Transference and countertransference in cognitive behavioral therapy

Transference and countertransference in cognitive behavioral therapy195• Demanding standards: Anankastistic or perfectionistictherapists often view patients as irresponsible, selfindulgent,and lazy. They believe that the expressionof emotions, or even uncertainty, is devastating. Theyhave difficulty expressing warmth and empathy towardpatients and place a great deal of emphasis on “logic“and “rationality“. The patient may feel that the therapyis simply an opportunity for the therapist to show thathe or she is smarter than the patient. Perfectionistictherapists may attempt to compensate his/her underlyingfeelings of incompetence and worthlessness bydemanding perfect performance from self and patient.A typical sequence of automatic thought can be: “Mypatient is not getting better I’m not doing my job I’ll be exposed as a fraud I’m a failure I can’t acceptany failure in myself.“ In some cases the therapistwith demanding standards can compensate for his/herperfectionism by demanding more and more from thepatient.• Abandonment: the therapist with an abandonmentschema will be worried that if he/she confronts the patient,then the patient will leave the therapy. Prematuretermination of the therapy is interpreted as a personalrejection of the therapist. Therapists concerned aboutabandonment issues can behave in many differentforms that reflect countertransference: for exampleon the one hand, excessive caretaking of the patient,or on the other, avoidance of entering into a meaningfultherapeutic relationship. Excessive caretakingtakes the form of trying to protect the patient fromany difficulties and taking on the patient’s problemsas the therapist’s own to solve. Therapists who avoidattachment on the other hand, often focus more onsuperficial techniques than on more meaningful personalissues. This type of therapist avoids difficulttopics with patients and refrains from using anxietyprovokinginterventions, such as exposure techniques.They often personalize the patient’s lateness, failureto show up for a session, or lack of interest in therapy.Patient’s resistance can be seen as a personal rejection.• Special, superior person: the narcissistic therapist viewstherapy as an opportunity to show of his/her specialtalents. Therapy with the resistant patient may beginwith grandiose hopes, expressed by the therapist thatthe patient has finally found the “right therapist“. Thetherapist’s investment in his/her own image as being aspecial, superior therapist may result in his/her sidingwith the patient to vilify all the other therapists whohave “failed“ the patient. This therapist feels entitledto having the cooperation and adulation of the patient.This may result in the therapist encouraging boundaryviolations by the patient or, in some case, the therapisthimself/herself may initiate these boundary violations.As the therapeutic relationship unfolds – if the patientdoes not make rapid progress – the narcissistictherapist may grow bored with, angry at, or punitivetowards the patient. He may label the patient “He’s aborderline, histrionic, paranoid, hypochondriacal...“Rather than empathize with the patient’s understanablefrustration with lack of progress, the therapistmay turn on the patient, blaming the patient for alack of desire to improve. To modify the narcissisticperspective, one needs to ask one question: “Whatwould your life be like if you had to walk in the shoesof this patient?“• Need for approval: The “pleasing“ therapist may behighly skilled in showing empathy for the patient. He/she wishes to make the patient feel good regardlessof what is going on, is averse to any expression ofanger or disappointment by the patient. The warmthand empathy of such a therapist are much appreciatedby many patients but he/she has difficulty recognizingthat borderline patients are very angry. Thistype of therapist will avoid raising questions about thepatient’s substance abuse, anger, resistance, and selfdefeat.These topics are viewed as too disturbing forthe patient, and therefore as not appropriate. Patientsmay act out by missing sessions, showing up late, ornot doing homework, but the high-need-for-approvaltherapist, who does not want to cause a “conflict“communicates the idea that acting-out behavior is acceptable.One therapist found it difficult to make thedecision to hospitalize a suicidal patient because ofhis/her concern that the patient would get angry withhim/her. The therapist may find that the patient’s angeris difficult to tolerate. He/she can personalize thepatient’s behavior and viewed the patient’s disapprovalas a sign of his/her own failing. His/her assumptionwas, “If the patient is angry at me, it means that Ifailed.“SELF-CORRECTION OF COUNTER-TRANSFERENCEBy anticipating and paying attention to such countertransferentialresponses, CBT affords the therapist the opportunityto recognize and manage such responses, whichreduces the therapist’s risk of retaliatory acting out 7 .Throughout the process of providing therapy, in additionto tending to the patient’s expressions, the therapisthas to make an effort to monitor his/her reactions to thecontent of the sessions. Therapist must take special careto recognize his/her strong emotional reactions to patient,both positive and negative; this is an opportunity to askhim/herself how much of what the patient is processingmatches the therapist s prior experiences or preexistingopinions.The therapist monitoring his/her (positive and negative)feelings, must be aware of these reactions:• Dreading or happily anticipating session with the patient;• Having exceptionally strong hateful or loving feelingstowards a patient;• Wanting to end sessions early or extend sessions;• Strongly wishing for or dreading termination.The first step in managing counter-transference is thetherapist recognizing that his/her feelings toward a patientare unusually strong, either positive or negative. It is use-