Psychoanalytic Dialogues, 3(l):93-110, 1993

Enactments, Transference, and

Symptomatic Cure
A Case History
Morris Eagle, Ph.D.

I present a case study in which the dramatic disappearance of the

patient's chronic symptom of dyspareunia followed a critical episode
in the treatment in which a core dynamic theme of defiance-
punishment was enacted in the patient-therapist interaction. Symp-
tomatic cure was not accompanied by the patient's explicit insight,
but rather seemed to be a function of a complex process of test-
passing and transference-countertransference enactments leading to
the discorifirmation of a core unconscious pathogenic belief. Con-
cepts of transference, transference cure, misalliance cure, and anal-
ysis of transference are discussed in the context of this case study.

^T^*HE CASE STUDY I PRESENT in this paper was originally written up

I many years ago. At that time, I took the trouble to write a rather
JL lengthy paper about this case for a number of reasons. The main
reason was that the patient reported a sudden and complete disappear-
ance of a troubling symptom (dyspareunia) of eight years' duration
following a critical and traumatic therapeutic session. In my experience
these dramatic "turning points" do not occur that often in any kind of
psychotherapy, and I wrote the paper as an attempt more fully to
understand what happened (see Stone, 1982, for a paper on "turning
points" in psychotherapy). How and why did the dramatic and sudden
"cure" (of the symptom) take place? My second reason was that events of
the therapy raised some interesting clinical and theoretical issues that, I
thought, were worth presenting.
In my original version of the paper, I focused mainly on the patient's

Morris Eagle is Professor at the Department of Applied Psychology, Ontario Institute

for Studies in Education, University of Toronto, and Senior Clinical Consultant, Clarke
Institute of Psychiatry. He is in part-time private practice in Toronto.

93 © 1993 The Analytic Press

94 Morris Eagle

supposed transference "distortions" and the therapeutic value of my

neutral silence in discomfirming these distortions during a critical ses-
sion. I also made the related point that the patient's chronic and
troubling symptom was removed without much explicit insight on her
part but rather by the implicit enactment between patient and therapist.
In rereading the paper and my process notes of the therapy sessions, it
became clear to me that I had missed some very important interactions
between the patient and myself. My perception of what went on largely
in the limited terms of the patient's transference distortions and the
therapist's neutrality had blinded me to some fascinating and important
patient-therapist interactions. What I had missed was an entire drama of
transference-countertransference sequences that shed a critical light on
the process and outcome of the therapy.
Between the time I originally wrote the paper and my current revision
of it, like many other people, I was influenced by more interactional
conceptions of the therapeutic process, in particular by Gill's (e.g., 1982)
writings on the concept of transference, by the work of Weiss, Sampson,
and their colleagues (1986) (which influenced the framework of the
original paper), by Mitchell's (1988) important book on relational per-
spectives in psychoanalysis, and finally by Lang's perspective criticisms of
the early version of the paper.
First I present a brief description of the patient, then an equally brief
description of the general course of the therapy, and finally, a more
detailed discussion of some critical events and interactions in the therapy
and the clinical and theoretical issues that they raise.
The patient, S, was a 26-year-old female graduate student. Her
presenting complaint was severe pain during sexual intercourse
(dyspareunia), which had been present since her first sexual experience at
age 18. The patient had been referred to me by a behavior therapist who
had been treating her with various behavioral techniques. Treatment
was unsuccessful. Further, the patient was offended by what she referred
to as the "gimmicks" and suggestions (e.g., masturbation) of the behavior
therapist. The patient also complained of unsatisfactory relationships
with men, which fell into either of two patterns: one in which an initial
infatuation, when reciprocated by the man, was followed by the patient's
anger, contempt, and loss of interest and another in which the man did
not return her interest and thereby remained indefinitely an object of
desire and admiration. She had never had what she considered to be a
fully satisfactory relationship with men. She dreaded sexual intercourse
Enactments, Transference, Symptomatic Cure 95

