Cartwright, C. (2004). Transference, Countertransference and Cognitive Behavioural Therapy. New Zealand Clinical Psychologist, 14(2), 18-23.

Transference, Countertransference and Cognitive Behavioural Therapy Claire Cartwright

In my training in the early 1980s, I was psychotherapies have beneficial effects on a introduced (not in-depth) to CBT, range of client problems and that the behaviour therapy, family therapy and difference in outcomes across a range of gestalt therapy. I was also introduced to the therapeutic approaches “are not as psychodynamic ideas around transference pronounced as might be expected” (p.180). and countertransference. This paper briefly This evidence of the effectiveness of a reflects on ideas that I have developed over number of different therapy approaches has a number of years about potential ways of been consistent over the last three decades bringing together psychodynamic and (Lambert & Ogles, 2004). traditional cognitive-behavioural approaches These reviewers (Lambert & Ogles, 2004) when working with clients who do not also confirm the previously established appear to benefit from traditional CBT. It importance of the therapeutic relationship as focuses on integrating ideas of transference a component of treatment effectiveness. As and counter-transference into cognitive Lambert and Ogles (2004) state: conceptualisations and uses hypothetical cases for illustration. These relationship factors are probably crucial even in the more technical therapies I welcome comment. Email: that generally ignore relationship factors and [email protected] emphasize the importance of technique in Cognitive Behaviour Therapy 1 is the their theory of change. (p. 181). dominant therapy approach practised by Despite the ongoing evidence of the Clinical Psychologists in New Zealand and importance of the therapy relationship, and taught in our Clinical Training programmes. CBT’s emphasis on empirical investigation CBT approaches continue to develop and and validation, CBT theorists and therapists treatment outcome research provides continue to pay less attention to the quality evidence that CBT approaches are effective and the meaning of the client’s relationship with a wide range of presenting problems with the therapist, relative to other (Hollon & Beck, 2004). CBT provides approaches. As an example of this lack of accessible models for working attention, two key CBT texts commonly therapeutically. These are often common used and widely respected (Beck,1995; sense and user-friendly for clinicians and for Padesky & Greenberger, 1995) make only the many clients who respond well to them. brief mention of the importance of the Whilst there is substantial empirical support therapeutic relationship. Beck, Freeman and for the effectiveness of CBT approaches associates (1990) provide more in-depth (Hollon & Beck, 2004), Lambert and Ogles discussion of working within the therapy (2004) conclude in their decade review of relationship with clients with personality research into treatment outcomes, that many disorders and use the terms transference and countertransference. The therapeutic relationship is also given a central position by Young, Klosko and Weishaar (2003) who combine cognitive, psychodynamic, 1 The term CBT will be used throughout to refer to attachment and Gestalt models in their Cognitive and Cognitive Behavioural Therapies. schema-focused therapy. However, these authors do not directly discuss the examined from a CBT perspective. For psychodynamic ideas of transference and example, a client’s core beliefs may be: “I countertransference. am unlovable” and “Others reject me”. The In this paper, I talk about ways that the client presents to the therapist seeking relief concepts of transference and from the impact that these beliefs have on countertransference can be applied by CBT her life and relationships. However, beliefs therapists in their work with clients. Before that operate in daily life can also be triggered doing so, however, it is important to briefly in therapy. The therapist may remind the consider how these terms are used. client of some-one from the past, or the Transference and countertransference can client may experience memories or emotions be regarded as cognitive-affective reactions associated with past experiences. Having or responses that occur within the regular sessions with a therapist who is therapeutic relationship. Transference refers interested, concerned and accepting in itself to the process by which the client brings can trigger transference responses. When a childhood patterns of relating into the client experiences a transference reaction in therapeutic relationship. At any given a therapy session, the therapist may notice moment, activation of a transference changes in the client. As examples, she may response manifests in how a client feels look away, seem to withdraw or appear to towards the therapist, thinks about the try harder to please the therapist. If the therapist notices a change in the client, s/he therapist and construes the therapists’ attitude towards him or herself. can then consider the possibility that the Countertransference, on the other hand, client is experiencing a transference reaction refers to the therapist’s cognitive-affective towards her. If this is so, it is possible that responses to the client. Sometimes the the client’s core belief(s) have been countertransference can be described as activated. The client may be expecting personal as the therapist’s reaction to the criticism or rejection from the therapist, client is based on his/her own personal similar to what she has experienced in other dysfunctional beliefs, or unresolved issues. earlier and sometimes current relationships. Objective countertransference refers to Perhaps the most important contribution to therapist’s reactions to the client’s understanding the complexities of the transferences. One way of checking to see if therapeutic relationship is the the therapist’s response constitutes an psychodynamic argument that objective objective countertransference is to think countertransference can be a source of about whether other therapists would be valuable information to the therapist who likely to have similar feelings in relationship attends to his or her own reactions to clients to the client. Many clinicians, for example, (see Brown & Pedder, 1991: Jacobs, 1999). would experience some negative feelings The notion of countertransference can also towards a client who is always late, cancels be integrated with CBT. If the therapist at the last minute or is irregular in payment. considers the possibility of a personal In the case of a negative personal countertransference and put this aside, then countertransference (negative feelings the question arises: What is it about the towards the client), the therapist can use a client that is leading me to feel this way. As CBT approach to work through her own a therapist gains experience, it becomes automatic negative thoughts and personal easier to distinguish between personal and beliefs that underlie the countertransference objective countertransference responses. If (Beck et al, 1990; Davis & Wright, 1994) in a therapist’s reaction to a client is order to protect the client from any negative unexpected or out of keeping with how s/he response. normally responds or feels towards the In psychodynamic therapy, therapists client, s/he can alerted to another observe and monitor clients’ and their own possibility: Is there something happening responses within