This document discusses countertransference identification and enactment in psychotherapy. It presents a case study of the author's work with a 17-year-old patient. The author began to overly identify with the patient, seeing himself in the patient. This led to an enactment where the author came to know the patient in a restricted, self-centered way. However, with the patient asserting his own identity and differentiation from the author, this helped disrupt the enactment. The author argues that allowing patients to personalize themselves rather than be known impersonally can help therapists avoid overly narrow understandings and move towards recognizing patients' uniqueness.

1. ONE WAY OUT OF ENACTMENT:
THE PATIENT’S DIFFERENTIATION
FROM THE THERAPIST
James Tobin, Ph.D.
Licensed Psychologist PSY 22074
220 Newport Center Drive, Suite 1
Newport Beach, CA 92660
949-338-4388
Assistant Professor of Clinical Psychology
Argosy University
601 South Lewis Street
Orange, CA 92868
714-620-3804
1

2. Case Vignette
Section I.
The Countertransference
Experience of Identification
2

3. Section I.
The Countertransference Experience
of Identification
• Although there are many forms of countertransference (CT)
experience, the therapist‘s reaction of tension or difficulty
has received the most attention, i.e., when the therapist has
the feeling of being ―triggered‖ or ―provoked.‖
• The therapist is characterized as having his ―buttons
pushed‖ – with the emergence of CT signaled by the
therapist feeling or acting in ways that are atypical, not his
usual style, etc.
• In this perspective, the emphasis is on how the therapist
struggles to ―manage,‖ ―control‖ or ―tolerate‖ such feelings in
the context of the therapeutic relationship and how,
potentially, to use these feelings to understand the patient.
3

4. Section I.
The Countertransference Experience
of Identification
• CT reactions of this form are theorized to be rooted in
unresolved issues in the therapist and/or in what the patient
is ―inducing‖ in the therapist (i.e., in response to the patient‘s
transference).
• Another form of CT experience that is often under-
emphasized is the therapist‘s feeling ―identified‖ with the
patient, when some core aspect of the therapist‘s
personhood is highly connected to the patient (often
described as a kind of nostalgic resonance).
4

5. Section I.
The Countertransference Experience
of Identification
• This experience is often construed as ―empathy‖ or
―sympathy,‖ a way of locating the patient, or projective
identification.
• Directives in supervision are frequently offered with the
intent of (1) helping the supervisee conjure up elements of
his or her own subjective life to open up identification
pathways in an attempt to understand the patient better or,
conversely, (2) warning the supervisee against overly-
identifying with the patient (the distinction between 1 and 2
is often unclear).
5

6. Section I.
The Countertransference Experience
of Identification
• Using case material from my work with a 17 y/o adolescent male
patient, I want to present how my own CT identifications evolved
into a particular type of a transference-CT enactment and how I,
with the help of my patient, got out of it.
• What I learned from this treatment informed my understanding of
various aspects of clinical technique including the ways in which
the therapist simultaneously knows and distorts the patient, and
how CT identifications shed light on particular aspects of the
patient‘s transference and repetitive interpersonal experience.
• The limitations of the projective identification viewpoint: my
emphasis is not on what the patient is disavowing/‖putting into‖
the therapist, but the therapist‘s ―valence‖ for the patient‘s
experience that already exists in the therapist.
6

7. Case Vignette
Section II.
Seeing Myself in the Patient
7

8. Case VignetteCase Vignette #1
8

9. Section II.
Seeing Myself in the Patient
• While there are many interesting elements in this initial
interchange with my patient John, I want to focus on the
theme of he and I being “like” each other/familiar:
-interview experiences of having our flies undone
(exposure)
-the assumed relationship between similarity and
understanding (John‘s comments about being hip
and young)
-my already being identified in John‘s mind with
someone else in his life (i.e., what seemed to initiate
his association to the memory of his interview was my
remark, ―I like you already‖) 9

10. Section II.
Seeing Myself in the Patient
• This interchange marked the beginning of a treatment in which
the familiarity between us expanded. My personal life and
history seemed to reference/match John‟s experience more
so than my other patients: John often felt ―like me‖ or at least
similar to what I remembered of my feelings and struggles when I
was his age.
• Early on, I felt this similarity was fortuitous and something I could
exploit to promote the alliance between us and enhance the
process of inquiry I was able to engender; it was also something I
attempted to talk about from time to time: I once told him,
“Sometimes I see myself in you” and he replied, “Save me
the suspense, and the grief: I don‟t want to grow up to
become a psychologist.” 10

