Challenges in the Analysis of Adult Patients With Histories of Childhood Sexual AbuseGlen O Gabbard; PO Box 829 !

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Introduction
Al)ost exa*tly a *entury ago +reud ,'89%- noted that .at the botto) of e/ery *ase00 there are one or more occurrences of premature sexual experience o**urren*es 1hi*h belong to the early years of *hildhood but 1hi*h *an be re"rodu*ed through the 1or# of "sy*ho(analysis in s"ite of the inter/ening de*ades2 ,"0 2&3-0 He ra"idly abandoned his /ie1 that *hildhood sexual abuse 1as ubi4uitous in neurosis and de*ided that fantasy 1as "robably )ore *entral to neurogenesis0 !his shift in/ol/ed an e)"hasis on "sy*hi* reality ,as o""osed to )aterial reality- and the /ie1 that fantasies of sedu*tion )ight a*tually defend against )e)ories of guilt(ridden infantile )asturbation ,+reud '9&5-0 Ho1e/er *ontrary to "o"ular )is*on*e"tions about the e/olution of +reud6s thin#ing he ne/er entirely abandoned the i)"ortan*e of real trau)a only its "er/asi/eness0 7n fa*t as late as '93' +reud noted .A*tual sedu*tion is *o))on enough0 7t in/ariably disturbs the natural *ourse of the de/elo")ental "ro*esses and it often lea/es behind extensi/e and lasting *onse4uen*es2 ," 232+reud6s *lini*al a*u)en led hi) to re*ogni8e that analysts )ust not un*riti*ally a**e"t e/erything their "atients say0 !easing out fantasy fro) real trau)a is a for)idable *hallenge0 Hen*e it is "arti*ularly ironi* that *onte)"orary +reud(bashers su*h as +rederi*# Cre1s ,'995- bla)e +reud for so(*alled re*o/ered )e)ory thera"ists 1ho en*ourage their "atients to belie/e in false )e)ories of *hildhood sedu*tions0 Bla)ing +reud for the )isad/entures of "oorly trained and nonanalyti* thera"ists 1ho see sexual abuse e/ery1here is li#e bla)ing Alfred 9obel for the O#laho)a City bo)bing0 7ndeed one *ould easily i)agine a s*enario in 1hi*h +reud is hailed as the hero of the .false )e)ory syndro)e2 )o/e)ent be*ause he 1as the first to re*ogni8e the fallibility of )e)ories of *hildhood sexual abuse ,:ear '99%-0 We ha/e *o)e through an era in "sy*hoanalysis in 1hi*h in*est and *hildhood sexual abuse 1ere 1idely negle*ted ,Si)on '992- and )ore re*ently "assed through a "eriod of redis*o/ery of the relati/ely high "re/alen*e of in*est0 Analysts are re*ogni8ing that )any of their "atients ha/e ex"erien*ed so)e for) of sexual abuse in *hildhood that su*h trau)a has /arying effe*ts on these "atients and in those in 1ho) it is a signifi*ant fa*tor in the etiology and "athogenesis of their "sy*ho"athology it "resents a host of *hallenges to the analyst0 7n this *o))uni*ation 7 fo*us on fi/e of those *hallenges and suggest te*hni*al strategies for dealing 1ith the); ,'- the *olla"se of analyti* s"a*e ,2- the /i*ti) role as .bedro*# 2 ,3- the e/o*ation of "roble)ati* *ountertransferen*es ,<- the li)its of inter"retation and ,5- the /eridi*ality of )e)ories0 !hese fi/e issues are inti)ately inter*onne*ted in the *lini*al situation and are here arbitrarily se"arated out for illustration0 =y *o))ents are dire*ted "ri)arily to the treat)ent of fe)ale "atients ,see Gabbard and !1e)lo1 >'99<? for a dis*ussion of )otherson in*est-0

1. The Collapse of Analytic Space

!he "sy*hoanalyti* situation de"ends on the *a"a*ity for both "arti*i"ants to establish a reality unli#e any other 7deas and feelings are ."layed 1ith2 in an illusionary real) 1here ex"erien*es are both real and unreal0 7t is a real) in 1hi*h the analyst )ay be ex"erien*ed .as if2 he or she is so)eone else 1hile the "atient si)ultaneously #no1s the analyst6s true identity0 !his illusionary @oint *reation has been referred to as analytic space by Ogden ,'989- or potential space by Winni*ott ,'9A9- and is generally regarded as *ru*ial to sy)boli* thin#ing0 !he loss or *olla"se of this s"a*e is one of the tragedies of se/ere *hildhood trau)a0 When a little girl has a*tually engaged in sexual relations 1ith her father along 1ith her inno*en*e she )ay lose a *ertain *a"a*ity for fantasy She *an no longer drea) about her father as a #night in shining ar)our 1ho )ight res*ue her fro) her )other6s irritability0 Su*h *hildren find it diffi*ult to "retend or to )a#e belie/e and 1hen as adults they *o)e for analyti* treat)ent they )ay be unable to "arti*i"ate in the "lay s"a*e the analyst atte)"ts to *reate0 !his ego defi*it often a""ears as a loss of the .as if2 in the transferen*e ,Bollas '989 Gabbard '99% Gabbard and Wil#inson '99< :e/ine '99& =odell '99%-0 As a result the analysand )ay not ex"erien*e the analyst .as if2 he 1ere her father; instead the analyst is the father0 One /ariation of this "heno)enon is 1hat Blu) ,'9A3- des*ribed as erotized transferen*e0 +ound "ri)arily in in*est /i*ti)s and borderline "atients the eroti8ed transferen*e is *hara*teri8ed by a tena*ious egosyntoni* de)and for sexual gratifi*ation0 !he analyst is not ex"erien*ed .as if2 he 1ere a "otential lo/er he is seen as the only "erson 1ho *an gratify the "atient6s sexual 1ishes0 !he eroti8ed transferen*e is but one /ariation on this ex*essi/e *on*reteness and in*a"a*ity to "lay So)e "atients a""ear to ha/e no *a"a*ity for sexual arousal as a result of the trau)a and do not

