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(Based on a
lecture given at the Israel Psychological Association 1995
convention)
Published in ISRAEL JOURNAL OF PSYCHIATRY, Vol. 36, Number 3,
1999
ABSTRACT
Freud used the concept of "abstinence" in relation to the patient-therapist relationship, and saw "deprivation" as a motivating force in the treatment. Later authors related to "deprivation" and "abstinence" in different terms. Kleinians tend to emphasize the non-gratifying approach, designed to produce transference of all kinds; Bion suggests that an atmosphere of deprivation and abstinence in the psychoanalytic treatment allows for an "intuitive" approach to mental events and phenomena; Kohut points at abstinence as a structuring aspect in the patient's personality; but he also speaks about optimal frustration.Winnicott recommends, in the treatment of people who suffered severe "holding" deprivation, maximum adjustment of the therapeutic setting to the patient's needs. Deprivation and abstinence, in this respect, apply to the therapist; but, on the other hand, a state of "holding" in the treatment allows the patient to experience severe deprivations and anxieties. This paper also discusses the extent to which wishes and needs are satisfied in the treatment as well as the causes for unnecessary abstinence and deprivation which are due to the therapist's mistakes or failures. Inspired mainly by Winnicott's spirit, this paper also deals with the paradoxes all therapists must face in their work.
INTRODUCTION
When he created psychoanalysis as a therapeutic method, Freud emphasized the need for abstinence, that is, the analyst's abstaining from responding to the patients' sexual wishes and renouncing any over-gratifying attitude towards patients.
In spite of the vast changes in post-Freudian psychoanalysis, these concepts of abstinence and deprivation have remained valid both theoretically and technically.
In the treatment, special conditions allow the patient's inner world expression. The therapist focuses on what takes place during the session, attempts to understand the patient and expresses himself in accordance with - that is, in the service of - the patient's therapeutic needs. In such a state of affairs abstinence and deprivation apply to the therapist, who focuses on the task and puts aside his own needs. Even those therapists who do "self sharing" with the patient only advocate such choice of action when it is believed to be in the service of the patient. But, on the other hand, this also implies a deprivation for the patient, since he yearns for a different type of relationship with the therapist.
The patient enjoys maximum expressive freedom. He expresses feelings, emotions and fantasies as freely as his inner world and the transference allow him to.
On the other hand, the patient is also required to relinquish immediate wish fulfillment both in and, to a certain extent, outside the therapeutic situation. Freud's instructions that patients refrain from major decisions while in therapy are not prevalent today but the patient is essentially invited to think and introspect and refrain from "acting". In this respect, the patient experiences abstinence.
Clearly stated boundaries and conditions, a fixed time and fee are part of the setting and the therapeutic contract. They become a source of frustration and deprivation for the patient while also allowing him to experience constancy and commitment. Seen in this light, they also induce a feeling of safety.
Freud, Winnicott and Kohut all state that the patient's expectations, namely, to receive some gratification from the therapist, cannot and should not be totally ignored; indeed, Freud even points out that doing so would be inhuman.
The broad range of patients for whom the psychoanalytic method is today thought applicable expanded and increased; in parallel, the significance of the concepts of deprivation and abstinence is gradually changing. I wish to elaborate on this subject, and particularly on Winnicott's approach.
FREUD
In "Observations on Transference-Love", (1915) Freud notes that the therapist must not dissuade the patient from loving him but, in the same time, will refrain from any cooperation. Freud writes: "...He [the analyst - B.B] must keep firm hold of the the transference-love, but treat him as something unreal, as a situation which has to be gone through in the treatment and traced back to its unconscious origins and which must assist in bringing all that is most deeply hidden in the patient's erotic life into her consciesness and therefore under her control."(1, p.166) Freud also says that only if the patient feels the therapist's strict avoidance will she feel safe enough to share her experience with him.
