Introduction to Countertransference in Therapeutic Practice

A Myriad of Mirrors

Paola Valerio

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138690103
• eBook ISBN: 9781315462073
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

While transference has been fully described in the literature, countertransference has been viewed as its ugly sibling, and hence there are still not as many reflective accounts or guidance for trainees about how to handle difficult emotions, such as shame and envy and conflict in the consulting room. As a counterpoint, this book provides an integrative guide for therapists on the concept of countertransference, and takes a critical stance on the phenomenon, and theorising, about the "so-called" countertransference, viewing it as a framework to explore the transformative potential in managing strong emotions and difficult transactions.

With an explicit focus on teaching, this book informs therapeutic practice by mixing theories and case studies from the authors' own clinical and teaching experiences, which involves the reader in case studies, reflection and action points. Countertransference is explored in a wide range of clinical settings, including in reflective practice and in research in the field of therapy, as well as in art therapy and in the school setting. It also considers countertransference in dream interpretation, in the supervision and teaching environment and in work with groups and organisations.

Introduction to Countertransference in Therapeutic Practice offers psychotherapists and counsellors, both practicing and in training, a comprehensive overview of this important concept, from its roots in Freud's work to its place today in a global, transcultural society.

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Part I

Countertransference in work with individuals

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Chapter 1

Between bodies

Working in the liminal zone with traumatised clients

Nicola Diamond and Paola Valerio

A skin surface . . . exists in its most radical state as a liminal zone, a threshold that is potentially shifting . . . on the borders of an inside-outside. It is precisely a border zone.

(Diamond, 2013, p. 160)

This chapter is based on a workshop that we facilitated at a Social Justice and Body Conference at Roehampton University in 2016 about countertransference and the liminal zone, or in-between space, in therapeutic work. In this chapter, we explore the countertransference as taking place in an interpersonal space where the clear borders between ‘I’ and ‘you’ seem to breakdown, and it is not easy in these moments to decipher if the affective state (often somatic in nature), derives from the analyst or the analysand.

Liminal derives from the Latin limens and means ‘threshold’; it refers to an ambiguous space. In anthropology, it is a term used when participants ‘stand at the threshold’ between the previous way of structuring identity and the transition to another emerging mode of being. A liminal space is undecidable, anticipatory and unknown, a transitional temporal dimension. It could be said to be a moment of creativity, where self becomes other in a communal activity. A liminal space in many ways encapsulates our thinking about the transference–countertransference relation, where the boundary of self and other organised around the ego breaks down, and there is a more intimate exchange between analyst and analysand. This liminal communication in the analytic encounter we will link to intersubjective and intercorporeal ways of being and we shall also root the transformation that brings about psychic change to this liminal ‘moment of meeting’.

Our focus is on working with trauma, as this kind of therapeutic work readily shows the limitations of conventional analytic approaches, which traditionally define the transference–countertransference experience as dominated by reflective processes and speech. In work with traumatised clients, the clinician is faced, often starkly, with the direct nature of the traumatic experience, which renders verbal transference interpretation unhelpful, involving the analyst in sensitising to these embodied and enacted styles of communications.

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In psychoanalytic therapy, there is a process of ‘working through’ in the transference relationship to the therapist. This can be difficult with severely traumatised patients, since telling the story is not always available to the traumatised patient, and interpretations can be too penetrative, abusive or simply too frightening in dissociative states when the attachment system is activated. Studies in memory research suggest that it may not be possible to tell the story or recover memories of abuse. This can be because the trauma was so overwhelming that it cannot be processed and the impact remains as an unprocessed affective state, or there is a form of amnesia, as in a number of cases of childhood abuse. We have noticed in our work that narration of experience is arrested when the patient has been neglected in childhood and there has been no validation of self so that the autobiographical fails to be elaborated and reflected on (Diamond, 2013; Valerio, 2011). This problem of accessing a verbal narration of experience renders affective communication as more direct and immediate in the room, via experiences that remain nonverbal and communicated in bodily form.

The therapeutic relationship, which involves expressing one’s vulnerability to a perceived more powerful other, leads to the activation of the attachment system, often of an abusive, disorganised pattern from childhood. Understandably less has been written about the impact on therapists and counsellors as witnesses and coauthors in the transference of such traumatic events which are conveyed in bodily form. This raises the question of whether present external reality may remain a continuing trauma – for both parties, and hence unmetabolised by the analyst who may also dissociate (Valerio, 2011).

