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This is an intermediate-level course. After completing it, mental health professionals will be able to:
This course is based on the most accurate information available to the author at the time of writing. However, cognitive psychology and neuroscience research on brain development, structures, and activities continues to shed light on what were once regarded as merely psychoanalytic concepts and processes. Thus, new information may emerge that supersedes some explanations in this course. Similarly, new research related to transference and countertransference interpretations as moderators and mediators of therapeutic outcome may call for some rethinking regarding their use, their timing and frequency, and their effectiveness with certain clients.
This course may provoke disturbing feelings in readers due to the sensitive nature of TL and CTL in tandem with painful affiliative conflicts readers have not resolved in their own lives. Guilt, remorse, shame, hate, and envy may be among these disturbing feelings. If they endure and/or become pronounced, readers may need to seek supervision, consultation, or personal therapy in order to deal with their distress.
Why take this course? Why risk trying to make benevolent use of phenomena that are inherently dangerous and potentially malevolent?
Why? Because TL and CTL come alive in non-analytic therapy no less than in analytic therapy. Just because non-analytic therapists have minimal understanding of them does not mean that they will lie dormant. Simply put, therapists cannot prevent their powerful activity during interactions with clients and within themselves (Brenner, 1982). In fact, over the course of time, TL and CTL will play a major role in most therapists’ work (Mann, 1999). That’s the bad news.
The good news is that TL and CTL are double-edged swords. Therapists can make these inherently transformational phenomena assets. By identifying them, understanding them, and using them skillfully, they can free their clients from the bondage of the past for a future full of wholesome self-love and interpersonal love. By using an evidenced-based learning process by which clients can develop their capacity for true intimacy (Schoenewolf, 2004), therapists can make therapy not only helpful but also benevolent.
This course focuses first on identifying TL and CTL as they arise, evolve, and become operationalized in therapy. It then deepens therapists’ understanding of these phenomena, which are either negative or positive mediators of therapeutic outcome. It presents theory and research-based guidelines on how therapists can manage the dangerous aspects of TL and CTL. Finally, it teaches therapists skills to help clients meet their affiliative needs through wholesome self-love and appropriate relationships with others.
A caveat, however, is that this course – in and of itself – will not make therapists experts in TL and CTL, let alone in analytic thinking. They will not become so knowledgeable and skillful that they can glide into successful processing of TL and CTL. No, they will always have to work hard to make benevolent use of these two ubiquitous and complex phenomena.
This course is the third in a three-part series, based on the last chapter of a book written in non-analytic language for professionals with cognitive-behavioral, existential, humanistic, and other non-analytic theoretical orientations. (Transference and Countertransference in Non-Analytic Therapy: Double-Edged Swords, by Judith A. Schaeffer, Ph.D. (Lanham, MD. University Press of America, 2007).
First, each section begins with questions. Taking time to answer them sets in place a mental schema in which new information can be accommodated or assimilated in the light of one’s unique clinical expertise and client population.
Second, because transference and countertransference are basically the same phenomenon, most of the time the term transference means both transference and countertransference. Similarly, transference love means both TL and countertransference love. Exceptions are made when directly quoting other authors and when the material would be confusing or misleading if both terms were not used.
Third, efforts have been made to change analytic jargon into commonly used terms. Because the material in this course is extremely complex, however, one should expect gradual assimilation of information. This is true partly because transference and countertransference are interactional phenomena that operate primarily in the unconscious mind. From the time of Freud in the early 20th century to the present, theorists and clinicians have struggled to understand and explain them. They remain challenging.
Fourth, in cases where gender-specific singular pronouns are used, the masculine and feminine forms are intended to be reversible.
Fifth, the content of this course is accurate and useful in that it is based on significant theory and research pertaining to TL and CTL, beginning in the early 20th century and continuing into the 21st century. However, the content of this course is limited by the fact that research pertaining to transference and countertransference in general and TL and CTL in particular does not always meet current scientific standards. It has not always been replicated, the number of participants has been low, or there is no control group. Thus it is not possible to draw firm conclusions from extant research.
At the same time, it is possible to use this research to glean valuable information from which treatment decisions can be made because it is complemented by theory based on a century of clinical practice. Research findings are complemented by the experience of some of the best clinicians in the history of psychology, social work, and psychiatry.
Finally, the impact that cultural diversity has on TL and CTL is short-changed in this course because of space and time limitations. For the most part, it is left up to the reader to perform the extremely important task of tweaking information to fit unique culture-based situations and conditions, both their own and those of their clients. It is crucial, however, for readers to consider dealing with TL and CTL in the context of their clients’ cultural diversity. For example, reaching out and shaking another’s hand may be a manifestation of erotic love in a stereotypic British context but not in a stereotypic Hispanic or Asian Indian context, where it most likely be simply non-erotic and appropriate for all persons or non-erotic but impolite for persons of a higher caste.
TL comes alive in therapy because of what are “kernels of truth,” (DeLaCour, 1985). In the intimacy of the therapeutic setting, clients interact, usually week after week, with another human being who bears a resemblance to a person whom they have wanted to love and be loved by. They were often able to do so with that person but never to the degree to which they longed. Hence, their mind holds an unresolved conflict.
Then, as clients interact with their therapist, he unintentionally contributes fragmentary, disguised data that serve as reminders of the original person. The therapist’s harsh voice, for instance, gives his client subtle reminders of a verbally abusive parent. The unconscious mind of his client is struck by sameness, or at least similarity, between the past and the present. The then and there and the here and now become one reality as the client finds “an ingenious way to use [his therapist’s] sensitivities” (Hedges, 1992, p. 18). Of course, therapists are vulnerable to doing the very same thing when their clients remind them of someone in their past.
Freud originally concluded that clients’ transference elicited therapists’ transference, called countertransference (1912.) Others, however, discovered that therapists could also elicit clients’ transference because they, too, failed to love and be loved to the extent they desired. Thus they, too, would have unresolved conflicts and unconsciously transfer material from them to their clients. Consequently, most theorists now hold that CTL arises both when it is elicited by clients’ TL and when therapists are the first to send memories to their clients.
Theorists also hold that TL and CTL are basically products and processes of the unconscious mind (unconscious). The conscious mind does not intend to produce them, initiate them, or respond to them. In the case of non-erotic transference love and CTL, for example, the conscious mind knows the difference between a therapist and a parent. It is not about to make the past the present. At the same time, the unconscious, where transferred love resides, knows only the present. The past lives on as the present (Faulkner, 1929). Thus, we all want to love and be loved in the now.
Furthermore, the conscious and unconscious minds operate both differently and separately. Their operations are parallel rather than interwoven. As a result, the conscious mind has virtually no access to what is in the unconscious. It can only pick up subtle hints of what it contains. Thus, TL, which hints that it is active in such things as dreams and involuntary muscle movements, can be detected by the conscious mind only when it detects these hints, which are termed manifestations.
Vignette:
“My client smiles so sweetly,” the therapist observed. “She seems to be indicating that she really enjoys our sessions. For me they are enjoyable also, kind of like sitting at the kitchen table talking to my mother when I was little. Wish she were alive. She died too early.”
“Great – I am not listening to her. Why is she now frowning? I guess I’ll have to ask her to ‘tell me more’ so that I cover my tracks here,” he said to himself. But when he asked her, she grimaced. “Now what?” he thought.
This reaction of the client puzzled the therapist because he was not aware of the real issue. The positive reaction he and his client were having to each other was a hint of transferential and countertransferential love. He was only aware of having become distracted because she reminded him of the mother he loved. Likewise, her facial change was an unconscious manifestation of her disappointment that he had disconnected from her. “He should not do this,” her unconscious concluded. “My recently deceased husband loved me so much he never did this. Why did he have to die before me!”
Indeed, TL and countertransference love had come alive. They were both outside the awareness of the conscious minds, but they had uncanny motivational and transformational power.
Notice that in this vignette, TL and CTL come alive because of stress inherent in an intrapsychic conflict: one part of the mind contradicting another. This is due to our experiences as well as to enculturation. In the case of our affiliative needs, for example, part of us believes we deserve love; part of us does not. Part of us believes others should find us lovable; part of us does not. Part of us wants to believe we can be all right without love; part of us believes we cannot. Part of us wants sexual pleasure; part of us knows that getting that pleasure, at least with the wrong person, is morally wrong. And so on.
This intrapsychic conflict is both multi-layered and potent. It causes emotional pain, often excruciating pain. In fact, neuropsychological research reveals that the human mind is forever looking for ways to resolve intrapsychic conflict because we fear for our very psychological survival if it continues (Ecker & Hulley, 1996).
Consequently, clients unconsciously regard therapy as an opportunity to meet their unmet needs. “I will take advantage of a noticeably kind, responsive human being who sits across from me,” clients unconsciously say to themselves. “Yes, this is the perfect time and setting to meet my need to love and/or be loved. This person will love me, and I will love him.”
Wanting to experience this love, clients unconsciously re-enact the past (Covington, 1996). They unintentionally transform their therapist into a figure from the past – usually a parent but sometimes a sibling or lover – and assign her the role of loving them and being a person they can love. They repeat the past; they replay it. They turn passive trauma into active mastery (Freud, 1912). They “actualize an internal scenario within the therapeutic relationship that results in the [person they are with] being drawn into playing a role scripted by [their internal role]” (Westen & Gabbard, 2002, p. 101). They make their interaction with their therapist an “adventure from which [they] hope to emerge changed and renewed” (Cooper, 1987, p. 518).
This happens easily because the therapy setting bears striking resemblance to early prenatal and/or natal experiences.
Think about it. Except for multiple births, we are alone in the warm, safe womb. We are enclosed, protected from the external environment (Laplanche, 1997), and given all that we need. We are even “waltzed around & set in motion, always accompanied by the rhythmic beat of a mother’s heart,” (Elise, 2019, p. 29). Then, when born, we are kept warm, dry, fed, and shielded from harm. We are picked up, held, and carried. Someone else does for us what we cannot do for ourselves.
So it is in therapy. Clients find themselves in a safe, “warm” environment where a person focuses intently on them, then “picks up” their ideas and “carries” them forward. This person mirrors what they say and comments on what they know but cannot put into words. Thus they feel validated, cherished, and nourished with the “food and drink” of unconditional, positive regard. They begin to feel loved as a mother/father-figure lightens their pain by holding it alongside them.
In the case of TL, clients gradually perceive that structures have been put into place whereby they can meet their long-lived affiliative needs. Seemingly incongruent things have come together. They may have to take some responsibility for resolving their intrapsychic conflict, but in the “womb” of the therapeutic setting, another person has already functioned for them and with them. They have been loved. They can risk believing that they are lovable. They can risk expressing and receiving love (Covington, 1996).
In other words, what they have yearned for in the past, can finally be achieved because they have unconsciously displaced the present with the past yet experienced it as the present. They have engaged in transference love and found it matched by CTL.
Yes, therapists unconsciously enable TL to come alive by “allowing” their own CTL to arise. They unwittingly both open themselves up to receiving their clients’ transference love and transfer their own TL to their client. They try, on an unconscious level, to resolve their own affiliative conflicts. In no time, unconscious bidirectional collaboration has occurred without it being consciously willed.
Furthermore, more often than not, in the case of non-erotic transferred love, both clients and therapists alternate roles. Like a kaleidoscope, “one moment the therapist is seen through the lens of the parental figure and the next” (Diamond, 2018, p. 411) through the lens of the infant (Diamond, 2018, p. 411). It is the same with the client as both therapist and client unconsciously try to meet the totality of their affiliative need: loving and being loved.
In sum, TL arises when clients perceive their therapist as someone from their past and thus transfer love related to an unresolved affiliate conflict from the past to the present. Countertransference love arises when a therapist does this.
Fortunately, what usually comes alive in therapy is non-erotic. However, love that is non-erotic can become erotic, eroticized, or perverse.
What are the forms in which TL and CTL arise in therapy?
TL takes four basic forms: non-erotic, erotic, eroticized, and perverse. These forms overlap but have unique characteristics. We begin with one that is far from pathological. In fact, it is a mediator and moderator of human development: non-erotic TL.
Freud (1912) believed that non-erotic TL is both intrapsychic and interpersonal. It is grounded in the innate human need to give love to and receive it from another person. Meeting this affiliative need is essential to human well-being not only in the womb and after birth but also throughout childhood. Indeed, it is essential to some degree throughout life.
We focus on unresolved affiliative conflicts with maternal figures in this course for the sake of brevity and simplicity. But this is not intended to underestimate the presence and power of other affiliative conflicts, starting with paternal and extending into sibling, friend, and significant other. Affiliate conflicts with all of these can and do trigger non-erotic TL in therapy because no interpersonal relationships completely satisfy human affiliative needs, let alone desires and longings. The result? Intrapsychic conflict.
Because we are finite by nature but virtually limitless in our expectations, early attempts to meet affiliative needs are both positive and negative. For most of us, our basic needs are met. But they are not met well enough. We are loved but not fully, not consistently, and not flawlessly. Yet we feel we have a right to it. Hence, we unwittingly endeavor to resolve the conflict between what we have received and what we believe we were and still are entitled to (Freud, 1912).
Non-erotic TL is a matter of our unconsciously re-enacting our early years so that new, positive experiences can replace painful memories of this conflict. We perceive empathic, understanding individuals as potential nurturing mother figures (Freud, 1912; Covington, 1996). We “seek intimacy, which ordinarily includes bodily contact, with those we experience as warm and accepting” (Schaeffer, 2007, p. 187). We want them to provide for us satisfying reparative experiences by acting in such a way that we know we are loved because we feel loved. We replace pain in the past with gratification in the present.
Thus, it is normative for non-erotic TL to come alive in multiple and various interpersonal settings: in therapy and outside of it, for therapists as well as clients, for mental health professionals as well as other providers.
The therapeutic setting, however, is especially conducive to this happening. Even in the first session, therapists extend unconditional acceptance, positive regard, and sustained benevolent interest in clients and what they share. Consequently, clients perceive their therapists as kind, caring, nurturing, and loving persons with whom they can enter into a whole-person, non-erotic, but gratifying relationship. Put succinctly, therapists become longed-for mothers, and therapy becomes an opportunity for clients to find vanished mother figures (Ferenczi, 1909).
Correspondingly, clients become longed-for infants and children because of their vulnerability and willingness to depend on their therapist, whose profession consists, in part, in acceding to the emotional demands of others (Hedges, 1992). The therapy room becomes an ideal setting for intimate contact through conscious and unconscious channels of communication (Tower, 1956) and the therapeutic process, an opportunity for therapists to nourish and nurture clients into new life. Thus therapists and clients enjoy the mother-infant quasi-union of the first months of life (Greenacre, 1954).
In Jungian terminology, the therapy room is a natural setting for the Mother Architype to become operationalized. Therapists see it as an opportunity to play maternal roles (Schaeffer, 2007) as their clients transfer their love for their biological mother to their therapist. Therapists’ unconscious enactment of their non-erotic CTL allows clients to conclude – also unconsciously – that the love they have transferred has been accepted. Alternately, it seems to them that they have every reason to transfer that love because they are already loved. All will go well. They will finally meet their affiliative needs.
Indeed, when all goes well, non-erotic TL is similar, if not identical, to non-erotic love outside the therapeutic setting. It is satisfying. It is fulfilling. That is the good news.
The bad news is that for those who are no longer infants or children, psychological maturation is a matter of integrating one’s capacity for self-nurturance and self-love into the psyche, rather than depending solely on being nurtured and loved by others (Ferenczi, 1909; Freud, 1940). In other words, adults must meet their affiliative needs primarily in and through themselves and only secondarily in and through others. Sole or even primary dependence on others is no longer developmentally appropriate.
Thus, TL proves not to be the panacea clients expect. The resolution of early-life affiliative conflicts is no longer possible simply because they receive non-erotic love from others. They also need to give it. And ironically, the therapeutic setting gives them an opportunity to do so because both male and female therapists fall quickly and naturally into taking on maternal roles and performing nurturing functions (Greenacre, 1954). They resonate with weak, vulnerable, and virtually helpless individuals needing their non-erotic love. To simple empathy and a caring attitude, therapists add affection for those hungry for love and for loving responses.
Their clients, in turn, welcome those expressions of love, for they believe they cannot heal from their affiliative pain unless they experience a phenomenon first described by Ferenczi: “It is the physician’s love that heals the patient” (Gerrard, 1999, p. 29). Alternately, it might well be the client’s love for the therapist that heals, which is what Freud (1974, pp. 8-9) meant when he wrote: “Essentially, one might say, the cure is effected by love” (Charles, 1999). Or it might be both. In any case, that’s the good news.
The bad news is that as much as non-erotic TL and CTL are beneficial during the therapeutic process, both can become liabilities. Even if they stay non-erotic, they can distract therapists and clients from focusing on the maturational work needing to be done. If they morph into the erotic, they add a new, very challenging dimension to already difficult therapeutic work. And if they become eroticized and/or perverse, both clients and therapists can be overwhelmed by powerful feelings and the impulse to act on them.
