Countertransference in Psychoanalytic Psychotherapy with Children and Adolescents

Dimitris Anastasopoulos, Brian V. Martindale, Anne-Marie Sandler, John Tsiantis, Dimitris Anastasopoulos, Brian V. Martindale, Anne-Marie Sandler, John Tsiantis

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429912344
• Edition: 1
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

This collection of papers from psychoanalysts across Europe is intended to highlight the similarites and differences between approaches to working with children and adolescents. Part of the EFPP Monograph Series.

CHAPTER ONE


Countertransference issues in psychoanalytic psychotherapy with children and adolescents: a brief review

Dimitris Anastasopoulos & John Tsiantis

The development of the concept of countertransference

The aim of this chapter is to present a selected review of the concept of countertransference and to follow its historical development, giving an overview of countertransference phenomena as it applies to psychotherapy with children and adolescents.

The first reference to countertransference comes in 1910, in a short essay by Freud entitled The Future Prospects of Psycho-Analytic Therapy” (1910d). Freud returns to the subject in the 1915 publication “Observations on Transference-Love” (1915a) in which he refers specifically only to erotic countertransference reactions. In both articles, Freud describes countertransference as an obstacle to psychoanalytic treatment and a “result of the patient’s influence on his [the therapist’s] unconscious feelings” (1910d, p. 144). It has been suggested (Brandell, 1992) that it was his work with hysterics and the Dora case (Freud, 1905e) (which included powerful erotic transference components) that led him to identify erotic countertransference as a significant hindrance to the psychoanalytic process. Unfortunately, Freud never published an article specifically on countertransference.

Much has been written since Freud’s time to develop and expand our understanding of countertransference phenomena. It was a significant development for psychoanalytic literature when countertransference began to be seen as a phenomenon of importance in helping the analyst to understand the patient. It was Paula Heimann who introduced the positive value of countertransference. Heimann (1950) describes it as “an instrument of research into the patient’s unconscious” (p. 81), concluding that the therapist’s countertransference is a “creation” of the patient, “a part of [his] personality” (p. 83).

Heinrich Racker (1968, pp. 134-135) has made a powerful contribution to the literature. In his well-known book, Transference and Countertransference, Racker accepts that countertransference phenomena are ubiquitous and that all the therapist’s emotional reactions to the patient are born of countertransference, in analogy to the patient’s transference.

Racker distinguishes two kinds of countertransference: direct countertransference, which occurs as a response to the patient’s transference, and indirect countertransference, which is a response to any important figure outside the analytic situation (supervisors, colleagues, the patient’s relatives or friends, and anyone else whose good opinion may be of interest to the therapist (Racker, 1968, p. 136). Racker further expanded his views to suggest that countertransference consists of two processes:

1. Concordant or homologous identification: in this type of countertransference, the therapist “identifies each part of her personality with the corresponding psychological part in the patient” (Racker, 1968, p. 134). Such countertransference is based on introjection and projection and is more or less the same as what others have called empathy.

2. Complementary identification, which is an “identification of the analyst’s ego with the patient’s internal objects”. It is “produced by the fact that the patient treats the analyst as an internal (projected) object, and in consequence the analyst feels treated as such; that is, he identifies himself with this object” (Racker, 1968, p. 135).

Racker thinks of countertransference as both the greatest danger to psychoanalytic work and as an important tool for understanding the patient during it. He also makes a distinction between the countertransference position, when the therapist is experiencing the feelings and attitudes without acting or intervening, and the countertransference response, when the therapist’s tolerance has been overcome by feelings that are acted upon, leading to intervention.

A notable contribution was made to the debate by Winnicott in his paper “Hate in the Counter-Transference” (1947). Winnicott suggests that countertransference should be seen as a therapeutically useful source of information about the intersubjective field and as a significant instrument for understanding aspects of the patient’s personality. He, too, describes two kinds of countertransference: one that is a pathological response on the part of the therapist (close to the traditional view), and another that is referred to as “objective countertransference” and described as “the analyst’s love and hate in reaction to the actual personality and behaviour of the patient” (p. 194).