11. Section II.
Seeing Myself in the Patient
• As treatment progressed, there were instances in which my
identifications with John seemed overly-inflated, intrusive, and
misleading.
• Rubin (1999) describes periods when the analyst relates to
the patient “habitually, repetitively, and self-centeredly” (p.
20); this was the emerging quality of my interactions with
John.
• John‘s college application essay about the poem ―Letter to My
Mother‖ (Phillips, 2000) became a central topic of our discussions
during the Fall of his Senior year, and was revisited over and over
again in the treatment.
11

12. Case VignettePoem ―Letter to My
Mother‖
12

13. Case VignetteCase Vignette #2
13

14. Section II.
Seeing Myself in the Patient
14
• My comment (―Right, but ….‖) had within it a particular focus
and intentionality that diverted me away from the patient‘s
emphasis: I was trying to get at my suspicion of John‟s
aggressive longing to tell his mother the truth of his
sexual life and, by so doing, shatter her construction of
him – this did not converge with his central point (i.e.,
his need to have and keep the secret and use it as a
psychological means of separating from his mother and
becoming a man).

15. Section II.
Seeing Myself in the Patient
• My intervention was motivated by my own interpretation of
the poem and my subjective experience with my own
mother – in this instance, my CT identification led to a
mismatch or disjunction, not understanding.
• I believe these moments are common in clinical practice
and are occurring, to a greater or lesser degree, all the time:
the way the therapist comes to “know” the patient
(often through identification) deviates from the patient‟s
experience and the metacommunication can be
devaluing/causing minor and major ruptures.
15

16. Section II.
Seeing Myself in the Patient
• The central dilemma in the poem, and for John and me, and
for the ultimate fate of the therapist who cannot help but to
experience CT identifications with the patient is this:
How does the patient emerge out of the CT-
identifications and breach the therapist’s coercive self-
referential constructions (e.g., “And of course you’ll
dress for dinner!”)
• This leads to a related question:
What characteristics of the therapeutic situation
support this occurrence, and allow the therapist to
tolerate and use it clinically?
16

17. Case Vignette
Section III.
Enactment and
“Depersonalized
Knowing”
17

18. Section III:
Enactment and “Depersonalized Knowing”
• As these CT-identifications continue in treatment and go
undetected, enactment occurs.
• A transference-CT bind gradually but definitively formed in
which the very way I came to know and understand John
manifested a repetitive problematic theme in his relational
life.
• I became a version of John‘s mother: viewing him from a
highly personalized, overly-determined and self-centered
vantage point.
18

19. Section III.
Enactment and “Depersonalized Knowing”
• The term ―enactment‖ has been described as a
transference-CT bind in which one or both participants in the
clinical situation become restricted in how the other is
viewed, related to and known (the other becomes a limited
approximation/faulty construction in the mind of the other).
• As the approximation mounts and the construction becomes
more firmly organized, the degree of inquiry, spontaneity of
relatedness, and access to disavowed aspects of self and
self-other/relational experience become limited.
19

20. Section III.
Enactment and “Depersonalized Knowing”
• In his important work ―Partners in Thought: Working
with Unformulated Experience, Dissociation, and
Enactment” (2010), Donnel Stern posits, ―All
experience is subjective, the analyst‘s as well as the
patient‘s … We must now understand that we all
continuously, necessarily, and without awareness
apply ourselves to the task of selecting one, or
several, particular views of another person from
among a much larger set of possibilities‖ (p. 8).”
20

21. Section III.
Enactment and “Depersonalized Knowing”
• This view of enactment emphasizes the paradoxical (and I
would argue, inevitable) development in the therapeutic
relationship of illusion and self-deception: as treatment
moves through time, the therapist (and the patient)
progressively see each other with greater conviction and,
simultaneously, with greater error; also, their capacity to
detect errors of construction seems to diminish.
21

