Enactment and the Treatment

of Abuse Survivors
Eric M. Plakun, MD, FAPA
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Regardless of the approach employed, treatment of patients with histories of sexual or

other abuse is a formidable challenge. One reason for this is the vulnerability to
“enactment” inherent in therapeutic work with such patients. Enactment is a recently
elaborated psychoanalytic notion, defined as a pattern of nonverbal interactional
behavior between the two parties in a therapeutic situation, with unconscious meaning
for both. It involves mutual projective identification between therapist and patient. This
paper clarifies the nature of enactment (conceptualizedhere as involving either refusal
or actualization of the transference by the therapist) and its treatment implications.
Transference-countedransferenceenactment paradigms encountered in work with sur-
vivors of abuse are presented.The therapeutic consequences of failing to recognize and
For personal use only.

respond to such enactments in work with these patients are explored. Unrecognized
enactments may lead therapists unwittingly to abdicate the therapeutic role by becom-
ing abusive, abused or vicariously traumatized, excessively guilty, seductive, overin-
volved, and/or exhortatory or to implant false memories. Ways of utilizing enactment to
advance treatment are also described and illustrated. (Harvard Rev Psychiatry 19985:
3 18-25.)

We in the world of behavioral health treatment are living in treatment of survivors of sexual, physical, or other kinds of
interesting times. Significant and perhaps unprecedented abuse.
advances in the understanding of disorders and the efficacy Some patients with abuse histories present with symp-
of treatment are occurring just as the limits of the resources toms of posttraumatic stress disorder, and allegations of
available to fund treatment are being reached.l Treatment abuse are also common in the histories of patients with
has been scaled back in numerous ways,24 and the focus of borderline personality d i ~ o r d e r . ”Some
~ patients meet cri-
treatment has become reducing symptoms and changing teria for both disorders. The treatment of the consequences
behaviors-often without paying attention to the context of abuse, particularly posttraumatic stress disorder and
and meaning of such symptoms and behaviors. The clinical borderline personality disorder, has generated considerable
wisdom of a century of work in psychoanalytic theory has interest over the last decade. Researchers have made
sometimes been forgotten. One of the areas in which this progress in understanding the psychobiology of trauma and
may pose a significant but remediable problem is in the at the same time have improved the psychopharmacological
treatment of these patients.’ Nevertheless, the difficulty of
working with patients with abuse histories remains consid-
From the Erik H. Erikson Institute for Education and Research, erable.
Austen Riggs Center, Stockbridge, Mass., and the Department of A trauma-based model of the psychopathology of disor-
Psychiatry, Harvard Medical School, Boston, Mass.
ders related to abuse has emerged and has influenced many
Original manuscript received 12 June 1997, accepted for publica- c l i n i c i a n ~ . ~As
J ~Piers’l and Lewis” have suggested, these
tion 4 August 1997; revised manuscript received 17September 1997. trauma-based models emphasize the etiologic significance
of an encasing or dissociation of trauma, with “the patient
Reprint requests: Eric M. Plakun, MD, FAPA, Austen Riggs Center, conceptualized as a passive and helpless transmitter of a
25 Main St., P.O. Box 962, Stockbridge, M A 01262.
past traumatic experience.”ll Piersll noted that following
Copyright 0 I998 by Harvard Medical School. this etiologic model leads to a conceptualization of treat-
ment of trauma survivors as a “corrective relational
1067-3229 f 98 /$5.O0 +0 3911187421 experience,” in which traumatic memories are detected,
318
 Harvard Rev Psychiatry
Volume 5, Number 6 Plakun 319