de/elo" sexual longings to1ard the analyst0 Bollas ,'989- has des*ribed the *ountertransferen*e des"air that often a**o)"anies this *losing of the analyti* s"a*e; I believe this confession of a transgression creates in the analyst's mind the very essence of the trauma of molestation. As I feel Well, that's the end of that and Well, hat no , I reflect the despair over a loss of reflective thought. !stensibly I feel this because as the patient asserts that she as violated, this has to be accepted as the undisputed source of her problem. I "no the patient ill scrutinize me for any signs of disbelief, and I "no I don't ish to be involved in any internal ad#udication over hether this really happened or didn't And hy not$ %ecause my mind gets ta"en up ith litigious factors, inside an imagina&ry courtroom, hich distracts me from my patient and ma"es the person one&dimensional And yet this is seemingly hat she ants. 'he demands that I ta"e her at face value (p. )*+,. 7nherent in the la*# of refle*ti/e analyti* s"a*e is a "ro"ensity to1ard a*tion0 =any "atients 1ho ha/e ex"erien*ed *hildhood sexual abuse feel the analyst )ust ta#e so)e for) of a*tion to address their "ain0 !his "ressure to a*t )ay ta#e the for) of a "sy*hologi*al dra)a "layed out in the intro@e*ti/e and "ro@e*ti/e "ro*esses bet1een analyst and "atient0 !he roles of o)ni"otent res*uer /i*ti) abuser and unin/ol/ed )other )ay be regarded as self(and ob@e*t(re"resentations 1ithin the "atient that are "layed out in the transferen*e(*ountertrans(feren*e di)ensions of the analysis ,Ba/ies and +ra1ley '992 Gabbard '992-0 Csing "ro@e*ti/e identifi*ation the "atient *oer*es the analyst into assu)ing one of these roles 1hile the "atient assu)es the *o)"le)entary role0 As Ogden ,'985has stressed the "ressure to ena*t that is inherent in "ro@e*ti/e identifi*ation interferes 1ith one6s *a"a*ity to )aintain an analyti* s"a*e and refle*t on 1hat is ha""ening bet1een analyst and "atient0 Desear*h by +onagy et al0 ,'99'a '99'b- has been of *onsiderable heuristi* /alue in "ro/iding a de/elo")ental understanding of this *olla"se of analyti* s"a*e !hese in/estigators found that ex"e*tant "arents6 )ental )odels of atta*h)ent "redi*t subse4uent "atterns of atta*h)ent bet1een infant and )other and bet1een infant and father0 Ea*h "arent has an internal 1or#ing )odel of relationshi"s that a""ears to deter)ine a "ro"ensity to for) se*ure(as o""osed to inse*ure( atta*h)ents in their *hildren0 =oreo/er the )other6s *a"a*ity to refle*t on the )ental state of another hu)an being a""ears to be a "redi*tor of the e/ol/ing relationshi" bet1een infant and "arent be*ause refle*ti/e self fun*tion see)s to "re/ent intergenerational trans)ission of inse*ure atta*h)ent0 +onagy defined reflective self function as the .*a"a*ity to thin# of their o1n and others6 a*tions in ter)s of )ental states F >that is the? ability to in/o#e )ental state *onstru*ts; feelings beliefs intentions *onfli*ts and other "sy*hologi*al states2 ,"0 2<'-0 7n other 1ords "arents 1ho *an use *onstru*ts li#e internal re"resentations of atta*h)ent relationshi"s are three or four ti)es )ore li#ely to ha/e se*ure *hildren than "arents 1hose refle*ti/e *a"a*ity is "oor0 !his resear*h on trau)a and atta*h)ent )ay hel" us understand so)e of the diffi*ulties in "sy*hoanalyti* treat)ent 1ith se/erely trau)ati8ed "atients0 So)e indi/iduals 1ho ha/e had se/ere *hildhood trau)a are unable to thin# refle*ti/ely about the)sel/es and about relationshi" ex"erien*es i e they *annot .)entali8e02 !hey *o"e 1ith the intolerable "ros"e*t of *on*ei/ing of the )ental state of their tor)entors through a defensi/e disru"tion of de"i*ting feelings and thoughts ,+onagy '993- !hey a/oid thin#ing about thin#ing Hen*e borderline "atients often la*# a**urate and detailed i)"ressions of affe*ti/e and *ogniti/e *ontent0 But there re)ains the en*ouraging "ossibility that abused *hildren 1ho *an )aintain refle*ti/e self fun*tion often through the assistan*e of a *aring adult )ight a/oid de/elo"ing se/ere "sy*ho"athology0 7n the "sy*hoanalyti* treat)ent of the adult borderline "atient this la*# of self(refle*ti/e fun*tion *ontributes to the fre4uent *on*reteness en*ountered in "sy*hoanalysis and to the absen*e of the .as if2 nature of the transferen*e !he loss of analyti* s"a*e and the .as if2 1ithin the transferen*e )ay result in intense affe*t states su*h as rage in the "atient 1ho ex"e*ts that the analyst should lo/e hi) or her as a "arent 1ould 7n extre)e *ases "aranoid rea*tions )ay lead the "atient to 4uit the treat)ent entirely !his understanding of the i)"a*t of trau)a 1hi*h deri/es both fro) e)"iri*al studies of *hildren and fro) the *ru*ible of *lini*al 1or# suggests so)e de*isi/e "ro"hyla*ti* )easures that *an be ta#en !here a""ears to be extraordinary /alue in ha/ing the trau)ati8ed *hild6s ex"erien*e /alidated affe*ti/ely and /erbally by "ri)ary *areta#ers or other signifi*ant adults0 !he ex"erien*e of being lo/ed /alidated and .held2 in the Winni*ottian sense of the 1ord a""ears to ha/e a "o1erful "ro"hylaxis against the se4uelae of trau)a0 !he "arents6 refle*ti/e self fun*tioning )ay not only "re/ent intergenerational trans)ission of negati/e ex"erien*es it )ay e/en )odify the de/elo")ent of "athologi*al internal 1or#ing )odels through intera*tions 1ith *aring and bene/olent ne1 figures0 Positi/e ex"erien*es of this nature )ay ex"lain 1hy so)e "atients 1ith sexual abuse histories retain the .as if2 in the transferen*e and re4uire little )odifi*ation of te*hni4ue0 !he *o)"lexity of this intergenerational )odel suggests that 1e need to be 1ary about o/ersi)"lified for)ulations that )a#e a straightfor1ard *ause(effe*t lin# bet1een sexual trau)a and *olla"se of analyti* s"a*e0 Clearly the 1ay the sexual abuse is *ontextuali8ed and handled by both *hild and signifi*ant adults has a great deal to do 1ith the ulti)ate out*o)e0 7n a si)ilar /ein it 1ould be erroneous for us to )a#e a redu*ti/e lin# bet1een sexual trau)a and borderline "ersonality disorder

=any "atients 1ith that diagnosis do not ha/e a history of sexual trau)a and e)"iri*al resear*h suggests that )any other "sy*hodyna)i* and biologi*al fa*tors )ay be in/ol/ed in the etiology and "athogenesis0 While the fo*us on the *olla"se of the analyti* s"a*e is "ri)arily on the "atient6s *olla"se it should be a""arent that the analyst )ay also find that his or her refle*ti/e *a"a*ity is se/erely *o)"ro)ised 1hile in the throes of intense "ro@e*ti/e identifi*ations that see) to "ress for so)e for) of *o)"elling a*tion Hen*e )any analysts find that they si)"ly *annot thin# *learly and analyti*ally in the fa*e of heated transferen*es by the se/erely trau)ati8ed "atient

2. Victim Role as Bedrock

Another reason that "sy*hoanalysts )ay find adult "atients 1ith histories of *hildhood sexual abuse to be unsuitable for analyti* treat)ent is that the "athogenesis in/ol/ed is *ontrary to that of the )odal neuroti* "atient as *lassi*ally understood0 7nstead of a )e*hanis) in/ol/ing intra"sy*hi* for*es that a*ti/ely o""ose one another the )odel is one of defi*it0 Passi/ely ex"erien*ed trau)a related to sadisti* ex"loitati/e beha/iour by adults and failures of other adults to inter/ene are )ore rele/ant than internali8ed )oral *onde)nation of the "atient6s infantile longings ,$illing)o '989-0 7n )y ex"erien*e as a su"er/isor and *onsultant to other analysts and in )y o1n *lini*al 1or# 1ith "atients 1ho ha/e had so)e history of *hildhood sexual abuse 7 ha/e seen a tenden*y for treat)ents to rea*h a stale)ate around the "atient6s ex"erien*e as a "assi/e /i*ti) of trau)a0 =any "atients "er*ei/e this notion of 1ho they are as bedro*#0 !hey do not /ie1 the analysis as a tool for )ining the ore 1ithin and ex"loring s"e*ifi* )eanings that the trau)a )ay ha/e had to the)0 !his sense of rea*hing a dead end in both analyst and "atient is often a**o)"anied by the "atient6s *on/i*tion of being bad and beyond rede)"tion0 A subgrou" of "atients )ay be *on/in*ed that sui*ide is the only real o"tion be*ause they are irre"arably da)aged0 Hen*e analysts 1ho find the)sel/es *ast in the role of res*uer of the "atient/i*ti) ex"erien*e a sense of futility as their atte)"ts to sa/e the "atient are th1arted by the "atient6s *on/i*tion of being unsal/ageable !he #ey to brea#ing su*h i)"asses in/ol/es re*ogni8ing that the role of /i*ti) is not bedro*# and that the "athology is not li)ited to a defi*it )odel0 Befi*it and *onfli*t regularly *oexist in trau)ati8ed "atients and one soon learns that the "atient6s feelings of irredee)able badness are inti)ately *onne*ted 1ith una**e"table longings and 1ishes0 As Eagle ,'98<- has noted .We are )ost *onfli*ted in the areas in 1hi*h 1e are )ost de"ri/ed2 ,"0 '3&-0 !he /i*ti) role )ay be an elaborate defen*e designed to "re/ent the "atient fro) re*ogni8ing the a*ti/e longings beneath the surfa*e ,:e/ine '99&-0 !here )ay be *o)"lex )ixtures of destru*ti/e and eroti* 1ishes to1ard the abuser and these )ay ha/e been a*ti/ated 1ithin the transferen*e as 1ell0 Psy*hoanalysis fo*uses "ri)arily on 1hat the "atient is a*ti/ely doing to "er"etuate "ast "atterns in the "resent0 Hen*e the analyst )ust get beyond the "atient6s "reo**u"ation 1ith the trau)a of the "ast and de)onstrate to the "atient ho1 it is un*ons*iously being re(*reated in the "resentGin both the transferen*e situation and analogous settings outside the transferen*e0 7n a re*ent re*onsideration of +rau E))y /on 9 +reud6s first *ase of hysteria Bro)berg ,'99%- )ade the follo1ing obser/ation; .We do not treat "atients su*h as E))y to *ure the) of so)ething that 1as done to the) in the "ast; rather 1e are trying to *ure the) of 1hat they still do to the)sel/es and to others in order to *o"e 1ith 1hat 1as done to the) in the "ast2 ,"0 A&-0