the therapeutic with this client that is not apparent to me? relationship. These processes can also be Has a transference reaction been triggered in the client? If so, what might that be? How cognitive responses related to her beliefs might this relate to the formulation? that she is incompetent and cannot cope To take an hypothetical example, imagine a alone. On the other hand, she might client whom you have begun to see a few consider the above but decide to provide the weeks before Christmas. She has a history client with the name of another therapist of mild chronic depression but this has who is willing to see the client during this become worse in the last few months since time, if the client feels unable to cope. her best friend went overseas. She cries a To further illustrate the use of lot through sessions and although she countertransference reactions, we can appears to accept the CBT approach, she consider a hypothetical male client who seems to prefer to talk to you about her experienced damning criticism as a child, as worries and resists doing the agenda and well as public humiliations. This client is in working through it. She says she is getting a a work situation that he dislikes intensely lot out of the sessions, it is just so good to and has wanted to change his job for three have some-one to talk to, and she does not years. However, he has not done so. He know how she would cope without seeing gets frustrated with himself and blames you. As a therapist you find yourself liking others whom he sees as stopping him from the client, appreciating her admiration and making changes. As therapist, you find find yourself thinking that whilst you have yourself feeling moments of annoyance with planned to have a 4 week holiday over him. These feelings come up suddenly and Christmas, you might make an exception for briefly during sessions. You attempt to not this client. In this instance, the let them show as you realise this would be countertransference can be described as detrimental to him and your relationship. positive. You like the client, you want to You wonder where the feelings come from. support her and if you examine your Between sessions you do not feel annoyed response, you might notice that you feel with him. You can see how “stuck” he protective towards her. feels. When you notice these feelings, you The challenge for the therapist, especially wonder if it could be a countertransference recent graduates, is to know whether this reaction. Are you are experiencing urge to protect is based on sound annoyance as a result of his transference professional sense (for example, the client is reaction towards you? For example, he may unable to cope with this length of break and be experiencing you as a “critical parent” or may be at risk), or if this is a expecting (not necessarily consciously) that countertransference response. In this latter you will be critical of him and experience instance, the client believes herself to be anger towards him as others do and have incompetent, feels frightened of her done. You have no way of knowing if he has emotional distress and is hopeful of begun to feel like this in the session but find engendering the therapist’s support. The yourself feeling some annoyance with him, a client is not so much motivated to challenge normal response to somebody who is her own cognitions and dependent “projecting” anger on to you or responding behaviour. Rather, at a level which is not towards you as if you are likely to get angry with him. Once you have developed this as fully conscious, she is more motivated towards engendering the therapist’s support a potential hypothesis, you can then check it based on the belief that she cannot cope with the client. For example, you might say alone with the feelings of vulnerability to him: I’m wondering how you are finding triggered by her friend’s departure. talking about this with me? If the client says something like: I imagine you are fed up Understanding the notions of transference with me; or, I feel really stupid talking about and countertransference, the therapist can this, you must think I’m an idiot, then this consciously consider that her urge towards partially confirms your hypothesis. It also protecting the client, and making the client a allows you to work with the client and the special case (by breaking into her holidays) is thoughts and feelings he is having in regard a reaction to the client’s emotional and to you. Further, the hypothesis that: He may expect me to get angry with him , then allows you to consider other aspects of the therapy References: relationship and therapy progress. Could this, for example, account for why he is late Beck, A., & Freeman, A. (1990). Cognitive therapy of or why he becomes uncommunicative at personality disorders. NY: Guildford Press. times, or why he complements you on your Beck, J. (1995). Cognitive therapy: Basics and work with him? Are there similarities to beyond. NY: Guilford Press. how he responded within relationships in Brown, D., & Pedder, J. (1991). Introduction to his childhood? Did he, for example, psychotherapy: An outline of psychodynamic withdraw from situations; did he attempt to principles and practice. London: Tavistock. ingratiate himself; did he become a Hollon, S. & Beck, A. (2004). Cognitive and cognitive caretaker. Hence, the countertransference behavioral therapies. In. M. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and becomes a source of valuable and perhaps Behavior Change. (pp. 447-492). NY: Wiley. otherwise unattainable information, or at least, a source of potential hypotheses about Jacobs, M. (1999). Psychodynamic counselling in action. London: Sage. the client. For a CBT therapist who is familiar with and works with the Lambert, M., & Ogles, B. The efficacy and psychodynamic ideas of transference and effectiveness of psychotherapy. In. M. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy countertransference, these hypotheses can and Behavior Change. (pp. 139-194). NY: Wiley. be considered in the light of the cognitive Padesky, C., & Greenberger, D. (1995). Clinicians’ formulation. guide to Mind Over Mood. NY: Guilford Press. Becoming familiar with the notions of Wright, J. & Davis, D. (1994). The therapeutic transference and countertransference relationship in cognitive behavioral therapy. therefore allows the clinician to move Cognitive and behavioural therapy, 1, 25-45. sideways, to take time to consider what is Young, J., Klosko, J., & Weishaar, M. (2003). NY: occurring out of conscious awareness for Guilford Press. both client and therapist, and to consider how this relates to the cognitive formulation. It is an extra check also to ensure that we are making decisions that are professional and not based on urges that feel professional but are countertransferential in origin. It provides us with a language to use when attempting to make sense of the sometimes complex relationship processes that occur in therapy. For relatively well-functioning clients, who are capable of a building a therapeutic alliance and working in a collaborative relationship, these concepts may be less necessary. For therapists working with clients who have a history of disturbed relationship patterns, the ideas of transference and countertransference are likely to provide further understanding that can complement CBT formulations. This understanding, in turn, sometimes opens up new avenues for assisting the client. Claire Cartwright, PhD, DipClinPsych, Dept of Psychology, The University of Auckland