because of its accompanying pain. She had periods of depression and

anxiety, which she attributed to the above sexual and relationship
problems. She functioned quite well in her work and presented no other
outstanding difficulties.
The patient was the oldest of three children. Her two siblings included
a younger brother (age 21) and younger sister (age 24). Her father was a
reasonably successful businessman and was described by the patient as
quiet, never given to anger, orderly, somewhat withdrawn, and most
likely to respond to family difficulties by denial. The patient felt that she
was her father's favorite because she was seen by him as the scholarly one
and the "good girl." She always felt loved by her father, but with the tacit
understanding that this love was conditional upon her being the "good
girl." She was convinced that her father believed she was still a virgin and
would deny any contrary information. She also expressed the belief that
she would be rejected by him were he aware that she was not conforming
to his expectations. Her mother was described as a "flashy dresser,"
somewhat hysterical and self-centered.
This picture of an average middle-class family is shattered by the
information that between ages four and five, the patient was physically
abused by her mother in reaction to what mother described as defiance
and misbehavior. The patient had absolutely no memory for these events
but was told by her mother—and this was confirmed by her father—that
during this time mother had been ordered by the court to seek psychi-
atric treatment (which she did) and was warned that her child would be
taken from her if the physical abuse continued. At that time, the patient
began treatment with a psychologist that she thought lasted for about a
year. She also had no memories at all of this experience. After the mother
entered psychiatric treatment, the child abuse stopped. The patient
reported that she had never been able to obtain a clear picture of her
father's role during this period or the specific circumstances that led to
intervention by the court.

Description of Treatment

Psychodynamically oriented psychotherapy was carried out on a once-

a-week basis for a period of nine months. It was known all along by both
therapist and patient that treatment would likely terminate after nine
96 . Morris Eagle

months because of the patient's plan, which had been made prior to
therapy, to continue her graduate studies in another city. However,
whether or not the patient would be admitted to the program to which
she applied was uncertain.
The initial sessions were taken up with the issue of whether the patient
could trust me and with expressions of futility regarding whether she
could be helped. Why I should be interested in her and how a concrete
symptom could change "just by talking" were frequent themes during the
first couple of months of treatment.
The next phase of therapy dealt mainly with two issues: the continu-
ing experience of her sexual symptom in her ongoing sexual relationships
with men and an exploration of her relationship with her parents,
particularly with her father. The main theme here was the need to be a
"good girl" and to submit to father's wishes in order to continue receiving
his love and approval. I made interpretations linking "submission" to
father and the experience of the sexual act as a "grin and bear it"
submission to the wishes of men. The patient generally accepted the
above interpretations as useful and enlightening but noted that the
sexual symptoms continued "even though I can understand some of the
connections." The patient's behavior continued to be that of enduring
the pain that she experienced during sexual intercourse, without any
protest or without informing her sexual partner of her pain. Indeed, she
felt that it was important that she hide her symptoms from the man lest
he reject her.
The patient spoke mainly about her father and tended to say little
about her mother or her relationship with her. As already noted, the
patient had complete amnesia for her early experiences of abuse and
seemed to experience virtually no connection between the mother who
was the abuser and the current image and description of mother. On a
few occasions, I linked her sexual symptoms to her early experiences of
physical abuse. Just as, early on, defiance of mother had been followed by
punishment and pain, so now, too, the sexual act, experienced as
defiance (that is, it violated father's need to see her as a virgin and a "good
girl"), was followed by pain. In one session, in response to this interpre-
tation, the patient reported the following: very frequently, before sexual
intercourse, the defiant phrase "If they could see me now" occurred to her
in an unbidden, obsessive manner. She made it clear that the "they" in
the phrase were her parents. This association made my interpretation
linking defiance and pain very real and convincing to the patient.
Enactments, Transference, Symptomatic Cure 97

I found little opportunity to make transference interpretations (of

interactions in which the above pattern was enacted with me), and the
few times I did make such interpretations, they were rejected impatiently
and somewhat angrily. On a couple of occasions, she referred to "that
Freudian crap—where I'm supposed to have all sorts of feelings for you."
At around the time of the above interpretations, the patient began a
relationship with a new man in whom she seemed quite interested and
expressed the usual anticipatory anxiety about the inevitability of sexual
intercourse and the pain and anxiety that would accompany it and the
inevitable feelings of rejection and defeat that would follow. I made the
comment that while rejection by the man could follow upon his knowl-
edge of her symptom, I questioned the assumption that such rejection
was inevitable. I also pointed once again to her feeling that she must
submit and endure (again, linking it to her relationship with father), that
is, that she had to continue with the sexual act even when it was very
painful. The patient responded by repeating her fear that if she did not
continue with intercourse, she would be rejected by her partner. As I
reflect upon my intervention here, it is clear that it is as much a thinly
disguised directive as an interpretation.
In the following session, the patient reported, enthusiastically and
happily, that she had talked to her new boyfriend about her sexual
problem and that he reacted with understanding and acceptance. Also,
during their last sexual encounter, when the pain became intense, she
had asked him to stop temporarily and he reacted with understanding.
Although her symptom persisted, she expressed some happiness at the
greater freedom available to her and reported that for the first time that
she could recall, she felt hopeful about changing. During the next few
weeks, however, the hopefulness and good mood palled somewhat in the
face of the continuation of the symptom.