!. "isidentification #ith the A$$ressor in the Countertransference

!he "atient6s un*ons*ious 1ish to stay .stu*#2 as a /i*ti) of "ast trau)a )ay effe*ti/ely defend against destru*ti/e fantasies in the "resent0 !his "osture )ay be )irrored by the analyst6s 1ish to a/oid identifi*ation 1ith the abuser fro) the "atient6s "ast0 !his disidentifi*ation 1ith the aggressor ,Gabbard in "ress- )ay be fuelled by the analyst6s deter)ination to )a#e u" for the "atient6s *hildhood trau)a by be*o)ing the "erfe*t "arent in the "resent0 Often a**o)"anying the "atient6s in*a"a*ity to 1or# 1ithin an analyti* s"a*e is a de)and for *on*rete de)onstrations of lo/e fro) the analyst0 !he )essage is often so)e /ariation of the follo1ing0 .Hour atte)"t to understand )e and assign )eaning to )y trau)ati* ex"erien*e is your agendaGnot )ine0 What 7 need is lo/e fro) so)ebody 1ho) 7 *an trust and *ount on02 SIndor +eren*8i is "erha"s the )ost 1ell(#no1n exa)"le of an analyst 1ho too# this )essage at fa*e /alue and tried to res"ond to it0 Con/in*ed that )any of the "atients he sa1 1ere /i*ti)s of se/ere *hildhood trau)a +eren*8i atte)"ted to "ro/ide the) 1ith the lo/e they longed for in ho"es of re"airing the da)age fro) *hildhood abuse and negle*t0 He *hara*teri8ed his a""roa*h as follo1s; .!o )eet the "atient as far as "ossible 1ith al)ost inexhaustible "atien*e understanding good 1ill and #indness2 ,'93' "0 '32-0 +eren*8i6s efforts to a/oid be*o)ing the abusi/e ob@e*t for the "atient in the transferen*e by fulfilling the "atient6s ardent 1ishes for a lo/ing "arent 1ere

*onta)inated ho1e/er by his gro1ing a1areness do*u)ented in his diary that he 1as des"erately fending off hate; .!he "atient6s de)ands to be lo/ed *orres"onded to analogous de)ands on )e by )y )other0 7n a*tual fa*t and in1ardly therefore 7 did hate the "atient in s"ite of all the friendliness 7 dis"layed2 ,Bu"ont '988 "0 99-0 +eren*8i 1as dis*o/ering that the "atient 1ho has been sexually abused as a *hild un*ons*iously de)ands an ongoing atta*h)ent to an ob@e*t of hate des"ite +eren*8i6s atte)"t at .all(*on4uering lo/e2 ,+ried)an '995 " 9%5-0 Be*ause it )ay be a*utely un*o)fortable for the analyst to inhabit the role of the hated abusi/e ob@e*t the analyst )ay "arti*i"ate in a s"litting )anoeu/re in 1hi*h a "er"etrator fro) the "ast is regarded as deser/ing un)itigated hatred 1hile the analyst in the "resent be*o)es the re*i"ient of the "atient6s 1ish for a "erfe*t lo/e that 1ill *o)"ensate for the horrifi* )istreat)ent in the distant "ast0 As +ried)an ,'995- has "ointed out in a dis*ussion of +eren*8i6s diary ho1e/er in this s*enario the analyst ulti)ately be*o)es "erse*uted by the "atient6s 1ish for lo/e0 +eren*8i found hi)self tor)ented by the in*reasing de)ands of his "atient to the "oint 1here he 1as doubling the nu)ber of sessions going to a "atient6s house instead of for*ing her to *o)e to hi) and e/en ta#ing her on /a*ation tri"s 1ith hi)0 At least +eren*8i 1as ulti)ately able to re*ogni8e the hatred de/elo"ing 1ithin hi)0 Other analysts )ay be*o)e *o)"letely obli/ious to their o1n aggression and sadis) as they es*alate their efforts to de)onstrate to the "atient that they are not li#e the abusi/e "arent and genuinely *are for the "atient !his effort )ay in/ol/e a /ariety of boundary /iolations in*luding ex*essi/e self(dis*losure not *harging the "atient and e/en "hysi*ally holding the "atient0 !his boundaryless for) of treat)ent is often rationali8ed by regarding the "atient as a defi*it(ridden indi/idual 1ho re4uires a .real relationshi"2 1ith the analyst to i)"ro/e 7ntra"sy*hi* *onfli*t is denied and a *ollusion often exists bet1een analyst and "atient to s"lit off or disa/o1 any *onfli*t or aggression 1ithin the dyad0 7n the 1orst s*enario the "atient is re/i*ti)i8ed sexually under the guise of trying to "ro/ide .lo/e2 for the "atient or res*uing the "atient fro) sui*ide ,Gabbard and :ester '995-0 As 7 ha/e des*ribed else1here ,Gabbard '99<; Gabbard and Wil#inson '99<- this de/elo")ent re"resents an externali8ation of an internal *onfli*t bet1een an abuser intro@e*t and a self( re"resentation of /i*ti)0 7nstead of feeling "erse*uted internally the "atient identifies 1ith the abuser and the analyst be*o)es identified 1ith the /i*ti) re"resentation and feels "erse*uted by the "atient0 !he role of the "erfe*t lo/ing healer is doo)ed to failure so it be*o)es a sour*e of "erse*ution to the analyst0 7 share +ried)an6s ,'995- /ie1 that in )any 1ays the essen*e of "ro/iding a holding en/iron)ent 1ith "atients 1ho are /i*ti)s of *hildhood sexual abuse has )ore to do 1ith )anaging the hatred in an o"en )anner than 1ith "ro/iding .lo/e02 Hatred be*o)es "erse*utory and destru*ti/e in the treat)ent "arti*ularly 1hen it is hidden and denied so the analyst 1ho atte)"ts to offer lo/e as an antidote to hate )erely "ushes the hate underground and intensifies its "erse*utory 4uality0 Het as $irshner ,'99<- has argued +eren*8i 1as onto so)ething i)"ortant regarding te*hni*al )odifi*ations in the treat)ent of trau)ati8ed "atients0 Be*ause the sy)boli* fun*tion of the internali8ed good ob@e*t has been da)aged by *hildhood trau)a these "atients )ay re4uire a*ti/e )easures fro) the analyst that other "atients )ay not0 7n other 1ords the basi* features of the "sy*hoanalyti* setting are not ex"erien*ed as safe enough for the "atient to reex"erien*e "ainful ordeals e/en 1ith the analyst6s hel" in fa*ilitating ne1 ob@e*t ex"erien*e0 Hen*e the analyst )ust stri/e for a )iddle(ground "osition 1here the "atient *an sense the analyst6s *on*ern and *aring but the analyst *an ne/ertheless deal forthrightly 1ith the abusi/e intro@e*t both in the "atient and as it surfa*es 1ithin the analyst through "ro@e*ti/e identifi*ation0 Sooner or later the "atient needs to understand ho1 he or she is identified 1ith the abusi/e intro@e*t 1ithin and has turned "assi/e into a*ti/e Analysts 1ho are out of tou*h 1ith their o1n aggression a*ti/ated by the "atient 1ill find it diffi*ult to assist the "atient6s 1or#ing(through in this area0 A /ignette fro) the analysis of a 35(year(old 1o)an 1ith a history of in*estuous relations 1ith her father )ay hel" to illustrate so)e of these te*hni*al *hallenges and the strategies used to deal 1ith those *hallenges0 !he "atient 1ho) 1e shall *all =s0 A0 1as )arried to a lo/ing and tolerant husband and had a fi/e(year(old daughter but she 1as haunted by )e)ories of the in*est and fre4uently *onte)"lated sui*ide be*ause she felt nothing 1ould e/er *hange0 After 2& )onths of analysis in 1hi*h she had fre4uently re*ounted the details of the in*est of 1hi*h she had *lear *ons*ious )e)ories throughout her life her /i*ti)i8ation had *o)e to be regarded as though it 1ere indeed .bedro*#2; I really can't see any reason to go on -othing changes I continue to have flashbac"s. I often a"e up ith nightmares. 'ometimes the flash&bac"s are so painful that I don't thin" I can get through them I don't ant to remember the pain, the fear, the shame, or the terror. I don't understand hy I have to "eep reliving these events and thin"ing about them I ish there as something you could do to #ust completely erase all memory from age ). on bac" 7 res"onded to her 1ish by in4uiring .Why age '2 in "arti*ularJ2