recovered through abreaction, and reintegrated into non- labeling suggests that we remain objective and uninvolved,
dissociated memory states. Piers also suggested that this the term has come to connote a behavior that we do not like.
approach, by placing the patient in a passive victimized Should we find ourselves having a reaction to the pa-
role, fails to attend to the major contribution of character tient’s behavior, we speak of our “countertransference.”The
both to the manifestations of these disorders and to the contributions of Heimann15 and Racker16 broadened
process of treatment. Freud’s earliest notion of countertransference as the ana-
Cognitive-behavioral treatments such as dialectical be- lyst’s transference to the patient into the modern concept
havior therapy13 are often prescribed for these patients. that involves the totality of the analyst’s response to the
Like the trauma-based treatment models, cognitive- patient. This includes both the kind of response that any
behavioral treatments tend to deemphasize the role of reasonable individual would have to a behavior (e.g., anger
character in psychopathology, as well as the role of inter- at a patient who has smashed something of value in our
pretation of meaning in treatment. This paper offers a point office) and the uniquely personal reaction that is reflective
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of view relevant to understanding the limitations of any of our own neurotic conflicts (our own “transference” to the
trauma-based or cognitive-behavioral model of treatment patient). In the first case the countertransference is elicited
that fails to attend to one product of character, the interac- in us as it would be in any other clinician in response to the
tional process i n both patient and therapist that is particu- patient’s action; in the second our own blind spots and areas
larly common in therapeutic work with patients with his- of conflict are an essential component.
tories of abuse and/or clinical presentations that suggest an From time to time analysts speak of “actualization of the
abuse history. transference,” a term that refers to an unfortunate coinci-
dence in which the reality of the therapeutic relationship
THE CONCEPT OF ENACTMENT duplicates the transference. An example is a patient, strug-
gling painfully with having been orphaned as a child when
For personal use only.

Enactment as a psychoanalytic concept represents an elab- both parents died in a motor vehicle accident, whose ther-
oration and extension of terms that have become part of the apist is seriously injured in an automobile accident and
everyday lexicon of most clinicians. This elaboration moves must interrupt the therapy sessions for several weeks.
toward recognition of the importance of the therapist’s Like “countertransference,” “projective identification”
participation in the phenomena unfolding in the therapeu- has gone through an extension and elaboration to include
tic situation. Enactments are not limited to psychoanalysis both patient and therapist. Initially, psychoanalytic
or psychodynamic psychotherapy any more than are trans- theorists16-19used this term to signify a defense in which a
ference or countertransference. All of these processes occur patient disavows an intolerable affect in himself or herself,
in all kinds of therapeutic settings, including individual, instead projecting it into a therapist, who is conceptualized
family, and group psychotherapies of every variety, a s well a s a neutral, passive, uninvolved antenna. A familiar ex-
as in medical model psychopharmacologica1 treatments. ample is the borderline patient who accuses a therapist of
Thase and Howland14 have noted the importance of abandonment after the patient has missed a session. Over
psychosocial factors in treatment-refractory depression. In time “projective identification” has been elaborated by the-
my own 20 years of experience consulting to patients with orists like Shapiro and Carr,20whose eight components of
failed treatments, unrecognized enactment has proven to be projective identification include notions of the therapist
a leading psychosocial contributor to this syndrome. Models having “an attribute that corresponds” to one that is dis-
of treatment may omit dealing with the possibility of avowed by the patient, “an unconscious collusion” with the
enactment, but omitting enactment from conceptualization process that sustains the projection, and a “complementar-
does not eliminate its impact on the treatment alliance or ity of projections-both participants project.” This increas-
on treatment outcome. Since enactments are inevitable and ing recognition of the therapist’s participation is essential
ubiquitous therapeutic phenomena, their detection, analy- in the extension of the concept of projective identification
sis, and interpretation offer an opportunity t o understand into the concept of enactment and the key t o its importance
something in a new way o r t o turn a corner in treatment. and therapeutic utility.
Understanding enactment requires differentiating it In the early 1990s McLaughlinzl and otherszz used the
from similar terms that have preceded it historically. “Act- ordinary English word “enactment” in a particular way to
ing out,” for example, is a term familiar even to nonclini- delineate a pattern of nonverbal interactional behavior
cians, signifying a defense employed by a patient who puts between therapist and patient that has unconscious mean-
an affect or impulse into action rather than words in a way ing for both parties. One might think of enactment as a
that assaults the boundaries of the therapeutic alliance multistep process in which there is first the usual “reenact-
and/or resists the therapeutic task. Note that acting out is ment” in the transference relationship of part of the pa-
a label given t o the patient’s behavior. Although the act of tient’s conflicted o r traumatic past. Freud captured this
 HaNard Rev Psychiatry
320 Plakun March/April 1998