22. Section III.
Enactment and “Depersonalized Knowing”
• This raises the issue of the therapist‟s epistemological
(Everitt & Fisher, 1995) position with regard to the
patient, the cognitive/emotional ―set‖ (Wachtel, 1993) with
which the therapist uses to organize, comprehend, and
understand the patient.
• Christopher Bollas‘ (1987) notion of the therapist‘s ―personal
idiom‖ suggests that all aspects of the therapist‘s personal
identity (family background, education, ethnic and cultural
identity, psychological/clinical preferences) influence and
bias what about the patient the therapist is sensitized
to, identifies with, and uses to form meaning.
22

23. Section III.
Enactment and “Depersonalized Knowing”
• Similarly, the psychoanalyst LaMothe (2007) presents the
work of the Scottish philosopher Macmurray (1991) who put
forth the construct “impersonal knowledge,” i.e., a form
of recognition always present in social interactions
which involves perceiving the other based on
categories, roles, etc. that obscure “the personal.”
23

24. Section III.
Enactment and “Depersonalized Knowing”
• Compelled to understand, the therapist is destined to use CT
identifications with the patient and to inevitably be fooled by them.
• Think of a statistical test such as the mean as an epistemological
construct employed to identify meaning within a chaotic array of
numbers – the application of the statistical test cannot be made
without assuming error.
• ―The path of least resistance‖ to understanding the patient is
through the therapist‘s personal experience (identifications);
sooner or later, impersonal knowledge is generated at the
expense of the personal and is confused with the personal.
24

25. Section III.
Enactment and “Depersonalized Knowing”
• Various accounts of this problem exist in the literature:
Hedges (1992) highlighted the therapist‘s premature certainty and
avoidance of pursing the meaning of CT experience, along with the
patient‟s collusion in being known impersonally: ―Armed with the
truth, the therapist may then assail the person in analysis with an
interpretive line in an effort to establish the validity or correctness of the
analyst‘s view—an endeavor with which the person in analysis is
altogether too likely to cooperate‖ (p. 25).
Benjamin (1988, 1990, 1995, as cited by LaMothe, 2007) dramatically
characterized the clinical encounter as an ensuing conflict in which the
therapist aims to ―struggle to control the other‖ by understanding (and
gaining ―autonomy from the patient‖) so as to avoid the absence of
understanding (―dependence on the other‖).
25

26. Section III.
Enactment and “Depersonalized Knowing”
• This perspective leads to an interesting re-conceptualization
of transference offered by LaMothe (2007): transference
consists of the patient‟s “history of depersonalizing …
relationships” (p. 285) and the patient‟s corresponding
desire for and fear of being personalized.
• LaMothe (2007) views psychological trauma as the
parent‟s failure to recognize the child‟s uniqueness so
that the child exists in a depersonalized capacity,
objectifying others and viewing his/her exposure of
uniqueness as anxiety-provoking.
26

27. Case Vignette
Section IV.
One Way Out of
Enactment:
Moving Toward
“Personalization”
27

28. Case VignetteCase Vignette #3
28

29. Section IV.
One Way Out of Enactment:
Moving Toward “Personalization”
• This material demonstrates enactment formed by
progressive CT-identifications: it is a depersonalized
interaction with an implicit directive, a
metacommunication about my preferred vision of the
patient that is coercive (e.g., “I would have assumed
….”).
• It illustrates LaMothe‘s view of transference and Stern‘s
description of the highly constricted relatedness that defines
enactment.
29

30. Section IV.
One Way Out of Enactment:
Moving Toward Personalization
• It also illustrates what I call “differentiation” (LaMothe‟s
term is “relational disruption”) in which the patient
establishes himself outside of the therapist‘s CT-
identification.
• Surprisingly, and fortunately, in the depersonalizing context,
the patient personalizes: John says emphatically, “I am
me, not you,” disagrees with my implicit directive, and
justifies his own choices.
30

31. Section IV.
One Way Out of Enactment:
Moving Toward Personalization
• Differentiation is an important clinical event that parallels
Stern‘s thinking: ―Enactments resolve only when one or the
other member of the analytic couple reestablishes
dialogue by gaining explicit awareness of how, at that
particular moment, the context he is supplying is
inappropriate to the other (or the „other‟ within himself)‖
(Stern, 2010, p. 51).
31

