Understanding Countertransference

From Projective Identification to Empathy

Michael J. Tansey, Walter F. Burke

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317758266
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Seeking to mediate between the "classical" view of countertransference as a neurotic impediment to the treatment process and the more recent "totalist" perspective, which assumes that the therapist's emotional response necessarily reveals something about the patient, Tansey and Burke stake out a thoughtful middle ground. They submit that the therapist's utilization of adequately processed countertransference reactions is in fact integral to treatment success, while arguing against the totalist assumption that the therapist's emotional to the patient must be revelatory in a direct and immediate way.

1

Introduction

The setting is a familiar one. Psychology and psychiatry residents, social work interns, postdoctoral fellows, and staff clinicians are seated in a circle for their monthly case conference. A tape recorder is present, and the resident whose work will be held up for scrutiny shifts nervously in his seat. At the designated time, the eagerly awaited consultant who is to discuss the case arrives promptly and moves to his chair, all eyes upon him. Small talk ceases as the invited guest is introduced.

The consultant asks a few brief questions: How old is the patient? How long and at what frequency has the patient been seen? What was the presenting complaint? Is there any particular problem with the case that the therapist wishes to be addressed? In the space of two or three minutes, these questions are answered by the therapist. Without further ado, the tape recorder is turned on and the audience listens attentively as a therapy session unfolds. Ten minutes into the session, the consultant leans over, pushes the stop button, smiles reassuringly at the presenting resident—who by this time is sweating bullets—and asks if anyone feels moved to comment on what has been heard.

There is a brief, uncomfortable silence. Finally, the boldest of the group ventures an observation about the patient’s dynamics and triggers a flurry of similar brief remarks by others. But the discussion fades quickly away. The members have come to hear not from one another but from the consultant, whose moment has now arrived. He does not disappoint. Turning to face the presenting resident, he proceeds to deliver a series of well-articulated formulations about the nature of the current therapeutic interaction, its relationship to the genetic history of the patient, and some feelings with which the therapist might be struggling that had not yet been mentioned. The presenter nods vigorously on all counts, and the consultant—who is clearly having a good day—goes so far as to predict a shift in the direction of the material that might be coming within the very session under examination. The recording is turned back on, to the wide-eyed anticipation of all, and—voila!—the predicted shift irrefutably occurs. The hour strikes, the consultant rises and quickly departs, leaving behind a room filled with buzzing, bedazzled conversation.

Variations in the foregoing scenario are extremely common. The format may include audio tapes, process notes, case histories, one-way mirror observation, or live interviews. The audience may consist of trainees or even experienced clinicians. Such experiences for the participants are often tremendously energizing and inspirational, providing exposure to identificatory models who demonstrate the highest levels of clinical acumen. There is, however, frequently a problem that accompanies the sense of awe and mystification engendered by the seemingly dazzling ability of the gifted and experienced clinician. All too often, the audience is left to wonder just how these clever formulations and predictions were constructed. Therein lies a serious didactic gap in clinical training and preparation for which the therapist, especially the newly initiated, often comes to feel privately responsible.

It is undeniable that at the heart of any sophisticated formulation is the ability to be empathic. Indeed, the very term empathy has become the password of self psychology, representing an entire school of thought within the psychoanalytic spectrum. Kohut, the founder of the self-psychological movement, wrote the following widely quoted passage in a landmark paper on the subject (1959): “We speak of physical phenomena when the essential ingredient of our observational methods includes our senses, we speak of psychological phenomena when the essential ingredient of our observation is introspection and empathy” (p. 460).

What is this creature, empathy? Is it an inborn trait? Can it be discovered or enhanced through personal analysis or psychotherapy? To what extent is empathy teachable? All too often, the clinician is given the vague directive, “Go inward, young man!” and nothing more. Despite the emphasis on its centrality to the therapeutic process, the empathic process remains, for many, as mystifying as ever.

The demystification of the empathic process stands out as a primary goal in this volume. We submit that empathic ability— like intellectual, musical, or athletic ability—may well be in large measure a function of genetic inheritance in conjunction with life experience, especially early life experience. We strongly agree with the widespread consensus that personal analysis or psychotherapy is enormously valuable in potentiating innate empathic sensitivity. All these factors, however, do not preclude the importance of clinical training and instruction in the development of empathic ability. We shall delineate the various elements of the empathic process and hope thereby to increase the reader’s opportunity for learning the inner workings of this mysterious phenomenon.

