Countertransference

Countertransference continues to be a controversial topic in psychoanalytic writings and is therefore well worth revisiting. In this paper I will look at the place of the countertransference in analytic work, reviewing some of the more classical literature both past and current. I will explore the meanings and vicissitudes of countertransference, and give some clinical examples as illustration. (There will be time for comments, questions & discussion at the end.)

The technique of psychoanalysis was born when Freud, after abandoning hypnosis, due to its short-lived effect, discovered resistance and repression, and the phenomenon of the transference. If one looks at the way in which he made his fundamental discoveries, one could postulate that it was by way of the use of countertransference, even though the concept had not been described then. Interestingly, Freuds writing about transference, and the Three Essays on Sexuality, were developed after his struggles with his patient Dora, a young woman embroiled in a family drama of sexuality, deceit and collusion, who prematurely and angrily broke off her treatment with Freud.

A radical shift occurred with Freuds discovery of the transference, because prior to this he engaged with the patient in a cathartic exploration of memories of figures and experiences largely in the past, and the focus was initially therefore outside the consulting-room. Thus to acknowledge and explore feelings in the room, between analyst and patient required a leap of courage, but also substantially increased the demands which the work places on both participants in the psychoanalytic encounter.

Interestingly, after introducing the term countertransference in his early writings up to 1915 (e.g. Observations on Transference Love), Freud did not focus on this important area in further writing. He indicated a view nevertheless, that the stirring up of unconscious conflict in the analyst by c/t could be detrimental to understanding the patient in analytic work.

Many writers since Freud however have addressed this important area, and definitions could be seen to coalesce in two directions: narrower and broader. As with explorations on the concept of transference, more recent trends have been in the broader direction.

Historically, the early definition of countertransference was the transference of the analyst onto his or her patient, and that this was a disturbance of, or possible distortion of the treatment. Thus it was seen as an element that should be avoided, rather than worked with. However, analysts in Britain in the early 1950s, such as Paula Heimann and Margaret Little, extended the definition to cover the analysts emotional attitude to the patient, including his/her responses to specific aspects of the patients behaviour, and that these emotional responses could be used to gain information from the patient about the true nature of his/her communications, and from this position to be able to interpret both more accurately and on a deeper level.

Laplanche and Pontalis draw our attention to the controversy between the two positions: on the one hand countertransference being used to encompass everything in the analysts personality which affects the treatment, in my opinion being too broad and too loose; on the other hand a more restricted definition is that it concerns the unconscious processes in the analyst brought to bear by the transference of the analysand. In this schema we could also ask then, what part do transference and countertransference play in each of the two participants in an analytic encounter?

Heimann had suggested we ask the question in analytic listening to a patient who is talking?, given that at any time the patients voice might reflect mother, father or an infant self, and also To whom is this person speaking, what are they talking about, and why now? Margaret Littles contribution extended further to this way of thinking about the clinical encounter by adding that each analyst could be asking how he or she is feeling, why they feel this way, and why now?

By the late 50s the British school of analysts were very aware of the continuous interplay of the transference and countertransference, and the important role played by projective identification in this process, and I will try to clarify this interplay, and to elucidate the process of projective identification.

Since transference refers to the displacement on to the analyst, of feelings and ideas which stem from the introjected figures or objects acquired in the patients past life, it is thus the place of interaction of the past and the present, and the aim of analytic interpretation is to differentiate one from the other. However, as Christopher Bollas (1987)[[i]][1] reminds us, a number of different transferences occur, according to which use the object (define what meant) is put. In any one session, different transferences, such as infantile or oedipal, may be operating and may even contradict one another. Also, our perception of a transference position will imply a countertransference state or disposition, and this has implications for technique. For example, we may feel ourselves in an analytic session to be like the referee at a football game, rushing up and down on boundary lines and moving between one internal dyad or triad within the patients mind (intrapersonal interactions), and simultaneously responding to the interpersonal, transference and countertransference interactions.

This scenario also exemplifies the dilemma, when there is more than one feeling going on in the countertransference, which one do we address, when, and why?

