Countertransference and the Therapist's Inner Experience: Perils and Possibilities (Book Review)

Author:  Gelso, Charles J. and Jeffrey A. Hayes
Publisher:  Lawrence Erlbaum
Reviewed By:  Dolores McCarthy, PhD, Fall 2008, XXVIII, No. 4, pp. 41-42

Psychotherapy and the need for countertransference: Perspectives from research and practice

Last week, a graduate student in my introductory course in psychotherapy asked the poignant question: “What if you don’t like a client? What if they really get on your nerves or you can’t accept some of the things they’ve done? What if they are, for example, a child sexual offender?” For some students, that was a revealing question, since they thought most of therapy is a collection of “techniques.”

After over 20 years in my clinical career, I would call countertransference one of the “pleasures of practice.” I am delighted to participate in a profession where I can use both my intellect and my emotions. “Countertransference” appeals to my artistic, creative nature, keeping every session and every patient fresh and alive. As psychoanalysts, we are familiar with and, in fact, draw therapeutic leverage from our subjective reactions during sessions; we also focus on our reactions to patients between sessions. The most exciting developments in contemporary relational theory are derived from the complexities of the therapist/patient dyad. What, however, if you were a beginning therapist, overwhelmed with your introduction to psychotherapy, may have never been in your own treatment and become aware of feelings towards your client? Or worse, are not aware of your feelings while the treatment is deteriorating?

Writing this review encouraged my own awareness of my subjective reactions to the text. Gelso and Hayes (2007) present a succinct, clear compendium on countertransference, interestingly based on a research approach. The authors outline the history of countertransference in clinical work and provide some basic definitions. By using an empirical research approach, readers are presented with a perspective that is unusual in most psychoanalytic writing. In some senses, this book is a “step back” from psychoanalysis, focusing on the generalities of countertransference. And in this lie the book’s strengths and weaknesses. The authors’ state: “This book is about the inner world of the psychotherapist, and how that comes into play and is enacted within the psychotherapy relationship.” (p. ix). It is important to note that the title emphasizes general psychotherapy, not the psychoanalytic relationship. Therefore, I see the title as technically inaccurate. Rather than “Countertransference and the therapist’s experience,” it should be called “Countertransference as the therapist’s inner experience.” This is because the book essentially raises awareness of countertransference, but does not delve into the phenomenology of the therapist’s subjectivity. As a result, this book is most appropriate at the more general level where the therapist may need to accept inner experience as a valid aspect of the treatment.

I had expected, and looked forward to, a deeper discussion of the phenomenology/inner experience of the therapist while in a countertransference state, especially in relation to case examples. Unfortunately, the authors emphasize the “management” of countertransference, not “use” of countertransference. No mention is made of more nuanced countertransference-related concepts: intersubjectivity, enactments, projective identifications, impasses and so on. There is little attention to other aspects of therapists’ “inner experiences,” including non-conflictual identifications, associations, musings and subjective empathic responses. Gelso and Hayes’ audience is not a group of fairly advanced psychoanalysts and candidates; they teach in a graduate program in counseling psychology, and their books are geared to such an academic arena. The authors are experienced educators and researchers with an interest in relational issues in psychotherapy. They do not necessarily come from a psychodynamic position, but rather remind readers that “countertransference” is present in all forms of therapy. Many forms of psychotherapy are practiced on a short-term basis. Of course in the shorter-term therapies, these areas are generally not the focus of treatment and may not be elaborated in earlier treatment stages. Yet there are times when such reactions do occur, and such times when short-term therapy evolves into more complex long-term work. Thus, there is a need for such writing outside the traditional psychodynamic setting. To their credit, the authors discuss countertransference across the psychotherapies: cognitive-behavioral, dialectical behavioral treatment, existential/humanistic and psychoanalysis.