Feeling bored or cut off from patient is very common in work with abused patients. We have come to see this in our practice often when working with clients who have been sexually abused or traumatised. We see this as a form of counterdissociation, for example, when clients are painting a very rosy picture of events or of people who have abused them. It is as if the analyst’s body mirrors theirs in cutting off from feelings which exist in the patient, yet without narrative and verbal recall of events. The thing about embodied countertransference reactions is that the therapist will also have periods of unawareness. The hope is to have enough active engagement with one’s own unconscious process to rapidly bring this into greater awareness so it can be worked with in the consulting room.

When it is impossible for traumatic events to be comprehended in their time, they cannot be restored to the generational history, and therefore cannot become history to the patient. Such events remain like ‘foreign bodies’; they are conveyed in their unmetabolised form as unprocessed affects which are passed down through the generations, who receive them in their unconscious minds and, more pertinently, bodies. Fraiberg, Adelson and Shapiro (1976) noted that there are negative patterns of attachment–reenactment that haunt us like ‘ghosts in the nursery’, and will repeat themselves in the mother’s way of treating her child. What Fraiberg is talking about is reenactment based on intergenerational transmission; the ‘ghosts’ relate to the associated affective experiences that are not remembered, the terror, the helplessness and humiliation that have undergone repression. Repression is not quite correct here, and dissociation, we would argue, is more accurate in terms of the mechanism of transmission; what gets inherited is not only the tendency to abuse but also the tendency to dissociate (Valerio, 2011).

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Arguably there has been a paradigmatic shift in psychotherapy; no longer is it ‘all in the mind’, but ‘in the body’. Both in theory and in practice, the focus is on the body, whether it is neuroscience, the importance of bodily memory or the way in which therapist and client communicate through the body. Countertransference communications are experienced affectively, by the therapist, feeling states or mood alteration, but often as a bodily reaction. Increasingly therapists are writing about this (Stone, 2006; Lemma, 2014; Orbach, 1999, 2010) and we now believe that an authentic ‘talking cure’ is not possible without some ‘interacting cure’, since enactment is often the communication wherein bodily memory is what is primarily accessed, and repetition and reworking is required in this nonverbal mode to facilitate the emergence of fertile thought and psychic transformation.

Current interdisciplinary thinking in psychoanalysis, developmental psychology and neuroscience is recognising the importance of the nonverbal level of communication and experience in depicting unconscious processes. Peter Fonagy argued (1999) that bodily memories cannot in fact be retrieved in psychoanalytic psychotherapy because these memories are largely preverbal and therefore cannot be accessed verbally. However, they can be accessed directly through action, as in the example of the sexually abused infant who acts out the memory through showing. The infant’s experience is enacted, in the way he or she plays with the dolls (Mollon, 2002; Valerio, 2011). In the same way, the client who persistently arrives late lets the therapist know through action what it’s like to be kept waiting by a neglectful parent (putting the therapist in her shoes), before words are found for the painful experience.

It used to be thought that the therapist observes the client’s subjective states; now there is recognition of a much more interactive process, which is interpersonal, and the therapist and client’s subjectivity is mutually involved. This is viewed as an intersubjective experience. Whereas interpretation had been seen as key, putting feelings into thought for the client, ‘the talking cure’, recent developments place greater emphasis on unconscious nonverbal bodily communications, interpretation being a more secondary process, tapping into this bodily mode of relating is seen as necessary if deep psychic change is to take place.

Intersubjectivity is now viewed as also intercorporeal (Diamond, 2013). Instead of contemplative thought, the emphasis is placed on enactment, what we do before we reflect, as a way of ‘knowing’, and this has changed the meaning of ‘acting out’. Hence ‘acting out’ is no longer simply viewed as a bad thing, as a way of evading thinking, but rather it is now seen as a required form of ‘acting in’, in order to find a way to reorganise past experience. Procedural body based memory as a nonverbal mode of relating has to be in play for more reflective and processed symbolic modes of thought to develop in the work. Embodied enactment is how the transference–countertransference interaction is expressed.

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One of us was working with a male patient whose father had committed suicide when he was 4 years old. He was talking about this in a very matter of fact way when the therapist’s eyes started to well up with tears. My own history is that I lost my father when I was not yet 2 years old. I felt embarrassed and relieved that my blurry eyes did not lead to actual tears. I sensed my patient had observed my disposition, and was watching carefully. I said something about his reluctance to acknowledge his loss, based on what we had been speaking about in previous sessions, that somehow keeping his father alive meant that he had not really been abandoned by him, and that he would not have to get in touch with his anger in relation to his father’s abandonment. But actually, I felt that it was only in our mutual and shared recognition, wherein he had witnessed my wound in the room, that he could now metabolise this verbal interpretation. I did not have control of my bodily response and could not have orchestrated this, what Stern et al. of the Boston School (1998) may refer to as a spontaneous ‘moment of meeting’, where my own experience was simultaneously a direct acknowledgement of his, an empathic joining.