At the same time, of course, these developments can give clients and therapists an opportunity to work on a deep and meaningful level, rather than a more comfortable though “arid and superficial” level (Charles, 1999, p. 258). By addressing the most crucial needs of the human heart, they can make therapy truly beneficial.
Erotic TL is a matter of clients “[falling] in love” with their therapist (Rabin, 2003, p. 677). It is a non-pathological form of sexualized love. It is clients’ normal sexual response to a certain person outside therapy being transferred to their therapist. Erotic CTL is the same: therapists’ loving their clients in a non-pathological but sexual way.
The feelings clients and therapists have for each other are as genuine as they would be in a non-therapeutic setting (Slavin, et al., 1998). They are also as natural and real as those of non-erotic transference love (Celenza, 2017).
Erotic TL begins as non-erotic (Freud, 1912). Like all positive human dynamics, it can be traced to an early erotic source: a sensual mother-infant relationship. “The early mother-infant bond is the first erotic relationship” (Schaverien, 1997, p. 10). Erotic TL stems from the infant’s spontaneous, primitive need to feel wanted and loved and to experience love physically. “Affectionate attachments from early childhood are retained in the personality through puberty, when they become enmeshed in an individual’s sexuality” (Hedges, 1992, pp. 18-19). The maternal-infant relationship “is maternal eroticism” (Elise, 2019, p. 29). The relationship of the mother to her infant can even be termed primal seduction (Laplanche, 1997).
In other words, erotic TL is as normative in therapy as non-erotic TL. Sexualized TL and sexualized CTL trigger each other (Dalenberg, 2000) because of our universal vulnerability as human beings (Celenza, 2021). Moreover, erotic TL and non-erotic TL tend to vacillate rapidly (Slochower, 1999).
Erotic TL is “genetically linked with sexuality and develops from purely sexual desires through a softening of their sexual aim” (Wrye & Welles, 1989, p. 5). Sensual pleasure easily gets “interpreted” as sexual because sexual desires lay at the deepest level of the human psyche. The needs from which they arise are as basic as those for food, drink, and sleep. Thus, both the conscious mind and the unconscious mind are ever alert for opportunities to fulfill sexual desires and meet sexual needs.
Furthermore, because human beings tend “to experience themselves as unlovable at a very deep level” (Mann, 1999, p. 19), they instinctively search out others who will make them feel lovable. They are determined to meet their affiliative needs. Correspondingly, others are motivated to meet those needs, showing them “once and for all that [they] are really loved” (Celenza, 2017, p. 159). And the most convincing proof of doing so is providing a sexual experience, at least in the “opinion” of the unconscious mind.
The unconscious mind is far more “experienced” than the conscious mind because it is a much older evolutionary development. Thus it is more able to motivate behavior than its younger partner.
Furthermore, it is easy and natural for sensual experiences to become sexual in the human psyche because the unconscious mind does not make a distinction between the body and the mind, as does the conscious mind. The latter “says” that there are differences between a person’s physicality, mentality, emotionality, and spirituality. The unconscious mind, in contrast, “says” that the mind must use bodily organs to function and therefore emotions and sensations are simply “two sides of the same coin.” Each emotion is felt as a sensation or a cluster of sensations. Each sensation or cluster of sensations automatically sends a message that an emotion or emotions are being experienced. Thus, feeling warm, comforting sensations “means” to the body that it is in proximity to someone who has positive, if not loving, feelings toward it.
Additionally, the unconscious mind makes no distinction between thinking and feeling because the one cannot help but accompany the other. It feels good, for example, to read the loving message on a valentine, even as feeling loved is automatically accompanied by the thought “I am loved.”
Furthermore, in the unconscious mind an emotional-cognitive experience of intimate love is also physiological. “When we touch another person, we do not just touch a body, we touch a being" (Celenza, 2017, p. 160), and vice versa. Emotional warmth and loving thoughts and words are simultaneously experienced as tender, loving bodily contact.
Put succinctly, the unconscious mind does not buy into the mind-body duality “claim” of the conscious mind. As a consequence, in the human psyche, lines between fact and fantasy easily fade. Similarities become sameness.
Thus, closeness evolves into enmeshment. Separateness morphs into merger. Then, in an effort to meet its sensual-sexual or erotic needs, the unconscious mind engages in transference. It displaces love for an early-life individual to an individual in the here-and-now. In the therapeutic setting, clients unconsciously conclude that their therapist is a mother who truly loves them. Moreover, they truly love their mother-therapist. Therapists, in turn, unconsciously conclude that their client is one whom they love, one whose affiliative needs they must meet (Hedges, 1992), and one who is able and willing to meet their own affiliative needs.
In other words, erotic TL and CTL is ignited by both therapists and clients (Schaverien, 1997), by men as well as by women (Silverman, 2019). Both bring to the therapeutic endeavor an erotic unconscious (Mann, 1999) and an erotic vulnerability (Celenza, 2021).
Erotic TL occurs naturally in therapy because during its course, therapists reveal things about themselves simply because of what they say and how they say it. Clients share sensitive information about themselves, and therapists open themselves to highly personal information about their clients. Indeed, clients’ tendency to discuss sexual material in therapy is a common characteristic of clients to whom therapists are attracted (Pope, et al., 1994).
Thus, it is common for both clients and therapists to feel something more (Dalenberg, 2000) than the non-erotic. It is the erotic: a combination of liking, having loving feelings, fantasizing desired sexual experiences, and falling in love (Rabin, 2003). It is a combination of the pleasure of mutual love and the “pleasure [of] proximity, [the] desire for fuller knowledge of [another person], [and a] yearning for mutual identification and personality fusion” (Menninger, 1942, p. 272).
Keep in mind, however, that transferring erotic love is not intentional. It is simply a matter of two individuals unconsciously allowing their imaginations to produce a fantasy of being loved and loving the person who loves them (Mann, 1999).
At the same time, there are actually “kernels of truth” to this fantasy because although the conscious mind is unable to detect TL itself, it is sensitive to manifestations or signs of it. They may be subtle and highly disguised, but they are detectable. The look in the eye of one who loves another erotically, for example, is inherently different from the one who loves another non-erotically.
Jung (1946) adds an interesting observation that explains why erotic TL is not uncommon in therapy. At a deeply unconscious level, he says, erotic transference not only connects clients and therapists in a fantasy, but also allows clients to find wholeness. They seek a therapist because they are broken and splintered. They have split from an unlovable-unloving part of themselves. They want “to be reconnected to a missing part of themselves, to some aspect of their own souls,” adds Jungian analyst Ulanov (1984, p. 76). They hope to reconcile with a split-away part of themselves: the one that they are transferring to their therapist.
Seen in this light, erotic TL, like non-erotic TL, is far from pathological. Indeed, it evolves from a willingness to share control of a relationship that blends love with other human feelings, aspirations, and needs. It is a complex phenomenon that integrates both aggressive urges and sexuality with love and tenderness (Gabbard, 1989). It brings with it ever-shifting feelings of love, shame, idealization, envy, rage (Davies, 1994), and even hate (Blum, 1997).
As a general rule, erotic TL first engenders shame and embarrassment, for both therapists and clients are aware of cultural and moral prohibitions against their fulfilling their erotic desires with socially inappropriate, unavailable individuals. In addition, the contract therapists make with their clients is to maintain a boundary between therapy and external life (Morris, 2012), between a therapeutic relationship and a real-life relationship. They will work to understand the client’s deepest human desires, but not fulfill them. They will gain insight, but not act on it.
In time, however, as therapy becomes more demanding, even painful, it is neither uncommon nor unnatural for therapists and clients to desire relief. They want to experience the pleasures of acceptance and appreciation along with intimacy and endearment. Thus they unconsciously bring about a relationship that permits experiences of love for one another as whole persons: human beings with intimacy desires, sexual needs, and sexual impulses. They no longer want to relate just intellectually or even just emotionally and/or spiritually. They want to act on what they feel, that is, to relate physically.
Put succinctly, erotic TL takes form “at the interface where mental and physiological experiences come together” (Davies, 1994, pp. 158-159). It is no wonder then that as non-erotic TL fuses with pleasure that is erotic, it quickens in both clients and therapists strong urges to take advantage of opportunities to gratify sexual desires (Etchegoyen, 1978). In spite of multiple prohibitions, the therapeutic setting becomes an opportunity for clients and therapists to meet their affiliative needs at the deepest level. They fantasize that a loving, sexual experience will enable them to love and feel loved. They will finally resolve a painful, foundational affiliative conflict they have endured for a long time.
In sum, erotic TL is a normal, whole-bodied, physiological, emotional-sensual-sexual phenomenon that is normative in a therapy setting. If carefully managed, it can be used to enable clients and therapists to work together to meet their affiliative needs in mature, fulfilling ways in real life. They will no longer be conflicted over the fact that “they should not want what they haven’t got – a message often received from those with too little to give” (Charles, 1999, p. 249). That’s the good news.
The bad news is that the therapy setting is fraught with danger. Erotic love can evolve – and can do so insidiously – into eroticized love and perverse love. Furthermore, when undetected and unmanaged, it can lead to immoral, unethical behavior.
Eroticized TL is a pathological displacement of love. It is clients’ unconscious attempt to heal their painful, negative memories of not being satisfactorily loved by expressing their attraction to their therapist in one or more forms of purely physical sexual behavior (Gabbard, 1994).
In the past, clients have experienced rejection from those whose love they sought. Now, they unconsciously fantasize that by acting out sexually with their therapist, they can fulfill their desire for intimacy. As they express their love physically, a sense of goodness will replace a sense of badness (Slochower, 1999). Their self-esteem will increase exponentially (Stacy, 1998). Gratification of sexual desires will replace their quest for understanding and being understood, which are the very heart of therapy (Freud, 1915). “All other deep unconscious wishes will prove superfluous in the light of all-consuming sexual gratification” (Schaeffer, 2007, p. 190).
Eroticized TL is pathological because it is truncated. It consists of sexual components alone (Person, 1995). In contrast to mature, seasoned love, it makes sexual gratification the end-all of interpersonal relations. Commitments to others are meaningless.
Eroticized TL that appears in early stages of therapy tends to result from clients’ frustration over not having the control they want over their therapy and their therapist (Eickhoff, 1998). In other words, eroticized transference serves as a defense against fears of helplessness and feelings of powerlessness. By contrast, eroticized TL that arises at termination is usually a defense against the pain of being separated from the therapist they have come to love.
There are then at least three possible outcomes to eroticized TL coming alive in therapy. The benevolent, indeed very benevolent, one is that therapists detect it and manage it skillfully and thereby help their clients meet their affiliative needs in developmentally appropriate, person-appropriate ways, outside the therapeutic setting.
A clearly malevolent outcome, by contrast, is that eroticized TL ignites subtle but powerful rescue fantasies that therapists fail to detect. They can then be seduced into meeting their clients’ sexual needs by enacting their own eroticized countertransference. Sadly, in spite of years of ethics courses and information from professional associations and state grievance boards, engaging in sexual activity with clients remains one of the main reasons therapists lose their license. They deny their responsibility to those outside of therapy. They break their covenant with their clients, betray them, and lose their trust. No matter how gratifying the experience in the short run, they grievously damage their clients as well as their own families (Celenza, 2021).
Another, though less malevolent, outcome is that eroticized TL makes therapists feel captured and bound rather than free to love. They experience a negative form of sexualized countertransference. They want to disconnect from clients they perceive as intensely needy, demanding, and self-centered. In that case, the clients come to realize how misguided their efforts to force love have actually been. They experience painful masochism. And their therapists experience shame and guilt related to their professional work.
These two malevolent outcomes would be the same, of course, if it were the therapists’ eroticized TL that began the process.
Even more pathological than eroticized TL is perverse TL, for it is actually a form of hate (Stoller, 1975). It is the hate once inflicted on the client by an abusive or neglectful other and now projected into the therapist as the client unconsciously reverses roles and becomes the abuser. Perverse CTL is pathological for the same reasons.
Verbal signs of perverse TL are hostile provocation, sarcasm, outright rejection of the other person’s ideas, and forcing one’s own on them. Paradoxically, emotional coldness can be a manifestation of perverse transference. In any and all cases, “perverts [are] not making love; [they are] making hate” (Kaplan 1991, p. 40). They are sadistically reducing another person to an inanimate object that can be used, abused, and then discarded at will. There may be no physical contact in the therapy setting, but the verbal and/or nonverbal behaviors of one individual make the other feel humiliated, violated, and exploited. Consequently, aversive emotional confusion soon debilitates both of them (Slochower, 1999).
Perverse TL is characterized by compulsivity, fixation, rigidity, and obligation (Kaplan, 1991). Those who engage in it have little if any choice. Their hatred is so deeply entrenched, and they understand it so little, that they can neither recognize it nor control it. Rather, they feel compelled to protect themselves, by acting out, from what they sense will lead to their own psychological destruction: their hatred of another (Springer, 1996).
In rare cases, perverse TL can take an alternate form. As one individual “grooms” another, they adopt an attitude of extreme, unfailing kindness (Gabbard, 1994). They normalize intimate exchanges in such a way that sexual material is inserted into their relationship without being noticeable. Even so, well informed and skillfully observant recipients of perverse TL will periodically perceive those who transfer it as children who have been painfully abandoned or abused. They are powerless individuals whose frightening emotional pain compels them to protect themselves against further abandonment and abuse by seducing those with whom they are presently interacting (Springer, 1996).
Blum (1997) perceives perverse TL in another way. He sees it as a sexualized defense against hate, hostility, humiliation, a desire to destroy, and a fear of being destroyed. It is a defense against the pain of having been deserted or abandoned – actually destroyed psychologically – in the early years of life. Those transferring perverse love are unconsciously hoping to seduce another person instead of being seduced.
Blum (1997) explains further that those who displace perverse love are unconsciously attempting to fulfill their desire to take revenge (Springer, 1996). By enacting this form of love, they are hoping to eliminate – or at least be separated from – another person. Their seduction, be it real or imagined, will make the other individual into an impersonal object. Thus they will be saved from being rejected by a real person whom they actually love (Khan, 1979).
Beneath the attempt to be saved from rejection by being the first to take revenge is a devastating affiliative experience (Russ, 1999). Hence, in the therapeutic setting, a therapist’s first and foremost endeavor must be to endure transferred feelings of hate long enough to experience that experience of the client. The biggest mistake the therapist could make is to refuse to deal with perverse love, for that would almost inevitably confirm the client’s “conscious or unconscious belief that his sexuality and aggression either sullies or violates” (p. 611) both him or her and the therapist. There would be no solution other than to despair. In contrast, daring to stay with perverse love long enough to deal with it can lead, later rather than sooner, to the “deep contact” (p. 611) that permits a person to hope for healing.
Springer (1996) contributes yet another useful theory. He believes that, at the deepest psychological level, perverse TL is a sexualized defense against the self. It gives the one who enacts it an experience of pseudo-wholeness and completeness, which is extremely exciting. Thus, it protects the individual from experiencing psychological disintegration. If one is experiencing overwhelming excitation, he or she cannot be disintegrating. Hence, the powerful reinforcement that propels serial rapists into repeated offenses.
Finally, Mann (1997) points out that perverse transference love is a desperate attempt to connect to another human being. It is an effort made by one person to relate to another for the sake of resolving an extremely painful affiliative conflict. Hence, those initiating it feel compelled to find one person after another to relate to. Hence the serial rapist.
What might therapists contribute to their client’s perverse TL? Nothing, we hope. But let us not forget that the phenomenon of transference depends on one person being open and willing to receive the transference from the one displacing it. As therapists begin to feel the burden of their therapeutic work – especially if they do not lead a balanced, wholesome life – their anger and aggressive urges can taint their maternal erotic CTL. It can even disappear in the face of growing dislike or actual hatred for their client (Schaeffer, 2007). It can lead to therapists meeting their own sexual needs with their client, violating the contract they have made with them to keep the therapeutic setting a safe place to share the most personal aspects of oneself. For therapists have promised “to maintain [their] awareness of separateness [from their clients] and inhibition of [their] own desires and needs” (Celenza, 2017, p. 159). They have promised “to forego cultivating, expressing, and acting on what [they] might personally desire” (Celenza, 2017, p. 161).
It is frightening but true that therapists who act out their eroticized and perverse CTL can unconsciously believe that they can discharge their disguised archaic instincts with impunity. They can hold the delusion that they can give sexual expression to their hatred and hostility without causing harm (Bachant & Adler, 1997).
On the other hand, identifying and talking through eroticized or perverse TL can be extremely beneficial to clients. Doing so says to them that although their desires will not be acted out because of the harm that would bring, they are accepted and valued. Aspects of them perceived as vile do not make them vile. Instead, they can process the painful affiliative experiences that have spawned a pathological form of love. They can reject it instead of incorporating it into their sense of self. Indeed, therapists who do not deal with their clients’ eroticized or perverse TL make their professed unconditional love “a mere platitude” (Charles, 1999, p. 260).
Under certain conditions, the probability of eroticized and perverse TL and CTL developing is high. A distinction is being made between TL and countertransference love even though they are interdependent and thus co-occur.
