Countertransference Reactions Research Articles

Countertransference Teaching: The Challenge of Going Beyond Literature: A Novel Approach

While countertransference in its various definitions has become central to psychoanalytic theory and practice, and countertransference is acknowledged as central to most care-giving practices, the opportunities to know and explore countertransference in most mental health training programs is limited. Applying approaches of Narrative Medicine didactics, this paper proposes and demonstrates how the group study of clinically relevant literature (novels and short stories) under guided discussion can lead to the identification and exploration of countertransference reactions. The scope of this paper is to report on a single class taught for ten years using literature to teach adolescent development with the finding that it became a forum to explore various countertransference arising in psychotherapies with adolescents, an approach that can be broadly applied.

Abrupt Terminations In The Treatment of Suicidal and Self‐Harming Young People: The Negativel in the Therapeutic Relationship

Psychotherapy with suicidal and self‐harming young people is complex, as this population group is difficult to engage in treatment and their internal reactions may remain concealed, leading to impulsive suicide attempts or abandonment of treatment. The resulting countertransference reactions of confusion, guilt and shame are most distressing and often cause psychotherapists to avoid treating this population group. Safety concerns increase when self‐destructive patients abandon therapy, or their condition worsens despite the therapist's best efforts. The vicissitudes of the adolescent developmental process suggest that, in some cases, withholding information, rejection of the therapist's caring interventions, and abrupt termination of treatment arise from the need for separation and independence and are ego syntonic and therefore suicide protecting. In other cases, the risk for suicide may be increased because of the transference experience of hostile abandonment. A negative therapeutic reaction (NTR) is a disturbing development in the course of psychotherapy that has not been adequately explained in the treatment of suicidal young people. This article is a consideration of whether these negative reactions associated with abrupt, unplanned terminations, in the treatment of self‐destructive young people, should appropriately be thought of as an NTR or as a developmental stage in separation.

Differentiating authentic versus pseudo vulnerability in therapeutic practice.

The importance of empathy and attuned care as key ingredients in therapeutic healing has been widely recognized. However, empathy that is delivered in ways that are misaligned with the client's clinical presentation and emotional states or 'modes' can have the opposite effect, reinforcing unhelpful coping patterns, and hindering recovery. In this theoretical development paper, it is proposed that 'pseudo vulnerability' is an important yet overlooked source of therapeutic impasses, often resulting in unremitting clinical problems, and poor clinical outcomes. A range of commonly occurring pseudo vulnerable presentations are described, including Complaining Protector, Attention/Recognition Seeking, and Self-Pity/Victim, with the addition of a new mode Helpless Surrenderer. Guidance on differentiating pseudo vulnerable modes from each other and from the authentic Vulnerable Child mode are delineated via characteristic clinical presentations and typical therapist countertransference reactions. Methods for managing pseudo vulnerability to facilitate access to underlying authentic vulnerability are described.

The Kvetch: Assessment, Pathogenesis, and Treatment of Patients Who Are Clinically Impaired by Chronic Complaining.

Clinicians often encounter patients whose presentations are characterized by long lists of complaints about their biological, psychological, interpersonal, and social conditions. The problems on which the complaints are based are variably reality-based and variably modifiable. Some of these patients display chronic complaining as a core, distinguishing feature. Accordingly, the aims of this article are to consider excesses of chronic complaining as psychiatric phenomena, explore possible pathogenetic contributions, describe approaches for treating conditions marked by clinically pertinent chronic complaining, and suggest areas for future research. Based on clinical observations enhanced by selective narrative literature review, we delineate and differentiate four groups of patients: 1) situational complainers; 2) chronic complainers due to unidentified medical problems; 3) mood-induced chronic complainers; and 4) personality-driven pan-dimensional chronic complainers. The last-mentioned group consists of help-seeking versus help-rejecting subtypes, the latter including a subset we designate as malignant chronic complainers. Strategies for managing these patients begin with detailed assessment of all complaints, ascertaining reality-based contributions to the complaints, including those initiated by patients themselves. Management approaches use specific biopsychosocial techniques based on patient-centered particulars. Psychotherapeutic strategies center on compassionate, empathic witnessing. Specific tactics include attending to unresolved grief and trauma, behavioral activation, cognitive and narrative restructuring and reframing methods, mentalizing and imaginal approaches, and psychodynamic methods including attention to attachment issues and transference. Sources of countertransference reactions to these patients should be identified and can be addressed. The many questions raised by these patients' presentations merit further research.

