Of Two Minds

A therapist forgets about a patient’s appointment. She becomes abnormally angry, unusually forgiving, atypically bored, or excessively voyeuristic. What is going on?

The therapist’s countertransference is making itself known. Gabbard¹ described countertransference as a hallmark of psychodynamic thinking-the patient and therapist have 2 separate subjectivities that interact in a meaningful way during the course of the therapy. The field of study thus involves 2 complex human beings-2 minds-each interacting and mutually influencing the other. The patient is continuously evoking a variety of feelings in the therapist.

The psychodynamic therapist is not a cold scientist devoid of emotion, objectively scrutinizing a human specimen. Rather, he or she is a fellow human being with his or her own conflicts and emotional struggles. He unconsciously experiences the patient as someone from his past at the same time that the patient experiences him as someone from his past.

What sets psychodynamic psychotherapy apart from other modalities of psychotherapy is its emphasis on the use of transference and countertransference to inform the therapy. While there have been many changes in psychodynamic psychotherapy over time, the evolution of our conceptual model of countertransference is one of the most significant.

The narrow view

Psychodynamic therapists have been of “2 minds” about the origins, usefulness, and management of countertransference. The initial view was identified by Freud^2(pp144-145) in 1910, in one of his rare comments on the subject. He wrote:

We have become aware of the “countertransference,” which arises in [the analyst] as a result of the patient’s influence on his unconscious feelings, and we are almost inclined to insist that he shall recognise this countertransference in himself and overcome it. Now that a considerable number of people are practising psychoanalysis and exchanging their observations with one another, we have noticed that no psychoanalyst goes further than his own complexes and internal resistances permit; and we consequently require that he shall begin his activity with a self-analysis and continually carry it deeper while he is making his own observations on his patients. Anyone who fails to produce results in a self-analysis of this kind may at once give up any idea of being able to treat patients by analysis.

This Freudian view came to be known as the “narrow” view, in that it was essentially the analyst’s transference to the patient. Countertransference was a signal that the therapist needed further analysis because its presence was interfering with analysis of the patient.

From this early view, an ongoing debate emerged and has been present in the psychoanalytic literature for the past 100 years. The original Freudian version of countertransference has a somewhat negative connotation, ie, the therapist has countertransference because of unresolved personal conflicts.¹ The implication is that one who is well-analyzed should not have such distractions. This pejorative tone is now considered a relic of the past.

The broad view

In the middle of the 20th century, the concept of countertransference began to broaden to an expanded view that regarded countertransference as the therapist’s total emotional reaction to the patient. In other words, all emotional reactions did not simply reflect the analyst’s unanalyzed conflicts. Some of the analyst’s feelings were induced by the patient and said more about the patient than the analyst.

This expanded definition also served to normalize the concept so that countertransference was not viewed as simply an obstacle to helping the patient or an interference in the therapy, but rather as a source of important information about the patient. With the “broad,” or “totalistic,” view, it became a major therapeutic and diagnostic tool that could tell the therapist a great deal about the patient’s internal world. This theoretical shift within psychoanalysis from a 1-person to a 2-person psychology has legitimized countertransference as a useful part of the therapist’s daily work.

What is already known about countertransference?

? What sets psychodynamic psychotherapy apart from other modalities of psychotherapy is its emphasis on the use of transference and countertransference to inform the therapy. The idea of countertransference has transformed from a negative connotation that the therapist needed further analysis, Freud’s narrow view, to a broad view that countertransference is a joint creation between patient and therapist.

What new information does this article provide?

? This article emphasizes the current view that countertransference is the culmination of the joint creation of past and present for both patient and therapist. In addition, the article emphasizes that countertransference is present in every moment of therapy, and in accordance with this, naturally shifts over time during therapy.

What are the implications for psychiatric practice?

? Emphasis is on reiterating that countertransference is ubiquitously present and is a joint creation between patient and therapist, which should be used to inform the therapy. The therapist should be vigilant to the feelings that arise during therapy and attempt to understand his or her own contributions in connection to the pressures being applied by the patient in his projective identification.