Client-related conditions under which eroticized and perverse TL are more likely to develop include:
Therapist-related conditions under which eroticized and perverse CTL are more likely to develop include:
Needless to say, if clients who have suffered from trauma and/or present with profoundly problematic characteristics meet with impaired therapists, the danger of their acting out is significantly higher. It may even be exponentially higher. That’s the bad news.
The good news is that protective factors can be put in place.
Protective factors that reduce the likelihood of clients and therapists enacting pathological forms of TL and CTL include:
Vignette:
The client wasn’t particularly pretty, but her occasional fun-loving flirting was charismatic. In time, her therapist noticed how much he looked forward to her sessions and how he thought much more about her than his other clients. Finally, he became aware of sexual feelings toward her, the same feelings he enjoyed while dating his ex-wife. He also realized that what was happening to him was becoming a problem. Worried about this, he decided to tell his client that she had made enough progress to try going on her own. They didn’t need to continue to meet.
Fortunately, through consultation with a colleague, the therapist realized what he was actually doing. He was avoiding dealing with his CTL by convincing himself and his client that they could terminate. As a consequence, at the beginning of their next session he said to her, “I find myself attracted to you,” he said. “But I’m trying to push it under the rug by suggesting we end our work. Could it be that the flirting you initiate, and we both enjoy, might be working against us?”
“Perhaps,” she replied sheepishly. “I just can’t feel good if a man isn’t in my life in a sexual way. Actually, more than one man, because I’ve had affairs while married as well as when divorced.”
With this disclosure, the client and her therapist were able to explore her affiliative needs. They eventually did much-needed trauma work regarding her need to act out early sexual abuse.
Therapists with protective factors in place need not terminate with clients when TL becomes problematic. In fact, doing so can imply that clients are neither honorable nor respectable, neither moral nor ethical. They are disgraceful because of their disorder, impairment, or immaturity. It would be too difficult, if not impossible, for their therapist to help them resolve their affiliative conflicts.
Instead, what these clients actually need is acceptance as individuals in dire need of help to meet their affiliative needs in wholesome ways. They need a therapist they can trust enough to share their affiliative pain.
Exceptions exist, of course, but rarely can a therapist determine clients with whom they cannot profitably work when TL first arises. In fact, the majority of clients respond well to boundary-based acceptance by therapists who show them how to put protective factors in place while both they and their therapist take responsibility for their behavior. Indeed, most clients benefit immensely from being respected as individuals whose basic affiliative needs are legitimate and whose capacity to meet those needs in mature and responsible ways can be developed.
TL and CTL come alive in the therapeutic setting just as they do in life in general. Their doing so – in and of itself – is benign. If they become operationalized, however, they gain the power to either re-wound or bring about healing.
TL and CTL come alive when a client or therapist unconsciously transfers affiliative material either onto or into the other person. If the material is put onto the other person, the process is called projection; if into the other person, projective identification.
For the process of projection to be completed, the other person must take on or take in the material being transferred. Taking on or simply receiving the material is called introjection; taking it in is called introjective identification.
Operationalization depends on whether the person taking on or in the material confirms it; identifies with it in the sense of owning it. Operationalization is a two-step process.
The first step is one person projecting – displacing or transferring – some aspect of his unfulfilled affiliative desires or unmet affiliative needs onto another person and the other person introjecting or receiving/taking on what is projected. These aspects may be feelings, sensations, thoughts, behaviors, or a combination of them.
What is sent must be received/taken on. Likewise, what is received/taken on must be being sent. In the case of TL, therapists can only introject the love that their client projects. In the case of CTL, clients can only introject the love that their therapist projects. If that does not happen, the displaced material simply returns to the sender.
The projection-introjection is done by the unconscious minds. When clients and therapists project TL, they do not realize that they are doing so. They do not even recognize what they are projecting as their own. It feels foreign to them. But it is conflictual and therefore painful: some kind of love that should have been reciprocated but was not. They deserved love but did not receive it. They tried to love another person, but their love was unrequited.
The unconscious knows only the here-and-now: the present. It does not know the there-and-then: past (or the future, for that matter). Thus an affiliative conflict that has in fact arisen in the past and outside the therapy room is experienced as occurring in the present and in the room. “My therapist/client is a person who loves me and/or is receiving my love,” the unconscious of the one projecting “says” to itself. “My affiliative conflict is being resolved.” Similarly, the unconscious of the one introjecting “says” to itself, “My client/therapist is a person whom I love and/or whose love I am requiting. Her affiliative conflict is being resolved.”
Projective identification and introjective identification can be thought of as mutations of projection and introjection; they take them “a step further” (Shedler, 2021) and “deeper.” Projective identification is a matter of one person unconsciously putting material into another. Introjective identification is a matter of another person unconsciously permitting that material to enter into her (Ogden, 1982). Thus, projective identification and introjective identification push the psyche of the one introjecting to complete the displacement process. It becomes harder – though not impossible – for the person not to do so.
Projective identification occurs because the human psyche fantasizes that it can split off a painful – and thus undesirable – part of itself by putting it into another person. Later on, it can recover a modified, non-painful version of that part (Grinberg, 1997; Ogden, 1982). In fact, while the one who receives the material holds it, the one who has sent it experiences a oneness with the recipient (Schafer, 1977).
Projective identification occurs because the human psyche unconsciously knows that it needs to learn how to deal with the past (Schore, 2003a). It needs to discover how to manage the unresolved conflictual pain it has thus far been unable to get rid of. Thus a client suffering from depression resulting from not being loved puts her unmanageable sadness and hopelessness into her therapist. Then she observes what her therapist does with those feelings.
Ideally – and this word is very important to remember – she notes how her therapist momentarily stops talking in order to calmly consider what words might match his feelings. Far from denying his distress or letting it overwhelm him, he is calmly preparing to describe it. He is collaborating in the projective identification process by internalizing the hopelessness and sadness inherent in depression. Observing this, the depressed client gets relief. Her therapist is depressed. She is not.
Furthermore, she is learning a new way to deal with depression caused by unmet affiliative needs or desires: verbalizing it calmly rather than denying it or letting it overwhelm her. As a result, her depression is manageable (Ogden, 1994). She can now safely re-own her sadness and hopelessness. She can recover the part of herself she has put into her therapist.
This does not always happen, however. What is being put on or into a person is not necessarily confirmed or owned by the one taking it in or on.
If one engages in simple introjection – takes on a projection – his unconscious immediately “reports” that there is something superficially wrong with him, such as “I don’t love others.” If he engages in introjective identification – takes in a projective identification – his unconscious “reports” that he is inherently defective, saying “I cannot love others.” In other words, if an unconscious message is delivered “with …vehemence,” the person receiving it is pressured to “feel and act in accord” with the message (Shedler, 2021, p. 23).
Thus introjective identification usually results in a deeply disturbing and often visceral experience. Introjectors “describe experiences of not being able to think their own thoughts or feel their own feelings, as if their minds have been colonized by something alien” (Shedler, 2021, p. 23; Gabbard, 1994). Therapists “may find themselves filled with hatred for their [clients] or impelled to cross professional boundaries to rescue them. Observable behavior…pulls, pushes, coaxes, and coerces [therapists] into their assigned roles” (Shedler, 2021, pp. 23-24). The same is true of clients.
Those who introject material that has been projected do not necessarily own it or identify it as theirs. They cannot help but feel what the projector has felt, but they do not necessarily make that feeling their own or agree that it is factual or true. They do not have to confirm it (Schafer, 1977). They can choose not to identify with it or own the feelings, thoughts, perceptions and sensations connected with it (Stamm, 1995).
Confirmation of a projection depends primarily on whether or not recipients have resolved their own intrapsychic conflicts related to what they have introjected (Westen & Gabbard, 2002). It depends primarily on “the extent to which the…projection meshes with aspects of [their] unresolved…conflicts” (Meissner, 1996, p. 43).
For example, if a client projects onto a therapist a hateful mother figure, if the therapist has not resolved her own affiliative conflict of loving as well as hating her own real-life child, she will confirm the projection. She will identify with, authentically feel, and own the “label” she is receiving. And she will tend to take the role that matches the label. As a result, she will enact her hate, perhaps by being emotionally unresponsive. She will withdraw. She will not listen empathically, if she listens at all, or soothe her client. She will move on even though her client is beginning to cry. She may even express her hate by disparaging her client.
Contrastingly, if a therapist has resolved her conflict of loving as well as hating her own real-life child, she will be unlikely to confirm her client’s projection of her as a hateful mother figure. She will not own the “label” her client gives her. She will not take the role of a hateful mother-figure.
If a therapist confirms negative projections of what she introjects, she is likely to create serious problems in the course of providing therapy; problems for herself no less than for her clients. For example, she will experience guilt. Then, in all likelihood, that guilt will prompt her to make amends. She might try to express love in ways that should convince the client of her love but will not be appropriate in a clinical setting. Being hugged or kissed, for instance, may comfort or satisfy a client at the time, but in the long run it harms him (Celenza, 2021). It sends him the message that his therapist is willing to love him as would a mother of an infant.
What is equally problematic is that the therapist will not be conscious of what she is doing at the time she is doing it. Only later will she realize the full impact of her actions. Before she becomes aware of how she has tried to meet her client’s needs, she will have harmed him.
Conversely, the more a therapist has resolved her affiliative conflicts, the higher the probability she will not confirm what she has introjected. Rather, she will use it to design appropriate interventions that mediate and/or moderate a positive outcome.
It is difficult, however, for therapists and clients to completely resolve conflicts related to affiliative needs because the human psyche wants to be loved perfectly and to love others perfectly. Thus, when experiences in therapy are less than perfect, both therapists and clients fail to find them authentic, let alone convincing. They tend to reject them and judge each other to be as guilty as were persons outside of therapy and in their past (Schaeffer, 2007). Even if therapists and clients perform close to satisfactorily, they will be condemned for not doing so perfectly. They will have added “insult to injury.”
It is no wonder, then, that Freud concluded back in 1912 that processes called transference and countertransference could never really resolve intrapsychic conflict and bring about lasting healing. In and of itself, acting on displaced material could not make up for past experiences of being unloved or unable to love or finding one’s love unrequited. Only understanding them and learning how to meet affiliative needs in the present could heal a person.
Unfortunately, however, the human brain is primed to engage in projection and introjection, along with projective identification and introjective identification, in an effort to get relief from painful memories or relieve someone else of them. Furthermore, it is primed to confirm the pain another psyche sends it in an effort to heal it by taking away its pain. Thus, both clients and therapists feel compelled to process emotional pain (Schore, 2003a). They are “wired” to remember what happens to them. They are physiologically and psychologically programmed to bring past unresolved affiliative conflicts into the present and expect them to be resolved by that alone. Thus, completing the process of TL and CTL is not surprising.
But is it adaptive? Does it work?
Do these processes heal persons in and of themselves? No. For when individuals introject material, one of two things happens. They either come to feel like those doing the projecting and become empathic toward them. Or they come to feel like the original recipients of the material and empathize with them. In the case of a depressed person, for example, it would be the people being affected by that individual’s sadness, hopelessness, lack of energy, and other symptoms. In the case of anger, it would be victims of the angry person’s verbal abuse.
Then, if a therapist feels empathic toward a client, healing may be underway. If not, the client experiences even more pain; once again not being understood and having affiliate needs unmet. That is the bad news.
However, it is good news if the therapist manages transference and countertransference effectively and thereby gains important information regarding what a client has contributed to his interpersonal problems and what she herself contributes to her own problems. She has learned about her client’s failure to deal with what he has contributed to his unmet affiliative needs. She can then use this information to provide client-specific interventions that will address exactly how her client might change his interpersonal interactions. If she has learned what she has contributed to her own unmet affiliative needs, she can use the information to improve her own interpersonal interactions.
This is not easy, however, because of the components and functions of the human brain.
Because of the human brain’s limbic system’s amygdala, it is always storing emotionally charged events, such as experiences with caregivers. Because of the brain’s limbic system’s hippocampus, it is always tagging time and place to affiliative memories so that they can be stored as narratives (Schore, 2003b). Because of neuromodulators that encode memories, the human brain is always in the process of forming painful memories of not being loved and failing to love others. Because of neurotransmitters that activate reward centers, the brain is always in the process of trying to get rid of emotional pain simply by experiencing the love of others.
Furthermore, because of the human brain’s mirror neurons, it reacts to someone else being loved simply because it is near that person. Thus clients and therapists are automatically and unconsciously communicating with each other as soon as there is activity in one of their brains. “You are my loving mother,” the client’s brain “says,” whereupon the therapist’s brain, which is just a few feet away, receives information regarding his or her maternal assignment and the role he or she is being told to perform (Schaeffer, 2007).
In addition, because of the brain’s implicit memory, it constantly stores and recalls what it learns experientially. It continually encodes and generalizes feelings, sensations, and images of what happens. Thus they are available when there are similarities between the past and the present. They serve as natural “building blocks,” making the present temporarily indistinguishable from the past and the therapeutic setting indistinguishable from a setting outside of therapy.
Cognitive theorists think of generalization as schema-making. Schemas tend to “proclaim” the beliefs within them. Thus they “encourage” transference and countertransference (Gabbard, 2001). “Mothers are emotionally cold even though I need to be loved,” proclaims a schema in the memory of the unloved child. “This is exactly what my therapist, who looks like my mother, is going to do,” proclaims the schema-making brain in the same, though adult, client. “I must reject this client who appears to need too much love,” proclaims the introjected schema in the therapist’s brain. “My whole body tells me not to be emotionally responsive to her.”
In other words, a client’s schemas serve as templates that can be imposed on new reality not only for them but also for their therapist. Should a therapist confirm and then enact the schema, it becomes an even more compelling belief in the unconscious of the client.
Matters are even more complicated because one schema builds upon the other. “Old schemas never die; they…are incorporated in various ways into subsequent schemas.” They are “periodically activated without conscious awareness,” (Westen, 1998, p. 331) as human needs activate similar information-processing channels.
What becomes problematic then in the course of therapy is that schema-nesting gives clients and therapists the opportunity to transfer their intrapersonal and interpersonal struggles to each other. Neural pathways of schemas remain intact even though they may be weakened or even made temporarily unusable. “Although perhaps inhibited, [neural networks] are capable of reactivation in certain circumstances” (Grigsby & Stevens, 2000, p. 97). That’s the bad news.
The good news is that recent research of Ecker, Hulley, & Ticic (2012) suggests that certain interventions can weaken, even destroy, neurons and neuropathways that have encoded toxic schemas.
TL and CTL can also be thought of as repetition and re-enactment due to similarity judging: pattern matching. The human brain is continually constructing and reconstructing experiences in the context of old ones. Thus new interpersonal experiences are understood in the context of old ones. “Transferential processes always reflect an integration of current and past experience, as patterns of activation resulting from current life experiences…interact with enduring ways of responding” (Westen & Gabbard, 2002, p. 130).
It may seem as if human beings just “take in” the world as it exists – as does a camera – but in fact their perceptions are constructed by their brain (Gazzaniga, 1995). Acting like a feature detector, the brain uses already existing sensory cues based on prior experience to see and hear and feel what it saw and heard and felt before. It “searches for a match between the current [or present] pattern of neuronal activation and patterns stored in memory [because of prior experiences]” (Pally, 1997, p. 1021). It finds patterns within itself. It makes “a quick assessment of just enough details to find a ‘good enough’ match. When one is found, perception occurs” (Pally, 1997, p. 1025). We “see” what we have seen before. Thus, we transfer the past to the present. That’s the bad news.
The good news is that TL that results from similarity judging need not result in negative outcome. If therapists perform subtasks that detect and manage it, they can “exploit transference for its optimal learning potential…. They can thereby convert a potentially…dangerous perceptual “mistake”…into an opportunity to adopt new, more effective patterns of meeting their own and [their clients’] affiliative needs” (Levin, 1997, p. 1147).
Because of an all-but-impenetrable barrier between the conscious and unconscious minds, the conscious mind cannot have direct knowledge of phenomena “residing” in the unconscious mind (unconscious). As a result, the conscious mind can detect transference only in the vague, shadowy signs of its presence. It can be identified only when it manifests itself in dreams, slips of the tongue, connotative language, sensations, emotions, body language, and behavior. For each of these “voiceless and vociferous little parts of [the self]…do their best to add their ‘two cents’ into the final product” (Wittig, 2002, p. 143): truly meaningful communication.
As an intrapsychic phenomenon, communication is from an individual’s unconscious to the individual’s conscious mind. The communication occurs because the two minds need to “talk” in order that the more logical conscious mind can work with the more emotional unconscious to resolve conflicts. Without the contribution of the unconscious, the conscious mind is not likely to deal effectively with life’s challenges (Schaeffer, 2007). It is not likely to resolve its affiliative conflicts.
As an interpersonal phenomenon, transference is a matter of two individuals’ unconscious and conscious minds communicating. The communication is a matter of subtle, indirect manifestations rather than clear, direct information. Nevertheless, the reason for the communication is the same as it is for the individual person: the four minds need to “talk” in order that the more logical, analytic conscious minds can work with the more emotional, intuitive unconscious minds to resolve conflicts.