32. Section IV.
One Way Out of Enactment:
Moving Toward Personalization
• LaMothe (2007) argues: ―These ‗old forms‘ of association
have the illusion of reality. In other words, they are real to
the extent that they are part of the person‘s memory and
identity; however, this reality is not accompanied by a
sense of being real, which comes from being
recognized and treated as a unique and inviolable
subject” (p. 284).
32

33. Section IV.
One Way Out of Enactment:
Moving Toward Personalization
• Benjamin (1990) theorizes that the capacity for recognition
is made possible only through negation. Negation involves
the emergence of difference or distinction (the other is
“not-me”).
• Negation echoes Davies‘ (2004) notion of enactment as the
collapsing of the boundary between self and other due
to mutual projections and counter-projections (recall
Vignette #2 in which John said he no longer wanted to be
transparent, that he wanted to have a private life
inaccessible to others).
33

34. Section IV.
One Way Out of Enactment:
Moving Toward Personalization
• A developmental perspective is also relevant here: LaMothe
(2007) references Winnicott‘s (1971) view of advances in
psychological growth and development prompted by the
parent‟s recognition of the child as like me, but not-me.
• LaMothe (2007) explains: “. . . an individual recognizes
the other as a unique person, like me and different (not-
me), which involves the individual‟s handing over
omnipotence and the desire for domination for the sake
of intersubjectivity and shared personal knowledge” (p.
274).
34

35. Case Vignette
Section V.
Summary and
Implications for Clinical
Technique
35

36. Section V.
Summary and Implications for
Clinical Technique
36
Figure 1. The Continuum of CT-Identification Experience: States of “Knowing”
Enactment/Depersonalization
(Restricted Knowing)
Identification
Intellectualization
Negative Capability
(Not-Knowing)
Uncertainty
Chaos
Guilt
Shame

37. Section V.
Summary and Implications for
Clinical Technique
• The therapist seeks to understand/construct (―know‖) the
patient according to a personal idiom and epistemological
framework.
• A continuum of CT-identification experience exists that
corresponds to the therapist‘s states of ―knowing‖ the
patient.
• This continuum marks distinct relational zones/ways of
being with the patient.
• The listening function is inherently subjective and tends to
migrate toward CT-identifications, leading to an
accumulation of impersonal knowledge and restricted
knowing.
37

38. Section V.
Summary and Implications for
Clinical Technique
38
Enactment/Depersonalization
(Restricted Knowing)
Identification
Intellectualization
Negative Capability
(Not-Knowing)
Uncertainty
Chaos
Guilt
Shame
Figure 2. How the Depersonalizing Enactment Evolves: A Model
Relational Disruption/
Differentiation
A
B
A: Restriction
B: Personalization
C: Relapse
C

39. Section V.
Summary and Implications for
Clinical Technique
39
• In the initial stages of a treatment, the therapist moves in
and out of various states of knowing/relational zones; there
may be little restriction and active fluctuation as new
material is presented by the patient and assimilated by the
therapist.
• Gradually, historical/transferential material (patient) and CT-
identification experience (therapist) coalesce and restrict the
fluctuation between relational zones; the therapist is pulled
toward one particular form of knowing (CT-identification)
and this migrates the therapeutic enterprise toward
depersonalizing interactions.

40. Section V.
Summary and Implications for
Clinical Technique
40
• An enactment ultimately ensues based on a pattern of
depersonalized relatedness.
• Ideally, relational disruption (―differentiation‖) interrupts the
enactment -- freeing the patient and therapist to experience
the patient outside of the therapist‘s limited epistemology
(―not-me‖).
• When this occurs, the therapist‘s construction of the patient
is challenged/subverted and the patient is recognized
uniquely (and embodies the experience of “being real”).

41. Section V.
Summary and Implications for
Clinical Technique
• With regard to technique, it is recommended that the therapist approach
inevitable CT-identifications with acceptance and curiosity, presuming
errors of construction and anticipating depersonalizing
enactments.
• The therapist adopts an attitude characterized by ―a radical sense of
openness‖ and the expectation of ―a radical deconstruction of all
narratives‖ (Safran, 2003, p. 22).
• The therapist observes the state of knowing and the
corresponding zone of relatedness he occupies with regard to the
patient; opportunities for shifts between zones (often cued by the
patient) are sought and optimized when they present themselves.
41

