Transference and Countertransference A Review

Transference and countertransference
Parth et al.
Transference and countertransference:

A review
Karoline Parth, MSc
Felicitas Datz, Mag.
Charles Seidman, BA
Henriette Löffler-Stastka, MD, PD
Originally a psychodynamic concept, the therapeutic relationship

(also therapeutic alliance, helping alliance or simply alliance) has
become a pan-theoretical model for the professional relationship
between a therapist and his or her client (Kivlighan, 1995). With
the development of this concept in the latter half of the 20th
century, psychotherapeutic theory and practice saw a paradigm
shift away from strict adherence to technique with little room for
responsive, individual behavior from the therapist and toward
the “authentic” human relationship at the core of therapy. This
meant that more consideration was given to the idea of mutual
influence from patient and therapist to the success of therapy
(Safran & Muran, 2006). This article aims to provide a com-
prehensive overview of the complex and shifting research on the
therapeutic relationship to promote a greater understanding of
the concept. (Bulletin of the Menninger Clinic, 81[2], 167–211)
Freud laid the groundwork for the idea of the therapeutic re-
lationship in the late 19th century when he first mentioned
transference (Levy & Scala, 2012). He defined it most clearly
in his 1912 paper, “The Dynamics of Transference,” where he
described how certain past “role models” could affect the rela-
tionship a patient had with his or her physician in a psychiatric/
psychotherapeutic setting (Freud, 1912/1958). Further contri-
Karoline Parth, Felicitas Datz, and Henriette Löffler-Stastka are in the Department for
Psychoanalysis and Psychotherapy, Medical University Vienna, Austria. Charles Seid-
man is at Emory University, Atlanta, Georgia.
Correspondence may be sent to Henriette Löffler-Stastka, MD, Associate Profes-
sor, Department for Psychoanalysis and Psychotherapy, Medical University Vienna,
Währinger Gürtel 18-20, A-1090 Vienna, Austria; e-mail: henriette.loeffler-stastka@
meduniwien.ac.at (Copyright © 2017 The Menninger Foundation)
Vol. 81, No. 2 (Spring 2017) 167

butions to the concept of transference and the therapeutic rela-

tionship were made, among others, by Sterba in his 1934 article,
“The Fate of the Ego in Analytic Therapy,” as well as Zetzel in
1956, when she painted a picture of the psychotherapeutic pro-
cess as a constant “oscillation” between periods dominated by
transference and periods dominated by cooperation.
The tripartite model

Greenson’s (1965) psychodynamic article, “The Working Alli-
ance and the Transference Neurosis,” was pivotal for the de-
velopment of the concept, as he coined the term working alli-
ance and pleaded for a clear distinction between transference
and the aforementioned alliance. According to his view, trans-
ference and working alliance are “full and equal partners” in
the forming of the patient–therapist relationship. Greenson’s
work between 1965 and 1967, when he first proposed that the
therapeutic relationship could consist of three separate compo-
nents—the working alliance, the transference, and the real re-
lationship—was crucial to further developments. The idea was
refined and more precisely defined by Gelso and Carter in 1985
and led to a significant body of research in the decades to come
(Horvath & Luborsky, 1993).
In fact, the tripartite model has served as such fruitful ground
for theoretical and empirical research on the nature and the
development of the therapeutic relationship that it seems nec-
essary to distinguish between the separate components when
considering all the literature that followed.
The working alliance. The working alliance aspect of the
therapeutic relationship has been investigated in great depth.
Bordin, who himself states that his work is an expansion on
Greenson’s theories, but that it also reflects the ideas of Otto
Rank (1945) and Carl Rogers (1951), was a key contributor to
the theoretical foundation of this research. Between 1975 and
1980, he published a series of papers which proposed that the
working alliance represented the therapist and the client seeking
change together. Thus, they both agree on tasks that will lead to
certain goals, and this positive collaboration forms a bond. This
168 Bulletin of the Menninger Clinic

Parth et al.
concept of tasks, goals, and bond, he states, treads a middle

ground between the silent, abstinent style of psychoanalysis and
the directive nature of cognitive and behavioral therapies (Bor-
din, 1994).
In 1980, Bordin added his thoughts on the dynamics of the
working relationship, theorizing that the therapeutic tasks that
patient and therapist must take on together, along with the
preexisting problematic behavior that compelled the patient to
undergo therapy in the first place, put a strain on the relation-
ship. He states that the dynamics that ensue from this strain, the
“tears and repairs” during the therapeutic process, are a key to
change (Bordin, 1994).
Luborsky’s research around this time also aimed to detail the
unfolding of the alliance. According to his theory, the helping
alliance changes during the process of psychotherapy: from an
initial emotional bond or attraction to the caring attitude of the
therapist during the first five sessions of therapy, to a second type
of alliance built on the feeling of client and therapist connected
in a shared effort to further the process. Although Luborsky
(1994) does not clearly distinguish between a working alliance
and a more general “helping relationship,” one could argue that
his ideas are congruent with Bordin’s concept of tasks, goals,
and bonds as well as with that of tears and repairs.
Picking up on the idea of tears and repairs, Safran and Muran
(1996) concentrated on the causes and solutions for ruptures
in the alliance as well as their predictive value for outcome.
While the definition of a rupture in the relationship is relatively
straightforward, its causes may be manifold and not as clear-
cut. More recently, Gelso (2014) theorized that the cause of
a rupture are the difficulties encountered by the patient when
the therapist aims to work out the patient’s problems, whereas
Safran, Muran, and Samstag (1994) described the cause as the
therapist “unwittingly participating” in maladaptive behavior
cycles; they also noted that instances of empathic failure on the
side of the therapist, resistance by the patient, or transference–
countertransference configurations (more precisely, transference
enactments) could all basically refer to the concept of rupture.
Vol. 81, No. 2 (Spring 2017) 169

Interestingly, there is mounting evidence that rupture-repairs

seem to hold potential for change and can be beneficent to treat-
ment. Safran and Muran (1996) began to show that ruptures
are a common occurrence in psychotherapy, and that effectively
recognizing and dealing with these ruptures can result in a bet-
ter outcome (Safran, Muran, Samstag, & Stevens, 2001). Ad-
ditionally, they identified two early markers of ruptures—disen-
gagement and confrontational behavior exhibited by the patient
(Safran & Muran, 1996).
Finally, credit must be given for another major contribution
to researching the working alliance by Horvath and Greenberg,
who developed and validated the Working Alliance Inventory
questionnaire (WAI) in 1989, incorporating Bordin’s ideas and
thus making the concept scientifically palpable. The WAI re-
mains the most widely used measure for the working alliance
(Hatcher & Gillapsy, 2007). As Gelso (gratefully) put it in 2009,
the working alliance is much easier to understand due to the
work of Horvath and Greenberg (1989), who devised a reliable
measure on the basis of the research done by Bordin (1979).
The real relationship. The same cannot be said for the real
relationship. In their 2013 review, Gelso, Bathia, and Palma la-
mented that because of “thorny theoretical, philosophical, and
political questions, the real relationship [has] received the least
empirical attention of the components of the therapeutic rela-
tionship.” On a superficial level lies the discussion about ter-
minology, but the problems go beyond pure semantics. Earlier,
Gelso (2009b) had already commented on the fact that the real
relationship is still regarded as highly complex and theoretical,
and that he believes a lack of empirical work is to blame for
this situation, despite adequate measures being available—first
and foremost, his own: the Real Relationship Index (RRI). This
measure was created and validated by Gelso and his colleagues
in 2005 to address and possibly solve the problem of a defi-
ciency of empirical research on the subject (Marmarosh et al.,
2009).
However, research remains sparse. Horvath (2009) has ex-
pressed appreciation for Gelso’s plea for more empirical research
in the direction of the real relationship, specifically in regards to

Parth et al.
developing a detailed relationship measurement instrument. He

has, however, also offered an explanation for the current lack of
empirical research. He bases his argument on Gelso’s definition
of the real relationship: that it is the relationship that “befits”
the respective protagonists and the current situation. Logically,
this makes it the counterpart to transference, which is defined
as an unreal relationship, or one that does not “fit” but is rather
a reenactment of a past relationship. Therefore, Horvath con-
cludes that along with the transference–countertransference
configuration, the real relationship is in fact deeply rooted in
psychodynamic theory, which could make it difficult to incorpo-
rate into the therapeutic relationship as a concept meant to span
all psychotherapeutic orientations.
Horvath could be right: According to Gelso, the real rela-
tionship makes appearances in psychoanalytic articles through-
out the 20th century, albeit not in the fleshed-out form it was
given by Greenson, Gelso, and Carter in the 1960s and 1970s.
Gelso (2009a) attributes one of the first references to this con-
cept to Sigmund Freud, who acknowledged in 1937 that not
every interaction between a client and a therapist must be based
on transference. Anna Freud had already expressed the idea
in 1954, stating: “With due respect for the necessary strictest
handling and interpretation of the transference, I still feel that
somewhere we should leave room for the realization that pa-
tient and analyst are two real people, of equal status, in a real
relationship to each other.”
The concept, however, also has a certain foundation outside
of psychoanalysis. Most prominently, the real relationship has a
great deal in common with Carl Rogers’s much-cited core con-
ditions. In his influential 1957 article, “The Necessary and Suf-
ficient Conditions of Therapeutic Personality Change,” he listed
six important conditions offered by a therapist and, of these six,
he said that four are essential to the relationship. In particular,
Rogers emphasized the importance of the patient experiencing
the therapist as a “congruent, genuine, integrated” person with
“warm acceptance” for the patient. Putting this article into his-
torical context, one passage can be regarded as being of excep-
tional relevance: “I am hypothesizing that significant positive
Vol. 81, No. 2 (Spring 2017) 171

