Countertransference, the phenomenon accounting for the therapist's emotional reactions to her patient, has been variously defined. In Freud's time, therapists regarded their emotional reactions to the patient as manifestations of their own ''blind spots''. In 1912, Freud stated that the therapist should behave:
.. .as a surgeon who puts aside all his own feelings, including that of human sympathy and concentrates his mind on one single purpose, that of performing the operation as skilfully as possible.
The metaphor of a surgeon who performs a clean-cut incision without the interference of his feelings profoundly shaped the analytic persona that many therapists internalised, supported by the armoury of the rules of abstinence, anonymity and neutrality (see Chapter 3). To this day, amongst some of the ego psychologists, the therapist's emotional reactions continue to be considered primarily a sign of unresolved issues in the therapist. Provided the therapist can monitor and analyse further her blind spots, she is thought to be free to function as the objective observer and interpreter of the patient's unconscious. It has been argued, however, that by restricting the countertransference to technical errors caused by the therapist's blind spots, Freud and the ego psychologists obscured the ''pervasiveness of the therapist's subjectivity" (Dunn, 1995: 725) in the therapeutic situation.
It was Heimann's (1950) work that redressed this skewed attitude towards the therapist's emotional responses. She drew attention to a different version of countertransference, one that favoured the therapist's emotional response to her patient as a technical tool, not a hindrance. This viewpoint profoundly influenced current contemporary practice. Bion's (1967) plea to resist the temptation of ''memory and desire''4 in the clinical situation in favour of reliance upon our emotional experience as the only ''facts'' available to us, signposts the contemporary emphasis on countertransfer-ence as a privileged source of knowledge about the mind of the patient. This position implies that we have access, through our own emotional reactions, to knowledge about the patient's state of mind without this knowledge needing to be communicated explicitly through the spoken word. Over the years, there has therefore been a marked shift from seeing countertransference as something that interferes with technique to viewing such responses by the therapist as a means of understanding the patient's unconscious communications, thereby acting as a direct guide for analytic interpretations of the current material.
From Kleinian and many object-relational perspectives, countertransfer-ence includes all the therapist's reactions to the patient, no matter what their source, allowing for greater tolerance of the therapist's subjectivity. In these approaches, our task is to understand who we come to represent for the patient and the internalised object relationships that are activated at any given point in time whilst simultaneously remaining connected with who we are when divested of these projections. This, as we all know, is easier said than practised because, as Dunn observes:
.. .the analyst's perceptions of the patient's psychic reality are also constructed through, and distorted by, the lens of unconscious fantasy. It is untenable to assume that the analyst is an objective observer, simply mirroring the patient's transference (1995: 725).
It is indeed difficult to see how it would be possible to reliably separate out our emotional reactions as a response to the patient's unconscious communication from our own so-called neurotic reactions. As Kernberg reminds us:
The analyst's conscious and unconscious reactions to the patient in the treatment situation are reactions to the patient's reality as well as to his transference, and also to the analyst's own reality needs as well as to his neurotic needs. This approach also implies that those emotional reactions are intimately fused (1965: 49).
In the course of any therapeutic relationship, we will experience temporary partial identification with our patients but our commitment is to relate
4Bion argued that memory was misleading because it was subject to the distortion by unconscious processes and desire (to cure) interfered with the capacity to observe and understand the patient.
to them as an "other" and not be confused with ourselves. This requires vigilant monitoring of our own projections as the interaction that evolves between us and the patient is determined by unconscious forces operating in both. Heimann provides a clear account of why this is so:
The mind.. .achieves adaptation and progress by employing throughout its existence the fundamental and basic processes of introjection and projection... Such taking in and expelling consists of an active interplay between the organism and the outer world; on this fundamental pattern rests all intercourse between subject and object... in the last analysis we may find it at the bottom of all our complicated dealings with one another (1943: 507).
More specifically, the suggestion is that the patient uses projective identification to dispose of unwanted aspects of the self into us. Projective identification, as we have seen in Chapter 6, assumes ''.. .a kind of pipeline from the unconscious of the patient to that of the analyst that facilitates direct transmission of mental contents from one to the other" (Jacobs, 2001: 6). Although the concept is inspired and clinically very helpful, it is important not to lose sight of the fact that "resonance is not the same as replication" (Jacobs, 2001). In other words, whatever the patient's projection onto or into us, this will be altered by our own personal experiences and phantasies. It can therefore never be the ''same as'' it is for the patient, but it may give us an approximate feeling of the patient's experience that we can employ to further our understanding of the patient.
The countertransference is now regarded by many, if not most clinicians as the fulcrum of therapeutic change. This position is, however, potentially problematic. In moving away from Freud's view of countertransference as reflecting the therapist's own blind spots that should be worked through, and therefore act as a cue for more personal analysis, we are now left with a concept potentially open to abuse. If what we feel, and how we may at times behave, can always be understood with reference to the patient's projections, we have here a neat way for explaining away behaviours that would constitute acting out on our part. Moreover, the importance of our emotional reactions has at times been so emphasised that the patient's actual experience and what he reports in a session are overlooked:
As recently as fifteen years ago, many therapists were reluctant to discuss their own feelings about patients, fearful that they might be criticised for them and that they were indicative of bad therapeutic practice. The situation today is completely different. If anything, it is sometimes difficult to get therapists to discuss the patient's material because they are talking about themselves and what they feel about the patient, rather than the reverse. (Giovacchini, 1985: 447).
Although our countertransference is a useful pathway to the unconscious of the patient, this has been so emphasised that there has been a neglect of those instances when countertransference responses interfere with our understanding of the patient. For example, there is some evidence to suggest that therapists who do not feel competent or have concerns about damaging their patients tend to have patients who break off treatment (Vaslamatzis et al., 1989). Likewise, therapists who are conflicted over their own aggression and have difficulties around loss tend to experience more problems working within brief therapy (Ursano & Hales, 1986). In Freud's initial meaning of countertransference, therefore, it is apparent that our own unresolved issues get in the way of helping the patient.
Countertransference in its more modern usage could therefore be said to both facilitate and potentially interfere with analytic work. As therapists, we do well to remind ourselves that we are not beyond the reality testing of the patient, nor are we beyond making mistakes. Therapeutic work presents us with opportunities to help our patients as well as opportunities to gratify our own needs, especially our need to be liked, to be needed or to be a saviour:
It is our natural and normal self-esteem needs operating as ever-present forces in analysis as they do in life that may, at times, constitute a significant source of difficulty for the analyst (Jacobs, 2001: 667).
Jacobs (2001) suggests that for defensive reasons patients often suppress, deny or rationalise their accurate perceptions of countertransference elements (i.e. the therapist's needs and conflicts) and do not confront their therapists with it. He helpfully reminds us that even though perception is filtered through transferential and projective identificatory processes, the patient may yet accurately perceive aspects of our behaviour.
When misused, the concept of countertransference gives us licence to discharge onto the patient our own unresolved conflicts. Nevertheless, when approached thoughtfully and with integrity, our emotional reactions to the patient are helpful guides to what the patient cannot articulate verbally. They provide us with important sources of information about the patient's mental state and his needs moment-by-moment. Taken together with our formulation of the patient's difficulties, and the history of the therapeutic relationship that we have developed with the patient, they provide one source of evidence for our eventual interpretations.
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