A Critical Event

At this point in the therapy, something occurred that, it turned out, had
an important impact upon the patient and the treatment. As noted, the
patient had total amnesia for the physical abuse by her mother. Refer-
ences to this experience came up frequently during the therapy, but there
were never any accompanying memories and we never went anywhere
with it.
98 Morris Eagle

I felt, perhaps incorrectly, that it was important that at least some

memories of the patient's experience of abuse be recovered. It also seemed
likely that there were important connections between the patient's
dyspareunia symptom and the physical abuse she experienced as a child.
I have already noted the thematic connection, namely, defiance followed
by punishment and pain. I felt impatient in response to the failure to
recover any memories connected with the abuse and suggested to the
patient that she try the couch, which, I thought, might help recover some
early memories or, at least, associations to the events surrounding her
abuse by her mother. The patient reacted to this with intense anger,
comparing my suggestion with the "gimmicks" of her previous behavior
therapist. During this outburst of anger, my reaction was silence—I said
nothing and made no interpretation. The hour came to a close, and the
patient left the session still quite angry.
As my process notes reveal, my decision to remain silent and not
interpret the patient's outburst of anger was based on the following
considerations. As noted, the patient consistently rejected any transfer-
ence interpretations, and I expected that she would also reject any
interpretations in relation to her anger at me. Also, in her description of
the pattern of her relationship with men, the patient had described her
contemptuous reaction when the man at whom her anger was directed
would attempt to question the reasons for her anger. She would take
such behavior as attempts to mollify and appease her and would react
with contempt. I remember having three fleeting thoughts: (1) something
important was going on, and because I was not too clear about what it
was, I would remain silent; (2) by my silence I was protecting myself from
the patient's contempt; and (3) I was also protecting the patient from her
own contemptuousness and her feared consequences of such contemp-
tuousness.
The patient came to the next session and said that she felt that she had
"overreacted" during the previous hour. She also said that she had
thought about my suggestion that she use the couch, felt uncomfortable
and somewhat frightened at the idea, and did not feel ready for that at
present. I accepted her comments, again without interpretation, and we
continued with treatment.
The very next session the patient came in elated and announced that
the night before she had experienced sexual intercourse (with her new
boyfriend referred to earlier) without pain for the first time in her life.
She expressed both elation and fear that it "was all too good to be true"
Enactments, Transference, Symptomatic Cure 99

and "wouldn't last." She also informed me that she and her boyfriend
were due to go away that weekend and she saw that as a kind of test of the
lastingness of her new freedom from her symptom.
The patient returned from the weekend, again elated, and reported
that the symptom had not returned and that sexual intercourse was even
enjoyable. During the remaining few months that therapy continued,
the symptom did not return and the patient began to feel more confident
that her new experience was a secure one. During this time, the major
themes dealt with in therapy were the relationship difficulties with her
boyfriend and the impending termination of the therapy (at this time,
the patient learned that she had been accepted to the program to which
she had applied). With regard to the boyfriend, it became apparent to the
patient that he was highly ambivalent and was looking for a way to end
the relationship. The patient dealt with this issue in a relatively mature
way and observed that her handling of this situation was different from
her past patterns.
Toward the end of therapy, the patient told me what she thought
accounted for the disappearance of her symptom. She said that the
session during which she became enraged at my suggestion that she use
the couch was a "turning point" in the therapy. She informed me that
after she left that session, she kept repeating to herself, "But, he didn't say
anything" (referring to my silence in the face of her anger), and she felt
that she had "overreacted" to my couch suggestion. She related this
"overreaction" to her general pattern with men. Her description of the
value to her of my silence read like a classic psychoanalytic account of the
therapist's neutral stance. It should be clear, however, that this patient
had read nothing of these accounts and was describing her own experi-
ences.
As of the writing of this paper, many years have elapsed since the
termination of therapy, and the patient has kept in touch with me during
this period with an occasional letter. She reports that her symptom has
not reappeared, that she is happily married, and that she feels generally
better and better able to cope with situations that have arisen.