personality change does not occur except in a relationship. This

is of course an hypothesis, and it may be disproved” (p. 96).
Some theorists have also hypothesized that the real relation-
ship could be linked to attachment theory (Gelso & Bathia,
2012). In a recent study with 75 clients, 48 of whom complet-
ed a required series of five therapy sessions, Marmarosh et al.
(2009) were able to show that attachment avoidance is nega-
tively correlated with perception of the real relationship. Addi-
tionally, clients who terminated prematurely also self-reported
significantly higher levels of attachment anxiety. These findings
are consistent with an earlier study by Fuertes et al. (2007), who
reported similar results.
As Gelso (2014) has emphasized, the real relationship is bur-
dened by an abundance of philosophical questions. For example,
to what degree can a relationship ever be real if every commu-
nication could be considered a coconstruct of the participants?
(Gelso, 2009a). How closely are transference and the real rela-
tionship intertwined? And what defines “real?” Horvath (2009)
calls this “a complex problem with a venerable history in the
annals of philosophy going back more than 2,000 years” and
prefers using the term personal relationship. Marmarosh et al.
(2009) dismiss the “reality” discussion quite effectively by say-
ing that any measure intended to assess the real relationship
would not try to measure “realness,” but rather the client’s and
the therapist’s accurate perceptions of each other, without the
distortion of transference. We believe these questions can only
be answered in part by empirical investigations, though they
certainly provide food for thought.
Despite these obstacles, there have been studies that, using
Gelso’s RRI, have shown a correlation between a strong real
relationship and therapy outcome, although results have so far
been contradictory as to whether the therapist’s or the client’s
perception is the better predictor of outcome (Fuertes et al.,
2007; Marmarosh et al., 2009). As noted before, more research
on the subject is needed.
Finally, Horvath (2009) has commented on the fact that the
RRI may not yet be a valid instrument for measuring the real re-
lationship, as he has showed that its scores correlate very closely

Parth et al.
with the Working Alliance Inventory (.79)—either that, or the

two constructs were never distinct in the first place. He points
out that the questionnaire may need refining, possibly by look-
ing to the Barrett-Lennard Relationship Inventory, and warns of
jumping to the “more exciting” task of empirical work without
an adequate instrument. Furthermore, he proposes a more lay-
ered concept of the real relationship, consisting of three distinct
“levels”—feelings, rational inferences/judgments (i.e., client’s
and therapist’s perceptions of each other), and the relationship
process or unfolding.
The transference–countertransference configuration. Trans-
ference is certainly the most enigmatic of the three components
in the tripartite model, and empirically not in much better shape
than the aforementioned real relationship. Nevertheless, some
consider transference to be Freud’s biggest discovery and con-
tribution to modern-day psychotherapeutic treatment (Gelso,
2014). Because transference and its counterpart are the focus
of this thesis, we would like to elaborate on this idea in greater
depth.
In brief, this part of the therapeutic alliance has not been with-
out its controversies. Some theorists say that its psychodynamic
roots represent a certain weakness in the tripartite model, mak-
ing it easy for opponents of this particular orientation to dismiss
transference as an artifact of psychoanalysis, while some doubt
its existence outside of psychodynamic therapy entirely (Gelso,
2014; Horvath, 2009; Marmarosh, 2012).
In the meantime, a small selection of studies have been able
to show that transference could be present across different types
of therapy (Gelso & Bathia, 2012). Andersen and Przybylinski
(2012) in particular have built a substantial body of research to
prove that past relationships with significant others influence
therapy as well as everyday life. In terms of impact on therapy
sessions and outcome, Gelso et al. (2013) have also shown that
negative transference as perceived by the therapist can be nega-
tively correlated with session smoothness and overall outcome.
These studies offer a glimpse into the concept of transference
and its effect on outcome beyond psychoanalytic therapy, but
in relation to the vast controversy surrounding the matter, the
Vol. 81, No. 2 (Spring 2017) 173

efforts seem almost modest. Horvath (2009) argued that even

when generalizing the term transference in order to compare it
with relational schemas, it cannot be claimed that such a con-
cept is present in all forms of psychotherapy. If the transference–
countertransference configuration should establish itself as a
universally recognized concept in psychotherapeutic research,
there will need to be more empirical work focused on nonana-
lytic therapists (Marmarosh, 2012).
Interaction of the elements of the relationship. This tripartite
model of real relationship, working alliance and the transfer-
ence–countertransference configuration still stands as a core
idea of the therapeutic relationship. It seems necessary at this
point also to cite Gelso (2014) when he states that these “ele-
ments are both interrelated and separate, and each influences
the others, as well as the process and outcome of treatment.”
Furthermore, he elaborates that during the therapeutic session
and in the communication between therapist and client, each
element can become most prominent on its own, but that they
are all present at any given time during the process.
Empirical alliance-outcome research

Since Greenson and Bordin’s defining groundwork in the second
half of the 20th century, many have looked at the therapeutic
alliance from a theoretical standpoint, aiming to answer ques-
tions ranging from concrete in nature to highly philosophical.
(For a more complete overview of these questions and ideas,
see Horvath, 2005.) Although some of these questions, as men-
tioned before in the context of the real relationship, will most
likely remain unanswerable, there is in fact a formidable body
of empirical research on the alliance worth considering.
The “Dodo Bird Verdict” and the search for common fac-
tors. The relationship between therapeutic alliance and therapy
outcome is a question that has been addressed in many studies
and a handful of meta-analyses. A core reason for the consider-
able amount of interest in the dynamics and prospects of a good
therapeutic relationship lies in the dispute over the Dodo Bird
Verdict, which was sparked when Rosenzweig first proposed the

Parth et al.
idea in 1936 and has been continuing since Luborsky, Singer,

and Luborsky gave it a name in 1975. According to this contro-
versial theory, all techniques of psychotherapy are equal in their
outcome due to underlying “common factors.” Since this pro-
posal, countless meta-analyses have been conducted to prove or
disprove the theory, but it appears that neither the opponents
nor the supporters of the theory have been able to produce con-
sistent effect sizes, and both sides have been known to accuse
the other of having an agenda (Freeman & Freeman, 2014).
Regardless of the effect sizes between outcomes of differ-
ent types of psychotherapy, the idea that common factors exist
among them and the search for what these may be remains “one
of the old controversies in psychotherapy research” (Barber,
Connolly, Crits-Cristoph, Gladis, & Siqueland, 2000). Over the
years, there has been considerable interest in trying to identify
the factors that make an effective therapist or therapy, and in
showing a possible correlation of single factors with outcome.
Possible factors that have been explored range from the most
basic of Rogers’s core conditions (“Two persons are in psycho-
logical contact”) to “the intertwined and sequential relationship
between alliance and client improvement” (Spinhoven, Giesen-
Bloo, van Dyck, Kooiman, & Arntz, 2007).
According to Horvath and Luborsky (1993), Rogers’s Thera-
pist Offered Conditions (TOCs), such as empathy and genuine-
ness, which are essential to Person Centered Psychotherapy but
present in varying degrees across all forms of therapy, have not
proved the most robust predictor for good outcome across all
therapy modalities. However, there does appear to be a “mod-
erate-to-strong” correlation with some of the TOCs and thera-
peutic alliance early in the therapy process. In particular, Gelso
(2009a, 2009b) highlights the importance of genuineness in the
forming of the real relationship.
Blatt, Sanislow, Zuroff, and Pilkonis (1996) used data from
a multicenter depression trial to divide participating therapists
into three groups (“more effective,” “moderately effective,”
and “less effective”) and then analyze the various orientations,
styles, and attitudes of these therapists. They were able to show
that a psychological rather than a biological orientation to
Vol. 81, No. 2 (Spring 2017) 175

treatment could correlate positively with outcome, while factors

such as a clinician’s work experience or an optimistic attitude
toward the patient tend to have less of an effect.
Much of the theoretical work on therapist variables goes
back to Beutler et al. (1994), who proposed a four-dimensional
model to categorize the differences between therapists: traits
(e.g., age, sex, ethnicity), states (e.g., training, experience, skill),
and, on a second axis, observable and inferred (Beutler et al.
include the therapeutic relationship in this category). To elabo-
rate on this concept in greater depth would be beyond the scope
of this article, but the empirical work done on the subject has
yielded interesting results. In a large sample study, Wampold
and Brown (2005) showed that 5% of outcome variance could
be attributed to therapist variables, and in their 2006 perspec-
tive article, Safran and Muran (2006) pointed out that therapist
variables could be responsible for up to 9% of variance. In ac-
cordance with Blatt et al.’s (1996) results, Wampold and Brown
also demonstrated that work experience had relatively little ef-
fect on outcome, and, in their study, neither did age, gender, or
education degree.
Quality of the therapeutic alliance and outcome. Shifting the
focus back to the concept of the therapeutic relationship, we
find a set of questions that various studies and, in turn, meta-
analyses have attempted to answer.
Can the quality of the relationship serve as a positive predictor for
outcome?
Can the relationship be a negative predictor for premature therapy

termination?
Does this correlation between therapeutic relationship and outco-

me show consistency across all techniques of psychotherapy?
Does the way in which the therapeutic alliance unfolds (tears and
repairs) correlate with outcome?
Over the course of the 1980s and 1990s, two major branches
of empirical research in the field of the alliance have yielded in-

