An exploratory investigation of psychologists' responses to a method for considering "objective" countertransference.
|Abstract:||Countertransference can be viewed as having both objective and subjective components. This paper presents a five-step method developed in New Zealand and designed to facilitate therapeutic understanding and management of countertransference. It also reports on an exploratory investigation of the impact of a two-day course designed to teach the method to psychologists. Twenty-eight psychologists completed pre- and post-course questionnaires that examined changes in their responses to brief clinical scenarios. An analysis of the qualitative data demonstrated a shift in understanding of countertransference post-course. Prior to the course, psychologists emphasized mainly subjective or personal issues. Post-course, the analyses of countertransference were more complex and tended to account for personal countertransference and also the interpersonal processes between therapist and client. This suggests that the method may be useful for psychologists when reflecting upon their responses to clients.|
(Beliefs, opinions and attitudes)
Countertransference (Psychology) (Methods)
Countertransference (Psychology) (Study and teaching)
|Publication:||Name: New Zealand Journal of Psychology Publisher: New Zealand Psychological Society Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 New Zealand Psychological Society ISSN: 0112-109X|
|Issue:||Date: March, 2011 Source Volume: 40 Source Issue: 1|
|Product:||Product Code: 8043300 Psychologists NAICS Code: 62133 Offices of Mental Health Practitioners (except Physicians) SIC Code: 8049 Offices of health practitioners, not elsewhere classified|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
This paper has two aims. First, it presents a five-step method
designed to provide psychologists with a systematic means of reflecting
upon countertransference. Second, it investigates psychologists'
responses to a course that teaches this method. The course was designed
by the first author for clinical psychology students and psychologists
trained mainly in cognitive therapy and other non-psychodynamic
approaches, in order to provide a systematic way of integrating the
concepts of transference and countertransference into reflective
practice. These concepts, as discussed briefly below, originated and
developed within psychodynamic traditions. However, as a result of
therapy outcome research, cognitive therapists are placing increased
emphasis on the therapeutic relationship (see Gilbert & Leahy, 2007)
and some have begun to integrate the concepts of transference and
countertransference into cognitive theory, practice and research (e.g.
Leahy, 2007; Miranda & Andersen, 2007).
Freud conceptualized "countertransference" as arising from the client's influence on the psychoanalyst's unconscious feelings, a manifestation of the psychoanalyst's unresolved issues, and thereby a potential impediment to treatment (Storr, 1989). This conceptualisation dominated until the 1950s when a new "totalistic" perspective emerged, in which countertransference is seen as all of the psychologist's emotional reactions towards the client (Gabbard, 2001; Hayes, 2004). In 1950, Hermann argued that the analyst's emotional response to the client was not simply a hindrance but an important tool in understanding the client (Gabbard, 2001). Around the same time, Winnicott wrote about "subjective" and "objective" aspects of countertransference (Gabbard, 2001). In the objective countertransference, the analyst reacted to the client as others did (for an overview of the historical development of the concept of countertransference see Gabbard, 2001 and 2004). According to this objective perspective, the client's distinctive personal style of relating evokes or "hooks" the therapist who responds countertransferentially (Kiesler, 2001; Gabbard, 2004). A number of theories attempt to explain how the process of objective countertransference occurs. The common thread of these explanations is that clients engage in behaviours that put interpersonal pressure on therapists, and in so doing, evoke a range of responses (Gabbard, 2004).
Gabbard (2001, 2004) argues that therapists of all persuasions have come to accept that countertransference can be an important source of information about the client. However, there appears to be disagreement about this (Norcross, 2001). According to Hayes (2004), for example, there is agreement that the therapist must understand the feelings elicited in him by the client and not act impulsively on them; and that both client and therapist contribute to the countertransference. He argues that there is less agreement on the "relative weight" given to the client or therapist contributions and conceptualizes all countertransference responses as due to the personal issues of the therapist (Hayes, 2004). In contrast, modern psychodynamic conceptions of countertransference consider the impact of the personality of the therapist and the client, and see the countertransference as "jointly created" (Gabbard, 2001, p.984).