Our study of the empathic process has inexorably led us in the direction of countertransference theory and, along the way, to an equally intensive study of the phenomenon of projective identification. We use the term countertransference theory as one uses the term psychoanalytic theory, recognizing that it encompasses a spectrum of positions that are often contradictory. Our position on countertransference theory falls firmly within the totalist (Kernberg, 1965)—as opposed to the classical—perspective, the former approach holding that countertransference, broadly defined as the totality of the therapist’s experience of the patient, represents a potentially useful tool in coming to understand the patient and in furthering the objectives of the treatment. Within the tradition exemplified by what Gill (1983) has referred to as the “interpersonal paradigm of psychoanalysis,” we maintain that psychoanalytic therapy is a radically mutual process fully involving two individuals who exert a mutual and ongoing influence upon one another. Far from seeking to become a blank screen, impervious to the patient’s influence, the well-functioning therapist strives to appreciate the ways in which he is being acted upon by the patient. Sandler’s (1976) idea that a compromise exists between the therapist’s unique personality makeup and the patient’s ability to infuse the therapeutic relationship with his own particular wishes and needs is especially useful in assessing the degree of influence exerted by the therapeutic interaction upon the self-experience of the therapist.

Insufficient recognition of the way in which the therapist is acted upon by the patient has contributed to a failure to appreciate the relationship between empathy and projective identification. In the pages that follow, we propose to expand upon our earlier formulation (Tansey and Burke, 1985) that the mechanism of projective identification from the patient is always involved in the therapist’s achieving empathic contact; and, conversely, that when a patient engages in projective identification, there is always the potential for the therapist to achieve an empathic outcome, whether or not this potential is actualized. Although empathy and projective identification have often been thought to be unrelated—if not downright antipathetic—we intend to develop our position further that they represent intimately related aspects of a unitary sequence for the therapist’s processing of “interactional communications.” By interactional communications, we mean all communications, both in words and in actions, that are transmitted consciously and unconsciously through the interaction by both patient and therapist. Because projective identification from a patient has the potential to lead to the stormy countertransference developments with which it is typically associated, we also shall broaden the scope of our previous examination (Burke and Tansey, 1985) of disruptions in the empathic process.

Numerous authors—notable among them Ogden (1979,1982) and Gill (1984)—have emphasized the need for a redefinition of traditional psychoanalytic concepts in order to integrate interpersonal and intrapsychic perspectives. Empathy, projective identification, and countertransference are three major bridging concepts that include both intrapsychic and interpersonal elements. We shall elucidate the interrelationship between these concepts by specifying the reciprocal influences of the interpersonal field and the intrapsychic experience for each of the three phenomena.

The format of the book is as follows. Chapter 2 presents an historical review and synthesis of the psychoanalytic literature dealing with the concepts of empathy, projective identification, and countertransference, which have frequently been considered separate and unrelated aspects of the therapist’s identificatory experience. In arriving at a different conclusion, we trace the historical progression of stages in the understanding of the therapist’s identificatory experience. This progression began with the acknowledgment (which took nearly 40 years to accomplish) that a therapist often responds with powerful emotions to his work with given patients and that this reaction does not necessarily indicate a pathological impingement from the therapist on the therapeutic process. The literature continued to evolve through the late 1940s and 1950s in the direction of emphasizing the potential usefulness of such powerful emotional responses. More recently, major efforts have been made to specify the varieties of countertransference experience. Having reviewed some of the gross and subtle distinctions in the uses of various terms, chapter 3 provides careful definitions of important terms as we are using them so as to obviate confusion. In addition, we elaborate our position that complementary identifications on the therapist’s part are to be included in the empathic process, and we discuss what we consider to be the intimate relationship between empathy and projective identification.

Chapters 4–7 present an expanded version of our unitary sequence for the processing of interactional communications. We propose a schema—rather than a cookbook recipe—that details the phases and subphases whereby a therapist receives a patient’s projective identification, processes it internally, and then communicates, both verbally and nonverbally, to the patient. With many brief clinical vignettes, there is extensive discussion of the countertransference experience as it may lead both to productive empathic outcomes and to disruptions in the empathic process. Specific subphases afford a comprehensive understanding of where disruptions may occur and how they can be addressed.

Validation of clinical hypotheses—whether countertransference based or not—is an area of glaring weakness in the psychoanalytic literature. In chapter 8, this thorny and elusive matter is examined. The simple fact that a therapist experiences one affective state or another while working with a given patient is by no means a guarantee that this feeling is in any way a useful tool for understanding the patient better. The effort to make sense of clinical material—including but not limited to countertransference material—is inescapably an inferential, hermeneutical enterprise. We divide countertransference-based hypotheses into two categories—those which pertain to the determination of the source of the countertransference experience and those which pertain to the underlying meanings for the patient of the countertransference experience. Following upon Schafer’s (1954) recommendations relative to the interpretation of Rorschach inkblot responses, we propose five “lines of inference” for each category of validation (source and meaning). Among the five lines of inference, the therapist must seek converging support for his hypotheses.

Chapter 9 focuses on the uses and abuses of countertransference disclosure to a patient. We review the psychoanalytic debate over countertransference disclosure as well as the accompanying technical and theoretical implications. In keeping with the consistent attempt throughout this volume to move back and forth between theoretical abstraction and the nuts- and-bolts of everyday clinical implementation, we differentiate useful from disruptive countertransference-based interventions by concentrating on the preparation, implementation, and ultimate impact of disclosive interventions.