In "Lines of Advance in Psychoanalytic Therapy" (1919), Freud relates to the need for the treatment to take place in a general atmosphere of abstinence. He relies here on his understanding of neurosis, which he sees as derived from frustration and deprivation. The symptom is a substitutive satisfaction. Every relief in the pathological state slows down the treatment and undermines the strength of the drive to heal. This is why we must prevent from an accelerated alleviation; for in the absence of deprivation and pain, there will be no drive to heal.
The therapist must prevent the patient from getting substitutive satisfaction. In certain cases, the patient will seek such satisfaction in the therapeutic process itself. Freud says: "Some concessions must of course be made to him….But it is not good to let them become to great.Any analyst who out of the fullness of his heart, perhaps, and his readiness to help, extends to the patient all that one human being may hope to receive from an other, commits the same economic error as that of which our non-analytic institutions for nervous patients are guilty. Their one aim is to make everything as pleasant as possible for the patient, so that he may feel well there and be glad to take refuge there again from the trials of life".(2, p.164) That means, by so doing they abandon any hope of strengthening their patients or helping them increase their own ability to resolve their personal problems. The conclusion is that abstinence creates a maintained state of deprivation, which is crucial for the continuation of the treatment.
M. KLEIN
Kleinian psychoanalytic treatment focuses on the exploration of pregenital and genital drives, anxieties and libidinal and aggressive object relations. It focuses on the processing of anxieties and object relations in the transference. Projection, introjection and projective identification are predominantly processed in transference.
The systematic processing of elements of the schizoid-paranoid position allows the emergence of the depressive position, characterized by an increase in introjection and integration of a good object and a bad one; and by a better differentiation between reality and fantasy, self and non-self. Therapeutic achievements may thus be stabilized by enhancing the introjection of a whole and integrative object, leading to an ability to feel guilt-responsibility toward the object and a wish for reparation. The subject no longer focuses just on protecting the self against persecutory objects but also shows loving generosity and concern for others (3) (4).
In order for such a process to evolve, abstinence must be kept in that the therapist maintains a neutral and non-gratifying approach, allowing for the unfolding of transference .
BION
Bion is one of the most Klein's eminent followers. He extended and deepened the kleinian concept of Projective Identification as a part of his very personal theory on thinking and mental development. As Freud, Bion stresses the need for abstinence in the therapeutic situation, and presents his arguments in an original way : "... there is a psychoanalytic domain with his own reality... These realities are "intuible". In order to exercise his intuition, the psychoanalyst has to let go of memory, desire and understanding".(5, p.315)
This personal adaptation of Freud's evenly suspended attention(6, p.111) truly emphasizes the importance of the therapist's abstinence. But Bion also makes it very clear that abstinence must apply to both participants in the therapeutic encounter.
Bion describes the treatment of psychotic patients, and demonstrates a sort of deep listening on the therapist's part, which allows him to connect with catastrophic anxieties and fragmentary objects as they exist in the patient's mind.(7)
KOHUT
Kohut supplements the Freudian drive theory with a theory of selfobject needs .. In therapy, that is, in a suitable and adequate environment, some patients experience the therapist as a selfobject, supposed to fulfill self needs, mirroring and empathy. Just as neurotic patients will manifest in transference instinctual needs, patients with self disorders will manifest selfobject needs. Kohut describes the basic therapeutic unit in the treatment as consisting of two phases: 1- understanding and 2- explanation by dynamic-genetic interpretations. In the first phase, that of understanding, there are three steps: 1- reactivation in the transference of self-needs or instinctual needs; 2- non-response by the therapist,
non-fulfillment of the need - instinctual or self-need - that is, abstinence; and 3- substitution of direct need fullfilment with the establishment of a bond of empathy between self and selfobjects or between self and objects.
We can see that Kohut stresses the structuring role of abstinence.