In this paper, the term countertransference is used to refer to all of the therapist's emotional-cognitive responses to the client. While subjective and objective countertransference responses may be intertwined in actuality, it is important to have systematic methods for considering both. Methods have been developed to guide psychology students and psychologists to consider their personal responses in therapy (e.g. Bennett-Levy & Thwaites, 2007; Haarhoff, 2006). The method presented here is designed to assist psychologists to reflect on the objective aspects of countertransference and to manage countertransference responses in a way that is supportive of the therapeutic alliance.
Empirical support for the notion of objective countertransference
Prior to providing an overview of the course, it is important to briefly consider the empirical support for the notion of objective countertransference. The clinical and theoretical literature supporting the notion of objective countertransference is extensive but the empirical investigation of countertransference has been relatively limited (for an overview, see Betan et al., 2005). Some laboratory and nonclinical studies have provided indirect evidence to support the notion of objective countertransference (Betan et al, 2005). These studies demonstrate the effects of an individual's expectancies in relationships on the responses of others. For example, there is evidence from a longitudinal field study of romantic relationship events, and a related laboratory study involving observations of couples, that women who have rejection expectancies tend to behave in ways that elicit rejection from partners (Downey, Freitas, Michaelis, & Khouri, 1998). There is also evidence that depressed individuals "desire" and "invite" negative evaluations from others compared to non-depressed individuals (Geisler, Josephs, & Swann, 1996). Similarly, depressed people elicit criticism from others that matches their own self-criticism (Swann, 1997).
There have also been a small number of clinical studies that have examined countertransference responses to different client groups. Colson and colleagues (Colson et al., 1986), for example, asked professional staff at an in-patient mental health unit to rate their emotional responses to 127 clients and then examined the responses to different diagnostic groups. They found that responses varied systematically across client groups with anger towards clients diagnosed with personality disorder; hopelessness towards clients with psychotic withdrawal; and protectiveness towards clients with suicidal depression. Similarly, Brody and Farber (1996) found that depressed clients evoked mainly positive reactions in the 336 participating therapists; borderline clients evoked the greatest degree of anger and irritation, and the lowest levels of empathy; and schizophrenic patients evoked the most complex mix of feelings along with the highest perceived need to refer. It is important to note that students and Interns described the strongest emotional reactions and were more likely to regret things that they said to clients (Brody & Farber), suggesting that therapists in the early stage of professional development may have more difficulty managing countertransference responses, be they subjective, objective or contain elements of both.
A recent study investigated the countertransference responses of 181 participating clinical psychologists and psychiatrists to randomly selected clients (Betan et al., 2005). The authors identified 8 countertransference dimensions. These included: overwhelmed/disorganized, helpless/inadequate, positive, special/ overinvolved, sexualized, disengaged, parental/protective, and criticized/ mistreated. Of special interest are the ways in which these patterns of countertransference varied across client groups in predictable patterns. For example, there were significant correlations between clinicians' countertransference responses and personality disorder symptoms. Clinicians tended to respond to clients with a diagnosis of personality disorder (including antisocial, borderline, histrionic or narcissistic) (APA, 2000) with an overwhelmed/disorganized pattern of countertransference. Betan et al. (2005) concluded that these clients elicit what they called "average expectable countertransference responses". Clinicians from different orientations had similar response patterns to clients with different types of problems and these emerged even if therapists did not believe in the notion of countertransference. The authors argue that the results support the view of countertransference as useful in diagnostic understanding of patients' dynamics where repetitive interpersonal patterns are present.
