rescued; and the seducer and the seduced. Davies and Frawley (1994) suggest that mutually dissociated traumatic experience is particularly susceptible to being enacted in the intensity of the therapeutic relationship.

This view is endorsed by Herman (1992). Writing from a traumatology perspective, she describes the traumatic or vicarious countertransference, suggesting that the patient’s dissociated trauma may overwhelm the therapist. One among several reactions to this situation is the therapist’s need to defend against unbearable feelings of helplessness. Thus, therapists who ordinarily are scrupulous in observing the limits of the therapeutic frame may find themselves violating the bounds of the therapy relationship and assuming the role of rescuer, thereby disempowering the patient. Under the intense pressures of the traumatic transference/countertransference, the therapist may take on an advocacy role for the patient, feel obliged to extend the limits of therapy sessions, allow frequent emergency contacts between sessions, and answer phone calls late at night or when on vacation. Herman (1992) points out that the therapist’s defence against feelings of helplessness may lead to a stance of grandiose special-ness or omnipotence, with the attendant risk of extreme boundary violations, up to and including sexual intimacy. Such violations are frequently rationalised on the basis of the patient’s desperate need for rescue and the therapist’s extraordinary gifts as a rescuer.

Paradoxically, as the relational literature shows, non abusive enactments may lead to profound therapeutic change (D. B. Stern, 2010), enhancing a sense of felt security and the capacities for affect regulation and reflective functioning or mentalisation (Fonagy, 2008). Indeed, there is a broad consensus that countertransference enactments are not only ubiquitous but also potentially useful (Aron, 1990; Chused, 1991; Renik, 1993; Renn, 2012). A relational perspective, informed by developmental studies, holds that the adequate repair of non-abusive ruptures constitutes therapeutic action, with the consequent gain of a constructive outcome (Beebe & Lachmann, 1994, 2002; Benjamin, 1995; Fonagy, 1998; Roth & Fonagy, 1996). Similarly, Chused (1991) argues that the benefit for the therapy is not the enactment itself, but rather the eventual understanding that derive from the enactments. Crucially, then, the outcome depends on how the enactment is worked with in the therapeutic relationship – can it be contained and collaboratively explored, validating the patient’s subjective reality and, thereby, provide a shared, co-constructed emotional experience as the rupture to the working alliance is repaired, or will it replicate past abusive relationships and thus risk re-traumatising the patient? In this context, Gabbard (1996) strikes a note of caution, stating: “Integral to the notion that countertransference enactments are useful is the understanding that analysts must catch themselves in the midst of the enactment when it is manifesting itself in an attenuated or partial form” (pp. 84/85, italics in original).

Enactments and Self Disclosure

Mitchell (1988) argues that in order to work relationally the therapist must be prepared to take risks in the service of connecting with the patient in a real and authentic way. Thus, passionate feelings of love and hate may often arise between the analyst and patient. In this context, Mitchell (2000) observes that relationally oriented clinicians are often “portrayed as wild analysts, doing and saying anything that occurs to them in an unrestrained fashion” (p. 127). He believes that this criticism is “ill founded”, arguing that relational analysts approach their clinical work with caution and responsibility (ibid.). However, Mitchell (1997) does make it quite clear that the question for the contemporary relational therapist is not whether to share countertransferential thoughts and feelings, but rather when and to what extent. In his view, selective disclosure of the countertransference may function to help the patient and therapist connect on an emotional level and, thereby, open up, vitalise and validate their subjective experience, providing them with a sense of being valued and understood. Handled insensitively, however, disclosure may close down and deaden the patient’s experience. Clearly, then, the decision to disclose requires a responsible, sensitive and judicious approach by the therapist that takes full account of the need to protect the patient’s personal integrity and boundaries. As Mitchell (1997) puts it, a delicate balance needs to be achieved whereby the therapist is neither excessively emotionally detached from the patient nor excessively intimate and intrusive.

Maroda (2010) defines self-disclosure as “any verbal expression of personal feelings or information on the therapist’s part, whether deliberate or not” (p. 108). Self-evidently, self-disclosure can have a positive or a negative impact on the therapeutic relationship. Indeed, Aron (1996) advocates allowing the patient access to the therapist’s subjectivity, in terms of disclosing their thoughts, feelings and fantasies. He argues that this leads to an acknowledgement by the patient of the therapist as a separate subject. This notwithstanding, in order to protect the patient, we need to ask ourselves what the therapeutic purpose is of self-disclosure, whether it would be useful, digressive or disruptive, and what the motivation is for disclosing personal feelings or information. Moreover, as Wachtel (2008) observes, considerations about how much, when, and how to disclose require sophisticated, reflective, and patient-centred attention. In broad terms, the therapeutic benefits accruing from sensitive and responsible self-disclosure are that it may confirm the patient’s sense of reality, break impasses and repair ruptures, promote new relational experiences, and facilitate shared states of mind and emotional honesty.