Institutional Transference in Serious Illness Care.

Institutional transference is a phenomenon describing patients' attitudes toward the institutions where they receive mental health or medical care. While transference toward individual clinicians in palliative care has been described, attitudes of patients with serious illness toward the institutions where they receive specialized care have not been described. Here, we present three cases which demonstrate the phenomenon of institutional transference in patients with serious illness and the resulting clinical implications, which include countertransferential responses of clinicians caring for them. We consider three conditions: (1) the idealized reputation of the academic cancer center, often a tertiary referral center; (2) loss of an institutional connection during care transitions; and (3) countertransferential reactions to institutional transference. We highlight characteristics and personality styles of individuals with cancer that may complicate and intensify institutional transference and identify potential interventions to address common challenges associated with institutional transference.

"Bringing and Removing Self from the Table": Therapists' use and management of eating disorder lived experience in the treatment of clients with eating disorders.

Therapists report significant countertransference reactions when treating clients with eating disorders (EDs). Countertransference may be pronounced among therapists with eating disorder lived experience (EDLE). Minimal research examines how therapists with EDLE negotiate their experiences while treating ED clients. Informed by the person-of-the-therapist philosophy, this study sought to understand how therapists use and manage their EDLE when working with ED clients. Using constructivist grounded theory methodology, semistructured interviews (Mtime = 89 min) were conducted with 22 therapists with EDLE. Results revealed that therapists engaged in two interconnected systems. The Central System helps therapists transform their lived experiences into clinical guidance. The Checks and Balances System allows therapists to find a balance between connecting with the client and allowing for differences in experiences to emerge. Lastly, three personal processes existing outside of these systems were found to impact therapists' use of self. Findings provide novel ways thattherapists can use their EDLE.

Malignant Self-Regard as an Overarching Framework for the Theory and Treatment of Depressive and Masochistic (Self-Defeating) Personalities.

Kernberg and McWilliams have spawned differing conceptualizations of the relationship between depressive and masochistic (self-defeating) personalities. Kernberg describes these personality styles as largely overlapping in features, whereas McWilliams accentuates important clinical differences that make up two distinct personalities. In this article, their theoretical perspectives are discussed and framed as more complementary than competitive. The malignant self-regard (MSR) construct is introduced and reviewed as an integrative self-representation that is shared by both depressive and masochistic personalities, as well as those often referred to as vulnerably narcissistic. We investigate developmental conflicts, motivations for perfectionism, countertransference patterns, and overall level of functioning as four primary clinical features through which a therapist may differentiate a depressive from a masochistic personality. We argue that depressive personalities tend to have more dependency-related conflicts and perfectionistic strivings motivated by lost object reunification, elicit more insidiously positive countertransference reactions in session, and are generally higher-functioning individuals. Masochistic personalities have more oedipal-related conflicts and perfectionistic strivings motivated by object control, elicit more aggressive countertransference reactions, and are relatively lower functioning. MSR is positioned as a bridge between Kernberg's and McWilliam's ideas. We close with a discussion of treatment implications for both disorders as well as how to understand and treat MSR.

Stigma and Countertransference in Resident Attitudes toward Patients with Substance Use Disorders.

Apprehending the full range of one's countertransference presents a challenge for the new therapist and psychiatry resident. Experiencing negative or aggressive feelings while also striving to consolidate one's professional identity and self-experience as a good, helpful, and competent doctor feels dissonant and contradictory. Developing and practicing the skills of countertransference awareness and analysis are crucial aspects of psychiatry and psychotherapy training. These skills can help the trainee navigate difficult clinical interactions through reflection on their own anxieties, as well as the unconscious social and personal biases and motivations that shape their countertransferences. This article examines some of the countertransference reactions that may be colored by social and personal stigma toward patients with substance use disorders. Acknowledging and exploring such countertransference reactions in training not only can provide valuable insights into the psychodynamic experiences of the patient and the treatment dyad, but also can sharpen a lifelong tool, helping the trainees weather powerful and disorienting countertransference currents, untangle their personal motivations and prejudices, and recognize the times when supervision may help to provide containment and clarity throughout their careers.