Little (1951) pointed out that not only do the analyst’s feelings mirror the patient’s feelings, but also the patient’s feelings mirror the analyst’s feelings and he often becomes aware of real feelings in the analyst before the analyst becomes aware of them. Little proposed the rather extreme view that the therapist should reveal her countertransference feelings to the patient.

Little (1951), Kohut (1971), and Shane (1980) have also contributed to the “totalistic” view of countertransference. According to them, the universal (totalistic) view of countertransference, which was epitomized in Kernberg’s article of 1965, sees countertransference as the total response of the child analyst to the patient, the parents, and the therapeutic situation. The analyst’s reaction reflects her characterological structure and personality traits (both healthy and conflictual) in response to the specific and general behaviour of the patient. It also includes reactions stemming from culturally determined attitudes, together with unintegrated identification(s) and unresolved transference issues towards the training analyst or other important persons in the therapist’s life.

Giovacchini (1981) has also made an important contribution to the field of countertransference, especially where countertransference problems in therapy with adolescents and severely disturbed adults are concerned. Although he emphasizes that unrecognized countertransference can have a deleterious impact upon treatment, he notes that countertransference is ubiquitous and to be found in every analytic interaction.

Giovacchini distinguishes two varieties of countertransference:

1. The homogeneous, which he sees as a rather predictable reaction due mainly to the patient’s psychopathology and attitudes and which would cause more or less the same reactions in most therapists.

2. The idiosyncratic, which is a reaction arising from the unique qualities of the therapist’s personal history and make-up (Giovacchini, 1985, p. 449).

Alvarez distinguishes between countertransference and what she calls “empathie perception” (Alvarez, 1983). In her article in this volume (chapter seven), she uses a narrow definition of countertransference, arguing that it includes “only the feelings aroused or evoked in the therapist by the patient” and not “a perception of something going on in the patient, which is unaccompanied by a similar or related feeling in the therapist”; the latter is what she calls an empathie perception. She believes that these perceptions are also useful for picking up previously unrecognized elements of the patient, but they are not countertransference.

In the traditional definition, what we might call “countertransference proper” includes the analyst’s unconscious reaction towards the patient’s transference, which is quite specific and originates in unresolved conflicts that complement those of the patient. The difference between the classic and the totalistic approaches to countertransference are discussed in detail by Brandell in his book Countertransference in Psychotherapy with Children and Adolescents, in which he gives a comprehensive review of the literature. He tabulates authors as being of Totalistic, Classicist, or Other orientation according to their theoretical conception or definition of countertransference (Brandell, 1992).

The definition of countertransference given by most authors, however, approximates to that of Epstein and Feiner (1983): that is, they see it as the therapist’s contribution to the therapeutic situation. It is an inevitable, normal, and natural interpersonal event, involving a therapist who is a genuine co-participant in an ongoing process. Countertransference is thus a more-or-less direct reaction to the patient’s transference. Marshall (1983) has proposed a categorization of countertransference reactions according to whether they are conscious or unconscious and whether they derive from the patient’s particular make-up and psychopathology or come from the unresolved conflicts and particular background of the therapist. We should also mention Joseph Sandler’s view of “countertransference and role responsiveness”. The patient, he argues, brings into the therapeutic relationship infantile role relationships that he seeks to express or enact, as well as the defensive role relationships that he may have constructed and may wish to impose upon the analyst, thus experiencing the role relationship as a vehicle for gratification. Sandler’s view is that the analyst’s “role responsiveness” shows itself not only in her thoughts and feelings but also in her overt attitudes and behaviour, as a crucial element in what he calls the therapist’s “useful” countertransference (Sandler, 1987). Others, such as Fliess (1953), Glover (1955), and Reich (1966), would define as countertransference any irrational response on the part of the therapist, and not only those stimulated by transference.