part of the process of enactment in the notion of the instead of looking a t her; his attention drifted in and out of
“repetition compulsion.” However, in a n enactment the the hour. He realized that his musings as he drifted often
patient’s associated unconscious affects are next disavowed included feeling self-righteously sorry for himself and re-
and projected into the therapist. Again, this is familiar luctant to return his attention to the patient. As he followed
terrain for dynamically oriented clinicians. Enactment be- his associations, the therapist realized he was reenacting
gins to become a unique concept, though, when the thera- his own painful childhood experience of feeling unjustly
pist then unwittingly participates by projecting back into criticized for failing whether or not he earnestly tried to do
the patient reciprocal unconscious conflicted countertrans- things right. He recalled with satisfaction the childhood
ference material from the therapist’s own life history. The experience of feeling sorry for himself captured in the
therapist inadvertently colludes with the patient in a pro- expression “damned if I do and damned if I don’t,’’ then
cess of mutual projective identification organized primarily recognized that this phrase often ran through his mind as
but not exclusively around the patient’s life history. Within he struggled with the patient’s responses to his words and
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such a n enactment the therapist is as much an active his silences. As a child he had learned to excel at school,
participant as the patient. where his efforts were rewarded by teachers and admired
Understanding the concept of enactment is facilitated by by peers rather than criticized. Eventually this pleasure in
recalling a relevant feature of the therapeutic role in competence and achievement became linked to his choice of
psychodynamic psychotherapy. The interpretive work of a career as a therapist. In fact, excelling in the ability to
psychodynamic psychotherapy is carried out from a position make precise interpretations was a source of considerable
of technical neutrality. For the current purpose the perti- self-esteem. Having a patient who complained about both
nent area of technical neutrality is the therapist’s comfort- his silences and his precise interpretations deprived him of
able and unflinching acceptance of the patient’s transfer- a sense of competence.
ences. Although such technical neutrality is the ideal, those The therapist realized that he was retreating from being
For personal use only.

who work in psychodynamic psychotherapy know that re- with Ms. A. by gazing out the window and regressing from
maining able to bear intense and often negative transfer- his therapeutic role to his earlier state of feeling “damned if
ences from a patient is often more easily said than done. In I do and damned if I don’t.’’ Further, although he had been
enactments the therapist may be thought of as joining the aware of the transferences to him as abusive mother and
patient in a process that moves the therapist away from the abandoning father, he had not previously recognized the
neutral acceptance of the transference. way in which his own need to excel academically was
A clinical example illustrates the concept of enactment. shaping his verbal and nonverbal behavior in the sessions.
Ms. A. was a 40-year-old widow with borderline personality He realized that in the transference he was not just the
disorder and recurrent major depression who entered three- abusing and abandoning parents, but also the parent who
times-weekly psychodynamic psychotherapy because of es- was smart, wise, and precise enough to know just how
calating suicidal and self-destructive behavior that was stupid, awful, and dirty the patient was. This latter trans-
part of a treatment-resistant depression. Ms. A.’s parents ference was particularly personally objectionable for him
were both respected educators in their community and were and, not surprisingly, had escaped his awareness. It was,
repeatedly disappointed in her for not doing well enough a t nevertheless, being enacted by him. The therapist did not
school. Her mother had severely abused her both physically report his distraction or his own life history or the distaste-
and emotionally throughout childhood, while her father had fulness of the transference to Ms. A. but instead used his
been a passive, silent, and abandoning witness, often leav- new awareness to offer himself a different way of looking a t
ing home during episodes of abuse. These episodes included things. He stopped feeling sorry for himself and was able to
the mother scrubbing Ms. A.’s genitals with steel wool accept rather than refuse the transferences to him as a
because she was as “dirty” as she was “stupid.” Ms. A. was particularly precise and judgmental abuser or abandoner.
often silent in sessions, although she occasionally protested Gradually he was able to interpret with less of a focus on
angrily about the way the male therapist allowed the being right and more of a focus on being with the patient by
sessions to unfold unproductively. However, whether the grasping her terrible dilemma of feeling either assaulted or
therapist offered curiosity, interpretation, or observation, abandoned. Over time Ms. A. began to accept his interpre-
his words were bitterly rejected as painful and intrusive tations rather than rejecting them. She softened in the
assaults. Interpretations about the way his words were sessions, announcing that the therapist had become less
perceived as maternal abuse and his silences as paternal harsh and judgmental, and risked revealing previously
abandonments fared no better than any others. withheld humiliating details of her childhood abuse.
Over months the therapist gradually became aware that As this vignette illustrates, the unfolding mutual projec-
he was spending many of the long and frustrating silences tive identification of a n enactment becomes a kind of
of the sessions gazing out the window behind the patient slippery slope on which the therapist is in danger of sliding
 Harvard Rev Psychiatry
Volume 5, Number 6 Plakun 321