But, in a sense, the phase of understanding fulfils emotional needs for empathy, in spite of the fact that self needs such as the need for praise or exclusiveness in a relationship are not actually fulfilled in the therapeutic relationship. Kohut refers to optimal frustration; that is, relative frustration according to each patient's vulnerability.(8)
WINNICOTT'S THEORY AND SOME NECESSARY CHANGES IN THE SETTING IT IMPLIES
In addition to instinctual drives, Winnicott also refers to needs, a concept derived from his work with severe disorders.
There is a close relation between Winnicott's developmental theory and his understanding of psychopathological states. He maintains that during childhood, a good-enough parental care allows a stage of omnipotence in which the baby is unaware of the existence of others, since his needs are fulfilled immediately (9). That is to say, the object appears immediately when the child "creates" it, or fantasizes it. Winnicott uses the word "create" so as to reflect the magical aspect of this experience. This is how hallucination and perception co-incide . The fact that this overlapping is not total, allows for the necessary disillusionment gradually to take place.
Winnicott describes how the object which is subjective - it exists as a part of the self - becomes objective.
In Winnicott's words, the subject destroys the object but the object survives as a good and non retaliative one. The object thus becomes objective- that is, it exists outside of the self; only thus can object use evolve. (10) In fact, prior to this point, there may be object relation but not object use. The subject has object relations in so far as the subject's world contains objects: but these objects do not have actual existence outside of the subject.
But this process is not always possible.
Winnicott explains that, usually, "...good-enough parents and good-enough homes do in fact give most babies and small children the experience of not having ever been significantly let down ... they are blissfully unaware of their good fortune, and find it difficult to understand those of their companions who carry around with them for life experiences of unthinkable anxiety..."(11, p.196).
Patients who had a "good enough mother" and did not experience "falling" or extreme anxiety, can enjoy psychoanalytic treatment focusing on repression, the oedipal conflict, ambivalent conflicts towards whole objects.
But there are those who did not enjoy the same conditions of holding and safety, that is, they had extreme experiences of falling. For them, unbearable traumas occurred in a time when they were babies, unable to protect themselves. Sub- sequently, they protect themselves by split. Winnicott suggests that in these cases, the therapist is required to allow regression in the treatment, by creating an appropriate environment where the patient may experience holding and omnipotence. This is the only way to reach significant progress in the treatment.
Winnicott's writings seem to indicate that in such cases, he tried to adjust the therapeutic setting to the patient's special needs. These adjustments may have to do with various parameters of the setting: sessions may last up to three hours, and occasional physical contact with the patient is allowed (12). Margaret Little tells us how Winnicott held her hand for a long time, while he remained in a fairly strenuous posture (13). Also, when necessary, extra attention may be paid to the arrangement of the various objects in the therapy room, in accordance with the needs or demands of the patients, who are in a state of extreme vulnerability.(14)
In such states of the patient's extreme sensitivity, the therapist's inevitable mistakes are endowed with a traumatic significance, allowing the patient an opportunity to be angry.The patient's aggression towards the therapist, combined with the therapist's surviving as a good and non-revengeful object, will become a decisive factor in the patient's ability to use the therapist as a real and "objective" object.
This therapeutic approach seems to lead quite naturally to such a paper as "Hate in the countertransference" (15), in which Winnicott enumerates the sacrifices made by the therapist which are described as closely resembling those made by the mother in care of her baby; e.g., the mother and the therapist have to go to great lengths for the baby and for the patient, without the baby/patient being aware of this. At least, this is so in the primary stage for the baby, and at the stage of "special setting" for the patient. On the other hand, the safe therapeutic situation allows the patient to experience deprivations previously unknown to him.
Then, as Winnicott puts it, where there used to be wordless trauma comes anger.
The "special setting" therefore enables regression, which facilitates dependence upon the therapist. The patient can thus experience both omnipotence and severe deprivation.