Hence, there is growing empirical support for objective counterteransference. One implication is that countertransference can provide the therapist with insight into the typical patterns of relationships that clients engage in or engender. A second implication is that psychologists, and trainee psychologists, need ways of understanding and managing countertransference responses in a safe way that supports rather than impacts detrimentally on the therapeutic relationship. Given this, it may be helpful to have methods for thinking about and managing objective countertransference as it occurs in therapy. While a lack of attention to subjective countertransference can lead to blaming clients (Hayes, 2004), under-attending to objective countertransference or over-attributing countertransference to the issues of the therapist may result in a lack of understanding of what the client is bringing to the therapeutic relationship (Keilser, 2001). The current paper presents a course developed to assist psychologists and student psychologists to reflect systematically on countertransference, and in particular objective countertransference. The course is outlined in the next section.
An Overview of the Course--Enhancing Reflective Practice: The Therapeutic Relationship
This section presents an overview of the course titled Enhancing Reflective Practice: The Therapeutic Relationship. This includes its aims, the concepts that are employed, and the five-step method. A case discussion is provided to illustrate the concepts and the five steps. The course is taught over two days, one to three weeks apart, to allow for consolidation of the theory into practice, although it has also been presented in briefer time frames (Author, 2010; Author, 2010). The first half-day involves the presentation of theory and the remaining time is spent discussing cases and applying the theory in small groups and in the larger group.
Emphasis is placed at the beginning of the course and also throughout on creating a safe and supportive environment in which participants can talk about their own experiences of countertransference and apply the five-step method.
Aims of the Programme
Initially, participants are introduced to the aims of the programme. These include: 1. Understanding and applying the concepts of transference and countertransference; 2. Using these concepts to reflect upon the processes that occur within the therapeutic relationship; 3. Developing strategies for managing countertransferential responses.
In the first part of the course, participants are introduced to the concepts of transference and countertransference, subjective and objective countertransference, and the two types of objective countertransference complementary and concordant (to be discussed below). Attempts are made throughout to demonstrate ways in which the concepts relate to different therapeutic models.
Transference and countertransference: Participants are given examples of definitions of transference and countertransference (e.g., Brown & Pedder, 1991, pp.60-61; Gabbard, 2004, pp. 9-11; Jacobs, 1999, pp.12-13). Two aspects of transference are emphasized: the client's feelings or responses toward the therapist (first aspect) that are based on past experiences with significant other/s (second aspect). A distinction is made between objective and subjective countertransference. Objective countertransference, the focus of the course, is defined as the therapist's feelings or responses that are evoked by the client's transference onto the therapist or the client's interpersonal patterns of relating. Subjective countertransference is defined as the therapist's feelings or responses to the client based on the therapist's life history and/or personal issues and sensitivities. Both transference and countertransference are seen as cognitive-affective responses with physiological and potentially behavioural components . When attempting to tease out subjective and objective countertransference, participants are encouraged to consider if other therapists are likely to respond in similar ways to any given client (objective countertransference) or if their reactions are more likely to be personal to them (subjective countertransference).
Ego-states and representations of self and other: Increasingly, there is a trend in psychology and psychotherapy to reject the notion of a unitary self and to view people as having multiple selves or self-states (Safran & Muran, 2000). This view of multiple selves is complementary to a number of psychotherapeutic approaches and concepts, including Transactional Analysis (TA) (Berne, 1961; child, adult, and parent ego-states); object relations (e.g., Stadter, 1996; self and object representations); attachment theory (Bowlby, 1988; internal working models of relationships and representations of self and other); relationship schema (Leahy, 2007); core beliefs about self and other in cognitive therapy (Beck, 1995); and reciprocal roles in cognitive analytic therapy (Ryle & Kerr, 2002).
In this course, the TA model of ego-states is used to provide a richer understanding and visual representation (see Figures 2, 3 and 4) of transference and countertransference processes (for previous applications of the TA model to the therapeutic relationship, see Brown & Pedder, 1991; Clarkson, 1992). According to TA, an ego-state is a consistent pattern of feelings, thoughts and behaviours (Stewart & Joines, 1987). A child ego-state is a state in which a person behaves, thinks and feel as s/he did in childhood; a parent-ego state is characterized by feelings, thoughts and behaviours learnt from parents or parent-figures; and the adult-ego state is one in which the person engages in reality-testing and responds to the current circumstances without being triggered into a child or parental ego-state.