Parth et al.
teresting results. First, and most thoroughly, results have come

from studies of the relationship between alliance (measured by
many different scales—prominently Horvath’s WAI) and out-
come (measured in symptom scales and parameters such as ter-
mination of therapy) (Horvath & Luborsky, 1993). In a review,
Luborsky (1994) remarked that in the 18 studies conducted
since 1976 and using several different measures, the alliance–
outcome correlation coefficient had varied between .20 and .45.
In addition, two major meta-analyses have shown an effect size
of .26 based on 24 studies, and a weighted alliance–outcome cor-
relation of .22 based on 60 studies (Horvath & Symonds, 1991;
Martin, Garske, & Davis, 2000). This suggests a “moderate” but
significant correlation (Martin, 2000), with an effect size that is
rather small but still comparable to that of other psychotherapy
variables (Horvath & Symonds, 1991).
More recently, Horvath, Del Re, Flückiger, and Symonds
(2011) found a .275 correlation over 190 independent samples.
In addition, early alliance ratings have also proven to be a ro-
bust factor for predicting therapy outcome even when control-
ling for other variables such as, for instance, relevant patient
characteristics as well as increase of well-being before the treat-
ment (D. N. Klein et al., 2007).
Premature termination of therapy, which can occur in up
to 50% of therapies, is also a good primary endpoint to look
at when considering outcome (Tryon & Kane, 1995). Bordin
(1994) had originally suggested that if client and therapist are
unable to agree on tasks and goals, this could lead to unilateral
termination. The first studies on this subject were conducted
in the mid to late 1990s. They showed a significant correlation
between termination and poor alliance as perceived by therapist
and client as well as significant differences in patients’ rating of
alliance when grouped by outcome (termination, poor outcome,
good outcome), with the dropout group “consistently rating the
lowest alliance scores” (Tyron & Kane, 1995; see also Samstag,
Batchelder, Muran, Safran, & Winston, 1998).
In a 2006 perspective article, Safran and Muran raised the
question of the continued “usefulness” of the model of the ther-
apeutic alliance. Although the effect sizes produced by Horvath
Vol. 81, No. 2 (Spring 2017) 177

and Symonds’ and Martin’s oft cited meta-analyses are signifi-

cant, Safran and Muran state that the alliance accounts for only
approximately 6% of outcome variance, which they deem not
to be a “whopping effect.” For them, the concept had a purpose
in moving the therapist community away from rigid adherence
to technique and shifting the focus to the relational aspects of
therapy. However, they do highlight the importance of these
“relational factors,” and that understanding how they work is
crucial to understanding the working mechanisms of psycho-
therapy.
Rupture-repairs and outcome. The second major field of in-
terest has been the management and development of the work-
ing alliance between client and therapist over time in the psy-
chotherapeutic setting, which represents a more qualitative
look at the concept. Based largely on Bordin’s ideas of “tears
and repairs” (or fluctuations) in the strength of the therapeutic
alliance, this branch of research also picks up on Luborsky’s
theories of the way the therapeutic relationship changes over
the course of therapy. He (1994) theorized that there were two
types of alliance (simply named “Type 1” and “Type 2” allianc-
es)—the first being an initial emotional attraction to the caring
attitude of the therapist during the first five sessions of therapy,
and the second being built on the feeling of client and therapist
that they are connected in a “joint struggle” against the troubles
that led the client to seek psychotherapy.
In 1995, Kivlighan investigated Mann’s 1973 theory of a
“U-shaped” working alliance, that is, the hypothesis that alli-
ance ratings dip during therapy and rise again toward the final
session (the “high-low-high” alliance theory). In Kivlighan’s
(1995) opinion, while “early theorists emphasized the tempo-
rally dynamic nature of the working alliance,” the empirical
work since conducted seemed largely based on static measures,
with little focus on the individual developmental curve of a
working relationship. Kivlighan also drew on Safran and col-
leagues’ (1994) earlier findings on the importance of working
through ruptures in therapy. However Kivlighan’s findings pro-
vided no support for the “high-low-high” alliance theory. In a
later article, Kivlighan and Shaughnessey (2000) proposed three

Parth et al.
different kinds of alliance patterns: (a) stable, with little change

across sessions; (b) linear progressive, with increasing alliance
ratings as therapy progressed, and (c) “quadratic growth,” or
U-shaped. In this study, clients with a quadratic growth pattern
showed significantly better outcomes than clients with the other
alliance patterns.
The idea of a U-shaped alliance pattern has also been ex-
plored by Stiles, Agnew-Davies, Hardy, Barkham, and Shapiro
(1998), who did not find support for Horvath’s theory that alli-
ance measures early in therapy were more predictive of outcome
than alliance ratings in later stages of the therapeutic process.
“Instead, the correlations appeared highly variable but often
tended to be relatively larger for alliance measures taken later in
treatment” (Stiles et al., 1998). In a study conducted using exist-
ing data from the Sheffield Psychotherapy Project, Stiles et al.
(2004) attempted to investigate the effects of alliance patterns
on outcome; however, they were unable to replicate Kivlighan’s
findings, as in fact none of their four clusters resembled the qua-
dratic growth pattern. Furthermore, they found no advantage
on outcome for any one cluster.
As mentioned earlier, Safran and Muran have been important
contributors to what they call “the second generation” of alli-
ance research. In 2011, they conducted two meta-analyses in an
attempt to answer two important questions regarding rupture-
repairs. First, they asked whether the presence of a rupture-re-
pair is associated with patient outcome, and second, they asked
whether rupture-repair training for therapists has an effect on
patient outcome (Safran, Muran, & Eubanks-Carter, 2011).
Four studies met inclusion criteria for the first meta-analysis;
however, one of them (which reported a correlation coefficient
of .29; Muran et al., 2009) had to be left out of the analysis
because of methodological differences. The aggregated correla-
tion result was .24, which represents a significant association
between rupture-repair and outcome, although the authors
note the relatively small number of relevant studies as a limi-
tation to their work. The second analysis included eight stud-
ies, and the mean weighted Pearson’s r was .65. Safran, Muran,
and Eubanks-Carter (2011) then recalculated this correlation
Vol. 81, No. 2 (Spring 2017) 179

coefficient excluding two studies that had produced “particu-

larly large effect sizes,” and the result was .52—still highly sig-
nificant. This finding is of particular clinical importance, as it
implies that the implementation of rupture-repair training for
therapists could have a positive effect on therapy outcome.
The alliance and personality pathology

Patients who fulfill criteria for borderline personality disorder
(BPD) display an inflexible, maladaptive personality structure
characterized by severe impairments in interpersonal function-
ing and emotional stability (Miller, Muehlenkamp, & Jacob-
son, 2008). Difficulties in establishing and maintaining a work-
ing alliance with these patients are often noted by clinicians,
and building a stable alliance has long been regarded the sine
qua non in working with BPD patients (Gabbard & Horowitz,
2009). However, despite considerable evidence linking thera-
peutic alliance to outcome in general, research on the specific
issue of the therapeutic relationship in regard to BPD is lim-
ited (Levy, Beeney, Wasserman, and Clarkin, 2010). Existing re-
search indeed suggests that higher Working Alliance Inventory-
Patient Rated (WAI-P) scores correlate with better outcome for
BPD patients, and that low alliance ratings early in therapy can
predict premature dropout (Spinhoven et al., 2007).
Some have suggested neurocognitive factors such as impair-
ments in executive functioning and vacillations in mental states
as sources of potential disruptions to the alliance (Levy et al.,
2010). Amygdala hyperreactivity leading to hypervigilance and
emotional dysregulation has also been explored (Donegan et
al., 2003). Because insecurities in interpersonal functioning are
seen as a core pathology in the disorder, attachment styles in
context with alliance and BPD have also been of interest, with
findings displaying a consistent “inverse relationship between
scores on borderline dimension and secure attachment” (Levy
et al., 2006; see also Levy, 2005). According to psychodynamic
theory, “intrapsychic factors—representations of figures from
one’s past and the feelings associated with those figures—shape
the patient’s perception and interpretation of experience, lead-

