This is an intermediate-level course. Upon completion of this course, mental health professionals will be able to:
This course is based on the most accurate information available to the author at the time of writing. Cognitive psychology and neuroscience findings regarding brain development, structures, and activities continue to shed light on what were once regarded as merely psychoanalytic concepts and processes, therefore new information may emerge that supersedes some explanations in this course. This course may provoke disturbing feelings in readers due to their unresolved conflicts, but it also gives them information about processes by which they might resolve the conflicts.
Transference and countertransference can contribute to positive therapeutic outcomes in non-analytic therapy no less than in analytic therapy. They can also contribute to negative outcomes and treatment failure. If existential, cognitive-behavioral, or any other non-analytically oriented therapists fail to notice these displaced phenomena at work in their sessions, they are limited in their ability to help their clients move beyond their one-sided accounts of problematic relationships and events outside of therapy. If, however, these therapists identify and decode displaced material that manifests itself during their sessions, their perception of what is going on relationally in therapy can complement and correct clients’ accounts. Then, as therapists sensitively share their insights and invite corroboration or correction, clients can begin to realize that what is in fact transpiring in therapy is very similar, if not identical, to the unresolved conflicts at the core of their present problems. With this balanced, integrated insight, they can resolve their conflicts. They can heal themselves from within and so change their relationships with others so that they transform their lives.
This course explores manifestations of transference and countertransference: words, affect, dreams, fantasies, daydreams, and behavior. It is intended to help clinicians identify the subtle, indirect ways in which transference and countertransference reveal themselves and sensitize them to transcultural and intracultural phenomena.
This course also focuses on the five tasks of diagnosing and interpreting transference and countertransference: receiving or taking in transference and countertransference, holding transference and countertransference and permitting regression, decoding transference and countertransference, formulating hypotheses, and verifying hypotheses with clients. This course explores the overarching responsibility of therapists to monitor their work throughout therapy, but particularly as they interpret transference and countertransference to clients.
Finally, this course familiarizes clinicians with what a therapist must do to make collaborative interpretive work an effective intervention. It describes in detail transference and countertransference interpretations, and suggests an attitude with which therapists should approach their interpretive work. It presents specific guidelines for wording transference and countertransference interpretations so that they meet effectiveness criteria. It concludes with information about interpreting transference and countertransference to appropriate clients and at appropriate times and frequency.
This is the second course in a two part series, based on the book Transference and Countertransference in Non-Analytic Therapy: Double-Edged Swords by Judith A. Schaeffer, Ph.D. (Lanham, MD: University Press of America, 2007).
Transference and countertransference challenge therapists in at least three major ways. First, because the conscious mind cannot have direct knowledge of phenomena “residing” in the unconscious mind, therapists can detect transferred material only in the vague, shadowy signs of its presence. They can discover it only as it manifests itself in words, feelings, dreams, fantasies, somatic responses, and behavior as each of “these voiceless and vociferous little parts of [the self]. . .do their best to add their ‘two cents’ into the final product” (Wittig, 2002, 143).
Second, because manifestations of transference and countertransference are a source of data but not a source of evidence (Smith, 1990), therapists cannot simply take them at face value. Rather, they must “unpack” them to the point of their yielding the truths they hold.
Third, therapists cannot forget that transferred material is characterized both by similarities across cultures and differences among cultures. Roles of women, for instance, are similar and yet distinctive in Asian cultures and American cultures, in Islam and Christianity, in the eyes of adolescents and those of senior citizens. Hence, therapists must attend to transcultural as well as intracultural variables in order to expose the precise nature of transferred material accurately.
Categories of transference and countertransference manifestations, which overlap and merge, are artificial in one respect. Emotions, for example, find expression in words, facial expressions, gestures, and dreams even as dreams consist primarily of actions cloaked in affect. Examining these categories separately, however, permits one to simplify extremely complex phenomena and create manageable templates that can be placed over actual therapeutic occurrences.
At least initially, therapists regard words that clients use as simply their means of communicating the problems and concerns of which they are aware. Therapists take these words at face value, that is, according to their dictionary definitions or denotations.
However, certain words with denotations that clients consciously use to convey meaning also carry connotations or affective associations of which clients may be relatively or totally unaware. Some words not only convey straightforward messages but also carry subtle, emotionally tinged nuances. A client who says that she wants to work on her relationship with her father, for example, may simply mean her biological father. But she may also be unconsciously revealing her need to improve her relationship with others she associates with her biological father: those in authority, those who provide for the weak, those who are simply older and male. Indeed, the client may even be implying her older female therapist. Similarly, a client who says, “I want to reduce my depression” may mean “my sadness, loneliness, and listlessness as they affect my daily life.” However, a client who uses this statement may also be unconsciously referring to the depressing quality of a therapeutic relationship that closely resembles a previous affiliation. Thus, therapists must be open to the possibility that the connotation-bearing words clients are unconsciously using to sharpen and refine their denotative communication are actually manifestations of transference.
But should therapists suspect the same of what they themselves say? Is it possible that the words therapists consciously choose reveal unconscious countertransferential phenomena?
Yes, according to psychoanalytic theory, for the unconscious mind is always trying to find ways to move its contents into consciousness. Therapists, like others, unintentionally say things that they consciously forbid themselves to say. “I am afraid I cannot schedule you next week,” for example, may unwittingly reveal therapists’ fear of their clients’ imminent revelations.1
Therapists intent on discovering transference must also examine the extra-therapeutic, seemingly unrelated material that clients introduce during sessions. At times, in introducing extraneous material, clients are consciously intending to shed light on their goals, give background material, or provide information about who they are as persons. At other times, however, clients are unconsciously revealing the nature of their therapeutic relationship (Kahn, 1997), for it is either hindering or facilitating their progress.2
In spite of the client’s clearly stated goal to learn to be a better parent, she began her second session by speaking of not being called back to substitute teach by a local school. She wondered if she had not done a good enough job. Her therapist, in turn, wondered whether his client was really asking about how well she had done during her first session. Had her performance been good enough for her therapist?
The therapist remembered that his client had called that morning to ask about the roads. Because heavy rains had made roads slick near her house, she wondered whether he thought the roads near his office were dangerous. Perhaps she really wondered whether her therapist would call her again, so to speak, or be like the school personnel? Was it dangerous to travel the “road” to therapeutic work?
The therapist decided to test his hypothesis that the call the client made to him was due less to the weather and more to concern about his evaluation of their first session. “Did I seem disappointed in our session?” he asked. “Did you call to find out how emotionally dangerous it might be to drive to my office?”
She breathed a sigh of relief and answered thoughtfully. Yes, there were similarities between him and the school personnel. Yes, he too was an evaluator who might find her wanting. Yes, it felt dangerous to her to think of returning for a second session.
Subsequently, she returned weekly, revealing in detail how her early years were marked by poor grades for performance in the “book” of her father. She explored the basis of her feeling inferior as a parent and teacher.
As this vignette reveals, when talking about a third party, clients may be displacing toward their therapist: unintentionally revealing their feelings about the person with whom they are working and who they are in relationship to their therapist.
Clients’ urge to do so – to reveal self-in-relationship – is unusually strong in the closeness of the therapeutic setting, for it is there that their unconscious desire to share what is really important – but too threatening – most easily breaks through the barrier between the conscious and unconscious minds. It is “intended” on an unconscious level.3
He complained bitterly of his religion teacher, saying how stupid and out-of-it the teacher was. He couldn’t stand her or her class. His cognitive-behavioral therapist listened attentively, waiting for moments of insertion, hoping to help her client recognize the value of doing his assignments for religion class in spite of his feelings toward his teacher. For not doing homework and skipping class were the client’s presenting problems. Though he was bright and capable, he was failing.
One morning, through a frantic call from the client’s mother, the therapist learned of her client’s drug problem. He had been expelled from school for smoking pot, and it wasn’t the first time. Realizing she should have decoded his hatred-for-teacher remarks much sooner, the therapist said, “You never even mentioned you were having trouble with drugs.” Her client looked painfully embarrassed but quickly shot back with, “I can’t talk to you about certain things. You’re too old. You don’t understand what it’s like to be me.”
Too late, far too late, was the client’s real message becoming clear. Had the therapist only decoded the transferential meaning of her client’s complaints about his teacher, she could have afforded him an opportunity to explore his belief that closeness in age was a key prerequisite for therapeutic collaboration. Without that, he could only presume that his therapist was as much “out-of-it” as was his teacher. He could not focus on his goals because he could not count on his therapist to assuage the pain of making the changes they required.
Extra-therapeutic material clients bring in at the beginning or end of sessions is especially noteworthy. Enigmatic, mysterious, and seemingly totally unconnected to hardcore therapeutic work, it often holds important transferential messages.
He walked in feeling very, very tired, saying he couldn’t get enough sleep. “Was he also saying that he was very tired of their therapeutic work?” his therapist wondered. Was his therapist’s insistence on his becoming self-sufficient tiresome for him?
“Maybe,” the client answered when asked about his in-session fatigue. “I am tired of people trying to change me,” he admitted. “It started back in grade school. The teachers always had something hard for me to learn. It made me wonder when it would ever end.” Then, after a brief period of silence, the client breathed a sigh of relief, saying “Nobody ever cared about how hard it was for me before today.” Subsequently he moved with uncharacteristic interest and feeling into what he himself needed to change.
Transferential feelings are those displaced to the therapist because of subtle similarities between the therapist and persons outside of therapy. Clients whose parents were intolerant of them, for example, may experience their therapist as intolerant because of displaced feelings triggered by a “kernel of truth:” the therapist’s slightly intolerant behavior.4
Though single, obvious feelings would not appear to require decoding, what appears to be a simple feeling may indeed be complex emotion with a second or even third feeling at the periphery of the obvious feeling. Anger due to a therapist being slightly intolerant, for example, may actually include fear of the therapist’s rejection and sadness because of it.
“She cancels for so many reasons,” her therapist thought. Some seem legitimate, but others seem flimsy. The therapist recognized that the material on which the client was working was intimate and embarrassing, but wondered, “Could it be that our therapeutic relationship is even more of an obstacle to her coming?”
When her client finally came for a session, the therapist listened and watched for displaced material that might help her decode what on the surface appeared to be positive feelings. She also opened herself to decoding her own countertransference: her annoyance that sessions were being cancelled and her fears of a premature termination.
Finally, when her client described her mother-in-law as controlling, and said she was going to set firm limits with her, the therapist decided to use a transference interpretation to ask if her client felt able to set limits during therapy sessions. Her client said that she wasn’t sure. Noting that ambivalence, however, the therapist began helping the client explore possible negative transference. The client, in turn, stopped canceling sessions.
Theorists vary as to which transferential feelings are most probable in therapy. Racker (1972) tells therapists to expect first what is nearest to consciousness. Clients want to partner, if not bond, with their therapist and therefore hope to be found worthy of their therapist’s efforts. Beneath this hope, however, can lie fear of being judged.5
Other theorists tell therapists to expect transferential feelings most likely to contribute to the therapeutic alliance, regardless of their closeness to consciousness. On the positive side are feelings of love, calm, and relief resultant from experiences of unconditional acceptance by others being transferred to the therapist who, in turn, provides “kernels of truth” in the form of unconditional positive regard. But even these feelings might be coupled with fear of the unconditional acceptance becoming conditional.
On the negative side are feelings of distrust of someone appearing too good to be true, fear of being engulfed, sadness because of previous broken promises, embarrassment because of shame assigned by others, or any combination of these feelings transferred from experiences with others. Since bonding experiences are at least partly negative, primitive negative feelings can easily combine with each other and with positive feelings. In fact, the earliest bonding experiences commonly consist of a positive experience of having one’s basic needs met on demand, followed by a negative one of learning one has asked too much or too often.
To decode feelings, then, is to derive the true meaning of complex, labile emotions that originally appear to be simple and stable. It is to study body language, especially the prosody of the speaker’s speech, for voice quality is the truest indication of emotions (Bostanov & Kotchoubey, 2004). It is to listen carefully to reports of dreams and fantasies, consider the connotation of words clients choose with particular attention to those suggesting affect, and note whether there are contradictions between these seemingly reliable manifestations of transference.
She came late, saying that she had rushed to get to her appointment. She was unsettled, overwrought, and uneasy. When her therapist asked about her rushing, she simply explained that she had not left the house in time. The therapist then had to decide whether to take at face value a poor judgment of time and distance or whether to decode her client’s words.
Noticing her client’s uptight body language and clipped sentences, the therapist decided to ask directly about whether leaving the house late might be connected to reluctance to come to her appointment. She then received what was a far truer answer. Her client said that she was not sure that the particular therapist she had chosen could really help her.
A fruitful exploration of the exact nature of their work and the relationship it implied followed, during which it became clear to the therapist that the client was transferring her disappointment with former teachers to her therapist.
Even as therapists decode transferential affect, they must be alert for countertransferential affect, for it can reveal both the interpersonal weaknesses of clients and the work therapists themselves must do to facilitate therapeutic progress. Having had negative experiences with teenagers, for example, therapists can perceive youth as crass and self-centered even as they enter the therapy room. Adolescents sense this unspoken attitude, become self-conscious, and come across as crass in their anxious response to a person who somehow dislikes them. Others have disliked them and inflicted harm, which has taught them a simple lesson: “Harm others before they harm you.”
Especially challenging for therapists are countertransferential feelings resultant from the projection of displaced feelings that clients cannot tolerate, own, or even put into language because they precede the ability to speak (Modell, 1980). Like infants who deliver subliminal affect-laden messages before they are able to use language, clients unconsciously hand over their feelings of being unloved, blamed, or confused to therapists who have the ability and readiness to receive them. Thus, by unconscious design, the truth about clients is discoverable first in what therapists experience on a non-verbal level and then in what their clients experience as their therapists put that initial truth into words.
As a general rule, therapists first discover the truth about themselves in feelings that seem excessive or inappropriate to what clients seem to be saying (Tower, 1956). Because these emotions are usually much nearer to the heart of the matter than reasoning, therapists’ unconscious, affect-based perception of a client’s unconscious mind is more acute and in advance of their conscious, cognition-based conception of the situation (Heimann, 1950).
Moreover, therapists’ behavior or somatic response can signal already existing affect. Sleepiness, for example, might indicate that therapists have felt abandoned by clients who frequently intellectualize, speak monotonously, or talk in circles (Racker, 1972).
She moved from topic to topic as skillfully as a skater circles a rink, returning periodically to certain issues but never completely dealing with them. Her therapist grew increasingly sleepy but tried to convince herself that a hot day and getting too little sleep was causing her head to feel heavy. She wondered, however, why nothing she did, including getting up to adjust the shades, alleviated her distress. “Should I be decoding” the therapist wondered, “because the client is ‘saying’ more by her language patterns than meets the eye?”
Finally, the therapist decided to test her hypothesis that the client’s circling speech might be unconsciously intended to disconnect from her therapist. “When you circle from topic to topic, I simply can’t follow you for long,” she said. “I get so frustrated that I disconnect from you. Could it be that you want to disconnect from me?” she asked.
“I don’t know,” the client responded, but I do know that this happens to me a lot. I’ve been so hurt by people not listening to me. Even as a child, when I said I wanted to play with other children, they never heard me. I need help with how to talk. I’ve needed it forever!”
Thus, decoding a countertransferential response proved invaluable in terms of “unlocking” affect and exposing childhood experiences from which the client continued to suffer.
Similarly, therapists’ feelings can indicate enactments in which they have already become embroiled (Hinshelwood, 1999). Therapists’ irritability, for example, may be in the service of staving off guilt feelings for having already acted out their dislike of a client (Schafer, 1997).
A closer look at therapists’ countertransferential affect begins with grouping commonly experienced feelings into the four categories of sadness, anger, fear, and gladness, followed by a feeling rarely discussed: envy.
Countertransferential sadness usually combines discrete states of feeling demeaned, inferior, sorry for oneself, hopeless, helpless, and depressed. Therapists’ depression, which encompasses the other feelings, merits special attention because remaining depressed can result in therapists’ losing the self-esteem and self-efficacy they need to function.6
Arlow (1985) asserts that therapists’ depression is basically a countertransferential reaction: a defense against the depression of clients. Clients come to therapy because of an unconscious sense of a bad self even as they consciously proclaim a good self in relation to bad others. Occasionally clients project a good self onto their therapist, but more often, they project a bad self (Epstein, 1977), which they subject to punitive measures in unconscious imitation of prior caregivers (Racker, 1968).
However, countertransferential depression also depends on therapists’ own sense of self. Therapists with a positive sense of self and an internal “caregiver” are in a favorable position to realize that their depressed clients are engaged in projective fantasies with which they must first resonate, then reject. In contrast, therapists whose own self-definition is basically negative may unconsciously add self-punishment to negative transference. Even worse, when therapists experience the combined force of their inadequate internal self and their clients’ projections, they can lose their capacity for rational, objective observation. Though they may never admit it to their clients, therapists can “agree” intrapsychically that they are inadequate (Epstein, 1977), as the following vignette illustrates.
First the minister came to therapy; then his son joined him. Their therapist, who had experienced painful humiliation at the hands of adolescent males, thought that in this instance she was secure. As the loose-lipped, surly adolescent attacked first his father and then other members of his family, however, she had to admit that she was becoming increasingly uptight. For his part, the father appealed to the therapist to set limits but still allow his son to express himself.
Feeling demeaned when the son shifted his focus from people to the “stupid” therapy sessions he was being forced to attend, the therapist began to articulate what she thought would be an acceptable agenda. People could express their feelings, but feelings would have to be combined with discussion so that both father and son could arrive at a solution they could both endorse. In formulating the plan, of course, the therapist was unconsciously attempting to lessen the negative impact that the adolescent was making on her, even as she was consciously steering the course of action from problem to solution. She was determined not to succumb to the adolescent’s negativity. She would side with the father in his need to get rid of it. She resolved to transform the adolescent’s resentment into problem-solving energy and thus reduce the resentment that she was feeling toward him.
The therapist’s failure to address transference and countertransference issues, however, proved fatal. Imbibing his son’s attitude, as it were, the father began to align with his son. He agreed that the family situation was so bad that it could not be fixed and that therapy was proving to be a waste of time and money. He implied that the therapist was unskillful.
