Managing Transference and Countertransference in Cognitive Behavioral
Supervision: Theoretical Framework and Clinical Application
D
Abstract
IE
Dysfunctional patterns, beliefs, and assumptions that affect a patient’s perception of other
people often affect their perceptions and behaviours towards the therapist. This tendency
has been traditionally called transference for its psychoanalytical roots and presents an
important factor to monitor and process. In supervision, it is important to put the patient’s
IF
transference in the context of the conceptualization of the case. Countertransference
occurs when the therapist responds complementary to the patient’s transference based on
their own dysfunctional beliefs or assumptions. Transference and countertransference
provide useful insights into the inner world of the patient, therapist, and supervisor.
R
Guided discovery is one of the most common approaches used by a supervisor and a
supervisee to map all types and directions of transference and countertransference. Other
options to map transference and countertransference are imagery and role-playing
VE
techniques.
Keywords: supervision, cognitive behavioral therapy, therapeutic relationship,
supervisory relationship, transference, countertransference
Introduction
,Comparing current and past experiences is automatic and mostly unconscious.1 Thus,
transference and countertransference reactions present valuable sources of information
about the individual’s inner world, either a patient, a therapist or a supervisor2,3,4,56.
Examining the supervisee’s countertransference is a crucial but delicate part of the
supervision process.5 However, transference and countertransference alone do not yet
provide sufficient insight into the inner world of the patient, therapist, and supervisor.
However, their careful identification and elaboration can be a useful source of clinical
information and help remove barriers to treatment.
D
Sigmund Freud introduced the history of the early development of countertransference in
IE
1909, as described by Stefana (2015).6 In the original psychoanalytic construction,
transference was understood as one of the numerous forms of resistance and difficulty
forming a required trusting relationship between therapist and patient.7 The concept of
transference has gradually become an essential tool of analysis, through which it has
IF
undergone profound changes in definition and clinical use. The transference was
recognised as a central element of the psychoanalytic process.9 Now classical
psychoanalysis recognizes transference as an essential component of the therapeutic
relationship.10 The basic tasks of supervision consist of clarifying the mutual
expectations of the supervisee and the supervisor, creating a credible supervisory
R
relationship as a basis for countertransference analysis, and examining “parallel
processes” between the supervisor and the supervisee.11 Examining the supervisee’s
countertransference is a necessary but delicate part of the supervision process.5 From the
VE
psychoanalytic perspective, the therapeutic relationship is the sum of the real relationship
between two people, the working alliance, transference and countertransference,12,13
Levy and Scala 2012).7,70 Watkins (2011)14 and Gelso (2017)13 explored a tripartite
model of the therapeutic relationship. This model postulates that a therapeutic
relationship contains a working alliance, a real relationship, and transference and
countertransference formation. Although the model seems theoretically and empirically
feasible, further research is needed to improve the model further. In transference, the
patients project to the therapist’s thoughts and feelings, originating from their experiences
,with important individuals they met earlier, especially in childhood and their mother and
father (Gutheil and Gabbard 1998).10,71
Some psychotherapists believe that the difference between psychodynamic
psychotherapy and cognitive behavioural therapy (CBT) lies mainly in the emphasis or
lack of attention on transference.15 This is one of the most common misconceptions about
CBT.15–18 However, CBT usually does not analyse the therapeutic relationship when
D
solving uncomplicated problems and disorders (Beck 1995).2,19,17
IE
When the patient trusts the therapist and actively engages in the therapy, the therapist acts
as a supporting expert who accompanies the patient in the individual steps of the therapy
and encourages them in their independent implementation.20 The patient does not depend
on the therapist but only seeks a colleague to discuss the steps performed on their own.
IF
The relationship is straightforward. In more complex cases, including patients with
personality disorders, the therapeutic relationship becomes an important therapeutic focus
(Beck 1995;17 Zanarini 2009;2,72 McCracken and Gutiérrez-Martínez 2011).73
R
When we look at the history of CBT perspectives of transference and
countertransference, we can recognise it from the beginning of cognitive therapy. Beck
mentions transference as a “schematic response” in his publications as early as the
VE
1970s.21 Although transference and countertransference were described early in CBT,
they were not of clinical interest in initial, especially short-term therapies, unless they
provided an example for the guided discovery of core beliefs or conditional rules
triggered in the therapeutic relationship.2,22,23 In cognitive-analytical therapy (CAT),
transference and countertransference are conceptualized as the organization of an
individual’s experiences and behaviours throughout patterns composed of self-confirming
sequences, including cognitive, emotional, and interpersonal processes based on previous
experience.24 Individuals play roles and seek or provoke reciprocal reactions from others.