Videoconferencing psychotherapy from a psychodynamic point of view. A qualitative analysis.

There is a growing interest in delivering videoconferencing psychotherapy (VCP) due to the enormous impact of the COVID-19 pandemic on our lives since the beginning of severe restrictions worldwide in March 2020. Scientific literature has provided interesting results about the transition to remote sessions and its implications, considering different psychotherapy orientations. Less is known about whether and how VCP affects psychodynamic psychotherapeutic approaches and reports on remote work with severe and complex mental health problems such as severe personality disorders are still scarce. The aim of the study was to examine the experiences of psychodynamic psychotherapists, mainly delivering Transference-Focused Psychotherapy (TFP), with the transition and delivery of VCP during the first wave of the COVID-19 pandemic. Four hundred seventy-nine licensed psychotherapists completed an online survey during the peak of the pandemic. Survey data were analyzed using qualitative analysis. Results are presented and discussed concerning advantages and disadvantages regarding the access to psychotherapy, the specificity of the online video setting, bodily aspects, the quality of the therapeutic relationship, the therapeutic process including technical aspects and therapist's experience. Furthermore, we analyzed and discussed the statements concerning transference and countertransference reactions differentiating between high-level borderline and neurotic patients and low-level borderline patients. Our results support the importance to identify patients who potentially benefit from VCP. Further research including more prospective randomized controlled trials are needed to investigate the therapeutic implications of the findings.

A change in frame and countertransference experiences: Transitioning from face‐to‐face to telepsychotherapy

AbstractUnprecedented changes in traditional psychotherapeutic practice arose from the lockdown restrictions associated with the COVID‐19 pandemic. These changes to practice included the imposed change to the therapeutic frame when transitioning clients from face‐to‐face meetings to delivery of psychotherapy sessions via videoconferencing (defined here as telepsychotherapy). The current study conducted qualitative interviews with 16 Australian psychologists who transitioned their existing adult psychotherapy clients from face‐to‐face therapy to telepsychotherapy and explored their novel experiences associated with countertransference reactions during this period. Thematic analysis of the interviews revealed several unique findings. The type of countertransference reactions towards existing clients was consistent across both face‐to‐face and online meetings; however, the felt intensity of countertransference reactions was reduced. Psychologists reported an increased hesitance to work with intense emotions during telepsychotherapy sessions and felt increased pressure to work harder during online sessions when compared to face‐to‐face meetings. Exposure to their clients' personal and home environments during telepsychotherapy sessions elicited several novel reactions towards their clients. These findings on countertransference and telepsychotherapy are informative for future practice and training. Awareness of these unique countertransference experiences is recommended prior to engaging in telepsychotherapy or when transitioning clients to this modality.

Countertransference in working with psycho traumatized patients

The paper presents the theoretical assumptions at the basis of the phenomenon of countertransference and then presents the specifics of countertransference in working with traumatized patients. Several clinical vignettes analyze some characteristics of countertransference reactions in working with psycho traumatized patients. The paper presents some results of countertransference research.

Hate in the service of love: the negative therapeutic reaction revisited in couple therapy

For many years, the negative therapeutic reaction (NTR) was regarded as a form of resistance arising solely in individual psychoanalytic treatment. The possibility, however, that the NTR may also appear in couples has recently emerged as worthy of exploration. After presenting a case in which NTR dynamics predominate, and reviewing analytic literature about the NTR, the authors propose a conceptualisation of a couple-based form of the NTR that relies upon both paradoxical motivations and paradoxical uses of projective and introjective identification. The countertransference reactions these couples tend to induce in therapists will also be explored, and methods for their management will be suggested.