DEPRIVATIONS OCCASIONED BY THE THERAPIST'S ERRORS OR INADEQUATE BEHAVIOR
Deprivation and abstinence reinforce the patient when dealing with frustration, anger, envy and jealousy. But there are times when patients suffer from unnecessary deprivation due to the therapist's errors, e.g., a therapeutic environment which is not warm enough, either too much distance or over-identification.
One such case of deprivation occurs when during the treatment, the patient's message does not receive adequate feedback and confirmation from the therapist. This is a case of disconfirmation, a concept taken from the Theory of Communication(16). Such a situation may become pathogenic since does not allow enough space for the patient as subject. It is, in fact, a lack of empathy.
Freud stressed the need for the psychoanalyst to undergo therapy himself: "he should have undergone a psychoanalytic purification and have become aware of those complexes of his one which would be apt to interfere with his grasp of what the patient tells him"(6, p.116). This rule should also reduce the likelihood of the therapist's projecting his or her own problems onto the patient.
Countertransference - the therapist's emotional reaction to his/her patient - is an important source of information about the patient, if and when we can carefully work it through. An important issue is to understand its main sources: wether it is patient-induced, therapist-induced or both. (17).
When countertransference is not adequately worked through, the therapist's work may be impaired. For example, through projective identification the patient may overwhelm the therapist's mind with "beta elements" which can sometimes even trigger the impulse of acting out (18). This is why supervision - self supervision or with colleagues- is so important: a certain distance is thus created which expands the therapist's ability to hold, contain and understand.
Naturally, if the therapist falls into the trap of assuming a seductive attitude, or even uses the situation for his own sexual gratification, the damage cannot be overestimated. The abuse of the therapeutic situation by a sexual relation between therapist and patient is present in all the therapeutic professions. It is not without reason that all professional ethical codes include explicit and specific restrictions on this issue; various papers have been published in the last decade on the subject (19).
But even without considering such extremes extremes of unethical conduct, our profession is one in which it is more than likely that some professional mistakes will occur.
Different therapeutic theories and concepts tend to lead to different misunderstandings and errors in the therapeutical praxis.
Examples of misunderstandings or errors related to different schools of thought
Racker disagrees with the contention that the classical freudian technique means passivity and silence on the therapist's part. He claims that only Eros can bring about Eros, that is, only a positive attitude on the therapist's part may allow for positive transference in the patient; he reminds us that in the cases described by Freud, he always holds an interested and active dialogue with his patients.(20)
Kohut's self psychology may be misunderstood as recommending to "cure through love", believing that Kohut intended the therapist to literally fulfill self-needs of the patient as glorification, etc.
As for some Kleinian therapists, they used to over-emphasize the destructive fantasies of patients who suffered severe basic deprivations, without linking these fantasies to those deprivations. Such therapeutic attitude is likely to cause the patient a renewed experience of alienation and neglect. Also, generally speaking, a certain tendency for "pathologization" of defenses or of processes which in fact fulfill a positive function in certain cases, does not really serve the patient (21).
PARADOXES IN TREATMENT
"Paradoxes" are typical of Winnicott's thinking. For example, he discusses the paradox related to the notion that when the child has a good-enough mother, he "fantasizes" the real breast. I wish to describe some paradoxes occurring in therapy, using notions taken from Winnicott as well as from other authors mentioned in this paper.
Paradox:
In the setting proposed by Winnicott for cases of basic deprivation, it is precisely the therapist's effort to adjust to the patient which arouses bitter complaints on the patient's part against the therapist- as in the following example:
A young female patient, eldest daughter of oriental immigrant parents, succeeded to maintain during the first three years of her treatment a self-sufficient image, attempting to deny basic needs and anxieties. She was gradually able to let go of her male-omnipotent self-image, to further develop the relationship she had been in, marry and give birth. Pregnancy and birth triggered a crisis since all defenses had collapsed and she was now in immediate and intolerable contact with primary deprivations. This is often referred to as "postpartum depression". The fact she was required "to give to the baby what she did not receive from her mother" gave us an opportunity to process primary contents. She was able to bring her infantile needs to the treatment along with a strong fear of abandonment. She developed aggressive thoughts towards the child along with difficulties in differentiating these thoughts from the intention of acting them out. She was filled with anxiety and guilt feelings.