Finally, Brandell (1992, p. 2) points out that “differences in the experience of countertransference are more often associated with such factors as the patient’s and the therapist’s personalities and the unique quality of the intersubjective discourse that develops in a particular treatment situation” than with which of the two treatment methods is used (i.e. child psychotherapy or child psychoanalysis). We share that view, and this brief review of countertransference in child and adolescent psychotherapy thus makes reference to both therapeutic modalities. Anyway, it is useful to have in mind that countertransference phenomena can have a powerful effect on psychotherapy either as a useful therapeutic tool in one’s work with patients, or as a hindrance with negative influence if the therapist is not aware of the origin of her own feelings.

Countertransfer ence and projective identification

We believe it would be useful to explore briefly the relationship between projective identification and the concept of countertransference.

Projective identification ought probably to be seen as an evolving psychoanalytic concept on this subject, and one that only in recent years has come to be accepted by an increasing number of analysts and psychotherapists, regardless of their school. An explanation of the theoretical differences and different view points goes beyond the scope of this chapter but can be found in Joseph Sandler’s comprehensive study, Projection, Identification, Projective Identification (1988).

Melanie Klein (1946) connected projective identification with the process of development and also with the distortion of the analyst’s image in the fantasies of the patient, though not—directly—with countertransference, which she saw as an obstacle to analysis (Klein, 1957).

Heimann gave projective identification a central and unique role in the development of countertransference phenomena, stating that in her opinion countertransference was “created by the patient” and contained “part of his personality” (Heimann, 1950, p. 83).

Racker linked the countertransference reactions on the part of the therapist to the mechanism of projective identification in the patient, arguing that it led to the analyst’s identification with the self or object representation with which the patient, too, identified her in the projection. As we have already seen, this allowed him to distinguish between concordant countertransference and complementary countertransference (Racker, 1968).

The interaction and cross-influence model of Bion (1962, 1963), which used the concepts of the container (which receives projection) and the contained (what is projected by the subject onto the object) is, of course, based on the mechanisms of projective identification, which it links directly to countertransference.

Rosenfeld is among the authors who have written extensively on the role played by projective identification in countertransference in work with schizophrenic, psychotic, and borderline patients (Rosenfeld, 1987). More specifically, Rosenfeld states: “Not only does it affect the aspects of the self which are moved about but the object under the influence of projective identification is strongly affected by it”; and a little further on: “Projective identification can include transformations of the self, and the object, leading to confusion, depersonalization, emptiness, weakness and vulnerability to influence which goes so far as being hypnotised or even put to sleep” (p. 170).

Joseph (1988) points out that although projective identification is a fantasy, it has a strong effect on its receptor. If the analyst is open and capable of recognizing what she is experiencing, it can be a very powerful method of understanding the true wealth of the phenomena of countertransference. Joseph argues that by means of the mechanisms of projective identification the therapist can be brought to the point of adopting attitudes and feelings that do not belong to her but are parts that the patient has projected on to her.

Kernberg (1988) argues that projective identification is the predominant psychic mechanism which (as in the case of very regressed patients) can cause such intense countertransference reactions in the therapist that she has to work them through outside the therapeutic sessions in order to be able to understand them.

Grinberg (1979) elaborates the concept of projective counter-identification in countertransference as a mechanism for describing the analyst’s reaction—or a significant part of it—that belongs to the intensity and unique quality of the patient’s projective identification. He thus sees countertransference as stemming from activation of the neurotic parts of the analyst.

Grotstein accepts Grinberg’s term “projective counter-identification” as a particular kind of countertransference. He argues that both projective identification and projective counter-identification are perceived by the analytical therapist as an “alteration in his state of mind while listening to the patient” (Grotstein, 1985, p. 200). He goes on to note that it is the therapist’s ability to contain that will convert this experience into something meaningful for the patient and the therapeutic process.

Feldman (1992) reports that in many cases the therapist has to deal not only with fantasy projections onto the object, thus ascribing to it capacities that originate in the psychic state of the patient, but also an active and dynamic process in which the psychic state of the object is affected by the projections.

