RESPONSE TO JEREMY HOLMES'S `TOO EARLY, TOO LATE'- COUNTERTRANSFERENCE AND ENDINGS

Dorothy Hamilton

If we say someone has left too early or too late, we are clearly referring to the experience ofthe patient: we are making a therapeutic judgement about that person's inner state. But if wetalk of a countertransference to the leaving, we are referring to the experience of thetherapist who feels it is too early or too late, either because he or she is accurately attuned, orbecause - and this is the sense in which the term `countertransference' is more likely to beused - he or she is caught perversely into some projection from the patient. I'm assuminghere that most of us have arrived at some form of Heimann's definition ofcountertransference - that is, all our responses to a particular patient, responses which maybe used both as a tool to understand the patient and as a monitor of the therapist'scompetence. In the matter of an ending that seems too early or too late, how can wedistinguish between our countertransference and our therapeutic judgement?

Jeremy gives an attachment theory model for countertransference. Describing theestablishment of a `secure base', both in reality and as an internal representation within thepatient, as the aim of attachment therapy, he says: `A secure base arises partly out of theresponsiveness and attunement provided by the therapist, partly from her capacity to acceptand metabolize protest and anger'. Responsiveness and attunement; the capacity to acceptand metabolize protest and anger: that, I think, is a lovely description, both comprehensiveand concise, of what many of us would call the `maternal reverie' of the therapist.

The attachment theorist's `attunement' may be likened to Freud's use of the unconsciousreceptive instrument; to the post-Kleinian `normal' or healthy countertransference (perhapsbased on `normal' projective identifications from the patient); and, as Jeremy says, to Racker's `concordant' countertransference. The words `accept and metabolize' refer to the capacityto take the undigested material the patient fires at the therapist - Bion's beta elements - andconvert it, through the therapist's alpha function, into digestible material. Too often, ofcourse, our identifications become, in Racker's terms, complementary - we identify, notappropriately with the patient's feelings and needs, but with his or her internal objects. Then,in Bion's language again, we find ourselves firing back beta elements at the bewilderedpatient.

DOROTHY HAMILTON presented this response at the AGIP Annual Conference in June 1996. Apsychoanalytical psychotherapist, member of and training supervisor for the Association for Group andIndividual Psychotherapy (AGIP), she was formerly Director of AGIP and Hon. Sec. to the UnitedKingdom Council for Psychotherapy. Address for correspondence: AGIP, 1 Fairbridge Rd., London N193EW.

British Journal of Psychotherapy, 14(2), 1997© The author

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The languages have their own delights. In our sessions, however, it's more messy:decisions have to be made on the hoof, and it's seldom clear in the moment whether what Ithink is a valid expression of my maternal reverie is in fact a counter-therapeuticintervention. Since we cannot always follow the detail, our security must lie in keeping agrasp of what is happening overall - the structure of the case. This is critical to whether wecan answer the question: Too early, too late? for any particular ending.

Sometimes the decision does seem straightforward. One of my patients is a mild form ofmultiple personality. The explicit dialogues she holds with and between the different parts ofherself lay out her internal world for me with great clarity. Overall, and despite manyepisodes of confusion and of deep negativity, she has generously enabled me to understandher. For years she was deeply dependent on me; now the transference has largely given wayto a real relationship, with the occasional reversion. She has moved gradually from foursessions a week to two, and now to one. We both know most of the elements of thisimpending ending, and believe it will be all right. Such therapies give us a benchmark, aconcept of `about right'; the alliance my patient and I have forged enables the quality of `about right' to be held and understood by us both.

But I want to consider a much less satisfactory ending, one I think that reflects theambiguity of our theme. This followed 18 months of therapy with a young woman. Weexperienced it as a tough, but mostly productive, battlefield. My patient faced her innermaterial with great courage: much of it was disturbing and sometimes terrifying to her, andshe acknowledged there were things she could not tell me, indeed did not dare to see clearlyfor herself. She called this dangerous inner mess `the black box'. She recognized that she hadfled her distant homeland to escape the parents who had contributed so much to the contentsof the box. In the therapy with me, the lid was never fully lifted.

In time came the negative transference. I became for her an ungiving teacher-like figure,demanding and impersonal. We interpreted her need for control, and her fear of beingcontrolled. But interpretations were not enough: the threat from me grew, and in the end shecould stand it no longer. She announced her intention of leaving. In vain I tried to show herwhat was happening, that everything she felt could be understood and interpreted in theterms we had used together, that her flight from me replicated that from her parents. Shetold me she understood all this (and I believe she did), but that she had to go. I went to mysupervisor and said: `I'm losing her. What shall I do?' He said: `Give her your blessing', and,just in time, I did. So she escaped this particular witch with some dignity and some comfort.

Such an ending would certainly be classified by Jeremy as a variety of `long-terminvoluntary'. An unworked-through transference, a countertransference state not sufficientlysensitively understood to enable me to do what was necessary to hold her: the therapeuticjudgement `too early' looks glaringly evident. And yet - the strongest impression this womanleft with me was one of a rather obstinate butterfly, emerging from a chrysalis and set onflying despite all obstacles - as butterflies indeed may be expected to do.

Where did this' image come from? Does it illustrate some truth about my patient, or is itan expression of my wayward countertransference (or indeed my transference)? Was thebutterfly my wish to justify the ending? Was it my supervisor's wish? - countertransferenceby proxy! Or was I the butterfly, taking flight from the constraining chrysalis of my ownfailure as a therapist?

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At this point in writing my response, I found myself struck by Jeremy's little matrix. As apsychoanalytical type, I felt a degree of virtuous scepticism about such a device, but Inevertheless checked myself and my patient against it - just as an exercise, I told myself. Forobvious reasons, I chose `avoidant' rather than `ambivalent' for my patient, then went to `tooearly' to describe our ending. Then I checked the therapist type. It said `structure' - that is, atherapist who overemphasizes structure. No, I thought, my doubts justified, that's not me - ifI make a mistake, it's more likely to be the other way.

Then I remembered a small incident, very near the end of the therapy, that at the timehad appeared to be the last straw for my patient. She had asked me about a picture in theroom, and whether it belonged to me. I responded by showing the classical analytic interestin her question: rather than giving any reply out of myself, I chose to stay well within mytherapeutic boundary. She became bitter, accusing me of withholding anything real from her.This matter was not resolved between us - she left shortly afterwards.

I can argue, of course, that to have given my patient what she wanted at that point wouldhave been to act out of an over-maternal countertransference - surrendering, in Kleinianterms, to her controlling projective identification. Freud might have spoken of gratificationof the infant wish; equally, he might have recognized an anal-retentive control in me - ineffect a therapist's transference, counter to her invasive question. Looking back, I think mypatient was right. I was in the complementary position here. I had identified, in mybewilderment and anger at her threat of leaving, with her punitive internal objects.

Maybe she did need to fly then, for reasons neither of us could fully understand. She hadbeen brave during the therapy, had gone to places she believed she could not. At times shewas aware of deep gratitude to me, and a part of her maintained that to the finish. She saidshe knew the flight was a repetition, but that it was also different, and the right thing to do.

In the end, I'm left with a simple question: What would have been my criteria for notgiving her my blessing?