The Power of Countertransference

Innovations in Analytic Technique

Karen J. Maroda

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135060527
• Edition: 1
• Topic: Psychologie
• Subtopic: Angewandte Psychologie

A signpost of the relational turn in contemporary psychoanalysis, Karen Maroda's The Power of Countertransference, published in 1991, is perhaps the first systematic effort to integrate the need for mutual emotional exchanges, which may include the analyst's own self-disclosures, into an interactive model of psychoanalytic practice. Maroda's call for emotional honesty and affective self-disclosure had an immediate impact on the field and led Harold Searles to comment, "If we follow the example set by Maroda, we shall be minimally likely to 'act in' our emotions in our sessions with our patients. They will benefit greatly as a result; we practitioners shall benefit; and the profession of psychoanalysis and psychoanalytic therapy will become healthier and stronger than it is at present." This revised edition includes a new Foreword by Lewis Aron and an Afterword in which Maroda clarifies her own position and comments on the evolution of psychoanalytic technique since the publication of The Power of Countertransference.

Chapter 1
The Myth of Authority

On Building a Working Relationship

The focus of this chapter is on the value of establishing a mutual, reciprocal, and non-authoritarian relationship between therapist and patient to facilitate an optimal treatment outcome. A more egalitarian treatment relationship maximizes individual freedom and promotes and encourages a working partnership. Conversely, authoritarian and autocratic approaches are stifling, infantilizing, and adversarial. Before use can be made of the countertransference, a tone that promotes disclosure of both the transference and the countertransference needs to be established in the treatment relationship, and this should be addressed from the moment the patient arrives for the first appointment. This is important for a variety of reasons. First, because of a desire for consistency and stability, or because of a fear of losing face or seeming indecisive to the patient, most therapists will not shift from their original positions. Second, while the texture and color of the transference and countertransference are determined in large part by the personalities of both parties and by the initial attitudes each brings to the therapeutic endeavor, the therapist controls the amount and degree of progress in the treatment. It is only in the most unusual circumstances that a patient can surpass his therapist. Although the question of which professional attitude serves to best promote and resolve the most significant aspects of the transference is not a new one, it remains vitally important.

Clinging to the Past

Issues such as how much power and control the therapist should have and what feelings toward patients are "healthy" or therapeutic remain controversial. The therapist who believes in the necessity of absolute authority will naturally set a different tone from the therapist who believes in a more mutual and non-authoritarian relationship. Similarly, the therapist who finds only compassionate or loving feelings to be acceptable and professional is certainly in a different position from the therapist who feels free to hate his patients.

Hirsch (1980-81), in his discussion of the psychoanalytic relationship, points out that the authoritarian position stems not just from the medical model, but also from the authoritarian society in which Freud lived. The anachronistic character of classical analysis is no doubt what produces discomfort and even disorientation in some patients, as they struggle to adapt to a situation so different from anything they know. Walking into some analysts' offices, where turn-of-the-century fainting couches, heavy draperies, oriental rugs, and busts of Freud prevail, can be like entering a time machine.

Wallerstein (1988) bemoans the tendency for psychoanalysis to be weighed down by its sense of history and its loyalty to its founder. He points out that even though Freud died over fifty years ago, we have still not come to terms with his death:

What this persisting feeling, of course, adds up to is that, unlike other sciences, psychoanalysis has not yet been able really to accept Whitehead's famous dictum: "A science that hesitates to forget its founders is lost." (p. 9)

The psychoanalytic institutes in America, in contrast to those in Europe, have proven to be particularly dogmatic, citing the Standard Edition as though it were scripture and viewing deviations from the classical approach as heresy. Though Freud continually reworked his views, occasionally altering major aspects of his theory and admitting failure in some of his experiments, this same evolution through maturation and trial and error has not been an accepted part of American psychoanalysis.

The tendency to cling to an idealized past has ramifications for every aspect of theory and practice in psychoanalysis. Clearly, an authoritarian stance is not compatible with establishing a cooperative partnership in therapy. It is worth considering that perhaps the Victorian medical model simply is outdated and not as effective as other approaches. Even Freud did not hold to this stance as fervently as American psychoanalysts do today. In fact, Freud wrote about his patients in a much warmer and more humane way than is evident in the current literature, and he was not above providing reassurance or even a small loan.

Another important point to consider is that psychoanalysis at the turn of the century was not only developed in a culture much different from our own, it was also conducted over a shorter period of time. Psychoanalysis in Freud's day was typically a six- to eighteen-month event. It seems only natural that a certain reserve in both parties would be maintained during that period. Analytic treatments today, however, typically last a minimum of five years, and frequently as long as seven to fourteen years. How on earth can a formal, unilateral relationship possibly survive that long? And why have our ideas about the nature and quality of the relationship not changed to keep pace with the dramatic change in treatment duration?

The most obvious area for rethinking and redefining analytic treatment is acknowledging the different stages and the greater intensity that are often the consequences of a very long-term treatment. It seems logical that, at least for those patients capable of participating, deeper and longer regressions will result, as well as longer terminations, so that both parties are able to come to terms with the end of a relationship that has been such an integral part of their lives for so long. It also seems likely that increasingly long treatments are more varied and complex, commanding a greater repertoire on the therapist's part.