Parth et al.
ing to stereotyped or rigid responses” (Gabbard & Horowitz,

2009).
Increasing focus has been put on adapting transference-fo-
cused psychotherapy for patients with BPD (Kernberg, Yeo-
mans, Clarkin, & Levy, 2008). While multiple studies have
demonstrated the efficacy of the method (Clarkin, Levy, Len-
zenweger, & Kernberg, 2007; Doering et al., 2010), some re-
search suggests lower ratings of patient–therapist alliance in
transference-focused psychotherapy than in schema-focused
therapy (Spinhoven et al., 2007). Other forms of psychotherapy
with support in the literature include dialectical behavior ther-
apy, mentalization-based treatment, and systems that train for
emotional predictability and problem solving (Biskin & Paris,
2012).
Transference and countertransference in psychoanalytic theory
Transference: Groundwork and discourse

What is transference? As with many psychoanalytic concepts,
the basic idea of transference goes back to Sigmund Freud. Af-
ter first proposing the subject in the form of “displaceable en-
ergies” in the late 19th century, he revised and elaborated it
around the turn of the century in “Studies in Hysteria,” “The
Interpretation of Dreams,” and over the course of his work on
the Dora case (Makari, 1994). Eventually, he formally defined
it in his 1912 paper, “The Dynamics of Transference.” Looking
across Freud’s body of work, there is a noticeable shift in his
ideas of the nature of transference itself. In his earlier works,
he regarded it as the “strongest resistance” and “the greatest
threat” to successful therapy, as “a phenomenon which is in-
timately bound up with the nature of the illness itself” (Freud,
1916–1917/1944), but he later formulated it more as a kind of
terrain upon which the patient and the physician must engage
together to overcome the underlying illness: “This is the ground
on which the victory must be won” (Freud, 1912/1958, p. 108).
As Steinberg (1988) put it, “There is a consistency and evolu-
tion to Freud’s viewpoint of the transference.”
Vol. 81, No. 2 (Spring 2017) 181

Freud (1916–1917/1944) described coming across the trans-

ference as a strange situation in psychoanalytic therapy—as an
“unexpected novelty,” something that had not been taken into
account. According to his description of the process, the patient
primarily develops a special interest in the doctor as a person,
accompanied by a substantial, objective improvement in his
condition. However, “such fine weather cannot last forever,”
and what was initially a motor for clinical progress eventually
becomes a significant resistance. Freud was convinced that these
strong feelings cannot possibly be justified by the therapeutic
setting alone. On the contrary, and here he made a crucial state-
ment, “we suspect […] that the whole readiness for these feel-
ings [Gefühlsbereitschaft] is derived from elsewhere, that they
were already prepared in the patient and, upon the opportunity
offered by the analytic treatment, are transferred on to the per-
son of the doctor.”
Where does the transference come from? Freud did not go
into detail on his ideas of the etiology of transference. It was in
1936 that Grete Bibring-Lehner postulated the id as the driving
factor in the transference neurosis. She based her theory on the
idea that neurosis is considered to be built on two factors—first,
the “instinctual structure and influences of childhood,” artifi-
cially revived by the analytic situation, and second, the “ex-
pression of unsatisfied and repressed instinctual wishes.” In this
context, she emphasized that “any of the analyst’s qualities”
(e.g., gender) can be very much associated with the transfer-
ence neurosis of the patient (e.g., mother-transference). How-
ever, she specifically pointed out that the transference is “not a
reactive, but an active manifestation … regulated not by reality,
but by spontaneous pressure by the id.” (Interestingly, Bibring-
Lehner drew from these conclusions the practical implication
that, should it become clear that a transference reaction is in
some way founded in a real trait of the analyst or the analytic
milieu, it would be favorable to have the therapy continued by
a different therapist.)
The most in-depth exploration on etiology of the time goes
back to Melanie Klein in 1952, in her much-cited article, “The
Origins of Transference.” Beyond transference theory, this ar-

Parth et al.
ticle marks a split for those who argue that the superego is
formed by introjection of parental figures over the course of the
Oedipus complex. Klein postulated that the earliest introjection
of objects from infancy accounts for the later superego, and that
there is therefore no reason to distinguish between “pre-Oedi-
pal” and “post-Oedipal” in analysis.
Klein’s (1952) theory focuses on the earliest experiences of
object relations in infancy. Immediately after birth, the infant
is confronted with its first object: the mother’s breast. It experi-
ences this object through significant splitting mechanisms; the
good breast becomes ideal, the frustrating breast is condemned.
At the same time, the infant’s own destructive impulses result
in a fear of retaliation and annihilation. Thus, the infant’s first
stage of ego development is governed by a persecutory anxiety,
and Klein termed it “the paranoid-schizoid position.” Accord-
ing to her, the constant projection and introjection of internal
and external objects constitutes the first step of superego forma-
tion, and that therefore the mother’s breast is the core of the
superego. As the ego’s integrating functions increase over time,
the infant becomes aware of having destructive ideas directed
at a loved object. With this development, persecutory anxiety
gives way to a depressive anxiety, and Klein argues that this is
the beginning of the Oedipus complex.
According to Klein (1952), the infant perceives the “very few
people” in its life as a multitude of different objects through
the prism of splitting, and constantly fluctuates between the
real and the fantastical, as every experience the infant has is
“interwoven” with internal fantasy. This could account for the
“strength in the transference, and for the swift changes—some-
times even within one session—between father and mother, be-
tween omnipotently kind objects and dangerous persecutors,
between internal and external figures” (p. 437).
In 1934, Richard Sterba published his ego-psychologically
oriented article, “The Fate of the Ego in Analytic Therapy,”
in which he detailed his concept of the “dualistic principle” of
transference—that it is at once an experience of instinct (id) and
immediate repression thereof (superego). According to Sterba,
the transference therefore serves two separate functions: First,
Vol. 81, No. 2 (Spring 2017) 183

it aims to satisfy the “object hunger” of the id, and second, it

is an organization that fulfills the demands of the superego. In
addressing the ego, the interpretation of transference leads to
a “therapeutic separation” (Goldstein & Goldberg, 2008) or
“therapeutic ego-dissociation” (Sterba, 1934), which can ulti-
mately resolve the transference conflict.
Most notably, Arlow and Brenner (1979) took issue with this
ego-psychological distinction, arguing that it had no clinical rel-
evance. However, they considered themselves an “unconvinced
minority” in this respect. For them, transference represents a
simultaneous expression of many different opposing forces
within the integrative capacities of the mind. They believe that
their “structural theory” of mind, by which they mean that all
structures contribute to mental functioning at once, can be seen
most clearly, and most strikingly, in the transference (Goldstein
& Goldberg, 2008).
Strongly influenced by Sandler, Otto Kernberg’s 1987 article,
“An Ego Psychology-Object Relations Theory Approach to the
Transference,” attempts to bridge the gap between Klein’s em-
phasis on the first year of life and the dual-drive theory, both of
which he believes do not do justice to the complexity of the mat-
ter. In Kernberg’s opinion, affects are the primary motivational
system and, as they are fixated in a framework of internalized
object relations, become “gradually organized into libidinal
and aggressive drives as hierarchical, supraordinate motiva-
tional systems.” Id, ego, and superego are built on internalized
self- and object-representations. Thus, Kernberg concluded,
intrastructural conflicts are “never simply between drive and
defense,” but rather between conflicting/contradictory units of
self- and object-representation. Additionally, internalized object
relations themselves are not mere representations of the past,
but constitute a mixture of fantasy and reality, distorted by the
defenses against them and projection of drive derivatives.
Building on this concept, Kernberg (1987) proposed that
transference is expressed either in “instinctual impulses ex-
pressed as affects,” or “identification reflecting internalized
object relations.” Transference analysis is central to Kernberg’s
practical approach, as, according to him, it simultaneously in-

Parth et al.
cludes the analysis of object relations and of id, ego, and super-
ego, with the conflicts between them.
Are there different forms of transference? In 1956, Zetzel
provided an overview of the work done so far and the current
issues with transference, taking into account (then) recent de-
velopments such as object relations theory. She was the theo-
rist who coined the term therapeutic alliance. One of the main
points of difference that she [highlighted] was the question of
the role of the superego in the transference situation. On the one
hand, in Freud’s original formulations, which “remain integral
to theory and practice,” the transference neurosis was regarded
as a neurotic symptom and consisted of a projection of parental
figures that had been internalized as the superego. Klein’s new
ideas, on the other hand, postulated the superego as being a
result of the earliest mother–child relations and questioned the
term post-Oedipal. Furthermore, ego-psychological theorists
believed that transference was not a phenomenon involving
solely the superego, but rather one of the ego (Bibring-Lehner)
or a dualism of superego and id (Strachey) (Zetzel, 1956).
Zetzel (1956) also raised her own concerns regarding a ba-
sic distinction she deemed necessary when considering transfer-
ence. She hypothesized that transference could sometimes be a
manifestation of transference neurosis (i.e., resistance), but that
at other times it could be considered a part of the therapeutic
alliance, or a kind of object relationship. In making this distinc-
tion, Zetzel laid the foundation for the concept of Greenson’s
tripartite model, which incorporates transference and counter-
transference as part of the relationship between therapist and
patient. In her conclusion, she further emphasized that the “res-
olution of the individual transference situation depends of the
analyst’s understanding of his own counter-transference.”
Greenson (1956) emphasized that his experiences and views
on the therapeutic alliance were “enhanced and clarified” by
Zetzel’s work. According to his definition, for something to be
termed as transference, it must be both (1) a repetition of the
past and (2) inappropriate to the present. Brief spells of inap-
propriate feelings in the analytic situation, which he deemed
well-termed “floating transference” by Glover (1927), are to
Vol. 81, No. 2 (Spring 2017) 185

