Therapist Countertransference Research Articles

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.

Metaphoric, metonymic and psychotic somatoform dissociation

The present paper seeks to propose, using a combination of psychoanalytic and linguistic thinking, a distinction between three degrees of symbolicity across the somatoform dissociative continuum: the metaphorical, in which there is a symbolic connection between the somatoform phenomenon and the traumatic content, the metonymic, which constitutes a revival of the traumatic experience without the ability to reflect on it, and the psychotic, in which the somatoform phenomenon is experienced as ego-syntonic, thus neither causes distress nor evokes thinking. Three clinical vignettes demonstrate how the higher the degree of symbolization, the more effective the therapeutic process. Finally, a fourth vignette demonstrates how acoustic association in the therapist's countertransference can constitute an antidote to the patient's acoustic dissociation, allowing the reclaiming of the capacity for linking.

Mentalizing in the context of Mentzos' dilemma-on the use of implicit work in the treatment of non-affective psychosis.

Current approaches to the treatment of non-affective psychosis include elements of mentalization-based treatment and the potential in enhancing mentalizing capacity in this patient group has been widely emphasized. This article presents the "psychotic identity dilemma", a concept by Stavros Mentzos, and a therapeutic approach considering this concept as a valuable complementary addition to these treatments. The idea of a dilemma between closeness and distance, which in itself cannot be represented mentally at first, helps to respond to specific needs of patients with psychotic disorders by placing the treatment focus on fundamental interpersonal processes. Following this train of thought, this article attempts to shed light on the importance of the "real relationship" between therapist and patient as well as the exploration of the "here and now", especially at the beginning of psychotherapeutic treatment. Two treatment modes are suggested, one characterized by the experience of interpersonality within the therapeutic relationship and a second one characterized by the reflection of interpersonal phenomena. These modes are framed by Stavros Mentzos' concept of an identity dilemma. We describe how mentalizing first needs to be addressed implicitly in a tolerable, exemplary relationship in which closeness and distance are regulated based on the therapist's countertransference, then explicitly. A series of interventions are described, which allow for moments of shared attention, promote intentionality and contingency and, later in the course of therapy, help to integrate experiences into narratives.

Observing and interpreting clinical process: Methods and findings from 'Layered analysis' of parent-infant psychotherapy.

This paper describes a method for investigating clinical process, Layered Analysis, which combines therapist countertransference reports and multi-faceted microanalytic research approaches. Findings from the application of Layered Analysis to video-recorded micro-events of rupture and repair in four psychoanalytic parent-infant psychotherapy sessions are presented. Layered analysis showed that countertransference and observation are complementary perspectives, which enable concomitant study of interactive events, conscious internal experiences, as well as nonconscious and unconscious elements of therapeutic interaction.Interactional rupture and repair were found to constitute co-constructed micro-events that occurred fleetingly and often implicitly, and differed in the structure, coherence and flow of interactions and in the relationship between verbal and nonverbal communication. Furthermore, interactional ruptures were found to sometimes 'get into' the therapist and transiently disrupt their self-organization, such that the therapist became a locus of disruption for the patient(s), actively contributing to the rupture, which thus became embedded in the therapeutic system. Interactive repair was found to be most often initiated by the therapist and to be underpinned by the therapist re-establishing self-regulation, through metabolizing embodied and verbal aspects of the rupture. Studying such processes can enhance our understanding of clinical process, inform therapist training and clinical supervision, and contribute to clinical outcomes.

Antisocial personality disorder in group therapy, kindling pro-sociality and mentalizing.

Patients with antisocial personality disorder (ASPD) are known for being difficult to treat. Treatment for ASPD is debated and lacking evidence. Among several reasons for treatment difficulties concerning ASPD, negative countertransference in health personnel is one central topic. Mentalization based treatment (MBT) is a reasonable candidate treatment for ASPD. From an ongoing pilot-study on MBT with substance using ASPD patients, we explore therapist experiences. Four experienced MBT therapists together with the principal investigator performed a focus group together. The therapists were themselves involved in performing this study and analyses are made as an autoethnographic study, with thematic analyses as methodological approach. As this study involved a qualitative investigation of own practice, reflexivity of the processes was performed. The aim was to explore in depth: therapist experiences and therapist wellbeing in MBT-ASPD. We found four main themes on therapist experiences. 1) gaining safety by getting to know them better, 2) gaining cooperation through clear boundaries and a non-judgmental stance, 3) shifting inner boundaries and 4) timing interventions in a high-speed culture. These four themes point to different therapist experiences one can have in MBT-ASPD. Our findings resonate well with the clinical literature on ASPD, the findings imply that clinical teams should have a focus on therapist countertransference and burnout, ensure that therapists uphold boundaries and open-mindedness in treatment of ASPD and that therapists experience vitalizing feelings in this line of work.

