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Margaret Macdonald

Is the value of transference and


countertransference to the therapeutic process
negative or positive?
Introduction
Transference and countertransference are important concepts within
psychotherapy. This essay explores these phenomena by frstly
defning what they are, and how they have been viewed in the
literature. Using case examples and recent literature, the context
and extent of their power to add to therapeutic success is
contrasted with the problems that can arise from their manifestation
and interpretation. The various positions are discussed from the
vantage of the practising therapist.
Defnition & Background
Transference (TR) and countertransference (TR) were frst
described by !reud ("#"$, "#"%) who e&uated the former with
'reincarnation, of some important fgure out of his childhood or past
and the latter as 'a result of the patient's infuence on [the
therapists] unconscious feelings(. !rom then on he said little about
counter)transference, leaving it to others, (*aplanche + ,ontalis,
"#-.) but expounded greatly on transference. /e recognised
transference as being positive (a0ectionate) as well as negative
(hostile) (!reud, "#1$) in2uences, and considered that positive
transferences put the client in a position of greater receptivity to the
therapist and hence more signifcant psychic change can be
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Margaret Macdonald
achieved. /e also concluded that transference is a universal
phenomenon of the human mind and 'decides the success of all
medical in2uence( (!reud, "#%3). *astly, he claimed if transference
was not present, or was negative, that 'there is no possibility of
in2uencing the patient by psychological means( (!reud, "#%3). The
mechanism !reud proposed involved the overcoming of the client(s
resistance to the pain of bringing these unconscious memories into
consciousness, and hence allowing transformation.
Transference is described as an unconsciously in2uenced emotional
reaction of the patient to the psychotherapist that originates from
the patient4s earlier experiences, usually related to signifcant
others, and that may manifest themselves as inappropriate in
strength, tone or content to the present context in which the
therapist is wor5ing (6uld + /yman, "##"). ountertransference is
the unconscious reactions of the psychotherapist that are stimulated
by a given patient, the characteristics of a given patient, and, in
particular, to the transferences of a given patient, that is,
7countertransference proper7 (8rr, "#31). 9f not consciously
recogni:ed, these internal reactions are li5ely to be dealt with
inappropriately by the therapist in their responses to the patient.
6s !reud stated (!reud, "#"%), transference is a universal
component of the human mind. ;very interaction we have, even
with inanimate ob<ects, there stands to be within us a transferential
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Margaret Macdonald
component. ;very moment of life, external elements impinge on us
with the potential to trigger some previous memory or experience
which may be conscious or unconscious, pleasant or horrible,
reassuring or frightening. ountertransference, it seems to me, is
simply transference in a specifc context. =o we are never in the
absence of transference, and hence the &uestion of whether
transference (or countertransference) per se is harmful or benefcial
to therapy needs clarifcation. There are three possible ways that
transference can impact within the therapeutic space and hence be
considered for its potential to hinder or assist healing > ". The
natural appearance of a distinct transference reaction (or TR)
perceived only to the host mind and probably not recognised by the
client as TR unless the therapist draws attention to it. %. The
therapist to provo5e a specifc TR deliberately in the client for them
to gain insight (seems a little unethical and unpredictable) or .. the
calling into full awareness of, ma5ing overt reference to and
suggesting interpretations of naturally arising TRs (and TRs) by the
therapist within the therapy session as part of a therapeutic
techni&ue.
My Personal View
6s a novice therapist, many of these concepts are di?cult for me to
comprehend. 9f a client is caused, unconsciously, by the therapist to
experience a transferential reaction, unless the client expresses it,
the therapist will have no awareness of this. 9n my own therapy
sessions this fre&uently happens and 9 usually contain it until 9 have
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Margaret Macdonald
decided whether it is a) safe and b) useful to mention it. @y then of
course the moment has passed and any description is in measured
language not representative of the original emotional intensity.
Aoes the existence of such a phenomenon help or hinderB Chat
about some aspect of the therapist causing an outburst in the
clientB !or example, in my placement, a light)hearted comment
about my own life (that 9 pay my daughter rent when 9 stay with her
during the wor5ing wee5) prompted an outburst of 'there(s no need
to mention things li5e that( from my client. Dy (unvoiced)
interpretation was that somehow it triggered a negative accusatory
feeling of not 'paying one(s way( in some form. /owever, 9 could be
wrong in that interpretation and if 9 then mention it, surely the
therapy starts moving down a false path. Dy interpretation then
triggers another TR response possibly, which triggers a TR in me,
possibly defensive from my status as beginner, or apologetic. @ut in
each case the interpretation may be incorrect. 9n these instances
TRETR seems to be non)productive and a hindrance to a
productive, trusting and safe environment. /owever, it is hard to
stay neutral about this. 9f 9 experience my client(s transferences as
harmful, perhaps 9 shall ma5e an e0ort not to trigger them.