be distinguished from transference neurosis, when “the ana-

lyst and the analysis become the central concern in the patient’s
life.” This stands in contrast to his idea of the working alliance,
a “relatively unneurotic, rational rapport which the patient has
with the analyst,” although the two are not entirely separate
and contain elements of each other.
For Greenson, the importance of the differentiation between
transference neurosis and working alliance lies in Sterba’s con-
cept of therapeutic separation. The alliance between the patient’s
reasonable ego and the analyst’s ego, motivated by the patient’s
own will to get better, forms the basis for improvement, while
the experiencing ego reacts instinctually to the therapist in the
form of transference. Transference, to Greenson, is driven by
dissatisfaction and the patient’s state of helplessness in regard
to her ailments. Within the treatment situation, this “mobilizes
early longings for an omnipotent parent” (Greenson, 1965).
In 1969, derived mostly from his analytic experience with
children, Sandler and colleagues made further differentiations
within the “broad spectrum of phenomena” covered by the
term transference. First, he listed Anna Freud’s concept of exter-
nalization, wherein the patient can project a major personality
structure such as the superego onto the analyst, as an essential
aspect under the “major heading of transference.” He further
described ideas of projection, in which “an impulse of the pa-
tient towards the analyst is felt by the patient as being directed
by the analyst towards him,” and displacements, which occur
when current situations outside of therapy (such as an argument
with a parent, or rejection by a friend) become displaced into
analysis and onto the person of the analyst (Sandler, Holder,
Kawenoka, Kennedy, & Neurath, 1969).
Another important point worth elaborating on is Sandler’s
take on the role of transference in the therapeutic alliance. While
at the time the alliance was usually “contrasted with transfer-
ence,” he expressed his support of Greenacre’s (1954) idea that
every working collaboration between a therapist and a client
must involve some form of “basic transference,” a primal need
and motivation to seek out human contact. Thus, transference
could be a necessary and positive part of the therapeutic alliance

Parth et al.
(Sandler et al., 1969). These statements clearly reflect Greenson’s

tripartite model and the discourse of the time. Greenacre (1954)
herself cautioned against merely “utilizing the basic transfer-
ence,” stating that the full transference relationship is the “most
delicate, subtle, and precious medium of work,” which deserves
to be safeguarded, encouraged, and thoroughly analyzed.
How can we work with the transference? What is it good for?
C. G. Jung made some relevant contributions to the concept
of transference after his split with Freud in 1912, although his
work is sometimes regarded as self-contradictory, particularly
in terms of the value of transference. One idea that remained
consistent throughout is that transference contains a certain cre-
ative element, or, in his words, “purposive value of the transfer-
ence neurosis” in that it serves multiple separate functions. First,
he proposed that it stands for an attempt at self-cure through
compensation and empathy, with the patient feeling into the
therapist, and finally that it constitutes a subconscious effort to
establish a relationship, albeit an adapted one. Jung’s later work
focused more on his ideas of “archetypal transference,” which
have not been taken up in the literature to follow (Steinberg,
1988).
In a 1939 textbook that was published in parts in the Psycho-
analytic Quarterly, Fenichel picked up where Sterba left off in
regard to ego separation and emphasized the importance of the
rule of abstinence. In particular, he advocated that the analyst
should not give in to offering the experiencing ego “transference
satisfaction.” He also theorized that the analyst’s abstinence
could provide an explanation for the heightened experience of
transference in the analytic setting: While he acknowledged that
“everyone’s life is full of transferences,” he stated that the main
characteristic of transference as a neurotic symptom is the de-
monstrableness of the phenomenon. This means that, for each
patient, the transference response is constant and uniform. In
day-to-day interactions, this uniformity is distorted by the vari-
ous different kinds of input given from other people. However,
in analysis, the therapist acts as a mirror and does as little as
possible to influence the patient’s feelings, thus exposing the
transference.
Vol. 81, No. 2 (Spring 2017) 187

Strachey’s work is based in a framework provided by Melanie

Klein’s ideas. As Freud’s principle translator, Strachey remained
loyal to Freud, although he is generally associated with the Mid-
dle Group and strongly influenced by Klein (Kosciejew, 2012).
He suggested that, in analysis, the therapist finds herself in the
position of the patient’s superego. In interpreting the patient’s
transference in a nonjudgmental way, she gives the patient the
opportunity to recognize the discrepancies between childhood
experiences, fantasies, and the present-day situation. Thus, the
patient can introject “a new piece of superego,” making the su-
perego less rigid and restrictive over time. The patient learns
to treat himself as the therapist has treated him (Goldstein &
Goldberg, 2008).
For Heimann (1956), the transference interpretation in and of
itself serves a pivotal function in the main objective of psycho-
analysis (the “task of extending the patient’s conscious knowl-
edge of himself”). The transference, both positive and negative,
is an expression of primitive personality content and fantasy
that has never before been verbalized by or for the patient. In
addressing the ego, words can give it the opportunity for con-
scious thought and structure, even if they may never do justice
to the content. In regard to the analyst’s function, Heimann ob-
jected to Strachey’s ideas of the patient introjecting a modified
superego. In fact, she even claimed that the (oftentimes painful)
struggle of working through is the only way to modify the ego,
and that an “introjection of the analyst as a benevolent and per-
missive figure short-circuits this development.” The analyst, as
much as his own personality is part of the process, must remain
abstinent and act as a supplementary ego for the patient.
Betty Joseph (1985) emphasized the (in reference to Klein)
“total situation” of the transference: how transference is a liv-
ing, breathing relationship, transferred by the patient with all
his objects, emotions, and defenses from the past to the pres-
ent. The countertransference, as the analyst becomes drawn
into these systems, is a part of this situation. An important con-
cept in her work is the constant movements and shifts within
this transferred relationship. An interpretation, therefore, “can
never be seen as a pure interpretation or explanation but must

Parth et al.
resonate in the patient in a way which is specific to him and his

level of functioning.”
Current points of discussion

Discourse surrounding the nature, etiology, and function of
transference has, in recent decades, become as pluralistic as
modern psychoanalysis itself (Westen & Gabbard, 2002). As
Sandler et al. (1969) had already commented: “What appeared
to be relatively simple in the beginning now turns out to be very
complicated indeed.”
One of the most crucial divides remains between American
or ego psychological and Kleinian or British object relationist
schools of psychoanalysis (Hinshelwood, 1999). Drawing from
Sandler’s ideas about “actualization of transference” and role-
responsiveness in the 1970s, American theorists began focus-
ing more on interactional aspects between analyst and patient,
who both move within the transference expectations shaped by
their childhood development. This concept, termed enactment,
stood for a kind of “purposeful interplay” (McLaughlin, 1991)
that represents “both a reflection of the patient’s dynamics and
an opportunity to rework them” (Westen & Gabbard, 2002).
Clearly this marks a contrast to one of the main principles of
psychoanalysis: the rule of abstinence. Renik (1993) argued that
a therapist’s self-awareness of an emotional response to a pa-
tient is necessarily a consequence of a behavioral manifestation
thereof, and that these self-observations could be beneficial.
Thus, “dispassionate analytic technique” may be the ideal, but
(re)action on the grounds of personal motivation must not nec-
essarily be detrimental to therapy.
Kleinians, on the other hand, have been more interested in the
notion of projective identification, a concept that goes beyond
Freud’s original idea of projection as a defense mechanism: that
a patient may project something onto the analyst, something
that the analyst in turn introjects and that can compel her to be-
have a certain way. At the same time, the patient identifies with
the part of himself projected into the clinician (Ogden, 1979).
Feldman (1997) more recently suggested that the “projection
of elements of a phantasised object relationship represents an
Vol. 81, No. 2 (Spring 2017) 189

attempt by the patient to reduce the discrepancy between an ar-

chaic object relationship and an alternative object relationship
that might be confronting the patient and threatening him.”
Beginning in the 1980s, multiple authors began making ef-
forts to integrate the concept of transference into newer neu-
rocognitive models. Wachtel (1980) spoke of Piaget’s assimila-
tion and accommodation principles and suggested that, in what
analysts call a “transference situation,” there is a stronger ten-
dency to assimilate current interactions with schemas from past
experience, rather than accommodating the present situation.
However, even if the scales between assimilation and accom-
modation can be tipped, there could never be full distortion of
the analyst. Singer (1985), commenting on the need for both
a generalizable concept and more empirical evidence on trans-
ference, worked out the applicable similarities between “sche-
mata, prototypes, nuclear scenes and scripts” and transference.
By bridging the gap between experimental cognitive psychology
and psychoanalysis, he attempted first to form a scientific basis
for the transference phenomenon, and second to define it as a
“general feature of human experience.”
Fried, Crits-Cristoph, and Luborsky (1992) published the
first empirical study on transference phenomena. Using in-ses-
sion narratives with a therapist and Core Conflict Relationship
Theme scores to compare patients’ relationships (N = 35) with
their therapist to their relationships outside of therapy, they
found that “patients have a relatively unique and pervasive re-
lationship pattern, with a demonstrable parallel between the
experience with the therapist and the experience with others”
(p. 328). However, the study’s control cases rated only slightly
(if still significantly) lower on the 1–7 similarity scale (3.0 ±
1.0 vs. 3.5 ± 1.0). Levin (1997) pointed out the importance of
transference phenomena deserving interdisciplinary attention
and emphasized the ubiquitous learning aspects of transference.
Westen and Gabbard (2002) more recently argued that, from a
cognitive perspective, patients never simply have a transference
but rather many transferences in a given situation, reflecting the
various cognitive processes and stored material in the brain.