!he "atient *larified that her father had sto""ed the in*estuous relationshi" 1hen she began )enstruating0 She 1ent on to say I never "ne hen he as going to start up again I used to lie a a"e at night and orry that he might come in drun" and pic" up here he left off. I also orried constantly about my little sister, ho as five years younger, because I "ept thin"ing that she ould be the next victim %ut as far as I "no , he never touched her. I'd li"e to learn to live in the present so I ouldn't d ell on this all the time, but there's a part of me that feels li"e I can't shift any of this/that the hole retched experience has permanently altered me 'ometimes I feel li"e a bird repeatedly flying into a glass indo . 0ach time the bird gets bac" up, stunned, and repeats his mista"e, you onder ho long it ill ta"e the bird to understand the solidity of the glass and learn to fly over or around the house. I'm tired of banging into the indo . Why can't I see the glass$ What's the point in continuing li"e this$ has permanently altered me 'ometimes I feel li"e a bird repeatedly flying into a glass indo . 0ach time the bird gets bac" up, stunned, and repeats his mista"e, you onder ho long it ill ta"e the bird to understand the solidity of the glass and learn to fly over or around the house. I'm tired of banging into the indo . Why can't I see the glass$ What's the point in continuing li"e this$ 7 had gro1n in*reasingly frustrated at a feeling of being stu*# ,@ust as the "atient felt stu*#-0 7 too often 1ished 7 *ould erase the "atient6s )e)ory0 7 tried to hel" her see that 1hile the trau)a itself *ould not be erased it 1as "ossible for her to begin to thin# about it differently0 7 had established a fairly good thera"euti* allian*e 1ith her and =s0 A0 basi*ally felt that 7 1as a trust1orthy indi/idual 1ho 1as *on*erned about her0 Het her attitude about the treat)ent suggested an un*ons*ious negati/e transferen*e 1hi*h des"ite )y efforts to "oint out to her she 1ould re"eatedly disa/o10 !he follo1ing is a ty"i*al ex*hange; =s0 A0; 7 don6t thin# the treat)ent is hel"ing )e 7 feel li#e one 1ay or another 76ll "robably end u" a sui*ide Analyst; Hou )ust be /ery disa""ointed in )e then be*ause 7 ha/en6t been able to "ro/ide you 1ith the hel" that you 1ere ho"ing for0 =s0 A00 9o no 76) not disa""ointed 1ith you0 7t6s not your fault0 Hou6re doing the best you *ould ha/e done but 76) @ust not treatable0 Analyst What )a#es you thin# you6re untreatableJ =s0 A0; !here is so)ething funda)entally 1rong 1ith )e that *an6t be fixed0 !he only ans1er is sui*ide0 !oday a next(door neighbour got fed u" 1ith )e and told )e that 7 1as .a )ess02 7t sort of *onfir)ed the 1orst /ie1s about )yself0 She6s li#e )y only friend and e/en she *an6t stand )e0 7 @ust feel li#e sui*ide is the only ans1er0 Analyst; What6s )a#ing you sui*idal right no1J =s A0; E/erything0 Analyst; Can you be )ore s"e*ifi*J =s0 A0 Well 7 thin# 76) @ust tired Analyst; 7 thin# there6s "robably )ore to it than that0 Can you refle*t on 1hat 1ent on inside in rea*tion to 1hat your neighbour saidJ =s0 A0; Well 7 *an6t really re)e)ber anything s"e*ifi* 7 @ust feel 76d be better off dead be*ause then 7 1ouldn6t ha/e to thin# about the abuse any)ore0 7n the )iddle of this session 7 felt as 7 often did in these i)"asses 1ith her0 =y efforts to sear*h for s"e*ifi* )eanings in her sui*idal 1ishes 1ere )et 1ith a *olla"se of analyti* s"a*e0 7 also noted a gro1ing anger and resent)ent that she see)ed to genuinely th1art any effort 7 )ade to try to ex"and her understanding about 1hat she 1as ex"erien*ing inside0 As 7 sat behind the *ou*h engaging in )y internal re/erie 7 had the fantasy of telling her that 7 did not see )u*h "oint in *ontinuing 1ith the treat)ent sin*e she *ould not benefit fro) the insight 7 1as trying to "ro/ide her0 7 also found )yself dreading ea*h session and often starting late as a 1ay of trying to a/oid the blea# lands*a"e that 1e @ointly *reated in ea*h session0 7 ex"erien*ed her *onstant tal# of sui*ide in a /ery "ersonal 1ay as though she 1ere thu)bing her nose at )e and letting )e #no1 that nothing 7 had to offer 1as useful in the slightest 1ay0 7 found )yself *onstantly trying to "ersuade her that there 1as a reason to li/e0 7n the )idst of this i)"asse the follo1ing ex*hange o**urred; =s0 A0; 7 1as reading to )y daughter last night before bedti)e She6s already reading and she hasn6t offi*ially started s*hool Analyst; Hour /oi*e brightens 1hen you tal# about her0 Hou *learly get a lot of gratifi*ation out of your ti)e 1ith her0 =s0 A0; 7 thin# you6re going to try to tal# )e out of sui*ide again0 Analyst; Hou don6t thin# that she )a#es your life 1orth1hileJ =s0 A0; 7 *an6t thin# about that0 =y husband #ee"s bugging )e about sex and 7 @ust *an6t bear to go through the )otions again tonight0 7 get nothing out of it0 Analyst; 7t sounds li#e you don6t 1ant to deal 1ith the 4uestion 7 raised about your relationshi" 1ith your daughter =s0 A0; Bo you find )e frustratingJ