At this point the therapist decided to provide a "special setting", visiting her at home following childbirth and occasionally telephoning on days when sessions were not scheduled. At the same time, the interpretative work continued. Her anger towards the therapist intensified, since in spite of all the therapist's efforts, she was not a "real mother". Her ability to be angry and to blame the therapist for the neglect and deprivation she had suffered, has allowed her, to his day, to cope with and work through primary deprivations which until this crisis have been "unknown" to her. She said that until that time she had lived a lie, a facade of a "superwoman" and a great need to help and asist others-parents and little brothers- while ignoring her own needs.
Paradox:
The patient's complaints about loneliness and deprivation indicate that these feelings are slightly less "total" and extreme. A verbal expression indicates an environment which is adapted to the patient- in Kohut's words, an empathic self-object. Winnicott says that instead of accumulating traumas, there is anger: naturally, for now there is an other at whom the patient can direct anger.
Paradox:
Patients use the setting in order to justify their relationship with the therapist as a part-object- a kind of rationalization. A patient says: "you keep our relationship formal, you don't tell me about yourself, this means you want me to think of you as a function". Another patient once told me: "You're not really someone, you're something symbolic". (This patient will be further described below). This is the need to keep the therapist as a subjective object.
Paradox:
We invite our patients to feel needs which we cannot satisfy, sometimes because we are unable to do so, or for therapeutic reasons- in order to promote growth. This becomes most conspicuous when the patients has built strong defenses in order to avoid intolerable pain. Often we have counter- transference difficulties, for we cause pain.
Of special interest is a patient who denies the "otherness of the other"-that the other is different from himself. The object's "engulfment" by the subject protects him from the traumatic experience of "falling" or from abandonment anxiety. Winnicott describes the need to allow the patient access to object use so that he can recognize and acknowledge the other's difference.
From a Kleinian point of view, such cases may be seen as a manifestation of projective identificacion, a defense against envy, as envy induces destructive fantasies towards the object, in which case the subject is again exposed to severe and intolerable deprivation since the object upon which it depends is destroyed (22).
Kohut, too, refers to the patient's need that the therapist should sometimes see things only in the same way that he, the patient, does. For the patient, the therapist's difference is traumatic. Only gradually can he take in "optimal frustration".
In the patient mentioned above - an artist, divorced, father of two children- an entrenched omnipotent attitude and a denial of the otherness were expressed in the treatment in various ways. In the beginning of the treatment, this patient suffered from ulcerative colitis, from which he recovered. During the treatment he expressed two theories which negated his parents' parenthood: he claimed that he had raised himself on his own and that the books he read in his childhood or the authors became parents to him. "Don't tell anybody; I don't love", he said to me a few years ago, and he didn't insinuate that he "hated" the other but rather that there simply wasn't any "other". He believed he knew what other people were thinking, myself included, and said that if any of the people close to him had disappeared, he would probably not feel any pain at all, because he felt best when he was alone. Only several years after the beginning of therapy did he start talking about the pain he experienced when the therapist wasn't meeting his eyes him just when he was speaking, and how difficult the end of each session had been to him.
The process of introjection of the therapist as an empathic selfobject, i.e., a therapeutic object which has survived its "annihilation as other" has allowed the patient to face deprivations. Simultaneously, the patient could free himself from unadjusted guilt feelings towards his parents, and his ability to experience self-empathy and self assertion increased, as he had a better knowledge of his own needs.
Paradox:
Throughout the treatment, patients express curiosity towards us, as "whole (a kleinian term) and objective (a winnicottian term) objects", this seems to indicate progress but, on the other hand, we will induce deprivation by not always satisfying the patient's curiosity.