Aches, Pains, Rumbles, and Stumbles: Applying Somatic Countertransference and Body Reactivity in Clinical Work and Teaching.

Recognizing somatic countertransference reactions is an essential tool for the psychodynamic clinician. Although the analyst's bodily reactivity has been written about throughout the history of our field, contemporary neuroscience, multiple code theory, and nonlinear system dynamics provide scientific buttressing to understand embodied phenomena. Patients often speak with and about their bodies, and the clinician who pays attention to these communications, as well as those emanating from his or her own body, has an additional resource to help the patient. Elvin Semrad's classic but largely unremembered "tour of the body" is one tool that can assist clinicians in how to receive and process body reactions that may be unconsciously split off, consciously withheld, or felt dangerous or beguiling. Three examples are used to illustrate embodiment and somatic countertransference as important clinical guides. An argument is made that these concepts should be taught and integrated into psychodynamic curricula.

Schema therapists’ perceptions of the influence of their early maladaptive schemas on therapy

Objective: This qualitative survey aimed to explore schema therapists’ perceptions of how their early maladaptive schemas are activated in their therapeutic work, and how they manage their reactions. Method: An online qualitative survey was conducted with 22 schema therapists. Following brief demographic questions, participants were asked three open-ended questions about their schema activation and associated reactions. An inductive-deductive hybrid thematic analysis of the qualitative responses identified four superordinate themes and 12 subthemes. Results: Participants described several negative impacts on their therapeutic work, including avoiding limit setting, becoming argumentative or aggressive, detaching or avoiding, and over-functioning. An array of strategies for managing schema and countertransference reactions were identified, including refocusing on the client’s vulnerability, caring for one’s own vulnerability and connecting with one’s healthy adult self, and engaging in supervision, training, personal therapy, and self-care. Notably, several participants described how their internal reactions can be used advantageously to conceptualize and support clients, and to facilitate therapists’ personal development. Conclusion: The findings highlighted that although schema and associated countertransference experiences can be challenging, awareness and effective management of therapists’ reactions can benefit treatment and promote personal growth.

Group psychotherapy for parents of patients with borderline personality disorder: Βasic assumptions and group containing function.

Patients with borderline personality disorders (BPD) have great difficulties with interpersonal relations. Their extreme difficulties with interpersonal relations are illustrated in psychic family interaction. Parents become the recipients of conflicts and patient's aggressive behaviour, while family stress increases due to suicidal tendency, self-injuries and substance abuse. The current report presents the introduction of group psychotherapy for parents of young adult patients with BPD, treated in a special unit of personality disorders at Eginition Hospital. The aim is, through the parallel group therapy of patients and their parents, to establish the conditions of continuing therapy for the patients as well as maintaining therapy outcomes and to construct a facilitating environment where the family's mental pain, anxieties, anger, shame, guilt and sadness can be contained. Clinical material from the first sessions of a 13-member parent group is presented to illustrate the resistances, the primitive defenses and the basic assumptions of dependency and fight-flight developing in therapeutic work with parents. Furthermore, the groups' split and hostile transference communications and the therapists' countertransference reactions are discussed. Τhe containing function of the group is described as a therapeutic process of transformation of the primitive anxieties and projective identifications, which is gradually established through the therapists' elaboration of their countertransference reactions and their tolerance to hostility and confusion. Containment facilitates the establishment of a group culture of empathic understanding for parents' unconscious resistances, denial of the illness and negative projections onto their child and the therapists, so that resistances gradually to be curbed and archaic projections to be transformed. Hence, the group is expected to function as a safe space to allow the manifestation and relief of destruction anxieties, and the expression of unuttered and intolerable emotions. Finally, the group as a mother-object is expected to be internalised as a model of positive parental care, enhancing the empathic and reflective ability of the parents so that they may repeat the parental role in a process of reparation.

"Are We Safe Analysts?" Cisgender Countertransferential Fantasies in the Treatment of Transgender Patients.

