An Introduction to Dynamic Psychotherapy: Transference and countertransference

An Introduction to Psychodynamic Psychotherapy

TRANSFERENCE, COUNTERTRANSFERENCE
AND THE UNCONSCIOUS
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In a general sense we respond to all new situations in terms of past experience. We may respond to people as though they are specific people in our past (especially in distress, when regression is common, and therapists, etc, may be treated very like parents).

Transference

Definitions of transference span the full range from treatment alliance to any aspect of the patient's relationship to the therapist. Such loose definitions are unhelpful.

Development of the concept of transference

Freud (formulation gradually developed between 1895 and 1914):

transference of feelings arising from the content of analysis to therapist

replacement of an earlier person (as object of impulse/wish) with the therapist

possible therapeutic agent by providing therapist with information about patient's conflicts, and allowing change within the transference relationship (previously seen as block to Rx)

"positive" (erotic) and "negative" (hostile) transference (NB can coexist and defend against each other)

"transference neurosis"; feelings repeated in transference, not simply remembered

Can be an important tool in understanding patients, but need to bear in mind:

1. Transference is only one of many different aspects of the relationship with the therapist. The patient is confronted by the unfamiliar in the therapist and reacts in terms of what is already familiar. A sense of similarity between the past and present may be triggered by behaviour of either patient OR therapist.

There may also be an overlap between the unconscious experience of the self and the other (roots of projection and introjection). Also subtle unconscious attempts to manipulate therapist to provoke repetition of earlier situations.

2. Inner feeling states (e.g. breaks in treatment, separation/loss events) may change perception of external reality, evoking earlier experiences with similar feelings.

3. It is necessary to distinguish between a general tendency to repeat past relationships in present (character traits, e.g. demandingness) and the process of development of feelings and attitudes in transference (specific to therapist, inappropriate to situation, etc). The attempt to re-enact the situations and fantasies of childhood is a regressive process.

4. Transference feelings apply to present not past. Subject feels they are wholly appropriate to present, although they are usually inappropriate. Any experience in the overlap between present and past experience is not distinguished in the timeless present of the unconscious. Thus transference has the sense of reality and immediacy.

"As if" quality of transference

Psychotherapist and patient relate in two ways at the same time - therapeutic alliance (roughly equivalent to adult-adult) and transference (roughly equivalent to child-parent). Need "ego-strength" to sustain paradox of coexistence of therapeutic alliance and transference. If lacking can get psychotic or delusional tansference, where feelings are grossly unrealistic or inappropriate. The patient may lose the perception of the therapist as therapist and behave as though transference is real. This can lead to a loss of therapeutic alliance and reality testing (no "as if" quality).

"Transference cure" and dependency

Dependence can develop very early and unexpectedly, especially as regression and ventilation are encouraged by the therapeutic situation. There may be very high demands made on the therapist by the patient's dependency (and beware meeting such demands inappropriately because of own countertransference).

"Transference cure" is the loss of symptoms after developing profound positive transference ("falling in love") with therapist.

Patients use therapists in ways that were impossible in earlier relationships. The risk is of the therapist behaving too much like the patient's parents (mutual involvement in the transference neurosis). The patient seeks ways to get in touch with old experience. If the therapist is provoked into a parental response (e.g. by acting out) then problems arise with the therapeutic relationship, transference and interpretation. Acceptance by therapist of a transference role may be based on unconscious cues from patient.

Transference interpretations

So-called "full" transference interpretation links all three corners of the triangle of person. This may take many sessions of work. Problem of when patient needs this kind of interpretation. Strachey (1934) suggests only "mutative" interpretations are transference interpretations.

Winnicott - "spatula game" - if you give infant an object then after a "period of hesitation" the child will play with the object in a creative way (with an "investment of interest"). If the child is hurried into the "correct" (or any restricted) use then there will either be protest and resistance (healthy) or passive compliance. In therapy patients are often regressed and behave with the therapist as if the patient was a child and the therapist an adult. The therapist must avoid impinging on patients in this way. The space between patient and therapist is one in which "playing" with the patient's material can lead to a creative growth in mutual understanding. The therapist is there to be "found" by the patient. The implication is that if material is interpreted too soon, or the focus is brought too quickly to the therapist (in the name of transference) then sense of interest and immediacy is lost. The patient moves from experiencing to thinking about what is going on. This may be a countertransference defence by therapist.

Countertransference

Freud (1910) coined the term in recognition of feelings arising in the analyst as result of the patient's effect on the analyst's unconscious. Countertransference (CT) was viewed initially as an obstruction to analytic work that needed to be overcome. "No analyst can go further than his own complexes and internal resistances permit." Freud described the danger of falling into "the temptation to project outwards some of the peculiarities of one's own personality".

May not be just historical material in therapist (therapist's transference), but current conflicts (e.g. over aggression/sexuality) that cause therapist to miss or avoid important material from patient ("resistances" in therapist). Therapist's anxiety leads to communications failure.

The therapist's theoretical orientation can act as "countertransference response to the familiar" (Casement) - similarities in patients provoke similar responses based on theoretical understanding.

Acting out in CT can be caused by needs in therapist, e.g. need to be admired, or cared for. Patients often respond to this (e.g. by agreeing with interpretations, only bringing material their therapist will like, etc).

Responsibility of therapist working with damaged patients to accept their worst transference/projections, etc and survive (c.f. Winnicott's "use of the object"). CT responses may indicate therapist's fears of not surviving in these situations.

Racker distinguished ‘concordant’ (identificatory) countertransference ("this part of you is I") and complementary countertransference where the patient treats the therapist as an internal (projected) object and analyst feels treated as such.

Uses of countertransference

Feelings in professional (e.g. anger, desire to help, and feelings of impotence, sexual feelings) can be useful information, if able to reflect on them and use them, and if sure they're roused by patient, not from you. Being able to discriminate your own feelings from the patient's requires experience and is the main reason for an experience of therapy being a training requirement for psychotherapists (personal analysis).

If the therapist listens with "free-floating attention", aware of his/her own feelings s/he can understand more of what is behind what patient is saying. The therapist may have elements of understanding of the patient that are not immediately conscious. In this sense the therapist's unconscious understands that of the patient. Strong, irrational or unrelated feelings may fall into this category. The therapist must therefore monitor his/her self.

Dangers of countertransference

Countertransference phenomena can interfere with therapy if therapist is not aware of them. If countertransference is contaminating therapeutic relationship with the therapist's unresolved problems, then it is harmful. If things happen in sessions that don't fit the patient's unconscious sense of what he needs, this may be indicated in various ways (the "countertransference interpretation" (Casement) by the patient) e.g.:

Prompting

overt

by displacement (e.g. criticise other authorities)

by contrast (praise other professional)

by introjective reference (self blame for therapist's mistake)

Resistances in response to therapist's pressure (may reflect past experience)

These are unconscious cues that require an appropriate response and should not merely be interpreted as the patient's pathology or resistance. Psychoanalysts are trained to monitor their countertransference responses, so that they don't respond to patient as a "transferential object". This is the origin of the required training analysis.

Countertransference is unavoidable

It has been suggested that the lack of recognisable counter-transference indicates that a talent and interest in psychotherapy may be lacking. CT phenomena are essential part of psychotherapy. The professional stance and the analytic setting (including the contract and boundaries) allows distancing from situation while remaining in touch with one's own and the patient's feelings. The therapist is therefore able to continue to think even when confronted with powerful feelings.

The moral is therefore NEVER attempt psychotherapy without supervision unless you are skilled and experienced. If you want to practice intensive analytically-orientated psychotherapy then spend time in personal therapy ("training") yourself first.

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