This work is very difficult because manifestations of transference cannot be taken at face value. They are sources of data regarding what is going on in therapy but not sources of evidence of exactly what it is (Smith, 1990). They must be unpacked “to the point of their yielding the truths they hold” (Schaeffer, 2007, p. 65).
This is especially true regarding the cultural variables inherent in manifestations of transference. Therapists must pay attention to their transcultural as well as within-cultural meanings. In a Hispanic culture, for instance, transferred maternal love is generally quite different from that in a British culture.
In the process of transferring its contents into the conscious mind, the unconscious uses a variety of ways. The following categories of transference manifestations are artificial in one respect. Emotions, for example, find expression in words, sensations, facial expressions. But we will examine the categories separately in order to simplify complex phenomena and create templates that can be used in therapy.
Words used in therapy might simply be means of communicating the problems and concerns clients and therapists are aware of. If so, they can be taken at face value, that is, according to their dictionary definitions or denotations.
Even so, some words not only convey straight-forward messages but also carry emotional overtones, connotations. For example, a client calling her biological father abusive may be unconsciously referring to all men as abusive.
Therapists should likewise suspect countertransference with words they sometimes choose, especially those that come “out of the blue.” “I’m afraid I can’t give you an appointment next week,” may also mean “I am afraid of hearing more about your sexual issues and therefore do not want to schedule you.”
Words spoken at the beginning or end of sessions are especially noteworthy in terms of transferred meaning. A client who walks in saying, “I am so tired of trying to relate to my unloving partner,” may also mean “I am tired of trying to get you to love me.”
Words that convey seemingly unrelated material may also be transferential. When talking about a third party, clients may be unconsciously revealing their feelings about their therapist. “I feel so attracted to my boss,” for example, may also refer to the therapist. It may not, of course, which is why it is very important to examine possible manifestations of transference.
Though single, obvious emotions would not appear to be transferential, what appears to be simple may be complex, with a second or third emotion at the periphery of the obvious emotion. Anger that a client expresses when talking about her husband, for example, may also include sadness because the therapist, like the husband, is not available as a lover.
Theorists vary as to which emotions are most likely to be transferred. But because clients and therapists want to bond with each other, love and fear of disappointment should be expected. Similarly, when therapy goes well, relief is often accompanied by fear of therapy coming to an end and thus a loving person disappearing from one’s life. In fact, the earliest bonding experiences commonly consist of a positive experience of needs being met on demand, followed by a negative one of learning that one has asked too much and/or too often (Schaeffer, 2007).
When decoding emotions, therapists must also consider body language and voice quality. The meaning of words can change dramatically if gestures or tone of voice or volume do not match the words. “I feel comfortable in here,” said with strained facial muscles and in an almost inaudible tone of voice, most probably means, “You make me comfortable, but I need more from you.”
In general, therapists first discover the truth about their own transferred emotions in those emotions which seem excessive or inappropriate for what clients say or do (Tower, 1956). Therapists’ sudden anger, for example, simply because their client is a few minutes late is most likely excessive. Indeed, therapists’ reactions, be they sensations or emotions, are typically based on already existing affect or physiological states. Their becoming angry might be based on their guilt related to disliking a client (Schafer, 1997) despite their belief that they should not dislike clients. Their becoming nauseated might be based on their anger with clients who talk in circles (Racker, 1968). Their sleepiness might be based on their already feeling abandoned by clients who habitually intellectualize.
Arlow (1985) theorizes that the depression therapists have in spite of their healthy lifestyle and overall professional success is basically a countertransferential reaction; a defense against the depression of their clients. More often than not, clients project a bad self (Epstein, 1977; Racker, 1968) onto or into their therapist because of similarities to prior caregivers. What is equally problematic is that therapists whose own self-definition is negative may unconsciously add self-punishment to negative transference. They may “agree” that they are inadequate (Epstein, 1977), for example, because they find it almost impossible to work with clients with endless affiliative needs.
The fear that therapists sometimes develop in their clinical work may be due to their unconscious experience of clients’ holding onto them as a form of voyeuristic intimacy, seduction, engulfment, or aggression (Langs, 1979). The apprehension therapists experience when a client asks them for more time than they can afford to give may be due to their unstable marriage or perhaps the erotic attraction they have to the client.
Dreams, daydreams, and fantasies are common means by which the unconscious mind tries to get the conscious mind to help resolve affiliative conflict. Thus, those which clients have during the course of therapy often manifest TL, especially when their therapist appears in them (Ferenczi, 1909). Similarly, those which therapists have often manifest CTL (Tower, 1956), especially when their clients appear in them.
Of course, sometimes figures appearing in dreams, daydreams, and fantasies simply represent the person producing them. At other times, however, they represent real-life persons with whom the dreamers, daydreamers, or fantasizers have been in close and/or frequent conflictual contact. Sometimes both are true, for the unconscious works hard to get the conscious mind to help resolve conflicts. It counts on the phenomena it creates to get through the barrier between it and its conscious counterpart.
Evidence-based methods of working with dreams, daydreams, and fantasies, particularly dialoguing with dream figures, have proven extremely helpful in understanding the nature of affiliative conflicts as well as in finding effective ways to resolve them. Unfortunately, exploring these methods is beyond the scope of this course.
Other well-documented manifestations of TL are body language or simple movement, complex movement, and somatization. They are universal, transcultural means by which the unconscious mind of one person speaks to its conscious mind as well as to the unconscious mind of another person through the body. Indeed, “the basic units of experience are [not words but] bodily interactions between self and others” (Fast, 1992, p. 449). The bodily action of both clients and therapists contains key information about what they are trying to convey to each other (Scaer, 2005). Details of posture, gaze, changes in skin color, and even respiration are noticed and unconsciously recorded by both therapy participants (Meares, 2005).
Moreover, because the body cannot lie, it is the richest, most accurate source of truth about what is going on in the present and what aspects of the past have been embodied in memories. The body has an uncanny “ability to tune in to the psyche; to listen to its subtle voice, hear its silent music and search into its darkness of meaning” (Mathew, 1998, p. 185). It has the ability to do so, and seemingly cannot resist doing so.
Arguably, what happens on a one-time basis may not be worthy of much attention. But body language that persists or repeats itself is. Again, it is not possible to go into detailed explanations or skill-building here, but note that facial indicators of unconscious communication are uniquely important. Subtle movements around the left eye and left side of the mouth (Schore, 1994), in particular, divulge hidden personalized feelings (Mandal & Ambady, 2004).
In contrast to body language that encodes a relatively simple message, unintentional complex movement communicates several displaced feelings and/or story-like thoughts. Thus complex movement that puts transferred feelings and thoughts into action is termed enactment. Thoughts and words become coercive action loaded with emotion that is related to figures in the client’s and/or therapist’s past, including the very recent, minutes-old past. It is action dictated by a “script” that is never actually seen, one written by the unconscious.
Transferential enactments are a matter of clients “assigning” to themselves and their therapist roles specific to past conflictual experiences. Clients “intend” to play a part and have their therapist play a corresponding one.
In the case of TL, clients unconsciously want to have a wholesome affiliative experience with their therapist. Those clients still conflicted over wanting to be nurtured gratis and not having that experience with their biological parents might fail to bring their copayments. Should therapists play a parental role by overlooking that breach of contract, they may well be enacting their own countertransferential conflict: needing to love unconditionally though they do not want to. Or perhaps they feel compelled to make amends for damaging their own children by not loving them unconditionally.
Similarly, therapists can enact their own countertransferential affiliative conflicts by treating their clients as if they were much younger than they actually are. For example, they might indulge their clients by asking less of them than they are capable of doing. They might absolve them of their obligation to change their behavior in a timely fashion. They might continue to work with those who want to make their therapist a friend well after they have attained their therapeutic goals.
Yet another manifestation of TL is somatization: acting-in. A thought stimulates an emotion that finds expression in a sensation. A thoughtless emotion, an unknown known (Bollas, 1987), expresses itself, usually in a sensation but sometimes in an inability to move.
Transferential somatization manifests itself in physical symptoms or bodily pleasures that have no real physiological cause. Common examples are sudden stabs of pain, tears, trembling, strange sensations in the solar plexus, poor sleep, and sensitivity to noise. Others are tightness in the chest, nausea, rising heat, cramps, barely perceptible odors or tastes, and, most revealing in the case of TL, sexual arousal (Boyer, 1997).
Indeed, somatization is the body’s revelation of what happened earlier in the mind and “heart.” Hence, it can be a rich source of information because so many unresolved affiliative conflicts occurred during a preverbal stage of development. For instance, therapists’ feeling of repeated and heightened physiological excitement when meeting with a particular client – even preparing for it – can indicate how much those therapists are unintentionally trying to meet their own affiliative needs. By contrast, getting a headache almost every time particular clients come can indicate how much therapists resent the clients’ requests to meet their affiliative needs.
If therapists suspect that a manifestation might be an affiliative communication disguised in one or more of its subtle forms, they need to evaluate that possibility. How intently they should do so depends on several criteria.
One is repetition. A manifestation that is repeated, such as a thought that becomes an obsession, is more likely than not to be data deserving further attention.
Another criterion is intensity. A dream one cannot shake, for example, is more likely than not to be a transferential communication. So are emotions that are clearly overreactions. So is bodily comfort or discomfort that takes so much of one’s attention that it is virtually impossible to attend to what a client is saying. So is doing something for a particular client that one does not do for other clients. Going overtime with a long-term client who says she is in crisis and cannot deal with it herself, for example, may not actually be justifiable. Rather, it may be a sign of TL and/or CTL.
Yet another criterion is unexpectedness; things being said or done “out of the blue.” Beginning to reach out to embrace a client, for example, may be a manifestation of CTL.
A final criterion is complexity. A dream that repeats itself and causes one’s body to be noticeably tense is very likely to be countertransferential. So is extending the session for a client who comes late on a regular basis and then going home with a headache.
Vignette:
The intern naturally wanted to make a positive impression on her supervisor. She wanted to be seen as mature and experienced. She really liked one of her clients, and the attraction seemed to be mutual. He not only kept all his appointments but started to share details of his affairs. They became more and more sexually explicit. Fearing to be seen as complicit in what was happening, the intern told her therapist what her client was doing but not how she looked forward to her sessions with him.
Finally, however, it became too much for her. She could not shake what happened in his sessions; she kept having to say “No” to thoughts and images of what went on between them. She decided to be candid with her supervisor.
She was. She revealed the whole picture.
To her great relief – as well as surprise – her therapist was pleased. She complemented her on suspecting TL and CTL because it could be used therapeutically. If she and her client could deal with it in his sessions, he could finally heal from the early sexual abuse he had experienced with a nanny and relate to women in non-erotic ways.
The intern was eager to develop the skills she needed to have in her present and future practice: those that would make her proficient in using TL and CTL beneficially. She set out to learn the challenging task and subtasks she needed to perform, along with strengthening her self-monitoring skills.
“As a blind man might come across a gem in a heap of garbage, in this way the Awakening Mind appears within oneself” (Shantideva, 7th century, India).
In order to deal well with TL and CTL, we need to slow down our mental activity. We must be like the blind man examining in his slow, methodical way the contents of the “garbage.” We need to slow down the fast pace of our conscious mind and give a manifestation of transference sufficient time to reveal its information. We need to process what we suspect is unconscious communication.
Effective processing of a manifestation involves four distinct but interwoven subtasks whose performance is a matter of supplementing the logic of the brain’s verbal left hemisphere with the intuition of the brain’s non-verbal right hemisphere. This is because TL, like most relational transactions, relies heavily on speaker-listener cueing and responding that occur too rapidly for simultaneous verbal exchanges and conscious reflection (Lyons-Ruth, 2000).
In order to integrate bi-hemispheric communication effectively, therapists must monitor themselves. They must evaluate how well they are performing each subtask and decide when they should move from one to another; whether to backtrack or move forward. In other words, therapists must perform the subtasks separately as well as blend them into one multitask process. So too must therapists monitor their clients in order to make sure that they stay within a window of anxiety that permits meaningful work to be accomplished.
The first subtask is to take in consciously the manifestations of transference we suspect we have already registered on an unconscious level. This subtask requires us to deliberately open ourselves up to what appears to be happening: conflict-laden contents in our clients’ and our own unconscious minds are causing sensations and movements in our body and/or thoughts, images, attitudes, and feelings that disturb us or make us uncomfortable. But we really do not know why.
The first subtask is to “be there” for ourselves and our clients in a new way (Heath, 1991). It is a matter of forming a composite picture of conscious and unconscious information from which we can, in time, derive fuller meaning than that based solely on conscious communication.
When we perform the first subtask, we intentionally “make room” in our conscious mind for unconsciously displaced material. We choose to increase our awareness of what our clients are transferring to us, and we are consequently responding to it (Bird, 1922), along with what we ourselves are transferring. We deliberately welcome past experiences that are replaying in the present. We intentionally offer to our clients our “entire availability”: all the time and mental space they need to deal with the unresolved conflicts they are transferring to us (Grinberg, 1997).
In the course of increasing our awareness of clients’ TL, we are also bringing to consciousness our own CTL. We are taking note of the roles we are unconsciously assigning our clients and ourselves. If we are assigned the role of being a parental figure for someone working through an early child-parent conflict, for example, we deliberately “accept” a fleeting image of ourselves as an unloving, self-indulgent person. If we are assigning the role of a disobedient, unlovable child to our client, we hold in focus the self-righteousness we have begun to experience from refusing to love that child. We allow ourselves to note, for instance, the muscle tightness of one who is “teaching a child a lesson.”
In sum, the first subtask is a matter of combining how we say, and/or how our clients say what they say, with what we or they say. Furthermore, it is a matter of adding our own unconscious perceptions and desires to the conceptions and intentions of which we are conscious. Put in 21st century neuroscientific and cognitive terms, we allow right-brain learning to augment left-brain learning. We open ourselves to receive nonverbal communication that cannot be put into words. Metaphorically, we allow ourselves “to keep adding spices and seasonings to the soup we are preparing, tasting frequently and adding one ingredient after another to bring out the soup’s full flavor.”
The second subtask is to hold the manifestations of TL and CTL and to permit whatever psychological regression happens in a deepened and broadened holding environment. The second subtask is necessary because TL can be safely dealt with only if it is fully experienced.
Thus, the second subtask is a matter of deliberately embracing the full impact of our client’s unconscious communication. As we continue to hold a manifestation of TL, we will come to realize that “this is the clearer, sharper, more complete message my client is giving me” (Smith, 2000). We make it possible for us to know experientially, for instance, that “This client is both fearful of losing my love and angry with me for not extending our session.”
We perform the second subtask by containing and autoregulating our own negative states so that we can act as affect regulators for our clients (Schore, 2003b). They can then experience us managing the distressful feelings, sensations, and thoughts they have transferred to us. They can continue to reveal their unresolved conflicts because we have not been overwhelmed by the heightened anxiety that has kept those conflicts in their unconscious mind. We are not only sharing their intrapsychic burden, but also managing it.
As we do this, that burden already seems to be lighter to the client. The safe holding environment provided by a therapist is one of the most potentially healing vehicles a client will ever find (Wilkinson, 2003).
We must engage in affection regulation in order to perform the second subtask (Casement, 1991). We must refuse to follow our natural inclination to disengage from distressful communication. We must avoid closure and tolerate ambiguity and uncertainty. We must choose to not understand – for the time being – complex, displaced relational experiences (Schore, 2003a). We must not return to clients prematurely what they have put on us or into us (Joseph, 1987).
The second subtask requires us to refrain from taking refuge in words. We must resist the impulse to shift into a left hemispheric state of mind and thus not respond verbally to transferred communication. Instead, we must hold uncomfortable sensations and awareness evoked by that communication (Stark, 1994). We must sustain the countertransferential feelings triggered by the transference. We must stay in the right hemisphere’s processing mode, its “Wait and See” (Federmeier & Kutas, 2002). We must do for clients what they were unable to do for themselves during their original affiliative experiences: allow psychic pain to remain in their conscious mind long enough to be understood and processed.
Performed well, the second subtask typically results in our having a somato-sensory experience of our clients’ unresolved affiliative conflicts (Kernberg, 1987). We feel their anger, fear, heightened sexual desires, and other distressful states. Thus we give them a profound gift; we let them use projection and projective identification to transform us into someone “bad,” someone deserving of disrespect, even abuse (Gorney, 1979). We, not they, are now “bad.” They can experience relief. They can be hopeful.
The second subtask also requires us to contain our own unresolved affiliative conflicts; to re-experience the breadth and depth of our own pain (Kernberg, 1975). We suffer the personal, painful countertransferential feelings and sensations that we might well be projecting onto or into our clients and thus triggering, or at least adding to, their pain (Roth, 2001).