Although it is generally agreed that self-disclosure works best when there is a strong therapeutic alliance, both Maroda (2010) and Wachtel (2008) emphasise that we cannot always correctly appraise when disclosure will be helpful and growth-promoting, and that we must, therefore, be prepared to work with the consequences of getting it wrong. These authors also stress that the interactions with the patient need to be individualised, recognising that what is appropriate for one patient may well not be so for another. As Maroda (2010) puts it, “therapeutic self-disclosure is a result of intuitive and artistic responses in a unique, creative moment with an individual client” (p. 113). As ever, the context needs to be taken into account in deciding whether or not to self-disclose. As Mitchell (2000) notes: “Love and hate in long-term relationships, like the analytic relationship, do not just happen. They are shaped and cultivated within contexts that are constructed slowly, over time” (p. 129).

With regard to erotic feelings in the therapeutic dyad, Mann (1997) argues that the therapist’s open recognition of their erotic desire and subjectivity indicates a mature awareness of the differentiation between self and other which may help to preclude the sexual abuse of the patient. Indeed, Celenza (2010) argues that erotic excitement is a normal and expectable experience in the therapeutic encounter. Moreover, she suggests that “all treatments must revolve, at some level, around the question ‘Why can’t we be lovers?’” (p. 66). In order to avoid boundary violations, she contends that this question “must be reckoned with and will involve the use of erotic arousal in the dyad” (ibid). Indeed, Searles (1965) argues that successful work depends on the therapist recognising and reciprocating the patient’s transference love without acting on these feelings. Mann (1997), however, advises against the disclosure of erotic feelings to the patient, a view generally shared by Maroda (2010), who states: “I am really against disclosure of erotic countertransference, with rare exceptions” (p. 218). For his part, Mitchell (2000) states: “Ultimately it falls to the analyst to make decisions about the constructive versus destructive implications of various affects in both participants in the analytic process, even though there is no way to make those judgments purely objectively. Part of the analyst’s responsibility is to participate in and enjoy that love, while it seems facilitative of the analytic process, but not to enjoy that love so much that it becomes a vehicle for the analyst’s own pleasure in a way that occludes his focus on the patient’s well-being” (p. 139).

Gabbard (1996), however, notes that the powerful and compelling nature of sexual and loving feelings may override the therapist’s reflectiveness. Countertransference enactments of such feelings occur along a continuum from overt sexual relations between patient and therapist at one end, to subtle forms of enactment involving partial transference gratifications of a verbal and nonverbal nature within the boundaries of the therapeutic frame at the other end. He states that: “In any countertransference enactment, analysts must strive to determine the relative balance of their own contributions versus the patient’s contributions. A key part of that reflective process is determining which role, if any, one is playing in the patient’s internal cast of characters” (p. 86).

Therapy, then, is an inherently intense, intimate and risky business. Trauma, like madness, is contagious, that is, it is transmitted interpersonally. Mutual or bi-directional influence, on both a conscious and unconscious level of mental functioning, is continuously in operation, for good or for ill. Therapist and patient get drawn into inevitable transference/countertransference enactments on a continuum of seriousness under the sway of nonconscious representational models, unresolved trauma, and mutual dissociation. Enactments can be a force for therapeutic change or a vehicle for abuse and re-traumatisation (Renn, 2012, 2013). This dichotomy is succinctly summed up by Kernberg (1995) who, in discussing the erotic aspects of the transference/countertransference, notes: “There is probably no other area of psychoanalytic treatment in which the potentials for acting out and for growth experiences are so intimately condensed” (p. 114).

Clearly, then, safeguards are required! The therapeutic frame includes an adherence to ethical codes and guidelines designed to protect the patient from abuse and boundary violations. These may be reinforced by regular supervision and membership of a peer support group. Maintaining the frame in a consistent and ethically boundaried way may allow the patient to feel sufficiently safe and free to develop, explore and express erotic and aggressive feelings in relation to the therapist, thereby providing grist to the therapeutic mill. The frame, then, provides a containing structure and creates the conditions for attachment security and the symbolic elaboration of dissociated and unmentalised wishes, desires, and affects deriving from unresolved trauma, loss, neglect or abuse. Conversely, breaching the frame by, for example, adopting a position of omnipotent rescuer may unwittingly disempower the patient and foreclose on opportunities for therapeutic change.

More generally and in conclusion, the respective findings of Roth & Fonagy (1996), Schore (1994), Stern et al. (1998), and Shedler (2010) indicate that the interactive emotion-transacting aspect of the therapeutic relationship is the main mechanism of intrapsychic change. Indeed, Gabbard and Hobday (2012) cite findings showing that “a solid therapeutic alliance” has “consistently been found to be the best predictor of outcome in psychotherapy research” (p. 246).

References

Aron, L. (1990). One-person and two-person psychologies and the method of psychoanalysis. Psychoanalytic Psychology, 7, 475-485.