[FIGURE 1 OMITTED]
Participants are also introduced to the object relations notion of internalized self and object/other representations, in which representations of self always exist in conjunction with representations of other (Miranda & Andersen, 2007; Stadter, 1996). These representations of self and other are developed in childhood and through formative experiences, and act as templates for relationships, including the therapeutic relationship. The diagram below (See Figure 1) illustrates four self and other representations that a hypothetical client Tom has as potential templates for relating to others. Tom has a representation of self as safe and trusting in relation to other as warm and accepting. This may provide a template for the early stages of therapy when the client sees the therapist as a potential or ideal source of support and assistance. However, the client has other dominant templates for relationships. Representations of self as hurt and withdrawing may be triggered in therapy by real or imagined therapist responses. For example, if Tom has a cognitive therapist who has suggested a homework exercise, he may shift into a withdrawn self prior to the next appointment in response to his difficulty with or resistance to doing his homework. He may then arrive late as a result of a negative transference to the therapist as a potentially critical and angry or withdrawn other. This transference arises from an established template that he brings to the therapeutic relationship. This template can also be conceptualized as made up of the core beliefs about self and other (Beck, 1995) or relationship schema (Leahy, 2007).
[FIGURE 2 OMITTED]
Complementary and concordant countertransference: Finally, the concepts of complementary and concordant countertransference, first introduced by Racker in 1957, (Brown & Pedder, 1991) are introduced. In a complementary countertransference, the therapist responds to the client in a way that complements the client's transference expectations. In this form of countertransference, the therapist may respond to Tom's expectations of criticism by feeling critical or judgmental; or alternatively may respond to Tom's desire to be looked after, with an urge to take care of (see Figure 2). In a concordant countertransference, the therapist experiences emotions, which are concordant with, or similar to, the client's emotions. This occurs most commonly when a therapist identifies with the self (or child) representation rather than the object/other representation (Gabbard, 2004). If Tom, for example, feels hurt and bewildered by what he imagines is the therapist's criticism of him, the therapist may find herself feeling hurt and bewildered. This could be experienced as empathy for Tom. It could also be experienced as feeling hurt and bewildered that the client is disapproving of her after her efforts to be a good therapist (see Figure 3).
Discussion of the above concepts and application of the concepts to examples provided by participants or the first author, help to form the basis on which the participants learn to use the 5 steps. These are presented below.
Step One: Monitoring and being aware of one's own responses
In order to be able to manage countertransference responses and make use of objective countertransference, the therapist needs to develop awareness of and monitor the experiences of self in relation to the client at any given moment in therapy. This involves a conscious observation of affective-cognitive responses, physical sensations and physiological reactions, and urges to act. The therapist holds in mind the potential for client transference and the potential for reflecting this countertransferentially.
Step Two: Recognizing potential objective countertransference responses
[FIGURE 3 OMITTED]
When therapists become aware of responses towards the client (for example, a feeling of annoyance, difficulty staying awake, or a sense of confusion and agitation), they are encouraged to ask themselves if they are responding to the client's transference at that moment in therapy: Does this tell me something about what the client is experiencing (or about a template for relationships that the client is bringing into the therapeutic relationship)?
Step Three: Developing hypotheses about the transference and countertransference
At this stage, the map provided by the TA model of ego-states is used to develop hypotheses about the interpersonal processes that are occurring in the therapeutic relationship. It is emphasized that this basic model is used as a way of mapping potential transference and countertransference responses and does not require people to become transactional analysts. Experienced therapists can develop these hypotheses as they work with the client. For students or less experienced therapists, it may work better initially to move to step four and to complete this process of reflective practice after the session and in supervision.
