DOES THE DEVELOPMENT OF COUNTERTRANSFERENCE AWARENESS INFLUENCE THE THERAPEUTIC RELATIONSHIP? A GROUNDED THEORY ANALYSIS SHELLEY GAIT Thesis submitted in partial completion of the requirements of the award of Professional Doctorate in Counselling Psychology Department of Health and Social Sciences and Applied Sciences, University of the West of England, Bristol Thesis submitted 1st November 2016 This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement. ACKNOWLEDGEMENTS I would like to thank my research team, in particular, Andrea Halewood, for all her support, inspiration and wisdom; I don’t think I could have done it without you. I would like to thank all those who took part in the research; I value your time and contribution to this piece of work. I would also like to thank my ever-supportive family, Simon, Dougie & Alfie; I am very lucky to have you. 2 Table of Contents Acknowledgments 2 Abstract 4 Introduction 5 Literature review 12 Research Rationale and Aims 32 Methodology, Method and ethical considerations 33 RefleXivity 54 Results 57 Discussion 94 Implications and Recommendations 111 Directions for further research & Dissemination of the 117 findings Evaluation and Limitations of research 118 Conclusions 122 References 123 Journal article 152 Appendices 182 3 ABSTRACT The psychodynamic literature suggests that countertransference is an inevitable part of therapy and a significant feature of the client-therapist relationship. However, countertransference is also considered to be a ‘double edged sword’; when it is reflected on by the therapist, it can offer valuable insights into the therapeutic relationship, but when it remains outside of awareness and therefore unmanaged, it can result in the therapist unwittingly acting out in the therapeutic relationship and responding in counter-therapeutic ways. While research into countertransference currently lags behind the voluminous theoretical literature on the construct, in recent times there has been a growing interest into countertransference management. While some key factors in this process have been identified, how awareness of countertransference develops has yet to be explored. The purpose of this research was twofold, to explore the development of countertransference awareness and how this may or may not influence the therapeutic relationship and to construct a grounded theory of the process. 15 qualified therapists were recruited and interviewed, either, face to face or via Skype, using a semi-structured interview. The grounded theory constructed from the data suggests that participants initially experienced countertransference as threatening and overwhelming. When the experience of overwhelm was contained in supervision and therapy, the work context and by their theoretical framework, participants could reflect on their countertransferential responses, make sense of their experience, which developed their self-awareness and other insights, to the benefit of the therapeutic relationship. Conversely, a lack of containment in these domains, resulted in participants acting out their countertransference and becoming either over or under available in the therapeutic relationship. Implications for practice, supervision and training are discussed, with recommendations for practice. In addition, avenues for further research are also explored. 4 INTRODUCTION The constructs of transference and countertransference, originally developed by Freud (1910, 1912, 1959), the founder of psychoanalysis, are one of the most ‘durable’ theories of human interpersonal relations within the field of psychoanalysis and psychotherapy (Levy & Scale, 2012). Transference, according to Freud, occurred when the client transferred strong feelings onto the analyst, which were rooted in the client’s interpersonal relationships from their past. In his early writings, Freud, considered the transference a hindrance to the analytical endeavour, however, he later revised this view and argued that the identification and interpretation of the client’s transference, was central to the work of analysis. Countertransference was understood by Freud to be the analyst’s transference to the client, which Freud believed could result in an emotional entanglement, with the analyst acting out in counter-therapeutic ways. Consequently, Freud argued countertransference should be removed from the analysis at all costs. While Freud revised is understanding of transference, in his view, countertransference remained an obstacle in the therapeutic endeavour. Today within the psychodynamic literature, while it is generally agreed that countertransference, broadly defined as the therapist’s emotional response to the client, is an inevitable and central part