Along the treatment, patients express curiosity about the therapist. The nature and significance of this curiosity may vary along the way. It can be related to the different stages of the oedipal complex, in accordance with Kleinian notions (23); it can be related to part-object relations, and signify intrusive and aggressive fantasies originating from envy- sometimes an aspect of projective identification. Alternatively, curiosity may be related to the therapist as a whole object, and acceptance of the therapist's relationships with others. This is an expression of an increasing contact with reality and an improved discrimination between self and not-self; hence a use of the object, that is, perceiving the object as objective. Such manifestations may indicate the patient's ability to experience a triad of whole objects, to deal with a mature oedipal problem. Not complying with the patient's curiosity emphasizes the frustration entailed in the position of being a third, facing a pair of parents.
DISCUSSION
From the patient's perspective, some needs are satisfied in the treatment. Needs of containment and empathic understanding find relative satisfaction, in accordance with the changes in the patient's inner world and the nature of the interaction with the therapist.
But, as Freud stressed, all treatment inherently implies pain. Indeed, it would seem that pain is inevitable in psychoanalytic treatment as the treatment attempts to remove defenses which were originally designed against pain (example: removing the defense of denial of the object being different). On the other hand, the treatment is also based on the belief that a therapeutic process will eventually bring about mental and psychological relief.
There is deprivation derived from the setting. But, on the other hand, the patient seeks therapy precisely because of frustration and suffering. Deprivation is partly inherently inevitable as the treatment raises questions related to primary needs, which the therapist cannot hope to fulfill. Many patients seek therapy when they are in a chronic regressive state - as opposed to other patients described by Winnicott, who enter a state of regression thanks to the experience of therapeutic holding. Both types of patients experience in the treatment catastrophic anxieties.
Their wish for an omnipotent object is relatively satisfied in transference, in the experiences of empathy, mirroring and idealization or in what Winnicott refers to as omnipotence; but there is also an inevitable disappointment. In his article "The depresive position in normal emotional development"(1954-55), (15) , Winnicott describes the mother who makes her child confront the reality through small doses. As for the therapist's attempts to regulate the patient's disillusionment: it is an impossible task. The therapist is in far worse a position than any good enough mother, as he has to deal with painful deprivations and anxieties derived from destructive fantasies and current occurrences, to which the patient with primary deprivations is particularly vulnerable, as he did not develop sufficient autonomy with regard to the external world.
Due to transference onto an omnipotent object, some patients may feel disappointment and anger in that the therapist does not spare them enough suffering. This becomes particularly emphasized in times of traumatic events; For instance, the Gulf War had shaken some patients' faith in their therapist, at least temporarily, because external reality did not respect their need for "gradual disillusionment".
Abstinence and deprivation awaits every therapist working with severely deprived patients. He or she has to cope with the patient's massive projective identification, agression, despair, devaluation. The therapist's loneliness in these cases increases his deprivation, and his abstinence consists in refraining from immediate relief through discharge or emotional detachment.
Winnicott created special concrete, real conditions which are particularly adapted to treating the childish or childlike aspects of patients which have never before received the attention they needed.
The issue of "special setting" raises many questions: is it a genuine satisfaction of needs? Is it not a deception, an illusion? Is it not as if Winnicott said "I am your mother, I will fulfill all your needs"? But on the other hand, could it not also be compared to child treatment where the therapist often plays a role in accordance with the patient's needs?
In "Child Psychoanalysis", Klein (24) refutes the idea that abstinence is impaired in the psychoanalysis of children. She notes that play is one of the child's best expressive means, just as adults use words. She also adds that more often than not, satisfaction in play is imaginary and not in reality.
Reflexions about deprivation and abstinence, and relative needs-satisfaction in psychoanalytic psychotherapy, stress the importance of considering the matter of simbolic versus real dimensions in psychotherapy, a subject that deserves special attention.