I also wondered if the experience had been more healing for me, yet I felt almost sure that a similar comment at any other time would not have had an effect upon my patient. I say this because it is important to own what is mine, and yet the experience benefited the patient. There is a fine line between a productive ‘moment of meeting’ and one where there is an unhelpful breaching of boundaries where either the therapist’s identification with their own pain supersedes their response to the patient’s needs or/and the analyst’s narcissism prevails (Valerio, 2005).

The therapist cannot be reflectively aware at every moment, and is also unconsciously engaged in the relational process, and this can involve a ‘more messy exchange’ where it is not always so easy to disentangle what is mine and what is yours, and this fuzzing of boundaries can be considered part of the communication.

As noted, contemporary understanding identifies intersubjective and intercorporeal relating as the basis of an embodied transference–countertransference communication. Intersubjectivity brings a new paradigm to traditional psychoanalytic understanding. Freud described the phenomena of transference and countertransference, but it remained difficult to explain how feelings and affective-body states could be passed so readily from one person to another. If we think of two discrete persons in the consulting room, how is it that feeling-body states jump across such an unbridgeable gulf? Indeed, as Freud (1915) observed, it is rather like a form of telepathy:

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[I]t is a very remarkable thing that the unconscious of one human being can react upon that of another, without passing through the act of consciousness. . . . This deserves closer investigation, especially with a view to finding out whether preconscious activity can be excluded as playing a part in it; but, descriptively speaking, the fact is incontestable.

(p. 194)

Intersubjectivity is a paradigm derived from phenomenological philosophy and introduced through developmental psychology, notably by Colwyn Trevarthen (1978, 1979) to psychotherapy and related understanding, and this answers the question of how to overcome the unbridgeable gulf (Diamond & Marrone, 2003). This paradigm involves a number of philosophical thinkers, not only Habermas, whom Trevarthen refers to, but also Husserl, Heidegger and Merleau-Ponty, to name a few.

There is a much more intimate connection between self and other than had been traditionally assumed. Heidegger noted that the idea of the two discrete individuals with a measurable distance between them is based on a Euclidean geometric notion of space, and whereas human beings are not pure objects, we affect one another; Heidegger refers to this as ‘dwelling in one another’. Someone can walk into a room and immediately we can pick up their mood state and are affected by it; this can be keenly felt, ‘in the gut’ so to speak, and groups can be ‘contagious’ in the way they can spread ‘felt states’. This we know does not just happen in the consulting room, and intensifies when we are attached to someone and build a more intimate relationship. The client–therapist relationship is a special type of relationship of this sort, in which there is intense involvement and a deep attachment is formed.

There is so much evidence now, from neuroscience, developmental psychology, attachment studies, philosophy and relational psychoanalysis, that my bodily self is intertwined with the other from the first and throughout the life cycle. From attachment neuroscience literature (Schore, 1994, 2003, 2010), we know that the baby and mother are in an interaction, where they directly affect each other, and that biological processes are simultaneously altered in this process. The positive or negative interaction in the attachment relation can alter the production of brain cells, hormones and the nervous system, and the regulation and deregulation of these systems. This is not one-way traffic, since the mother is likewise affected by her baby; she is less vulnerable, but still affectively and physically affected. We also know from developmental psychology (Trevarthen, 1978, 1979) that the baby and caretaker are interacting in an interpersonal space. This is an interpersonal bodily exchange dominated by nonverbal bodily communication, referred to as intercorporeal in nature. From the first, the baby derives the sense of embodied self via the other’s mirroring and tactile interactions. This interpersonal bodily experience is something that carries on throughout our lives, and is happening all the time on less conscious levels in human interaction whatever age we are.

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We commonly think of the skin acting as a literal border, indeed a protective barrier that separates my body from others. Freud refers to ‘the ego [as] first and foremost a bodily ego; it is not merely a sur...

Table of contents

• Cover Page
• Introduction to Countertransference in Therapeutic Practice
• Praise
• Title
• Copyright
• Dedication
• Contents
• Notes on Contributors
• Foreword
• Acknowledgements
• Introduction
• PART I Countertransference in Work with Individuals
• PART II Countertransference in the Wider Context in Supervision, Teaching, Group Therapy and in Organisational Work
• PART III Countertransference in Reflective Practice, Research and in Case Studies Co-written with Patients in Treatment
• Index