There is also the importance of individual differences: no two analysts would necessarily have the same countertransference reactions to the same patients material. In his 1985 paper, Countertransference as compromise formation Charles Brenner noted that countertransference is not a synonym for intuition or empathybuta set of compromise formations which expresses the conflicting and cooperating psychic tendencies at work in the mind of an analyst in his professional capacity. And, just as some circumstances, in particular some patients, make analysis less enjoyable and less easy to do well, other circumstances, in particular other patients, make analysis more enjoyable and easier to do for a particular analyst.

A paper by Annie Reich (1966) entitled Empathy and Countertransference explored the pitfalls of the analyst being able to oscillate freely between transient unconscious identification with the patient and a return to a more neutral position. An acting out of the countertransference may occur when the analyst gets stuck in one of these trial identifications. Defences against the countertransference, such as sleepiness, forgetfulness or our own parapraxes,

are also important here. For example, if one opens the door and much to ones surprise it is not the patient one expected to see, the question could well be asked what was it in the last session with Patient A ,which made me expect patient B in patient As place?

Paula Heimann (1960) noted that sometimes there is a time-lag in recognition of countertransference issues as an indication of processes in the patient, only too obvious with the benefit of hindsight. She postulates that this time-lag between unconscious and conscious understanding may occur because transference factors may have gone unnoticed.

At this point I thought it might be useful to also revisit ideas about introjection and projective identification because of their relevance to exploring countertransference issues.

Introjection can be described as the process by which the relationship with an object (outside) is replaced by one with an imagined mental object (inside). Introjection is both part of a normal process, leading to a sense of autonomy, and may also be used as a defense against anxiety caused by separation. The infant and toddler may use a transitional object, such as a piece of blanket or teddy, to introject something of the relationship with mother, in order to master anxiety about separations.

The complexity of the term projective identification is reflected in the differing views expressed about its definition. The concept was first centred on the unloading of unwanted or feared aspects of the self into another: a later paper by Melanie Klein shifted the emphasis to the question of vicarious existence inor possession ofthe other person, with a strengthened connection with primitive envy.

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Another important contribution to the understanding of countertransference was made in 1955 by Roger Money-Kyrle[[ii]][2], entitled Normal countertransference and some of its deviations. This paper I think also helps to clarify the relationship between: empathy, identification (both projective and introjective) and countertransference. Freud had spoken of a benevolent neutrality, implying that the analyst whilst concerned for the welfare of his patient, was not emotionally involved in his conflicts, yet remained tolerant, but not indulgent or indifferent. Money-Kyrle suggested that the analysts concern for the patient derived from two basic drives: the reparative (counteracting destructiveness which is latent in all of us) and the parental. Whilst it is not suggested that the patient stands only for a child, it is the unconscious child in the patient with which the analyst is most concerned, and because the transference often elicits analyst / parent associations for the patient, this is a common theme for transference / countertransference interactions

Kleinian analysts including Rosenfeld (1987) have sought to examine the analysts feelings in order to uncover projective identifications by the patient into the analyst, so that according to Rayner (1991) countertransference in the last 50 years has been seen as the manifestation of projective identification as an **interpersonal **phenomenon.

I have often found it helpful and important to remember that the projected elements may either be unwanted, where an attempt is made to get rid of them, or they may be valued, where the attempt is to locate them in the other for safekeeping purposes .

Paula Heimanns creative and historically important paper Countertransference written in 1959, emphasised the importance of the analysts sensitivity in perception of events as they unfold in the psychoanalytic encounter. To quote from this paper The analytic situation is a relationship between two persons. What distinguishes this relationship from others is not the presence of feelings in one partner, the patient, and their absence in the other, the analyst, but the degree of feeling the analyst experiences and the use he makes of his feelings, these factors being interdependent.

The contemporary British analyst John Steiner has written that thinking in terms of projective identification provides a model of one way in which mental capacities can be inhibited or lost, when they are disowned and attributed to others, and in the course of analysis the patient can regain access to them. A necessary milieu however, is the analysts provision of containment (Bion, 1962), so that the patient can separate his own mental processes from those of his analyst, and thus attain a truly independent mind. To quote Steiner again Containment can lead to an experience of being understood in which the patients projective identifications are given meaning in relation to other elements in the total situation which involves a differentiation from other unrelated aspects of the analysts mental state.