Analyst So)eti)es 7 do0 So)eti)es 7 feel li#e 1e get into argu)ents in 1hi*h you ta#e the "osition that your *urrent life is not gratifying enough to go on li/ing and that you should #ill yourself be*ause of bad things that ha/e ha""ened to you in the "ast that are *ontinuing to haunt you0 7 then ta#e the "osition that your "resent life is re1arding and that it re"resents a reason to li/e0 =s0 A Hes 7 #no1 1e go round and round about that Analyst; But you don6t a*tually atte)"t sui*ide 1hi*h suggests to )e that at least "art of you shares )y "osition that your daughter is 1orth li/ing for0 7 ha/e the feeling that you ta#e your internal *onfli*t and externali8e it into an argu)ent in 1hi*h 7 ta#e one side of the *onfli*t and you ta#e the other =s0 A0; 7 do 1ant to see her gro1 u" and 7 don6t 1ant to hurt her 7 @ust *an6t stand to ha/e that a)bi/alen*e 1ithin )e0 76d rather )a#e you into the one 1ho has to sto" )e fro) doing it0 76) also terribly afraid to feel o"ti)isti* or ho"eful be*ause e/ery ti)e that has ha""ened in )y entire life so)ething terrible follo1s0 Analyst !hat 1as true in the "ast but in the last ten years or so things ha/e gone "retty 1ell for you0 =s0 A0; 7 1ish 7 *ould li/e in the "resent but 7 *an6t0 76) stu*# in the "ast0 7n this inter*hange 1e see one of the )a@or resistan*es to any "ositi/e *hange in the treat)ent of su*h "atients0 As Bro)berg ,'99%- has noted the anti*i"ation of )isfortune )ay be the "ri)ary 1ay that these "atients "rote*t the)sel/es fro) the "ossibility of future trau)a0 !he "atient "re"ares herself for an a)bush that she is *ertain 1ill *o)e es"e*ially if she starts to feel safe or ho"eful !his "osture 1ill not "re/ent the trau)a fro) ha""ening but at least it "re/ents unexpected trau)a fro) o**urring ,Bro)berg '99%-0 Hen*e any a""earan*e of i)"ro/e)ent in the "ro*ess )ay be "er*ei/ed by the "atient as false ho"e0 !his inter*hange also de)onstrates ho1 dire*tly addressing as"e*ts of the aggression in the analyti* dyad "arti*ularly by noting )y frustration in res"onse to her obser/ation of it led to a useful dis*ussion of *onfli*t !he inter"retation of the *onfli*t as an externali8ation of an intra"sy*hi* a)bi/alen*e hel"ed her to get in tou*h 1ith other as"e*ts of *onfli*t in her "er*e"tion that she 1as stu*#0 !1o sessions later the follo1ing inter*hange o**urred0 Analyst; 7 ha/e the feeling that you are so)eho1 in/ested in staying .stu*#02 !here6s a "art of you that 1ould "refer that the )e)ories not be erased =s0 A0; 7 don6t #no1 ho1 you *an say thatK Hou don6t ex"erien*e the horrendous flashba*#s0 Analyst Be that as it )ay 7 ha/e the i)"ression that you don6t 1ant to )ourn 1hat ha""ened and )o/e on to li/ing in the "resent 7t )a#es )e 1onder if in so)e 1ay you felt /ery s"e*ial to your father and are relu*tant to gi/e that u"0 =s A0; >after a "ause? On*e in a 1hile 1hen he 1as in a good )ood he 1ould ta#e )e do1nstairs and )a#e lo/e to )e in the 1ay a husband )a#es lo/e to a 1ife0 7nstead of being for*eful or 4ui*# or /iolent li#e he usually 1as es"e*ially 1hen he 1as drun# he 1as tender and he 1ould *aress )e0 E/en though it 1as in*redibly "ainful it so)eho1 )ade )e feel extre)ely s"e*ial to hi)0 7 1ish 7 *ould @ust hate hi) but there is a *onfli*t here that 7 *an6t get rid of0 +or so)e reason 7 also felt lo/ed by hi)0 He al1ays told )e that 7 1as the "rettiest girl in the neighbourhood and that he lo/ed )e )ore than he lo/ed =o)0 =o) 1anted nothing to do 1ith )e0 When 7 brought ho)e a straight(A re"ort *ard she 1ould stare at it blan#ly li#e she didn6t gi/e a da)n0 She had to #no1 1hat 1as going on but she didn6t do anything0 One ti)e 1hen 7 1as nine )y father bought me a ne dress and anted me to go do n to the basement 1ith hi) As 7 1ent do1n the stair1ay 7 loo#ed ba*# at )y )other6s fa*e and 7 *ould tell by the 1ay she loo#ed that she #ne1 1hat 1as going on bet1een )e and Bad0 7t )ade )e furious that she 1ouldn6t do anything to sto" 1hat 1as ha""ening0 +or the longest ti)e it ne/er o**urred to )e that she )ight be @ealous be*ause 7 @ust assu)ed that Bad only had sex 1ith )e not 1ith =other When 7 told the nun 1ho !his "arti*ular session 1as a turning("oint in the analyti* 1or# be*ause she 1as finally able to shift fro) the /i*ti)(as(bedro*# role and be*o)e )ore refle*ti/e about the nature of the intra"sy*hi* *onfli*t that sustained her )isery0 As long as she held onto the "ast and felt stu*# she retained the s"e*ialness e/en though it 1as a**o)"anied by "ainful feelings of selfloathing0 7 1as then able to inter"ret to her that she had re*reated in the transferen*e a situation )u*h li#e that 1ith her )other0 7n other 1ords 7 1as no1 the )other 1ho #ne1 about the in*est and her suffering but *ould do nothing to sto" it 7 1ould @ust sit idly by 1hile she *ontinued to be tor)ented by /i/id )e)ories of the "ast0 By re)aining stu*# she re*reated the *hildhood situation in the *onsulting roo) but had for )any )onths refused to refle*t on it as analogous to so)ething in the "ast0 =y "ersistent efforts to loo# at )eaning in her sui*idality e/en 1hen she resisted finally su**eeded in "rying o"en so)e analyti* s"a*e0 By fo*using on 1hat 1as going on bet1een us and "arti*ularly the *onfli*t that had been externali8ed she 1as able to .)entali8e2 )ore *learly and de/elo" the refle*ti/e self fun*tion that "er)itted her to i)agine that 7 1as be*o)ing frustrated 1ith her and to e)"athi8e 1ith )y ex"erien*e0 E/entually she *ould see that at so)e le/el she 1anted )e to gi/e u" on her as her )other did so she and her father *ould "reser/e the s"lendid isolation of the dyad 1ithout a third "arty interfering0 She *a)e to re*ogni8e that the analyti* situation itself re"li*ated the abusi/e situation fro) *hildhood in that it raised a ho"e for *ure that to her 1as a false ho"e0 A0 "art of her sa1 )e as sadisti*ally *reating a situation in 1hi*h the hunger for an all(lo/ing figure 1ould

on*e again be a*ti/ated 1hile on*e again being frustrated She *ould also a*#no1ledge the fli" side of this situationGin 1hi*h 7 felt "erse*uted by her tena*ious atta*h)ent to the hated ob@e*t of the "astG1hile th1arting )y efforts to be hel"ful0

%. The &imits of Interpretation

7n re*ounting this frag)ent of the analyti* 1or# 1ith =s A 7 fo*used on the i)"asse and the shift fro) a fixed /i*ti) "osition based on a defi*it )odel to a )ore *onfli*t(ridden internal 1orld that resisted the analyti* 1or#0 7n so doing 7 o)itted a long "eriod in 1hi*h 7 1or#ed on de/elo"ing a sense of safety so the analyti* "ro*ess *ould unfold and so the "atient 1ould /ie1 )e as so)eone 1ho /alidated her ex"erien*e0 7n this long "reli)inary "hase of the analyti* 1or# inter"retations 1ere not 1el*o)e and )u*h of )y 1or# 1as in an affir)ati/e /ein in the ser/i*e of *onstru*ting a sy)boli* good ob@e*t for her $illing)o ,'989- has stressed that affir)ati/e inter/entions are ne*essary for the defi*it as"e*ts of "athology 1hile inter"retation )ay be )ore suited to *onfli*tual as"e*ts0 Confli*t(based "athology re/ol/es around a *on*ealed )eaning that the analyst tries to re/eal to the "atient in the *ourse of the analyti* 1or#0 7n the early "hases of treat)ent ho1e/er adult "atients 1ho 1ere sexually abused as *hildren )ay be un1illing and uninterested in for)ing an allian*e to un*o/er or ex"ose *on*ealed )eanings0 Su*h "atients are li#ely to hear inter"retations as a**usations atta*#s or )isunderstandings0 =s0 A for exa)"le a""roa*hed the beginning of the analysis 1ith the ex"e*tation that she 1ould not be belie/ed or that 7 1ould see her as uns"ea#ably a1ful )u*h in the 1ay the nun at s*hool had res"onded0 =any of )y inter/entions 1ere geared to affir)ing that she had a right to feel the 1ay she did0 7n this sense the "atient felt that her /ery existen*e 1as /alidated0 As $illing)o ,'989- noted .By *onfir)ing exa*tly the 1ay the "atient is feeling the analyst relates to the )ost urgent need of the "atient of defi*it that is the need to feel that L7 a)M and that L7 ha/e the right to beM2 ,"0 A%-0 !he ai) of the affir)ati/e inter/ention is to re)o/e doubt ,$illing)o '995-0 !rau)ati8ed "atients often ex"erien*e early inter"retations as doubt a *hallenge to their sense of reality0 7n other 1ords if the analyst says .What you really are feeling is anger not sadness 2 they feel as though their reality is not being res"e*ted and /alidated0 By affir)ing the ex"erien*e the analyst allo1s "atients to feel that their reality is a*#no1ledged 1hi*h then allo1s a stronger *onne*tion to the analyst0 !his *autionary note about inter"retation )ay a""ly "arti*ularly to those based 1ithin the transferen*e0 7n the =enninger !reat)ent 7nter/ention Pro@e*t ,Gabbard et al '99<- 1e studied audiota"ed trans*ri"ts of "sy*hoanalyti* "sy*hothera"y 1ith borderline "atients0 We noted that a)ong "atients 1ith early ex"erien*es of trau)a transferen*e inter"retation of the "atient6s aggression *aused the thera"euti* allian*e to deteriorate0 !his de*line in the *onne*tion bet1een "atient and thera"ist a""eared to relate to the "atient6s "er*e"tion that the thera"ist did not re*ogni8e that real tor)entors 1ere in/ol/ed0 By *ontrast e)"athi* /alidation and affir)ation of the "atient6s transferen*e "er*e"tion of aggression i)"ro/ed the allian*e0 =s0 A0 had *lear *ons*ious )e)ories of in*est through her entire lifeti)e and to *hallenge the) 1ould ha/e been to *all her a liar and da)age any "ossibility of a thera"euti* allian*e0 An affir)ation that hel"s solidify the allian*e and re)o/e doubt de"ends on the tone of /oi*e as )u*h as the 1ords ,$illing)o '995- and falls in the *ategory of the a*ti/e )easures ad/o*ated by $irshner and others that are ne*essary for trau)ati8ed "atients to feel .held2 in the analyti* setting0 =any "atients 1ith histories of *hildhood sexual abuse ha/e nu)erous ex"erien*es of being told that reality is different fro) 1hat they thin# and that they are distorting 1hat really ha""ened0 While affir)ati/e inter/entions )ay see) )ore su""orti/e than analyti* they )ay be ne*essary to laun*h an analyti* "ro*ess0 A#htar ,'992- has stressed that su*h inter/entions *an be )ade fro) a relati/ely neutral "osition and do not i)"ly any s"e*ial indulgen*e of the "atient0 9ot only do they strengthen the thera"euti* allian*e they also )a#e the "atient ulti)ately )ore a)enable to inter"retations0 !he balan*e of affir)ati/e and inter"reti/e inter/entions in A#htar6s /ie1 refle*ts the flu*tuation in the analyti* setting bet1een addressing the "atient6s needs and the "atient6s ishes0 =oreo/er 1ith the .1idening s*o"e2 "atient there is a gro1ing a*#no1ledge)ent of the need for su""orti/e inter/entions to *reate a *li)ate for inter"retation ,Gabbard et al0 '99< Hor1it8 et al0 '99%-0 7n Wallerstein6s ,'98%- final re"ort of the =enninger Psy*hothera"y Desear*h Pro@e*t he noted that all treat)ents e/en the )ost ex"ressi/e su*h as analysis are *hara*teri8ed by su""orti/e inter/entions at ti)es and 1e need to rethin# the "e@orati/e attitude 1ith 1hi*h 1e regard su*h su""orti/e inter/entions