However, rather than address her painful countertransferential feelings of inferiority and impotence, the therapist again set out to convince the father, if not the son, of the value of patience and hard work, both within and outside therapy, and to convey her hope that things could change. As her professional and psychological survival became uppermost in her mind, she continued to de-emphasize her powerful countertransferential feelings.
Eventually, when the therapist failed with her agenda, she admitted to herself that therapy was going nowhere, that she was incapable of reversing the negativity, and that she could no longer count on her clinical expertise. When the father finally refused another appointment, the therapist merely mentioned her availability if he changed his mind.
Thus the therapist’s insidious sense of self-impotence and low self-esteem clouded her vision, leading her to self-destructive despair. Her acting-in contributed to therapeutic failure no less than her adolescent client’s acting-out.
Countertransferential anger includes hatred of abusive clients as well as disdain for victims of abuse combined with revulsion and disgust for what happened to them. Thus displaced anger manifests itself in various forms of acting out: withdrawing from clients (Plakun, 1998); becoming irritable because of precious time being taken up with what seem relatively small problems, leading to restlessness; and feeling bored because of mundane therapeutic issues, leading to sleepiness. Countertransferential anger may also reveal itself as therapists’ resentment of the emotional barrenness of clients’ communications or helplessness and frustration (Cohen, 1952), all of which may induce sleepiness.
Therapists’ extended frustration over lack of progress in therapy, which is often due to narcissistic transference, can also produce countertransferential anger. This, in turn, can result in inattention, annoyance, and forgetfulness (Schwaber, 1990).
Countertransferential anger can also stem from transferential guilt resultant from clients’ inducing their therapists to act in an angry fashion in order to appease their own guilt (Chused, 1992). On the other hand, in response to aggressive transference, therapists may experience subjugation. In time, however, even submissive therapists feel vengeful and angry and subsequently fear these feelings (Racker, 1972). Then, if they actually attempt to resolve their discomfort through subtle recrimination, they experience guilt.
At times, countertransferential anger can also be provoked by clients’ rejection of a state of dependence that is being “asked for” by therapists who assume the role of “savior” (Racker, 1972). At other times, countertransferential anger can stem from therapists’ inability to tolerate shame resulting from not living up to their clients’, their colleagues’, and their own expectations (Winnicott, 1958). Therapists’ anger can serve as a defense against the experience of shame resultant from therapeutic failure (Lewis, 1987).7
Ironically, countertransferential anger can also be the result of therapists’ efforts to protect themselves (Rothschild, 2000). It can be a response to having been threatened, hurt, or scared. Similarly, the fruits of elevated anger or aggression can actually be akin to a life force composed of activity and movement that can lead to loving, hating, or both, as therapists interact with the object of their aggression (Winnicott, 1965).
Countertransferential anxiety, a response to some internal stimulus (LeDoux, 1995), usually takes the form of therapists feeling scattered and confused. They are unsure of relating to clients similar to others whom they have found difficult and uncertain of therapeutic progress (Schafer, 1997).8
Countertransferential fear, in contrast, is a response to the environment. It makes therapists feel disconnected, disorganized, and even unable to think in response to autistic clients (Gomberoff et al., 1990), attention deficit clients, or hyperactive clients. It causes therapists to experience disequilibrium in response to schizophrenic or manic clients (Kantrowitz, 1997), or terror in the presence of clients with an antisocial personality disorder.
All of these experiences can result in therapists’ desire to get relief by imposing their own ideas and solutions on clients rather than patiently and painstakingly helping their clients to discover at their own pace what they must do to change.9
Therapists’ fear and anxiety sometimes develop because they experience clients’ hold on them as an unconscious fear of intimacy, seduction, engulfment, aggression, or dread of therapeutic regression (Langs, 1979). Therapists may become apprehensive, for example, when clients ask them for more time and attention than they can afford to give.
Paradoxically, countertransferential anxiety and fear may combine with guilt feelings and result in actions and words indicative of submissiveness. This submissiveness, in turn, may cause therapists to avoid frustrating clients, pamper those they already have, or search for quick resolution of complex situations in an effort to get relief (Racker, 1972).
Gladness runs the gamut from contentment to joy or elation. Gladness may also manifest itself in therapists’ feeling superior and wanting to boast (Handley, 1995) or monopolize the therapeutic conversation.
At times, countertransferential gladness lures therapists into engaging in the unwholesome practice of competing with their clients or other professionals, such as teachers, in working with their clients. Therapists can become insistent, for instance, that clients follow their advice rather than think for themselves or consult competent others (Blum, 1986a).
However, the two-edged sword of countertransferential gladness usually rekindles hope in clients and thus proves extremely helpful. It contributes to the formation or repair of the therapeutic alliance. But danger lurks even here, for gladness on the part of therapists may induce in them a desire for sustained positive feelings about therapeutic progress, feelings that are unjustified because they rest on denial of still-needed and difficult therapeutic work.
Because envy of clients is considered so shameful and unprofessional even when it is not acted out, therapists rarely admit it. Unfortunately, however, therapists’ determination to not be outshined by clients whom they envy at the same time that they desire to be helpful is more common than therapists would like to believe (West & Schain-West, 1997). Envy of clients’ real accomplishments, or even of their potential to achieve, may lead to therapists not supporting or encouraging their clients (West & Schain-West, 1997). Envy of clients may even result in premature termination if clients feel their therapist’s subtle rejection.
Decoding countertransferential envy begins with becoming aware of the anxiety that accompanies it (Racker, 1968) and that in time may grow into lack of joy and satisfaction as therapists focus on what their clients, not they, possess. Envy might also be suspected if therapists become competitive during sessions, need to prove their competence by knowing as much – if not more – than their clients, or feel confused, ambivalent, and uncertain.
Dreams that clients bring into therapy are rich sources of transference, especially when therapists are dream figures (Ferenczi, 1909). Therapists’ dreams are also valuable sources of countertransferential material, particularly if dream figures are clients (Tower, 1956). Because they are highly symbolic, containing both primitive urges to act without regard to reality and rational motives for acting or not acting, dreams are often complicated, extended, and exceedingly confusing. They call for extensive decoding.
Only an in-depth presentation would do justice to the decoding of dreams, but consideration of the following account may at least reveal the value of doing so.
The therapist noticed her client’s uptight facial expression and her forced congeniality. She claimed she was eager to work on assertiveness; but even when her therapist began helping her with specific assertive skills, she remained tense. It was only when she introduced her dream that her therapist could decode it and discern what was really going on.
In her dream, the client was being chased down narrow halls from one room to another. Wherever she turned, doors opened into other rooms and never to the fresh, freeing outside. The “enemy” chasing her was so close that she even felt its hot breath down her back. The client thought that the narrow halls and rooms were those of her own home, and her critical, demanding husband was the “enemy” always breathing down her back with his instructions. She couldn’t escape him. She couldn’t get free.
While this interpretation may have been accurate, the therapist wondered about transferential implications. Could the rooms be the contents of therapy sessions, which were packed with information but never let the learner breath freely and easily? Could the “enemy” chasing her be her therapist, whose words felt like suffocating hot air? Could the client be feeling as if she were being chased by a well-meaning therapist intent on doing good but nevertheless robbing her of her freedom?
Sharing the hypotheses that she derived from decoding, the therapist learned that her interpretation of the transference was also accurate. Had she not done her own decoding, she would have never realized that she was harming, not helping, her client.
Fantasy includes all mental images or sets of mental images created by needs, wishes, or desires, particularly daydreams occurring during non-sleep states. Daydreams are extended fantasies, even as fantasies can be thought of as “kernels” of daydreams. Though both may seem simple, fantasies and daydreams are actually intricate, detailed, and elaborate.
Fantasies and daydreams involve both primitive urges and believable presentations (Herron & Rouslin, 1982). They are means of accommodating to the environment, understanding what is occurring, internalizing environmental events, and discharging the energy from conflict (Piaget, 1962). Hence, they can reveal transference and countertransference.
Furthermore, as fantasies and daydreams bring ideals into reality, they become the basis for hopes and expectations in interpersonal relationships. As ideals, however, fantasies and daydreams aid and abet disappointment, confusion, and dislike – even hatred – of real persons who inevitably fall short of ideals. As representations of emotional “activity” needing to be understood and worked with, fantasies and daydreams provide clues about clients’ emotional responses, including their reactions to therapists (Herron & Rouslin, 1982). They call for serious efforts to decode their messages.
However, clients seldom share fantasies and daydreams with their therapists because they see them as distractions not worth their attention. Consequently, therapists must be ever alert to their presence, suspecting them in their own daydreams and fantasies as well as in clients’ subtle body movement and body language, particularly in lapses of focused attention or mini-dissociative episodes. Clients whose eyes become “glassy,” for instance, may well be daydreaming. Subsequently, they may make reference to the material.10
One fruitful way of decoding fantasies and daydreams in non-analytic therapy is to look for the needs that they encode, particularly those that can be met by others.
After a chance encounter outside of the therapy office, the therapist found it difficult to stop fantasizing about her client for several hours. “Strange,” she thought, “I have so many other things to think about. Why am I distracted by thoughts of the young man I see on Fridays?”
During supervision, however, the therapist became increasingly aware of her positive attraction to the client. His good looks, optimistic attitude, and refreshing viewpoints made him “the perfect client.” “Still,” she asked, “why do I fantasize about him?”
The therapist then began to notice subtle associations related to junior high when boy-girl crushes were rampant. The therapist hypothesized that this positive countertransference, related to her own need to enjoy what are called crushes on someone of the opposite sex, might well be reflecting exactly what her client also needed to look at: the part he played in opposite-sex “rituals” that struck others as adolescent infatuation. Indeed, her client had said that, though he disagreed, others described him as flirtatious.
The therapist worded her countertransference interpretation carefully during their next session: “Could the thoughts I keep having about junior high days be originating solely within me or you are contributing to them? They’re positive, but out of place.”
The client at first appeared bewildered, but when asked to take his time to respond, he realized his attraction to his therapist, although he didn’t think that his feelings were something that he could put into words. He never verbalized these kinds of feelings, he reported. He always tried to tell people that he liked them by “just being himself.” “Could that be why people say I’m ‘flirting?’” he pondered. Later, for the first time in his life, the client began to deal with behavior he had previously deemed inconsequential.
Manifestations of transference and countertransference behavior – body language, simple movement, complex movement, and physical sensations – are messages from unconscious to unconscious through bodily means. Indeed, “the basic units of experience are [not words but] bodily interactions between self and others” (Fast, 1992, 449). The behavior of the body contains key information that determines exactly what clients and therapists are trying to convey to each other (Scaer, 2005). Both therapists and clients are being unconsciously influenced by a series of slight, even subliminal, signals. Details of posture, gaze, tone of voice, even respiration, are noticed and recorded by both therapy participants (Meares, 2005).
Moreover, because the body cannot lie, it is a source of truth about the present as it embodies memories of the past.11 The body has “the ability to tune in to the psyche: to listen to its subtle voice, hear its silent music and search into its darkness of meaning” (Mathew, 1998, 185). Hence, in order to discover transferred material, therapists must decode their own and their clients’ bodily behavior.12
In the context of displaced material, body language or simple movement refers to inadvertent responses of the body to subtle, unconscious “messages” from the right hemisphere. “You are in some kind of danger,” for example, is a common message that makes clients fold their arms in front of them. However, when asked whether their body language indicates feeling threatened, clients usually say, “No,” for the transaction that sent the message from the right hemisphere to the arms was unconscious. Thus it becomes extremely important for therapists to study their clients’ and their own muscular movements, postures, gestures, and other somatic reactions during therapy.
Of particular importance are right-hemisphere-controlled facial indicators, especially subtle movements around the eyes and mouth (Schore, 1994). For the left-hemisphere-controlled right side of the face registers socially appropriate affective responses whereas the right-hemisphere-controlled left side divulges hidden personalized feelings (Mandal & Ambady, 2004).13
While what happens on a one-time basis may not be worthy of much attention, body language that persists or repeats itself is especially noteworthy. For as in dreams, the unconscious mind produces again and again important material whose overlooked messages need to break through to the conscious mind (Jung, 1946).
No matter what she talked about, the client sat back in her chair, keeping a safe distance, as it were, between herself and her therapist. “She has made progress, to be sure, but could more have been made?” her therapist wondered. “What needs to be done to increase her comfort, if that is indeed a prerequisite for further work? Rather than just space her sessions farther apart, I should address the sensitive topic of our progress.”
In the course of the exploration that followed, the client reaffirmed her difficulty with getting beyond the roles in which she had been cast as a child, roles so deeply cultural that someone from outside her culture would hardly believe them. It seemed as if the client needed to uncover the deterrents to changing her ways. She had to trust someone who could understand how much she would be an exception to her group if she changed.
“She sits back for that reason,” her therapist decided, “she is telling me in body language how alienated she feels.” So the therapist said, “It’s hard to trust someone from a different culture, isn’t it. We seem so different, though we may have a lot in common.”
To her therapist’s relief, during the next session the client reported a shift in her attitude toward making a change. She hadn’t actually made the change, she explained, but she was planning it in detail. And she leaned forward slightly when sharing her news.14
In contrast to body language that encodes relatively simple messages, complex movement communicates several displaced feelings and story-like thoughts. Complex movement that puts transferred feelings and thoughts into action can be called enactment.15
Enactment is the last step of “information processing that builds and exploits emotional databases of mind and brain” related to displaced material (Levin, 1997, 1136). Thoughts and words become coercive action loaded with emotion that usually relates to figures in the client’s or therapist’s early years. It is action dictated by a “script” never actually seen (Field, 1989), one most likely written between conception and eighteen months, when tone of voice, facial expressions, and gestures served as primary means of communication (Meares, 2005).
In carrying out transferential enactments, clients assign to themselves and their therapist roles specific to past experiences that have remained conflictual. They “intend” to play a part and have their therapist play a related one for various, sometimes overlapping reasons.16 They may be revisiting the past in order to have it turn out better. They may be unconsciously testing with their therapist a pathogenic belief acquired in childhood (Sampson, 1992), asking “Is that belief really true or will this person give me reason to negate it?” Then, by closely monitoring their therapist, clients hope for the evidence they need to substitute a new, wholesome belief for a disconfirmed pathogenic one (Silberschatz, Fretter, & Curtis, 1994).
Enactment of negative feelings and thoughts is usually called acting out. Because it strains boundaries, acting out is considered a regressive interaction “experienced by either [client or therapist] as a consequence of the behavior of the other” (McLaughlin, 1990, 595). It must be quickly decoded and, if necessary, examined, lest it limit the capacity for therapeutic work and exacerbate extra-therapeutic interpersonal problems. For ordinarily, others soon find the “mind reading” required by acting out to be overwhelming, if not maddening. Clients must learn that others greatly prefer words that describe feelings.
Meissner (1996) notes that the potential for countertransference difficulties to influence the therapist’s thoughts, feelings, attitudes, and words is great enough; the potential for these unconscious processes to find expression in the therapist’s…behavior and action is even greater (51).17
The same is true, of course, for transferential difficulties influencing client’s behavior. In turn, words used in therapy can become, on a subliminal level, incitement to action on the part of both clients and therapists (McLaughlin, 1990). Both unconsciously desire responses in themselves and others in line with their transference and countertransference schema. Both want to “shape a happening, bring about an enactment, in accord with [their] fears and hopes;” (McLaughlin, 1990, 599) fears that the present might otherwise be simply a repetition of the past, and hopes that it could be better.
Countertransference enactment is often a matter of therapists’ participating in the acting out of clients’ transference.18 Therapists unconsciously collude with clients in mutual projective identification organized primarily around clients’ unresolved conflicts (Plakun, 1998). Thus, countertransference enactment conveys meaning regarding clients’ transference conflicts (Sandler, 1976). Clients who are still conflicted over wanting to be nurtured gratis and finding parental figures unwilling to do so, for example, might fail to bring their copayment. Should therapists refuse to play a parental role, asking instead for payment, they will be actually addressing that conflict.
Countertransference enactment can also be a matter of therapists communicating indirectly their own unresolved conflicts. Therapists with unresolved narcissistic conflicts, for instance, might repeatedly insist that they are right (Wilson & Weinstein, 1996). Those with unresolved aggressive conflicts might act belligerently; those with unresolved security conflicts, dogmatically (Casement, 1991).
At other times, countertransference enactment will be a matter of therapists attempting to counteract their own weaknesses. Those who are indecisive, for instance, may exaggerate their open-mindedness (Wilson & Weinstein, 1996).
An in-patient adolescent ended his session by telling his therapist that another staff member regarded her as incompetent. Unable to process her embarrassment and anger sufficiently, the therapist set out to prove her competence. During a staffing hours later, she vigorously defended her client, blaming others for his bad behavior, and insisting on the soundness of her judgment. Unfortunately, exoneration was the opposite of what her crafty client actually needed, which was to take responsibility for his behavior.
Impressed with the therapist’s reasoning, however, the staff pardoned the client, who in time not only repeated his behavior but took an even more adamant stand that he should not be held responsible. He was the worse for his therapist’s erroneous defense. He had been significantly harmed by his therapist’s acting out, a result of her blindness to both his manipulating her and her own unresolved conflicts over being thought incompetent.
Ogden (1994) thinks of countertransference enactment as a powerful non-verbal “interpretation” being unconsciously conveyed to clients. The “interpretation” may take a simple form, such as ending a session early when stress levels are high. Similarly, therapists may use facial expressions that indicate confusion instead of asking for clarification.19
Countertransference enactment has been identified as an unconscious means of either indulging or punishing clients. By indulging their clients, therapists infantalize them: ask less of them than they are capable of giving, provide for them what they have the potential to do themselves, and absolve them of their obligation to change. By assuming rescuer roles, therapists do clients the disfavor of not having them face their dysfunctional patterns.
Therapists unwittingly indulge clients by caressing them with words in order to quiet their persistent negative feelings. They speak in soft tones or assure clients that all things are passing. They praise clients for minor achievements that are more likely to be the result of chance than hard work. Similarly, therapists try to divert clients from painful countertransference-causing conflictual material by directing attention to non-countertransferential material. They avoid all mention of pervasive distress on their part, sparing their clients from painful self-discovery related to the way they treat others.