away from the therapeutic role of accepting the patient’s project personal greed into the provider and limitless de-
transference. This should not be construed as suggesting pendency into the patient. In these situations a utilization
that enactments are “bad,”happen only to “ b a d therapists, reviewer may see the therapist as advocating for treatment
or can be entirely avoided. In an endeavor as complex as because of personal financial gain rather than legitimate
psychotherapy, enactments that put therapist and patient clinical need, and the patient as willfully needy and depen-
on a slippery slope are as inevitable a part of the work as a dent rather than as ill. Similarly, both patient and thera-
slippery snow-covered slope is to the endeavor of skiing. In pist may collude in projecting evil into a utilization re-
fact, in both situations the trick is to learn to use the viewer who limits treatment, while avoiding the negative
dynamics of the slippery slope to get to the bottom of things. transference in the therapeutic work and denying the
Therefore, an enactment is neither tragedy nor cause for reality that in psychiatric treatment, as in the rest of the
celebration, but an inevitable event and an opportunity to world, we are in an era of limited resources. On this
find meaning through a new way of looking at things. particular slippery, enactment-prone slope, all three parties
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Recognizing and utilizing enactments requires a view to an enactment (patient, therapist, and utilization re-
broader than the traditional idea of therapy as composed of viewer) are in danger of proceeding without attention to the
two parties in a dyad, one of whom is an omniscient expert impact of enactment on the treatment process. This issue
who competently applies technical knowledge. The concept has been addressed e l s e ~ h e r e . ~ ~ ~ ~ ~
of enactment is predicated on the notion that the therapy Patient factors may also contribute to an enactment-
occurs in a “supraordinate” context or third space beyond prone clinical environment. The more primitive the charac-
the dyad, in which both participants have the capacity to ter structure and the more immature the defensive constel-
become lost. The therapist’s task is not only to try to lation of an individual, the more likely enactment is to be a
understand and interpret how the patient is engaging him significant clinical issue. Action defenses, such as acting out
o r her in the dyadic relationship, but also to detect, under- through suicidal or parasuicidal behavior, evoke in thera-
For personal use only.

stand, and interpret enactments involving both parties in pists such strong countertransference responses as to cre-
the dyad from the perspective of a supraordinate third ate an enactment-prone environment. I have presented
space. It is not the therapist’s job entirely to prevent elsewherez6 a model for working with self-destructive pa-
enactments within the dyad, but rather to establish and tients with borderline personality disorder in a way that
maintain a reflective outside perspective on the dyad that can facilitate establishment and maintenance of a viable
can detect and utilize enactments. This may be accom- therapeutic alliance. The impact of early trauma, such as
plished through cultivation of a self-reflective capacity sexual or physical abuse, often shifts subsequent intrapsy-
learned through one’s own analysis or psychotherapy, but it chic maturation toward lower-level functioning, making
is often best provided via a concurrent outside perspective these patients particularly prone to enactment.
such as consultation, supervision, or case discussion.
Through the use of this reflective space, a therapist can ENACTMENTS AS REFUSAL OR ACTUALIZATION OF
detect the presence of an enactment and translate its THE TRANSFERENCE
meaning into words.
Enactments generally occur when the therapist’s own blind
ENACTMENT-PRONECLINICAL SITUATIONS spots and character lead him or her to drift away from
acceptance of the transference toward either actualization
Factors related to the therapist, to the treatment context, of the patient’s transference or refusal of it. The impact of
and to the patient may all contribute to an enactment-prone actualization or refusal of the transference may be quite
environment. Such therapist factors as poor boundaries, subtle or may become part of a major boundary violation, as
poor impulse control, inadequate education, excessive ther- will become apparent below.
apeutic zeal,““ and personal blind spots concerning treat- Actualization of the transference has been defined above
ment issues profoundly increase the likelihood of enact- as a coincidence, which is often the case. However, actual-
ment. ization does not always take the form of the unmotivated,
The context in which we practice our clinical skills may coincidental automobile accident offered above as an illus-
also play a role. For example, in the current managed care tration of the concept, but may be a behavior unwittingly
environment in which most treatments are conducted, im- engaged in by the therapist that actualizes the patient’s
pingements from the third-party payer contribute to an transference through acting out of the countertransference.
enactment-prone treatment setting. Theoretically, man- An example is the case of Ms. B., a patient with a history of
aged care utilization reviewers may serve as a useful third verbal and physical abuse, who complained bitterly over
party, helping the therapeutic dyad to stay in touch with several months that her therapist was shouting at her
the reality of resource limitation. Sometimes, however, they when, in fact, he was speaking at a normal volume. The
 Harvard Rev Psychiatry
322 Plakun March/Aoril 1998