of therapy, which, when left unmanaged, can result in a negative therapeutic outcome, such as the therapist acting out towards the client (Burwell-Pender & Halinski, 2008; Casement, 1985; Coren, 2015; Gabbard, 2001; Gelso & Hayes, 2007; Hayes 2004; Ligie & Gelso, 2002; Marroda, 2004; Pope, Greene & Sonne, 2006; Rosenberger & Hayes, 2002; Rowan & Jacobs 2002; Stark 2000, Zachrisson, 2009). Conversely, it is now agreed, that if countertransference is reflected on and managed, it can benefit clinical work, by illuminating both the client’s and the therapist’s interpersonal dynamics. Countertransferential material is, therefore, considered an important part of therapy, which requires of the therapist both awareness and the motivation to examine and work through these feelings as they arise (Burwell- Pender & Halinski, 2008). 5 Critique of countertransference research While there has been substantial theoretical and clinical interest into the construct of countertransference, empirical research in the area has been relatively sparse (Hayes, 2004). According to some researchers and authors (e.g. Fauth, 2006; Friedman & Gelso, 2000; Gelso & Hayes, 2007; Hayes, 2004; Najavities, 2000; Pope Greene & Sonne, 2006), there has been a reluctance within the school of psychoanalysis to engage in empirical research of any kind due to stark differences in epistemological values between practitioners and scientists. This has resulted in a research lag, with much of the theoretical literature focusing on debating the elements which constitute the construct (Fauth, 2006; Hayes, 2004). According to several authors (e.g. Fauth, 2006; Friedman & Gelso, 2000; Gelso & Hayes, 2007; Hayes, 2004; Najavities, 2000; Pope Greene & Sonne, 2006), there has also been a general resistance and reluctance among therapists to talk openly about their vulnerabilities, which has also inhibited research into the construct, contributing to a lack of empirical scrutiny. According to psychoanalyst and psychologist Mills (2004), many therapist’s view countertransference as detrimental to therapy, which has led to the construct being deemed, either irrelevant or something to hide, due to fears about negative judgement, criticism and professional exposure by colleagues. This is perhaps why most of the research into the construct has taken place in a laboratory setting, using analogue studies based on hypothetical situations and scenarios (e.g. Brody & Farber, 1996; Hayes & Gelso, 1993; Peabody & Gelso, 1982; Robbins & Jolkovski, 1987; Sharkin & Gelso, 1993). While it could be argued that these studies have been useful in expanding and advancing current understandings of countertransference, in that they suggest that therapist’s feelings do affect the way they respond towards their clients (Hayes, 2004), it could also be argued that they say very little about countertransference in the real world or have any real ‘ecological value’ (Hayes, 2004, Kachele, Erhardt, Seybert & Buchholz, 2015). Furthermore, given that these studies tend to only offer participant’s formed choice responses or prepared written statements, they perhaps limit what can be captured of the actual process under investigation. 6 More recently, however, there has been a move by some researchers out of the laboratory and into the field (e.g. Fauth & Williams, 2005; Hayes, 1995; Hayes, Riker & Ingram, 1997; Van Wagoner, Gelso, Hayes & Diemer, 1991). One common focus of interest has been exploring how countertransference management relates to therapy outcome (e.g. Peabody & Gelso, 1982; Robbins & Jolkovski, 1987; Sharkin & Gelso, 1993; Van Wagoner, Gelso, Hayes, & Diemer, 1991). This seems to mirror research into therapy more widely on the therapeutic relationship and therapy outcomes (Lurborsky, Christoph, Mintz & Auerbach, 1998; Mearns & Coopers, 2010; Wampold, 2001). While it could be argued that these studies into real therapy situations have more credibility, because they are reliant on self-report measures, they are not without limitations. While self-report instruments and measures are an efficient way of gathering data, especially when studying larger numbers of participants, they can lack ‘construct validity’ when different measures are used across studies, as it is difficult to know with any certainty what is being measured (Fauth, 2006, Friedman & Gelso, 2000). This is further complicated by the fact that countertransference often resides outside of awareness (Fauth, 2006). Due to the methodological limitations of these studies, as well as the disparity and variance of the findings, it is difficult to develop a clear understanding of how countertransference arises within the therapy process, which may be one of the reasons it has been