Countertransference and Regression

This interesting book, written primarily for experienced psychoanalysts, consists of two forewords, an introduction, “A Conversation With L. Bryce Boyer” by Sue von Baeyer, and 12 previously published papers by Boyer (one “with the assistance of Laura Doty”) dating from 1983 to 1997. We are told that these papers, most of which are short and of uneven quality, constitute the second volume of Boyer’s collected papers.

One has to accept Boyer’s Kleinian orientation on faith; one either takes it or leaves it. The reader will need a certain familiarity with Kleinian psychoanalysis to appreciate Boyer’s work. The forewords, one by James Grotstein and the other by David Rosenfeld, are extremely laudatory about Boyer and might function to reinforce one’s belief in his speculations, such as, “It is held here that whatever the analyst experiences during the analytic session constitutes his idiosyncratic introjection of the patient’s verbal and nonverbal communications, containing the patient’s projections, and the analyst’s predominantly unconscious reactions to those introjections” (p. 9). Boyer views “each analytic session as though it were a dream, in which the major unresolved transference-countertransference issue of the last or last few sessions composes the day residue” (p. 12). Probably the most extreme example of Boyer’s approach is found in chapter 12, “The Verbal Squiggle Game in Treating the Seriously Disturbed Patient.”

Boyer’s reputation and experience are based on his willingness to attempt psychoanalysis with psychotic and other very difficult and extremely regressed patients, and he is enthusiastic regarding his success in this kind of work. He argues that if there is a well-established holding environment and holding alliance, psychotic reactions “will be confined almost exclusively to the consultation room. The analyst and patient must be able to tolerate them, learn from them, and use them for therapeutic ends” (p. 122). As he worked in this mode, he turned more and more to a study of his own emotional and physical reactions to the patient’s productions.

Boyer gives us admittedly subjective statistics (pp. 114–115) on his work. He treated 112 patients, 50 in face-to-face psychotherapy once or twice weekly and the rest in psychoanalysis four, five, or, rarely, three times weekly. “The choice of treatment was determined almost exclusively by finances and geography.” Thirteen of the 50 patients in psychotherapy improved, and one “was much improved.” Nine of the psychoanalytic patients stopped during the first year, and one improved. Eighteen left in less than 2 years; 15 of these were “somewhat” improved, and “one was much improved.” Twenty-nine continued to termination; three were improved, and 26 “much improved.” He cites colleagues as having been impressed with his capacity to tolerate regression and maintain therapeutic contact with a patient through the course of a regression, allowing the basic structure of the therapeutic situation to continue and providing and maintaining “a consistent, optimistic, empathic environment in which indirect ego and superego support is given” (pp. 115–116).

The book contains some valuable clinical pearls for the psychiatrist interested in practicing psychoanalytically oriented psychotherapy. It also contains statements such as this:

If the reader can get past this, there are two chapters that have especially valuable information for psychoanalytic psychotherapists. These are chapter 5, “On Man’s Need to Have Enemies,” and chapter 7, “Psychoanalysis With Few Parameters in the Treatment of Regressed Patients, Reconsidered.”

In chapter 5, which is based on the work Boyer and his wife did among the Apaches of the Mescalero Indian reservation, there is a study of how important externalization of rage through the creation of enemies seems to be in the handling of massive human aggression. Only through dealing with this aggression can humans function effectively in a civilization, so that “man needs external objects, real or imaginary, that he defines as bad, or as enemies, upon which to externalize his inner bad self- and other representations in order to maintain a favorable self-image and peace in his group” (p. 95).

Chapter 7 emphasizes how important the setting and the reliability of the analyst are, especially in the treatment of sicker patients. There is a great deal of discussion of splitting and projective identification in preoedipally damaged patients. By a study of the “unfolding transference-countertransference situation” (p. 117), Boyer believes he found the way to reduce impasses in psychotherapy and remain both objective and empathic. The bottom line of this approach is to treat each session as if it were a dream, attempting to uncover the latent conflicts that energize it through focus on the unfolding transference-countertransference situation. He greatly emphasizes the therapeutic impact of the holding and facilitating environment and the relationship with a new object, the analyst, as crucial in the treatment process: “The more the patient is regressed, the greater is the importance of environmental facilitation in his treatment and of the capacities of the analyst to interact comfortably with the individual whose drives are urgent and untamed, whose superego is archaically sadistic, and whose communication techniques are confusing and determined (as is much of his perception and behavior) by his use of primitive psychical mechanisms” (p. 118). Boyer argues that the psychoanalytic relationship offers a special opportunity to the patient for a new beginning (borrowing from the work of Balint), and he takes the controversial stand that controlled regression during psychoanalytic treatment is an important therapeutic factor that “can enable the patient who has been partially fixated at such an early level of psychic organization to develop to higher levels of organization” (p. 164).

In summary, this book will have something of interest for psychoanalytically oriented psychiatrists and psychoanalysts, but it requires some background knowledge of Kleinian psychoanalysis in order to make it intelligible, as well as a certain faith in the validity of Boyer’s reports and statements.