42. Section V.
Summary and Implications for
Clinical Technique
• The therapist develops the capacity for subjective and
objective modes of self-relatedness, i.e., being inside of
the identification while also globally challenging the
veracity and consequences of the identification.
• The therapist models for the patient humility and
enthusiasm for deconstructed knowledge/new knowledge,
socializing the patient into an interactive/relational ―play
space‖ of ideas, meanings, and subversions.
42

43. Section V.
Summary and Implications for
Clinical Technique
• As Rubin (1990) describes: ―The analyst can literally sit with
and through a greater range of affect without the need to
shield himself or herself by premature certainty or
intellectualized formulations. There is then a greater
tolerance for complexity, ambiguity, and uncertainty. There
is less pressure to know and to do. Not-knowing is then a
more comfortable stance of being for the analyst. The
analyst experiences more ‗beginner‘s mind.‘ ‗In the
beginner‘s mind there are many possibilities,‘ notes Shunryu
Suzuki (1970); ‗in the expert‘s mind there are few‘ (p. 21).
The analyst who has a beginner‘s mind takes less for
granted, is more receptive to the unknown, and is more
capable of being surprised‖ (p. 20). 43

44. Section V.
Summary and Implications for
Clinical Technique
• These suggestions for attitude and technique may not
prevent depersonalizing enactments, but may foster briefer
cycles of convergence/divergence, more rapid transitions
between zones of relatedness, and the gradual dissolution
of guilt- and shame-based reactions/humiliations when the
therapist realizes his self-deception.
44

45. Section V.
Summary and Implications for
Clinical Technique
45
―Play space‖
Figure 3. Subjective and Objective Modes of Self-Relatedness:
The Optimal Course
Enactment/Depersonalization
(Restricted Knowing)
Identification
Intellectualization
Negative Capability
(Not-Knowing)
Uncertainty
Chaos
Guilt
Shame
Relational Disruption/
Differentiation

46. Section V.
Summary and Implications for
Clinical Technique
• Implications for supervision involve approaching CT with an
interest in:
(1) Exploring the trainee‘s possible hesitation to occupy
certain segments of the continuum of CT-identification
experience/states of knowing;
(2) Increasing the trainee‘s capacity to detect cues from the
patient that depersonalization may be occurring; and
(3) Developing the trainee‘s capacity for subjective and
objective modes of self-relatedness.
46

47. References
• Benjamin, J. (1988). The bonds of love. New York: Pantheon Books.
• Benjamin, J. (1990). Recognition and destruction: An outline of
intersubjectivity. In S. Mitchell & L. Aron (Eds.), Relational
psychoanalysis (pp. 181-210). London: Analytic Press.
• Benjamin, J. (1995). Like subjects, love objects. New Haven, CT: Yale
University Press.
• Davies, J.M. (2004). Whose bad objects are we anyway? Repetition
and our elusive love affair with evil. Psychoanalytic Dialogues, 14, 711-
732.
• Everitt, N. & Fisher, A. (1995). Modern epistemology. A new
introduction. New York: McGraw-Hill.
• Hedges, L. (1992). Interpreting the countertransference. Northvale,
N.J.: Jason Aronson Inc.
• LaMothe, Ryan (2007). Beyond intersubjectivity. Personalization and
community. Psychoanalytic Psychology, 24, 271-288.
• Macmurray, J. (1991). Person in relation. London: Humanities Press
International.
47

48. References
• Phillips, R. (2000). Spinach days. JHU Press.
• Rubin, J.B. (1999). Close encounters of a new kind: Toward an integration
of psychoanalysis and buddhism. American Journal of Psychoanalysis, 59,
5-24.
• Safran, J.D. (2003). Introduction. In J.D. Safran (Ed.), Psychoanalysis and
buddhism. An unfolding dialogue (pp. 1-34). Boston: Wisdom Publications.
• Suzuki, S. (1970). Zen mind, beginner’s mind. New York: Weatherhill.
• Stern, D.B. (2010). Partners in thought. Working with unformulated
experience, dissociation, and enactment. New York: Routledge.
• Stern, D.B. (2004). The eye sees itself: Dissociation, enactment, and the
achievement of conflict. Contemporary Psychoanalysis, 40, 197-237.
• Wachtel, P.L. (1993). Therapeutic communication. Knowing what to say
when. New York: Guildford Press.
• Winnicott, D.W. (1971). Playing and reality. London: Routledge Press.
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