Needless to say, the second subtask is extremely difficult. As we perform it, we are likely to experience excruciating emotional pain; being found inferior, flawed, and valueless (Slochower, 1999), and thus unlovable or unable to love. We are likely to regress to the point of re-experiencing the rejection and humiliation that make early affiliative experiences too painful to bring to conscious awareness. As our painful emotional state exacerbates that of our client, we might even slip into a psychologically primitive space. As our clients’ toxic material mobilizes our own (Dosamantes, 1992) and we “return the favor,” we might even experience quasi-insanity.
Quasi-insanity must not be underestimated. It is an experience of disequilibrium within the right hemisphere. It easily leads to deterioration in technical competence (Spence, et al., 1996) along with an inability to think clearly and find appropriate words to use. It triggers overwhelming fear of “losing it.”
Even so, the second subtask asks this of us. We must prepare to deal with the unregulated or under-regulated forces that underlie TL and CTL. We must temporarily relinquish the adaptive goals and values inherent in our rational mind (Schwaber, 1990). We must hold pieces of internal, unconscious phenomena that are not only contradictory but also “crazy” and exceedingly disturbing (Isakower, 1963). That’s the bad news.
The good news is twofold. First, regression can be managed. It is not an all-or-nothing phenomenon that cannot be brought under control. We can set limits to how long and to what degree we engage in it. We can end it before it impairs our basic ego functions (Levin, 1997). We can come in and out of it so that we never lose sight of the fact that what clients are transferring to us still belongs to them (Deutsch, 1926). Furthermore, we can stop ourselves from actually performing the transferential roles we are being assigned or the countertransferential roles we are assigning ourselves.
We can accomplish all of this by skillfully setting limits to regression. We can interweave regression with grounding. We can make sure we go back and forth between the then-and-there and the here-and-now. We can make sure we dialogue with ourselves about what is occurring and what needs to be done with it (Kernberg, 1987).
Second, regression gives us insight into what is actually going on in the therapeutic interaction at hand and thus what is very likely to be going on in extra-therapeutic interactions. As a consequence, it sheds light on the affiliative conflicts a particular client needs to resolve. It enables us to zero in on precisely what will ensure a positive therapeutic outcome.
Once holding TL and permitting regression have yielded their fruits, we can decode or “break the code”: derive hidden significance from apparent meaning. Thus we can bring greater clarity to what we and our clients are trying to communicate about their unmet affiliative desires and needs.
Decoding what our clients transfer to us is difficult because we are simultaneously reacting to our own feelings, attitudes, and thoughts. It is laborious because “transference [love] … has to be detected almost without assistance and with only the slightest clues” (Freud, 1905, p. 116).
Decoding is even harder with CTL. We are “never in a favorable position to make a clear or clean-cut interpretation of … countertransference” (Hedges, 1992, p. 22). We are extremely challenged in decoding it as it is unfolding (Bennett, 2021). Hence, we must permit the third subtask to be a multi-step process of interweaving intensive cognitive work and meticulous attention to detail with the emotional-sensory-motor experiences we are having.
First, we must identify what makes us suspicious. Is it the client’s choice of words? Reported dreams or fantasies? Small movements? Or our own tension? Then we must put to the side the apparent meaning of what we have observed so that we can identify less obvious meaning, such as tone of voice, volume, gestures that match or fail to match content, muscle movement that supports or contradicts speech, and other nonverbal forms of human communication.
We must also identify our own spontaneous response to what we are noting: our feelings, sensations, thoughts, movements, and urges to do something. We must determine whether they contradict or correspond to what our client is overtly communicating. Those which contradict are more likely to be transferential. Those which correspond may or may not be transferential. Especially if they are exaggerated and/or sustained and/or repetitive, they may be triggering our own unresolved issues.
Keep in mind, of course, that we are always contributing something to our client’s transferential communication. It is a matter of how much and to what degree.
Vignette:
“Why does this woman irritate me so?” the therapist queried. “Why am I not simply flattered that she has asked to meet with me more often? She is intelligent and articulate and seems to want to make progress.”
“Yet there seems to be something subtly seductive about her. Though she does so nonchalantly, she keeps placing her hand on her low-cut blouse.”
In looking at his own countertransference, however, the therapist recognized that he was also experiencing distress in his abdomen. He had to admit that he was frequently looking at where that hand was guiding him.
“Something is not right here,” the therapist acknowledged. “Although what I am doing corresponds to what she is doing – it’s just a natural human response – I must get at the deeper meaning of what is going on. What are some hypotheses?”
Hypothesizing, the second function of the third subtask is a matter of determining possible explanations for why the phenomena we have decoded are occurring; the most probable reasons why something that occurred in the past has become part of the present. It is a matter of coming up with possible causes of our clients’ and our own distress.
Ideally, hypotheses are simple statements. One hypothesis about what is occurring in the previous vignette, for example, might be “I am bringing to the sessions my own need for erotic love.” Or “I am distressed because I should not have indicated that I am available.” Or “My client and I might both be contributing to my distress because both of us have a need to love and be loved.”
The fourth subtask is a matter of verifying the most likely hypothesis or hypotheses that we have formulated. Sometimes we simply do so by ourselves. At other times we seek out third parties. At still other times we share the hypotheses with our clients and ask for their feedback.
One would presume that the fourth subtask is easier than the previous three, that just as we are eager to confirm our hypotheses, we are also eager to disconfirm them. However, disconfirmation is more difficult for us than confirmation, for formulating hypotheses inaugurates a fondness for what we have conjectured and an unconscious search for supportive evidence. Indeed, most of us do not actually want to re-consider our hypotheses. We just want to accumulate more evidence to prove them – and ourselves – right. Hence, the fourth subtask requires us to impose on ourselves the discipline of being as objective as possible about our hypotheses and about whether we should verify them by ourselves or do so with others.
When we have more than one most likely hypothesis, one effective way to start is by paying close attention to our own somatic response to the one that is most emotionally powerful. Our body will invariably, though sometimes subtly, agree or disagree with what our mind is concluding. Being physically energized, for example, usually suggests an accurate hypothesis, while experiencing uneasiness or tension suggests the hypothesis is at least partially inaccurate.
Third parties are invaluable during the verification process. Particularly in cases involving significant CTL, we would be unwise not to share our hypotheses with colleagues, consultants, or our own therapist.
We might also share our hypotheses with our clients – sometimes before, sometimes after consulting or meeting with our own therapist. If we share sensitively and tactfully, we can give our clients a wholesome interpersonal experience. They can learn how to clarify their affiliative needs and desires and decide how best to pursue them rather than simply repeat unsuccessful solutions or try an unpromising new one.
However, before considering just how we might share our hypotheses with clients, let us explore a meta-task that must be performed throughout the four subprocesses: monitoring.
In order to use TL and countertransference love benevolently, we must monitor ourselves to evaluate how well we are performing the subtasks and auto-regulating our countertransferential love. Concurrently, we must monitor our clients in order to make sure that they stay within a window of anxiety that permits meaningful, even deep, experiencing of transference, but does not overwhelm or retraumatize them.
We must maintain a “binocular vision” (Holmes, 1992). As we attend to conscious communication, we must attend to our own and our clients’ emotional and physiological functioning in the course of allowing our unconscious minds to penetrate our conscious minds.
Self-monitoring begins with noting how well we are observing our own CTL, for we must base our outward response to clients no less on how they are doing than on how their displaced material is affecting us. Clients may be extremely embarrassed, for example, and therefore unable to hear what we have to say. At the same time, we may have become defensive and desirous of setting limits to our clients’ expression of affiliative needs. The question, of course, is always what is best for clients within the limits of our own tolerance.
We must continuously self-monitor because TL and CTL can impact the therapeutic relationship at any time. We never want to either minimize or maximize them, but neither do we want them to impair our clinical functioning. We want to give them enough “room” to display themselves – even to develop – but not so much “room” that we end up thinking poorly or acting unprofessionally.
As we self-monitor, of course, we monitor our clients’ tolerance levels. We observe how well they are auto-regulating by balancing thinking with emotions; balancing judging; and wondering about, observing, and controlling intrapsychic and intrapersonal phenomena. This monitoring allows us to create the conditions under which clients can become increasingly aware of what once was – and remains – conflictual, but not to repeat past experience. Rather than have one more negative affiliative experience, they should feel safe enough to risk feeling unsafe again in order to work through their affiliative conflicts.
If clients assign us the role of a sexually abusive caregiver, for example, we want to experience being one to the degree that we realize what our clients have gone through. Concurrently, we want clients to realize that we know experientially what they have gone through. However, we are not going to go so far as to abuse them, even verbally. Rather, we are going to help them learn how to defend themselves from being victimized in the present, and to lower, if not erase, the power victimization memories have over them.
Similarly, if clients displace positive feelings toward us, such as experiencing us as a nurturing mother figure, we will allow the TL to continue until basic bonding takes place. But we will not allow clients to become dependent on us to meet their need to be nurtured. We will not console them each time they are disappointed or protect them from feeling abandoned when we go on vacation. We will not be the mother figure they are capable of being for themselves.
Monitoring is important during the first subtask when we consciously take in TL and CTL (Hinshelwood, 1999), for we need to decide whether we might perform those roles on a temporary basis as a means of bonding with clients. Those who feel very unlovable, for example, might benefit from time-limited signs of parental acceptance and approval. They might not be able to bond with those who do not appear to accept or approve of them. Even so, they need to learn to accept and approve themselves along with experiencing maternal and/or paternal love from appropriate people in their everyday lives.
Monitoring during the first subtask also enables us to gauge the extent to which we are unconsciously projecting our own unresolved affiliative conflicts onto or into our clients. Without this internal supervision, even experienced therapists are prone to simply re-enact their own and their clients’ maladaptive interpersonal experiences in countertransferential behaviors (Dreher, et al., 2001). As a result, clients and therapists never realize the contributions they make to therapeutic failures, nor determine how they might conduct themselves differently (Weiss & Sampson, 1986).
Monitoring is crucial during the second subtask when we contain transferred material and permit regression. We must stay with clients on a psychobiological level in order to engage in necessary experiential learning. But we must not go so far as to lose our ability to stand apart and take note of our participation in the realms of TL and CTL (Racker, 1968; Gorkin, 1997; Gelso & Hayes, 1998; Nissen, et al., 2020). We must remain disengaged enough to ask questions such as “Is my client trying to seduce me?” and/or “Am I being seductive?”
Monitoring becomes especially important when we permit conscious regression. We must become vulnerable to the workings of displaced material at a sufficiently – but not dangerously – deep level (Winnicott, 1965). We must be partially aware of the process we are undergoing in order to discontinue it at any time. We must periodically employ our observing ego to “keep track of the pressure to become trackless” (Schafer, 1977). We must “swim” in the sea of others’ TL but not “drown” in our own CTL” (Racker, 1968, p. 16).
Furthermore, only if we monitor our own regression can we be aware of the regression our clients might be undergoing. They can benefit only from carefully regulated exposure to the pain that so overwhelmed them in the past that it could not be processed. They cannot benefit if they are re-traumatized.
Monitoring is necessary during the third subtask when we decode and hypothesize about TL, for it is operating even as we are deriving meaning from it, and determine exactly what is going on. We must stand aside to decode and hypothesize yet remain available to our clients. We must not allow the length and intensity of the decoding and hypothesizing processes to do away with interpersonal contact. Clients want to be accepted, listened to intently, and followed closely. We harm them if we engage in difficult cognitive tasks for what seems to them to be “forever.”
On the other hand, we need to self-monitor to see if we are allowing ourselves enough time to decode and hypothesize. Though we may not be certain of what is occurring, we must come up with hypotheses that can be tested.
Monitoring is crucial during the fourth subtask when we verify hypotheses, for we need to balance testing hypotheses with keeping an emotional connection with our clients. At the same time, we must continue to receive and hold new material that will allow us to revise inaccurate hypotheses.
Finally, we must monitor during all four subtasks in order to be able to move quickly and smoothly from one subtask to another. At times, we must decode what we have uncovered in order to know what more we need to discover. Similarly, we may need to experience more in order to verify what we think we understand. At other times, we must gather new information in light of our hypotheses proving inaccurate. At still other times, when we suspect inaccuracy, we must stop decoding and test our hypotheses. Put simply, wholesome interpersonal interactions rely heavily on monitoring our decisions related to focusing: what to focus on, whom to focus on, where to focus, and even how to focus (Hubble, 1999).
To summarize, by systematically performing the four subtasks while judiciously monitoring ourselves and our clients, we can know our clients on a deeper, more meaningful level than we could otherwise. We can also gain insight into ourselves. Thus we can facilitate a detoxification process whereby clients can finally address their unconscious affiliative conflicts. They can strip transferential material of its dangerous characteristics (Grinberg, 1997) and use the truths it reveals to finally meet their affiliative needs.
Therapists who share their hypotheses about TL and CTL provide a protective factor for both themselves and their clients by fostering within themselves an attitude of humility and detachment. They thereby reveal that they do not have all the answers. They are simply observing and wondering. They are saying to their clients, “Let us together determine whether what I think is going on between us rings true for you. I can – and want to – learn from you” (Churchill, 2019).
To observe and wonder with humility and detachment is not to have an agenda for what clients are supposed to think or feel. It is not to be ahead of clients in ascertaining personal and interpersonal reality. Indeed, it is to be open to whatever happens when two persons try to understand unfamiliar phenomena. “As clinicians, we are enjoined to be agenda-free; we may have our preferred models of the mind, but they are not to be superimposed on [clients’] material” (Schwaber, 1990, p. 237). We are to simply observe and wonder so that we do not become attached to our interpretations, despite our attempts to treat them as hypotheses (Cooper, 1993).
To simply observe and wonder rests on therapists’ willingness to describe nonjudgmentally what seems to be TL and CTL. Particularly in non-analytic therapy, an effective interpretation of both TL and CTL rests on an attitude of “I know less rather than more” (Schwaber, 1990). It echoes what Winnicott (1960) said whimsically: “I interpret mainly to let the [client] know the limits of my understanding” (p. 711).
In other words, therapists need to be open to rejection or revision no less than acceptance or confirmation of their hypotheses. They need to respect clients’ experience of their therapy sessions and their relationship with their therapist.
At the same time, therapists need to bring directness, pertinence, inclusivity, and concreteness to what are fundamentally subjective experiences. Rather than dispense truths and meanings, they prepare for a trial-and-error process involving dialogue with their clients (Cooper, 1993). They need to await something relatively definitive: truth that requires the active cooperation of clients to develop (Bezoari, et al., 1994). Indeed, both therapists and clients are holders of partial truths that can be known in their fullness only when the parts are shared. Indeed, if TL or CTL are occurring during therapy, it will be verified – eventually, if not at the moment – in the psyches of both therapist and client.
Therapists who wish to collaborate with their clients to verify suspected TL and CTL begin the process by using a transference or countertransference interpretation.
A transference interpretation (TRI) is an explicit reference to what a client appears to have displaced from the past, including the very recent past, to the present therapeutic setting. A TRI makes unconscious material conscious so that it can be subjected to legitimate evaluation. If it is inaccurate, it can be revised. If it is accurate, it can be used to resolve an intrapsychic affiliative conflict.
A TRI is “a creative re-description that implicitly has the structure of a simile. It says, ‘This is like that’” (Schafer, 1977, p. 57). A TRI reveals how present behavior is a re-enactment of past experience rather than something happening on its own. “I wonder if I strike you as maternal when I keep listening to you even though our time is up,” is a TRI related to an affiliative issue.
The use of TRIs is based on a therapeutic premise espoused by clinicians of major theoretical orientations; it is crucial that TRIs be subjected to legitimate conscious evaluation as well as to unconscious attitudes and beliefs to which clients have been holding fast. Some of them may be adaptive and thus worth holding. Others, however, may have been adaptive in the past but are detrimental to wholesome relationships in the present. They create unresolved conflict-based anxiety both for the one who holds them and for the one to which they are supposed to apply. “I don’t care if my father does not love me because my mother does,” a client may have believed as a child. That belief – that maternal love can replace paternal love – kept anxiety in check at the time. Thus it became a schema or principle of knowing that the client could unconsciously use in both male and female relationships. It became a “certainty” in spite of its never being validated (Schafer, 1977). As a consequence, a client who holds the schema continues to rely only on maternal love without questioning her belief. She not only overvalues it but also requires one maternal figure after another to play a maternal role in her life, even though having to mother another adult does not work well for most maternal figures. Even if it did, because the client is no longer a child, it is developmentally inappropriate. Hence, it is “ripe” for processing by means of a TRI.
In brief, a TRI is intended to help clients acquire new experiences from which more adaptive principles of knowing can be derived and reality-based schema can be created. The TRI above, for example, is intended to help the client question her belief that all maternal figures should be willing to give her extra time and attention because she must rely primarily on maternal love. It is intended to help her restructure an old belief and resolve its underlying conflict: being an adult biologically and intellectually, but a child emotionally and interpersonally.
A TRI is a therapist’s means of asking clients to consider how their thoughts and feelings toward their therapist might be coming primarily, though not solely, from past experiences with persons similar to the therapist. “Could it be that your resentment toward me because I ended our session on time is tied to your mother’s not giving you enough attention?” a therapist might ask.