Parth et al.
Countertransference
Groundwork
Definitions. A clear definition of the term countertransference
does not exist to this day. Classically, it was regarded as the ana-
lyst’s own transference reaction to the patient, “the counterpart
of the transference in the analytic situation, its complement in
the analyst” (Racker, 1982, p. 1). Hence it was, like transfer-
ence, initially considered to be merely a disturbance, jeopardiz-
ing therapeutic progress (Racker, 1982). The original definition
has since been widened to include all feelings experienced by the
analyst toward a patient because, as Heimann (1950) argued,
“the prefix ‘counter’ implies additional factors.” This broaden-
ing of terms has not been without controversy. Most notably,
Melanie Klein is said to have thought that a wider concept could
easily be misused and “would open the door to claims by ana-
lysts that their own deficiencies were caused by their patients”
(quoted in Spillius, 1992), although newly released archival ma-
terial has hinted that she might not have been violently opposed
to the idea (Hinshelwood, 2008).
As mentioned earlier, most modern theorists now acknowl-
edge countertransference both as a potential obstruction of ana-
lytic work and as an invaluable source of information about the
patient, which the analyst can access by meticulous self-study.
In fact, some go so far as to discuss an “interactive model” of
analysis, “where the emphasis is on the significance of the ana-
lyst’s own subjective experiences in his understanding of and his
method of responding to his patient” (Feldman, 1997).
This was not always the case. As with his ideas about trans-
ference, Freud’s views on the topic were originally somewhat
one-dimensional, and he mentioned countertransference only
insofar as to briefly point out that it constituted a reason for an
analyst to undergo analysis himself, lest it get in the way of the
principle of abstinence. Freud likened the analyst to a mirror or
a telephone receiver, and he stood by his idea that every emo-
tional response to a patient represents a resistance on the side
of the analyst (Hinshelwood, 1999), and that countertransfer-
Vol. 81, No. 2 (Spring 2017) 191

ence was a “limiting factor to an analyst’s effectiveness” (Hin-

shelwood, 2008). In fact, Freud’s thoughts on countertransfer-
ence can be seen as the principle reason for the introduction of
didactic analysis, something that remains a pillar in psychoana-
lytic training to this day (Racker, 1953). But while Freud him-
self revoked his first ideas on the phenomenon of transference,
the paradigm shift on the topic of countertransference was not
to happen in his lifetime (Racker, 1982).
Paradigm shift. Forty years after Freud’s first mention of
countertransference, the topic had still received little scientific
interest (Racker, 1953). In the 1950s, however, in the wake of
the introduction of projective identification and mounting cri-
tique of the “blank-screen view of the analyst’s role,” Klein’s
followers began to develop a more nuanced concept of counter-
transference (Hinshelwood, 1999). The movement was sparked
mainly by Heimann’s pivotal lecture at the Psychoanalytic Con-
gress in 1949, which also marked the beginning of Heimann
distancing herself from Klein and moving toward the Indepen-
dents. In this speech, she addressed some difficulties that young
analysts had been facing: the notion that, if they had any kind of
emotional reaction to a patient, they themselves were to blame,
and the feelings of guilt and fear that they experienced in work-
ing with this idea. Heimann (1950) argued that self-analysis was
never intended to turn analysts into “a mechanical brain which
can produce interpretations on the basis of a purely intellectual
procedure,” but to fine-tune the clinician to emotions, and to
learn to acknowledge their own feelings without “discharging”
them onto the patient.
In fact, Heimann went even further than to lift the blame
off the candidates in postulating that, instead of condemning
these emotional reactions, which she considered to be coun-
tertransference, one could view them as one of the “most im-
portant tools” in analytic work. Heimann (1950) stressed the
relationship factor in analysis—a relationship that, she said, is
not distinguished by “the presence of feelings in one partner, the
patient, and their absence in the other, the analyst,” but rather
by the way feelings are acknowledged and worked with. The
analyst’s feelings, far from being merely a source for trouble,

Parth et al.
are more akin to an “instrument of research into the patient’s

unconscious.”
Heimann (1950) did not leave the concerns of classical ana-
lysts uncommented. She noted that only if an analyst had com-
pletely worked through her own infantile fears could she be sure
that her emotional reaction was truly countertransference and
not merely her own transference. Furthermore, she cautioned
that overly strong emotions had no place in analysis because
they would only cloud the analyst’s judgment and harm the pro-
cess. Thus, she concluded that an “analyst’s emotional sensitiv-
ity needs to be extensive rather than intensive, differentiating
and mobile.”
These ideas are also reflected in Reich’s (1951) paper, “On
Counter-transference,” published the following year, in which
she emphasized the “double-edged” character of countertrans-
ference. While she embraced the analyst’s unconscious as an
important tool for understanding the patient through counter-
transference, she also cautioned that it “may degenerate into
acting out.” Reich was especially interested in the conditions
under which unconscious countertransference reactions “con-
stitute a foundation for adequate or even outstanding function-
ing, and when they serve to interfere with or at least to compli-
cate the activity of analysing.”
Words of warning were also voiced by Little (1951) in a pa-
per read at a meeting of the British Psycho-Analytical Society in
1950. She argued that one of the reasons the current definitions
of countertransference are so “clumsy and unmanageable” is
that countertransference as such can never be observed because
it resides within the unconscious of the analyst. Rather, we can
see only the effects it has on the analysis and the patient, by
which time the analyst has already succumbed to repeating the
patient’s past relationships and allying with the patient’s super-
ego: “These things are so insidious that our perception of them
comes slowly.”
Heimann’s work in 1950 coincided with Heinrich Racker’s
change of views from his initial lecture on countertransference
in 1948, when he supported a more classical view of the issue,
to his (1957) “Observations on the Countertransference as a
Vol. 81, No. 2 (Spring 2017) 193

Technical Tool.” In this second article, he agreed with Heimann

and offered three principle points for discussion: first, that coun-
tertransference reactions should serve as tools; second, that the
analyst’s countertransference stems from his identification with
the patient’s internal objects; and, third, that the specific char-
acteristics of countertransference reactions may be used to draw
conclusions about the inner psychology of the patient.
Racker’s third article (1957) on the concept discusses coun-
tertransference from a completely new angle, and is unique in
its scope. He begins by asking a question he deems “clearly im-
portant”: How could a concept that formed the basis for di-
dactic analysis and thereby shaped numerous generations of
candidates have received so little platform for discussion in the
analytic community for so long? Racker saw this problem at the
very root of the analytic community, a problem passed down
from each generation in training to the next. For him, the rea-
son lay in the ideal of the “truly objective” analyst. He con-
sidered overcoming “our own infantile ideals” and “accepting
more fully the fact that we are all still children and neurotics
even when we are adults and analysts” (p. 307) to be an impor-
tant prerequisite for the work of an analyst, one that was to be
reached through self-analysis. “The first distortion of truth in
‘the myth of the analytic situation’ is that analysis is an interac-
tion between a sick person and a healthy one” (Racker, 1957,
p. 308).
As Racker (1957) argued, the countertransference reaction
consists of both the analyst’s own inner objects and the transfer-
ence of the patient. However, the analyst can only interpret the
influence the transference is having on her if she is well aware
of her own neuroses and transference, her own internal objects.
“To summarize, the repression of countertransference […] leads
to deficiencies in the analysis of transference” (p. 308). If, in di-
dactic analysis, a candidate’s transference is not fully analyzed,
this in turn will lead to “repression and other mishandling of
countertransference as soon as the candidate becomes an ana-
lyst” (p. 308).
This has a slightly more banal and practical implication in
the therapeutic situation itself, as Racker (1957) supposed that

Parth et al.
every transference from a patient evokes a countertransference

reaction in the analyst. This reaction can be suppressed but not
avoided and will, if the analyst is unaware, affect his behavior
toward the patient. Therefore, awareness is key—otherwise, the
patient will see her past experiences repeated once again in the
analyst’s reaction (a reaction that her unconscious transference
willed into existence), and the cycle of her neuroses must con-
tinue.
The mother-infant relationship and the analytic situation