The therapist was uneasy, not once but almost every time she met with her highly educated and wealthy client who had a subtle habit of demeaning her. She did not want to admit the uneasiness, however, either to herself or to her client. Instead, the therapist reasoned that she would be noticeably prepared when her client came and thus prove herself his equal. “Competition for outstanding performance is good for a person,” she said to herself. “It makes people reach for the heights others have attained,” she thought as she recalled seminars in which she felt inferior to male students.
Sessions appeared to go relatively well as the therapist conveyed information the client professed to want. In his termination form, however, the client referred to a stifling atmosphere within his sessions. There was an absence of free exchange, he wrote, for his therapist seemed defensive. He couldn’t say that he felt disrespected, but he knew deep down that mutual respect was simply not there. Rather, there was some kind of a power struggle going on. In a primitive attempt to outdo one another, both parties were indulging each other on the surface, but battling for superiority in the “deep.” Sadly, by not addressing her countertransference, the therapist indirectly punished her client. She failed to help him deal with his self-destructive interpersonal behaviors.
In contrast, punishing clients directly includes discounting them by unconsciously performing the exact opposite of the roles that clients assign. Plakun (1998) tells of a client who had been victimized assigning her therapist an abuser role. Instead of discussing the client’s desire to be abused, however, the therapist assured the client that he was totally kind and caring. He refused not only to abuse her but also to accept countertransferential feelings of guilt. In doing so, he denied his client the opportunity to work through her experience of being victimized.20
Alternative ways of punishing clients are responding in a hostile, distant, frozen manner or taking a moralistic stance and condemning in clients what therapists cannot tolerate in themselves. Therapists may become excessively sympathetic to third parties, for instance, and “take clients to court in a superior or angry way” (Pick, 1985, 164). They may “forget” to bring up something important, become highly distracted, or dissociate. For extended periods of time, they are available for their clients in body only.
Therapists also punish their clients by simply becoming silent, whereby they strike a compromise between their hostility and its rejection. They identify with a persecutor at the same time that they withdraw from that identification (Racker, 1972).21
In brief, whatever its unconscious motivation, enactment is an extremely significant psychic operation that is directly or indirectly tied to the very reason clients enter a therapeutic relationship in the first place. Dealing appropriately with enactment can finally resolve clients’ conflicts. Conversely, dealing with them inappropriately is one of the major reasons for treatment failure (Plakun, 1998).
Somatization, a source of truth known in the present but pertaining to the past, is the body’s revelation of what happened earlier in the mind and “heart.”22 Hence, it can reveal transference and countertransference. A client’s smiling uneasily as she protests her love for her child, for instance, may reveal transferred prior negative experiences with the child. Transference may also manifest itself in psychosomatic illness aimed at drawing “the psyche from the mind to the original intimate association with the soma” (Winnicott, 1949, 254).
Transference often manifests itself in somatosensory form because so many unresolved conflicts occur in a preverbal period. While somatization may originally be adaptive, it is usually a maladaptive learned response to a situation once uncontrollable but now controllable. Clients can experience “butterflies” before being able to use language to explain anxiety, for example. They then retain the ill physiological effects even after they can reason away or otherwise process their anxiety.
Somatization in therapists, a twin of depression and a form of acting in, is usually a matter of either thoughts stimulating emotions that then find bodily expression, or of emotions themselves finding bodily expression. Like transferential somatization, countertransferential somatization manifests itself in symptoms and bodily conditions that have no clear physiological cause. Relatively common are sudden stabs of pain, tears, trembling, or a growling stomach, strange sensations in the solar plexus, fits of coughing, poor sleep, sensitivity to noises, sleepiness, tightness in the chest, nausea, rising heat, abdominal cramps, barely perceptible odors or tastes, and sexual arousal (Boyer, 1997).
She was more than tired after a certain session with a couple that she was counseling, the therapist noted. The clients were pleasant, even cooperative, and they were making progress. Why was she so tired instead of relieved or energized?
It was only when her clients slipped back substantially that the therapist realized she was investing more energy than they in therapy. Like many clients, the couple was ambivalent about improving their relationship. Though they both agreed they had to make personal changes, they resented having to make the effort. Furthermore, they unconsciously resented the therapist that supported their doing so.
Being relatively sure of the countertransferential meaning of her fatigue, the therapist interpreted her countertransference. “I’m not sure why I’m so tired after your sessions,” she said, “but could I be putting more into this work than you?”
“Now that you mention it,” the husband replied, “we are always being asked to account for what we did or did not do during the week. There’s more to life than doing therapy assignments!” After the conversation that followed, the couple finally began to take more responsibility for their progress. Slow but steady, their progress matched their own timetable rather than their therapist’s.
Indeed, it is important for therapists to stand in the spaces of different pieces of their self-experience and not use language too quickly, for words can never adequately substitute for bodily experience (Bromberg, 1991). Rather than telling clients what they think they know, therapists must be more interested in listening to their clients and to themselves from an embodied place. To understand their client’s displaced relational patterns, therapists must become aware of what it actually feels like in their own body (Looker, 1998).
Damasio (1994) reminds therapists that somatization is common because emotions are actually conglomerates of sensations, which are integral experiences of the body. Each emotion has a different bodily expression, starting with a unique pattern of skeletal muscle contraction that is visible on the face and notable in body posture. Each emotion also feels different on the inside of the body, for different visceral muscle contractions are discernible as body sensations that are automatically and involuntarily transmitted to the brain. Shame, for example, feels like heat rising in the face, and sadness like wet eyes (Rothschild, 2000).
Thus, therapists who are willing to experience their body subjectively will discover clues to phenomena occurring in clients’ interpersonal past, especially at a time when no words were available, when psychic trauma could not be distinguished from physical injury (Balamuth, 1998). A feeling of deadness in therapists, for example, might reveal how clients were neglected, or loved and then rebuffed, and hence never really experienced the vitality otherwise natural to infants (Field, 1989). Being able to engage in only shallow breathing might reveal clients’ unwillingness to experience their emotions fully.
In order to identify, decode, and interpret transference and countertransference, therapists must involve their non-verbal right brain no less than their verbal left brain. For transference and countertransference, like most relational transactions, rely heavily on client-therapist cueing and responding that occur too rapidly for simultaneous verbal exchanges and conscious reflection (Lyons-Ruth, 2000). The right brain, the “center” of unconscious material must assist the left brain, the “center” of conscious material.
Besides using both hemispheres, therapists will find it helpful to slow down their mental activity and break it into five distinct but interwoven tasks. All the while, therapists must monitor themselves closely in order to decide how well they are performing each task and when to move from one to another. They must also integrate the tasks in order to accomplish their main goal of interpreting transference and countertransference.
Therapists perform the first task by making a conscious decision to continue to take in what they suspect they have already received on an unconscious level – namely manifestations of clients’ transference – and responded to within their own unconscious mind – namely manifestations of their own countertransference. The first requires therapists to deliberately open themselves up to what they sense is occurring on an unconscious level: conflictual contents of their clients’ and their own unconscious minds attempting to enter their conscious minds.
Thus the first task is a matter of therapists trying to “be there” for clients and themselves in a new way (Heath, 1991). They endeavor to form a composite picture of conscious and unconscious information from which they and their clients can, in time, derive fuller meaning than that based solely on conscious communication.
The mechanisms by which therapists receive unconscious material from their clients and themselves, namely transference and countertransference, operate first on an unconscious level. Without knowing it, therapists receive the affective, cognitive, and sensate messages their clients displace. Without intending it, therapists respond to subtle messages from the recesses of their own unconscious mind and transfer material to their clients.
Then, when therapists perform the first task, they intentionally “make room” for displaced material in their conscious minds. They choose to increase their awareness of the feelings, attitudes, fantasies, dreams, images, thoughts, sensations, and behaviors that they and their clients are unconsciously transferring to each other (Bird, 1922). Therapists open themselves to a state of “convergence” of past and present. They offer to clients their “entire availability:” all the time and mental space they need in order to deal with their still-unresolved conflicts (Grinberg, 1997).23
In performing the first task, therapists take seriously their professional responsibility to regard displaced material as central to therapeutic reality (Deutsch (1926). They become congruent with the painful, unconscious memories of their clients (Vanaerschot, 1997).
By deliberately increasing their awareness of what their clients are transferring, therapists also bring to consciousness their own countertransference. They take note of the roles they are unconsciously assigning clients as well as the roles their clients are unconsciously them. Therapists who are assigned the role of being a parent figure for a client working through early child-parent conflict, for example, deliberately “accept” an otherwise fleeting image of themselves as a controlling, self-indulgent parent. Similarly, if they themselves are assigning the role of unruly child to their client, therapists hold in focus the emotional satisfaction they have begun to experience from subjecting another to their will. They allow themselves to note in detail the muscle tightness of one who is immobilizing, on a fantasy level, a struggling child.
Thus the first task is one of adding latent content to manifest content. Therapists combine unconscious clients’ body language and meta-language with what they consciously say. Therapists also add their own unconscious perceptions and desires to conceptions and intentions of which they are already conscious, or which they at least suspect. Therapists allow right-brain learning to augment left-brain learning. They open themselves to receive nonverbal communication that cannot be put into words.
Therapists perform the second task by holding the transference and countertransference they have received, often for more than one session (Bion, 1961), and permitting the regression that tends to occur in a deepened and broadened holding environment. They embrace the full impact of their clients’ displaced – and usually negative – reality. “This is the clear, sharpened, whole message my client is giving me,” therapists come to realize as they hold, over a period of time, various manifestations of transference (Smith, 2000).
Therapists perform the second task by containing and autoregulating their own negative states long enough to act as affective regulators for their clients (Schore, 2003b).24 Clients become aware of therapists successfully managing the distressful feelings, sensations, and thoughts they have transferred to them. Clients conclude that they can continue to reveal their unresolved conflicts without being overwhelmed by the distress, particularly the anxiety, that has kept them from reaching consciousness. Their therapists are sharing their “burdens.”25
Casement (1991) describes this affect regulation as therapists refusing to follow their natural inclination to disengage from the distressful transferential communications their clients send. Rather, therapists avoid closure, tolerate ambiguity and uncertainty, and permit lack of differentiation in order to share their clients’ meaningful, displaced relational experiences (Schore, 2003a). They do not return prematurely what their clients project into them (Joseph, 1978). They renounce their own need for gratification.
In performing the second task, therapists refrain from taking refuge in words. They resist their impulse to shift into a left-hemispheric dominant state and to respond verbally to clients’ verbal messages. Instead, they hold sensations evoked by unconscious communication (Stark, 1994) and sustain the countertransferential feelings that transference triggers. They stay in the right hemisphere, which has a “wait and see” mode of processing (Federmeier & Kutas, 2002). Thus therapists do for clients what they were unable to do for themselves at the time of their original conflictual experiences: allow psychic pain to remain in their conscious mind.26
As they remain silent, therapists observe their clients’ posture, gestures, and movements, take note of the tone, syntax, and rhythm of their clients’ speech. Therapists allow their own felt sense to act as a body-based perception of meaning (Bohart, 1993).27For the sake of understanding through experiencing, they permit themselves to contain their clients’ unresolved conflicts in their own bodies (Kernberg, 1987). They endure the desires and disturbing feelings and sensations their clients unconsciously put into them. In more cases than not, they let clients use projective identification to transform them into someone “bad,” someone deserving of disrespect, even abuse (Gorney, 1979) and let themselves feel that negative label physiologically.28
The second task also requires therapists to re-experience the breadth and depth of their own unresolved conflicts, phenomena that constitute a key element in any countertransference response (Kernberg, 1975). Therapists willingly suffer the painful countertransferential affect and sensations that reflect their clients’ conflicts (Roth, 2001) and deliberately entertain the countertransferential phenomena that act as stimuli for these conflicts.
Ordinarily, therapists find the second task difficult for three reasons. First, clients persist in displacing conflictual material because on some deep unconscious level they are unwilling to entertain the possibility of alternative perspectives. They want to hold on to the illusion that they and their therapists are one person and that, once their therapists are feeling precisely what they are feeling or what they want them to feel, they, the clients, will no longer suffer (Slochower, 1999).
On yet another deep unconscious level, therapists also want to hold on to the illusion that they can resolve clients’ conflicts without holding the transference and countertransference in which they are revealed. In particular, they want to understand transference without experiencing it (Bonnet, 1991). They want to make therapeutic progress in spite of distancing themselves from painful displaced affect by asking questions or shifting their focus to routine observations (Schwaber, 1990).29 However, clients take note of these false assumptions and respond by displacing their conflictual material yet again.30
Second, therapists experience significant anxiety as they hold their clients’ and their own displaced material and they and their clients assign each other conflict-related roles. Clients’ toxic material mobilizes therapists’ toxic material (Dosamantes, 1992). Therapists’ anxiety compounds clients’ anxiety, which, in turn, exacerbates therapists’ anxiety.31
Third, therapists experience regression – to one degree or another – as they provide a holding environment for their clients’ and their own primitive affective states (Winnicott, 1949). They regress “in the service of countertransference” (Bigras, 1979, 312) as they contain their clients’ distressful communication. They even risk experiencing disequilibrium within their right brain (Spence et al., 1996) that leads to deterioration in technical competence.
Already in the middle of the last century, Little (1951) described successful therapy as both a normal process of two conscious minds sharing information, and a pathological process of conscious regression. A little later, Glover (1955) explained that therapy is fruitful because therapists allow themselves to regress temporarily to early-life stages. They permit themselves to enter a state of regression for the sake of broadening and deepening within themselves their clients’ experience.
The use of regression in this context is, of course, an extension in meaning of a word originally reserved for an unconscious process. Strictly speaking, unconscious regression cannot become conscious. However, the process of willingly entering into a regressive state so resembles doing so unconsciously that no other terminology seems appropriate.
Racker (1953) connects conscious, intentional regression with therapists’ acceptance of the fact that though they are adults and professionals, they are still children and neurotics.
When they set aside some of the secondary aspects of mature mental functioning and embrace primitive states, they feel neurotic. When they deliberately allow themselves not only to hold but also to deepen the hurt, anger, and fear inherent in the transferential roles their clients assign them, therapists experience a strong urge to engage in retaliating, withdrawing, or other counterprojective processes.
Rather than doing so, however, therapists performing the second task subject themselves to the psychic forces that characterize transference and countertransference. They relinquish the personal values and goals that are often rationalized and hidden behind models of the mind (Schwaber, 1990). They intentionally allow disturbing images, fantasies, and memories to arise: pieces of internal, unconscious experience that are often contradictory, “crazy,” and disturbing (Isakower, 1963). They undergo fragmentary experiences that they hope will shed light on or add clarity to perceptions of their senses and conceptions of their conscious mind.
Levin (1997) makes it clear, however, that therapists who are performing the second task must not permit conscious regression to impair their basic ego functions. In particular, therapists must not lose hold of the fact that what their clients are transferring to them still belongs to their clients (Deutsch, 1926).32 Therapists must not become delusional and think, for instance, that they are in fact the sibling of a client assigning them the role of an abusive sibling. They must not believe that they are allowed to actually perform their transferential roles.33 They must not suspend their ability to recognize and regulate the negative affect being projected into them.
Nor must therapists who allow themselves to regress suspend their ability to recognize their own countertransference and regulate its negative affect and disturbing sensations.34 In fact, in performing the second task, therapists must dialogue with themselves often in order to balance affect and sensation with thoughts about what is occurring and what needs to be done with it (Kernberg, 1987). They must periodically decide whether to begin decoding what they have been holding or to continue to extend the holding environment for the sake of additional information. Furthermore, they must ultimately decide whether to process the displaced material they are experiencing intrapsychically, consult with others, interpret it to clients, or combine these methods of managing transference and countertransference. Said succinctly, because of the other key functions they must perform, therapists who permit conscious regression must not allow themselves to become thought-disordered in the strict sense of the word.
However, therapists who regress may – and often will – experience what may be termed a thought disturbance: things will appear false to their sense of self. They and their client will feel as if the therapist were a parent. They will accept, on a temporary basis, a parental definition that allows them to want to act in parental ways. In other words, when therapists permit themselves to regress in the course of containing displaced material, they will experience something that seems true on one level but false on another. Regressing to babyhood at the request of a client who wants to be a parent, for example, will seem strangely true from an affective standpoint but not true from a perceptual standpoint. Similarly, regressing to the toddler age will seem strangely true from a sensory standpoint but not true from a linguistic standpoint.
When therapists temporarily set aside some of the reality-testing functions of their ego as they entertain the evidence of past phenomena, they give their clients a powerful non-verbal “message.” They say, in effect, that they trust their clients enough to become vulnerable in their presence (Kantrowitz, 1997). They are allowing themselves to feel confused and stupid at best, depleted and “lost” at worst (Money-Kyrle, 1956), and anxious in any case (Wallerstein, 1990). They are choosing to remain in a “world” where things that are not right are the norm.
From the viewpoint of clients who have regressed because of transference, nothing benefits them more than this. They can trust one who has willingly descended into the depths of their transferential emotional state. They can trust a “kindred soul” who is also experiencing a loss of understanding and insight (Bion, 1961). They can trust a “partner” who is willing to learn their primitive “language” in spite of their regressive fear.
Indeed, clients communicate early, primitive material that’s most important to them only when their unconscious mind is fused with the unconscious mind of their therapist (Isakower, 1963). Critical images, fantasies, and memories arise from both client and therapist only when their minds are fused in a state of temporary regression within the confines of therapy. Clients learn to observe the present while experiencing the past only when their therapists learn to experience the past while observing the present.
With this basic trust established, regression becomes for clients not only considerably less frightening but also enabling. It allows them to continue to convey a sense of early and complex experiences otherwise not communicable. In addition, conscious regression permits therapists to add key experiential data to information their clients consciously provide, which, in turn, gives therapists a relatively complete “message” they must set out to decode.