Though it may or may not directly mention the client’s past, a TRI is intended to address what the client has displaced from the past. “Could it be that you are sad because I kept you waiting, as did your mother?” and “Could it be that you are sad because I made you wait?” are both acceptable TRIs. So are “Could it be that you are frustrated with me because I reminded you of your unpaid fee the way your teachers reminded you of unfinished homework?” and “I wonder if your sadness comes from my telling you that I will be on vacation for two weeks.”
Thus a TRI is an invitation for a client and a therapist to consider together various explanations for the dynamics of their sessions, to tease out what is past-based or outside-of-therapy-based and what is actually happening in their sessions. It is an invitation to distinguish between the past and the present, as well as between the in-here and out-there foundations of feelings and thoughts. A TRI is an implicit acknowledgment of the powerful impact that people not actually in the therapy room – and events connected with them – can have on what arises in therapy. A TRI is also an implicit acknowledgment of the need to make conscious an unconsciously held maladaptive attitude or belief.
Though a TRI may be stated in the declarative as in “I think you may be sad because I acted like your mother,” it remains open to evaluation. Thus, “When the interpretive process is working well, therapist and patient are engaged in the exploration of hypotheses [regarding their relationship] arrived at by a collaborative process” (Meissner, 1996, p. 257).
Vignette:
At the beginning of the session, the therapist remarked that her client had not paid her fee for the third time in a row. Though the client acknowledged this and promised to send a check the following day, she responded curtly to several of her therapist’s subsequent compliments on her accomplishments that week. Recalling the client’s accounts of her overly critical father, the therapist finally said, “It seems to me that you are annoyed with me today, perhaps because by referring to your unpaid fee I reminded you of your critical father.”
Using this feedback, the client admitted that she was angry with her therapist. She refused to admit, however, that she was expressing that anger inappropriately.
Two sessions later, though, when the therapist again made a tentative connection between the client’s brusque dismissal of her therapist’s observations and her father’s criticism of her, she conceded. She was then able to slowly own the painful humiliation she still experienced when others found her at fault. Thus, TRIs enabled client and therapist to explore previously inaccessible material.
A countertransference interpretation (CTRI) is an explicit reference to the client-therapist relationship as the therapist is experiencing it. “I wonder if I am hurt by your continued silence today, just as you were when your mother ‘cold-shouldered’ you,” is an affiliative-related CTRI.
CTRIs are based on therapists’ countertransference: what a client has displaced onto or into them, or what therapists transfer to a client from their own past. Thus, CTRIs reflect the fact that countertransference, like transference, is co-created.
Said a little differently, CTRIs are revelations of therapists’ reactions to what a client does and/or says. They are means of sharing what therapists believe a client is unconsciously communicating as he or she is reminded of past events and persons. They are also means of sharing what therapists are bringing from their own past to the therapeutic setting. “I am hurt by what you just said. I wonder whether that reminds me of how my mother hurt me,” a therapist might say when describing both transferential and countertransferential love phenomena. Another example would be, “Could it be that my headache is due to how hard it feels to have my thoughts accepted by you today?”
It might appear as if CTRIs are invitations to explore therapists’ conflicts. But that is not the case. Rather, CTRIs are ways into exploring clients’ conflicts. To make that clear, therapists might need to add to a CTRI something like, “You, not I, are our focus, even though I told you that I am attracted to you. How do you feel right now?” (Danzer, 2018).
Ideally, CTRIs refer to a conflict that therapists are experiencing while working with a client because that conflict is likely to have been identified, or at least implied, in the client’s presenting problems. Consider, for example, this CTRI shared with a client wanting to deal with her habit of obsessing about the mistreatment she has suffered:
“When you focus repeatedly on how badly you were treated, I begin to feel mistreated myself. I feel trapped in an unending hopeless situation.”
Vignette:
The client elaborated on a pleasure trip he had just made, providing comical anecdotes interspersed with interesting descriptions. Though at first the therapist was intrigued by her client’s account, she soon noticed herself becoming morose. The incongruity between his enthusiasm and her negative response was striking.
The therapist began to recall confronting her client previously about taking numerous trips with his friends in light of his goal being to spend more time with his autistic son. She also believed that she had modeled how to put the child first by rescheduling an appointment so that the client could attend his son’s school play.
Suspecting TL, the therapist interrupted her client and said, “I’m saddened by your account of your trip. Is it shedding a light on how your son might have felt when you left home without him?” Then after pausing, she added, “Could it be that my sadness is what you also feel when you focus on your child?”
Thus the therapist suggested what might be at the heart of her client’s difficulty in implementing his goal: the deep sadness that impairs his judgment when it comes to choosing himself and his friends over his son. Though it was true that the therapist was also recalling times when her alcoholic father’s failure to keep his promise to come to her school events caused her deep emotional pain, she did not refer to it in her CTRI. Rather, she chose to set an appointment with her own therapist.
In sum, CTRIs are intended to shed light on the heart of the matter, the reason for clients’ presenting problems: why they might find it challenging to bond with another, for example, in spite of their good intentions; what they might need to address before they can even address their goals as such; and how they might be contributing to problems they see as being caused solely by others. If countertransference truly opens the “door to a slice of life,” a CTRI holds that door open. It enables therapists and clients to collaborate in observing and exploring what they may never have suspected. Then, when new insight and emotional processing follow, the “slice of life” has yielded its rich contents.
Vignette:
The client insisted that his wife, who had recently divorced him, was unjustified in saying that she was doing so because of how angry he was. He was conscious of the opposite: he did not express his anger, he simply accepted her verbal abuse and went on. “As long as she takes good care of the children,” he told himself, “I can live with what she does to me. I do not have to retaliate or even express my own anger toward her.”
However, gradually his therapist became aware of subtle signs of feeling belittled during sessions. It seemed that he routinely corrected her reflective summaries with low-grade impatience and subtle criticism. His facial expression and tone of voice said in effect, “You didn’t remember what I told you and therefore missed the mark again. You should be smart enough to remember and get it right!”
She reminded herself, however, that she saw him at the end of a long day. “It is annoying to hear distortions of what you say,” she added to his criticism. “I might need to change the time of his appointment.”
But she also heard the nagging thought: “I am not an acceptable person because I do not remember all the details my client shares with me. I am not that perfect recorder of his communications, that infallible computer that encodes every communication given me.”
Rather than change his appointment time, she chose to stay with the pain of being an unacceptable person. It reminded her of how she had been found unacceptable by her best friend in middle school and her mother’s dismissal of it as just “an opportunity to get rid of a ‘bad apple’ by finding a really ‘good apple.’”
As she purposefully regressed in performing the second subtask, the therapist experienced excruciating sadness related to her own past. She also noted subtle signs of distress in her client: his fighting back tears, his furrowed brow, and his hunched shoulders. “Could it be,” she asked herself, “that he tried hard not to express his anger toward his wife in the hope of at least keeping her at least nominally in their marriage? Was he doing the best he could to prevent her from finding him unacceptable?”
Because her countertransferential reaction allowed her to put her finger on what neither she nor her client had previously suspected, she was able to hypothesize. “The indirect expression of his anger might well be what his ex-wife had experienced: his passive-aggressive, difficult-to-identify expression of anger.” This insight permitted her to formulate a CTI: “I feel belittled when you correct what I say, even though I believe you are not consciously demeaning me. Could your ex-wife have felt the same way?”
Though her client wanted to dismiss the interpretation as meaningless, he was willing to look at it when he sensed his therapist’s empathy. In the next session, he entertained the thought of how hurt his wife may have felt. In subsequent sessions, he made efforts to stop himself in the course of correcting his therapist. He was on his way to addressing what he had contributed to his marriage ending in divorce.
Interpreting countertransference is especially valuable, perhaps even essential, when clients have experienced trauma at preverbal stages of development or trauma so severe it could not be put into words. In cases like these, it is only through countertransference that therapists can gain insight into the troubled world of clients (Racker, 1968; Sandler, 1976; Viederman, 1974), phenomena already “known” to them on some level (DeLaCour, 1985; Herron & Rouslin, 1982; Lear, 1993).
Vignette:
Regardless of how many times the therapist returned her client’s frantic phone calls – or chose not to in non-emergency situations – he consistently rebuked her for either taking too long or not doing so at all when she sensed she was being manipulated. She found herself feeling resentful. She became increasingly eager to enforce the limits she had set early in their work: no phoning between sessions unless there was a true emergency. She could put the matter on the table without damaging the therapeutic license, she thought. “Though he was severely abused and neglected as a child, my consistent patience and responsiveness over the three years of our work have certainly given him ample evidence of my care and concern,” she reasoned.
So she endeavored once again to help her client see how some of his frequent phone calls were not as necessary as he made them out to be. Nonetheless, each time, the client disparaged his therapist’s viewpoint and protested that he had to have his phone calls returned.
Finally, the therapist decided to share her countertransference. She said in a calm voice, “I’m feeling resentful because it seems as if your frequent phone calls are making me the parent to an adult. Could we talk about this?” During what ensued, the therapist added that she might have been trying too hard to be an all-good mother to make up for his experiences of an all-bad mother. Then, when her client continued to have difficulty appreciating his therapist’s feelings, she said, “When I feel verbally abused for not being responsive to you, I feel like separating myself from you, even at times of true emergencies.”
At the time that the therapist voiced the second CTRI, her client was incredulous but willing to talk about what she said. During the following week, he called only once. Shortly thereafter he playfully referred to her as “a mother that had to have time for herself so that she could be there for her children when they really needed her.” During his termination session, he described his therapist as the "good-enough mother” he had never had as a child.
Thus, by using carefully worded CTRIs, the therapist modeled how to be honest as well as how to explore unintended consequences of her client’s behavior. She gave him a real-life example of how his behavior was contributing to his unmet affiliative needs. Additionally, by interpreting her countertransference, the therapist strengthened the therapeutic alliance. She offered concrete and convincing evidence of her attunement to her client and her willingness to accept and respect him. She gave him a safe place to consider replacing his maladaptive way of meeting his nurturance needs with more adaptive ones.
To summarize, TL-related TRIs and CTL-related CTRIs are statements or questions that shed light on client-therapist dynamics in therapy sessions related to affiliative needs. They are means of bringing into consciousness unresolved conflicts regarding those needs. They are invitations to identify distortions, misinterpretations, and unfair attributions as a prerequisite for arriving at accurate meaning. They enable clients to work with their therapist to replace old schemas and patterns of relating with other people with new, age-appropriate ones. Thus they give clients an opportunity to finally meet their affiliative needs, perhaps not totally, but as satisfactorily as possible. That’s the good news.
The bad news is that TRIs and CTRIs regarding TL and CTL are usually uncomfortable for therapists to voice and for clients to hear. If they refer to negative phenomena, they can make therapy participants experience embarrassment and shame, if not humiliating rejection. If they refer to positive phenomena, as does “I find myself attracted to you, partly because you are open about your sexuality,” they can make a therapist appear seductive (Audet, 2011). Furthermore, if shared TRIs and CTRIs are verified by clients, they call for the difficult, risk-taking work of replacing familiar old patterns with unfamiliar new ones. Thus, therapists tend to shy away from using them.
The good news is that if TRIs and CTRIs are worded carefully and shared sensitively, they create a safe environment in which to launch that hard work.
Vignette:
The client, a mid-ranking naval officer, kept coming to therapy but made only minimal progress in managing her anxiety in spite of learning and using several new cognitive-behavioral interventions to reduce her anxiety during presentations she made to her superiors. If she couldn’t stop having these near-panic attacks, she might well be demoted, she feared.
Very early in therapy, she had revealed her extra-marital affairs to her therapist, but six months later she said that she had not engaged in any inappropriate relationships since beginning therapy. “Why then,” wondered her therapist, “did I get sexually stimulated during our last session? She is clearly an attractive woman, but I greatly enjoy my relationship with my wife. Why now? What might I be contributing?”
When his countertransferential reaction re-occurred in the following session, he decided to use a CTR: “My sexual attraction to you is getting to be a problem for me. Can we talk about what might be going on between us?” His client seemed to freeze as she heard his words. She opened her mouth slightly but could not speak. After some silence, however, she said that she was seriously considering having an affair with a married colleague. Nothing had happened yet, but she had been struggling for a few weeks.
With this disclosure, the therapist was able to help her better understand why she continued to be anxious when meeting with her superiors. The military would never condone what she was thinking of doing. Her entertaining the idea of such an affair was an impediment to managing her anxiety. She had to make a choice.
TRIs (including CTRIs) are to be given in such a way that they calm clients (Strachey, 1934). However clients respond, they will not be criticized. They can deny, confirm, question, revise, or reject the TRI, all with impunity.
TRIs calm a client when therapists simply indicate that they have received a communication from their client. This holds even though it might be a criticism (Casement, 1991). An example would be, “I wonder if by coming late you are telling me that in the last session, I said something hurtful. Am I right?”
Bollas suggests that therapists introduce TRIs with such calming phrases as, “What occurs to me,” or “I have an idea,” (Bollas, 1987, p. 206) or “I’m curious about what you think of this,” or “I’d like to share a thought with you,” or “You may not agree with me but …,” or “I wonder.”
TRIs that calm clients make them feel secure. Their therapist can survive the negative thoughts and feelings they have transferred. Their therapist can hold their projections up to the light of scrutiny without “falling apart” or being devastated if their negative messages are confirmed.
Of course, therapists must convey calm through such prosody as tenor, volume, tone, and pitch. In some cases, they must even add a respectful look and/or a reassuring gesture or facial movement.
In order to make TRIs calming, therapists might need to take a moment between hearing and speaking; a short pause between what clients say and what they say. During that time, they can address their own diminished capacity to think clearly due to strong emotional reactions (Churchill, 2019). By pausing, they give evidence of their “holding” their client’s communication calmly before using gentle wording to asking them to consider the truth it might reveal.
TRIs must also be emotionally immediate (Strachey, 1934; Nissen, et al., 2020). They must clearly identify distressful or problematic emotions, however uncomfortable it may be for both client and therapist to hear them. Furthermore, to be most helpful, TRIs should be given as closely in time as possible to clients’ experience of their feelings. An example would be “Could we stop and explore what might be the need you have when you ask if we could meet in a restaurant?”
At first it seems a contradiction for a TRI to be both calming and emotionally immediate. But these qualities are not actually mutually exclusive, because emotions can be expressed in varying shades of intensity. The challenge for therapists is to find that balance between accurate reflection of and containment of the client’s feelings. Even a TRI like “You seem to hate me. If that is true, can we talk about it?” can be said in a polite tone of voice. Thus it conveys that although hate seems to be the primary feeling of the client toward the therapist, the therapist has not internalized the hate. Moreover, it is not being returned.
With certain kinds of material, it is especially important for therapists to make TRIs emotionally immediate. In the realm of sexual abuse, for example, if a therapist waits too long to interpret a client’s communication, the client may experience the therapist as being afraid to face facts. As a consequence, the therapist’s activity can become a re-enactment of a past person turning a blind eye to the client’s plight (Casement, 1991).
TRIs must be neutral statements, not unquestionable pronouncements or indisputable moral judgments. They must come across as objective observations that expose, clarify, or explicate. They simply reflect what the therapist has noticed.
TRIs should be voiced without defensiveness on the part of the therapist (Gill, 1982) because clients “are acutely sensitive to the hidden meaning in what their [therapist] says. It is harmful … when [therapists] appear to ignore a client’s accurate perception or interpret defensively in the face of it” (Casement, 1999, p. 131).
Neutral TRIs invite clients to observe what seems to be the case; to check out their therapist’s impressions (Schwaber, 1990). They are invitations to do some reality-testing in order to acquire insight (Casement, 1991). They give clients the “okay” to feel and express feelings, even very primitive ones (Gill, 1982), with impunity.
Neutral TRIs are devoid of moral judgments. They do not suggest to clients that their therapist finds them guilty of something. Thus therapists say, “You may be angry with me,” or “You appear to be angry with me,” or “I believe you are angry with me,” rather than “You are angry with me.”
Of course, the requirement to keep TRIs neutral requires a tolerant tone, restrained tenor, modulated volume and speed, subdued pitch, and dispassionate inflection, all of which combine to create mood and interpersonal atmosphere. TRIs voiced with neutrality enable clients to conclude that their therapist is simply noticing. This is extremely important because clients tend to listen primarily to “mood;” some do not even hear the words (Pick, 1997). Especially when very disturbed and in need of soothing, clients acutely scan interpretations to assess what is happening in their therapist’s mind (Hinshelwood, 1999). Is it retaliation? Is it resentment? Is it forgiveness?
Examples of TRIs that connote neutrality are:
“You may be angry because …,”
“It appears as if you are angry because …,”
“I wonder if your anger with me is something even you don’t feel good about,”
“I wonder if you are suffering a great deal from punishing yourself,” and
“It’s almost as if you are experiencing this suffering as some kind of punishment.”