The joint creation view

In recent decades, the polarization of the narrow view and the broad view has lessened because most contributors to the literature recognize that both views may be relevant. In other words, the idea of countertransference as a joint creation that involves contributions from both the therapist’s past and what is induced by the patient has emerged as a common ground.³ Terms such as “projective identification” and “countertransference enactment” have entered the literature to describe this jointly constructed view. Both of these concepts have worked their way into everyday discourse among psychoanalysts and psychodynamic therapists. Both involve similar processes, but the former is derived from Kleinian and object relations thinking, while the latter developed out of the work of American ego psychologists.

Projective identification. The definition of projective identification that has become the preferred way of viewing the construct and is in common usage, although by no means universal, involves 2 steps. A self or object representation is projectively disavowed by the patient, who then unconsciously projects it onto the therapist. This phenomenon occurs through the patient’s interpersonal pressure on the therapist, thus “nudging” the therapist to experience or unconsciously identify with that which has been projected.¹ The first step is a type of transference, whereas the second step can be regarded as countertransference proper.

In view of the broad consensus that projective identification relies on interpersonal pressure, or nudging, rather than on a mysterious passage of mental contents from one party to another, the countertransference response arising in the therapist must be viewed as having been a latent structure that was present and somehow triggered by the patient’s nudging. The previous nature of the therapist’s own conflicts, defenses, and internal object relations will determine whether or not a projection and its recipient are a good “fit.” While projective identification may feel to the therapist like an alien force sweeping over him, what is actually happening is that a buried self or object representation, typically seen as “not me” by the therapist, has been activated by the interpersonal pressure of the patient. Hence a therapist’s usual sense of a familiar, continuous self has been disrupted by the emergence of the repressed aspects of the self.

Symington⁴ described this process as one in which the patient “bullies” the therapist into thinking the patient’s thoughts rather than the therapist’s own thoughts. Part of the reaction to the patient is based on the therapist’s past relationships brought into the present, as in transference. In addition, other aspects of the therapist’s feelings are induced by the patient’s behavior. Through projective identification, the patient re-creates an old “script” from his unconscious in which the therapist plays a principal character from the patient’s drama.³

CASE VIGNETTE

Annie, aged 25 years, starts therapy at the request of her parents, because she continues to abuse alcohol, does not perform adequately in the family business, and makes irresponsible financial decisions. Over the course of therapy, the therapist, Dr M, takes on a more directive and authoritarian stance when Annie begins to behave in a manner that is reminiscent of how she behaves with her family. In the midst of a session during which Dr M was trying to control the patient’s behavior, Dr M has a sudden flash to her sister’s face during an argument in childhood. The therapist recognizes that there is some resonance between what is happening with her patient and what happened with her younger sister.

In this scenario, there is a perfect “hook” for the therapist that is triggered by the patient’s behavior because of her past relationship with her sister. A therapist with different life experiences and relationships may be more resistant to the pressure to take on the role of punitive parent. Contemporary experiences in the therapist’s life that mirror what is going on in the patient’s life may also trigger intense countertransference feelings. It is commonplace, for example, for a therapist to feel uncomfortable when a patient’s marital conflicts mirror his own.

The key point here is that not all therapists will have the same countertransference responses to the patient. The notion of a “hook” (or lack of it) in the therapist and a good “fit” between patient and therapist implies that the therapist’s internal world will determine to some extent the nature of the response to the patient’s transference.

Ogden^5(p236) made the following observation: “Projective identification is a universal feature of the externalization of an internal object relationship, ie, of transference. What is variable is the degree to which the external object is enlisted as a participant in the externalization of the internal object relationship.” Hence, some therapists may not have their “buttons pushed” by a particular patient as much as another therapist might. Sometimes transferring a patient to another therapist improves the therapeutic situation because the new therapist has an entirely different subjectivity and is not as easily provoked.

Therapists may begin to appreciate that the projective identification is occurring when they begin to experience that they are not acting like themselves. Behaviors and feelings that are uncharacteristic for the therapist should make the therapist curious about the possibility of projective identification. When a therapist begins feeling that “I’m not myself,” he should carefully consider what might be transpiring between him and the patient.

