Transference and countertransference in cognitive behavioral therapy

Transference and countertransference in cognitive behavioral therapy193of the therapist. Explicit discussion of the patient’s ongoingrelationship with the therapist is compelling when itis accurate. Focus on the transference makes it possiblefor the patient (and therapist) to become directly awareof the distinction between reality and fantasy in the therapeuticencounter. However, in brief therapy, transferenceinterpretations may be too anxiety-provoking.COUNTER-TRANSFERENCECounter-transference occurs when the therapist reactsin complementary fashion to the patient’s transference.Attention to emotional reactions of both patientand therapist is a fundamental component of cognitivebehavioral therapy, especially during the process of therapywith difficult patients. Despite the manualization oftreatment and emphasis on techniques and pharmacotherapy,countertransference exists. No therapist is freeof countertransference. To guide patients effectively indiscovering their thoughts and expressing their feelings,the therapist needs to have a foundation of skills for recognizing,labeling, understanding, and expressing his/her own emotions 16 . To understand our own limitations,our own resistance to change, is necessary to discovermore about the patient and ourselves; as we learn how thepatient’s behavior affects our own countertransference,we are also learn about how the patient affects others 23 .Rather than having no feelings, or being an expert at repression,the cognitive therapist is attuned to personalemotions that might affect the therapy environment. Justas the therapist would encourage a client to do, cognitivebehavioral therapists use awareness to their own physicalsensations and subtle mood shifts as cues, suggestingthe presence of automatic thoughts. Any changes in thetherapist’s typical behavior might signal an emotional reactionand associated automatic thoughts, such as talkingin a commanding (or hesitating) tone of voice, increasedfrequency of thoughts about a client outside sessions, orperhaps avoidance of returning a client’s phone call ortardiness in starting or ending a session.TYPES OF COUNTER-TRANSFERENCEBetan et al. 24 studied a national random sample of 181psychiatrists and clinical psychologists in North America.Each completed a battery of instruments on a randomlyselected patient in their care, including measures of axisII symptoms and the Countertransference Questionnaire,an instrument designed to assess clinicians’ cognitive, affective,and behavioral responses in interacting with a particularpatient. Factor analysis of the CountertransferenceQuestionnaire yielded eight clinically and conceptuallycoherent factors that were independent of clinicians’ theoreticalorientation: 1) overwhelmed/disorganized, 2) helpless/inadequate,3) positive, 4) special/overinvolved, 5)sexualized, 6) disengaged, 7) parental/protective, and 8)criticized/mistreated. The eight factors were associatedin predictable ways with axis II pathology. An aggregatedportrait of countertransference responses with narcissisticpersonality disorder patients provided a clinically rich,empirically based description that strongly resembledtheoretical and clinical accounts.Countertransference patternswere systematically related to patients’ personalitypathology across therapeutic approaches, suggesting thatclinicians, regardless of therapeutic orientation, can makediagnostic and therapeutic use of their own responses tothe patient 24 .In some cases, the focus on the patient’s problemsmay allow the therapist to compartmentalize and avoidhis/her own personal problems or allow the therapist todisplace his/her conflicts with others onto the patient 23 .Some people are attracted to being therapists becauseit allows them a sense of competence, superiority, andapparent efficacy. This illusion of competence may allowthe therapist to unconsiously pursue other goals, such asthe need to have power or control, or the need to compartmentalize,intellectualize, and isolate oneself fromone’s own problems.Table 2. Examples of the counter-transference and possible strategies for a change.Type ofcountertransferenceModeratepositiveAdmiringOverprotectiveExamples of typicalthoughtsI like him, he is nice,good cooperation withhim, he will do well.That person is special(especially beautiful,original, intelligent, etc.)He cannot make decisionson his own, Leedshelp, advice, it will be myfault, if something wronghappens to him.EmotionalreactionsBehaviorNice tune Cooperation, support, empathy NoneAdmiration,fascinationFear, insecurityTherapist does not make appropriateexaminations, does not conduct thetherapy. Possible non-compliance ofthe patient is deprecated, does notrequire patient’s homework, tends totalk about the exceptional propertiesof the patientHe gives advice, protects, ensures,takes control over the patient, doesnot allow patient’s independentdecision making, doubts patient’sabilitiesStrategies of changeClarify own attitudes, their background, the effecton the behavior, advantages + disadvantages for thetherapy. Supervision needed. “Normalization of thetherapy”: conduct the same way like the others. In casethat the behavior is impossible to change and make astandard therapy, necessary to open that problem withthe patient or the patient should change the therapistClarify own attitudes, their background, the effecton the behavior, advantages + disadvantages for thetherapy. Supervision needed. Stop the directive leadingof the therapy, let the patient plan things, stop ensuring.Otherwise the patient should change the therapist.