Personality disorders and therapist countertransference: A review

IntroductionThe countertransference of the therapist is crucial in psychotherapy. Although the concept of countertransference arose from psychoanalysis, it is considered a construct that occurs in any type of therapy.ObjectivesThe purpose of this review is to examinate the relationship between personality disorders and countertransference.MethodsA systematic literature review was performed on PubMed using the keywords “personality disorder” and “countertransference”. All papers published between 2015 and 2020 were evaluated.ResultsThere were significant relationships between and patients’ personality disorders and patterns of countertransference. Criticized countertransference were associated with paranoid and antisocial personality disorders. Borderline personality disorders was related to helpless, overwhelmed, and overinvolved responses. Narcissistic and schizotypal personality disorders were associated with disengaged therapist responeses. Helpless countertransference was associated with schizoid personality disorders. Avoidant personality disorders was associated with postive responses. Special/overinvolved therapist responses were associated with obsessive-compulsive personality disordersConclusionsSeveral studies suggest that therapists’ emotional responses occur consistently in any kind of therapy. Moreover, specific personality disorders are associated with concrete emotional responses. Therefore, therapists can make therapeutic and diagnostic use of their conuntertransference.

Working With Severe Borderline Patients: A Clinical Study of Destructiveness and Its Communicative Potential.

Destructive behavior is one of the most challenging aspects when treating severe borderline patients because both the therapist and the psychotherapeutic method are called into question. Drawing on three in-depth psychoanalytic sessions of a severe borderline patient, the authors present and discuss the communicative potential of destructive behavior in the transference relationship during treatment. A step-by-step analysis and the working through process of the therapist's countertransference led the authors to recognize several complex dynamics of the patient's pathological organization and to the containment and first representation of unsymbolized early anxieties generated during the original encounter with the object.

Exploratory analyses of intake sessions in psychodynamic psychotherapy: do processes differ for engager versus non-engager clients?

ABSTRACT We investigated differences in negative indicators and topics discussed during intakes for one engager and one non-engager (i.e. dropout) client for each of 18 therapists in psychodynamic psychotherapy. Results indicated that engager clients had fewer negative indicators (patient-therapist interaction, errors in techniques) and more coverage of client goals for treatment than did non-engager clients. Engager and non-engager clients did not differ in terms of client pathology, therapist countertransference, or order in which they were seen in the clinic. Preliminary findings suggest that therapists should be educated about negative processes and encouraged to discuss client goals to lessen the likelihood of dropout.

Patient attachment and therapist countertransference in psychodynamic psychotherapy.

Patient attachment and therapist countertransference in psychodynamic psychotherapy.

놀이치료자 발달수준과 역전이관리능력의 관계에서 자아존중감의 매개효과

놀이치료자 발달수준과 역전이관리능력의 관계에서 자아존중감의 매개효과

The Developmental Moment: Where Theory and Technique Intersect

ABSTRACTThis article introduces the concept of “developmental moments,” which are moments throughout a session where the clinical material, along with the therapist's countertransference, provide guideposts for assessing the patient's immediate developmental need. When integrated with modern analytic contact styles, the developmental moment helps the analyst identify which maturational tasks are likely to play out in the interpersonal field at any given time and when interventions are most likely to help the client progress in treatment.

The development and initial validation of the Countertransference Management Scale.

Countertransference is an important aspect of the therapeutic relationship that exists in therapies of all theoretical orientations, and depending on how it is managed, it can either help or hinder treatment. Management of countertransference has been measured almost exclusively with the Countertransference Factors Inventory (Van Wagoner, Gelso, Hayes, & Diemer, 1991) and its variations, all of which focus on 5 therapist qualities theorized to facilitate management: self-insight, conceptualizing ability, empathy, self-integration, and anxiety management. Existing versions of the Countertransference Factors Inventory, however, possess certain psychometric limitations that appear to constrain how well they assess actual management of countertransference during a therapy session. We thus sought to develop a new measure that addressed these limitations and that captured the 5 therapist qualities as constituents (rather than correlates) of countertransference management that manifest in the treatment hour. The development and initial validation of the resulting 22-item Countertransference Management Scale (CMS) is described here. Exploratory factor analysis of ratings of 286 therapy supervisors of current supervisees indicated that the 5 constituents of countertransference management could be grouped into 2 correlated factors: "Understanding Self and Client" and "Self-Integration and Regulation." Evidence of convergent and criterion-related validity was supported by CMS total and subscale scores correlating as expected with measures of theoretically relevant constructs, namely, therapist countertransference behavior, theoretical framework, self-esteem, observing ego, empathic understanding, and tolerance of anxiety. Results also supported the internal consistency of the CMS and its subscales. Research, clinical, and training implications are discussed. (PsycINFO Database Record

Dimensions of Activity in Countertransference and Therapist Reactions: Therapist Reactions During Sessions with Depressed Patients.