6lternatively, if 9 am convinced they are the 5ey to transformation,
then perhaps 9 shall contrive to ma5e them happen. ;ither way
sounds false and dangerous but what does the literature say about
itB
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Transference and countertransference as detriental to
psychological healing
There are a large number of papers putting forward the case for
transference awareness as damaging. Ceiss + =ampson ("#FG)
consider that the therapist drawing the client(s attention to the
occurrence of transference could be damaging to the client(s feeling
of positive experience and level of trust. Ho matter what TR)related
insights might be available, the client experiencing their therapist as
accepting and safe is the 5ey to their releasing their defences and
re)experiencing their repressed mental life. Dentioning TR threatens
this (Ceiss + =ampson,"#FG). 6lso Iacobs ("#FG) believes insights
from TR can distract from distressing non )transferential material
within presenting problems. /e considers issues introduced by the
client must be the frst priority.
9 can support this point of view from my own limited experience of
therapy. ;ven at my frst session with my frst client, a young
woman of "F years old, 9 could sense that she felt acute self)
consciousness and anxiety at the unfamiliar concept of
'counselling(. 9t might have been very invasive had 9 as5ed if she
thought her present nervousness with me e&uated with the fear
she described, of being sent for by the head master and
'&uestioned( i.e. transferential. 9t may be that with more robust,
analytical clients this approach might feel more comfortable.
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Aiamond, ("#F#), /oglend ("##.) and =trachey ("#G#) all caution
that any revelations from wor5ing with TR and TR phenomena
constitutes ris5 to patients with moderate psychopathology or worse
because of the possibilities of regression that may be di?cult to
manage. 9t seems to me that transference can be thought of as a
form of pre)regression as it involves reacting as if from a former
time. 9f that too5 hold it could develop into a 'reliving( which may
involve great di?culties if it occurs spontaneously and the therapist
is unprepared. 9n my own therapy sessions something that possibly
relates to this occurred. 9n response to my frustration at lac5 of
progress, my therapist retorted 'that(s because you didn(t follow my
suggestions(. 9 was shoc5ed at this in<ustice > but suddenly 9 was
transported bac5 to a place of deep shame, along with a host of
memories where the only connection was the feeling of shame. 9f 9
had brought this into the reality of the session, and depending on
the therapists response , it might have stayed with me and become
the present rather than a sense memory that 9 was able to consign
to the past. !urthermore my reaction may have provo5ed
countertransference in my therapist which they might have
described as irritation at my being so cowed. This might go on to
compound and reinforce the shame. Ae*aour ("#F3) suggests
clients might fnd the therapist(s countertransference worrying and
there may be conse&uential therapeutic errors both of which have
the potential to destroy a trusting, safe atmosphere.

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6s TR is primarily an unconscious phenomenon (=egal, "#--)
made up of a complex interplay between the pasts, presents and
'unfnished business( of both client and therapist, =tolorow ("##.)
suggests therapists can 5now its true nature only after signifcant
relevant personal wor5, which may not have occurred, and sharing
suspected aspects of TR with the client may be virtually
meaningless, confusing and troubling. Corse still, =egal states,
sharing incomplete or inaccurate insights may prove very harmful.
(=egal, "#--). =imilarly Jrunebaum ("#FG) believes sharing TR and
TR can feel invasive and demeaning to patients, resulting in self)
consciousness, embarrassment, and subse&uent guardedness.
6nd is utilising TRETR worth the ris5B 6re there valuable outcomes
from ta5ing this routeB 6lthough small numbers, inade&uate
sampling, and confounding variables ma5e their results
&uestionable, =trupp and /adley ("#-#) found that psychodynamic
therapists using TR interpretation had no more success than
untrained college professors not using them. 8utcome, which was
measured by therapists, independent clinicians, and sub<ects, was
not signifcantly di0erent for the two treatment groupsK male college
students su0ering from depression or anxiety reactions.