At this step, participants are encouraged to consider three questions to assist in the analysis of the countertransference: 1. Am I responding/ feeling the way that my client expects or hopes that I will respond? (Objective complementary countertransference, Figure 2); 2. Am I feeling like my client felt (repeatedly) in the past in relation to a significant other and/or is feeling now in therapy? (Objective concordant countertransference, Figure 3); 3. Am I feeling this way because my own personal issues have been triggered? (Subjective countertransference).
Step Four: Employing a calming strategy
This step assists therapists to manage their own emotional-cognitive responses and to avoid a countertransference enactment (behavioural or verbal). Therapists are encouraged to use a calming or breathing techniques they teach their clients, or one that they use themselves, as a way of managing their own responses. Recent advances and training in mindfulness may also be useful here, as mindfulness strategies emphasize a non-judgmental and accepting awareness that is a useful position for therapists to adopt towards their own countertransference responses (Safran & Muran, 2000).
Step Five: Moving back into the Adult
In this step, participants are encouraged to consider the TA model and to imagine or coach themselves to "move back into the Adult" (Figure 4). Taken together, steps four and five facilitate therapists taking active steps to calm themselves and to shift out of the countertransference response into an adult or therapist response, which is more compatible with maintaining the therapeutic alliance (Brown & Pedder, 1991). However, it is important that the therapist is also mindful of the countertransference and its potential meanings as they make this shift. This will be more difficult to achieve with powerful countertransference responses although repeated practice of this technique is likely to increase its effectiveness.
[FIGURE 4 OMITTED]
The study was approved by the University of Auckland Human Participants Ethics Committee. A questionnaire was designed to examine the participants' understanding of transference and countertransference and the utilization of these concepts through the use of brief clinical scenarios (see below). Participants took approximately 20 to 3 0 minutes to complete the questionnaire and answered questions 1-5 (below) pre- and post-course and questions 6 and 7 post-course.
1. What do you understand by the term transference?
2. What do you understand by the term countertransference?
3. If you suddenly found yourself feeling sad in a session, how would you explain this to yourself?
4. If you found yourself feeling annoyed in a session, how would you explain this to yourself?
5. If you were working with a client who appeared to be positive about the sessions with you, but came late for three sessions in a row, what would you think might underlie this?
6. What, if any, has been your most valuable learning from this workshop?
7. What changes do you recommend to the course?
Participants also completed an evaluation of the course using the rating system provided for anonymous student evaluations by the University, the results of which were compiled independently by the university evaluations centre and then provided to the first author. Participants rated the following statements on a 1 to 6 point scale from strongly disagree to strongly agree: The class discussions were effective in helping me to learn; I have learned something I consider valuable; and, The course has enabled me to enhance my professional practice.
Participants were recruited through advertisements sent out to practising psychologists. Twenty-eight psychologists, 26 female and 2 male, completed the two day course in the method outlined above. Twenty-one were European and the remaining participants were New Zealand Maori or of Asian descent. Participants came from a range of psychotherapeutic backgrounds although the majority were not psychodynamically trained.
The study aimed to examine the use of the concepts of transference and countertransference by participants in the pre- and post-course questionnaires. Hence, the responses to question 1 and 2 were examined and compared to the definitions of transference and countertransference taught in the course.
In questions 3, 4, and 5 (clinical scenarios), the data were examined and coded for use of the concepts of personal countertransference (PC) and objective countertransference (OC). Some responses did not fit into either of these codes. A content analysis (Bowling, 1997) was conducted on the data that did not code to PC or OC in questions 3, 4 and 5.
Finally, a content analysis was also conducted on the data from questions 6 and 7 that pertained to the most valuable aspects of the course and to recommended changes.
Once these data analysis procedures were agreed upon, two researchers (the first author and a research assistant) conducted the analyses separately and then compared their results. This was done systematically for each response to each question for all questionnaires. The analyses were compared and the final results were established including the frequency of different types of response.
