Countertransference Enactments in Couples Therapy
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- I I .1IJ •L: ) Ji, . ; t i•. f' '\: '( J COUNTERTRANSFERENCE ENACTMENTS IN COUPLES THERAPY A dissertation submitted to the Sanville Institute in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Clinical Social Work LIM SID AARONSON June 23, 2007 © 2007 SID AARONSON ALL RIGHTS RESERVED THE SANVILLE INSTITUTE DISSERTATION APPROVAL PAGE We hereby approve the dissertation COUNTERTRANSFERENCE ENACTMENTS IN COUPLES THERAPY by Sid Aaronson Candidate for the degree of Doctor of Philosophy in Clinical Social Work Doctoral Committee Sylvia Sussman, Ph.D p /O Chairperson / . (tre / bate Cynthia O'Connell Ph.D. Committee Member Signatire Date Jan Mill Ph.D. External Member Gareth Hill Ph.D. Dean LW ABSTRACT COUNTERTRANSFERENCE ENACTMENTS IN COUPLES THERAPY VA SID AARONSON This qualitative study explored how therapists experience, think about, and deal with countertransference enactments in couples therapy. The study examined situations when therapists get caught up in and/or act out their countertransference while working with couples; these types of reactions are referred to as countertransference enactments. Open-ended, semi-structured interviews were conducted with ten experienced psychodynamically-oriented therapists who specialize in couples therapy and who come from varying professional fields and theoretical orientations. Data from the interviews were analyzed using the constant comparative method as developed by Glaser and Strauss (1967). A primary finding of the study showed that, while the concept of enactment was not well understood among most participants, all were able to reflect upon times when they were caught up in an enactment and reported several examples of such occurrences. Common countertransference affect themes were present during enactments, such as frustration, anger, ineffectiveness, helplessness, dread, and anxiety. However, what best captured the essence of couples therapists' countertransference experience during an enactment was the experience of pressure. Therapists experienced the build up of pressure with couples in a lv variety of ways including: the couples' high expectations, triangulation pressures, the sheer amount of clinical material to track and the pressure to stop hurtful and destructive dynamics between partners. After becoming aware of the enactment, therapists attempted to work it through while managing their countertransference reactions. Therapists attempted to understand why the enactment occurred by analyzing their countertransference triggers as well as exploring the case dynamics. Some therapists interpreted the transference-countertransference dynamics of the enactment and how it played out among the threesome in an effort to facilitate a deeper understanding of its meaning in the treatment. Therapists also often had to deal with clinical issues related to repairing the rupture or break in the therapeutic relationship. They also used a variety of coping strategies to help them manage and contain their countertransference reactions, such as self restraint, self supervision and consultation. ACKNOWLEDGEMENTS I could not have written this dissertation without receiving the support and encouragement from the many caring people in my personal and professional world. For that, I am grateful, and have many people to thank. First, I appreciate the members of my committee. As the dissertation chair, Sylvia Sussman, provided the right combination of qualities to guide me through this project; she was focused, optimistic, held me to the task, and I always felt re-energized after speaking with her. Cynthia O'Connell, as a committee member, carefully read my work, supported and discussed ideas with me, and helped move my work along. I am deeply indebted to my external committee member, Jan Mill, who was fundamental in helping me think through the conceptual aspects of my dissertation. She graciously gave her time to my project. I wish to express my sincere thanks and gratitude to the psychotherapists who participated in my study and who so generously volunteered their time. Their willingness to be candid in sharing their countertransference enactments added depth and richness to my research. I thank the faculty and Dean of the Sanville Institute, especially my mentors Judith Schiller and Mary Coombs who helped guide me through the Doctoral program. I also thank my fellow students who, along with the faculty, provided a lively culture for learning and growth at the institute. Special thanks are extended to Tina Casenza and Angeleen Campra for always being there to hold down the fort. VI The support and caring of my friends and family was very important to me. Special thanks to my best buddy Ken Miller, my loyal friends