CBT therapists have also pointed out how a patient relates to a therapist may reflect on
, their past emotional bonding difficulties, previous relationship patterns, and learned
maladaptive emotion processing. Previously learned cognitive and emotional processes
can lead to blocks in therapy.25
Nevertheless, specific difficulties in dealing with the disruption of the therapeutic
relationship due to transference or countertransference have rarely been discussed.26 A
deeper interest in theoretical and clinical views on transference and countertransference
D
appeared at the turn of the millennium. From a socio-cognitive approach, it is important
to recognise the therapeutic relationship as a co-construction so that what the patient
brings and what the therapist brings are important for the way the relationship pattern is
IE
formed.27 According to their model, transference supposes that internal representations of
important persons are in memory and could be activated by related signals in any context.
Once the transference is activated, the individual looks at the other person through the
glasses of the earlier representations of important persons. Leahy (2007)28 portrays a
IF
therapeutic relationship as an interactive game in which the therapist and the patient
follow their previously learned rules and use them to expect the other to behave and adapt
their behaviour accordingly. Previously developed relationship patterns and expressions
of emotions significantly impact building and developing a therapeutic relationship. Eg, s
therapist with unrealistic standards may unintentionally authorise a negative belief in a
R
patient’s relationships. Understanding transference and countertransference allows the
therapist to overcome the pitfalls of the therapeutic relationship and the blocks in therapy.
It also helps the therapist better understand how the patient’s interpersonal world is
VE
reflected in the current relationship in therapy.28 Leahy (2007) states that the transference
relationship consists of intrapersonal and interpersonal processes between the patient and
the therapist. These processes include personal schemas about the self, others, and the
world entering a therapeutic relationship. These patterns that make up the transference
relationship can be recognised through guided questioning and Socratic dialogues and
corrected by working with thoughts and schemas. To recognise countertransference, the
therapist needs to apply the same procedures to themselves and train in self-reflection in a
therapeutic situation.29 In his monograph, Newman (2013)23 also emphasises the
importance of CBT therapists using CBT methods and strategies for themselves and
Supervision: Theoretical Framework and Clinical Application
D
Abstract
IE
Dysfunctional patterns, beliefs, and assumptions that affect a patient’s perception of other
people often affect their perceptions and behaviours towards the therapist. This tendency
has been traditionally called transference for its psychoanalytical roots and presents an
important factor to monitor and process. In supervision, it is important to put the patient’s
IF
transference in the context of the conceptualization of the case. Countertransference
occurs when the therapist responds complementary to the patient’s transference based on
their own dysfunctional beliefs or assumptions. Transference and countertransference
provide useful insights into the inner world of the patient, therapist, and supervisor.
R
Guided discovery is one of the most common approaches used by a supervisor and a
supervisee to map all types and directions of transference and countertransference. Other
options to map transference and countertransference are imagery and role-playing
VE
techniques.
Keywords: supervision, cognitive behavioral therapy, therapeutic relationship,
supervisory relationship, transference, countertransference
Introduction
,Comparing current and past experiences is automatic and mostly unconscious.1 Thus,
transference and countertransference reactions present valuable sources of information
about the individual’s inner world, either a patient, a therapist or a supervisor2,3,4,56.
Examining the supervisee’s countertransference is a crucial but delicate part of the
supervision process.5 However, transference and countertransference alone do not yet
provide sufficient insight into the inner world of the patient, therapist, and supervisor.
However, their careful identification and elaboration can be a useful source of clinical
information and help remove barriers to treatment.