This paper presents the interaction structure between the therapist's countertransference and the patient's affect based on identified dimensions of how therapists feel and react during sessions with depressed patients. 639 sessions were audio-recorded and rated by trained raters. These recordings were obtained from the Munich Psychotherapy Study and analyzed with the PQS, the AREQ, and the TRQ/CTQ. Seven components with good to excellent internal consistency (Cronbach α = .745-.902) were found and labeled Hostile Feelings, Positive, Disengaged, Overwhelmed and Encroaching Feelings concerning countertransference and therapists' emotional reaction, while the therapist's behavior was scored on separate dimensions. The middle and final sessions reveal significant correlations between a patient's positive affect experience and positive countertransference. The confirmed pattern implies not only that a positive affect is related to a positive countertransference reaction, but also that a positive countertransference entails a positive affect. The fact that this pattern could be accounted for only during the middle and the last sessions indicate that the working alliance is not fully established at the beginning of the treatment.

Demeter's Compromise: Separation, Loss, and Reconnection in Mothers with Daughters Entering Adulthood

abstractDrawing on contemporary theory of female development that focuses on the dynamics of the mother/daughter relationship regarding issues of separation and individuation, this article examines the treatment of a middle aged mother as she navigates her way through her daughter's adolescence and early adulthood. Psychoanalytic object relations, psychoanalytic relational theory, and feminist theory serve to frame an understanding of the case material in terms of developmental challenges that are uniquely female. Issues around mother/daughter attachment, separation, competition, conflict, and love are explored in the relationships between the patient and her mother, the patient and her daughter, and the patient and the therapist. The therapist's countertransference, intensified by her relationships with her own mother and daughter, suggests the possibility of both pitfalls and opportunities in the treatment. The article attempts to address a gap in psychoanalytic developmental theory, which offers little understanding of the challenges for women in midlife.

Relationship-focused psychotherapies for eating disorders come of age.

This is a commentary on 3 case studies of relationship-focused therapies for eating disorders. The 3 approaches vary along a number of dimensions, but nevertheless share important similarities especially related to the role played by variables such as interpersonal problems and affect dysregulation. I briefly review research on interpersonal- and attachment-based models of eating disorders that provide the evidence-base for theories of therapy that are relationship-focused. The Interpersonal Psychotherapy case presented by Tanofsky-Kraff, Shomaker, Young, and Wilfley (2016) illustrates how a group context can facilitate change in key role disputes and role transitions in an adolescent at risk of developing an eating disorder later in her life. The Integrative-Dynamic Therapy case presented by Richards, Shingleton, Goldman, Siegel, and Thompson-Brenner (2016) is a novel sequential combination of cognitive-behavioral therapy followed by dynamic psychotherapy for a young adult with bulimia nervosa that likely reflects what most clinicians do in everyday practice. The Psychoanalytic Psychotherapy case presented by Lunn, Poulsen, and Daniel (2016) of a patient with severe personality pathology demonstrates how treatments for eating disorders sometimes must address complex attachment dysfunction, self-organization, and therapist countertransference in order to provide a useful therapeutic experience. Relationship-focused theories and therapies for eating disorders have come a long way over the past decades, thus providing therapists with a wider range of approaches that can be truly personalized to their clients. (PsycINFO Database Record

Chronique de la vie ordinaire d’une normopathe

ObjectivesThe issue of mental functioning among subjects who are “too normal” is not often discussed in psychiatry, first of all for the obvious reason that it is rarely encountered. Patients of this type are in general referred to psychoanalysts for reasons that they feel are: “exterior to their psychological state”, such as the occurrence of somatization. Here, the author provides extracts from the therapy of a patient who consulted after receiving the medical injunction to “have psychotherapy”, following a transient ischemic attack (TIA). MethodSeveral key moments are reported, pinpointing the countertransference movements generated in the analyst by the patient. The physical sensations in both parties are an integral part of this work of psychic regeneration. ResultsAs described in the work by psycho-somaticians in the Paris school, the psychotherapy of patients functioning on an operating mode entails the establishment, through the therapist's countertransference, of a “maternal function” linking therapist to patient. Thus between the patient and his therapist, a sort of “chimera” is created, in the terms of de M’Uzan, where what has been lacking in the patient's early life appears in the countertransference insights of the analyst. DiscussionIn this context, the appearance of a somatization is an appeal, testifying to suffering that is not yet conscious but is demanding to be so. To back up these dynamic hypotheses, the therapy with Mrs. S. shows the particular technical difficulties inherent in this type of case. ConclusionsThe different aspects of “normopathy” cause a certain amount of difficulty for the psychoanalyst. Indeed, he or she needs to know how to adjust the framework to enable a genuine encounter with the patient. The question regarding the patient's relationship with madness can be apprehended in their dread of being in contact with their unconscious functioning. In this context, the appearance of somatization must be heeded and treated as a warning, an appeal that testifies to a suffering that has not yet found psychic expression.