This point might seem less critical in a worldwide mental health delivery system that emphasizes, if not imposes, increasingly shorter treatments that often consist of not more than ten sessions. Since few people have the resources required for a long psychoanalysis, brief dynamic treatments are more common, and techniques are needed to respond to these changes. Given this state of affairs, how relevant is use of the countertransference? Even though using the countertransference is seemingly easier and less risky in longer treatments, I believe that it is still of great value in shorter treatments. In such treatments, the therapist needs to be actively engaged with and responsive to the patient early in the treatment. And, it seems to me that patients who know from the start that they will only be in treatment for a short time tend to ask for more feedback earlier in the treatment process. They are just as in need of emotional responses as patients who are in longer treatments, but they do not have the luxury of easing their way into the transference-countertransference relationship. Unfortunately, because patients in briefer treatments do not have the opportunity to establish the complex and emotionally diverse relationships with their therapists that analytic patients do, both the transference and countertransference are less rich. But the patient's need for insight and understanding of his emotional impact on others remains the same. For these reasons, countertransference can be used to benefit patients in both short and long treatments.

The Optimal Therapeutic Stance

Before discussing the nature of the therapist's repertoire, we must first decide the issue of the optimal therapeutic stance. The basic authoritarian position is defined, not as one in which the analytic therapist is cold, hostile or domineering, but rather as one in which the therapist maintains a certain personal distance throughout the treatment. He believes that self-revelation pollutes, distorts, or inhibits the transference; that "acting-out" is likely to permanently bury an issue that needs to surface; that the traditional "blank screen" is the appropriate analytic stance; that important decisions affecting the course, circumstances and duration of the treatment are primarily the therapist's responsibility; that a decision made cannot be recanted; that information that reveals the therapist's affective state or details of his personal life is usually a burden to the patient and, as such, constitute irresponsible and inappropriate disclosures in most cases; that the therapist is emotionally healthier than the patient; and that the patient is likely to try to influence the therapist in the direction of repeating the patient's past pathological episodes or relationships. This final point is commonly labeled the "resistance" and represents the dragon to be slain by the authoritarian, yet benevolent, analytic practitioner.

In discussing these points with Dr R, a traditional yet open-minded colleague, I found myself up against a wall of resistance when I suggested that she might have something to gain from behaving differently with her patients. She told me that many of her patients were quite angry with her because she extended her planned three-week vacation to four weeks, owing to her mother's sudden illness and hospitalization. Upon returning from her "vacation" several of Dr R's patients felt that she had been unfair and even abusive to them in staying away an extra week. They all shared similar fantasies that she, on a whim, had merely decided that she didn't feel like returning to work and wanted an additional week off.

This left them feeling unimportant, hurt and angry, as well as confused regarding her professionalism and commitment to them. She said that she found their reactions particularly hard to take, especially after a grueling week at the hospital with her mother. She admitted to feeling a bit martyred, but said that this was all in a therapist's day.

I asked her if it bothered her that her patients honestly believed that she had abandoned them in pursuit of a good time. She said of course it did, but, after all, how could they possibly know or suspect that something like a family emergency had occurred precisely at the end of her vacation, requiring her to fly out again as soon as she had arrived home? What else were they to think other than that she had decided to vacation a bit longer?

I asked Dr R if she had thought about telling them the truth, particularly after they had revealed and explored their own fantasies and feelings about the situation. She said, oh no, she couldn't do that. I asked her why not. She said that she wouldn't want to burden them that way, that they would only feel guilty and terrible about being angry with her, and she naturally didn't want that to happen.

I pointed out to her that, as things stand now, they are disappointed and resentful, questioning her ethics and involvement with them, and that the working relationship seemed pretty strained. And if that wasn't a burden to them, what was? Could knowing the truth be worse? She argued that it was, that they would feel foolish and asinine if they knew the truth.

I counterpointed, saying that she had admitted to me that she had had to withdraw emotionally during some sessions in which she was severely criticized by her patients because it had been too much to take on top of her mother's illness. Knowing that she was innocent of the crime of which she was accused made it even more difficult. I told Dr R that it seemed to me that if she had told them the truth she would not have had to withdraw from them and, just as important, they would not have reason to question her professionalism. Telling the truth would serve both sides by maintaining rather than weakening the therapeutic alliance.

She responded by saying that she did not want her patients to feel guilty about their anger—what about that? I said that she could simply tell them that she understood how they could think and feel that way, that all she had to do was convey the natural empathy that she was feeling for them already. It was just a matter of verbalizing her thoughts to them.

She had to admit that it sounded good but, if it really works, why does everyone say that you are "burdening" the patient if you tell them the truth? And why don't people practice this way if it really works? After a minute or two of cognitive dissonance she shook her head and decided that she had done the right thing after all. My ideas were interesting, she said, but that is just not the way analytic therapy is done.