Decoding, a left-brain activity, is a matter of extracting the probable meaning of what clients and therapists are displacing from the past to the therapeutic setting. It is a matter of deriving hidden significance from apparent meaning. Decoding “breaks the code” in which complex human communication is transmitted, bringing clarity to what therapists and clients really mean to share.
Decoding is a matter of discerning the significance of garbled messages related to the work needing to be accomplished in therapy. It is a matter of amending what is said in words by what is conveyed through association or communicated through body language.
Decoding is an essential element of all forms of psychotherapy because truth and its bedrock of facts are usually shrouded from both clients and therapists in spite of their earnest attempts to reveal them. With rare exceptions, material that clients and therapists transfer from other people to each other lies largely, if not completely, outside the awareness of their conscious minds. Buried within the unconscious mind, it is inaccessible to the conscious mind except in subtle, camouflaged signs such as unwarranted or overblown affective responses, mysterious dreams, fleeting flashbacks, enigmatic somatic responses, surrealistic fantasies, and urges to act that seem to have no basis in reality.
Indeed, these encoded signs account for impressions others receive without individuals intending to reveal themselves. Not wanting to be known as hating their guests, for example, hosts make every effort to show acceptance and tolerance. But when leaving, their guest may find themselves hearing a negative feeling word imbedded in such a superficially positive statement as, “We hate to see you go.” In spite of themselves and the “front” they have presented, their hosts have allowed their personal reality to “drip from their pores,” as Shakespeare penned centuries ago.
Similarly, in the clinical setting, much of what clients communicate is not really who they are and what they really mean to convey. For they have unconscious needs equally important to their well-being as solving their stated presenting problems. They hope to resolve age-old conflicts with others. They hope to be valued, esteemed, and loved.
As a consequence, clients unconsciously convey information that is quite different from their verbal explanations of what they do and why they are in therapy. A client rushes in late, for example, and blames his lateness on traffic. But because of subtle discomfort in her own mind, his therapist suspects another message: “I am resentful.” She wonders whether her client’s lateness is only the result of his battling traffic. She wonders whether he resents something his therapist said the previous session that made her resemble a disliked person from the client’s past. In any case, as the therapist questions the intent of her client’s explanation for coming late, she inaugurates the difficult process of decoding.
Decoding is difficult for yet another reason: therapists are unconsciously filtering reality through the lens of their own experience and expectations. What therapists believe they perceive is somewhat different from what clients are actually unconsciously communicating. The unconscious message of clients cannot pass through the unconscious mind of their therapists without some distortion.
Hence, therapists must also subject their own feelings, attitudes, thoughts, and behavior to the decoding process. What appears to be a positive urge, for example, like wanting to extend the session of the client who comes late, might actually be harmful because of its accompanying detrimental meta-message: “You are so valuable that I will be generous with my own time. You do not need to say clearly that coming here is hard for you.”
Decoding is necessarily a multi-step process because deciphering mysteriously encoded psychological material is laborious. It requires intensive cognitive work involving meticulous attention to detail as well as a willingness to evaluate vague intuitive possibilities. “Transference...has to be detected almost without assistance and with only the slightest clues...” Freud (1905, 116) declared almost a century ago. Since then, that task and that of decoding countertransference have not become easier.
In order to decode transference and countertransference, therapists must first consider their clients’ and their own choice of words, expressed affect, reported dreams, suspected fantasies, and behavior, including somatic reactions. Some manifestations will be direct contributions of the therapy participants; others, reactions to the contributions that the other participant has made (Smith, 2000).
Then, therapists must hold in abeyance apparent meaning while remaining open to interpersonal meanings beyond personal meanings. They must take note of tone of voice, volume, word emphasis, gestures that match or fail to match content, muscle movement that supports or contradicts speech, and countless other signs of human communication. They must consider their own feelings and whether they match those of their clients. They must acknowledge bodily discomfort, noting sensations and physical responses that either contradict or correspond to what clients are saying.
Therapists must also be open to how they might be contributing to the therapeutic experience of clients. They must be willing to distinguish what their clients are inducing in them from what they themselves are bringing to the therapeutic setting. Feelings of success during a session, for example, may be explained more by occurrences removed from the therapeutic setting than by the therapist’s skill and client’s progress.35 Similarly, therapists’ feelings of envy may be due more to their own lack of similar professional success than their client’s boastful demeanor, though it may be due to both.
“Why does this client irritate me so?” the therapist queried. “Why am I not simply flattered that he has come to see me? He is intelligent, articulate, and seemingly ready and willing to get to the heart of his problems. Yet there seems to be something subtly boastful about him. At least he strikes me that way,” the therapist came to realize. “Though he does so nonchalantly, he keeps drawing attention to the recognition he has received for his films.”
In studying his own countertransference, the therapist had to admit that he was envious. He also desired to make a name for himself professionally, but had not been very successful. The difference between their professional success was playing against his desire to be empathic at times and neutral at others. He was bringing to the sessions the pain of his failures.
“Rather than interpret this countertransference to my client,” he thought, “it would be good for me to process these feelings with a colleague.” If they continue in spite of that, I may consider sharing them with my client. The effect he has on me may well be his unintended effect on others.”
The process of formulating hypotheses consists of therapists providing for themselves tentative explanations for why the phenomena they have decoded are occurring: probable reasons why certain aspects of the past are now protruding into the present.
Ideally, hypotheses are simple statements. A hypothesis about familial relationships, for example, might be, “My client is transferring to me jealousy toward an older sibling.” The simpler the formulation, the more clear-cut can be verification of the hypothesis.
In some cases, hypothesis formulation occurs not after but at the same time as decoding. A therapist may think, for example, that a client’s anger, which includes anxiety, is being caused by prior experiences of rejection. Thus the hypothesis at the time is likely to be, “My client is both angry with me and anxious about my rejecting her.”
In other cases, hypothesis formulation must follow decoding because material is so complex that efforts to decode it yield only an affective or cognitive label. The hypotheses that can be derived at that time are limited to “My client is angry” or “My client thinks that I am mean.” Hence, therapists formulating a full hypothesis must sometimes continue to look for causal links. They continue to open themselves up to the experience of their clients in relation to themselves with the expectation that new and more specific material will shed light on what is already present. The client who relates a story about a verbally abusive bus driver that she encountered on the way to therapy, for example, may be unconsciously providing an explanation of an original experience of victimization. But she may also be saying that her therapist’s “taking” her along a certain therapeutic path feels abusive to her. By continuing to listen carefully, her therapist will receive confirmation of one, if not both, of her hypotheses or at least know she must entertain others.
For effective therapy to proceed, therapists must verify the hypotheses they have formulated. They may do so by themselves, with consultants, and/or with clients.
One would presume that just as therapists are eager to confirm their hypotheses, they are also eager to disconfirm them. The facts seem to be, however, that disconfirmation is more difficult for therapists than confirmation, for formulating hypotheses inaugurates a bias or fondness for what is conjectured and encourages a search for supportive evidence. Hence, to be effective, therapists must learn the discipline of being as objective as possible about their hypotheses.
One important way therapists have of accomplishing this is paying close attention to their own somatic response to their verbal attempts to explore transferred material. The body will invariably, though perhaps subtly, “agree” or “disagree” with what the mind concludes. Being physically energized, for example, usually suggests appropriate hypothesis verification, while experiencing repeated fatigue, uneasiness, or worry suggests the opposite. This is especially true of hypotheses related to how helpful therapists are being to clients.
When her client came in for his session, the therapist felt a deep calm. She was able to remain appropriately focused on what he was saying and was usually able to resist giving advice or talking in place of holding the material her client was presenting. “He is given to intellectualizing,” she reminded herself frequently. “He does not need me to offer additional intellectualization. Nevertheless, she hypothesized, “He is transferring to me an intellectualizing function once performed by a significant other.”
On occasion, however, the therapist did talk instead of listening. She “grabbed” her client’s thoughts and feelings and carried them swiftly to her mind, responding cognitively. In no time, her body gave evidence of her interference. She lost the calm she originally possessed. Then, consciously returning to a non-verbal stance, she once again became calm and tranquil.
Thus, her bodily reaction had verified her hypothesis: “He needs me to allow him to feel,” she would remind herself. “He does not need me to help him intellectualize.”
Supervisors and consultants are also invaluable during the verification process. In addition, especially in cases involving significant countertransference, therapists are wise to interpret transference and countertransference to clients, asking them, in effect, to help them attain accuracy.
By interpreting transference and countertransference, therapists also enable clients to know experientially the benefits of identifying what actually is, rather than engaging in fantasy. For only reality can serve as a solid basis for changing – rather than learning to live with – what has brought the clients to the therapeutic setting. Wishing for that which is not – and can never be – merely prolongs immature psychological states and reinforces ineffective interpersonal patterns.
Self-monitoring consists of internal supervision for the sake of checking the quality of one’s work. It involves watching oneself in order to verify thinking, observing in order to control affect, and evaluating in order to determine what behavior to continue or discontinue.
During therapy sessions, therapists self-monitor for the sake of autoregulating the stressful countertransferential alterations that their client’s transferential communications evoke. They attend to their own functioning even as they and their client engage in mutual exploration of issues of which they are conscious and communicate on an affective level (Perna, 1997). They maintain a “binocular vision,” (Holmes, 1992) distinguishing what they are feeling from what they are responding to.36
Self-monitoring during therapy begins with therapists noting how well they are observing clients, for choices regarding interventions that are intended to further the treatment plan must be made on the basis of how they impact clients. Therapists also note their own well-being, for clients’ thriving is partially dependent on therapists’ sense of how well they are bonding with clients. By extension, therapists make calculated observations of their interactions with the particular client before them in order to judge whether their sense of self-efficacy is based on those particular interactions rather than the client’s own innate capacity or already-developed skills. “Is the direction I am going increasing my client’s insight?” therapists ask themselves, “or is she able to continue satisfactorily without my interpretation?”
In one sense, therapists must self-monitor continuously because of powerful forces like transference and countertransference pervading the entire therapeutic process. In the intimacy and regularity of the therapeutic setting, reenactment of unfinished “business” takes place over and over again without the conscious intent of either party.
In another sense, however, therapists must engage in self-monitoring periodically rather than continuously. Transference and countertransference must have enough “room” to display themselves – even to develop – during the therapeutic process but not so much “room” that they enable full-blown acting out or acting in.37 If, through transference, clients assign therapists the role of hateful parent, for example, therapists must permit themselves to experience hatred of their clients to the degree that its contributory “causes” become identifiable. Therapists may not, however, go so far as to say something hateful to clients or even to let their neutral statements carry hateful nuances.38
Similarly, if clients displace positive feelings toward them – see them as a mother figure, for instance – at the beginning of therapy, therapists must ordinarily allow the transference to continue until the therapeutic alliance is firmly in place. But they must not allow their clients to become dependent on them to the point of needing to call frequently between sessions or finding themselves unable to provide honest feedback when they feel patronized.
Thus, self-monitoring is especially important during the first task, when therapists consciously take in the transference whereby they suspect both the roles they are being asked to play and the ways they are inclined to play commensurate roles in the process of countertransference (Hinshelwood, 1999). Therapists need to decide whether or to what extent they might perform those roles as a means of furthering their therapeutic and working alliances. Clients who are fearful of authority figures, for example, might benefit from time-limited signs of maternal acceptance or paternal approval.39
Self-monitoring during the first task also enables therapists to gauge to what extent they are unconsciously projecting their own unresolved conflicts onto their clients. Without this internal supervision, even experienced therapists are prone to simply re-enact their clients’ maladaptive interpersonal experiences in countertransferential behaviors (Dreher & others (2001). As a result, clients may never realize the contributions they are making to their own unresolved conflicts and thus determine how they might act differently (Weiss & Sampson, 1986).40
Self-monitoring is also crucial during the second task, when therapists contain transferred material and permit appropriate regression. Therapists must stay with clients on a psychobiological level in order to engage in necessary experiential learning, but not go so far as to lose their ability to stand apart and take note of their participation in the realms of transference and countertransference (Racker, 1972; Gorkin, 1997; Gelso & Hayes, 1998). They must remain disengaged enough to ask a question such as, “How am I being manipulated to play the role of a demeaned person?”
Self-monitoring becomes especially important when therapists permit conscious regression. They must become vulnerable to the workings of displaced material at a sufficiently deep, but not too deep, level (Winnicott, 1965). They must be partially aware of the process they are undergoing in order to discontinue it at any time. They must periodically employ their observing ego to “keep track of the pressure to become trackless” (Schafer, 1997). They must “swim” in the sea of clients’ transference but not “drown” in their own countertransference (Racker, 1972).
Furthermore, only if therapists monitor their own regression can they be aware of the regression their clients are undergoing. Because of non-analytic therapy’s customary time restrictions, therapists must ordinarily stop their clients from experiencing a full-blown neurosis. But they can permit clients to engage in mild-to-moderate regression in the safety of the therapeutic environment. For most clients – as well as their therapists – benefit greatly from carefully regulated exposure to pain that so overwhelmed them, it could not be processed.
Self-monitoring remains necessary during the third task, when therapists direct their attention to decoding transference and countertransference, for these phenomena are operative even as therapists are trying to derive meaning from them. Therapists must stand back to decode, and yet remain available to their clients so that the length and intensity of the decoding process do not weaken or destroy the therapeutic bond. Clients want to be accepted unconditionally, to be listened to intently, and to be followed closely. They do not want their therapist to engage in the difficult cognitive task of decoding for what seems to them to be too long a time. On the other hand, therapists need to self-monitor to see if they are allowing themselves enough time to decode accurately.
Self-monitoring during the fourth task, hypotheses-forming, is also necessary, for therapists must decide whether they are spending a sufficient amount of time and effort to hypothesize reasonably well. Though they may not be sure of what is transpiring, they must come up with at least probable explanations.
Self-monitoring continues to be crucial during the fifth task, when therapists are verifying hypotheses. Therapists clearly need to test hypotheses, but they also need to balance this cognitive work with keeping an emotional connection with their clients. At the same time, therapists must continue to receive and hold new material that will allow them to revise inaccurate hypotheses.
Finally, therapists must self-monitor during all five tasks in order to be able to move quickly and smoothly from one task to another. At times, therapists must decode what they have uncovered in order to know what more they – and sometimes their clients – need to discover. Similarly, therapists may need to experience more in order to verify what they think they understand. At other times, they must gather new information in the light of their hypotheses proving inaccurate. At still other times, when they suspect inaccuracy, therapists must stop decoding and “test” their hypotheses. Put simply, successful therapy lies heavily on therapists’ self-monitoring their decisions related to focus: what to focus on, whom to focus on, where to focus, and even how to focus (Hubble, 1999).41
In order to appreciate specific guidelines for wording transference and countertransference interpretations (TRIs and CTRIs), readers first need to define these interventions. They need to hold them to the light of the theoretical bases on which they depend as well as place them within the context of non-analytic therapy. Readers also need to become familiar with an attitude that has been found to precede and accompany effective TRIs and CTRIs: an openness to simply observing each client’s unique phenomenology and the therapist’s own distinctive responses to it.
A transference interpretation (TRI) is a comment or question voiced by the therapist to call the client’s attention to an apparent problem within the client-therapist relationship that appears to be the result of transference. The therapist experiences a conflict between what is transpiring in the therapeutic setting and the way the client and therapist need to interact so that their collaborative work is fruitful.42
In the non-analytic tradition, a TRI may simply state the transference-based problem, as in, “You seem frustrated with me because of my limit-setting.” Alternately, the TRI may link the therapy situation to a current or past conflictual relationship that the client has described or somehow alluded to (Pearson, 1995), a relationship being transferred to the therapy session. The therapist may say, for example, “You seem frustrated with me because I set limits similar to those your teachers set.”
A TRI that directly refers to displaced material, Schafer (1977) says succinctly, is “a creative re-description that implicitly has the structure of a simile. It says ‘This is like that.’ It adds new actions to the life [clients] have already lived” (57). It helps them see pre- or extra-therapeutic experiences as sources of unquestioned beliefs and unchallenged emotions that cause interpersonal problems. It suggests that the client may be imposing presuppositions, without question, on new experience (Cooper, 1987). The following TRI, for instance, would help a client question the belief that all adults make unreasonable demands: “I wonder if you see my request that you pay before your session as your teachers requiring you finish labor-intensive assignments before you eat lunch.”
Indeed, a TRI suggests that the therapeutic relationship has become a re-enactment of clients’ previous or current unresolved conflictual experiences outside of therapy. It is an implicit acknowledgment of the powerful impact that people not actually in the therapy room and events connected to them can exert on feelings and attitudes arising in therapy. It alludes to here-and-now cognition and emotion based on there-and-then experience. It identifies clients’ unconscious expectations of others and asks them to evaluate their appropriateness. Said succinctly, a TRI encourages clients to subject potentially harmful beliefs and emotions to the criterion of factual evidence. Clients may need to ask, for example, “Are others’ requests actually unreasonable demands?” “Could not their demands be reasonable even though I feel resentful?”43
Even a TRI that does not directly refer to displaced material, but exposes a conflict in the client-therapist relationship that has arisen because of transference, encourages clients to discover whether their interpersonal schema are adaptive or maladaptive. “Do I need to hold more realistic expectations of myself and others?” clients may need to ask.
Clients’ expectations tend to rest on both conscious beliefs for which there are usually some objective evidence and unconscious assumptions to which clients have been holding fast, often against objective evidence to the contrary. The belief that those in authority have power to make demands, for example, has objective validity. The assumption that one person in authority will make unreasonable demands because another like her has done so, however, lacks that objective validity. Nevertheless, in spite of unconscious “certainties” never being personally validated, clients tend to accept them as principles of knowing and guidelines for interpersonal relationships (Schafer, 1977). To use the previous example, clients perceive their therapist as a person in authority and experience his or her request for prompt payment as unreasonable.
Consequently, clients need to look at how they are unconsciously constructing the therapeutic relationship in accordance with their unconscious principles of knowing. If they do not do so on their own, therapists need to help them by interpreting the transference that betrays the assumptions. “I wonder if you see my asking you to pay your fee as an unreasonable demand similar to those made by your teachers,” a therapist might say.