In this context, the importance of the analysts own personal analysis is obviously paramount, and beyond training, the capacity to draw on this and continue a highly-tuned self- reflective ability, especially when the demands placed on one by the patient are relentless and intense.

It is part of the challenge of the work of the analyst to be able to be clear that his/her emotional reactions to the patient are not motivated by personal agendas, and that these are then not attributed to the patient inappropriately.

Again to quote Heimann from her previous paper  On countertransference(1949)[[iii]][3], (the analyst) will have achieved a dependable equilibrium which enables him to carry the role of the patients id, ego, superego and external objects which the patient allots to him, or projects on him, when he dramatizes his conflicts in the analytic relationship.

A clinical example is relevant here. A woman in her late thirties came with enormous difficulties in sustaining relationships after an early experience of actual abandonment of her and her brother, by mother. She produced in me a strong feeling that I was being duped, the feeling in me beginning after agreeing to begin the analysis the week immediately after the assessment sessions. I could not locate the origin exactly of the feeling, but found myself asking her about some level of commitment to the analysis, whilst realising with her somewhat desperate response that she had nowhere else to run to now, that I was asking her in a sense for something which pertained to the precise reason that she came to me - that she was unable to commit herself to intimate relationships past a certain stage. Her own fear that she would be duped by me , then abandoned, as with mother, became quite clear to me, but clear at a feeling level, by way of the experience of the countertransference, rather than just knowing by way of the story from the history. Whilst I may have enacted something of the countertransference in asking for the commitment, I also felt it appropriate in that it was actually liberating in relation to insights gained from the interaction (for both participants). In a way, I was enacting something of her own repetition of the plea to mother please dont leave me again.

It is by virtue of our own personal analysis, reflecting recognition of our own early self , and our empathy and insight, as distinct from theoretical understanding, which enable us as analysts to be in a position to partially identify with the infantile aspects of the patient, to rely on this partial kind of identification, and facilitate the working through of the infantile transference.

Paula Heimann in a subsequent 1965 paper viewed countertransference also as a response to deeply regressed patients, whereby the analysts emotional attunement may be akin to the nursing mothers response to primitive undifferentiated states in the infant.

When an analysis is proceeding well, as the patient speaks, the analysts understanding of the patient is facilitated by introjective identification, or taking into his mind those aspects of the patients damaged objects which he can recognise, then reproject and interpret to the patient. If the patient receives effective interpretations, these in turn help him to respond with further associations that can be understood. In this example, countertransference is based on the sense of empathy with the patient on which the insights leading to interpretation are based.

Because analysis is about communication between two people, Rycroft [[iv]]4 describes how the analysts sensitivity and intuition in picking up the meanings between and behind words is vital.

In one of my favourite more recent papers, Slouching towards Bethlehem or Thinking the Unthinkable in Psycho-analysis, Nina Coltart (1986) reminds us in exploring the difference between psychotherapy and psychoanalysis, that In analysis we can afford to ignore (the signposts), in the slow and attentive working towards a deeper nexus of feeling, fantasy, experience, and what Bion called Beta elements, that is slouching along in an as yet unthinkable form. Clues we note and store away, but need not, often must not, hear them as distracting sirens songs to be fallen for and followed.

Another early but fundamental view of countertransference was put forward by Racker[[v]][5] in 1957., who proposed that countertransference implies both a recognition of the patients transference, but also facilitates the articulation of transference communications. As the British analyst Christopher Bollas reminds us, if we believe in the ubiquitous nature of countertransference, and its value, then a space will be available in which the patients communications can be received and processed, because the patient will unconsciously perceive this belief and space. Thus non-verbal or primitive states of mind are more likely to find expression, and thereby to facilitate the working through of conflicts.

More recently the recognition of the importance of the pre-verbal levels of experience and of how profoundly they affect subsequent developmental stages has made us more aware of how these pre-verbal experiences may be expressed nonverbally in the analytic setting. This area interests me because I think sometimes very powerful feelings can be transmitted by the patient, without words, and it is only when the analyst is able to make available a space in his mind to register his own thoughts and feelings that some sense may be made of the wordless communication.