in my Men's group (Murray, Kevin, Barry, Lance), my brother Les and his wife Karen, my sons Brendan and Ruben, Kate, Lieba, Michael, Gina, Stephany and Pearl. They believed in me and cheered me on throughout the process. I am especially appreciative of my friend, Cheryl Jern. We began and ended the Doctoral program together and were best school buddies. We supported and spurred each other on; complaining, competing, discussing ideas and talking about all the knit- picky things that go into making a dissertation. Finally, I am eternally grateful to my wife, Corisa. She was excited about my subject and always willing to talk out ideas. She read my drafts and gave excellent suggestions, often helping me think through the rough patches. She listened to my endless kvetching and encouraged me when I was ready to give up. She is also an excellent editor and provided those skills to my final drafts. She was truly always there for me and was invaluable. She is precious. Vii TABLE OF CONTENTS ABSTRACT ACKNOWLEDGMENTS vi CHAPTER 1: INTRODUCTION 1 The Problem and Background 1 The Research Question 8 Significance of the Study 9 CHAPTER 2: LITERATURE REVIEW 13 Enactments 14 History of the Concept of Enactment 15 Current Views on Enactments 25 Potential Therapeutic Pitfalls of Enactments 29 Projective Identification 30 Countertransference in Couples Therapy 35 Introduction 35 Influences From Family Therapy 39 Object Relations Couples Therapy 41 The Scharffs 46 Oedipal Countertransference 51 Concordant and Complementary Countertransference Identifications 59 Countertransference as Diagnosis 61 Viii Countertransference in Working With Difficult Couples 64 Borderline and Narcissistic Disorders 65 Partners Who Have Been Severely Traumatized 67 Domestic Violence 69 Misalliances 70 Secrets 71 Polarized Couples 73 Parenting Disagreements 75 Countertransference From Ethical and Moral Dilemmas 76 An Intersubjective Approach to Countertransference in Couples Therapy 79 Transference 81 Countertransference 83 How Therapists Work With Countertransference 87 CHAPTER 3: METHODS AND PROCEDURES 92 Methodological Approach and Research Design 92 Reliability and Validity 94 Participants 96 Nature of the Sample 96 Criteria for Selection 98 Recruitment 99 Data Collection: The Interview 100 Procedure 101 ix The Topics of the Interview Guide 102 Awareness of Transference/Countertransference Dynamics 102 Experiencing Countertransference Reactions 103 Getting Caught Up or Acting Out Countertransference 104 Thinking About the Enactment 104 Dealing with Countertransference Enactments 105 Data Analysis 105 Procedure for Data Analysis 106 Presentation of the Findings 108 CHAPTER 4: FINDINGS 109 Participants 110 Overview 112 Findings 120 The Complexity of Transference and Countertransference in Couples Therapy 121 The Emotional Intensity of the Couple Relationship 121 Multiple Transferences and Countertransferences 125 Triangulation 128 How Therapists Conceptualize Enactments: What Is an Enactment? 131 Defining Enactments 131 Properties of Enactments 137 What Happened? Therapists Describe Their Enactments 143 Patterns of Enactments 144 x Clinical Vignettes 147 How Therapists Recognized That an Enactment Occurred 155 Distinguishing Enactments From Other Countertransference Phenomena 155 Learning About the Occurrence From the Client 157 Clues From Self-Reflection 158 How Therapists Analyzed the Enactment: Attempts to Understand Why the Enactment Occurred 160 Therapists' Analysis of Their Countertransference Triggers 161 Frustrated and angry 162 Ineffectiveness and helplessness 167 Dread and anxiety 171 The Therapist's Achilles heel 174 Three-person dynamics 178 Therapists' feelings about the enactment 183 Therapists Conceptualizing Case Dynamics 186 How Therapists Worked Through the Enactment 191 The Value of Paying Attention to Enactments 192 Repairing the Rupture in the Therapeutic Relationship 195 Interpretation/Explanation 204 How Therapists Manage Intense Countertransference: Therapists' Coping Strategies 211 Self-restraint 212 Self-supervision 214 Xi Developing empathy 215 Consultation 218 CHAPTER 5: DISCUSSION 221 Therapists Under Pressure: The Therapist's Countertransference Experience in Couples Therapy 222 Couples' High Expectations 223 Triangulation Pressures 225 Sheer Amount of Clinical Work: Pressure from the Intensity of the Work 227 Feeling Ineffective: The Pressure to Help 229 Hurtful and Destructive Dynamics 230 Familiarity With the Concept of Enactment 234 How Therapists Worked Through the Enactment 236 Two Groups of Enactments 237 Enactments Causing Rupture 239 Ongoing Enactments 244 Further Clinical Considerations 249 Enactments That Derailed the Therapy 254 Value of Working Through Enactments: "It was a good mistake to make" 258 Relevance of the Findings to the Literature