What Went on in the "Turning Point"?

When I first wrote this paper and tried to account for the dramatic
disappearance of the patient's symptom, I focused on the role of my
100 Morris Eagle

silence and neutrality (and the patient's repeated comment to herself,

"But he didn't say anything") in helping the patient confront her
transference distortions and the degree to which her rage was inappro-
priate to the current situation. This idea was somewhat supported by the
patient's comment that the "critical" session was a "turning point" partly
because following that session she really attended, perhaps for the first
time in the treatment, to what was going on inside her (why she was so
enraged). I also understood the critical session and the subsequent
disappearance of the patient's symptom as involving an enactment in the
treatment of the patient's core dynamic theme. I continue to believe that
both above factors are important. As I reread my process notes and
thought about this case again, however, I was amazed at the interactional
drama, the transference-countertransference dance, I had overlooked.
It is now clear to me that my suggestion that the patient use the couch
was an inappropriate one, partly because I was suddenly changing the
terms and conditions of the treatment. As I have indicated, however,
this session was followed by a dramatic disappearance of the patient's
symptom. Surely, there is a connection between these events. But what
kind of connection? I understand the sequence of events in the following
way.
The patient experienced my suggestion regarding the couch as an
invitation (more likely, as a demand) that she submit sexually. She
reacted to this invitation or demand with defiance and rage. As we have
seen, a core theme in the patient's life is that defiance is followed by pain
and punishment. This time, however, pain and punishment did not
follow—therapy simply continued. The patient expressed this idea with
the recurrent thought "But, he didn't say anything" after the critical
session. In describing this recurrent thought, the patient made clear to
me that the meaning of the thought was that I did not react with outrage
to her defiance and rage—in short, that I did not punish her defiance (by
terminating the treatment). Keep in mind that this basic theme of
defiance followed by punishment characterized her early relationship
with her mother, her long-term relationship with her father, and her
current relationship with men. In all these relationships, the patient felt
that she had to submit and comply in order to receive love and/or avoid
rejection and punishment.
My questioning the patient's assumption that sharing her sexual
problem with her boyfriend would inevitably lead to his rejection of her
and my raising the question of why she did not stop sexual intercourse if
Enactments, Transference, Symptomatic Cure 101

it became too painfiil may have helped to break the chain of submission,
pain, and rage. The boyfriend's actual positive reaction probably also
helped. But neither of these experiences, by itself, led to removal of the
symptom, although they may have prepared the ground and, in interac-
tion with the "critical event," contributed to the eventual disappearance
of the symptom. To use the patient's own words, the "turning point"
came when she could reject my couch suggestion, which to her meant
sexual submission, and find that despite her rage and refusal to comply
with my suggestion, therapy and the therapeutic relationship continued.
In going over my process notes in preparation for this paper, I found
some material that I had missed in my original version of the paper,
material that sheds important light on what preceded the critical session
and on the transference-countertransference interaction between the
patient and myself.
For a period of time, I had noticed the patient's habit of unbuttoning
and buttoning a button of her blouse during the sessions but did not
comment on it. A few weeks prior to the critical session, she unbuttoned
and left unbuttoned two buttons so that the top of her brassiere was
visible. When I did finally comment on this apparently distracted "habit,"
the patient dismissed my observation as "Freudian crap." It is clear to me
now that my suggestion that the patient use the couch was, in part at
least, an unconscious response to her earlier seductive behavior of
unbuttoning her blouse. Thus, to a certain extent, the patient's construal
of my suggestion as a sexual cue was justified. What she was not aware of,
however (and neither was I), was her earlier seductive "invitation" to me
and its link to my suggestion to use the couch. So we have here an
unconscious transference-countertransference "dance" in which the pa-
tient offers a seductive invitation that I accept and act on. These
interactions and communications were taking place without either the
patient's or my conscious awareness of them.
I want to note here parenthetically a shift in my conception (which
parallels a shift on the part of many others in our field) of transference
from the original to the current version of this paper. In the original
version, I understood the patient's enraged reaction to my couch sugges-
tion as a clear case of the patient's transference distortion of me. After all,
was she not reacting to me as if I were her punitive mother or her
compliance-demanding father? Viewing transference, however, as a
more interactional phenomenon in which, as Gill (1982) points out, the
patient elaborates and imbues with personal meanings actual cues pro-
102 Morris Eagle