A clinical example of this occurred when a patient who had been in analysis for some years, came in one day, lay on the couch and during some minutes of silence, I suddenly developed a pressing headache, which I have not experienced before. As I began to think what this may have to do with the patient, he exclaimed I had a terrible headache when I came in, and when I lay down, it disappeared!, to which I thought, yes, and I know where it went!. Later in the session we were able to make sense of a previously unthought -about painful experience, which was connected with the headache for the patient.

Pearl King (1978)[[vi]][6] makes the point that just as the infant cannot be studied in isolation, apart from the mother or caregiver, then the metaphor applies to analyst and patient in terms of affective attunement. Thus the analyst may be able to uncover preverbal levels of trauma in the patient by paying close attention to the affective responses which the patient evokes. The patient referred to earlier often leaves me with a sense of having had both an analytic session, and a session of infant observation, as he sometimes thrashes around on the couch, gasping, rubbing his face with his hands, and giving many signs of a distressed infant.

In a wonderful recent paper entitled Psychoanalytic Theory and Infant Development by Judy Shuttleworth, in the book Closely Observed Infants, she describes Winnicotts concept of **primary maternal preoccupation **as a kind of attuned reverie which epitomises an openness to be stirred up emotionally by the baby.

Here I might also mention Bions model for thinking about the development of the mind: the notion of the container and the contained, in which he says that our capacity to be intuitively responsive to an others state of mind depends on our receptivity to being stirred up emotionally by contact with them. In infant observation seminar groups, the group may need to act as container for the observer when experiences of the baby or baby-mother dyad are particularly distressing or painful. The observer may also serve to contain some unbearable experience on behalf of the baby or the mother.

Patients with psychosomatic complaints have particular relevance here, as the symbolic expression may have bypassed verbal levels to be expressed in a bodily symptom instead. The countertransference experience with these patients is often profound, and very disturbing.

Winnicott[[vii]][7] and Bick describe how we think conceptually of a human having an inside and an outside, the representation of the boundary being the skin as the container. The infants concerns are first with the inside and inside experiences, both in body and mind, and hence have a simple meaning as psycho-somatic. But one can see here how also ill-health can become fused with doubt about oneself. For the child or adult suffering from hypochondriacal anxieties, the problem is self- doubt rather than physical illness. Conversely bodily health is very reassuring to the infant dealing with psychic doubts and uncertainties. When the balance of good and bad forces within is upset, the infant, child or adult suffers, and whether this is displayed in psychosomatic form depends on the intrapsychic level of symbolic functioning which has been reached.

I will give a clinical vignette here to illustrate the powerful countertransference which may be experienced with someone exhibiting psychosomatic complaints. Ms. A., a young woman in her 20s came to see me about a persistent psychosomatic complaint, which troubled her immensely. She was unaware of any meaning of her symptom, but knew that it had begun after a family secret of physical illness which she had been forbidden to tell the parents about. The pressure of what had to be left unspoken was evidently a powerfully connecting factor with the development of the symptom. She told me that she never remembered her dreams. She conveyed to me a sense of great anxiety, and of tightly holding herself together, as though she were afraid of falling apart. Whilst projecting a sense of strength and capability in her workplace, she struck me as both frightened and fragile. She had been a very compliant child, leaving rebelliousness to her older siblings.

As the analysis got underway, I began to be quite startled by the effect this patient had on me. Whilst she presented a measured, controlled and extremely polite exterior, she evoked in me chaotic and violent images, including ones which related to her symptom, such that at times I felt as though I was going to be driven mad (tearing my own hair out, as it were.) A transformation then occurred some months later when, no sooner was she in the room than I would feel an overwhelming drowsiness, and would then drift into a semi-dream, the images from which I was actually able to use to make some contact with her. For example, I saw her adrift on a boat at sea, and then was able to say to her that maybe she felt so cut-off that she feared no-one would be able to reach her. This stage lasted for another few months, and then to my surprise, she began to remember dreams for the first time. Interestingly, the first one was rather reminiscent of the fairytale of the Sleeping Beauty, including pricking her finger on a thorn, and then reaching out when she awoke for a mother-figure who was ambiguously good or evil. I certainly felt as though I had been the witch-mother figure with my violent images, but that also in my Sleeping Beauty state I had somehow been able to do her dreaming for her, in a sense, or digest the indigestible violent fantasies so that she was able to begin to remember her dreams herself.