The results of the data analyses are presented below with quotes given to illustrate participants' responses.
Definitions of transference and countertransference
Twenty participants (71%) gave an accurate pre-course definition of transference and this did not change post-course, although fifteen said that they now had a "deeper understanding" or were "more comfortable" or "more confident" in thinking about transference. The remaining participants, except for one, changed their post-course definitions in line with traditional notions of transference as taught in the course.
There was more variability in the definitions of countertransference and a greater degree of change across the course. All except two participants wrote about countertransference as the therapist's response to the client on the pre-course questionnaire. However, 46% of participants pre-course also included the notion that countertransference can be a response to the client's transference (objective) and three indicated that it was a source of information about the client.
In the post-course questionnaire, 25 (89%) included this objective aspect of countertransference. Some participants also wrote about the benefits of this new view of countertransference, as this quote illustrates,
Clinical scenarios: Therapist sad, therapist annoyed
As mentioned previously, the pre- and post-course data for the scenarios (questions 3, 4, and 5 on p.13) were examined and coded according to the explanations given for the therapist's countertransference. The codes included objective countertransference (OC) and subjective countertransference (SC). As discussed previously, a number of other explanations also emerged. These were examined and included "empathic responses", "professional responses", and "contextual responses".
Given that similar changes occurred in the responses to the first two scenarios (therapist sad and therapist annoyed), the results for these two scenarios are presented together. It is important to note that some participants gave responses in more than one of the categories presented below. In the "sad" scenario, fourteen participants (50%) pre-course wrote about the possibility of the response of sadness being an empathic one, although empathy was not named by anyone in regard to feeling annoyed.
Pre-course, twenty-six (93%) of the participants for "sad", and 27 (96%) for "annoyed", gave personal issues as a potential explanation for the therapist's emotional response, as these quotes below illustrate,
Another group of responses (5 for "sad" and 14 for "annoyed") gave professional explanations or included comments about how the emotions might be managed, as this quote demonstrates,
Finally, at pre-course, only four participants (14%) talked about concepts related to objective countertransference for each of the scenarios (sad, annoyed). Hence, most participants attributed their responses to the therapist's own personal issues, to empathy for the client in the case of therapist sadness, or discussed professional issues. The majority did not question the role of the client nor see the countertransference as a source of potential information about the client.
In the post-course questionnaires, participants still talked about the possibility of subjective countertransference, but there was a strong shift in emphasis from a dominant personal perspective to the inclusion of an objective countertransference perspective, in which the therapist's emotional response leads to a consideration of the client's experience. Twenty-two participants (sad) (79%) and 26 participants (annoyed) (93%) gave a response that demonstrated consideration of objective countertransference, for example,
Some participants also commented on their change of perspective,
Finally, approximately 50% of the participants named the particular models that they would use to make sense of their own countertransference responses and a number wrote down the three questions, as illustrated above.
Scenario: Client arriving late
The previous scenarios focused on the therapist's emotional response to the client. This scenario is somewhat different as it provides information about the client, that is, the client appears positive about the therapy but arrives late three sessions in a row. The results of the analysis of the data, pre- and post-course, revealed two new categories of response. Fourteen participants pre-course accounted for the lateness using contextual factors, including "traffic problems", "transport", "They live in Auckland and traffic sucks!" Twenty-three participants (82%) wrote about client factors or characteristics,
Pre-course, 17 responses (61%) also fell into a category of professional responses, for example,
Only 2 responses directly linked the client behaviour to a transference issue,
In the post-course questionnaire, 23 participants (82%) gave a response that included transference and/or countertransference notions, as this quote demonstrates,
The remaining participants emphasized client characteristics.
What, if any, has been your most valuable learning?
Two main content areas (Bowling, 1997) emerged from the analysis of the data from this question. Many participants touched on both. These were: the usefulness of the models and theory for understanding the interpersonal processes in therapy, and the value of case discussions. Twenty-one (75%) of the participants wrote about the usefulness of the models and the theory. Seventeen of these wrote about the greater understanding of processes occurring within the therapeutic relationship.