vided by the therapist permitted me to understand better that the

patient's rage reaction was not a simple distortion but a response to the
sexually tinged nature of my invitation. I would add that, as in the
present case, the therapist's "cues" can, in turn, represent a response to
the patient's unconscious "invitations." In short, the transference-
countertransference reactions and the cues that elicit them are best
understood not in a linear fashion but as a continuous sequence of
circular processes.1
Although my suggestion regarding the couch was, I am now con-
vinced, clearly the product of countertransference, it nevertheless even-
tually played a salutary role in the disappearance of the patient's symp-
tom. Why and how did that happen? Let me speculate on some of the
reasons for this salutory outcome. The theoretical frarriework for my
speculations is Weiss et al.'s (1986) "control-mastery" theory. In the
context of that theory, one reasonable way of understanding the pa-
tient's "habit" of unbuttoning and buttoning her blouse is as a test of my
1
Recently, I came across an article by Jacobs (1986) on "countertransference enact-
ments" that bears directly on this issue. What Jacobs refers to by this term is not the
countertransference reactions that are "noisy" and blatant and most frequently discussed
in the literature but those aspects of countertransference that are expressed subtly
through such dimensions as vocal qualities, ways of listening, choice and tone of
interpretations, choice of material on which to focus, decisions regarding termination,
and so on.
Jacobs points out that even "correct" and proper analytic elements such as, for example,
empathic listening, "correct" interpretations, focus on the transference, and neutrality
can constitute subtle expressions of countertransference reactions and can communicate
subtle cues to the patient. What Jacobs makes strikingly clear in this paper is the myriad
and pervasive ways in which nonobvious and "silent" countertransference reactions—
including behavior that implements proper technique—enter into the analyst's behavior
and generate unconscious cues communicated to the patient. It seems to me that implicit
in Jacobs's paper are the related ideas that (1) countertransference should be thought of
as a continuum and (2) much, if not all, of the analyst's behavior falls somewhere on this
continuum and contains at least some countertransference elements. It can also be seen
that Jacobs's description is entirely congruent with Gill's (1982) claim that the patient-
therapist interaction always contains elements of a transference-countertransference
dance in which each participant's reaction is a product of his or her construal of the cues
communicated by the other.
I have identified only a small sample of the ongoing transference-countertransference
interactions in this paper. Had I been more aware of this ubiquitous issue at the time of
the psychotherapy work with my patient, I might have noted and been able to describe
in this paper the more subtle ways in which 1 encourage (and discourage) other aspects of
the patient's behavior.
Enactments, Transference, Symptomatic Cure 103