Transference and Countertransference in CBT and Schematherapy of Personality Disorders

Countertransference occurs in CBT when the relationship with the patientactivates automatic thoughts and schemas in the clinician, and these cognitionshave the potential for influencing the therapy process. Countertransferencealso occurs during supervision and is an indispensable part of the supervisor's response to the supervisee. CBT is typically short-termtreatment – intensity of transference is usually muchlower than in longer-term, dynamically oriented psychotherapy. Neverthelessduring the long-term CBT of the personality disorder or other complex cases, high intensity of transference and countertransference can develop. Schema therapy shares the view thatschemas are crucial to understanding of personality disorders, but also canhelp to understand the emotional reaction of therapist. A mode is the set ofschema operations that are in one moment functioning for a person. It is acircumscribed complex pattern of emotional, cognitive a behavioral experiences, which operate in typical situations. When therapist suspects that countertransferencemay be developing, he/she could try to identify her/his automatic thoughts andschemas. More comprehensive approach is to quickly identify in which modehim/her are at that moment and reflect it such reaction is for the patientbenefit or not. Understanding therapist countertransference reactions andtheirs management are a significant point of supervision. Self-reflection and realizing the countertransference can therapist help toovercome it and may be necessary for overcoming stagnation in therapy. Understanding own mode and theirflipping into the therapeutic session is an important tool in psychotherapy andsupervision.

Patient personality and therapist countertransference.

The purpose of this review is to provide a comprehensive and critical examination of the empirical literature about the relation between patient personality and therapist countertransference. The therapist's countertransference can play a crucial role in psychotherapy outcomes, especially in the treatment of personality disorders. The therapist's emotional responses to patients can accomplish the following: inform the clinician about the patient's personality, impact therapy outcome, influence patient resistance and elaboration, mediate the influence of the therapist's interventions and influence therapeutic alliance. In the last years, several studies have empirically demonstrated the presence of a specific pattern of therapist responses that are related to different patient personality disorders. Other works showed how the effects of the therapist's technique depend on the emotional context in which they are delivered and in particular countertransference experiences. Moreover, researchers suggest that the therapist's emotional responses occur across all kinds of therapy and are independent of the therapist's theoretical preferences.

Parental Presence and Countertransference Phenomena in Psychoanalytic Psychotherapy of Children and Adolescents

One of the characteristics of psychotherapeutic work with children and adolescents is parental presence, which introduces additional parameters into the setting and function of the therapist. Parental presence makes the existence of the external world constantly present, increasing the risk of bias in interpreting and understanding the intrapsychic world. Interference is common in the therapeutic setting, and mostly challenges the therapist's tolerance. Meetings with parents may trigger fantasies in the therapist's mind, which interfere with the game of identifications with the child and the fantasized parents. The common bond with the child creates conscious and unconscious reactions, and there is always the risk of the therapist being overwhelmed and losing his or her capacity to understand object relations and transference phenomena. The therapist's function may be influenced either through weakening of the symbolizing capability or through hampering the capability to understand the child's function of fantasy. Parents are always present, while the therapist's countertransference movements evolve. Given that the technique of interpretation is not always available, the main goal is to use countertransference challenges in the service of the child's psychotherapy, by understanding the child's internal reality, resistance, and experience, as well as the intensity and nature of external experiences within the family.

EPA-1419 – Schema modes, transference and countertransference

Transference and counter transference could be significant sources of insight about the patient's, therapist's and supervisor's inner worlds. Transference phenomena are viewed as a reenactment in the treatment relationship of key elements of previous significant relationships. Counter transference occurs in CBT when the relationship with the patient activates automatic thoughts and schemas in the clinician, and these cognitions have the potential for influencing the therapy process. Counter transference also occurs during supervision and is an indispensable part of the supervisor's response to the supervisee. Schema therapy shares the view that schemas are crucial to understanding of personality disorders, but also can help to understand the emotional reaction of therapist. A mode is the set of schema operations that are in one moment functioning for a person. It is a circumscribed complex pattern of emotional, cognitive a behavioral experiences, which operate in typical situations. When therapist suspects that counter transference may be developing, he/she could try to identify her/his automatic thoughts and schemas. More comprehensive approach is to quickly identify in which mode him/her are at that moment and reflect it such reaction is for the patient benefit or not. Understanding therapist counter transference reactions and theirs management are a significant point of supervision. Self reflection and realizing the counter transference can therapist help to overcome it and may be necessary for overcoming stagnation in therapy. Understanding own mode and their flipping into the therapeutic session is an important tool in psychotherapy and supervision.