Chapter 10 comprises three extended clinical vignettes that operationalize, in very concrete terms, the unfolding of the empathic process. All three are difficult cases, involving powerful projective identifications from patients contributing to counter-transference responses which are problematic. In closing, chapter 11 pulls together the various threads of this volume and suggests some new directions for future efforts.

The consultant in our opening vignette was not the Delphic oracle, but rather a gifted clinician who had learned to absorb material in a variety of different ways and to direct his “evenly hovering attention” not only to information coming from the outside but also to subtle responses emanating from within. This book is written not only for young clinicians whose needs are obvious, but also for experienced clinicians who are interested in methodological guidelines for becoming more systematic in teaching, supervision, and the objective scrutiny of their own subjective experience.

2

Countertransference, Empathy, and Projective Identification

An Historical Perspective

Examinations of the experience of the psychoanalytic therapist have traditionally fallen under the heading of countertransference and—for those authors who make this distinction— noncountertransference. The clinical processes of empathy and of projective identification also figure prominently in efforts to understand the arousal of identificatory experiences for the therapist. Whereas empathy is typically related to a therapist’s skillful functioning, projective identification is commonly associated with countertransference turmoil. In subsequent chapters we develop the argument that the processes of empathy and projective identification, far from being unrelated or even antipathetic, are in fact intimately related in a way that is critical to the fullest possible understanding of countertransference responses to virtually all patients. The strongest and most obvious link between empathy, projective identification, and countertransference is that all three involve the arousal of an identificatory experience—whether transient or enduring— on the part of the therapist.

Our intention here in the present chapter is to trace major historical trends in psychoanalytic approaches to countertransference theory. The historical development of this literature comprises three stages. First, clinicians and theoreticians, struggling with the goal of “scientific objectivity,” had to acknowledge that identificatory experiences for the therapist— even those of a powerful nature—occur with regularity. This acknowledgment made possible subsequent efforts to use the emotional experiences of the therapist constructively within the treatment. The progression has culminated in current attempts to specify the varieties of countertransference experience with increasing clarity.

Advances in psychoanalytic understanding of the identificatory experience of the therapist-in-interaction have frequently come as the result of mutually enriching cross-fertilization between the theoretical developments of empathy, projective identification, and countertransference. This enrichment has occurred despite the frequent involvement of opposing theoretical perspectives within the psychoanalytic community. In his 1965 review of the countertransference literature, Kernberg distinguished between the “classical” and the “totalist” approaches to countertransference. The former restricts the concept of countertransference to the therapist’s unconscious, pathological reactions to the patient that reflect unresolved conflicts that need to be overcome in order for the therapist to work well with the patient. In contrast, the totalist approach broadens the concept to include the therapist’s total response to the patient—conscious and unconscious, “real” and neurotically “distorted.” The totalist camp argues further that the usual distinction between the therapist’s so-called realistic perceptions and his neurotic perceptions is fallacious, since perceptions virtually always involve elements of past and present reality. The classicist views countertransference as a pathological impediment to be overcome; the totalist views it as a potentially useful tool for understanding the patient. As will become clear, the disagreement is partly substantive and partly attributable to different definitions of terms.

1910: Freud’s Seemingly Contradictory View of Countertransference

To understand the apparent schism that exists in countertransference theory, we must reexamine Freud’s introduction of the term in 1910:

We have become aware of the “counter-transference,” which arises in the physician as a result of the patient’s influence on his unconscious feelings, and we are almost inclined to insist that he shall recognize his counter-transference in himself and overcome it [p. 144].

The question arises as to what Freud meant by “overcoming” countertransference. Did he mean eliminate the countertransference response, which is to be regarded only as an impediment deriving solely from the analyst’s unresolved conflicts; or did he mean attempt to analyze and understand the experience, thereby reducing its intensity? The first interpretation coincides with the classical view; the second accords with the totalist. In the same paper, Freud prescribed a self-analysis for the analyst, stating that “anyone who fails to produce results in a self-analysis of this kind may at once give up any idea of being able to treat patients by analysis” (p. 145).

Beyond these initial penetrating comments, Freud wrote very little on countertransference. In his 1912 technical paper, he alluded to the subject in the following widely quoted passage:

I cannot advise my colleagues too urgently to model themselves during psychoanalytic treatment on the surgeon, who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible …. The justification for requiring this emotional coldness is that it creates the most advantageous conditions for both parties: for the doctor a desirable protection for his own emotional life and for the patient the largest amount of help we can give him today [p. 115].

Both of the foregoing passages are invoked as support for the classical view. A case can be made, however, that Freud’s writings also contain the seeds for the totalist perspective on countertransference, defined broadly as the therapist’s total response to the patient.

For example, in the two paragr...