An important corollary to making TRIs neutral is that it is helpful for therapists to use what they think they know and to find a way of approaching this through not yet knowing rather than to simply reflect what clients are saying. “You seem to be suffering a great deal from punishing yourself,” and “It is almost as if you are experiencing this suffering as some kind of punishment, but it isn’t clear what you are feeling guilty about,” are examples of TRIs worded with the “not yet knowing” corollary in mind. They convey that the therapist needs the client’s collaboration to arrive at the truth of the matter.
When clients use strong terms in describing themselves or others, formulating neutral TRIs becomes a special challenge. For example, soon after a therapist has set limits to the client’s in-session behavior, an adolescent might cry, “My mother is a witch!” To maintain neutrality and calm, and yet keep the interpretation emotionally immediate, the therapist might reply, “You put great emphasis on how your mother is a witch. Would you like to say more about that?” An alternative might be, “I wonder if by referring to a witch you are saying that you find your mother mean to you. Am I on target?” Still another would be, “I wonder if you are referring to me when you say your mother is a witch.”
In phrasing TRIs in these ways, therapists play back clients’ descriptions as clearly the client’s perception, rather than both the client’s and the therapist’s. Thus therapists keep a balance between respecting clients’ points of view as subjectively valid and questioning their objective validity; that is, not necessarily being objective facts. As a consequence, the therapy room stays a safe and secure, open and receptive space in which to process what is most disturbing to clients. Their therapist has remained neutral but has also noted the forcefulness and immediacy of their feelings. They can safely look at a painful experience that they might or might not be perceiving accurately.
Neutrality is extremely important when clients give feedback in such a way that therapists feel criticized. They must then find some way of dealing with their clients’ experience without reacting with hurt feelings or anger that would dissuade clients from being honest in the future.
At times it is best for therapists to simply refrain from even naming their client’s or their own feelings. They can simply acknowledge what is transpiring, as in “I can see how you could have heard what I said as critical.” If, by contrast, therapists focus first and only on transference or countertransference feelings, clients might experience their therapist as defensive and intent on denying elements of objective reality in the client-therapist relationship (Casement, 1991).
While TRIs are neutral, they must also be precise and clear about the TL distortions clients seem to be making, or about the specific relational actions that are affecting their therapist (Kiesler, 1982). They are specific: detailed and concrete (Strachey, 1934).
TRIs are not abstractions or vague assertions. In all likelihood, for example, clients would hear, “You seem to be getting upset about what I’m saying,” as an ambiguous remark. They might also have a chance to thwart their therapist’s attempts to make unpleasant unconscious material conscious (Strachey, 1934). They might take the opportunity to slip out of responsibility for their communications into what has felicitously been called a “gentleman’s agreement.” “We won’t get into difficult, painful matters,” that unspoken agreement goes. “We will just note in passing that we don’t feel comfortable with something going on between us. Like gentlemen, we will cease and desist and thus resume our comfortable relatedness” (Wolstein, 1996, p. 507).
If, on the other hand, TRIs clearly identify observable signs or manifestations of the suspected transference, clients are given a sound foundation on which to consider their therapist’s hypothesis. If the hypothesis is shared in a clear, concrete, and precise TRI, and it is true, the client will resonate with it. Intrapsychic boundaries will be permeated (Lear, 1993). Client and therapist can then collaborate to discover the exact nature of an interpersonal affiliative issue.
“Could it be that you are angry with me because I said your behavior is inappropriate?” is clear and concrete. So is “You seem to be resentful because I commented on your tardiness.” So is “I’m wondering if you dislike me now that I have questioned whether the blame is entirely your sister’s.”
Effective TRIs are tentative. They are not as informative as communicative (Brodbeck, 1995), not as certain as probabilistic (Schafer, 1983). “Could it be that…,” “I wonder if…,” and “Perhaps it’s that…” all invite the client to respond in agreement, disagreement, or partial agreement. Thus TRIs pave the way for further clarification. They allow therapists to watch and listen for evidence of consensual reality or organized experience that supports clients’ and their own perceptions or conclusions (Schafer, 1983).
Tentative TRIs are intended “to be played with – kicked around, mulled over, torn to pieces – rather than regarded as … official versions of the truth” (Bollas, 1983, p. 7). If therapists come across as certain rather than tentative, clients then have to contend with an individual who seems to already know what is going on. They have already decided what the client is contributing – versus what the therapist is contributing – to an interpersonal problem in therapy. But the truth is that there are no reliable means of identifying for sure what belongs to whom (Field, 1989) other than through interactive work: client and therapist testing the validity of the TRI together (Bacal, 1990).
Thus, clients benefit from TRIs that therapists phrase tentatively. Far from being dogmatic and certain, therapists make it clear that they are intending their perceptions to be explored for potentially different meanings (Winnicott, 1971). They are offering to their clients “a scrap of material and a chance to elaborate on it (Bollas, 1987, p. 206)”, a chance to ponder rather than automatically validate feelings and judgments.
Tentative TRIs tend to convey that therapists are having difficulty putting into words what they believe their client is feeling or thinking. When therapists openly struggle to find the right words, they model how to deal with what they somehow “know” but cannot easily describe or what they suspect but do not really know. They counteract that certainty with which clients have often been judged and judge themselves. They invite clients to collaborate in an effort to discover the complexity of the human person, especially in relationships. They emphasize the value of putting subjective experience under scrutiny (Bollas, 1987).
Pertinent TRIs are designed to give clients a chance to lead their therapists to insight that is unique to them and often quite new (Casement, 1991). In contrast, stereotypic TRIs that are easily formulated and foremost in thinking, tend to be unhelpful generalizations (Hedges, 1992).
Because they are personal, pertinent TRIs tend to be uncomfortable or even painful for clients to hear (Hedges, 1992). Not wanting to increase their clients’ distress or reveal personal information about themselves, therapists also find pertinent TRIs difficult to voice. This is especially true in the area of TL because of its sexual overtones (Danzer, 2018).
One way to increase clients’ comfort is to make pertinent TRIs inclusive; to link the here-and-now maladaptive habits clients reveal in therapy with the there-and-then conflicts they have had in life (Safran, et al., 2011). Such TRIs help clients focus less on the embarrassment they are feeling, and more on a habit they have developed. They also zero in on the reason for the habit, a reason that makes sense. Such a TRI as “I wonder if you are being unintentionally seductive with me, just as your brother was with you,” could help a client move from a subjective feeling state to an objective cognitive state, while not denying the feeling. It conveys “empathy and understanding for the position the [client] feels she is in” (Carsky & Chardavoyne, 2017, p. 403).
Furthermore, this kind of TRI would very likely strike the client as worth exploring. Problematic interactions in therapy tend to be very similar to those outside of therapy.
Another way to increase clients’ comfort with pertinent TRIs is to connect them to the goals they have set. A TRI that reveals how brusque a client’s remark has come across to the therapist in spite of the client’s goal to maintain friendships, for example, can move the focus from inappropriate behavior as such, to why it would be beneficial to replace it with something that enables goal attainment. It might be worded like “When I try your patience and you say ‘Whatever’ and change the subject, I feel devalued. Would you like to find some alternatives?”
A third way to make clients more comfortable is to voice a TRI that normalizes TL (Danzer, 2018). An example would be “People tend to be attracted to those they perceive as caring about them. They even have sexual fantasies about each other. Could that be our case here?”
A simple way to formulate inclusive TRIs is to start with an observation the client has made about the past and then follow the direction of the transference to where the past is spilling into the present. For example, “When you were dependent upon your parents, they went away and left you. When I went away on vacation, did I remind you of your parents?” This wording offers clients insight into their past distress while keeping the focus on the present.
Similarly, inclusive TRIs might link material from a previous session with what is happening in the present session. For example, “Last week you spoke of John’s unkindness toward you. I wonder if you are finding me unkind today.” Or inclusive TRIs might link what clients are saying about a third party with what they might like to say to their therapist. For example, “You seem so intent on raking your father over the coals. Would you also like to do that to me?”
In fact, Gill (1982) recommends routinely including the words “also” or “in addition” in TRIs. Thus clients can learn the ancient and deep source of the feelings and impulses they are re-experiencing. “Remembering and re-experiencing will become organically blended,” Kahn (1997, p. 59) adds.
At the same time, TRIs do not have to be inclusive to be pertinent. They need only to refer to core conflicts clients need to resolve in the here-and-now. They only need to assure clients that the issues they have come to work on are being dealt with (Gill, 1982). If here-and-now incidents are actually linked to there-and-then incidents, clients will link them mentally if not verbally.
A final point is that the criterion of pertinence is valuable because of our tendency to make what is already known into something universal and ubiquitous. Instead of being quick to use old insights, therapists are to tolerate longer exposure to what they do not yet understand. “And, when they…think [they] recognize something familiar in a [client], [they are to remain] … receptive to that which is different and new” (Casement, 1991, p. 29).
As valuable as inclusivity is, however, it must not cancel out brevity and simplicity. Though complex in that they link key events, TRIs should focus on one and only one main point. They should not require such extensive cognitive work that their affective impact is diminished. After all, the very reason they are mutative is that they are charged with emotion.
To make TRIs simple is to acknowledge the fact that transference is a relatively simple unconscious phenomenon. The unconscious mind considers only one characteristic of an object, disregarding all others and making this feature equal to the whole (Matte Blanco, 1975). Thus Harry Stack Sullivan is quoted as saying that interpretations should not be longer than seven words (Swift & Wonderlich, 1990).
For the sake of brevity, therapists might have to divide a TRI into two successive TRIs. The first would address just the emotional or cognitive-emotional nature of the client-therapist relationship. The second would add the extra-therapeutic or pre-therapeutic material. For example, after processing with the client such a TRI as “I wonder if you are turning me off because I have hurt you,” the therapist might pause. If the client does not say anything, the therapist might add, “Could it be that you feel that same hurt when your wife fails to appreciate your help, as you mentioned last week.” Similarly, the first TRI might address present or in-session phenomena, and the second might link the present with the past or with out-of-session phenomena (Roth, 2001). For example, “Could it be that you are very attracted to me because I come across as maternal?” would be followed by, “Is it possible that I remind you of the mother who died when you were a child?”
TRIs that are respectful leave clients feeling esteemed even though they might have developed dysfunctional patterns of relating. They feel respected for their approach to life and for their struggles to change (Kiesler, 1982). Furthermore, far from feeling attacked in isolation, they feel included as collaborators in a process designed to help them change and thereby gain even more respect.
One of the most common ways to be respectful toward clients is to ask their permission to consider a certain topic. Thus a TRI beginning with “Would you be all right with…,” or “Could we look at our attraction to each other?” conveys a deferential attitude on the part of the therapist.
For their part, CTRIs should leave therapists feeling esteemed even though they might have made an error. Thus Hedges (1992) cautions therapists against being too ready “to assume personal responsibility for the emerging disruption of untoward feelings” (p. 25). Their doing so could indicate to clients that they can “[sidestep] completely the more important interactional component” (p. 25) of the transference phenomenon. Rather, in the case of TL, they need to explore how both parties might have a desire for affection, or for an overly supportive relationship, or for total love (Zilcha-Mano, 2017).
Distinguishing clients who can benefit from TRIs and CTRIs from those who cannot is far from easy. However, the following two principles provide guidance. First, TRIs and CTRIs are appropriate only with clients who are open to them and ready for them and thus able to benefit from them. Clients with low self-esteem who are experiencing painful narcissistic injury, for example, could hardly benefit from having their attention directed to their contribution to their therapist feeling demeaned.
Second, in general, only clients with at least moderate ego-strength and generally low-to-medium levels of affective arousal – at the time – have the capability of benefiting from TRIs and CTRIs. Though they may be temporarily hurt or angered by what they hear, these clients can use higher-level defense mechanisms to protect themselves from the worst of the pain. In particular, they can avoid the use of the splitting defense that labels them as “all bad” and prevents them from using their cognitive capacities. They can use their reality-testing function and thus counteract their tendency to confuse facts with feelings. They can subject perception to rational scrutiny.
To say this, however, is not to imply that TRIs and CTRIs are appropriate in any and all sessions with these clients. There will be times when highly aroused clients simply need to be listened to and allowed to process their feelings in their own way, even if that takes the entire session.
On the other hand, clients with at least moderate ego-strength sometimes do not need the entire session to lower affective arousal. Because they are not in the habit of relying primarily on the splitting defense, they can return to their more discriminating cognitive functions. If needed, they can use less primitive defenses such as intellectualization and rationalization.
At the same time, some clients with moderate ego-strength and generally low levels of affective arousal, present with embarrassing or highly sensitive identified problems. If therapists experience these clients as repeatedly defensive, oppositional, or passive, they should conclude that they are not ready for TRIs and CTRIs.
Similarly, when clients repeatedly or strongly reject material, more often than not they are indicating their inability to make proper use of their cognitive functions. Especially if they are highly internalizing persons, they could easily experience TRIs as invasive. Instead, they might benefit from their therapist simply clarifying what they are trying to say.
It would be the same with highly externalizing clients who are under great stress. They usually need help with symptom reduction and skill building rather than insight and relational work. This would be true even if they had moderate ego-strength. They could benefit from carefully timed and infrequent TRIs, but only if they are interspersed with plentiful externalizing interventions, particularly those that are cognitive-behavioral, (Beutler, 2000).
Similarly, clients with a strong need to merge with idealized others would find it hard to combine their defense mechanism with CTRIs exposing their therapist’s limitations and flaws, at least until well into therapy. Simply stated, it is usually necessary for therapists to leave unchallenged an idealized transference in the beginning phase of therapy (Kernberg, 1987).
Clients with pronounced limitations justifying dual diagnoses also find it hard to benefit from TRIs. They lack sufficient ego-functioning because of such things as significant alcohol and drug dependence; a well-developed habit of acting out feelings and desires, especially those that are antisocial or suicidal; and a limited capacity to see connectedness (Crits-Christoph & Barber, 1991; Pollack & Horner, 1985; Davanloo, 1990).
Indeed, clients with a borderline personality disorder deserve careful consideration because of their impulsivity and habit of acting out their feelings (Denny, et al., 2008). Particularly if they are functioning at a low level, these clients are likely to perceive TRIs as expected and deserved counter-assaults. Instead, therapists might simply clarify the way these clients use splitting and other defenses and are thereby distorting perceptions.
Occasionally, however, even highly disordered persons can benefit from interpretations. Franch (1996), for example, writes of a child with autism and an inability to overcome two-dimensionality and the existence of a world without meanings. Because the child could experience neither inside nor outside as such, Franch started to work almost exclusively with his own countertransference. Fearing that interpreting the child’s transference would seem invasive to him, he used his own feelings, sensations, fantasies, and associations to get information about the client’s state of being. He then assigned meaning to the countertransferential data and communicated it through CTRIs. Somewhat surprisingly, as Franch communicated the information, the child’s “frozen” internal world began to “thaw.” His transference had arisen in response to his therapist’s countertransference interpretations.
Timing depends on clients “inviting” their therapist to interpret (Joyce, et al., 1995). They generally do so by identifying a conflict or problem and then elaborating on their distress related to it. They focus inwardly and stay with their feelings. They attribute personal significance to the content of a trial-TRI or trial-CTRI and show willingness to elaborate on it (Sifneos, 1979; Winston, McCullough, & Laikin, 1993).
As with many other principles, however, it may be easier to identify times when TRIs and CTRIs should not be used.
It would be unwise to use TRIs and CTRIs, for example, if moderately ego-strong clients were already dealing with a significant past conflict (Swift & Wonderlich, 1990). Their attention should not be diverted to a negative therapist-client relationship and its unwholesomeness if they are already exploring a problematic relationship in the past that is being repeated in the present. They have identified and owned the destructive pattern they are using outside the therapeutic setting. They have gotten the point (Pearson, 1995).
Vignette:
She came to therapy sessions very early and stayed after her therapist ended the sessions. In addition, she focused on the affairs her husband had had even though he had dealt well with his doing so in the couples’ therapy they had had before she started in her individual work. “Should this be brought to her attention?” her therapist asked herself. Was there not good reason to use a very gently worded TRI so that she might consider her own sexual behavior? She alluded to how she herself had also been unfaithful, but when her therapist tried to stay with this matter, she brushed it aside more than once and more than quickly.
At the same time, she gave evidence of significant emotional instability. She changed topics frequently, hyperventilated regularly, and spoke of needing to take a break from therapy.
“No,” her therapist decided. “It’s better to stay close to what she is feeling and doing rather than put TL on the table. She needs to stabilize and build trust. She is close to revealing something more fundamentally serious than her adult sexual behavior. Perhaps it’s her relationship with her son, which she wanted to deal with as her second goal.”
When her client referred to taking a break a second time, however, the therapist said, “Yes, we sometimes need to take a break. But sometimes we need to be brave and look at the possibility of our being uncomfortable with the person we are with because of our sexual orientation and theirs. Would you be open to doing that with me? Or at least considering doing so when you get back?”
Similarly, it would be unwise to use TRIs and CTRIs with clients experiencing extreme distress related to such things as the death of a significant other, including a pet; rejection; humiliation; and abuse, including verbal and/or emotional abuse. A much more effective intervention would be simple reflective listening.