'. The Veridicality of (emory

7n the *ase of =s0 A there 1as little 4uestion about the funda)ental fa*t of her trau)a be*ause she had *ontinuous )e)ories of )any instan*es of in*estuous a*ti/ity and for the )ost "art had not disso*iated or re"ressed these e/ents0 With other "atients ho1e/er there )ay be /arying degrees of a)nesia or frag)entary )e)ory that lea/e the "atient 1ith a great deal of doubt about the /era*ity of her )e)ories of trau)a0 !he analyst )ay si)ilarly be filled 1ith doubt0 Whether or not )e)ories of trau)a are a**urate has unfortunately be*o)e the *entre"ie*e of a highly "oliti*i8ed debate 1ithin our field0 !he "olari8ation of this issue into an .eitherNor2 *ontro/ersy is totally unne*essary and ignores the broad )iddle ground 1here )ost of us reside as "sy*hoanalyti* *lini*ians0 =e)ory is *onstantly re/ised through ea*h subse4uent de/elo")ental "hase0 As 9o/i*# and 9o/i*# ,'99<- ha/e argued .!he "ast transfor)s and is transfor)ed by the "resent2 ,"0 '%%-0 As =odell ,'99%- has indi*ated this "oint of /ie1 is *onfir)ed by the 1or# of the 9obel Pri8e(1inning neurobiologist Gerald Edel)an ,'992-0 =e)ory is definitely not a fixed re*ord of ex"erien*e inextri*ably e)bedded in the 1ay fil) re*ords an e/ent0 Dather it is li#e a theatri*al "rodu*tion in 1hi*h ea*h run(through of the "lay is so)e1hat different fro) the "re/ious one as the "lay e/ol/es0 !here is no "ure re*a"itulation or re/i/al of the "ast only re*onstru*tions based on indi/idual )eanings that the "atient attributes to the e/ent0 =e)ories )ay also be true but ina**urate ,Bar#ley '98%-0 As S"iegel and S*heflin ,'99<suggested .7t is illogi*al to reason fro) the fa*t that a )e)ory has false details to the *on*lusion that there is no real incident fro) 1hi*h this false )e)ory is an ina**urate de"i*tion2 ,"0 <'2-0 Per*e"tion and )e)ory are al1ays a*ti/e "ro*esses of *onstru*tion0 We *annot i)agine a )e)ory that is not influen*ed by the obser/er0 Hen*e there is a 1ide s"e*tru) of a**ura*y in )e)ories that 1e see *lini*ally0 !hese 1ould range fro) the totally false )e)ory indu*ed by thera"ists 1ho are either "oorly trained or uns*ru"ulous to reasonably a**urate )e)ories in 1hi*h the details are )ore or less inta*t0 Bet1een these t1o extre)es 1e 1ould see a *ontinuu) in/ol/ing /arying degrees of a**ura*y ,Allen '995As +reud noted in his *lassi* '9'< "a"er .De)e)bering De"eating and Wor#ing(!hrough 2 1hat *annot be re)e)bered is re"eated in the analyti* setting0 +reud used the ter) acting out here to )ean the re"etition of 1hat 1e no1 *all "atterns of un*ons*ious internali8ed ob@e*t relations that are not a/ailable to *ons*ious a1areness0 9e1 resear*h on )e)ory sheds ne1 light on +reud6s "rofound *lini*al obser/ation0 =e)ory resear*hers ha/e identified t1o different syste)s of )e)ory0 ex"li*it or de*larati/e )e)ory and i)"li*it or nonde*larati/e )e)ory0 !he latter is *onditioned e)otional )e)ory that is not related to intentional re)e)bering is "resent fro) birth and is lin#ed to habits and s#ills Su*h )e)ories *an be e/o#ed by strong affe*ts or other situational *ues and ex"ressed through i)ages feelings or beha/iours ,S4uire '992- 7n *ontrast de*larati/e or ex"li*it )e)ory is *onne*ted 1ith /erbal sy)bol for)ation and is the ty"e of )e)ory lin#ed to autobiogra"hi*al e/ents and fa*ts0 7n other 1ords 1hen a *lini*ian is deter)ining the /eridi*ality of a )e)ory it is an ex"li*it or de*larati/e )e)ory that is in 4uestion be*ause narrati/e or autobiogra"hi*al details fall under that *ategory0 Ex"li*it or de*larati/e )e)ory is also a**essible to *ons*ious re*olle*tion !rau)ati* reena*t)ents a""ear to be dri/en by i)"li*it )e)ory ,Segal '995-0 7n*luded in this *ategory 1ould be )any of the transferen*e(*ountertransferen*e ena*t)ents that +reud 1as referring to 1hen he said that )e)ories are re"eated rather than /erbali8ed and ex"lored !he #ind of data that unfold in the "sy*hologi*al dra)a bet1een analyst and "atient are not readily a/ailable through other )eans0 !hrough "ro@e*tion and intro@e*ton bet1een analyst and analysand the analyst has a uni4ue "ers"e*ti/e on the internal 1orld and the "ast of the "atient0 7n fa*t it is a*tually in*o)"lete to refer to )e)ories of trau)a as being re"ressed or disso*iated0 As +airbairn ,'952stressed .What are "ri)arily re"ressed are neither intolerably guilty i)"ulses nor intolerably un"leasant )e)ories but intolerably bad internali8ed ob@e*ts2 ,""0 %2(%3-0 7 1ould add to +airbairn6s *o))ent that 1hat is often erased fro) *ons*iousness is intolerably bad internali8ed ob@e*t relations0 !he horrifi*ally "ainful /ie1s of self and other )a#e the "atient resist /erbal sy)boli* )e)ory of 1hat ha""ened but in the unfolding dra)a ta#ing "la*e in the transferen*e(*ountertransferen*e these "atterns are re"eated )a#ing the) a**essible to analyti* refle*tion0 7n )y ex"erien*e as an analyst and a su"er/isor of other analysts one of the )a@or "roble)s 7 ha/e en*ountered in the treat)ent of sexually abused "atients is an ar*haeologi*al a""roa*h to the origins of the trau)a in 1hi*h the analyst digs into the buried "ast sear*hing for *on/in*ing reli*s of that trau)a0 !his a""roa*h )ay *ollude 1ith 1hat Bro)berg ,'99%- has ter)ed the "atient6s .fore*losure of the Lhere(and(no1M on behalf of the Lthere(and(then2M ," A&-0 A "reo**u"ation 1ith 1hat .really2 ha""ened *an derail the 1hole "ro*ess0 A gli)"se of 1hat ha""ened is being ena*ted in the *onsulting roo) and no ex*a/ation is re4uired to study it =ental )odels of relationshi"s in/ol/ing fear )istrust and abandon)ent are *reated by trau)a and re*a"itulated in the treat)ent setting ,Segal '995-0 =oreo/er the ar*haeologi*al sear*h is often a for) of *ountertransferen*e *ollusion 1ith the "atient to a/oid the "atient6s dire*t ex"ression of aggression or rage at the analyst and the