Put in a slightly different light, a TRI reminds clients that transferential wishes, feelings, and cognitions connected with their present relational conflicts exist within their own psyche and need to be recognized as such. They may or may not reflect objective reality. Thus a TRI is a means of performing one of therapists’ fundamental tasks: “to help clients recognize that current interpersonal conflicts are, in actuality, intrapsychic conflicts” (Gill, 1982, 21).
Of course, many TRIs also refer to the interpersonal nature of clients’ conflicts. “I believe I have done something to anger you,” a therapist might add, to recognize that he or she is an active, though unwitting, participant in transferential aspects of the therapy process (Cooper, 1987).
Similarly, many TRIs clearly link previous life experiences with emotions and cognitions arising in the current therapist-client relationship (Cooper, 1987). “Could you be angry with me because I made you wait today, just as your mother made you wait for supper?” a therapist might say. Other TRIs refer to current experiences outside of therapy, as in “Could it be that my upcoming vacation feels like the abandonment you are experiencing because of your friend’s death?”
When therapists interpret transference as a new here-and-now enactment of an old conflict, and ask clients to evaluative what they are doing, therapists bring to clients’ consciousness all aspects of the new experience: its past origins, its present operations, and its future implications. They invite clients to take a trip back in history for the sake of insight (Cooper, 1987) and future interpersonal relationships. Should they be based solely on long-held assumptions, or should they also be allowed to develop in accordance with the unique facts that define them?
Unlike a psychoanalytic TRI, which suggests that clients process intrapsychically the information the interpretation provides, a non-analytic TRI is an invitation to clients to process the information collaboratively. A non-analytic TRI encourages clients to talk about the dynamics of their session with their therapist in order arrive at insight in a relatively short time, as befits most session-limited non-analytic treatment.
A non-analytic TRI is often a question like, “Could it be that you are angry with me because I remind you of your mother?” Even if it is a declarative statement like, “I think you are angry with me because I acted like your mother,” a non-analytic TRI invites verbal response because of its open-ended intonation.
There may be no clear, immediate agreement or disagreement on the part of the client to whom a TRI is voiced, but as a general rule, when clients hear TRIs that strike them as accurate, they tend to elaborate on the material. When TRIs appear inaccurate, they do not.
Hence, Meissner (1996), agreeing with Jacobson (1993) and Treurniet (1993), writes, “When the interpretive process is working well, therapist and [client] are engaged in the exploration of hypotheses [regarding their relationship] arrived at by a collaborative process, based on the [client’s] intrapsychic content” (257).
At the beginning of the session, the cognitive-behavioral-oriented therapist drew her client’s attention to the fact that she had not paid her fee for the third week in a row. Though the client acknowledged this and promised to send a check the following day, she responded curtly to several of her therapist’s subsequent reflections on her accomplishments that week. Recalling the client’s stories about her overly critical father, the therapist finally said, “Could it be that you are annoyed with me today because at the beginning of our session I reminded you of your bill? Perhaps I sounded like your father when he chastised you for your unfinished schoolwork.”
Responding to this countertransference interpretation, the client admitted that she was angry with her therapist. She refused to admit, however, that she was displacing feelings toward her father, at least not during that session and the one immediately following. In time, though, when the therapist again made a tentative connection between the therapist’s remarks, the client’s behavior, and its possible relationship with how her father treated her, she conceded. Afterwards the therapist and client were able to explore together the deep pain the client had suffered – and was still suffering – because of her father’s rebukes.
Thus by making conscious an unconscious memory, a TRI helped a client free herself from having to relate in the present as she had in the past.
A countertransference interpretation (CTRI) is a comment or question voiced by the therapist to call attention to a problem that the therapist is experiencing which seems to be linked to displaced material. It may be being displaced by the client, the therapist, or both. The therapist shares that he or she is experiencing a conflict between what is transpiring in the therapeutic setting and the way the client and therapist need to interact in order to make their collaborative work fruitful.
At times, the CTRI links the feelings, thoughts, and behaviors of the therapist to phenomena transferred to the therapy session by the client. “I feel attacked by the remark you just made, and I wonder whether you are unconsciously trying to show me how your mother used to attack,” a therapist might say. At other times, the CTRI links the therapist’s problem directly to his or her own displaced material. “I feel demeaned by the comment you made, just as I sometimes felt demeaned by teachers. Can we talk about what’s going on?” the therapist may say. At still other times, the CTRI suggests that the therapist’s countertransferential response is linked both to the client’s transferential behavior and to the therapist’s own personality, history, or current extra-therapeutic life. “I wonder if my sleepiness is due solely to not getting enough sleep last night or whether something going on in here is putting me to sleep,” the therapist may say.
In any case, the CTRI is an invitation to clients to identify distortions, misinterpretations, and unfair attributions that their therapist might be unconsciously making, with the hope that this will increase clients’ insight into both their intrapsychic conflicts and their interpersonal problems. The CTRI is not an invitation to explore the therapist’s problem, as such. It is meant to facilitate an exploration of the client’s conflict.
As with non-analytic TRIs, a CTRI may name only the therapists’ feelings, thoughts, and behaviors which the therapist suspects are being elicited by the client’s transference. Especially when previous CTRIs have done so, a CTRI does not have to refer directly to the client’s transferred material. “I am frightened by your yelling in anger when I ask you to pay your bill,” for example, is a revelation of the therapist’s reaction to what the client does when reminded of similar conflicts. Similarly, a CTRI may simply refer to what therapists themselves are doing in sessions, and question whether transference or countertransference is at work. “I feel so angry today and am not entirely sure why. Is something negative going on in here today as a result of some unfinished business?” a therapist might say. Though it does not do so explicitly, this kind of CTRI is still intended to help clients identify what they are contributing to the client-therapist interaction.
Finally, it is helpful to consider Racker’s (1953) distinction between concordant and complementary CTRIs. Concordant CTRIs tell clients that their therapist is identifying with them, as in “I feel so sad as I listen to you and I wonder if you are not only angry with your brother but also sad because of him.” Thus the therapist is revealing that the client has transferred unacknowledged feelings to the therapist.
Complementary CTRIs, on the other hand, tell clients that their therapist is identifying with those affected by their client’s words and actions, as in “I experience humiliation in listening to your report of how you dealt with your son. Is it possible that your son felt humiliated when you scolded him?” Therapists are sharing their understanding of what significant others might feel when interacting with their clients.
The client elaborated on a pleasure trip he had just made, providing comical anecdotes interspersed with interesting descriptions. Though she was at first intrigued by her client’s account, the Rogerian-oriented therapist soon noticed herself becoming bored and irritated. The incongruity between his enthusiasm and her negative response was striking.
She began to recall previously confronting her client about taking time off work in light of his family obligations, for his goal was to have fun without neglecting familial responsibilities. The therapist also wondered if her irritation might be also due to her going out of her way to accommodate her client. She had rescheduled an appointment for his convenience, she recalled, which had extended her workweek.
The therapist hoped that by using a CTRI linking the client’s actions to her own irritation, she could help him address an issue he had identified earlier. In the course of that she might also process her own negative feelings, but that was not her primary goal. She had noted her complex countertransference, but would focus only on an aspect of it clearly related to her client’s goal.
Eventually the therapist interrupted the client and said, “I’m feeling irritated by this account of your trip. Could it be that your detailed account is preventing me from addressing how that trip might have imposed a hardship on your family? Your goal, you recall, is to balance fun with familial responsibilities.”
Thus, the therapist used her own emotional response to her client to help him look at his behavior and its impact on therapy, with the hope that he would also gain insight into how his in-therapy behavior related to the attainment of his goals.
Therapists who choose to share their hypotheses about transference and countertransference with clients increase their chances of being effective if they agree to simply observe and wonder. “It is...observation itself, its meaning sought without preconception, which enables the interpretation to follow in such subtle form that it may lie simply in the answer given by the [client]” (Schwaber, 1990, 234-5). By observing and wondering, therapists say to their client, “Let’s together determine what is going on between us.”
“To observe and wonder is not to be ahead of clients in ascertaining impersonal and personal reality. It is to give up an agenda for understanding new and unique phenomena,” saying, in effect, “I know less rather than more” (Schwaber, 1990, 237). When therapists simply observe and wonder, they refrain from superimposing their preferred ways of thinking on clients’ transferred material. They follow the lead of Winnicott (1960), who said whimsically, yet insightfully, some 30 years earlier: “I interpret mainly to let the [client] know the limits of my understanding” (711).
Therapists who simply observe and wonder remember that both transference and “countertransference [are sources] of data but not [sources] of evidence” (Smith, 2000, 105). They suggest complex realities but do not provide proof. Even if based on what appears to be relatively conclusive evidence, transference – and even more so countertransference – are vulnerable to bias. Interpretations of them, conscious derivatives of unconscious phenomena, cannot be used to describe them definitively. Neither therapist nor client is truly objective in spite of sometimes feeling strongly that he or she is. Neither is without pathology, anxiety, or vulnerability to defense mechanisms (Racker, 1972). Both are holders of partial truth that can be known in its fullness only when parts are shared.
Thus therapists who wonder are open to rejection or revision no less than confirmation of their hypotheses regarding transference and countertransference. They resist their tendencies to become attached to their interpretations and to forget that they are only hypotheses Cooper (1993). They await something definitive – truth that develops only with the active cooperation of clients (Bezoari et al., 1994) – rather than dispense to clients truths that they, therapists, have already gleaned (Cooper, 1993).
In fact, therapists who observe and wonder go one step further. They assign secondary importance to their knowledge in order to know clients by what they reveal (Smith, 2000). They acknowledge the working primacy of the truth that the client holds. “It is the [client] and only the [client] who has the answers,” (Winnicott, 1960, 711) however key to the client’s discovery the therapist’s intuition and insight may be.
Furthermore, for therapists to observe and wonder is for them to simply watch the past becoming dynamically present in therapy through transference and countertransference. It is to understand gradually how the past is being re-experienced in the present and to share that understanding with clients (Casement, 1991). It is to be open to what might be the actuality behind the appearance and the reality beneath the surface. It is to acknowledge that, because material in the unconscious is highly undifferentiated, it is extremely difficult to determine exactly what and how much clients, versus therapists, are contributing. It is to wait and see whether transferential “truth” actually resonates in the countertransference. For it takes the psyches of both therapist and client to verify what is actually occurring.
Effective transference and countertransference interpretations are worded in such a way that they meet the following criteria:
Though effective TRIs usually convey disturbing information, they are calming (Strachey, 1934) for three reasons. First, they recognize the value of what might otherwise be considered destructive subjective feeling states, as in “You seem to be angry with me. Can we look at how that anger may be related to what you experience toward your spouse?” TRIs indicate that, far from being unmanageable, affect can be used to acquire insight into a problematic interpersonal dynamic. TRIs allow painful reality to finally overcome clients’ efforts to repress it. Thus TRIs bring relief, even comfort, as they reveal what clients unconsciously “know” but prefer to deny in spite of the psychic energy that it takes to deny reality (Lear, 1993).
Second, because TRIs are voiced by therapists who are noticeably calm, they signal that clients are in a safe environment. Therapists are holding their countertransferential response up to the light of scrutiny without “falling apart,” collapsing, or retaliating (Winnicott, 1960; Casement, 1991). Hearing, for example, “I believe that by yelling at me you are communicating your fury toward your father. Am I right about that?” clients can deny, confirm, question, revise, or reject the TRI – all with impunity.
Third, effective TRIs reveal that therapists have simply received a communication; they are not determined to correct a client’s inappropriate behavior (Casement, 1991). Clients can remain calm, for example, when therapists say, “In yelling at me, you may be unconsciously trying to show me what it was like to be a child in your family. If so, can we talk about that?”
Bollas (1987) suggests that therapists introduce TRIs with such calming phrases as, “What occurs to me,” “I have an idea,” “I’m curious about what you think,” “I’d like to share a thought with you,” or “You may not agree with me but...” (206). Beginning TRIs in such a way that clients feel calm is the surest way that therapists have of not getting drawn into client-initiated re-enactments. In the case of rage, in particular, therapists can be unwittingly seduced into continuing an intense transferred feeling through their interpretations.
In order to make TRIs calming, therapists might also need to take a moment between hearing and speaking, during which they monitor for the potential re-enactment that may be concealed within the first interpretation that comes to mind. A short pause between what clients and therapists say can serve as an indication that therapists are truly “holding” what their clients are expressing. Therapists are not so eager to process disturbing feelings that they cannot hold them calmly as a first step in the interpretative process.44
Like TRIs, CTRIs should calm both clients and therapists. Therapists must even report feeling insulted in such a way that they remain tranquil in spite of their unpleasant experience and the paranoid anxiety that might accompany it (Little, 1951). They can survive being treated badly (Winnicott, 1971) when transference is negative. Similarly, they can manage positive transference, such as being idolized. They need not let it stop them from demanding hard work from both themselves and their client.
Occasionally, therapists may need to refrain from naming an emotion in order to remain calm. Instead of saying for example, “I feel demeaned by your last remark and recall how you said your mother demeaned you,” they might simply reflect upon what has just occurred. They might simply say, “I am experiencing a communication from you that’s coming in the only way you know – by behaving towards me as your mother behaved towards you.” Having established a calm atmosphere, therapists can then use the precise word for their experience without sacrificing tranquility. Similarly, therapists may need to preface CTRIs by an explanatory remark in order to remain calm. “I get the impression that you have often had the experience of being put in the wrong,” a therapist might say before adding, “I think that that’s why you have been putting me in a similar position today and making me feel blamed” (Casement, 1991, 147).
Of course, meta-language markers must be equally calming for TRIs and CTRIs to be effective. Therapists must convey calm through such secondary features as tenor, volume, tone, and pitch. In some cases, they must even add a reassuring look or respectful gesture.
Strachey (1934) states emphatically that if TRIs are to be mutative at the same time that they are calming, they must be emotionally immediate, that is, charged with emotion. TRIs must clearly identify the affect underlying clients’ transference conflict, however uncomfortable that naming may be for both client and therapist. Furthermore, for TRIs to be mutative, they must be given as closely as possible to clients’ emotional experiences.45
It may seem contradictory for an interpretation to be both calming and charged with emotion, but these qualities are not actually mutually exclusive. Emotions can be expressed in varying shades of intensity, all the way from hardly conveying the emotion to subsuming content by pure volume and strident tonality. The challenge is to find a balance between accurate reflection of emotions and their containment within the boundaries of the rational mind. It helps if therapists think in terms of mild to moderate – rather than strong – levels of affect, Kiesler (1982b) writes.
Winnicott (1971) enjoins therapists to examine and sift ideas and feelings that come to mind before they speak. After reflecting, they can say, for example, “You seem to hate me” in such a way that there is no doubt that the therapist has simply observed and recorded the primary feeling of the client toward the therapist. The therapist has not internalized it or necessarily found it justifiable.
Crowley (1988) uses an especially apt metaphor to describe the challenge of balancing emotional immediacy with calm: “...it is tremendously important for [therapists] to burrow through the exaggerated parts of [their] reactions to the healthy rational substratum...” (87). The anger that therapists experience, for example, may be largely inappropriate, and they must recognize that. At the same time, they must use the anger to hypothesize about what the client did to provoke it and why. They can then meet the criteria of immediacy and calming by using a TRI such as, “You appear to be angry with me right now because I, like your father, said that your behavior is unacceptable. Can we talk about what you are feeling?”
Regarding countertransference, Maroda (1995) suggests that therapists offer emotionally immediate CTRIs to appropriate clients under most conditions. CTRIs are most effective not because they are intellectual statements but because they are revelations of genuine emotion. She writes that “Ouch!” can be more effective than “I am hurt by your remark!” Similarly, “I think your wife’s comment is very abusive. I can’t believe that you didn’t get angry with her!” can be more effective than “I’m disturbed by your not being angry with your wife.” However, Maroda (1995) also warns that in formulating CTRIs, therapists must express feeling without losing control. CTRIs, like TRIs, should be accompanied by mild to moderate levels of affect, Kiesler (1982b) instructs clinicians.
Therapists must also time emotionally immediate CTRIs carefully. Using them when clients are already highly aroused can overwhelm them. Using CTRIs when clients are already very anxious can disrupt their ability to use the interpreted material profitably.
Volkan (1995) states that TRIs must come “from the side of the ego,” (213) especially when directed to significantly regressed clients. They must not come from the side of the id in that they simply accept reality as it appears to be or as one would like it to be or to demand that reality conform to one’s impulsive and instinctual desires. In contrast to an id-based interpretation like “You are angry because I kept you waiting,” an ego-based TRI would be “You may be angry because I kept you waiting.” The wording of this second TRI implies that a strong reaction, while accurately reflecting a client’s affect, is unlikely to be the totality of the client’s state of mind and related communication.46
Neither must TRIs come from the side of the superego in that they pass irrefutable judgment on clients’ versions of reality. Instead of teaching yet another version of the truth as understood by the therapist, TRIs must be neutral with regard to the truth. For instance, a therapist should use an ego-based TRI like, “Your anger with me may be something that even you don’t feel good about” instead of its superego-based counterpart: “I think you are angry because you can’t tolerate the faults in you that you see in me.” The ego-based TRI implies that emotions have neither immoral overtones nor morally unacceptable meanings.47
Ego-based TRIs – and one might add CTRIs – invite clients to observe and face their own truths (Schwaber, 1990). They encourage clients to examine what seems to be happening: to verify perceptions, check out impressions, and elaborate on deductions. They further the client’s work of reality-testing by facilitating a process within which a coherent truth can gradually emerge. They are means whereby clients gain insights that make sense of their transferential experience (Casement, 1991) and their therapists’ countertransference.