therapist became impatient with the patient’s protests and story in detail, Ms. C. turned to her silent therapist and
felt falsely accused. He did not grasp that the accusation of protested about being left in silence, although it had only
shouting was a transference re-creation or that, although been for a few seconds. The therapist felt confused, eager to
he was not shouting, his tone in response to the accusations take care of the patient, and uncomfortable with being seen
was becoming subtly more curt, strident, and defensive. as silent and abandoning, like the patient’s mother. Having
The therapist gradually connected this sense of feeling forgotten Ms. (2,’s explanation in the previous session that
falsely accused to the way he felt criticized for teasing his she did not need to be coddled, she began to offer a series of
younger siblings as a child. In fact, his brothers and sisters rambling, vague, and unintegrated interpretations to the
had learned to control him by blackmail, threatening to patient that left her feeling like a foolish caricature of a
turn him in for teasing that had never occurred when they therapist. When she discussed the case with colleagues, the
were left in his care. The therapist began to realize that he therapist realized that she, like her patient, had felt forced
had drifted into using a curt, impatient, and sadistic tone into performing a kind of “oral” act-of empty interpreta-
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with Ms. B. out of his frustration with her false accusations tion. She was caught in an enactment in which she had
that he was abusing her by shouting. He was inadvertently acted like the inadequate “shell” she feared being. She had
actualizing the transference to him as verbal abuser, “refused the transference offered to her of silent, incompe-
hooked by his own vulnerability to feel hurt and angry tent, and abandoning mother, fleeing from it into empty
when falsely accused. Once aware of his tone, the therapist pseudointerpretation to cover her tracks. In retrospect, the
was able to return to a more neutral and empathic one. therapist found herself puzzled that she had not simply
Although this did not stop the patient’s complaints about asked what her silence meant to Ms. C. or noted that Ms. C.
his shouting, he and Ms. B. were subsequently able to had been left in silence in childhood just as she now felt left
explore together what it felt like to be shouted a t by in silence in the therapy. As she explored this with col-
someone she depended on so much. leagues, the therapist became aware of experiencing the
For personal use only.

The following case illustrates an enactment in which a patient’s aggression toward her for the first time. The
therapist refuses the transference. Ms. C. was an intelligent therapist’s fears of being judged to be incompetent and just
38-year-old narcissistic woman with a history of childhood a shell and her eagerness to be smart and a good caretaker
sexual abuse and of abandonment by her mother. She was had gotten in the way of her awareness that Ms. C.,
admitted to a residential treatment facility offering inten- damaged as she might be, was also imperious, derisive, and
sive psychotherapy because two outpatient treatments had controlling. This awareness allowed the therapist to stick t o
reached impasses and suicide was a growing concern. Ms. her therapeutic role with more determination and freed her
C. had requested an older woman therapist, but one was not to face Ms. C.’s aggressive contempt as an issue to engage
available, so she was assigned to work with a younger and interpret in the therapy-not something to avoid stir-
woman, who often felt not very bright compared to the ring up in Ms. C., lest the therapist be unmasked as an
patient. The patient spoke of herself as having “no skin,” as incompetent.
feeling unprotected and disorganized in the world, but often
revealed grandiosity and contempt for even the most senior TRANSFERENCE PARADIGMS IN ABUSE
staff, whom she would describe as incompetent and only
“shells” lacking inner substance. Although the therapist As is apparent in the above three clinical vignettes, enact-
feared being seen as such a “shell,”inadequate and stupid, ments are highly personal and rich in individual detail from
her only consciously acknowledged feeling toward Ms. C. the lives of both therapist and patient. However, certain
was a wish to take care of her in a maternal way. transference-countertransference paradigms of work with
Silences were a particular problem in the therapy. Ms. C. patients with abuse histories or those who present with
experienced the lack of words from her therapist as a sign of symptoms suggestive of abuse are familiar and repetitive
either incompetence or abandonment. In one session Ms. C. enough t o be deciphered in terms of the meaning they
spoke of how, after her mother had abandoned the family, frequently carry. Some of these are presented here to offer
she was forced to take naps as a child by her emotionally therapists working with such patients the opportunity to
unavailable maternal caretaker. During nap time Ms. C. discover and then utilize the enactments to advance the
would secretly sneak out the window to explore the family therapeutic work. For the sake of clarity these paradigms
farm. Ms. C. explained that this story showed that she did are presented separately, but there is no assumption im-
not need to be “coddled with naps and was not afraid t o find plied that only one transference element will be operative at
her way in the world. a time. The details and complexity of these enactments
In the next session Ms. C. revealed for the first time have been omitted in an effort to simplify and summarize
details of sexual abuse a t age eight by a farmhand who them. Nevertheless, having rough templates available can
forced her to perform oral sex. Having told this harrowing assist a therapist in looking for the uniquely personal and
 Harvard Rev Psychiatry
Volume 5, Number 6 Plakun 323