seducibility. In fact, one can think of the blouse unbuttoning behavior as

a series of tests in which the ante is increased. That is, for a while, one
button is unbuttoned and then buttoned. I do not respond to this
behavior at all, which could, perhaps, be viewed as passing a test, insofar
as my response is pretty neutral. Neither am I being seduced, nor am I
being punitive. The ante is then upped: two buttons are now unbut-
toned, and they remain unbuttoned. After initially passing this test, too,
I then fail the test by making a suggestion that can readily be experienced
as seductive (or, at least, as colluding with the patient's seductiveness).
The patient reacts to my failure with rage and disappointment in me. By
remaining silent, however, by expressing understanding (in the next
session) of her refusal to use the couch, and by simply continuing the
therapy, I pass the more basic test related to the core defiance-
punishment theme. That is, I am neither punitive nor destroyed in
response to her defiance and anger but simply continue the therapy, with
the result that she experiences the sequence of events as a "turning point"
and that her deeply distressing symptom disappears.2
This may seem far-fetched, but I wondered when I reread my process
notes whether the patient unconsciously wanted me to fail the
seducibility test so that we could set up the more important and core test
involving defiance and punishment. There is room for this sort of
possibility in Weiss and Sampson's concept of the patient's "unconscious
plan." In contrast to Weiss and Sampson's research reports, however, I do
not have reliable data to support this idea, and it must remain, therefore,
as perhaps a far-fetched speculation.
It should be noted that virtually everything I have described occurred
without obvious emergence of unconscious material into consciousness
2
I do not believe, nor do I want to give the impression, that the couch incident was the
only factor that led to the disappearance of the symptom. There were undoubtedly other
experiences both within and outside the therapy that contributed cumulatively to this
outcome—for example, the earlier interpretations of, and insight into, the link between
defiance and punishment-pain (highlighted by the patient's report and understanding of
her obsessive thought, "If they could see me now," prior to sexual intercourse) and her
ability to confide the nature of her symptom to her new boyfriend and to ask him to
withdraw when she experienced vaginal pain. These experiences probably helped her to
become aware of, and begin to deal with, her deeply held conviction that defiance and
assertion were necessarily followed by punishment and pain. I do believe, however, that
the intensely emotional interaction with me represented a further and decisive contribu-
tion (and, therefore, a turning point) to the disruption of the defiance-pain link and,
hence, to the dramatic removal of the symptom.
104 Morris Eagle

and without specific and clear insight into what was being enacted. In
this regard, this case is somewhat different from the typical examples
discussed by Weiss and Sampson in which the conscious emergence of
warded off contents is a consequence of test passing and is a critical step
in the achievement of therapeutic improvement. In the present case,
passing of a critical test was followed not by such an intervening step but
directly by disappearance of the presenting symptom.
The patient did achieve a somewhat intellectualized insight into the
way in which the defiance-punishment dynamic characterized her rela-
tionship with mother and father and her sexual relationship with men.
This insight was useful in "making sense" of her symptom, in particular,
in relating it to her lifelong interpersonal patterns. As I have described,
however, the enactment of the core pattern in the therapy, rather than
the patient's insight into that pattern, had the major impact on the
patient's positive therapeutic outcome. Furthermore, as far as I could tell,
the patient never did achieve any significant insight into the degree to
which she was enacting with me her core conflict relationship theme
(Luborsky, 1984).
I understand the patient's improvement as the result of what can be
broadly referred to as a "corrective emotional experience" (Alexander
and French, 1946), but one in which the concept is elaborated and
developed so that it includes the kinds of considerations—such as test
passing, test failing, and unconscious plans—highlighted by Weiss et al.
(1986). That is, quite often (perhaps always), a "corrective emotional
experience" is best understood not simply as the result of a therapist's
responding in a therapeutic and corrective way to a patient—for exam-
ple, in a manner that is different from the patient's "neurotic" expecta-
tions—but rather as the result of a subtle and complex interaction in
which the patient is actively engaging in a variety of activities that elicit
the "corrective" behavior from the therapist.
It seems to me that this case suggests that positive therapeutic outcome
can occur through transference enactments rather than always requiring
direct interpretation and analysis of the transference. Findings consis-
tent with this conclusion have also been reported by Weiss et al. (1986),
who note that emergence of warded off contents and other improved
behavior can occur without interpretation, directly as a consequence of
test passing. Indeed, in the context of control-mastery theory, test
passing and other "corrective emotional experiences" can be understood
as involving implicit interpretations or at least implicit communications.
Enactments, Transference, Symptomatic Cure 105

Thus, the therapist's test-passing behavior involves an implicit commu-

nication that disconfirms an unconscious pathogenic belief. In the
present case, my benignly neutral reaction to the patient's defiance and
anger constituted a "silent" and implicit interpretation to the effect that
defiance need not be followed by punishment and pain. Indeed, that kind
of implicit communication is perhaps the core component of a "corrective
emotional experience." And it appears that that communication need
not be made explicit in order for it to function therapeutically.