Winnicott’s 1949 article, “Hate in the Counter-Transference,”
was and remains an equally distinctive contribution to the dis-
cussion. He asked a crucial question: Can hatred for a patient
ever be justified? Could it be possible for an analyst to hate his
patient objectively, that unlikability could even be a symptom or
characteristic of certain psychiatric diagnoses? Along with other
theorists at the time, he also noted that “objective hate” can
only be achieved once the analyst has “through his own analysis
[…] become free from the vast reservoirs of unconscious hate
belonging to the past and to inner conflicts.” In fact, keeping
any kind of hatred latent in analysis is only possible by being
“thoroughly aware of it.”
More importantly, however, Winnicott (1949) argued that,
during the process of analysis, at one point or another, analyst
and patient will find themselves in a relationship comparable to
that between a mother and a newborn, such as it is detailed in
Klein’s (1952) “Origins of Transference.” Regressed and vulner-
able, the patient “cannot identify with the analyst or appreci-
ate his point of view any more than the fetus or newly born
can sympathize with the mother” (Winnicott, 1949). Just as a
mother must tolerate and manage her hatred for the baby, so
the analyst must be aware of and deal with his hatred for the
patient. Winnicott summarizes the practical implications of ac-
cepting objective hate concisely: “If the patient seeks objective
or justified hate he must be able to reach it, else he cannot feel
he can reach objective love.” The matter of if, when, and how
to actually disclose this hatred to the patient remains a danger-
ous one.
Vol. 81, No. 2 (Spring 2017) 195

In the context of his work with schizophrenic patients in the

mid to late 1950s, Bion developed similar ideas regarding the
mother–infant relationship in the analytic situation. In 1954, he
first discussed how the countertransference had influenced him
in his interaction with a psychotic patient. Later he focused on
a concept he termed “linking”—the most basic link being that
of the infant to the breast. Linking was to be understood as any
kind of reaching out for contact or mutual understanding. In
the earliest stages of life, the newborn’s only way of dealing with
anxieties too large for it to cope with (fear of annihilation and
abandonment, primary aggression) is to split them off and, by
means of projective identification, place them into the mother.
The mother must be able to introject and tolerate these fears
while remaining balanced. Bion (1959) calls this process on the
side of the mother “containment”—one of the analyst’s main
responsibilities in a therapeutic setting.
For in therapy, we encounter the deeply regressed patient, a
patient, perhaps, whose mother was not able to contain the pa-
tient’s fears in infancy. The consequences are twofold. First, the
analyst is placed in the position of the mother. As Bion (1959)
put it, “the patient feels he is being allowed an opportunity of
which he had hitherto been cheated” (p. 313). Second, in his
distressed state, the patient resorts to the earliest (and perhaps
only) form of linking he knows: projective identification. If the
analyst denies the patient the “use of the only method of com-
munication by which he feels he can make himself understood”
(p. 313), the patient is filled with resentment. The coexistence of
“gratitude for the opportunity […] and hostility to the analyst”
(p. 313) make up the complexity of the analytic situation.
Projective identification and the countertransference reaction

The term projective identification is based on Klein’s (1946) un-
precedented “Notes on Some Schizoid Mechanisms,” although
the concept itself takes on a more marginal and ambiguous role
in her writings (Gabbard, 1995). The article predates the “Ori-
gins of Transference” by 6 years, yet it already details Klein’s
ideas on the schizoid workings of the infant mind. The primary
defense mechanisms employed by the early ego are, according

Parth et al.
to Klein, splitting both of external objects and of the ego itself,

introjection of good objects, and projection, thereby deflecting
the death instinct outward. These processes go hand in hand
with idealization and denial. Projection of bad aspects of the
self is necessarily associated with identification with these as-
pects within the object, which leads to directing self-aggressive
impulses outward. Klein (1946) theorized that both projection
and introjection are necessary for the foundation of an ego ca-
pable of integration, but that an excess can jeopardize ego de-
velopment. Thus, the phenomenon of projective identification
is, as Ogden (1979) later described it, “simultaneously a type of
defense, a mode of communication, a primitive form of object
relationship, and a pathway for psychological change.”
Money-Kyrle (1956) described the analytic situation as a
“rapid oscillation” of projection and introjection between pa-
tient and analyst. He suggested periods of “normal counter-
transference,” a basic sense of intuitive empathy without getting
too involved with the patient’s emotional distress, alternating
with times in therapy when the analyst reaches the boundar-
ies of her understanding. According to him, the analyst’s un-
derstanding will most likely fail when an aspect of the patient
resonates too closely with a part of herself that she has not yet
fully understood. The intense feelings of countertransference
that follow, he concluded, are at least in part the patient’s doing.
He also emphasized Winnicott’s ideas on the parental aspects
of being an analyst, in that the analyst must be able to identify
with the patient as a parent does with the child and, recogniz-
ing parts of himself that had already been analyzed within the
patient, analyze the patient in turn.
By the 1960s, discussion of the countertransference phenom-
enon had fallen into two main categories. These were, as sum-
marized by Kernberg (1965), the “classical” approach, which
defined countertransference as the analyst’s unconscious reac-
tion to the patient’s transference (represented by the likes of
Reich, Little, and Glover) and a “totalistic” position, accord-
ing to which countertransference includes any and all emotional
reactions from the analyst to his patient (supporters included
Heimann, Racker, Winnicott, and Weigert). The important
Vol. 81, No. 2 (Spring 2017) 197

practical implication of this distinction is that the totalistic view

regards the therapist’s responseas a reflection, at least in part, of
the patient’s level of interpersonal functioning, thus acknowl-
edging its diagnostic value (Colli & Ferri, 2015).
Kernberg’s article (1965), “Notes on Countertransference,”
combined ideas of countertransference and projective mecha-
nisms. He hypothesized that countertransference, acting as a
receiving set for intense transference and archaic defenses such
as projective identification, could be “helpful in evaluating the
degree of regression” a patient was in. At the same time, he em-
phasized the dangers of “empathetic regression” on the part of
the analyst: The analyst may fall victim to blurred ego boundar-
ies by way of projective identification just as the patient does.
Fliess termed this counter-identification (quoted in Kernberg,
1965).
Ogden (1979) and other American analysts were significantly
influenced by the connection of Bion’s mother–infant contain-
ment model to projective identification. The distinction in Og-
den’s work lies in his emphasis on projective identification as an
intersubjective process, one in which the therapist’s introjective
fantasies play a crucial role. Projective identification goes be-
yond mere projection in that the patient identifies with parts
of herself that she has projected into the analyst. The projector
then exerts real pressure on the clinician “by means of a multi-
tude of interactions,” which compels the recipient to behave in
accordance with the patient’s projective fantasies. Ogden com-
pares this to “the pressure on an infant to behave in a manner
congruent with the mother’s pathology, and the ever-present
threat that if the infant were to fail to comply, he would become
non-existent for the mother.” These mechanisms between thera-
pist and client, of feeling separate and simultaneously “at one”
with one another, lead to a unique transference–countertrans-
ference reaction (Gabbard, 1999).
Most modern Kleinians acknowledge projective identifica-
tion as a mechanism that leads to unsolicited countertransfer-
ence feelings in the clinician (Gabbard, 1999). Joseph (1989)
noted how patients tend to “nudge” their analysts into behav-
ing in accordance with what they are projecting. Spillius (1992)

Parth et al.
likewise stated that an analyst is invariably influenced by pro-

jection, while Burke and Tansey (1985) spoke of the pressure of
the interaction, after which a therapist introjects “a communi-
cation which exerts a modifying influence on his experience of
himself in the interaction,” the reaction to which can act as a
“signal affect.”
Current research
In the latter half of the 20th century, a consensus transcending
the various schools of psychoanalysis began to form: that coun-
tertransference was a phenomenon created by both the therapist
and the client, and that while “personal countertransference”
seemed to stem largely from the analyst’s own past objects and
remains a danger to effective judgment and work, “diagnos-
tic countertransference” could still offer valuable information
about the transference of the patient (Gabbard, 1999). In fact,
toward the end of the 20th century, the notion regarding the
usefulness of countertransference became “widely accepted”—
a development that coincided with “a gradual recognition that
contemporary Kleinians and classical ego psychologists have a
good deal in common” (Gabbard, 1995). The main exception
is the followers of Lacan’s teachings, who, in a classic Freudian
sense, still regard countertransference as the main resistance on
the side of the analyst (Hinshelwood, 1999).
In attempts to reach beyond psychoanalysis, authors have
begun commenting on the transtheoretical nature of counter-
transference embedded within the relatively new concept of the
therapeutic alliance, and are investigating its prevalence across
the various schools of psychotherapy (Hayes et al., 1998). In
the first comprehensive review of countertransference research,
Singer and Luborsky (1977) concluded that “uncontrolled
countertransference has an adverse effect on therapy outcome.”
At the time, there was a relative dearth of quantitative research;
however, work over the subsequent decades has begun to sup-
port this claim. Two major questions have since been investigat-
ed more thoroughly: first, whether the patient’s symptom sever-
ity or level of psychological functioning correlates with stronger
therapist response, and second, whether certain diagnoses or
Vol. 81, No. 2 (Spring 2017) 199

groups of diagnoses elicit specific countertransference reactions

(Colli & Ferri, 2015).
Hayes, Gelso, and Hummel (2011) presented three meta-
analyses about countertransference. Across 10 studies, they
found a modest negative correlation between countertransfer-
ence and outcome (r = −.16) and, over seven studies, they found
a strong positive correlation between successful countertrans-
ference management and outcome (r = .56). They concluded
that, although empirical research on countertransference is cur-
rently very limited, awareness and active management thereof
appears to be significantly correlated to positive therapy results.
Empirical evidence on the relevance of countertransference for
outcome can also be taken indirectly from research on counter-
transference as an aspect of the therapeutic alliance.
Countertransference and personality disorders