As a final note, I asked her how she would feel and how it would affect her practice if her mother died soon. She said she would be terribly upset and would definitely have to take time off from her patients. I asked how she would confront this situation with them. She said that, of course, she would have to tell them that her mother had died. There simply would be no reasonable explanation for another absence and, besides, they would be able to tell that she was very upset. Then she would have to tell them the truth.

I tried to show her that this was somewhat hypocritical, as well as destructive to her patients, because many of them would probably accurately surmise that her mother's death was connected to her earlier absence and that they had been wrong all along in what they thought. I also thought that Dr R's patients would not only feel extremely guilty about having punished her for her prior absence, but they would also feel newly abandoned, having to deal with their guilt and anguish alone as Dr R left town to bury her mother. But Dr R felt that life crises of this type, as often illustrated in the literature, legitimately call for the therapist to come clean. She said that she thought this would qualify as one of those times when an exception needed to be made.

This anecdote illustrates many of the characteristics of the typical authoritarian stance as I outlined it. Dr R declined to tell her patients the truth concerning her extended vacation and, as a result, stimulated reactions of hurt and anger in her patients. They felt unimportant and Dr R ended up feeling like a martyr, exposing herself to needless confrontations with her patients. In some cases, her patients were so enraged that Dr R had to withdraw from them emotionally. To her way of thinking, being honest with her patients was a "burden" that she could not expose them to, so rather than be truthful, she decided to test, unnecessarily in my view, the strength of the therapeutic alliances with her patients. I also believe that her effectiveness will be seriously compromised if and when her mother dies, at which point she will have to tell her patients the truth.

I think this anecdote also illustrates not only how difficult it is for therapists to change the way they practice, or even to conceive of practicing differently, but also how accepted analytic practice can break down at the most critical times in the lives of patient and therapist. It seems that at the junctures where all that is truly important is what the person is feeling, and all that is therapeutic is a human response to that feeling, traditional psychoanalytic technique often fails.

Giving up power and authority is not easy for anyone, which makes it easy to understand why many analytic therapists are reluctant to do so. Yet at the same time the negative aspects of authoritarianism cannot be ignored. Balint, in The Basic Fault (1968), said:

The more the analyst's technique and behavior are suggestive of omniscience and omnipotence, the greater is the danger of a malignant form of regression. On the other hand, the more the analyst can reduce the inequality between the patient and himself, and the more unobtrusive and ordinary he can remain in his patient's eyes, the better are the chances of a benign form of regression, (p. 173)

Though most therapists might agree with Balint's statement, conveying this sense of humanness so that the patient does not forever remain the imperfect child in relation to the perfect parent is difficult. How does the non-traumatic de-idealization of the therapist occur without the admission of human weakness and failure? And when this hurdle is successfully jumped in an analytic treatment, is it because classical technique was followed down the line, or because the "parameter" of admitting to a mistake and apologizing was used? And if all of us regularly do this, why is it considered to be a "parameter" rather than accepted technique?

It can be argued that we should not admit to our mistakes because a patient who had a parent who would never admit that he was wrong will lose the opportunity to confront the therapist on the same grounds. In other words, too quick an apology will bury that aspect of the transference. Though this has always been the "party" line, most of us know from experience that it simply is not true. In fact, most of our patients tend to accuse us over and over again, no matter what our response, until they can resolve an issue in some meaningful way.

For example, a patient I came to care about very deeply insisted that she was unlovable and, as she became more attached to me, grieved terribly over the thought that I could never reciprocate her feeling. Finally, one day when she was particularly depressed, she asked me how I felt about her, and I said that I cared very much about her. Though I believe that she accepted my response at the time and that it confirmed what she had perceived but dared not believe, it certainly did not settle the issue of her feeling unlovable. It came up over and over again, regardless of my feelings for her, simply because it was still a problem for her. I believe that my admission of feeling for her helped to validate her own perceptions and perhaps give her hope, but it naturally could not wipe out her deep feelings of unworthiness. What is more critical, it also did not in any way suppress or repress this important aspect of her treatment. In fact, it helped clarify for her the difference between feeling unloved and actually being unloved. She had always believed that no-one had loved her because she could not sustain the feeling of being loved and lovable. Gradually she began to realize that many other people had cared deeply for her, and that her inability to sustain those relationships was based on her feeling unworthy, and not because no-one wanted her.

The idea that many of the same issues appear and reappear over the course of every individual's treatment is addressed by Hirsch (1980-81):

. . . one trend of thought suggests that a conflict, once resolved via acting-out, will never again emerge and present itself for healthy resolution. The analysis is tainted and incomplete at best. An alternative position is that issues appear and reappear repeatedly. The beauty of analysis is that one rarely loses an issue by missing it the first time or by seeing it handled through acting-out (p. 110)

Hirsch also believes that an authoritarian relationship only serves to further the patient's pathology. As he says, "Fromm (1956) summarizes the whole course of therapy as the patient freeing and curing himself of attachment to irrational authority" (p. 105). And Hirsch argues convincingly for a therapeutic relationship that breaks this irrational tie to authority rather than encouraging it.

Defining a New Relationship

The problem, of course, is to de...