Sometimes this is the way it has to be - for the patient to relive something in the here-and-now means that we inevitably come to not only represent mother, father, siblings and so on, but to be them in a sense. Here also it is important to resist the pressure to act out the countertransference, and so unwittingly repeat history for the patient. Sometimes we will inevitably be drawn in to act out something from a powerful countertransference, but then the challenge will become being able to take a step back and again interpret something of what we feel has been going on.

In his paper The analysts act of freedom as agent of therapeutic change, Neville Symington reminds us that it is the analysts ability to access his core feelings and to make these available to the patient, via interpretation, which leads to the patient being able to psychically separate from the mother glue, as he puts it.

Chasseguet- Smirgel makes an interesting point however, that if we overdo transference interpretations too insistently, we run the risk of transmitting an unconscious message to the analysand that he is forbidden to invest in objects other than the analyst, and thus to leave the analytic womb, as it were. A clinical example is relevant here. A 10 year old child Ill call Ben was referred for persistent problems at school, including terrorising and bullying other children. He had been in analytic psychotherapy twice a week with me for some months when he began to get exasperated by my linking his angry complaints about all and sundry to his anger and disappointment with me, that I wasnt making everything magically better for him. He retorted furiously, throwing the cushions across the floor I have one big problem, and its YOU! Later in the treatment of another child, Tom, aged five, who had developed a more positive transference to me, told me that he was going to keep coming till he was really big, in fact hed buy a car when he was 18, and drive himself to see me. (He did, however, manage to leave the analytic womb, well before driving age!)

In her book, Sexuality and Mind Chasseguet-Smirgel discusses the issue of maternal aptitude and countertransference, and notes the contradiction that whilst the sex of the analyst is usually said to be immaterial, it is nevertheless often recommended for a second analysis that the analysand choose an analyst of the opposite sex to the first analyst. Does countertransference differ between the sexes? Chasseguet-Smirgel suggests that it is maternal aptitude, and particularly femininity in the sense of the capacity to wait and watch a relationship develop, that are important in both sexes, and which allow preverbal and subverbal exchanges. She also postulates that it is the femininity of analysts which allows them to accept the long gestation period of an analysis. She adds that the analysts bisexuality needs to be well integrated to facilitate the development of the analytic baby, the product of the analyst and analysands work together, and which represents the analysand himself recreated.

Sometimes significant dreams brought by the patient, or enactments of

dreams within the session can be central turning points, after a period of impasse in the transference/countertransference. This brings me to mention Winnicotts important contribution elaborated in his paper Hate in the Countertransference[[viii]][8], because we may indeed feel hate towards a patient who is behaving in a hateful way, or who provokes or manoeuvres us to say something we regret. Sometimes our patients need us to hate them, and to survive this experience, without experiencing the rejection they may fear, or unconsciously provoke. Winnicotts point is that we dont have to be ashamed of feeling hate towards our patients if we can harness the hate and utilise it. Owning hating feelings can be an important step forward in terms of both honesty to ones self and ones patient, may be a self-protective device and may facilitate the patients movement through an impasse.

Bollas uses the term loving hate to describe a situation where someone preserves a relationship by sustaining a passionate negative feeling, either by hating or by being hateful and inspiring the other to hate him.

Perhaps at this point Ill look at some of the pitfalls or hazards of the countertransference, such as the analyst reacting to the intensity of the patients instinctual strivings and failing to identify and then extricate him or herself again. In these instances the analyst may be driven to act out and for example return love with love, or hate with hate.

Thus instead of going through trial identifications with the patient for the purpose of understanding him or her, the analyst may remain identified with him, behave or feel like him and therefore have a blind spot in relation to the patients defences. These pitfalls are less likely to occur if the analyst keeps a focus on the patient as a separate individual, and does not feel his identity altered by the patient. Sometimes this is easier said than done!