In some cases, TRIs and CTRIs can also meet the criterion of being ego-based and neutral in that they encourage clients to process specific defenses being used by the ego, defenses that should be dealt with prior to addressing primitive urges and impulses (Freud, 1926). Indeed, with many clients, therapeutic work needs to focus less on their negative emotions than on the reasons for them, that is, the defensive functions of the emotions. An interpretation that identifies the insecurity underlying arrogance, for instance, directs attention to where therapeutic work should be done. A TRI such as “When you feel threatened, you try to protect yourself. Then I experience you as being arrogant and overlook the possibility that you may be trying to defend yourself from feeling small,” opens the door to an examination of the defense rather than the emotion and reduces the combative atmosphere created by the client’s arrogance.48
The ego-based and neutral criterion leads to an important corollary: it is often more helpful for therapists to use what they “know,” and to find a way of approaching this through “not yet knowing,” than it is to simply reflect what clients are saying. An example would be, “You seem to be envious of me as was your younger brother of you, but I sense you don’t want to be.” Clients who hear this are likely to deduce that their therapist is siding with a reality-focused ego rather than a guilt-assigning superego.
For their part, CTRIs should simply state what therapists are feeling and thinking about their clients. They should not encourage a heightened emotional response in clients. “I am afraid of you today because of your shouting,” for example, simply reports the experience of the therapist, provided, of course, that its tone, volume, and intonation are modulated and respectful. Similarly, CTRIs should not include overt or covert justifications of what therapists are experiencing in relation to their clients. “I am angry with you today,” said in the right way, should imply neither that the client is guilty nor that the therapist is justified. The therapist’s emotion simply deserves to be looked at. It is to be condemned by neither client nor therapist (Little, 1951). To make this clear, therapists might add, “Can we take a look at what I am feeling and try to understand it?” or “Would it be all right to try to see where my anger is coming from?”
Schafer (1983) writes that, in contrast to unquestionable pronouncements or indisputable moral judgments, TRIs and CTRIs are to be expository as befits the therapist’s clinical role. They are to be clarifying, explicating, or enlightening observations. They are to come across as objective in that therapists voice them without defensiveness, Gill (1982) adds. They are to give clients the “okay” to feel and express feelings, even to re-experience the earlier times when they were felt. “You may be angry with me” or “You appear to be angry with me” or “I believe you are angry with me” are much less likely to carry condemnatory or judgmental overtones than “You are angry with me.” Similarly, “I seem to be angry with you” or “I’m finding it hard not be angry with you” sound more ego-based than “I am angry with you.”
Of course, the requirement to keep TRIs and CTRIs ego-based and neutral depends on an accepting tone, courteous tenor, modulated volume and speed, calming pitch, and respectful inflection, which combine to create an appropriate mood and interpersonal atmosphere. As Pick (1997) asserts quite accurately, some clients only listen to the “mood;” they do not even hear the words. Hinshelwood (1999) corroborates, observing that very disturbed clients acutely scan interpretations to assess what is happening in their therapist’s mind: Is it retaliation? Is it resentment? Is it forgiveness?
Indeed, while almost anything can be said in an accepting atmosphere, even the most sensitively worded message will meet with resistance in a client who is negative. It is “important to remember that some [clients] are acutely sensitive to the hidden meaning in what the [therapists] says” (Casement, 1991, 131).49
Rather than being abstract or relying on implications, effective TRIs and CTRIs are precise and clear about the distortions that clients or therapists are making or the specific actions that have impacted therapy (Kiesler, 1982b). Effective TRIs and CTRIs are detailed and specific (Strachey, 1934). They befit the therapist’s discerning, clinical role in that they can be challenged up front (Schafer, 1983).
TRIs that clearly identify transferential phenomena provide clients with precise information about how their behavior contributes to interpersonal problems. They awaken unconscious resonances and permeate intrapsychic boundaries (Lear, 1993). “You seem angry with me because I said your behavior is inappropriate, as did your teacher,” is clear, concrete, and direct because it specifies the client’s behavior as an interpersonal problem. Even more specific are, “You seem to dislike me now that I have suggested, as did your mother, that you also are to blame” and “It seems as if you are afraid to tell me that you are angry with me. Instead, you just come late. Is this true?”
In contrast, if clients hear a TRI such as, “Could it be that you are disturbed because of my remark?” or “You seem to be getting upset about what I’m saying,” they may be left with an ambiguous message. They may be unsure about what “my remark” or “what I’m saying” means. Vague, imprecise TRIs can also give clients a chance to thwart their therapist’s attempts to bring unpleasant unconscious material to consciousness (Strachey, 1934).
Like TRIs, CTRIs should bear correspondence to historical facts or to specific features of clients’ scripts (Joyce & Piper, 1993). Ideally, CTRIs should refer, directly or indirectly, to clients’ presenting problems, major themes of their work, and the metaphors that they use repeatedly. “I am angry right now because of not getting any real information today. Could it be that your spouse also finds it hard when you don’t share with her?” would be an example.
If possible, CTRIs should include clear references to what is happening in therapy in the here-and-now. They should identify specific affective reactions that therapists have just experienced or concrete behaviors they have just performed. At the least, CTRIs should identify events that clients will recall as having occurred in the therapeutic setting (Strachey, 1934; Swift & Wonderlich, 1990; Stolorow, 1993; Stone, 1984; Strupp, 1989; Casement, 1991; Piper et al., 1993). “I am aware of being frustrated with your silence today,” a therapist might say. Or “I looked at my watch so often today, perhaps out of a desire to disconnect from you.”
At first it might seem as if the criteria of clarity, precision, and concreteness on one hand, and tentativeness on the other, are mutually exclusive. But both criteria can and do apply to effective TRIs and CTRIs. They must convey specific information as well as indicate that they can be revised, even rejected. Rather than being conclusions made by therapists, TRIs and CTRIs are invitations to clients to collaborate in discerning the validity or invalidity of therapists’ observations. Tentative TRIs and CTRIs are clearly “meant to be played with, kicked around, mulled over, and torn to pieces rather than regarded as official versions of the truth” (Bollas, 1983, 7).
If therapists are always certain of what they say, clients have to contend with a dogmatic individual who claims to know more than what is actually knowable (Field, 1989). They feel pressured to submit to a purely receptive and acquiescent style of working (Bacal, 1990) rather than feeling free to interact with their therapist to explore different potential meanings (Winnicott, 1971).
When therapists use tentative TRIs and CTRIs, they bring a subjective state of mind into play by offering to clients “a scrap of material and a chance to elaborate on it” (Bollas, 1987, 206). Therapists are open to questioning, clarification, and revision. They are listening for evidence or consensual reality that supports their own or their clients’ perceptions and judgments (Schafer, 1983). They are hoping that both they and their clients can gradually understand their displaced perceptions and feelings.
“Could it be that…,” “I wonder if...,” “Perhaps it’s that I don’t know whether you will agree with me, but...” “What occurs to me…” “I have an idea…” and “I don’t know if you are going to like what occurs to me, but...” all signal the tentativeness of the interpretation and invite clients to respond in agreement, disagreement, or partial agreement (Bollas, 1987). They introduce TRIs and CTRIs that are more communicative than informative (Brodbeck, 1995) and more probabilistic than certain (Schafer, 1983).
It is especially important, Bollas (1987) contends, for therapists to acknowledge the difficulty of putting into words what they believe clients are feeling toward them. When therapists struggle openly to find the right words for what their clients experience, they model how to deal with what they somehow “know” but cannot easily describe, or with what they suspect but may never have known. Therapists counteract that certainty with which clients have often been judged and judge themselves. They invite clients to collaborate with them in an effort to discover the complexities of the human person, especially in relationship to others. By using tentative TRIs and CTRIs, therapists underscore the wisdom of passing subjective perceptions back and forth until only those that withstand scrutiny survive. By using tentative rather than irrefutable TRIs and CTRIs, therapists make a fundamental distinction between interpreting “countertransference as one indicator of what might be going on in a complex field and using it as the complete explanation of what is transpiring” (Herron & Rouslin (1982, 146).
Tentative phraseology is even more appropriate for the countertransferential unthought “known:” what therapists feel but do not understand because it is being transferred from extremely primitive parts of the client’s unconscious mind (Bollas, 1987, 232). Yet this material is extremely valuable because, though the core of its significance has yet to be discovered, both therapist and client recognize it as meaningful communication. “Could it be that my frustration today is related to some kind of message you are giving me? I can’t put my finger on what is causing this feeling,” the therapist might say, for example. Besides reducing defensiveness, such wording allows therapist and client to “play with” meaning and significance in a relaxed and respectful way (Winnicott, 1965), kicking them back and forth until meaning becomes lucid, and significance compelling.50
Closely related to criteria for TRIs and CTRIs to be clear, precise, and concrete is the requirement that they refer, either directly or indirectly, to phenomena pertinent to the issues that clients have identified and the goals they have set. The criterion of pertinence also pertains to clients getting exactly what they need during a given session. Stereotypic interpretations – those used easily, those foremost in thinking – are better off delayed, because when clients are given time, they lead therapists to insight that is more specific and often quite new (Casement, 1991).
While TRIs and CTRIs may refer to past figures, they are now considered more pertinent if they address material related to those problematic core conflicts presently occurring both outside and within the therapeutic setting. Not focusing on the present, Gill (1982) warns, can make clients feel that therapists are examining relatively non-significant past relationships at the expense of their presenting problems. By interpreting the here-and-now, by contrast, therapists imply that clients’ presenting problems are more important than their past difficulties.
Most contemporary non-analytic theorists find it more important to work with clients’ reactions to their therapists than for clients to recognize them as transferred. In addition, because most intrapersonal issues involve others, TRIs are said to be most effective if they are “pertinent to unresolved impediments to congruous and continuous relationships with people in the present,” (Wolstein, 1996, 505) both the therapist and people outside therapy. What happens in therapy sheds light on problems that clients have already identified, intrapsychic as well as interpsychic, for even personal problems tend to arise from interpersonal conflict (Wolstein, 1996).
The criterion of pertinence – meaning here-and-now, in-session occurring – is based on the fact that therapists are not always able to discern the true source of clients’ and therapists’ feelings toward each other, although both parties perceive those feelings. Moreover, feelings usually precede thoughts. In time, therapists may identify previous phenomena, but initially, they are likely to be aware only of their feelings and their suspicion that they cannot be accounted for solely by what is happening in the session.
Indeed, the criterion of pertinence is met by here-and-now, in-session occurring TRIs and CTRIs because therapists can validly suspect displacement from the past or from outside therapy simply when they notice their sudden, strong, or unusual affective and somatic reactions to the therapeutic situation. It is unrealistic to expect therapists to be certain of the fact that transference or countertransference is occurring, let alone certain about the source of displaced feelings and attitudes. As a consequence, the criterion of pertinence does not require therapists to tie “then” and “there” happenings to “here” and “now” incidents. If they are actually linked, clients will link them, mentally if not verbally. Or therapists themselves will obtain further data to link the then-and-there and the here-and-now in subsequent interpretations.
Though the criterion of pertinence allows TRIs and CTRIs to refer only to the present, there is a place for inclusive interpretations that link the present with the past or the therapeutic interaction with that which occurs outside it. When it is relatively clear that therapeutic events are being triggered by non-therapeutic experience, therapists may say, for example, “I wonder whether my being judgmental toward you today is partly the result of your finding various reasons to not come to therapy for more than a month.” Or they may remark, “Is my being judgmental toward you today solely the result of my having a hard day?”51
In some circumstances, if TRIs and CTRIs are not inclusive, clients may feel more comfortable but draw erroneous conclusions. Simple here-and-now TRIs and CTRIs may imply that therapists are afraid of their feelings. As a consequence, clients may suppress their strong feelings for fear of their therapists not being able to cope with them. Similarly, here-and-now TRIs and CTRIs may lead clients to think that their therapist’s examination of the therapeutic relationship is being done at the expense of their presenting problems or other very real concerns (Bauer & Mills, 1989).
One way to meet the criterion of inclusivity is to start with an observation that the client has made about the past and follow the direction of the transference to where the past is spilling over into the present. For example, “When you were dependent upon your mother, she went away and left you. Because you were feeling dependent on me before I took a vacation, you may now experience me as the mother who left you when you most needed her.” By wording TRIs this way, therapists are offering insight into the client’s past distress while keeping the focus on the present, the time of expressed transferential feelings.
Similarly, clients can benefit from therapists’ introducing material from a previous session while focusing on the session at hand. “Last week you spoke of John, who is unkind to you. I wonder if today you are also finding me unkind,” for example. In fact, Gill (1982) recommends routinely including also or in addition in inclusive TRIs and CTRIs, for these words clearly link “there” with “here” and “then” with “now.” Thus clients are “helped to learn the ancient and deep source of the re-experienced impulses. Thus remembering and re-experiencing become organically blended” (Kahn, 1997, 59).52
As valuable as inclusivity is, however, it must not destroy the brevity and simplicity of TRIs and CTRIs. Though complex in that they link key events, TRIs and CTRIs should not require such extensive cognitive work that they require clients to dissociate from the feelings that their transference and their therapist’s countertransference are revealing.
Matte Blanco (1975) rightly argues that TRIs and CTRIs should be simple because transference and countertransference, products of the unconscious, are relatively simple. The unconscious considers only one characteristic of objects, disregarding all others and making this feature equal to the whole. While this process is certainly not simple in the strict sense, it bears the stamp of deduction and simplification and consequently puts the client’s mind in a simple mode. It makes the client comfortable with interpretations in that same mode.
Swift and Wonderlich (1990) recount that Harry Stack Sullivan purportedly said that interpretations should not be longer than seven words. They should be short (Sullivan, 1954; Strupp, 1989), simple (Schafer, 1983), and to the point (Joyce & Piper, 1993). Thus for the sake of brevity, therapists might have to divide TRIs and CTRIs into two successive TRIs and CTRIs, with the first addressing just the emotional or cognitive-emotional nature of the client-therapist relationship and the second adding the extra-therapeutic or pre-therapeutic aspect (Roth, 2001). For example, after processing with the client, “I wonder if you are turning me off because I have hurt you,” a therapist could add, “It could be that you feel hurt when your wife fails to appreciate your help, as you mentioned earlier.”
A second way to ensure brevity is to focus on just one aspect of the transference: how clients’ experience of the therapist relates to their organizing activity, for example (Gelso & Hayes, 1998). Therapists might simply say, “You can’t trust me because your sister betrayed you. You use what she did to you as a model of how other women will act.”
Similarly, to keep CTRIs simple and brief, therapists might focus on just one affect or one behavior. “I am impatient today,” is preferable to, “Even though I want to be patient today, I am feeling impatient.” So is, “Your not coming on time frustrates me,” preferable to, “Your not coming on time and presenting a hard-to-believe excuse frustrates me.”
Respectful TRIs and CTRIs leave clients feeling accepted, affirmed, and esteemed even though they have developed dysfunctional relationship patterns. Far from feeling demeaned, clients feel respected for their approach to life and their struggle to change (Kiesler, 1982b). Far from feeling attacked in isolation, clients feel included as collaborators in a process designed to gain them respect.
Respect is not easy, however, when clients express both pronounced and pervasive negative transference and are resistant to looking at it. It is hard for therapists not to unwittingly resort to bullying clients, most often through an attacking style of interpreting rationalized as being aimed at “dealing with resistance.” To counteract this and make sure that TRIs and CTRIs are respectful, therapists are wise to remind themselves that pathology is not only a defense, but also a form of communication without which some clients cannot get along (Casement, 1991). “It seems hard for you not to be angry with me,” a therapist might say. “You seem intent on helping me know how awful someone’s anger can feel," the therapist might add in order to remind both herself and her client that harsh treatment of others is more often intended to communicate distress than punish others.
Making TRIs and CTRIs humility-informed is related to making them ego-based. Truly humble therapists who share their interpretations do not imply that they are superior to their clients in insight or intelligence (Bollas, 1983). They accept, rather than deny, their weaknesses and limitations. They are skeptical about their own objectivity and how well they perceive their clients’ reality (Gill, 1982). They offer equal partnership in a process that creates or “restores mutuality in the ‘affective response’ of one to the other” (Winnicott, 1960, 117).
TRIs and CTRIs prefaced by such humility-informed phrases as “This may sound crazy, but..,” and “I could be way off base, but...” enable clients to feel secure. They can survive revealing – and hearing their therapist reveal – their personal weaknesses because their therapist also acknowledges limitations and learns from mistakes (Casement, 1991). Indeed, their therapist is willing to learn from his or her clients.
The criterion of interpretations needing to be humility-informed also calls for therapists to be wary of minimizing their countertransferential reactions. As a general rule, they must not deny the truth, telling themselves that the distress that they are experiencing is too insignificant to mention. Racker (1953), among others, warned against failing to interpret countertransference because it does not seem worthy of attention.
Finally, TRIs and CTRIs must be externally consistent: sensitively timed and accompanied by appropriate tone, volume, gestures, and other meta-verbal characteristics. During the course of non-analytic therapy, however, as therapists are eager to accomplish goals, they may use TRIs and CTRIs too soon, too frequently, or too enthusiastically. Just as moderation is always the best rule, so is careful monitoring of clients’ level of anxiety or comfort, and therapists’ own tendency to use TRIs and CTRIs simply to express negativity or to accomplish their own goals rather than patiently seek the well-being of their clients.
It is Blum (1986b) who has warned therapists most succinctly. Even where interpretation is correct in content, the countertransference [or transference] may be conveyed through inappropriate timing, tact, or tone, and in the subtle nuances of preferential attention or lack of interest (321). Thus a TRI or CTRI can be ineffective or even harmful.
Admittedly, attempting to meet eleven criteria for wording TRIs and CTRIs is a challenging undertaking. Beginners certainly want to remember that the more they actually use TRIs and CTRIs without being harsh critics of themselves for making minor errors in wording, the more adept they will become. In addition, they will be more relaxed if they simply observe and wonder about the interpretative task they are performing.
Therapists increase their chances of using transference interpretations (TRIs) and countertransference interpretations (CTRIs) effectively when they keep in mind the characteristics of their clients. Though recognizing clients who can benefit from TRIs and CTRIs is far from easy, two fundamental principles provide guidance. First, TRIs and CTRIs are appropriate only “within the omnipotence of the patient, which has to be challenged sensitively and very, very cautiously” (James, 1960, 289). TRIs and CTRIs are to be used with clients who are open to them, ready for them, and able to benefit from them.