9n a comprehensive research design that included extensive
examination of hundreds of hours of interviews, Ceiss and =ampson
("#FG) concluded that the unconscious can and does act
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autonomously to bring into consciousness previously resisted issues.
9t does not need the interpretations of therapists. 9t thin5s, plans,
and decides without the beneft of discussing TRs how to master
con2ictual material and they state that it wor5s, without the need
for interpretations, to change pathological beliefs by testing them in
relation to the therapist (=ampson, "##%).
8thers have found awareness of TR to be actually harmful. ,iper et
al ("##.) provided %$ once)wee5ly, sessions for "$3 persons, most
of whom had a0ective, ad<ustment, anxiety, and impulse)control
disorders. 6 balanced sample of G1 who completed the treatment
were then classifed as either mature or immature personalities.
Cith the immature, even accurate TR interpretations led to bad
outcomes. lients with a life)long predisposition for inordinate
dependence, extreme reactions to real or imagined loss, and
destructiveness did not improve when they had TRs explained to
them that lin5ed negative transference with past con2icts.
!urthermore, ,iper et al.("##.) found in the same study that, though
mature men and women could beneft from accurate TR
interpretation, for women an inverse relationship existed between
the number of TRs and a favourable outcome. Comen with a life)
long predisposition to engage in mature give)and)ta5e relationships
did not beneft from an emphasis on the con2ict)based TR aspects of
the client)therapist relationship. 6nd the therapeutic alliance was
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Margaret Macdonald
wea5ened as the TRs became more fre&uent. To be benefcial, TR
interpretations had to be infre&uent.
Traditionally (Rac5er, "#GF) it was suggested that
countertransference arose in the therapist as a direct conse&uence
of the transference of the client. 6nd that in both cases it was
repressed and unconscious aspects that emerge. 6 danger of this
according to Rac5er is if the therapist does not recognise their own
part in this interplay. @y recognising and scrutinising one4s own
countertransference from unresolved con2icts, anxieties, defences,
the theory suggests you can unbloc5 one4s understanding of the
patient. @y becoming aware of and attempting to resolve the issues
that generate these blind spots and barriers, one will remove or
attenuate these barriers and will therefore be more li5ely to better
understand the patient, particularly his or her unconscious mental
processes. @ut this relies on an experienced therapist who can at
the same time as concentrating on the client, distinguish their own
processes analyse them and put them appropriately to one side. 9f
this doesn(t happen there seems a serious ris5 of misunderstanding
and rupture.
Transference and countertransference as helpful to therapy
6ccording to ooper ("#F-) transference reactions are more
concrete and therefore more verifably genuine than patients4
conscious reports. They also less vulnerable to progress)impeding
defence mechanisms, and may reveal and confrm the nature of
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con2icts in their lives and unwholesome interpersonal patterns that
the client may be reluctant to address (ooper "#F-).
=ome authors consider transference reactions strengthen the
therapeutic alliance by solidifying and developing it (Dalan, "#FGL
Mernberg, "#F3) especially important in brief therapy. Therapists
increase interpersonal intimacy by demonstrating attunement to
patients4 feelings. They create a safe environment in which patients
can explore developmental longings and hidden con2icts (=tolorow,
"##.).
Aiscussion and awareness of TRs can even create a therapeutic
alliance and can even be elicited to address resistances relating to
rapport (!reud, "#"%). The therapist might say 79 wonder if you
have been hurt too often to ris5 sharing the truth with me,7 This
interpretation of transference of defence, in particular, may bring
about rapport when it was previously absent (Jill "#F%).
9n my own short experience as a therapist with young people, it
seems to me that transference is often very powerful and its
emergence can frighten by its intensity. 8ne girl has a su0ocating
mother and 9 have to be very careful not to be too 'mothering( .
8nce 9 said to her as she left, 'ta5e care(. =he responded with
'you(re not my mother(. 9t is too impenetrable for me to see
whether this is a useful response or not. 8ne thing that ma5es me
cautious is the possibility of this 5ind of interaction leading to
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antagonism which, 9 feel, would not be productive. 8n the other
hand it was a cue, 9 felt, to a deeper connection with her which, had
9 been a little more experienced, 9 might have pursued.