case-specificelements of the enactment that may be present with an abuser may have been the only one in their life in
in work with a particular patient. Finally, it is worth noting which they felt cared for and special. This is frequently
that enactments may range from those entirely within the accompanied by intense humiliation, shame, and guilt in
boundaries of competent practice and professional ethics to the patients, who feel that they were to blame for the abuse.
those involving egregious acting out and ethical violations. A brief vignette illustrates such a situation and its resolu-
tion.
Transference to the Therapist as Abuser Ms. D. was a 30-year-old woman who had been sexually
A patient with an abuse history commonly experiences the abused as a child by an uncle. She was the youngest child of
therapist in the transference as the perpetrator of abuse. five, and the result of an unplanned, unwanted pregnancy.
Actualization of these transferences may be manifested by Her parents, both active substance abusers, had left her
the therapist becoming abusive, sadistic, and unempathic with the uncle during their own absences for extended
in an enactment, as described in the vignette concerning periods of drinking. The patient tried to tell her parents and
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Ms. B., who felt her therapist was shouting at her. If siblings about the abuse but felt ignored. Years later she
recognized, this can be worked with productively, often entered psychotherapy for depression and self-destructive
allowing access to the issue of the patient’s aggression in behavior. In the therapy she initially spoke of her anger at
the therapy. A much greater problem with an enactment her uncle, as well as at her parents and siblings, but over
through actualization of this transference occurs when the time she began to reveal how much her uncle had made her
therapist breaks the frame of the treatment and engages in feel special, wanted, and worth loving. She felt that the
actual abuse of the patient (for example, sexual contact). abuse had really been her own fault. The therapist, a
Despite therapists’ frequent claims in such cases that they woman with a genuine wish to be helpful and a particular
are acting out of love and caring for the patient, perhaps disdain for perpetrators of sexual abuse, found these feel-
demonstrating that the patient is lovable or offering a ings intolerable, experiencing countertransference revul-
For personal use only.