Second, and more specifically, TRIs and CTRIs are generally appropriate with clients who have at least moderate ego-strength and low-to-medium levels of affective arousal. Though clients with these characteristics may be temporarily hurt or angered by what they hear in an interpretation, they can use higher-level defense mechanisms to protect themselves from the worst of the pain. They can avoid, in particular, the use of the splitting defense that labels them as “all bad” and prevents them from using such cognitive abilities as discriminating, relativizing, and accommodating to disturbing information. At the same time, they can use their reality-testing functions to distinguish between what is intruding from the past and what is being experienced in the present. They can counteract the common tendency to confuse facts with feelings and can subject perception to rational scrutiny.
To say this, however, is not to imply that TRIs and CTRIs are appropriate in any and all sessions of these clients. For there will be times when highly aroused clients, albeit those with moderate ego-strength, simply need to be listened to and allowed to process their strong feelings in their own relatively defensive way. If that takes the entire session, therapists simply refrain from interpreting transference and countertransference.
Specific highly charged emotions that rule out TRIs and CTRIs include hostility, bitterness (Pick, 1997), and paranoia accompanied by high levels of interpersonal sensitivity (Lasky, 1990). When clients are experiencing these strong interpersonal negative affects or attitudes, especially at a moderate-to-strong level, they are functioning in an autistic, infantile-omnipotent manner. Emotionally – and to some extent cognitively – they have temporarily regressed to an earlier developmental stage. They are already under too much debilitating stress to tolerate participative interventions like TRIs and CTRIs that seem invasive, blunt, and personal (Searles, 1975). At least for the time being, they must defend their reputation for righteousness through denial, rationalization, intellectualization, and other defense mechanisms.
In contrast, clients with at least moderate ego-strength sometimes do not need an entire session to lower a relatively high level of affective arousal and cognitive impairment. Because they are not in the habit of relying on primitive defenses – especially splitting – or do so for only short periods of time, they routinely return to more discriminating cognitive functions, using less primitive defenses if need be. They thereby process their negative affect at least to the degree that their hostility is replaced by anger or irritation; their bitterness or regret by disappointment; and their paranoia by mild suspicion or wariness. They do not have to cling to a reputation of being all good, for example, and be angry about being thought less of. They can rationalize what they did, admit the possibility of being somewhat in error, and be simply irritated both with themselves and those who have judged them.
On the other hand, clients with moderate ego-strength and generally low levels of affective arousal, who bring to therapy embarrassing or highly sensitive identified problems, may sometimes benefit from TRIs and CTRIs. Through exploring not only how they feel and think when talking with their therapist but also how their therapist feels and thinks, they may come to see that others are not actually despising them or looking down upon them. Rather, common humanity draws from others’ understanding and compassion. However, therapists are wise to take their repeated defensiveness, noticeable opposition, or prolonged passivity as indications that they are not ready for interpretations.
Similarly, when clients repeatedly or strongly reject material, more often than not they are indicating that their heightened arousal makes them unable to think well. They do not have the intellectual capability to manage the feelings that have been aroused. Especially if clients are highly internalizing and feel awkward, TRIs and CTRIs seem to intrude on their fragile mental capacities. TRIs and CTRIs may feel invasive. For instance, clients who already feel deeply rejected by a significant other might hear such a TRI as “You are refusing to let me in on your pain” as simply critical of them. The interpretation indicates that they are being rejected because they are protecting themselves so staunchly from their therapist’s efforts to help them. They must be accepted for doing so, these clients reason, for they cannot risk intimacy, which either reminds them of the intimacy that they have lost or has the potential to lead to more rejection. When this is the case, therapists are wise to engage in reflective listening and clarify presenting problems without referring directly to transference or countertransference – or at least to make only discreet, indirect reference to them.
Even highly externalizing clients with moderate ego-strength need help with symptom reduction and skill building rather than with insight and relationship work when they are under great stress. Though they are in the habit of sharing their emotional life with others, they are feeling too vulnerable to do so at the time. Although they may benefit from a few carefully timed TRIs and CTRIs, in general they need externalizing interventions like paraphrasing and summarizing to achieve a positive therapeutic outcome (Beutler, 2000).
Others who are generally unable to make good use of TRIs and CTRIs are clients who lack ego-strength or suffer other serious deficiencies, such as pervasive, high levels of affective arousal. They are emotionally unable to tolerate the honest feelings and thoughts of their therapist and cognitively unable to process them. These clients see others as basically identical to themselves and, as a consequence, cannot separate their own feelings from those of their therapist. Asking them to do so by using TRIs or CTRIs that focus on feelings may even harm them.
Similarly, clients with a strong need to merge with idealized others cannot usually tolerate working with limited, vulnerable therapists, as is sometimes revealed in their CTRIs. Clients with strong narcissistic tendencies, for example, need to bolster their sense of self-worth by being worthy of only obviously capable therapeutic partners. For this reason, Kernberg (1975) warns against challenging an idealizing transference, at least in the beginning phase of therapy. Instead, therapists might simply ask for clarification.
Most persons with dual diagnoses must also be added to the list of clients who do not ordinarily have sufficient ego functioning to work with TRIs and CTRIs. They include those with significant alcohol and drug dependence, those who habitually act out their feelings and impulses – especially those that are antisocial or suicidal – and those without the mental capacity to see connectedness (Crits-Christoph & Barber, 1991; Pollack & Horner, 1985; Davanloo 1990).
Clients with a borderline personality disorder present yet other problems with regard to TRIs and CTRIs. Because they are habitually inclined to act out their feelings and impulses – particularly if they are functioning at a lower level – they are likely to perceive TRIs and CTRIs as expected and deserved counter-assaults. They simply cannot appreciate them “as therapeutically meaningful [statements] offered in good faith, because such things are not expected from one’s most immediate enemy,” (Epstein (1977, 461) albeit one’s most perfect friend minutes before – even if he or she is a therapist.
Kernberg (1975) explains that clients with a lower-level borderline personality disorder do not do well with TRIs and CTRIs because they either distort them or cannot put them to use. Their core self is simply parts of others, adds Searles (1979), especially in the early phase of therapy. Because of their excessive use of splitting and their self-observational, judgmental, rational, and other executive ego-function limitations, they do not have the ego-strength to handle TRIs and CTRIs (Lasky, 1990). More often than not, they experience heightened levels of affective arousal (Swift & Wonderlich, 1990) that interfere with the cognitive work necessary for processing interpretations.
Instead of using TRIs and CTRIs with clients with a lower-level borderline personality disorder, therapists may simply wish to clarify the way these clients use splitting and other defenses and thereby distort perceptions during their sessions. Rather than focusing on their clients’ interpersonal patterns, therapists may simply need to slowly and indirectly resolve the resistances of these clients (Spotnitz, 1976).
If, on occasion, therapists interpret transference and countertransference to clients with a lower-level borderline personality disorder, their TRIs and CTRIs should ordinarily refer not to genetic material (Volkan, 1995) but to the here-and-now. They might say, for example, “It’s hard for you to share your bad experiences” rather than “It’s always been hard for you to trust others enough to share your bad experiences.” This focus will enable therapists to supply corrective data in concrete detail as soon as they note their clients’ perceptual distortions. Or therapists might say, “I wonder what has prevented you from saying almost nothing for half an hour” and add, “Is my questioning coming across as critical of you?”
At times, however, even highly disordered persons can benefit from TRIs and CTRIs. An example would be the autistic child client that Franch (1996) describes as unable to overcome two-dimensionality and relate to a world without meanings. Because the autistic child can experience neither inside nor outside, Franch approaches him almost exclusively from his countertransference. Using his own feelings, sensations, fantasies, and associations to get information about the client’s state of being, Franch assigns meaning to these data, communicates it through CTRIs, and achieves a positive outcome. The child’s “frozen” internal world gradually begins to “thaw,” and his transference arises in response to his therapist’s countertransference.
Aware of their responsibility to distinguish clients who can benefit from TRIs and CTRIs from those who cannot, therapists still face the major questions of when and how often or with what frequency (Piper et al., 1993) they should use interpretations.
Joyce and others (1995) state that timing depends on clients’ “inviting” their therapists to interpret. Clients “invite” when they are in a state of readiness: they are able to give up their defenses, focus inwardly, and attribute increased personal significance to the content of the interpretation. They can profit from an interpretation and begin to process affect connected with it under these circumstances.
As with many other principles, however, it may be easier to identify times when TRIs and CTRIs should not be used. Therapists would be unwise to use TRIs or CTRIs, for example, if moderately ego-strong clients were already dealing with significant past conflict. It would ordinarily be inappropriate to divert clients’ attention to an unwholesome negative therapist-client relationship if they were already exploring a past unwholesome relationship that is being repeated in the present (Swift & Wonderlich, 1990). The clients have understood correctly if they have recognized a destructive pattern outside the therapeutic setting (Pearson, 1995). On the other hand, it would be appropriate for therapists to be on the lookout for transference data that persisted after the therapeutic work was apparently completed, for that unresolved conflictual material would indicate a need for additional work.
Similarly, therapists would be unwise to use TRIs and CTRIs when clients were already profitably focused on there-and-now present extra-therapeutic relationships, or there-and-then past extra-therapeutic relationships, or there-and-will-be extra-therapeutic relationships that are likely to develop. In all likelihood, these clients would already be in the process of identifying their dysfunctional patterns of relating, patterns like those appearing in the transference and countertransference.
Neither would therapists use TRIs and CTRIs when clients were already dealing with highly intrapsychic material, such as an experience of death, significant rejection or humiliation, and severe abuse. Simply listening respectfully and, perhaps, reflecting the client’s pain would be much more effective in these cases.
However, if the manner in which the clients choose to share their experiences causes problematic negative reactions in therapists – reactions of which the clients are virtually unaware – therapists might consider using very carefully crafted and sensitively timed TRIs and CTRIs. They might say, for example, “Your shouting is scaring me into focusing on harm that might come to me, even though I want to focus on how awful the experience you are relating is for you.”
In general, therapists should also refrain from using TRIs and CTRIs when clients are dealing with material too primitive for language; when they cannot “give voice” to what they were experiencing. If clients cannot give information, talk slowly enough to be understood, or speak coherently, TRIs exposing those phenomena would deepen clients’ already disturbing experience. More effective in these cases would be attentive silence or short affective responses that prepare clients for a clearer focus on transferential and countertransferential affect. Clients might then feel comfortable with expressing subjective experience that is just partially known (Bollas, 1987). They might, in time, rely on the attunement of their therapist to bring partial awareness to fuller consciousness. They might then tolerate their therapist’s CTRIs or direct expressions of subjective states that reduce the quality of the therapeutic interaction, given that such expressions would repair some damage in the relationship and thus preserve it in the long run.
Several additional guidelines – some seemingly contradictory – have guided clinicians well in determining when to use TRIs and CTRIs. First, these interpretations should not be used too soon. They should be used only when there is some evidence of the necessary comfort level associated with the therapeutic alliance. Otherwise, they encourage intellectualization and other defenses against resolving transferential conflict (Brenner, 1982). In other words, TRIs and CTRIs should be used after – not before – more supportive interventions (Gabbard et al., 1994). Clients must feel accepted and valued in their therapy before they can examine how they have contributed to interpersonal failures. CTRIs will be experienced as premature if clients are suffering from intense guilt related to not fulfilling their responsibilities. They will react with intensified guilt to any intimation that therapists are not finding sessions helpful. Clients in this condition cannot accept responsibility for their therapists’ mental states, even if they are occurring in therapy (Searles, 1975).
Second, TRIs and CTRIs should be used to further – in some cases even to establish – the therapeutic alliance. They should be used to help clients discover that their unprocessed feelings toward their therapist – strongly positive or strongly negative – are creating an impasse in their therapeutic work. Used carefully, these interpretations can facilitate clients’ trust and respectful acceptance of their therapist and thereby provide the energy needed to create a functional therapeutic alliance.
Third, TRIs and CTRIs should be considered when the therapeutic alliance or the working alliance is ruptured. When therapists have made a mistake – for example, when they are chagrined and notice their clients’ corresponding distress – they might need to say something like, “You seem disappointed in me because of my insensitive remark. Can we talk about your feelings?”
Fourth, TRIs should not be used when therapists suspect that transference is actually a resistance to facing extra-therapeutic problems. Rather than focusing on the transference, therapists should address the problems being resisted (Brenner, 1982). Suspecting this situation, they might say, “You started our session by telling me how disappointed you are in your sister. Am I right in thinking that your disappointment in me might be less important?”
Fifth, TRIs are to be used when therapists can correlate what clients are doing in therapy to their behavior outside therapy or to the issues and problems that clients have identified in their presenting problems. Especially in the case of erotic transference, therapists should avoid TRIs until the underlying linkages to past relationships and to current extra-transference relationships approach conscious awareness (Gabbard, 1996).
Sixth, there are times when therapists may use TRIs before they are fully aware of their connection to extra-therapeutic phenomena. Provided they are relatively certain of a TRI’s basic meaning, therapists may interpret tentatively when they suspect that negative transference is revealing pervasive, harmful interpersonal patterns. Therapists might admit that they could be wrong but want to help clients avert major interpersonal mistakes if they are right.
A general, research-based rule is that TRIs should be used infrequently rather than frequently (Piper et al., 1991; Hoglend, 1993; Joyce & Piper, 1993) because other interventions are often equally appropriate or more appropriate. The same rule is even more applicable to CTRIs, which have an even greater potential than TRIs to divert attention unnecessarily from clients’ presenting problems. TRIs and CTRIs should be alternated or interwoven with active listening, explorations, clarifications, confrontations, and other kinds of interpretations (Grunebaum, 1986). It is especially important to move back and forth between TRIs and supportive interventions, Bond and colleagues (1998) discovered, for only in that way is a successful working alliance established for personality-disordered persons – findings which may be generalized to other kinds of clients.
Furthermore, neither TRIs nor CTRIs should be used in place of supportive interventions, especially when those interventions would be more effective. Therapists must always heed the cautionary words of H.S. Sullivan (1954): Since “the supply of interpretations is greater than the demand,” the needs of a client must take precedence over a therapist’s desire for insight.
However, the guideline of infrequency in no way diminishes the potential of TRIs and CTRIs to contribute to mediators of successful outcome. The therapeutic and working alliances in particular benefit significantly from the candor, immediacy, and honesty of these interventions.
