On the last track we discussed control over switching. Two ways to help your client gain control over switching are overcoming host fears and facilitation of the switching process.
On this track we will discuss transference. For the purposes of this track, we will use Lang’s definition of transference. Lang defines transference as ‘responses by the client to his or her therapist that are primarily based on, and displaced from, the client's significant childhood figures. These significant childhood figures might be parents and siblings.’
This track will cover working with transference in multiples, principles of treating transference, and precipitants of transference reactions, as well as techniques described by Putnam for keeping the client straight and being real with the client.
Working with Transference in Multiples
First, let’s discuss working with transference in multiples. As you know, formal transference neurosis is often defined as ‘an emotional illness that evolves from, and is an elaboration of, transference responses and fantasies.’ When your clients exhibit transference, is your treatment goal a resolution of the transference neurosis? Do you conceive your treatment goal as a replay of the client’s past experiences currently being experienced with the therapist?
If so, you might find that transference reactions in clients with DID are generally not well organized and may need to be worked with in a more step by step approach. Therefore, in the treatment of DID, therapists may find it productive not to search out, emphasize, or refer to passing transference phenomena unless they represent major obstacles to therapeutic progress.
Principles of Treating Transference
I have found that when transference issues hinder therapeutic progress, I try to trace back to the roots. Then identify the period from the client’s life during which the past experiences generated the transference. Perhaps your client’s level of functioning at the time of this experience is embodied in an alter personality’s reactions. You might find that the material transferred contains a mixture of memories, fantasies, and past perceptions; both realistic and unrealistic.
Precipitants of Transference Reactions
Third, let’s discuss precipitants of transference reactions. As you know, some transference reactions may be therapist evoked. Sources of therapist evoked transference may include aspects of or items in the therapeutic setting. A colleague of mine, George, had a client with a major abreactive episode in which George was perceived as her incestrous father. The stimulus which created this client’s transference reaction was George’s blazer. George’s blazer was similar to one her father owned. Also, I have found that DID clients are extraordinarily sensitive to misdirected or poorly executed therapeutic interventions.
Technique: "Keeping the Client Straight"
Have you felt overwhelmed, as I have, by the sheer volume of information that must be tracked and processed regarding your DID client? I find that some alter personalities compound this difficulty by being insulted or angered when a therapist incorrectly attributes some fact or feeling to them that actually belongs to another alter. Such experiences, when repeated, may result in transference or even countertransference feelings of anger or resentment toward your client.
As you know, there is no simple way to eliminate this problem. The first step you might take for "Keeping the Alters Straight" is keeping a card file or other record of the alters and their attributes. Prior to a session with a DID client, I review the card file. When the session is over, I like to update the information as part of a process record and progress notes. However, it is still a challenge to not mistakes or forget which personality said what, when, or where? Like Alan’s alter personalities, many DID clients seem to have an uncanny ability to remember this sort of information.
Alan stated, "I think my obsession with the minute details of these therapy sessions has something to do with losing time when the others come out." Do you have an Alan whose close attention to detail regarding client-therapist interactions could be explained as a compensation for time loss or amnesic episodes? Could admitting fallibility and asking for clarification help reduce some of your client’s transference reactions?
Being Real With the Client
Next, let’s discuss being real with the client. I once heard an experienced psychoanalyst say, "I find myself having to be much more ‘real’ with her than I am with my other clients." This psychoanalyst was referring to the first DID client he ever treated. Would you agree that dissociative identity disorder can push against traditional therapy boundaries and can cause discomfort in therapists attached to a particular theoretical orientation? I find that such therapists may find themselves caught between pragmatic observations of what works and the dictates of professional training.
Therefore, the technique of being real with the client can benefit DID clients who are unable to tolerate the traditional unresponsive, ‘neutral’ therapeutic stance advocated by psychoanalytic theory. Alan required me to relate to him in some way. Before I managed to do so, there was a break in the therapeutic alliance. You might find that this pressure to abandon your usual manner of relating to a client can produce feelings of being manipulated and having your therapeutic authority undermined. If so, you might consider discussing with your colleagues ways to achieve equilibrium between the reality based need of your client to be responded to in an active and direct manner and your need to maintain a therapeutic stance toward the client in which you are both comfortable and effective.
Clearly, your current therapeutic stance is effective, or you wouldn’t be practicing. However, I find, as with Alan, I must be flexible to be effective, yet rigid with regard to certain treatment boundaries. Otherwise, as you know, the therapy degenerates into chaos. Would you agree that such paradoxes permeate the treatment of DID?
On this track we have discussed transference. This track covered working with transference in multiples, principles of treating transference, and precipitants of transference reactions, as well as techniques for keeping the client straight and being real with the client.
On the next track we will discuss ‘talking through.’ ‘Talking through’ is a technique to ensure that as many alters as possible are actually listening.
Peer-Reviewed Journal Article References:
Abbass, A. (2017). Review of Transference focused psychotherapy for borderline personality disorder: A clinical guide [Review of the book Transference focused psychotherapy for borderline personality disorder: A clinical guide, by F. E. Yeomans, J. F. Clarkin & O. F. Kernberg]. Psychoanalytic Psychology, 34(1), 131–133.
Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology. Advance online publication.
Garcia, D. J., Waugh, M. H., Skadberg, R. M., Crittenden, E. B., Finn, M. T. M., Schmidt, M. R., & Kurdziel-Adams, G. (2021). Deconstructing criterion a of the alternative model for personality disorders. Personality Disorders: Theory, Research, and Treatment, 12(4), 320–330.
Gazzillo, F., Dazzi, N., Kealy, D., & Cuomo, R. (2020). Personalizing psychotherapy for personality disorders: Perspectives from control-mastery theory. Psychoanalytic Psychology. Advance online publication.
MacIntosh, H. B. (2015). Titration of technique: Clinical exploration of the integration of trauma model and relational psychoanalytic approaches to the treatment of dissociative identity disorder. Psychoanalytic Psychology, 32(3), 517–538.
Online Continuing Education QUESTION 7
What are two techniques which can be effective in minimizing transference reactions in dissociative identity disorder clients?
To select and enter your answer go to .