analyst6s identifi*ation 1ith the abusi/e intro@e*t0 7t is al1ays te)"ting to for) an allian*e 1ith the "atient by dire*ting hatred and aggression to1ard distant figures fro) the "atient6s "ast 1hile "reser/ing the analyti* relationshi" as an island of lo/ing ideali8ed understanding0 7n this )anner the analyst *an a/oid being the target of the rage that lur#s 1ithin the "atient0 One 1ay to *on*e"tuali8e the analyti* 1or# is to /ie1 the analyst as )a#ing the i)"li*it ex"li*it0 7n other 1ords the analyst obser/es and inter"rets the un*ons*ious ena*t)ents fuelled by e4ually un*ons*ious "atterns of internal ob@e*t relations0 As +onagy and !arget ,in "ress- ha/e e)"hasi8ed )e)ories *onsistent 1ith these "atterns )ay be se*ondarily a*ti/ated but the return of su*h )e)ories is best /ie1ed as )erely an e"i"heno)enon and the a**ura*y of those )e)ories is i)"ossible to as*ertain0 7n any *ase *hange in autobiogra"hi*al or ex"li*it )e)ory does not a""ear ne*essary for thera"euti* i)"ro/e)ent0 !he *riti*al fa*tor is the *hange in "atterns of li/ing 1ith oneself and others0 Degarding the /eridi*ality of the )e)ories that )ay surfa*e in the *ourse of analysis analysts )ust stri/e to a/oid "utting the)sel/es in the "osition of being arbiters of truth no )atter ho1 ardently the "atient 1ishes to ha/e the analyst in that role One si)"le fa*t )ust be #e"t in "lain /ie1G1e *an ne/er #no1 exa*tly 1hat ha""ened to our "atient 7ntense e)otionally *harged )e)ories that are /i/id 1ith i)agery are no )ore li#ely to be true than those that are /ague ,Brenneis '99< =ins#ey '98&-0 7n*idents of real trau)a )ay be e)bellished and transfor)ed in 1ays that )a#e )any of the details false0 When "atients li#e =s0 A0 ha/e *learly re)e)bered )e)ories of abuse that are lifelong 1e *an of *ourse e)"athi8e 1ith their ex"erien*e and ex"lore the s"e*ifi* "ersonal )eaning0 When )e)ories are )ur#ier the analyst *an still res"ond affir)ati/ely to the "atient6s affe*ti/e ex"erien*e and fran#ly a*#no1ledge that he or she *annot #no1 1ith *ertainty the a**ura*y of the fa*ts0

Conclusion
A *o)"onent of the .un*o))on sense2 that *hara*teri8es solid "sy*hoanalyti* 1or# in/ol/es the analyst6s *a"a*ity to res"ond *ounterintuiti/ely to the "atient 7n the *ase of the adult analysand 1ho has ex"erien*ed sexual abuse as a *hild *o)"elling for*es are at 1or# to dislodge the analyst fro) a "osition of refle*ti/e understanding !he "ressure to a*t instead of thin# to be*o)e entren*hed in a "erse*utor/i*ti) )odel of "athology that denies the autono)y and effi*a*y of the "atient and to be*o)e the real lo/e ob@e*t of the "atient to heal 1ounds fro) the "ast all need to be noted *ontextuali8ed and brought forth as "art of the analyti* dis*ourse0 A balan*e bet1een the @udi*ious use of affir)ation and inter"retation )ust be )aintained so that both *onfli*t and defi*it are addressed in the *ourse of treat)ent0 !he *onte)"orary analyst in other 1ords stri/es for a )iddle ground bet1een +reud and +eren*8i0 While the analyst )ust "ro/ide a good ob@e*t ex"erien*e and fa*ilitate the analyti* "ro*ess the ob@e*t "ro/ided *annot be .too good02 7n fa*t he or she )ust be .a bad enough ob@e*t2 ,Dosen '993so that the "atient *an reex"erien*e and 1or# through bad ob@e*t ex"erien*es fro) the "ast0 As illustrated in the *ase of =s0 A0 one 1ay the analyst be*o)es the aggressor is to fail the "atient @ust as a father or other signifi*ant figure )ay ha/e failed the "atient in the "ast !he "otential failure of the treat)ent )ay be a 1indo1 into the aggression and hatred *onne*ted 1ith internal ob@e*t relations bet1een abusers and /i*ti)s0 +inally the analyst )ust be able to fran#ly a*#no1ledge the li)its of 1hat he or she *an #no1 about the "atient6s *hildhood0 :i/ing 1ith the un#no1n is the analyst6s lot in life0 We )ust al1ays doubt0 7 a) 1ary 1hen 7 feel too sure of )yself and 7 find that a healthy s*e"ti*is) is an essential "art of the analyst6s role0 We )ust hel" our "atients to a**e"t that the truth about the self that they see# in the analyti* enter"rise is one that *ontains a /ariety of a)biguities and un*ertainties0 Su))ary Adult "atients 1ho *o)e to analysis 1ith se/ere se4uelae fro) *hildhood sexual abuse "resent the analyst 1ith *hallenges that in*lude ,'- the *olla"se of analyti* s"a*e ,2- the /i*ti) role as .bedro*# 2 ,3- the e/o*ation of "roble)ati* *ountertransferen*es in*luding disidentifi*ation 1ith the aggressor ,<- the li)its of inter"retation and ,5- the /eridi*ality of )e)ories0 O"ti)al "sy*hoanalyti* te*hni4ues to deal 1ith ea*h of these *hallenges are dis*ussed0 Clini*al /ignettes illustrate the strategies0 ' !his "a"er 1as originally "resented at the !hird Annual Bay in Psy*hoanalysis for the Ouebe* English Bran*h of the Canadian Psy*hoanalyti* So*iety .!rau)a De)e)bered !rau)a Cnre)e)bered 2 A"ril 2% '99%0 Deferen*es ' A#htar S0 ,'992-0 %ro"en 'tructures 'evere 1ersonality 2isorders and 3heir 3reatment 9orth/ale 9P0 Pason Aronson 0 2 Allen P0 G0 ,'995- !he s"e*tru) of a**ura*y in )e)ories of *hildhood trau)a0 4arvard 5ev 1sychiatry 3 8<(95