Based on Kernberg’s (1967) idea that psychotic and borderline
patients seem to employ more infantile defenses in the form of
projective identification and thus evoke a stronger diagnostic
countertransference reaction in the therapist, some empirical
research has been done in the way of connecting personality
pathology and therapist response. Brody and Farber (1996) had
336 therapists complete questionnaires on clinical vignettes de-
scribing schizophrenic, depressed, and borderline patients. They
found that “patient diagnosis was significantly related to thera-
pist ratings” (p. 376), in that depressed patients tended to elicit
positive feelings, while schizophrenic patients evoked a “com-
plex mix of CT reactions” (p. 378) and BPD was correlated
with high degrees of irritation and anger.
McIntyre and Schwartz (1998) investigated the differences
in countertransference reactions between patients diagnosed
with borderline personality disorder and depressed patients.
From their findings they concluded that “countertransference
reactions can be measured empirically, that differential coun-
tertransference reactions are evoked toward clients manifesting
different symptoms, and that awareness of countertransference
may be important for positive therapeutic outcome.” Rossberg,
Karterud, Pedersen, and Fritz (2010) investigated subjective

Parth et al.
symptom severity in connection with therapists’ countertrans-

ference feelings as assessed by the Word Feeling Checklist 58
and found a positive correlation “between higher patient scores
on the symptom dimensions and the therapists’ feelings of being
bored, on guard, overwhelmed and inadequate” (p. 191). Ad-
ditionally, they found that positive symptom development cor-
related with more positive countertransference over time.
Betan, Heim, Zittel Conklin, and Westen (2005) examined
Westen’s Therapist Response Questionnaire (TRQ) using factor
analysis and found eight countertransference dimensions that
were “robust across extraction methods and rotations: 1) over-
whelmed/disorganized, 2) helpless/inadequate, 3) positive, 4)
special/overinvolved, 5) sexualized, 6) disengaged, 7) parental/
protective, and 8) criticized/mistreated” (p. 895). According to
the authors, the questionnaire could provide a tool for examin-
ing a more differentiated picture of the countertransference re-
action, rather than the simple distinction between positive and
negative therapist response.
Furthermore, by having a sample of 181 therapists complete
the TRQ and a battery of other tests about a patient in their
care, Betan et al. (2005) were able to analyze these reactions in
relation to personality disorder clusters. They found that, al-
though every therapeutic encounter is different, countertrans-
ference emerges in distinct patterns depending on diagnosis.
“To put it another way, patients not only elicit idiosyncratic
responses from particular clinicians (based on the clinician’s
history and the interaction of the patient’s and the clinician’s
dynamics) but also elicit what we might call average expectable
countertransference responses, which likely resemble responses
by other significant people in the patient’s life” (p. 895). Their
results pointed to associations between Cluster A personality
disorders and criticized/mistreated therapist responses; Cluster
B personality disorders with overwhelmed/disorganized, help-
less/inadequate, and sexualized responses; and finally Cluster C
with parental/protective reactions. Numerous studies have since
replicated Betan at al.’s findings in regard to Cluster B personal-
ity disorders, although results regarding Clusters A and C vary
(Colli & Ferri, 2015).
Vol. 81, No. 2 (Spring 2017) 201

Colli, Tanzilli, Dimaggio, and Lingiardi (2014) let a sample

of clinicians (N = 200) complete the TRQ for a randomly select-
ed patient in their care along with the SWAP-200 to assess for
personality disorders and level of functioning. They too found
connections between certain personality disorders and therapist
reactions. In support of Betan et al.’s findings, they saw a signifi-
cant correlation between narcissistic personality disorder and
disengaged countertransference and, in the BPD patient group,
they too found correlations with the helpless/inadequate and
overwhelmed/disorganized reaction types. However, where Be-
tan et al.’s study found no connection between overinvolved/
special therapist response and borderline personality disorder,
Colli et al. found a correlation with a Pearson’s r of .22. In gen-
eral, physicians tended to have stronger negative countertrans-
ference reactions to patients with lower levels of functioning.
In a recent review, Colli and Ferri (2015) summarized the
current issues with empirical countertransference research in
regard to investigation perspective and study design. In particu-
lar, they emphasized the need for more work that makes use of
both clinician-based and observer-based ratings, because these
methods differ in terms of internal and ecological validity. Fi-
nally, they pointed out that it is still poorly understood how
countertransference processes within the clinician influence the
therapeutic relationship, actual behavior in session, and thus,
outcome.
Outlook
In an effort to clarify some of the issues addressed by Colli and

Ferri (2015), Löffler-Stastka, Fink, Matuszak-Luss, Glehr, and
Ruhs (2016) examined correlations between therapist reactions,
using the TRQ, and client transference, using the Affect Regu-
lation and Affect Regulation Q-sort Test (AREQ). Data came
from audio recordings of sessions with patients with major de-
pressive disorder. Most importantly, therapist reactions were
scored by blind raters, considerably reducing potential bias. It
was found that positive therapist reactions engendered positive
transference reactions on the part of the client and vice versa.

Parth et al.
It is also important to note the impact of other factors on

the working alliance, such as the type of therapy given. Löf-
fler-Stastka et al. (2016) recently demonstrated, again using the
CTQ and AREQ measures, a rise in therapist feelings of hostil-
ity toward the client in response to the client’s rising levels of
negative affect. This effect, however, was found only in patients
receiving psychodynamic therapy and cognitive-behavioral
therapy. For patients receiving psychoanalytic therapy, the cor-
relation was reversed, with therapists exhibiting less hostility
toward their clients as client negative affect increased. While
implications are further discussed in that study, it is important
to note that differing therapeutic orientations play an important
role in shaping the nature of the working alliance.
Most recently, Gazzillo et al. (2015) asked 148 clinicians to
assess one of their patients in treatment for “enduring maladap-
tive patterns of motivation, affect, cognition, and behavior” (p.
240) using the TRQ and the Psychodynamic Diagnostic Man-
ual (PDM). They found that the most predictive factor for a
patient’s overall level of personality organization was helpless/
overwhelmed countertransference (r = .46), and several differ-
ent countertransference reactions were in fact predictive of dif-
ferent personality disorders (as they are described in the PDM).
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Transference and countertransference

Transference and countertransference:

Originally a psychodynamic concept, the therapeutic relationship

Vol. 81, No. 2 (Spring 2017) 167

butions to the concept of transference and the therapeutic rela-

The tripartite model

168 Bulletin of the Menninger Clinic

concept of tasks, goals, and bond, he states, treads a middle

Vol. 81, No. 2 (Spring 2017) 169

Interestingly, there is mounting evidence that rupture-repairs

170 Bulletin of the Menninger Clinic

developing a detailed relationship measurement instrument. He

Vol. 81, No. 2 (Spring 2017) 171

personality change does not occur except in a relationship. This

172 Bulletin of the Menninger Clinic

with the Working Alliance Inventory (.79)—either that, or the

Vol. 81, No. 2 (Spring 2017) 173

efforts seem almost modest. Horvath (2009) argued that even

Empirical alliance-outcome research

174 Bulletin of the Menninger Clinic

idea in 1936 and has been continuing since Luborsky, Singer,

Vol. 81, No. 2 (Spring 2017) 175

treatment could correlate positively with outcome, while factors

Can the relationship be a negative predictor for premature therapy

Does this correlation between therapeutic relationship and outco-

176 Bulletin of the Menninger Clinic

teresting results. First, and most thoroughly, results have come

Vol. 81, No. 2 (Spring 2017) 177

and Symonds’ and Martin’s oft cited meta-analyses are signifi-

178 Bulletin of the Menninger Clinic

different kinds of alliance patterns: (a) stable, with little change

Vol. 81, No. 2 (Spring 2017) 179

coefficient excluding two studies that had produced “particu-

The alliance and personality pathology

180 Bulletin of the Menninger Clinic

ing to stereotyped or rigid responses” (Gabbard & Horowitz,

Transference and countertransference in psychoanalytic theory

Transference: Groundwork and discourse

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Freud (1916–1917/1944) described coming across the trans-

182 Bulletin of the Menninger Clinic

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it aims to satisfy the “object hunger” of the id, and second, it

184 Bulletin of the Menninger Clinic

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be distinguished from transference neurosis, when “the ana-

186 Bulletin of the Menninger Clinic

(Sandler et al., 1969). These statements clearly reflect Greenson’s

Vol. 81, No. 2 (Spring 2017) 187

Strachey’s work is based in a framework provided by Melanie

188 Bulletin of the Menninger Clinic

resonate in the patient in a way which is specific to him and his

Current points of discussion

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attempt by the patient to reduce the discrepancy between an ar-

190 Bulletin of the Menninger Clinic

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ence was a “limiting factor to an analyst’s effectiveness” (Hin-

192 Bulletin of the Menninger Clinic

are more akin to an “instrument of research into the patient’s

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Technical Tool.” In this second article, he agreed with Heimann

194 Bulletin of the Menninger Clinic