I have found the concept of the internal supervisor is helpful here. In the heat of the moment in a difficult or stressful encounter with a patient, such as the inevitable battles occurring over such issues as payment, times, and breaks in the treatment, it can be liberating to envisage in the minds eye a third party looking on at the therapeutic couple in the room, and ask just why is this going on now and what is it that is actually going on.

Of course the role of external supervision cannot be underestimated, especially in getting help with unravelling deadlocks in countertransferential feelings. I will give an example here from a supervisee. Dr. A. felt her patient Ms. B to be unusually sensitive and demanding such that Dr. A. felt constrained to the extent that she felt whatever she said to Ms. B. would have to be perfect, or Ms. B. might take flight. Dr. A. was aware of feelings of both helplessness and hopelessness. The patients relationship with her actual mother was claustrophobically close, engendering a helplessness in terms of being able to psychically separate and get on with a life of her own. When we discussed this in supervision, Dr. A. was able to see what pressure this patient put her under to be the perfect mother, which enabled a subsequent freedom of movement with the patient from this constrictive mantle.

Another interesting dimension to consider is countertransference in the supervisor / supervisee relationship. There may be multidimensional transferences and countertransferences going on here, especially when something becomes transferred from one dyad to the other, further complicated when the supervisee has his or her own analysis, although at least there is another venue for unravelling to occur. The supervisee may re-enact something of a transference to the patient, within the supervision, or ask for help with an impasse with the patient when there is a blindspot to a similar problem in the relationship with the supervisor. I have had the experience of supervising someone asking me for help with issues of withholding payment of fees by his patients, whilst he enacted the same problem in himself by not paying me promptly or paying an amount which bore no relation to the amount of the account. This played havoc with my accounting system! Conversely, supervisors may enact something of their countertransferential feelings towards the supervisee. I was certainly aware of my own frustration with the above-mentioned supervisee, but attempted to avoid an enactment of it, by addressing the connections of the difficulties in his work with the patients and with me, and trying to tactfully suggest it may be something to take to his own analysis (which he had referred to previously).

I will conclude with a brief summary of what I have tried to cover in this extensive topic of countertransference. A brief history of the origin of the term countertransference was given, including a definition and an attempt to elucidate some related concepts such as introjection and projective identification. Some early developmental issues were then covered, including preverbal, nonverbal and psychosomatic levels of functioning, and illustrations of the significance of these exemplified by looking at working with the countertransference in some clinical examples. Finally, some issues of countertransference in supervision were discussed. The parallel was made of the subtleties of communication between infants and mothers, maternal aptitude, and the analyst-patient transference and countertransference interactions.

References

[[i]][9] Bollas, Christopher. The Shadow of the Object: Psychoanalysis of the Unthought Known. Free Association Books. London. 1987.

[[ii]][10] Money-Kyrle, Roger. Normal Countertransference and Some of its Deviations. In Melanie Klein Today. Chapter 2. Volume 2 The New Library of Psychoanalysis. Volume 8. Tavistock/ Routledge. 1988.

[[iii]][11] Heimann, Paula.(Reference as above, Chapter 4)

[[iv]][12] Rycroft, Charles. An enquiry into the function of words in the psycho-analytic situation. Int. J. Psycho-Anal. 39:408-15. 1958.

[v] Reich, A. Empathy and Countertransference In Psychoanalytic Contributions. New York. Int. Univ. Press. 1973 pp324-360

viii Racker, H. (1957) The Meanings and Uses of Countertransference in Transference and Countertransference. London.(1968)

King, Pearl Affective responses of the analyst to the patients communication Int.J. Psycho-anal. 1978 59:329-34.

Symington, Neville The analysts act of freedom as agent of therapeutic change

[[vii]][13] Winnicott, Donald Countertransference (1960) in The Maturational Processes and the Facilitating Environment. London. Hogarth Press. 1965.

[[viii]][14] Winnicott, Donald Hate in the Countertransference (1949) in Collected Papers: Through Paediatrics to Psycho-analysis. London. Tavistock. 1958

Coltart, Nina E. C. Slouching towards Bethlehem or Thinking the Unthinkable in Psycho-analysis

In The British School of Psychoanalysis: The Independent Tradition. FA Books 1986