Beebe, B., & Lachmann, F. M. (1994). Representation and internalisation in infancy: Three Principles of Saliency. Psychoanalytic Psychology, 11, 127-165.

Beebe, B., & Lachmann, F. M. (2002). Infant Research and Adult Treatment: co-constructing interactions. Hillsdale, NJ: The Analytic Press.

Benjamin, J. (1995). Recognition and Destruction: An Outline of Intersubjectivity. In Like Subjects, Love Objects: essays on recognition and sexual difference, (pp. 27-48). New Haven: Yale University Press.

Blum, H. P. (1994). Reconstruction in Psychoanalysis: Childhood Revisited and Recreated. Connecticut: International Universities Press.

Celenza, A. (2010). The Analyst’s Need and Desire. Psychoanalytic Dialogues, 20, 60-69.

Chused, J. F. (1991). The evocative power of enactments. Journal of the American Psychoanalytical Association, 39, 615-639.

Davies, J. M., & Frawley M. G. (1994). Treating the Adult Survivor of Childhood Sexual Abuse. New York: Basic Books.

Fonagy, P. (1998). Moments of Change in Psychoanalytic Theory: Discussion of a New Theory of Psychic Change. Infant Mental Health Journal, 19(3), 346-353.

Fonagy, P. (2008). The Mentalisation-Focused Approach to Social Development. In F. N. Busch, (Ed.), Mentalisation: Theoretical Considerations, Research Findings, and Clinical Implications. (pp. 3-56). Hove: The Analytic Press.

Freud, S. (1905e). Fragment of an Analysis of a Case of Hysteria. In J. Strachey (Ed. & Trans.). The standard edition of the complete psychological works of Sigmund Freud (Vol. 7). London: Hogarth Press.

Gabbard, G. O. (1996). Love and Hate in the Analytic Setting. Northvale, NJ: Jason Aronson.

Gabbard, G. O. & Hobday, G. S. (2012). A Psychoanalytic Perspective on Ethics, Self-Deception and the Corrupt Physician. British Journal of Psychotherapy, 28(2), 235-248.

Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.

Jacobs, T. J. (1986). On countertransference enactments. Journal of the American Psychoanalytical Association, 34, 289-307.

Jacobs, T. J. (2005). Discussion of Forms of Intersubjectivity in Infant Research and Adult Treatment. In Beebe, B., Knoblauch, S., Rustin, J., & Sorter, D. Forms of Intersubjectivity in Infant Research and Adult Treatment: A Systems View, (pp. 165-189). New York: Other Press.

Kernberg. O. F. (1995). Love relations: Normality and pathology. New Haven, CT: Yale University Press.

Mann, D. (1997). Psychotherapy: An Erotic Relationship. London: Routledge.

Maroda, K. J. (2010). Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship. New York: The Guilford Press.

Mitchell, S. A. (1988). Relational Concepts in Psycho-Analysis: An Integration. Cambridge, MA: Harvard University Press.

Mitchell, S. A. (1993). Hope and Dread in Psycho-Analysis. New York: Basic Books.

Mitchell, S. A. (1997). Influence and Autonomy in Psychoanalysis. Hillsdale, NJ: Analytic Press.

Mitchell, S.A. (2000). Relationality: From Attachment to Intersubjectivity. Hillsdale, NJ: The Analytic Press.

Renik, O. (1993). Analytic interaction: conceptualising technique in light of the analyst’s irreducible subjectivity. Psychoanalytic Quarterly, 62, 553-571.

Renn, P. (2012). The Silent Past and the Invisible Present: Memory, Trauma, and Representation in Psychotherapy. New York: Routledge.

Renn, P. (2013). Moments of Meeting: The Relational Challenges of Sexuality in the Consulting Room. British Journal of Psychotherapy, 29, 2, 135-153.

Roth, A., & Fonagy, P. (1996). What works for whom: Limitations and implications of the research literature. New York: Guilford Press.

Sandler, J. (1976). Countertransference and role-responsiveness. International Review of Psycho-Analysis, 3, 43-47.

Schore, A. N. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Hillsdale, NJ: Lawrence Earlbaum.

Searles, H.F. (1965). Oedipal love in the countertransference. In Collected papers on schizophrenia and related subjects. Madison, CT: International Universities Press.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, (2), 98-109.

Stern, D. B. (2010). Partners in Thought: Working with Unformulated Experience, Dissociation , and Enactment. New York: Routledge.

Stern, D. N., Sander, L.W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan, A. C., Bruschweiler-Stern, N., & Tronick, E. Z. (1998). The Process of Therapeutic Change Involving Implicit Knowledge: Some Implications of Developmental Observations for Adult Psychotherapy. Infant Mental Health Journal, 19(3), 300-308.

Wachtel, P. L. (2008). Relational Theory and the Practice of Psychotherapy. New York: The Guilford Press.