Transference and countertransference in cognitive behavioral therapy

190 J. Prasko, T. Diveky, A. Grambal, D. Kamaradova, P. Mozny, Z. Sigmundova, M. Slepecky, J. VyskocilovaPsychodynamic therapists view transference as a powerfultool in understanding the patient and eventually effectingchange. They believe that cognitive behavioraltherapists eschew transference as an intervention thatwould distract the patient from outside relationships andrisk therapeutic rupture 6 . Although the interpretation oftransference is not a central tool of cognitive therapy,automatic thoughts and feelings related to interactionswith the therapist are very much within the scope of explorationand may provide valuable opportunities for testingand modifying dysfunctional automatic thoughts 2,7 .A good therapeutic relationship is an important issue forthe effective treatment in cognitive behavioral therapy.Cognitive behavioral therapists generally aim to establishan open collaborative relationship at the start of therapyand then to work directly towards them without payingtoo much attention to interpersonal issues. Clinical competence,conviction, and consistency seem to predict amore successful psychotherapeutic outcome 8–10 . However,when working with difficult patients (e.g. patients withpersonality disorder, hypochondriasis etc.) psychotherapyis rarely strightforward. The dysfunctional schemas, beliefsand assumptions that bias the patient’s perceptions ofothers are likely to bias their perception of the therapist.The dysfunctional interpersonal behaviour strategies,manifest in the patient-therapist relationship. If theyare not addressed effectively, interpersonal difficultiesarising in the patient-therapist relationship can disruptthe therapy. However, these difficulties also provide thetherapist with an opportunity to directly observe anintervention rather than having to rely on the patient’sreport of interpersonal problems occuring outside thesessions 11 . Therefore transference and countertransferencefeelings/reactions are a valuable source of informationabout a patient’s (and therapist’s) inner world.TRANSFERENCE FROM THE COGNITIVEBEHAVIORAL POINT OF VIEWAlthough the word “transference” is not part of thejargon of cognitive behavioral therapy, examination ofthe cognitions related to the therapist apropos past significantrelationships is an integral part of assessmentand treatment within CBT 12,13 . The patient’s emotionalreaction to the dynamics of therapy and therapist areimportant especially in working with difficult patients.Always alert but not provoking, the therapist should beready to explore these reactions for more informationabout the patient’s system of thoughts and beliefs. If notexplored, possible distorted interpretations persist andmay interfere with the collaboration. If exposed, they oftenprovide rich material for understanding the meaningsand beliefs behind the patient’s idiosyncratic or repetitiousreactions. Some forms of therapy depend on theuse of transference. Simply stated, transference occurswhen the patient superimposes prior experiences on thetherapist 14 . The patient may perceive something about thetherapists personality, style, demeanor, or appearancethat may remind him or her of a significant person in thepatient’s past, such as a parent; hence, the patient may beginto respond to the therapist as the patient would to thatparent. Effective transference is facilitated by the therapistpersistently withholding self-disclosure, presenting as avirtually unbiased blank slate (tabula rasa) wherein thepatient is free to superimpose (transfer) his or her feelingsfor a significant person in his or her own life (a parent,spouse, sibling, peer, etc.) onto the neutral therapist 15 .This is not the aim of CBT. Self-disclosure, warm andempathetic atmosphere, collaborative relation and stresson the self-efficacy of the client may pollute this transferencepotential 14 .There are many telltale signs of transference. Theseare the same signs that suggest the presence of automaticthoughts during the session. E.g. there may be a suddenchange in the patient’s nonverbal behavior: sudden changein expression, abruptly switching to a new topic, stammer,block, pauses in the middle of a train of statements,slumping posture, clenching fists, kicking, tapping footand so on. One of the most revealing signs is a shift inthe patient’s gaze, especially if he/she has had a thoughtbut prefers not to reveal it 16 . When asked, the patient maysay, ”It is not important.” The therapist should press thepatient nonetheless, gently, as it might be important.The therapist should pay attention to any negative orpositive reactions to him/her that arise but should notdeliberately provoke or ignore them. He/she should bevigilant for signs of disappointment, anger, and frustrationexperienced by the patient in the therapeutic relationship.Similarly the therapist should be alert to excessiveidealization, praise or attempts to divert the attention oftherapy onto the therapist. These reactions open windowsinto the patient’s past and actual relations outsidethe therapy. The therapist would be unable to view themeanings or beliefs beyond these windows if the arousalof their own affective responses is viewed as a distractionto be controlled, avoided, or suppressed. Hoffartet al. 17 examined whether therapists’ emotional reactionsto their patients mediate the effect of personality disordersand interpersonal problem behaviours on the outcomeof treatment with a focus on an Axis I disorderand, whether the therapists’ reactions mediate the effectof personality disorders on the course of interpersonalproblems. Therapists completed a checklist of emotionalreactions to individual patients after the end of residentialcognitive or guided mastery therapy for 46 inpatients withpanic disorder with agoraphobia. The severity of DSM-III-R personality disorder was related to the therapists’insecurity feelings but not to interest or anger. A higherlevel of therapist insecurity feelings was related to lessreduction in self-reported agoraphobic avoidance duringtreatment, whereas the therapists’ emotions were unrelatedto symptomatic course after treatment. Therapists’insecurity feelings appeared partly to mediate the relationshipbetween patient severity of personality disorderand persistence of patients’ interpersonal dominance andnurturance problems.