It would also be unwise to use TRIs and CTRIs when clients are dealing with material too primitive for language, when they cannot “give voice” to what they were experiencing. If clients cannot give information, talk slowly enough to be heard, or speak coherently. TRIs and CTRIs exposing those phenomena would most likely reinforce their uncomfortable state. More effective interventions would be attentive silence or short affective responses.
Yet another situation for questioning the wisdom of using TRIs and CTRIs is when transference is positive. Though positive transference is a distortion to some extent, it might be necessary for the therapeutic alliance to develop in clients whose ability to bond is elementary at best. If their attention is called to their positive transference, it might frighten them, make them highly self-conscious, or discourage future bonding efforts (Freud, 1905). As a general rule, positive transference is best left alone if it does not interfere with therapeutic work or if it is clearly a means of solidifying and maintaining the therapeutic alliance.
Furthermore, TRIs and CTRIs should not be used too soon, even under the constraints of brief therapy. They should be used only when there is evidence of a comfort-level characteristic of a solid therapeutic alliance (Benner, 1982). In other words, TRIs and CTRIs should ordinarily be used after more supportive interventions (Gabbard, 1994). Clients need to feel accepted and valued in their therapy before they can look at how they have contributed to their failures. This is especially important if clients are suffering from significant guilt.
In some cases, however, TRIs and CTRIs can be used to establish the therapeutic alliance. They can be used to help clients see that their strongly positive or strongly negative unprocessed attitude toward their therapist is creating an impasse in their therapeutic work (Colli, et al., 2021). TRIs and CTRIs can also be used when the therapeutic alliance or the working alliance has been ruptured (Schaeffer, 2007).
The answer to the question of frequency of TRIs and CTRIs begins with a general, research-based rule: since other interventions are often equally or more appropriate, TRIs and CTRIs should be used infrequently (Piper, et al., 1991; Hoglend, 1993; Joyce & Piper, 1993). They should be alternated or interwoven with active listening, explorations, clarifications, confrontations, and other forms of interpretation (Grunebaum, 1986).
It is especially important to move back and forth between TRIs or CTRIs and supportive interventions (Bond, et al., 1998) for personality-disordered individuals. In that way, a solid alliance can be established and maintained.
How can therapists decide what to do with TL and CTL that becomes operationalized in their clinical practice?
How might their practice be affected if they virtually ignored TL and CTL?
How might clients benefit if therapists made TL and CTL one focus of their clinical practice?
Do TRIs and CTRIs cause positive therapeutic outcome? Or do they act as mediators and/or moderators of outcome?
Does research support theories that recommend using TRIs and/or CTRIs to enable TL and CTL to contribute to positive outcome?
Does research support theories that recommend not using TRIs and/or CTRIs in order to avoid a negative outcome?
How scientifically sound is research on what to do with TL and CTL in actual practice?
Even if that research is less sound than is desirable in general, are certain findings still worth serious consideration?
Would it be benevolent for therapists to use TRIs and thus invite clients to collaborate with them to deal with their TL?
Would it be benevolent for therapists to use CTRIs and thus invite their clients to collaborate with them to deal with their transference love as it appears in CTL?
The question of what to do with TL and CTL must be answered, because – like it or not – they act as powerful, unconscious motivators for both clients and therapists to find ways to meet their affiliative needs.
We begin with an ethical principle that holds no matter what therapists decide to do with TL and CTL.
To ensure that TL and CTL do not become a liability, therapists must refrain from enacting them. “Treatment must be carried out in abstinence,” (Freud, 1915, p. 163). Both therapists and clients must refrain from any form of physical expression of their felt need for love and affection. For without exception, when clients’ “advances [are] returned, it [may be] a great triumph for [a client or therapist] but a complete defeat for the treatment” (p. 164)
The principle of abstinence is absolute in the case of erotic, eroticized, and perverse transference (including countertransference love). But even non-erotic TL that is acted out can cause confusion and distress in a therapeutic context. Accepting gifts, for example, on all but a rare occasion can give clients the impression that their therapist is willing to be in a love-based relationship. Touching clients more often than absolutely necessary can also “say” to clients that their relationship with their therapist is virtually the same as with those with whom they and their clients express their love outside of therapy. As stressed earlier, the four forms of TL are neither mutually exclusive nor likely to remain distinct.
Therapists bear primary responsibility for maintaining abstinence. They must set limits. They must replace their felt needs and those of their clients with the “counterweight” of a greater love, either the love of truth and one’s obligations to self and others, or the passion for healing others (Freud, 1937). Therapists must set firm boundaries. In some cases, they must go so far as to tell clients that therapy will be terminated if abstinence cannot be maintained (Kernberg, 1998).
Having accepted their responsibility to abstain from enacting TL and CTL, therapists can choose to put it aside – virtually ignore it – during sessions with clients. Therapists most inclined to choose this option are those whose needs to be admired and respected trump their willingness to be vulnerable with their clients (Charles, 1999).
Of course, this first choice can also be based on the theoretical position that non-analytic therapists are insufficiently prepared to deal directly with TL. “A [client] sharing sexual feeling for a therapist can be one of the most difficult experiences for both parties. Such experiences combine the anxiety of intense emotional expression and negotiation of a relationship while affirming professional and personal boundaries,” (Malark, 2017, p. 418; McWilliams, 2004). Furthermore, there are other ways to help clients deal with unconscious desires and motives related to their affiliative issues. Similarly, there are other, purely personal and/or collegial ways to process CTL.
In any case, therapists choosing to ignore TL that arises in their clinical work should seriously consider engaging in one or more of the following: evaluating between sessions the impact of transference love during sessions; using interventions other than interpretations, especially standardized assessments (Churchill & Ridenour, 2019) to discover and address TL that becomes problematic; dealing with countertransferential issues in their own personal therapy; and/or consulting with supervisors or experienced colleagues. The appropriateness of the latter might even head the list in light of how difficult it is to assess the impact of TL in the actual setting. In fact, valid and reliable assessment by an involved clinician himself might even be “impossible” (Churchill & Ridenour, 2019).
The value of dealing with transference and countertransference love in one’s own personal therapy and with one’s supervisor cannot be overestimated. Research reveals that therapists, especially those still in training, feel most comfortable talking about sexual attraction with their therapist, followed by their supervisor (Williams, et al., 2016). Research also reveals how difficult it is to assess the impact of TL and CTL in the actual therapy setting. In fact, valid and reliable assessment by an involved clinician himself might even be impossible (Churchill & Ridenour, 2019).
Therapists’ second choice is to draw clients’ attention to TL and invite them to co-process it during sessions by using TRIs but not CTRIs. Doing so is based on the theoretical position that abstinence from enactment should not mean “deprivation of everything that the [client] desires” (Freud, 1915, p. 163). It should not result in therapists’ becoming cold, aloof, or distant, for these reactions can imply that TL is unacceptable, even disgusting. It may even reinforce the belief of many clients that they are truly unlovable (Gerrard, 1999).
Therapists who choose to use TRIs but not CTRIs base their decision on theory that holds that therapists’ intrapsychic processing of their countertransference is usually sufficient to counteract enactment of it unless it is extremely subtle or unusually potent. Furthermore, using CTRIs can give clients the impression that their therapist is more interested in himself or herself than in them (Schaeffer, 1998).
In addition, pinning down the exact nature of CTL is generally more difficult for therapists than doing so with TL. It is hard to meet the criterion of emotional immediacy with CTRIs. Even if it is met, CTRIs can be meaningless to clients in that they may be inaccurate or incomplete. If countertransference is especially negative, it is also hard to meet criteria of calmness, neutrality, and tentativeness. Thus CTRIs can damage clients because of prosody: tone, volume, inflection, and accompanying body language (Schaeffer, 1998).
Therapists who choose to use just TRIs also base their decision on theory supportive of their relationship to positive outcome. TRIs foster that outcome because they build rapport as well as strengthen and repair the therapeutic alliance. Furthermore, TRIs that clearly refer to clients’ here-and-now core conflicts, and/or connect therapists to parents and siblings, contribute to treatment efficacy. Clients also benefit from TRIs that link their affiliative needs and desires with the responses of others, beginning with those of their therapist. Furthermore, TRIs are easily combined with non-transferential interventions, such as reflective listening, explorations, clarifications, questions, and even gentle confrontations. These interventions, in turn, have been found to be very efficacious (Schaeffer, 1998).
Finally, therapists who are adequately prepared to perform the subtasks related to formulating and verifying TL are in a position to use TRIs to help clients with a variety of mental health diagnoses. Unless clients’ goals are purely personal, therapists can use the therapeutic setting to help clients attain those goals of relating to others in truly loving ways. They can make the therapeutic setting a safe place to do that difficult work by putting clients’ TL into words and inviting their clients to collaborate with them so that they understand what they are bringing to their sessions. Therapists can become safe persons with whom clients can learn how to meet their affiliative needs in mature and wholesome ways – loving themselves along with nourishing adult-adult affiliative relationships – perhaps for the first time in their lives (Schaeffer, 2007).
Therapists’ third choice is to use both TRIs and CTRIs. It is based on the theoretical position that both TL and CTL deserve to reveal their potential for helping clients resolve their past-based psychological conflicts and meet their present affiliative needs. Therapists who adhere to this position consciously choose to “sink into” their own and their clients’ affiliative phenomena without “drowning” in them (Gabbard, 1994). They work to increase their own and their clients’ comfort level with viewing themselves as human beings complete with erotic – no less than non-erotic – desires. They have by nature both pathological and non-pathological propensities to meet their affiliative needs. Therefore, they are willing to incorporate TRIs and CTRIs related to affiliation into their work. They are willing to risk making therapy overly relational as well as intrapsychic.
Indeed, using TRIs and CTRIs makes explicit the potential both TL and CTL have toward meeting affiliative needs in truly wholesome ways. Doing so means directly helping clients replace mindless and unproductive action, namely simple reenactment (Freud, 1915), with conscious and productive processing of affiliative needs. They can thereby experience a generative shift leading to a deeper level of self-experience (Slochower, 1999). They can experience themselves and others as profoundly good, genuinely desirable, and actually loved (Schaeffer, 2007). They can move from “I love you mainly because you love me,” and “I love you because I need you,” to “I am loved because I love myself,” and “I need you because I love you” (Fromm, 1976).
In addition, using TRIs and CTRIs enables therapists to help clients realize that with TL and CTL comes the opportunity to mourn, perhaps for the first time, the loss of early parental love. Their grief is appropriate because what they always wanted from parental figures was and still is unattainable (Maroda, 2000). They must mourn not being able to go back in time to become infants. They must replace that desire, first and foremost, with providing that love for themselves. By truly loving themselves, they will then be able to enter into unselfish, loving, and mutually satisfying relationships with others.
The decision to make the second and third choices, of course, also calls for a nuanced approach made possible only by weighing the following pros and cons based on extant research findings.
While quantitative, qualitative, and quantitative-qualitative research regarding the use of TRIs and CTRIs is impressive, it is important to keep in mind that it is limited in both quality and quantity. There have been relatively few scientifically sound studies of TRIs and even fewer of CTRIs according to current standards. Some of these studies were neither adequately designed nor methodologically sound. Some did not use control groups or sufficiently large populations. Most were not replicated or longitudinal. Thus it is not possible to draw firm conclusions from most studies conducted thus far. At the same time, it is possible to use research data to inform treatment decisions.
TRIs and CTRIs do not cause positive therapeutic outcome. Rather, they act as mediators and moderators of outcome (Schaeffer, 1998).
Acting as mediators, TRIs can enable clients to address the issue of their present affiliative needs by identifying past conflicts related to them (Malan, 1976; Marziali, 1984; Luborsky, et al., 1988). TRIs can help clients disconfirm pathological beliefs resultant from childhood trauma (Fretter, et al., 1994).
Indiscriminate use of TRIs, however, can distract clients from focusing on the issues they explicitly brought to therapy (Grunebaum, 1986). Acting as moderators, too many TRIs – or TRIs used inappropriately – decrease the benefit of focusing on the non-transferential issues clients identify as important to them when they seek therapy.
TRIs can contribute indirectly to negative outcome if they are used with inappropriate clients or used too frequently (Piper, et al., 1993; Grunebaum, 1986). At the same time, accurate, sensitively timed, and occasionally used TRIs can make an indirect contribution to successful outcome by positively affecting correlates of that outcome: rapport building; the therapeutic alliance; continuance in therapy; and the working alliance (Fretter, et al., 1994; Luborsky, et al., 1988; Foreman & Marmar, 1985; Piper, et al., 1993; Joyce & Piper, 1993).
Careful use of TRIs can contribute to successful outcome with a variety of diagnostic categories and non-diagnostic populations (McCullough & Winston, 1991).
Though little research has been conducted on the use of CTRIs as such, therapeutic success for clients correlates with early-session interpretations that accurately link participants’ needs and wishes with how others respond. CTRIs can lead to successful outcome because of clients’ increased awareness of the contribution their behavior makes to their therapist’s well-being or lack thereof (Crits-Cristoph, et al., 1998). Thus, CTRIs are mediators of successful outcome and moderators of the level of that outcome.
CTRIs have also been found to be mediators of positive outcome in that they draw clients’ attention to universal human vulnerability as well as to the capacity for self-regulation (Beard, 1992) and for reflective thought rather than mindless action (Feldman, 1997).
CTRIs have also been found to perform a useful modeling function. “The willingness to self-disclose on the [therapist’s] part facilitates self-disclosure by the [client], and therefore productive dialectical interchange between [therapy participants] is maximized” (Renik, 1993, p. 529). Thus, CTRIs are mediators and moderators of successful outcome.
Clients are usually aware of their therapist’s feelings, whether communicated or not (Racker, 1968; Crowley, 1988). Using CTRIs is one way of processing what clients are already aware of.
If therapists do not process their countertransferential feelings during sessions; that is, do not name them, validate them, or give them minimal expression; it is highly probable that they will act them out in silence, withdrawal, coldness, distancing (McDougall, 1978; Danzer, 2018), fatigue, or inappropriate timing, tact, or tone (Jacobs, 1986; Myerson, 1993).
Unaddressed countertransference conflicts are also likely to result in acting-in, taking such forms as depression and somatization. In fact, Boyer (1961) found that unaddressed countertransference conflicts are the major reason for therapeutic failure.
By sharing countertransference, therapists increase the probability that they will become enlightened about themselves, their clients, and the work their clients need to do in therapy. Therapists’ thoughts, sensations, and feelings act as mirrors reflecting what clients perceive that their therapists are experiencing (Little, 1957), even as therapists are acting as mirrors for their clients (Casement, 1991). Thus, through countertransference that is shared, clients are in a position to enlighten therapists as to what they as clients want to accomplish in therapy (Ehrenberg, 1996).
Sharing countertransference has a powerful modeling effect (Little, 1957; Bollas, 1983; DeLaCour, 1985; Bandura, 1971). It demonstrates for clients appropriate ways of dealing with problematic feelings in close, interpersonal settings (Bollas, 1983). When countertransference is shared, clients learn how to acknowledge and care for the archaic or unconscious (Loewald, 1986); how to be honest (Searles, 1979); and how to struggle with feelings, frustrate them, manage them, contain them, explore them, and eventually integrate them (McDougall, 1978). CTRIs teach clients how to be emotionally available (Viederman, 1991).
CTRIs can contribute to the formation and strengthening of the therapeutic alliance (Kiesler, 1982; Alpert, 1992). They offer concrete and convincing evidence of therapists’ attunement to their clients (Stolorow, 1993).
TRIs and CTRIs can be cost-effective, even though therapeutic outcome does not depend on their use (Gassner, et al., 1982; Fretter, et al., 1994; Weiss & Sampson, 1986; Silberschatz, et al., 1986; Schaeffer, 2007).
A given intervention such as using TRIs and/or CTRIs can affect outcome, but not determine it, because all therapeutic interventions combined account for only 40% of successful outcomes (Lambert, 2001).
TL and CTL arising in therapy are ubiquitous double-edged swords. They can be harmful if not recognized and regarded as phenomena that reveal our innate, life-long needs to love and be loved.
At the same time, they can be beneficial if carefully worked with in the light of their being potential mediators and moderators of healing long-held psychological pain. They can facilitate a generative shift in the course of which clients and therapists experience themselves as innately good, genuinely desirable, actually loved, and able to love others in developmentally appropriate ways.
Thus we are wise to weigh the forewarning of Gerrard (1999): “Until and unless there can be felt moments of love for the [client] by the therapist, the [client] is not able to develop fully. It is only when [he or she] can arouse [the therapist’s] deepest loving feelings (not empathy) that [therapists] can hope for a truly positive outcome from [their] work” (p. 30).
We are also wise to reflect on the attestation of Rabin (2003): TL and CTL that are processed well can make therapy a truly benevolent experience. It can enable clients to deal with difficult situations outside of therapy.
And we are wise to ponder the findings of Bachant & Adler (1997): if clients are able to tolerate passionate love, they will undergo a maturation that would not have occurred otherwise. They will learn the deepest lessons of the heart.
And their therapists will also.
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