Note 1. Clients somehow know when their therapists are open to connotations carrying displaced material. They sense that it is safe to imitate their therapists: to look within themselves for exactly what furthers or hinders their wholeness. When therapists are not open to the possibility of countertransferential communication, by contrast, clients do not feel safe enough to proceed with their work (Kantrowitz, 1997). (Go back)
Note 2. It can be argued that when clients bring in extra-therapeutic material for the sake of dealing with out-of-session problems, it is more appropriate for therapists to accept it at face value and teach clients the rudiments or refinements of skill building. With this approach, however, the question remains of whether or not those skills are actually used outside of therapy. Clients describing their behavior may be merely relating how they hoped they acted. On the other hand, when therapists admit the possibility of the transferential meaning of extra-therapeutic material, they pave the way for making the therapeutic setting itself a venue for interpersonal skill building. As they get first-hand experience of clients’ transferential behavior, therapists can instruct, coach, and all but guarantee skill acquisition. (Go back)
Note 3. By comparison, when clients treat their therapists as if they were third parties, they may be displacing away from their therapists. They may be expressing their feelings, attitudes, and impulses toward third parties. It is likely that they are doing so because they have recognized themselves behind or in these extra-therapeutic persons and wish to reveal who they are by referring to the third parties (Giovaccini, 1967). When this is the case, if therapists are to really know the interpersonal styles of their clients, they must also decode this non-transferential material. (Go back)
Note 4. The concept of transferential feelings implies that, ordinarily, the experience of similarity initiates the affect rather than the affect initiating the experience of similarity. However, it is more likely that either both are initially operative or the distinction is artificial. The feeling imbues the experience just as the experience imbues the feeling. (Go back)
Note 5. Of the feelings striving for expression, fear appears to be the most pervasive. Consequently, it is the most common transference affect. At times, clients transfer to their therapist hostile behaviors and qualities that inspire fear. At other times, they let basic fear create the appearance of threatening behaviors and qualities in the therapist, for at the same time that early parental figures were nurturing and life-sustaining, they were also capable of withdrawing that care and sustenance at any time. Indeed, they held what felt like absolute authority and appeared to require clients to please them in order to win their love. If parents were displeased, their negative attention could inspire only fear. Thus clients knew no middle ground, softened emotions, or counteractive force. All was primitive: all-good or all-bad. (Go back)
Note 6. Depression is regarded as a major form of acting-in because the anger and anxiety at its core are being turned inward and directed toward the self. Because these two emotions are less responsive to inhibitory efforts that reduce the likelihood of acting-out, therapists unconsciously conceal them in depression. (Go back)
Note 7. Therapists are wise to decode their feelings of being punished in order to uncover their possible anger-base though they can explain neither the exact nature of the punishment nor the reason for it. It may be that in punishing their therapists, clients are asking them to respond positively to a negative experience. They are hoping to revise their beliefs about themselves and their interpersonal worlds through witnessing their therapists return good for evil. On the other hand, therapists’ feelings of being punished may stem from their being taken for granted, used, or even abused. They may resent having to give precious time to clients whose issues seem mundane in comparison with the horrific problems of other clients. After therapists have worked with sexual abuse victims or have been victimized themselves, for example, they may find it difficult to appreciate clients’ distress resultant from relatively minor setback like receiving a poor essay grade. (Go back)
Note 8. To a certain extent, of course, anxiety is characteristic of all countertransferential reactions, for in the process of being impacted by clients’ transference, therapists lose cognitive control (Kantrowitz, 1997). Rarely, however, are they conscious of losing it. (Go back)
Note 9. Therapists may rationalize their tendencies by saying that their clients need their insight; but more likely than not, therapists are discounting their clients’ insight more than adding to it (West & Schain-West, 1997). (Go back)
Note 10. Because clients often conceal their fantasies and daydreams, methods like Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro, 1995) are valuable interventions. When the bilateral movement sets that are central to EMDR stop and clients are asked to answer a question such as, “What is there now?” therapists often become privy to transferential fantasies that clients would not otherwise share. (Go back)
Note 11. Space and time do not permit a full exploration of why the body reveals transferential truth, indeed why it cannot lie. But research suggests that memory is spread throughout the body in wavelike frequency patterns along a network of fibers on all nerve cells rather than stored in specific cells or even cellular tissues. Memory capacities, therefore, exist not just in cerebral neurons but in all parts of the body’s nervous system and not just in the nervous system but in all cellular tissues of the body (Oschman & Oschman, 1995b). Furthermore, because the body as a whole is a continuous, unbroken fabric and a living matrix, throughout its entire system it retains a “record or memory of the influences that have been exerted upon it, both as an individual and as a member of the race” (Oschmann & Oschmann, 1995a, 65). The body remembers both ancestral information through genetic transmission and personally experienced events, especially those charged with emotion (Schacter, 1996). Because of this highly developed capacity to retain memories, the body is constantly responding to present stimuli against a background of past experiences. Cells are being reminded of previous similar experiences, all the way from simple sensations to highly structured cognitions that give events meaning. (Go back)
Note 12. Some theorists assert that all therapeutic behavior, including verbal behavior, is motivated by and reflective of transference and countertransference (McLaughlin, 1990). Most, however, find some therapeutic behavior, but not all, is rightfully connected to transference and countertransference. Clients may come late, for example, not because of early familial patterns but because of traffic problems or resistance to being in therapy in the first place, no matter how little their therapist reminds them of a parental figure. Thus therapists must at times discontinue decoding no less than engage in it. (Go back)
Note 13. Research reveals that body language or simple movement may prove beneficial to clients and contribute to positive outcome if it is truly a response to clients’ attachment affect, namely sadness, fear and anger (Dreher et al., 2001). On the other hand, simple movement may be harmful to clients and contribute to negative outcome if therapists simply match the behavior of their clients. Therapists’ smiling back, for instance, appears to be especially harmful when clients are feeling shame in addition to anger. Therapists may consciously intend to strengthen the therapeutic alliance by smiling even while feeling angered by what they hear from clients. Unconsciously, however, therapists may be denying the degree of their anger. In addition, their smiling may be countertransferential in that therapists learned earlier in their lives to smile when anxious about expressing their anger. Hence, therapists’ responsibility to decode their urge to smile. (Go back)
Note 14. Clients who lean forward may be indicating that they have come to trust their therapist enough to share intimate information. In contrast, clients who remain chair-bound may be “saying” that they do not feel comfortable enough to reveal what is painfully humiliating. (Go back)
Note 15. Although it is appropriate on select occasions to show feelings in action, if doing so is the only way in clients’ repertoire, they may need to discover that acting-out usually creates a mine-field of negative interpersonal relationships. (Go back)
Note 16. Transference enactments fall into two categories depending on how therapists respond to the roles they are assigned (Levin, 1997). In the first and more common, therapists actually assume the role they are being assigned and thus fulfill their client’s transference expectations. In the second, therapists refuse that role and thus fail to meet their clients’ expectations. In fact, in order to help their clients realize that they are living not in the past but in the present, where they must assume responsibility for their own self-care, therapists may have no other choice but to decline their role assignment. (Go back)
Note 17. Factors increasing the likelihood of countertransferential enactments originating in therapists are permeable boundaries, poor impulse control, inadequate education, excessive therapeutic zeal (Searles, 1979) and blind spots (Plakun, 1998). (Go back)
Note 18. Factors increasing the likelihood of countertransference enactments triggered by clients are certain personality disorders and the use of primitive defense mechanisms. For example, clients may replay the trauma that they are presently suffering outside of therapy, assigning roles of victims to themselves and abusers to their therapists. In contrast, they may reverse roles, becoming abusers themselves and making their therapists, victims. (Go back)
Note 19. Whatever their specific form or immediate cause, countertransferential enactments must be decoded lest they cause the therapeutic focus to shift unnecessarily from what clients need to achieve to how they are relating to their therapists. If clients’ conflicts with their therapists closely resemble those with non-therapists, all is well. If not, however, clients must use precious time and energy dealing with the disconnectedness that has ruptured their relationship with their therapist instead of exploring their own issues. Therapists who are overly sensitive to slights, for instance, can revert to defending their treatment-related actions and blaming clients for not cooperating with them when clients complain that therapy is not benefiting them. Having to focus on their therapists’ powerful defensive feelings, clients are not able to explore the negative feelings that explain why treatment is not working. (Go back)
Note 20. The same kind of failure can result from therapists’ insistence that clients are not and never were responsible for such a thing as participation in sexual abuse as children. Therapists may do so in the name of reality testing, Plakun (1998) explains, but they thereby prevent clients from processing the painful feelings of guilt that some sexual victims carry. (Go back)
Note 21. This response contrasts with silence that is appropriate when content loses its importance or when interpreting strikes clients as nagging or doing something they could do (Bird, 1922). (Go back)
Note 22. It also appears as if the human brain can exploit what are called holographic principles. Each part of the brain can contain both a fragment of a memory and the entire memory in miniature. Consequently, association upon association is possible, with every cellular tissue capable of “revealing” the truth the whole person “knows” (Pribram, 1971). Thus somatic memory may indeed hold the “truth” about what clients have displaced from significant, pre-therapy and extra-therapy persons to their therapists. (Go back)
Note 23. The deliberate reception of transference begins a process whereby therapists acquire the intuitive empathy necessary for the therapeutic alliance. (Go back)
Note 24. The clinician’s primary function is as an affect regulator for the client’s primitive, traumatic states, including those that are walled off by dissociation. (Schore, 2003a, 246). Dissociation, the blocking of the path between the limbic system and the cortex, is an early appearing, very primitive defense against traumatic affects that are stored subcortically in the right hemisphere. (Go back)
Note 25. Wilkinson (2003) calls such a safe holding environment the most potent vehicle for healing. (Go back)
Note 26. Bion (1967) suggests that containing is required because clients’ mother’s capacity to contain the clients’ distressing emotions was insufficient. They were therefore returned to the clients little changed and difficult to integrate. The mother was unable or unwilling to provide a model for the clients’ containment of their own feelings; this the therapist must do. (Go back)
Note 27. As Gilboa and Revelle (1994) explain, “The longer the period during which a person is influenced by physiological and cognitive processes activated by emotion, the higher the probability that this experience will be subjectively perceived as important and meaningful”(135). (Go back)
Note 28. Because early relational trauma is stored in the right hemisphere, therapists choose to engage in right brain-to-right brain emotional communication. They refrain from using their left brain to put their experience in words. Instead, they tolerate uncertainty, for it is fundamental to a healthy growth process. Even though it is anxiety producing, it is an opportunity for change (Schore, 2003a). It is an opportunity for clients to create something out of themselves (Balint, 1968). By contrast, if therapists block their own negative somatic markers by shifting out of their right brain into their left brain, they cut off their empathic connection to their own pain and therefore to their clients’ pain. If therapists speak quickly, their clients are likely to perceive them as critical (Ryle, 1994). (Go back)
Note 29. The challenge of projective identification for therapists is to reveal to clients in a non-threatening way that they have received their unwanted traits. This is extremely difficult for clients to receive, however, for those using projective identification are already in dread of what they had to project in the first place (Kernberg, 1987). Then, in using projective identification, which is a matter of action rather language, they have regressed to a pre-verbal time (Maroda, 1995). Only with great difficulty can they accept the feedback that they have put their own unwanted trait into their therapist and now attribute the trait solely to the therapist. (Go back)
Note 30. These are false assumptions because only by holding clients’ transference can therapists facilitate an expansion of clients’ narrow personal psychological space and collaborate with them to fashion what is real, in contrast to what they want to be real (Slochower, 1999). (Go back)
Note 31. By containing and eventually processing transference, however, therapists facilitate a detoxification process whereby clients’ unwanted transference projections lose their potency. By the course of holding transference, therapists really know their clients well enough to help them make transference a resource under the control of their reality-testing ego. By holding transference, therapists and clients together strip displaced material of its dangerous, uncontrollable pathogenic elements and make it simply a memory residing in the unconscious mind (Grinberg, 1997). (Go back)
Note 32. Dealing appropriately with projective identification is difficult for therapists because of a delay between clients’ projection of unwanted traits and therapists’ becoming conscious of what has happened. In the interval, therapists can easily act in accordance with the traits or at least be disturbed by the feelings they stimulate. They find it hard to hold or contain their clients’ painful feelings and allow their clients’ experience to fully impact them (Roth, 2001). They desire to defend against an awareness of the projection and its painful feelings, They act them out in an effort to get rid of them. (Go back)
Note 33. Indeed, therapists cannot initially prevent themselves from being what their clients unconsciously want them to be. At the same time, according to Ogden (1994), successful outcome depends on therapists’ maintaining sufficient psychological distance from the projective identifications. Therapists must be open to receiving projective identifications – receive them, hold them, and identify with them – but not own them or enact them. Instead, they must enable clients to own them and subject them to reality testing. (Go back)
Note 34. Sometimes therapists label what is happening as pure projective identification when it is actually avoidance of responsibility for their own countertransference (Finell, 1986). (Go back)
Note 35. If feelings of success during a session are due primarily to clients’ transference, the therapist’s work might entail helping them realize that their wanting to sustain a positive therapeutic relationships is making them reluctant to reveal facets of their lives likely to inspire disgust or dislike in their therapist. This, in turn, might result in wasted therapeutic effort. On the other hand, if feelings of success during a session are due primarily to therapists’ displaced attitude, they may need to manage their feelings carefully in order to stay attuned to the feelings of their clients, which are often those of failure. Should therapists allow their good fortune to become more important to them than their clients’ feelings of deprivation or misfortune, clients may have yet another poignant experience of being compared to others and found wanting. (Go back)
Note 36. In terms of the right brain, therapists shift up and down between its higher and lower levels: those connected to cognition and those connected to emotion (Schore, 2003b). (Go back)
Note 37. When therapists unconsciously assume the roles that their clients have transferred, they experience in themselves strong, even intense, countertransference attitudes and feelings (Diamond, 1989). Therapists fear clients’ anger. They are disturbed by clients’ erotic, dependent, or sadistic feelings and frightened by clients’ desires to merge with them or to humiliate them. They are anxious about clients who have become victims of abuse and worried about how much their clients can take (Pick, 1997; Wallerstein, 1990). At times therapists even worry about how much they themselves can take: how many times they can be asked to take with impunity roles of harsh authority figures, of victimizing sibling figures, and on and on. Concurrently, they wonder how many times they can unconsciously dredge up their own memories of painful interpersonal relationships brought to mind by their clients’ self-revelations. (Go back)
Note 38. Neither may therapists end the session early simply because feelings of hatred have become too strong for comfort. For while this solution might be helpful in the short run, it is harmful in the long run in that it implies that hatred is too unmanageable to be contained in the therapeutic environment. If hatred cannot be contained in the therapeutic environment, by inference it cannot be contained anywhere. It must be staunchly repressed, which only increases its power. (Go back)
Note 39. Self-monitoring adds conscious processing of countertransference to intuition and other unconscious mental operations (Arlow, 1985). (Go back)
Note 40. Contrary to what common sense might suggest, the goal of psychotherapy is not for therapists to be better parents by undoing pathological repetition or repairing conflicts for clients. Rather, it is for therapists to create the conditions under which clients themselves can become increasing able to manage what once was – and still is – pathologically conflictual. The goal of therapy is for therapists to ensure sufficient security within which clients will feel safe enough to risk feeling unsafe again in order to work through the feelings associated with earlier difficult experiences (Casement, 1991). The goal of therapy is for clients not to remain vulnerable and inappropriately dependent on external forces but to develop enough psychological strength to act in truly appropriate independent and interdependent ways. (Go back)
Note 41. However central clients are to the therapy “product,” therapists must remain the heart of the therapy “process.” (Go back)
Note 42. Readers will note that TRIs and CTRIs are being defined in accordance with the operational definitions of transference and countertransference. It is especially important to note that TRIs and CTRIs need not refer directly to the unresolved conflictual relationships being transferred to the therapy relationship. Rather, they can simply identify a therapist-client conflict that is available for immediate and concrete examination. Later, if it is in the interest of the client, the therapist and client can explore the original experiences that lay the groundwork for the therapist-client conflict. (Go back)
Note 43. Therapists should also be wary of their own tendency to see evidence of what they are expecting to find, for it is human to relate to something familiar as if it were universal and ubiquitous. “We do not have to be so quick to use old insights when we can learn to tolerate longer exposure to what we do not yet understand. And, when we do think we recognize something familiar from a [client], we need still to be receptive to that which is different and new” (Casement, 1991, 29). (Go back)
Note 44. One might argue that if clients are not calm, TRIs should be reflective of that state. If therapists attempt to calm disturbed clients immediately, they give them the message that their disturbing feelings are not acceptable. While this point is well taken, responding to heightened, unprocessed emotional disturbance in kind is not as therapeutic as those who are disturbed would like to believe. It is not the harboring of disturbance that is healing but the recognition, containment, and interpretation of it. It is new and different thinking that both serves as a basis for remedial action and leads to an emotion’s demise. (Go back)
Note 45. Especially in the realm of sexual abuse, therapists must make TRIs emotionally immediate. If they wait too long to interpret material, clients can experience therapists as being afraid to face facts. Therapists can appear to be re-enacting like someone who turned a blind eye to what was happening (Casement, 1991). Timing of TRIs is crucial, however, because immediacy must be tempered by emotional readiness on the part of both clients and therapists. TRIs referring to sexual abuse, in particular, must not be spoken too soon, lest clients experience therapists as either voyeuristic or uneasy with the material. (Go back)
Note 46. Neutrality is especially important when clients give their therapist negative feedback about a TRI, such as their feeling criticized because of it. “It is harmful...when [therapists] appear to ignore clients’ accurate perception or interpret defensively in the face of it” (Casement, 1991, 131). Focusing first and only on the transference could strike clients not only as therapists’ being defensive but also as their denying the elements of objective reality in their relationship. It could be detrimental to the working alliance to say to a client something like “I wonder if you see me as critical because I resemble your critical father” (Casement, 1991).
Instead, therapists might simply acknowledging the reality, saying, for example, “I can see how you could have heard what I said as critical.” In some cases, therapists might also add, “I must have sounded critical.” They would thereby be acknowledging the client’s feelings but not admitting doing something that justifies those feelings. (Go back)
Note 47. A possible rewrite would be: “I wonder whether you are suffering a great deal from punishing yourself.” One might even add, “But it isn’t clear what you are feeling guilty about” when clients’ superego attacks are already so acute that it takes very little for them to hear TRIs as condemnations. (Go back)
Note 48. In some instances, if positive therapeutic outcome is to be achieved, TRIs must focus not just on defenses or resistance. Therapists must also refer to client’s wishes and fears (Winston et al., 1993). For example, if a client were speaking of a third party as especially supportive, the transferential message to the therapist could simply be a wish that the therapist were similar. The client could simply be signaling that there is a conflict between what is being experienced and what is hoped for and that this conflict needs attention (Casement, 1991). In such a case, the therapist should simply say, “Do you wish that I would be more supportive of you also?”
At times therapists should also refer to the fear or anxiety which causes the defense or resistance. They might say, “It seems as if you are extremely anxious about sharing with regard to your past. Could we look at what that anxiety is all about?” rather than “What is so hard to share?” or “You seem so unwilling to share.” It is safe to focus on the anxiety before the content accounting for the resistance, Klein (1952) assures therapists not wanting to lose important content. The content associated with the anxiety will not recede permanently; it will return.
However, there are times when clients must be helped to cope with old, dangerous situations before they can even admit their fears (Greenson & Wexler, 1969). Thus a TRI such as, “You seem unable or unwilling to share with me today. I wonder what might be going on,” would be a more effective than, “Could it be that you fear me today, that you see me as your abusive mother?” (Go back)
Note 49. When clients use strong terms or exaggeration to describe others, they make therapists wonder if their clients are also referring to them, which makes it more difficult for therapists to remain ego-based and neutral. “My mother is a witch!” an adolescent might cry soon after a therapist sets limits to the client’s behavior. To maintain neutrality and calm and yet keep the TRI emotionally immediate, the therapist might reply, “You put great emphasis on how your mother seems to you to be a witch. Are you experiencing someone – maybe me – as being mean to you?” In using phases like these, therapists play back clients’ descriptions as clearly their perception, rather than both theirs and their therapist’s. Thus therapists keep a balance between respecting clients’ points of view as subjectively valid and questioning their objective validity, their being defenses against reality rather than facts. Therapists remain neutral at the same time that they note the forcefulness and immediacy of clients’ feelings.
By contrast, if clients talk about their “shitty feelings” and therapists also refer to their “shitty feelings,” clients might be relieved to hear their therapist accepts their viewpoint. But they might also hear in the interpretation, “Your feelings really are shitty” and consequently not examine feelings that they themselves may actually question. Indeed, further questioning seems unnecessary if clients’ descriptions and perceptions have been accepted as accurate by their therapist. By contrast, “You have come to regard your feelings as shitty. How did this come about?” gives clients the psychological space within which to examine their feelings. Similarly, a TRI that invites further examination, such as “I think you expect me also to see your feelings as shitty,” permits clients to hear a helpful reflection (Casement, 1991). (Go back)
Note 50. It is also especially important for therapists to use tentative CTRIs when they attempt to share an instinct, Viederman (1974) explains, because it is an experience on the boundary between the somatic and the psychic. Vague, obscure, nameless, and barely outlined, an instinct demands tentative language of those who try to share it. (Go back)
Note 51. In an attempt to be appropriately inclusive, a therapist might say, “I wonder if you resent my not being pleased with your progress. You would like me to say you have done enough to acquire a new habit even though you really haven’t been consistent.” Or a therapist might reflect, “Could it be that you fear my judgment so much that you exaggerate your progress? You see me as a more important judge of your conduct than you are?” (Go back)
Note 52. The following inclusive CTRI serves as an additional example of movement from here-and-now to there-and-now. “My anger toward you may be similar to your wife’s anger toward you, the anger you said you simply couldn’t understand.” So does, “Could it be that my getting distracted when you talk too long is reflective of what your wife does?” (Go back)
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