D
Sigmund Freud introduced the history of the early development of countertransference in
IE
1909, as described by Stefana (2015).6 In the original psychoanalytic construction,
transference was understood as one of the numerous forms of resistance and difficulty
forming a required trusting relationship between therapist and patient.7 The concept of
transference has gradually become an essential tool of analysis, through which it has
IF
undergone profound changes in definition and clinical use. The transference was
recognised as a central element of the psychoanalytic process.9 Now classical
psychoanalysis recognizes transference as an essential component of the therapeutic
relationship.10 The basic tasks of supervision consist of clarifying the mutual
expectations of the supervisee and the supervisor, creating a credible supervisory
R
relationship as a basis for countertransference analysis, and examining “parallel
processes” between the supervisor and the supervisee.11 Examining the supervisee’s
countertransference is a necessary but delicate part of the supervision process.5 From the
VE
psychoanalytic perspective, the therapeutic relationship is the sum of the real relationship
between two people, the working alliance, transference and countertransference,12,13
Levy and Scala 2012).7,70 Watkins (2011)14 and Gelso (2017)13 explored a tripartite
model of the therapeutic relationship. This model postulates that a therapeutic
relationship contains a working alliance, a real relationship, and transference and
countertransference formation. Although the model seems theoretically and empirically
feasible, further research is needed to improve the model further. In transference, the
patients project to the therapist’s thoughts and feelings, originating from their experiences
,with important individuals they met earlier, especially in childhood and their mother and
father (Gutheil and Gabbard 1998).10,71
Some psychotherapists believe that the difference between psychodynamic
psychotherapy and cognitive behavioural therapy (CBT) lies mainly in the emphasis or
lack of attention on transference.15 This is one of the most common misconceptions about
CBT.15–18 However, CBT usually does not analyse the therapeutic relationship when
D
solving uncomplicated problems and disorders (Beck 1995).2,19,17
IE
When the patient trusts the therapist and actively engages in the therapy, the therapist acts
as a supporting expert who accompanies the patient in the individual steps of the therapy
and encourages them in their independent implementation.20 The patient does not depend
on the therapist but only seeks a colleague to discuss the steps performed on their own.
IF
The relationship is straightforward. In more complex cases, including patients with
personality disorders, the therapeutic relationship becomes an important therapeutic focus
(Beck 1995;17 Zanarini 2009;2,72 McCracken and Gutiérrez-Martínez 2011).73
R
When we look at the history of CBT perspectives of transference and
countertransference, we can recognise it from the beginning of cognitive therapy. Beck
mentions transference as a “schematic response” in his publications as early as the
VE
1970s.21 Although transference and countertransference were described early in CBT,
they were not of clinical interest in initial, especially short-term therapies, unless they
provided an example for the guided discovery of core beliefs or conditional rules
triggered in the therapeutic relationship.2,22,23 In cognitive-analytical therapy (CAT),
transference and countertransference are conceptualized as the organization of an
individual’s experiences and behaviours throughout patterns composed of self-confirming
sequences, including cognitive, emotional, and interpersonal processes based on previous
experience.24 Individuals play roles and seek or provoke reciprocal reactions from others.
CBT therapists have also pointed out how a patient relates to a therapist may reflect on
, their past emotional bonding difficulties, previous relationship patterns, and learned
maladaptive emotion processing. Previously learned cognitive and emotional processes
can lead to blocks in therapy.25
Nevertheless, specific difficulties in dealing with the disruption of the therapeutic
relationship due to transference or countertransference have rarely been discussed.26 A
deeper interest in theoretical and clinical views on transference and countertransference
D
appeared at the turn of the millennium. From a socio-cognitive approach, it is important
to recognise the therapeutic relationship as a co-construction so that what the patient
brings and what the therapist brings are important for the way the relationship pattern is
IE
formed.27 According to their model, transference supposes that internal representations of
important persons are in memory and could be activated by related signals in any context.
Once the transference is activated, the individual looks at the other person through the
glasses of the earlier representations of important persons. Leahy (2007)28 portrays a
IF
therapeutic relationship as an interactive game in which the therapist and the patient
follow their previously learned rules and use them to expect the other to behave and adapt
their behaviour accordingly. Previously developed relationship patterns and expressions
of emotions significantly impact building and developing a therapeutic relationship. Eg, s
therapist with unrealistic standards may unintentionally authorise a negative belief in a
R
patient’s relationships. Understanding transference and countertransference allows the
therapist to overcome the pitfalls of the therapeutic relationship and the blocks in therapy.
It also helps the therapist better understand how the patient’s interpersonal world is
VE
reflected in the current relationship in therapy.28 Leahy (2007) states that the transference
relationship consists of intrapersonal and interpersonal processes between the patient and
the therapist. These processes include personal schemas about the self, others, and the
world entering a therapeutic relationship. These patterns that make up the transference
relationship can be recognised through guided questioning and Socratic dialogues and
corrected by working with thoughts and schemas. To recognise countertransference, the
therapist needs to apply the same procedures to themselves and train in self-reflection in a
therapeutic situation.29 In his monograph, Newman (2013)23 also emphasises the
importance of CBT therapists using CBT methods and strategies for themselves and