Participants also talked about personal and professional benefits. These included gaining confidence in understanding transference and countertransference and in managing one's own responses, as the quote below suggest,
Although the value of the case discussions was implicit in most comments, a third of the group specifically mentioned this.
There were two broad categories of response in terms of recommended changes. The first category involved supplementary activities. Three suggested readings prior to the course, 2 suggested case practise between sessions, and 4 suggested a follow-up session. The second category of response related to course content and presentation: 3 participants suggested shorter but more case discussions, and 8 suggested an emphasis on areas of interest, such as defence mechanisms and the integration of the psychodynamic ideas with other models.
As mentioned previously, the anonymous ratings of the course were collated independently through a University evaluation system. Using a 6-point scale (from do not agree to strongly agree), the mean rating for the statements "I have learned something valuable" was 5.8; "The class discussions were effective in helping me to learn" was 5.6; and "The course has enabled me to enhance my professional practice" was 5.7. These suggest a high level of satisfaction.
This paper presents a five-step method designed to provide psychologists with a systematic method of considering their own countertransference responses. It also presents the results of an exploratory investigation of psychologists' use of the method when reflecting upon clinical scenarios. Before discussing its implications, it is important to note its limitations. First, it relies on participants' responses to clinical scenarios and does not examine the impact of the method on the reflective practice outside of the course. Hence, it is not possible to conclude if it had ongoing benefits for participants within their clinical practice. Second, participants received a free two-day course and may have been well disposed to give positive feedback.
Despite these limitations, the method appears to have potential benefits for psychologists when reflecting upon their countertransference responses to clients. Systematic methods have been developed for assisting psychologists and psychology students to examine their subjective countertransference responses (Bennett-Levy & Thwaites, 2007; Haarhoff, 2006). This method offers a systematic means of examining objective countertransference.
The results from the current study suggest that the majority of the participants found the concept of objective countertransference convincing and valid, and utilized the method when reflecting upon the scenarios. The majority made the shift from the view that countertransference was personal or subjective to the view that it can also have an objective component. They also rated the learning as valuable and perceived that it contributed to their professional practice.
While the study was designed to examine the impact of the course and the five-step method on reflective practice, the results also provide insight into the impact of therapeutic emphasis on subjective countertransference. The results from the pre-questionnaire, in which the participants mostly posited personal explanations, demonstrate the potential problems associated with an over-attribution of countertransference to personal issues. Rather than protecting the client from personal issues of the therapist (Hayes, 2001), this attribution tendency could result in a lack of understanding of the client's contribution to the therapeutic relationship and to the therapist's response. As Keisler (2001) states, by rejecting the notion of transference "one finds oneself in the unfortunate position of not attending to or detecting aspects of the client's "live" behavior with the therapist that might express his / her basic interpersonal issues" (p.1054).
Given the importance of the therapeutic relationship to therapy outcomes (Gilbert & Leahy, 2007) it is essential that psychologists have tools for understanding the complexity of this relationship. Utilization of the five-step method and its concepts led to more complex and rich explanations or hypotheses about events in the therapeutic relationship rather than simply events in the internal world of the psychologist. For example, in the case of Tom, a hypothesis of a concordant countertransference allows the psychologist to consider that he or she may be experiencing something akin to the hurt and anger Tom has repeatedly experienced. This is in contrast to the hypothesis that Tom's apparent disapproval is evoking her own sense of inadequacy as a therapist. It is important to consider the latter but the prior explanation allows for a greater awareness of possibilities within the therapeutic relationship. Finally, the method may also be a means by which psychologists can manage strong emotional responses to clients thereby increasing the likelihood of safe practice.