To conclude, countertransference can be seen—in accordance with the authors cited above and with others who agree with their position—as the therapist’s reaction to the patient’s projections into her. The reaction may stem either from the stimulation or awakening of immature neurotic parts of the therapist herself or from the creation or generation of feelings and fantasies that are wholly to be attributed to the intensity and quality of the patient’s projective identification. Needless to say, the more emotionally open (and thus ready to accept projection) the therapist is, and the more regressed the patient is, the greater will be the likelihood of the formation of powerful countertransference reactions which can be used to understand the material during therapy. It would seem that both these conditions would also apply to psychotherapeutic work with children and adolescents.

Countertransference in child psychotherapy

One would have expected that in parallel with the development of countertransference theory and technique in therapy with adult patients, there also would have evolved delineation’s of different kinds of countertransference emanating from the psychoanalytic psychotherapy of children. However, this was long delayed, and such themes have begun to appear in the literature only in recent years. Some possible explanations of this have been advanced, and the most important of them are described below.

First of all, there was a long delay in the general recognition and acceptance of transference neurosis in the analysis of children. Secondly, the absence of any concern about countertransference in the past may also have been a reflection of the special nature of the personality of child therapists, regardless of their pre-analytic background. The first child analysts were predominantly educators (Kohrman, Fineberg, Gelman, & Weiss, 1971), and they dealt with children from the lower socio-economic strata; adult therapists, however, work in the medical mode, in which there is a distinct distance between patient and therapist. This gave rise to confusion in psychotherapeutic technique between the pedagogical and the psychotherapeutic type of intervention. Apart from its other differences from psychotherapy, the pedagogical intervention meant that the therapist became a parental surrogate, gratifying the needs of the child without maintaining a stance of analytic neutrality. In this context, Temeles (1967) notes that gift-giving in child psychotherapy was used at this time—in part, at least, because the children treated were deprived and in part because of social stereotypes about childrearing. This approach reflected, inter alia, loyalties, identifications, and unresolved transference by the therapist to teachers, who were closely identified with these issues. The pedagogic attitude to child psychotherapy, stemming from tradition and theory, supports the acceptability of such counter-reactions. It is difficult to say which came first: the technique, the theory, the loyalty to and identification with the teacher, or a countertransference reaction that became justified or acted out and defended through the technical modification used subsequently.

Factors evoking countertransference reactions

We now move on to a description of the factors that are the cause of countertransference reactions in child and adolescent psychotherapy and which may be triggered by the therapist herself, by the child, by the parents, or by the particular features of the therapeutic relationship.

Although countertransference always “comes” from the therapist, a countertransference response can be triggered by the psychopathology of the patient or some other element in the situation which is the result of a “fit” between patient and therapist. If the therapist’s response is at least partially based on her early needs and is not solely the result of the influence of the patient, then we can talk about countertransference in the totalistic definitive. Clearly enough, most reactions include some component of countertransference (Schowalter, 1985). Furthermore, countertransference refers to both the influence of the past on the therapist’s anxieties and feelings about the child or the parents and the influence that they have on the psychotherapist’s feelings and associations. Even if countertransference feelings denote elements of the therapist’s unresolved conflicts, they still express a response to the distress and most painful anxieties of...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Acknowledgements
• About the Authors
• Table of Contents
• Foreword to the Series
• Introduction
• Chapter One Counter-transference issues in psychoanalytic psychotherapy with children and adolescents: a brief review
• Chapter Two Thoughts on countertransference and observation
• Chapter Three Reflections on transference, countertransference, session frequency, and the psychoanalytic process
• Chapter Four Some problems in transference and countertransference in child and adolescent analysis
• Chapter Five The transference mirage and the pitfalls of countertransference (with special emphasis on adolescence)
• Chapter Six The influence of the presence of parents on the countertransference of the child psychotherapist
• Chapter Seven Different uses of the countertransference with neurotic, borderline, and psychotic patients
• Chapter Eight Bisexual aspects of the countertransference in the therapy of psychotic children
• Chapter Nine Transference and countertransference issues in the in-patient psychotherapy of traumatized children and adolescents
• References
• Index