An Overview of Countertransference

I attended a very good lecture last week on contemporary views of countertransference. It inspired me to write a brief overview of the concept here, with more to follow.

To understand countertransference, it helps to tackle transference first. Transference was a word coined by Sigmund Freud to label the way patients "transfer" feelings from important persons in their early lives, onto the psychoanalyst or therapist.

Psychoanalysis was specifically designed to encourage transference. intentional opacity and non-disclosure by the therapist promote transference; the patient naturally makes assumptions about the therapist's likes and dislikes, attitude toward the patient, life outside the office, and so forth.

These assumptions are based on the patient's experiences with, and assumptions regarding, other important relationships, such as childhood relations with parents. In this way, the patient's formative dynamics are re-created in the therapy office for both participants to observe. Patients discover that some of their assumptions about others, and themselves, are unfounded or outmoded and do not serve them well. This is an important type of insight that can lead to lasting psychological change.

Freud realized that transference is universal and therefore could occur in the analyst as well. He did not write much about this, except to say that "countertransference" could interfere with successful treatment. The analyst experiencing countertransference should rid himself of these feelings by having further analysis himself.

Since the 1950s, psychoanalysts and psychodynamic therapists have held a more benign view of countertransference. It is no longer seen as an impediment to treatment (at least not inevitably), but instead as important data for the therapist to use in helping the patient.

Countertransference can serve as a sensitive interpersonal barometer, a finely tuned instrument in the field of social interaction. For example, a therapist who feels irritated by a patient for no clear reason may eventually uncover subtle unconscious provocations by the patient that irritate and repel others, and thereby keep the patient unwittingly lonely and isolated.

In using countertransference this way, the therapist must consider multiple sources of his or her feelings. Some feelings, positive or negative, may be evoked by the patient. These are particularly helpful ones to notice, especially when the cause is not immediately obvious, as in the example just given.

Often, however, feelings may be stirred up by irrelevant characteristics in the patient (e.g., the patient physically resembles the therapist's sibling or spouse), by the prior patient, or by factors unrelated to therapy (e.g., bad traffic getting to the office, a quarrel at home, an upcoming vacation).

This strongly argues for dynamic therapists to pursue such therapy themselves: It "tunes the instrument" to better distinguish countertransference evoked by the patient, versus similar feelings that arise from other causes. Freud's advice for analysts — to seek additional analysis themselves in the face of countertransference — is wise, although not for the reasons he gave.

I teach psychiatry residents to go through a mental checklist whenever they become conscious of possible countertransference:

1. Is this feeling characteristic, i.e., does the resident have it much of the time? If so, it may say a lot about the resident, but probably nothing about his or her patient.
2. Is the feeling triggered by something unrelated to the patient? Feelings caused by hunger, one's personal life, bureaucracy in the medical center, and so forth are not useful data for helping the patient.
3. Is the feeling related to the patient in an obvious way? Feeling put off by a patient who is screaming obscenities and viciously destroying the office is countertransference of a sort, but not very illuminating.
4. Is the feeling uncharacteristic of the therapist, a reaction to one particular patient, and yet the exact trigger is not immediately obvious? These are the most helpful feelings to notice in oneself, as they often shed light on subtle yet important dynamics in the patient.

Countertransference is not always helpful. Particularly when it is unexamined — or, worse, unrecognized — it can indeed interfere with effective treatment. This can occur even with positive countertransference, as when a therapist is so entertained by a patient's jokes that the underlying bitterness is ignored, or when an attractive patient is never challenged because the therapist desperately yearns to be liked.

Transference Essential Reads

On Being a Therapist: The Good, Bad, and the Ugly

More often, though, countertransference is problematic when it is negative. The therapist feels bored, irked, paralyzed, or contemptuous in the presence of a particular patient. It is the therapist's job to recognize these feelings and deal with them. Occasionally a therapist must refer the patient to a colleague when the original therapist's countertransference is unmanageable. Fortunately, in most cases, these uncomfortable feelings, once recognized by the therapist, can not only be understood but also used constructively in the treatment.

©2010 Steven P. Reidbord MD