“corrective sexual relationship,” they are in fact abusing sion about the patient taking the blame for the abuse and
their patients as well as themselves as they violate the countertransference guilt about the inclusion of such feel-
boundaries of their role in precisely the same way as does a ings in the therapy. When Ms. D. spoke of feeling special or
sexual abuse perpetrator. loved by the uncle, the therapist began to refuse the
When the therapist is faced with a transference as associated countertransferences in the name of reality test-
abuser, he or she may respond with refusal of the transfer- ing, exhorting Ms. D. not to feel guilty because, as a child,
ence as abuser (as in the case of Ms. A., above) or with what she could not have been at fault and should not feel that
amounts to refusal of the reciprocal guilty countertransfer- way. The therapist began to advocate that Ms. D. report her
ence. In these latter instances the therapist may unwit- uncle to the authorities, but Ms. D. resisted this suggestion,
tingly enter an enactment organized around excessive re- became silent during the sessions, and began to come late or
assurance of the patient t o expiate guilt. This may take the miss appointments for the first time. A senior colleague
form of the therapist seductively assuring the patient that with whom the therapist consulted noted that the thera-
he or she cares or altering the therapeutic frame’s time or pist’s view of the patient not being at fault was true, but
financial boundaries to demonstrate that the patient is utterly beside the point if the patient was struggling pain-
wrong about the therapist, who is really warm and caring. fully with such feelings. The consultant helped the thera-
An even more problematic enactment organized around pist t o see that Ms. D. was refusing the treatment with her
refusal of the guilty countertransference involves displace- in the same way that the therapist was refusing her
ment of the guilt onto someone else. This may occur when a countertransference responses to Ms. D. The therapist
therapist cannot tolerate the guilt associated with the began t o recognize that Ms. D. could not be talked out of
transference to him or her as a sexual abuser and becomes her feelings. She decided to enter supervision with the
intent on discovering the true abuse perpetrator. Enact- consultant and became more prepared t o hear and hold Ms.
ments involving unwitting refusal of the abusive transfer- D.’s guilt and her own associated countertransferences. Ms.
ence, with displacement of a guilty countertransference D. began to speak and attend sessions regularly again, and
onto the newly discovered perpetrator, account €or some the therapy progressed with a focus on her experience
instances of so-called “false memories” of abuse. The con- rather than on the therapist’s values.
cept of enactment thus offers a way of conceptualizing false
memories of abuse as not necessarily the result of malicious Transference to the Therapist as Victim of Abuse
intent on the part of the therapist, but rather as uncon- A frequent transference from borderline patients who have
sciously motivated phenomena. abuse histories involves the patient’s identification with the
Yet another form of refusal of the guilty countertrans- aggressor (for example, an identification with an abusive
ference may occur in patients for whom the relationship parent). In these transferences the therapist becomes a
 Harvard Rev Psychiatry
324 Plakun March/April 1998

target of abuse, often struggling with a countertransference major boundary violations. Therapists may unwittingly
of feeling abused or victimized. When this transference is abdicate the therapeutic role by becoming abusive, abused
refused, the therapist may be inclined to drift into lecturing or vicariously traumatized, excessively guilty, overinvolved,
the patient about his or her aggressive behavior, or into seductive, andor exhortatory, or by implanting false mem-
either retaliatory abuse or emotional withdrawal from the ories. On the other hand, enactments, if detected and
patient. When this transference is actualized, the therapist interpreted, offer opportunities to avoid or move out of
often fails to notice the abuse, masochistically surrendering therapeutic impasses or to become more deeply aware of the
to it in a way reminiscent of an abuse victim who continues complexity of the patient’s inner world and its relationship
to endure abuse, as if deserved. It is probably this kind of to the underlying treatment issues.
enactment, involving an actualized transference, that con- To capitalize on the opportunity offered by enactments,
tributes to what Pearlman and other^^^,^^ have described as therapists need to be aware of their inevitability. Cultiva-
the “vicarious traumatization” of a therapist who works tion of a personal self-reflective space through personal
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with a number of abused patients over time. analysis or therapy, andor solicitation of an outside per-
spective on the therapeutic dyad through supervision, con-
Transference to the Therapist as Passive sultation, or case discussion, helps a therapist attend to the
and Abandoning unfolding transference-countertransference matrix. Using
With abused patients there is often a passive witness who this kind of reflective perspective on the therapy, the
has silently consented to the abuse. This is frequently a therapist can cultivate the capacity to be aware of the
mother who wittingly or unwittingly failed to notice or transference, and to determine whether the countertrans-
intervene in the face of abuse of her daughter by her ference response is moving him or her out of technical
husband or lover. A therapist may actualize such a trans- neutrality and into refusal or actualization of the transfer-
ference by being unable to tolerate awareness of the details ence. Should one of the latter be the case, scrutiny of the
For personal use only.

of the abuse or by withdrawing emotionally. The actualiza- transferences suggested by the patient’s history and mani-
tion of such a transference was part of the case of Ms. A. fest in the therapeutic work, and of personal conflicts that
Alternatively, this transference may be refused, with the have unwittingly led to collusion with the patient’s projec-
therapist drifting into efforts to rescue or otherwise seduce tions in an enactment, offers an opportunity to interpret
the patient away from the abandoning transference. Such meaning in a new and deeper way.
refusals of the transference may lead to enactments be-
The author is grateful to Drs. Edward Shapiro, Craig Piers,
cause the details of the abuse evoke such intense counter- Chris Fowler, Yasmin Roberts, and Margaret Woodruff for clinical
transference affects of revulsion and disgust in the thera- material and for suggestions on the manuscript.
pist that he or she finds them intolerable. The case vignette
of Ms. C. serves as an illustration.

CONCLUSIONS
REFERENCES
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