The book’s character is shown in its reference section. The bibliography lists few familiar psychoanalytic names, although there are brief references to Arlow, Eagle, Fenichel, Fromm-Reichmann, Gabbard, Klein and, of course, Freud. It does, however, list many psychotherapy researchers, such as Robbins, Williams, Carozzoni, Baehr, Cutler, McClanahan and McCracken. This is of note for those readers who wish to explore the countertransference research field in more detail, which can be informative. The authors emphasize a traditional research position, with all the advantages and disadvantages of that perspective. Much of this research is in the area of cognitive-behavioral psychology. Gelso and Hayes comment:

One of the hallmarks, and strengths, of cognitive-behavioral work has always been its scientific approach to treatment …judging from the relatively scant attention paid to the therapist’s internal experience in cognitive behavioral literature, one might conclude that the therapist’s use of this internal data is unimportant.” (p.57)

But even then, they contextualize the literature on countertransference; according to the authors, even Freud only mentioned countertransference five times.

Being primarily clinicians, we may not be aware of the research on countertransference, even as it may be rather conceptually limited. Yet, many comments in the book are valuable to experienced therapists and analysts, mostly as reminders. For example:

• “Countertransference as too much, too little, too positive, too negative.” (p. 37). When countertransference is stimulated, therapists often fail to maintain an appropriate therapeutic distance. They either withdraw or act out in an enmeshed way. On the other hand, countertransference can, but does not necessarily interfere with therapy outcome. (emphasis added)

• Although countertransference is largely based on intrapsychic and interpersonal phenomena, cultural factors are often centrally involved as origins and triggers. (p. 134); “culturally reinforced countertransference.” (p. 135). This includes cultural attitudes towards gender, age, ethnicity and so on.

• Self-disclosure is a controversial area in research. In particular: “Therapists should think carefully about disclosing their countertransference, especially when the working alliance is not solid” (emphasis added). (p. 123) In other words, countertransference disclosure does not usually deepen the work under conditions of a weak alliance.

• Characteristic and behaviors that facilitate countertransference management include: conceptual skills, self-insight, anxiety management, empathy and self-integration.

Some concerns arise, of course, regarding the limitations of clinical research methodology. Drawn largely from a college counseling center population, these situations may not always resemble the sorts of patients we see in regular practice. Further, empirical research on countertransference is often conducted in lab simulations, as most research, treatment provided by beginning level graduate students, not experienced psychoanalysts. Most clinical examples offered by the authors are short-term cases; the nuances of transference-countertransference phenomenon are rarely addressed in brief therapy. Thus, the book presents the more overt forms of countertransference, not the more subtle interactions that most psychoanalysts wish to explore.

Thus, the book is largely geared to students, academic researchers, and practitioners of cognitive behavioral and humanistic psychotherapy. It is important to note that most other forms of psychotherapy such as humanistic, cognitive-behavioral, solution-focused therapy, and psychoeducation are likely to be practiced by graduate students and many therapists practice directly after graduation; psychoanalytic work requires additional postgraduate courses, supervision and personal analysis. Much of this extensive training actually relates to transference and countertransference phenomena. The authors stress that, while humanistic therapists have always emphasized the importance of the therapeutic relationship, they may minimize the complexities of the patient-therapist configuration. While contemporary cognitive-behavioral therapists are beginning to explore “common factors” issues in psychotherapy (especially relational issues) they are also working on a more short-term, problem focused model. Perhaps because some cognitive-behavioral psychologists are ideologically opposed to psychoanalysis, they have dismissed the relational perspective until recently. Further, cognitive-behaviorists, as well as other shorter-term therapists, do not generally emphasize the importance of a personal psychotherapy or analysis where much countertransferential material can be addressed. Thus, these clinicians may welcome a text that explores the emotional realities of clinical work outside of the research environment.

These comments are not meant to detract from the importance of Gelso and Hayes’ work for psychoanalysis. One hidden value in this book is that (perhaps unintentionally) it strengthens the contribution of psychoanalysis, especially relational and interpersonal psychoanalysis. For as we have noted, it is the psychodynamic approach that most welcomes countertransference. Perhaps reconsidering psychoanalytic thought in this way can expand of the value of psychoanalysis. By privileging the use of and also the understanding of complexities of the treatment relationship, we offer psychotherapy not focused on utilitarian techniques, but on a human encounter. By drawing also on over a century of psychoanalytic theory and practice, we also provide attention to levels of relationship and their interpretation. Perhaps Gelso and Hayes will inspire graduate students to study further into psychoanalytic work so that they can bring their humanness into the therapy in a disciplined way. If this is the case, I applaud the authors for breaking ground by using scientific research to expand the study of psychotherapy relationships.

Dolores McCarthy

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