Finally, it is important to comment on anecdotal evidence that the participants appreciated the group format of the course. This was expressed on the questionnaire but also verbally during and at the end of the course. While the group process and the experiential component of the course was not a focus of this study, it seems possible that participants benefited from hearing other psychologists openly discussing their experiences of countertransference. This potentially normalized the prevalence and potential strength of countertransference as part of everyday life for psychologists. Using the method in the whole group, and also in smaller group situations, may also have allowed for a sense of mastery as participants had the experience of understanding countertransference from a different perspective.
In terms of future directions, it is important that researchers continue to examine the validity and usefulness of the concept of countertransference and its application to practice. It would also be useful to have longitudinal studies that examine psychologists/ methods of managing their countertransference responses, both subjective and objective, and the impact on their therapeutic relationships with clients. Finally, given that many New Zealand psychologists are often trained as cognitive therapists, it seems desirable that the method presented here is further developed in such a way that it uses language and concepts that fit comfortably with cognitive models.
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Claire Cartwright, University of Auckland
John Read, University of Auckland
Dr Claire Cartwright
Department of Psychology
University of Auckland,
Private Bag 92 019
Previously I understood countertransference as a negative event, a reflection of a personal limitation. Now I view countertransference as something to be identified and considered from both the therapist and client perspective as something that adds information to the therapeutic relationship and provides a prompt for deeper exploration of client feelings.
Identify with the client's sadness? Similarity to myself- own personal experience or? Actual "sadness" of client's experiences/ situation.
Difficult to answer without example--imagine that there has been some dialogue between myself and the client that may have raised some of my vulnerabilities--that is, the impact of client on my own core beliefs re myself- probably just contain this and reflect more after session. Question, what happened just then that caused my annoyance? What did it remind me of (or whom). Recognize that the response is likely to be personal life experience. Refocus attention on client's experience and discuss in supervision.
I would certainly ask myself what was going on. If the reason is obvious I might address it as a "therapy-interfering behaviour" (DBT) if relevant. I would probably discuss it in supervision. I probably would also try to generate empathy for the client by understanding the origin of behaviours.
I would wonder what it was about the client that was resulting in or contributing to my reaction. I would ask myself the three questions. So this would enable me to hypothesise about what might be occurring for the client.
Before my focus was totally on what this said about me. I am now more aware of the role of the client. I would ask myself the questions: Am I feeling what the client is feeling? Am I feeling what the client expects me to feel? Am I feeling what the client has experienced before in a previous relationship? I could also consider what "hooks" the client may have activated for me. Process it between sessions and note it. Also I'd try and identify the client's signification object relations.
Depends--could be testing boundaries--on client formulation--may have difficulty time-keeping; may have a tendency to please and self-sacrifice so does so much for others prior to coming that can't get there on time--sees therapy as something for them so more likely to self-sacrifice this and do task for others.
I would think that there were some underlying issues that needed to be explored and resolved. My perception of the client being positive is likely inaccurate. Is the client fearful about something that is likely to crop up in future sessions. Have I not explored feelings enough/likely obstacles to attending sessions/ and in my particular case--are they re-offending?
Could be client be pushing/testing boundaries to see my reaction, may be that they are experiencing some transference and not sure what to do with it, escape/ avoidant.
I would think that the client was ambivalent about the therapeutic interaction. On the other hand, he wants to be there but on the other is testing the boundary to see if the therapist is able to handle the test effectively or back away. This serves to confirm or disconfirm the client's hypothesis about the therapist behaving in a way a person in a past relationship would have. Yet again, I would also explore the source of lateness.
It has helped to clarify how I can use these ideas in practice. I particularly like the object relation templates, the TA model and the 3 questions to ask yourself about an emotional reaction. This gives me a clear structure for how to apply these ideas.
Bringing in the TA model alongside transference and countertransference. It helped me with the concept (or strategy) of returning to the Adult self when noticing my countertransference, so as not to enact the countertransference.
Using case studies to demonstrate and explain the concepts presented, such as internal and object representations. Working through these in groups and on the board was especially beneficial.
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