Ae*aour, ("#F3) suggests when therapists interpret transference
sensitively but accurately, they model an appropriate way of
handling negative perceptions of others. They demonstrate a non
defensive way of exploring behaviour based upon distinctions
between transference material and present reality. They not only
occasion symptom relief, especially from fear of communicating with
therapists, (Ae*aour, "#F3L Dalan, "#-G) but also facilitate
detoxifcation and eventual integration of patients4 unacceptable
feelings. They help patients ac&uire a 2exible, mature pattern of
relating with others (@auer + Dills, "#F#) and thus promote lasting
characterological change. (Dalan, "#-GL =ifneos, "#-#L Aavanloo,
"#F$).
9n the case of my client, then, her response 'you are not my mother(
was an opportunity to model the handling of negative perceptions.
9n fact 9 thin5 9 said (5indly) 'you are &uite right, 9 am not(.
Dalan4s wor5 shows a positive correlation between favourable
outcome and TRs that lin5 patients4 present reactions to therapists
with their past reactions to parents (Dalan, "#-G) Though the study
included only %% sub<ects and no control group, supporting evidence
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Margaret Macdonald
for favourable outcome was based on both clinical <udgment and
content analysis. =uccessful outcome correlated with early, though
infre&uent, TRs and thorough interpretation of TR.
Dar:iali4s replication of Dalan4s study (Dar:iali,"#F1) with a small
but independent sample and stronger research methodology
supported Dalan4s fndings. !avourable outcome, as measured by
independent sets of raters, correlated with the fre&uency with which
therapists4 interpretations referred to emotions experienced in the
transference relationship that were similar to those experienced in
relationships with parents and other important persons
=haring TR can have a powerful modelling e0ect (Ae*aour, "#F3L
,eebles)Mleiger, "#F#L @ollas, "#F.). 9t demonstrates appropriate
ways of setting limits to processing problematic reactions in
intimate interpersonal settings (@ollas, "#F.). 9t shows patients how
to 7ac5nowledge and care for the archaic or unconscious7( *oewald,
"#FGL =earles, "#-#) and how to struggle with feelings, manage
them (Daroda, "##3) contain them, explore them, (DcAougall,
"#-F) and integrate them (,eebles)Mleiger, "#F#). 9t teaches
patients how to be emotionally available (Niederman, "##") as well
as emotionally responsible (Daroda, "##3L Ae*aour, "#F3). =haring
TR strengthens or repairs the therapeutic alliance (Daroda, "##3).
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!urthermore, when clients are invited to collaborate in
understanding TR, the therapeutic relationship is enhanced by
deepened respect, e&uality, and ac5nowledgment of mutual
resourcefulness (@auer + Dills, "#F#). Chen a therapists is able to
say, for example, 7This bit of information is coming from my
sub<ectivity rather than my authority. an you and 9 learn its true
meaningB7 it nurtures patients4 self)esteem by presuming their
collaborative s5ills (@ollas, "#F.).
Discussion
Transference and countertransference are ubi&uitous, complex
reactions that also have enormous variety, strength and timbre.
6ccurate and properly used transferences appear to sometimes
ma5e a contribution to successful outcomes by positively a0ecting
correlates of that outcome, principally rapport building, the
therapeutic alliance, and continuance in therapy. To be highly
e?cacious, however, TRs must re2ect with precision the uni&ueness
of the therapeutic situation at hand, their formulation, focus, and
timing responding with sensitivity to the nature and degree of the
client4s problem and above all must not be overused. !rom the
literature it is not clear that each therapeutic setting is easily
classifed, and the accuracy or otherwise of the transference
interpretation, sub<ective. 9f this is determined solely by the
ac&uiescence of the client, then accurate interpretation must be
challenged and suggestion must be suspected.
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!rom a personal point of view as a novice therapist, transference is
intimidating, causing unpreparedness as they emerge unannounced
and without warning and may be of either convoluted, sophisticated
origin or deceptively simple. 9t seems to me that, in expert hands,
with an appropriate style, a honed wor5ing model and a suitable
client, the use of transference may be very powerful. /owever, as
with all powerful tools, they seem to me to be ill advised for the
beginner. 6lthough the literature is extensive, few general
principles are observable. Dany of the studies are criticised for their
lac5 of power in participant numbers and selection, as well as lac5 of
control groups and defnitions of outcomes. 9nevitably, then, for the
time being we must conclude the '<ury is still sitting ' in the
<udgement of the beneft or ha:ard of transference and
countertransference within psychotherapy.
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