Bar#ley C0 D0 ,'98%- S*he)ati8ation of autobiogra"hi*al )e)ory0 7n Autobiographical 6emory ed B0 C Dubin0 9e1 Hor# Ca)bridge Cni/0 Press ""0 82(990 < Blu) H0 P0 ,'9A3- !he *on*e"t of eroti8ed transferen*e 7. Amer. 1sychoanal. Assn. 2' ; %'(A% ,APA0&2'0&&%'5 Bollas C0 ,'989- 8orces of 2estiny9 1sychoanalysis and 4uman Idiom 9orth/ale 9P0 Pason Aronson % Brenneis C0 Q0 ,'99<-0 =e)ories of *hildhood sexual abuse0 7. Amer. 1sychoanal. Assn. <2 ; '&2A(5< ,APA0&<20'&2AA Bro)berg P0 =0 ,'99%- Hysteria disso*iation and *ure E))y /on 9 re/isited0 1sychoanal. 2ial. % ; 55(A' ,PB0&&%0&&558 Cre1s +0 ,'995-0 3he 6emory Wars 8reud's :egacy in 2ispute 9e1 Hor#0 9e1 Hor# De/ie1 9 Ba/ies P0 =0 +ra1ley =0 G0 ,'992-0 Bisso*iati/e "ro*esses and transferen*e( *ountertransferen*e "aradig)s in the "sy*hoanalyti*ally oriented treat)ent of adult sur/i/ors of *hildhood sexual abuse 1sychoanal. 2ial. 2 ; 5(3% ,PB0&&20&&&5'& Bu"ont P0 ed0 ,'988-0 3he ;linical 2iary of '<ndor 8erenczi trans = Balint and 9 R0 Pa*#son Ca)bridge = A Har/ard Cni/ Press '' Eagle =0 ,'98<-0 5ecent 2evelopments in 1sychoanalysis. A. ;ritical 0va luation 9e1 Hor# =*Gra1(Hill 0 '2 Edel)an G0 ,'992- %right Air, %rilliant 8ire 9e1 Hor#0 Basi* Boo#s '3 +airbairn W0 B0 D0 ,'952- 1sychoanalytic 'tudies of the 1ersonality !a/isto*#NDoutledge :ondon and 9e1 Hor#0 ,RB$0&&A0&&&''< +eren*8i S0 ,'93'-0 Childhood analysis in the analysis of adults 7n 8urther ;ontributions to the 1roblems and 6ethods of 1sychoanalysis. :ondon Hogarth Press '955 "" '2%(<20 '5 +onagy P0 ,'993- Psy*hoanalyti* and e)"iri*al a""roa*hes to de/elo")ental "sy*ho"athology0 An ob@e*t relations "ers"e*ti/e 7. Amer. 1sychoanal. Assn. <' , su""l0 -0 2<5(%&0 ,APA0&<'0&2<5'% +onagy P0 Steele =0 =oran G0 Higgitt A0 C0 ,'99'a-0 !he *a"a*ity for understanding )ental states0 the refle*ti/e self in "arent as *hild and its signifi*an*e for se*urity of atta*h)ent Infant 6ental 4ealth 7. '3 0 2&&(2'% 'A +onagy P0 Steele =0 Steele H0 ,'99'b-0 =aternal re"resentations of atta*h)ent during "regnan*y "redi*t the organi8ation of infant()other atta*h)ent at one year of age0 ;hild 2ev. %2 88&(93 '8 +onagy P0 !arget =0 ,in "ress- !he re*o/ered )e)ory debate0 An e)"iri*al and "sy*hoanalyti*al "ers"e*ti/e 7. Amer. 1sychoanal. Assn. '9 +reud S0 ,'89%- !he aetiology of hysteria '. 0. 3 0 2& +reud S0 ,'9&5-0 !hree essays on the theory of sexuality0 '. 0. A 2' +reud S0 ,'9'<-0 De)e)bering re"eating and 1or#ing(through ,+urther re*o))endations on the te*hni4ue of "sy*ho(analysis 77-0 '. 0. '2 22 +reud S0 ,'93'- +e)ale sexuality0 '.0. 2' 0 23 +ried)an P0 A0 ,'995- +eren*8i6s *lini*al diary On lo/ing and hating Int. 7. 1sycho&Anal. A% 95A( A50 ,7PP0&A%0&95A2< Gabbard G0 O0 ,'992- Co))entary on .Bisso*iati/e "ro*esses and transferen*e( *ountertransferen*e "aradig)s2 by Pody =essler Ba/ies and =ary Gale +ra1ley 1sychoanal. 2ial. 2 ; 3A(<A ,PB0&&20&&3A25 Gabbard G0 O0 ,'99<-0 1sychodynamic 1sychiatry in ;linical 1ractice 3he 2'6&I= 0dition 0 Washington BC A)eri*an Psy*hiatri* Press 0 2% Gabbard G0 O0 ,'99%- :ove and 4ate in the Analytic 'etting0 9orth/ale 9P0 Pason Aronson 0 2A Gabbard G0 O0 ,in "ress-0 Bis*ussion of Boston Psy*hoanalyti* So*iety and institute *onferen*e on ."sy*hoanalysis and sexual abuse2 1sychoanal. In>. 28 Gabbard G0 O0 Hor1it8 :0 Allen P0 G0 +ries1y# S0 9e1so) G0 Colson B0 S Coyne :0 ,'99<-0 !ransferen*e inter"retation in the "sy*hothera"y of borderline "atients A high(ris# high( gain "heno)enon 4arvard 5ev 1sychiatry. 2 ; 59(%9 29 Gabbard G0 O0 :ester E0 P0 ,'995- %oundaries and %oundary =iolations in 1sychoanalysis 9e1 Hor#; Basi* Boo#s 3& Gabbard G0 O0 !1e)lo1 S0 W0 ,'99<-0 !he role of )other(son in*est in the "athogenesis of nar*issisti* "ersonality disorder 7. Amer. 1sychoanal. Assn. <2 ; '59(AA ,APA0&<20&'A'3' Gabbard G0 O0 Wil#inson S0 =0 ,'99<-0 6anagement of ;ountertransference ith %orderline 1atients0 Washington BC0 A)eri*an Psy*hiatri* Press 32 Hor1it8 :0 Gabbard G0 O0 Allen P0 G0 +ries1y# S0 H0 Colson B0 B0 9e1so) G0 E0 S Coyne :0 ,'99%- %orderline 1ersonality 2isorder9 3ailoring the 1sychotherapy to the 1attient Washington BC0 A)eri*an Psy*hiatri* Press 33 $illing)o B0 ,'989- Confli*t and defi*it 7)"li*ations for te*hni4ue0 Int. 7. 1sycho&Anal. A& %5(A9 ,7PP0&A&0&&%53< $illing)o B0 ,'995- Affir)ation in "sy*hoanalysis0 Int. 7. 1sycho&Anal. A% 0 5&3('8 ,7PP0&A%0&5&3-

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$irshner :0 A0 ,'99<-0 !rau)a the good ob@e*t and the sy)boli*0 A theoreti*al integration Int. 7. 1sycho&Anal. A5 ; 235(<2 ,7PP0&A50&2353% :ear P0 ,'99%-0 De/ie1 of !he =e)ory Wars; +reud6s :ega*y in Bis"ute by + Cre1s 7. Amer. 1sychoanal. Assn. << 58&(8A ,APA0&<<0&58&3A :e/ine H0 B0 ,'99&- Clini*al issues in the analysis of adults 1ho 1ere sexually abused as *hildren 7n Adult Analysis and ;hildhood 'exual Abuse ed H B :e/ine Hillsdale 9P0 Analyti* Press "" '9A(2'8 38 =ins#ey =0 ,'98&- ?&:ines A theory of memory ;ognitive 'cience. < ; ''A('3 39 =odell A0 H0 ,'99%-0 !rau)a )e)ory and the thera"euti* setting0 7n 6odes of 3herapeutic Action in 1sychotherapy and 1sychoanalysis ed : :ifson0 Hillsdale 9P0 Analyti* Press "" 23(32 <& 9o/i*# $0 $0 S 9o/i*# P0 ,'99<-0 Post(oedi"al transfor)ations :aten*y adoles*en*e and "athogenesis 7. Amer. 1sychoanal. Assn. <2 '<3(%9 ,APA0&<20&'<3<' Ogden !0 H0 ,'985- 3he 6atrix of the 6ind9 !b#ect 5elations and the 1sychoanalytic 2ialogue. 9orth/ale 9P0 Pason Aronson 0 <2 Ogden !0 H0 ,'989- 3he 1rimitive 0dge of 0xperience 9orth/ale 9P0 Pason Aronson 0 <3 Dosen 70 D0 ,'993-0 Delational )aso*his)0 !he sear*h for a bad(enough ob@e*t0 Presented to !o"e#a Psy*hoanalyti* So*iety Panuary 2' '993 << S*hafer D0 ,'992- 5etelling a :ife -arration and 2ialogue in 1sychoanalysis 9e1 Hor#0 Basi* Boo#s 0 <5 Segal B0 P0 ,'995-0 =e)ory trau)a and "sy*hothera"y 7 1sychother. 1rac 5es. < 0 93('22 <% Si)on B0 ,'992- .7n*est(see under Oedi"us Co)"lex20 !he history of an error in "sy*hoanalysis 7. Amer. 1sychoanal. Assn. <& 955(88 ,APA0&<&0&955<A S"iegel B0 S S*heflin A0 W0 ,'99<- Bisso*iated or fabri*atedJ Psy*hiatri* as"e*ts of re"ressed )e)ory in *ri)inal and *i/il *ases0 Inter 7 ;linical and 0xperimental 4ypnosis <2 ; <''(32 <8 S4uire :0 D0 ,'992-0 Be*larati/e and nonde*larati/e )e)ory =ulti"le brain syste)s su""orting learning and )e)ory0 7 ;ognitive -euroscience. < 232(<3 <9 Wallerstein D0 S0 ,'98%-0 8orty&3 o :ives in 3reatment A 'tudy of 1sychoanalysis and 1sychotherapy 9e1 Hor# Guilford 5& Winni*ott B0 W0 ,'9A9-0 1laying and 5eality0 9e1 Hor# Basi* Boo#s 0 ,RB$0&'A0&&&'-

!his "ubli*ation is "rote*ted by CS and international *o"yright la1sand its *ontent )ay not be *o"ied 1ithout the *o"yright holder6s ex"ress 1ritten "er)ission ex*e"t for the "rint or do1nload *a"abilities of the retrie/al soft1are used for a**ess0 !his *ontent is intended solely for the use of the indi/idual user0 Canadian Pournal of Psy*hoanalysis '99A; /05 ,'- "' ,25""0-