REFERENCES
1) Freud, S., Observations on Transference-Love (Further Recommendations in the Technique of Psycho-Analysis III)(1915) The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. XII, Hogart: London, 1958
2) Freud,S. Lines of Advance in Psycho-Analytic Therapy (1919), The Standard Edition Edition of the Complete Psychological Works of Sigmund Freud , vol. XVII, Hogart: London, 1958.
3)Segal, H., Introduction to the Work of Melanie Klein, Basic Books: New York, 1963
4)Klein, M., On the Criteria for the Termination of a Psychoanalysis, Int. J. of Psychoanalysis, vol. 31, pp. 78-80, 1950
5) Bion, W.R., Cogitations, Karnac: London-New York, 1970
6) Freud, S., Recommendations to physicians practising psycho-analysis, 1912, The Standard Edition The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. XII, Hogart: London, 1958
7)Bion, W.R., Second Thoughts: Selected Papers on Psychoanalysis, Heineman: London, 1967
8) Kohut, H., How does Psychoanalysis Cure?, The University of Chicago: Chicago, 1984
9) Winnicott, D.W.,The Theory of Parental-Infant Relationship (1960) in The Maturational Processes and the Facilitating Environment, Hogarth: London, 1965
10)Winnicott, D.W., The use of an object and relating through identifications (1968), Playing and Reality, Tavistock, Karnac: London: 1971. Also in Psychoanalytic Explorations, ed. by C. Winnicott, R. Shepherd, M. Davis, Karnac: London, 1971
11)Winnicott, D. W. The concept of Clinical Regression compared with That of Defence Organization (1967) in Psychoanalytic Explorations, ed. by C. Winnicott, R. Shepherd, M. Davis, Karnac: London, 1971
12)Winnicott D. W. The mother-infant experience of mutuality (1969) in Psychoanalytic Explorations , ed. by C. Winnicott, R. Shepherd, M. Davis, Karnac: London, 1971
13 )Little, M., Psychotic anxieties and Containment, Jason Aronson , Northvale: New-Jersey, London: 1990.
14)Winnicott D. W. The importance of the setting in meeting regression in psychoanalysis (1964) in Psychoanalytic Explorations, ed. by C. Winnicott, R. Shepherd, M. Davis, Karnac: London, 1971
15)Winnicott, D.W., Through Paediatrics to Psycho-Analysis, Hogarth Press: London, 1947
16)Watzlawick, P., Helmick Beavin, J. & D. Jackson Don, Pragmatics of Human Communication, Faber: London, 1968
17)Springman, R.R., Countertransference: Clarifications in Supervision. Contemporary Psychoanalysis, Journal Back Issues, The William Alanson White Institute, vol. 22, 2, pp. 252-77, 1986.
18)Grinberg, L., The Theory of Identification, in The Goals of Psychoanalysis: Part One, Karnac: London, 1990. (Spanish: Teoria de la Identificacion)
19) Witztum E., Margolin J., Levy A., Sexual relations between doctors and patients: state of the art. Harefua, Journal of the Israel Medical Association, vol. 131, October 1996, 257-59
20)Racker, H., Transference and Countertransference, International Universities: New York, 1968 (original in Spanish: Estudios de Tecnica Psicoanalitica)
21)Alvarez, Ann: Projective Identification as a communication: Its grammar in borderline psychotic children. Psychoanalytic Dialogues 1997; 7; 753-768
22)Rosenfeld, H., Projective Identification in Psychosis, in Problems of Pychosis, P. Doucet & C, Laurin Eds. (pp. 115-28), Excerpta Medica, The Hague : 1971
23)Segal, H. The Oedipus Complex Today: Introduction, J. Steiner ed. Karnac :, London, 1989
24)Klein, M. The Psychoanalysis of Children, Rev. Ed., Hogarth: London, 1975