The authors examine the impact of countertransference in two clinical cases of transgender patients treated by two cisgender analysts who are accustomed to receiving nonconforming gender patients in France and Brazil. The context is that of contemporary views of transphobic countertransference reactions, specifically the work of Griffin Hansbury, who describes these reactions in terms of "unthinkable anxieties." Like other theorists with expanding notions of countertransference, the authors view transphobia in analysis as an "instrument of research" and consider how taking responsibility for the transference is particularly relevant in respect to clinical cases that also reflect societal changes. Following the authors' case presentations, they identify four different fantasies and countertransferential reactions that sprang from their efforts to be safe analysts or, in other words, analysts concerned about the perpetuation of discrimination, violence, and oppression that may have guided their work.

Transference and Countertransference Dynamics in a Multifamily Group for Transgender Adolescents.

This article is an account of a pioneering multifamily group for transgender adolescents. Meetings were conducted in a Sexual Identity Consultation Service in a Child and Adolescent Psychiatry Department in Paris. In addition to enabling both teenagers and their parents to escape a certain form of isolation, this novel mental health care setting also reinforced the ability of participants to free associate and to cathect substitute objects. The author highlights specific characteristics of transference movements and countertransference reactions of the therapists in this framework. An additional goal is to promote these innovative groups and to recommend similar groups for transgender adolescents and their parents.

Empirical support for the use and further study of the countertransference construct in the clinical care of patients with bipolar disorder.

We thank Andrew Shaw and colleagues for their recent paper1 inBipolar Disorders, highlightingthat theeffectivetreatment of patients with bipolar disorder requires a good therapeutic alliance,which is related to the clinicians' countertransference reactions and their management. The authorssuggestthat the integration of a psychodynamic approach into the biological paradigm in psychiatry might be helpful to increase countertransference awareness in clinicians, andpotentially improvingdyadic communication,resolution ofalliance ruptures, and treatment adherence. Theyalsomention that although the theoretical literature on countertransference is well developed, no good empirical studies exist that investigate the countertransferential responses experienced by mental health clinicians involved in the care of individualsduring acute phases of bipolar disorder. We would, however, like to add some examples of empirical evidence for the use (and further study) of the countertransference in the clinical care of these patients.

Impact of Intergenerational Patterns on Coaching Effectiveness

This exploratory study examined the influence of intergenerational family patterns and transgenerational transmissions on coaching effectiveness. It specifically focused on the potential impact of coaches’ intergenerational patterns on their countertransference risks and development of coaching resources. Fifteen executive coaches were socioanalytically interviewed with a focused genogram and a self-as-instrument approach to understand the impact of intergenerational patterns and underlying family dynamics on coaching effectiveness. Results indicated a relationship between these factors and coaching effectiveness. This was especially the case with regard to the development of functional and adaptive coping behaviour rather than transmitting dysfunctional, maladaptive behaviour only. Analysing and debriefing live coaching situations with a focus on potential countertransference reactions would further validate these findings in future research. Given the results of this study, it seems essential to integrate the reflection of intergenerational patterns and related countertransference risks into the training and supervision of coaches.

The Experience of Working With Individuals Who Sexually Offend.

Providing treatment to those who have committed sexual offenses can be difficult and challenging work. Older studies have suggested that service providers may experience changes in mood, symptoms of trauma, and countertransference reactions due to their work. Recent research has found that effective coping and self-care strategies may mitigate these negative outcomes. Given the relative dearth of recent empirical studies, we assessed the prevalence of self-reported mood, trauma symptoms, and countertransference reactions and their relation to coping styles and self-care practices in a sample of 32 male and 52 female therapists who provided treatment to individuals convicted of sexual offenses. As expected, we found minimal levels of clinically significant depressive (4%) and trauma symptoms (9%). Some countertransference reactions to clients were reported, including intense anger, retributive fantasies, sexual attraction, and arousal. A problem-solving coping style was associated with higher levels of psychological well-being, while avoidant coping was related to increased depressive and trauma symptoms. Approximately 10% of therapists with an abuse history reported re-experiencing their own victimization. The majority of therapists reported engaging in self-care practices. The findings are discussed as they pertain to those who provide services to individuals convicted of sexual offenses.