Countertransference enactment. In the 1990s, a number of American ego psychologists began contributing papers on the topic of countertransference enactment in therapy. The term gradually took on a meaning quite similar to projective identification. The fundamental idea was that “enactments occur when an attempt to actualize the transference fantasy elicits a countertransference reaction.”^6(p629) These enactments were often regarded as involving both the narrow form of countertransference and something induced by the patient. Roughton⁷ described this as actualization: subtle forms of manipulation on the part of the patient that induce the therapist to act or to communicate in a slightly special way or to assume a particular role with the patient that silently gratifies the transference wish or, conversely, defends against such a wish.

It is important to acknowledge that countertransference is present in every second of every session. Since countertransference is initially unconscious, sometimes an action, such as forgetting an appointment or ending an appointment early, may be the first sign of it. American ego psychologists have emphasized that there can be acting in by the therapist that parallels the acting in by the patient. The therapist’s actual behavior influences the patient’s transference, while the patient’s actual behavior influences the therapist’s countertransference.

Shifts in countertransference

Because countertransference is ubiquitously present, it is logical that a therapist’s countertransference to a patient shifts over time, rather than remaining static. Just as we now think of multiple transferences instead of “the” transference, we now also think of countertransferences rather than “the” countertransference. In the course of therapy, the countertransference shifts as the therapist plays different roles in the patient’s internal drama.

CASE VIGNETTE

Mr T, a divorced 40-year-old attorney, comes to therapy with Dr K, who sees Mr T as charming and attractive. Dr K feels protective toward him-she sees him as a victim when he describes the dissolution of his romantic relationships. As his sadistic and narcissistic modes of relating are revealed during the course of therapy, her countertransference transitions to a more balanced view. It occurs to Dr K that her transition from a charmed and sympathetic observer to a disenchanted and cynical party to his mistreatment of women parallels the way women in his life experience him.

Thoughtful disclosure of the therapist’s feelings toward the patient can be helpful, although self-disclosure is not generally regarded as a dynamic psychotherapeutic intervention. Most therapists refrain from disclosures about their private lives or about personal problems. However, a specific type of disclosure involving feelings that emerge in the here and now of the therapeutic situation may be highly effective in helping the patient see the effect that he has on others.¹

Because we cannot always be sure what our intentions are when we disclose our feelings to a patient, self-disclosure should be used only when we have reflected on possible consequences that cannot necessarily be foreseen. Talking with a supervisor or consultant to discuss potential unforeseen consequences is generally a wise course of action. Some feelings, however, should probably not be disclosed for fear of burdening the patient unnecessarily or collapsing the analytic space in which the perception of the therapist is in the “as if” realm.¹ Some of these include sexual feelings for a patient and feelings of hate or disgust.

Transference and countertransference are the enactment of the unconscious worlds of 2 minds in the analytic space. Psychodynamic therapists must be aware of these processes at work, accept them, and understand their therapeutic utility. They are what defines what we do as psychodynamic therapists.

References:

Acknowledgment-The author wishes to offer special thanks to Glen O. Gabbard, MD, for his helpful contributions to this article.

References

1. Gabbard GO. Long-Term Psychodynamic Psychotherapy: A Basic Text. Arlington, VA: American Psychiatric Publishing, Inc; 2010.

2. Freud S. The future prospects for psycho-analytic therapy (1910). In: Strachey J, ed. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 11. London: Hogarth Press; 1961:139-151.

3. Gabbard GO. Countertransference: the emerging common ground. Int J Psychoanal. 1995;76(pt 3):475-485.

4. Symington N. The possibility of human freedom and its transmission (with particular reference to the thought of Bion). Int J Psychoanal. 1990;71(pt 1):95-106.

5. Ogden TH. The concept of internal object relations. Int J Psychoanal. 1983;64(pt 2):227-241.

6. Chused JF. The evocative power of enactments. J Am Psychoanal Assoc. 1991;39:615-639.

7. Roughton RE. Useful aspects of acting out: repetition, enactment, and actualization. J Am Psychoanal Assoc. 1993;41:443-472.