"Transference Cure"

Positive therapeutic outcomes of the kind I have described in this paper

have often been referred to as "transference cures" in the classical
psychoanalytic literature. Indeed, the conclusion that a "transference
cure" had occurred was the modal response when I presented this case to
a psychoanalytic institute with which I am associated. What is most often
meant by transference cure in the literature is a cure that is the direct
result of the transference rather than of insight and the resolution of
conflict. It is also often assumed that such a cure is more superficial and
more ephemeral.
It seems to me that the whole concept of transference cure and the
radical dichotomy between transference cure and a "real" cure need to be
reexamined. The more recent emphasis in the psychoanalytic literature
on the curative effects of the therapeutic relationship suggests that it is
increasingly difficult, even from a theoretical point of view, to make a
hard-and-fast distinction between a transference cure and a presumably
genuine psychoanalytic cure. Furthermore, unless one establishes reli-
able criteria (e.g., lastingness of therapeutic change, capacity for self-
observation, relative immunity to future stresses), a radical distinction
between the two is not very meaningful.

"Misalliance Cure"

It is also possible to understand the events I have described as a

"misalliance cure" (Langs, 1973), that is, a "cure" that is mainly the
product of the therapist's "deviations" and a mutual acting out and
106 Morris Eagle

avoidance on the part of both patient and therapist. Although the con-
cept of "misalliance cure" may, in principle, have some important and
defensible meaning, I suspect that it would be extremely difficult to secure
reliable identifications of its presence. Also, the concept of "misalliance
cure," particularly when it is applied too liberally, implies that there is a
correct psychoanalytic or psychotherapeutic technique and that any de-
viation from it carries the risk of leading to this false kind of cure. It also
implies that we know enough not only to make clear distinctions between
a genuine and a false cure but also to specify the kinds of therapeutic
interventions that lead to one or the other type of cure. Only if one is very
certain regarding what constitutes the "correct" kind of intervention can
one feel very confident about what constitutes a "deviation." Also, I
strongly suspect that most therapeutic situations are sufficiently complex
so that they include all sorts of subtle "deviations" and interactions of the
kind I have described in this paper (see Jacobs, 1986).
The very idea of "deviations" (resulting in "misalliance cures") often
seems to involve the application or perhaps imposition of principles
derived from "classical" psychoanalytic technique to all forms of
psychodynamic psychotherapy. Interventions that may constitute a
"deviation" or "misalliance cure" in the "classical" psychoanalytic context
(and I am not at all sure that it is uniformly justified even in that context)
do not necessarily do so in the context of psychodynamic psychotherapy.
In short, although they may, at times, point to important phenomena,
both concepts of "transference cure" and "misalliance cure" often imply a
degree of precision and of knowledge about what goes on and what is
supposed to go on in the therapeutic process that is simply not warranted
by the facts.
Finally and ironically, what is known about the therapeutic process
suggests that what some see as a "transference cure" may well be one of
the more effective ingredients in therapeutic outcome. That is, the
patient's experience of the therapist as helpful and supportive is one of
the treatment process variables that are significantly related to positive
therapeutic outcome (e.g., Luborsky et al., 1988).

Conceptions of Transference

According to the traditional Freudian view, transference reactions are

primarily the result of the ever-present press for discharge of infantile
Enactments, Transference, Symptomatic Cure 107

instinctual urges, the particular mobilization of such urges by the regres-

sive features of the therapeutic situation, and the ubiquitous presence
and strength of resistance characterized by the patient's push to gratify
rather than remember (the conflictful urges). From this traditional
perspective, my patient's seductive behavior can readily be seen mainly as
an attempt to express and gratify sexual urges and aims.
One can contrast the above traditional conception to one proposed by
Weiss et al. (1986) in which the essence of transference reactions is found
in the patient's attempts not to gratify unconscious instinctual wishes but
to disconfirm unconscious pathogenic beliefs. In this latter conception,
transference reactions do not necessarily constitute peremptory drive
expressions, resistances, and the obligation "to repeat . . . instead of
remembering" (Freud, 1914, p. 151). Rather, they may represent enact-
ments of core relationship themes along with the unconscious aims of (1)
evoking responses from the therapist that are different from the (experi-
enced) responses of parental figures and (2) mastering early pathogenic
beliefs, anxieties, and conflicts (see Freud, 1920, pp. 16-17, on the issues
of mastery).
Luborsky et al. (1988) recently reported some data that seem to
support the above view. Luborsky and his colleagues have developed the
Core Conflictual Relationship Theme (CCRT) method in which the
relationship episodes described by the patient are scored for the wish or
need expressed (W), the experienced and anticipated reaction of the
other (RO), and the consequent reaction of the self (RS). They found
that even in successful treatment the patient's core wishes remain
relatively unchanged. Rather, what changes is the experienced responses
from the other (RO) and the subsequent responses from the self (RS).
Patients' experienced negative response from other and consequent
negative response from the self decrease from early to late in treatment.
Contrastingly, experienced positive response from the other and conse-
quent positive response from the self increase from early to late in
treatment. Furthermore, these changes in the course of treatment tend to
be correlated with changes in symptoms, suggesting that they are indexes
of good therapeutic outcomes. As Luborsky et al. (1988) put it:

Apparently, tendencies toward certain wishes, needs, and intentions

in relationships are relatively intractable, yet the expectations of
others' gratifying or blocking one's wishes and the consequential
emotional responses to these actions or expectations have more flexi-
108 Morris Eagle

bility or malleability. Patients of a successful therapy learn to recognize

and cope with their inclinations in a way that leads to fewer negative
and more positive responses [p. 259].

(Note that this is very different from the picture painted by classical
psychoanalytic theory in which successful treatment is characterized by
the patient's relinquishment of hitherto intractable infantile wishes; e.g.,
see Waelder, 1960.)
I noted earlier Luborsky et al.'s (1988) finding regarding the relation-
ship between positive outcome and the patient's experience of the
therapist as helpful and supportive. If one combines that finding with the
above findings on changes in negative and positive responses from other
and self, one can hypothesize that a critical factor in effecting changes in
the expected response from the other is the therapist's supportive and
accepting response to the patient's expression of his or her needs and
wishes. Thus, successful treatment need result not in relinquishment of
needs and wishes but rather in a greater expectation and confidence that
one's needs and wishes will be responded to positively by the other.3
This may not apply to all needs and wishes expressed in treatment—
some, indeed, may need to be relinquished. In the present context,
however, the point to be made is that transference reactions do not
consist solely in attempts to gratify instinctual wishes but also consist in
attempts to evoke from the therapist constructive responses to one's
wishes and needs, to disconfirm pathogenic beliefs, and to master
anxieties and conflicts.

Analysis of the Transference

In coming to the end of this paper, I want to turn to the issue of the role
of analysis of the transference in therapeutic outcome. Interpretations of
the transference have been held by many to be more primary and more
3
It is important to point out here that Luborsky et al. (1988) do not distinguish between
inappropriate infantile wishes and age-appropriate wishes (e.g., wish to be accepted) and
that the latter kinds of wishes seem most frequently represented in the relationship
episodes discussed by Luborsky and his colleagues. Furthermore, my impression is that
most of the wishes discussed by Luborsky in his CCRT method are conscious (or at least
preconscious) rather than unconscious.
Enactments, Transference, Symptomatic Cure 109

imitative (indeed, for some, only transference interpretations are thera-

peutically useful) than other interpretations for a number of reasons. For
example, as Strachey already noted in 1934, transference interpretations
are more likely to have a here-and-now emotional immediacy often
lacking in other interpretations (see Gill, 1982). It seems to me, however,
that as one's conception of transference changes, one's conception of the
role and nature of transference interpretations also changes. As long as
one conceptualizes transference solely in terms of the patient's distortions
and his or her attempts to gratify infantile instinctual wishes as well as
the defenses and conflicts surrounding these wishes, it would follow that
interpretations of transference are primary and constitute the major
mode of treatment. For it is the conglomerate of the patient's wishes,
defenses, conflicts, and distortions expressed in the transference that
constitutes a replica of his or her neurosis and that therefore must be
analyzed. If, however, the conceptualization of transference is broadened
to include such factors as testing the therapist, unconscious plans, and
enactments that are at least partly geared to disconfirming pathogenic
beliefs and to mastering conflicts and anxieties, then one need not view
explicit interpretations of transference reactions as the primary aspect of
psychodynamic psychotherapy. As I have tried to show in this paper—
and implicitly in Weiss and Sampson's mastery control theory—certain
enactments between patient and therapist, to the extent that they
constitute "corrective emotional experiences," test passing, and the pro-
vision of conditions of safety, can function as "silent" and emotionally
powerful interpretations that contribute to the disco nfirmation of patho-
genic beliefs and the mastery of early anxieties and conflicts.

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Department of Applied Psychology.

O.I.S.E., University of Toronto
252 Bloor St. W.
Toronto, Ontario
M5S IV6