Countertransference has been a controversial topic throughout the history of clinical practice (Balint & Balint, 1939; Benedek, 1954; Gabbard, 1994; Gill, 1982; Wolstein, 1988). Con-cerning the psychotherapy of personality disorders, countertransference is much more of a cogent and relevant issue for two reasons: it is one of the bigger obstacles therapists face in doing therapy with clients with personality disorders, and it represents one of the deeper dimensions of the therapeutic process.

The term countertransference has been given various definitions. In traditional psychoanalysis, countertransference refers to undesirable reactions on the part of the analyst with Oedipal underpinnings (Ernsberger, 1979), whereas, in object relations work, countertransference is viewed as a natural response to the client’s projective identifications. It is seen as a vital and fundamental dimension of the therapeutic relationship (Bollas, 1983; Ogden, 1982). For the purpose of this article, countertransference is defined as: “All those emotions in the therapist that interfere with the ability to provide a therapeutically neutral frame” (Masterson, 1993).

Countertransference can be an important source of therapeutic data for the therapist to learn more about the interpersonal and intrapsychic dynamics of the client. These dynamics become even more accentuated in clients with personality disorders, and these clients often use the therapist as a depository for their own projected affects due to primitively split object relation units, poor affective regulation, impulsivity, and frequent projections onto the therapist. These projections can stir up countertransference reactions in the therapist either by projective identification (the therapist identifies with the projection) or by triggering personal issues in the therapist.

Countertransferences are often multilayered interactions and, therefore, the experience challenges the therapist to be quickly conscious enough to put anything into words. In fact, recent research in neurobiology and the brain suggests the right hemisphere encodes massive amounts of nonverbal information before our left hemisphere can put it into conscious language. For example, Allen Schore’s research (1994) shows the right hemisphere capable of implicitly encoding up to 30 different emotional feelings per second. Though consciously we are not able to explicitly process all of this at the same time, it shows the plethora and richness of the unconscious interpersonal space between the therapist and the client that makes countertransference such a primary domain of clinical focus.

What happens in therapy
Clients with personality disorders and addictions will tend to project even more of their affects onto their environment, including the therapist. Often addictive behaviors are a defense against the “abandonment depression.” Abandonment depression is at the core of personality disorders, also known as disorders of the self (Masterson, 1981, 1993, 1995), occurring when insufficient libidinal availability on the part of the caretaker toward the child results in a developmental arrest for the emerging self of the child. Instead of the real self blossoming, this development arrest gives rise to a “false defensive self”(Masterson & Klein, 1995). This false defensive self develops different defenses and protective behaviors designed to defend against the affects of the abandonment depression (i.e., homicidal rage, suicidal despair, anxiety, aloneness, sadness, emptiness, and hopelessness). One of the more common defenses is addictive behaviors. It is probable that the more self-destructive the addiction (i.e., substance abuse, sexual addiction, and eating disorders) is in terms of duration, frequency, and depth of damage, the more likely the client has a personality disorder.

It is with these dual diagnosis clients that countertransference becomes problematic as the projective identifications are unconsciously and frequently put into the therapist in any given session. Historically, projective identifications have been pathologized as a primitive form of interaction between two individuals. However, due to recent work in attachment theory and neurobiology, it is now seen to be one of the normal mechanisms behind creating the attachment bond (Schore, 1994; Siegel, 1999). Attachment is often defined as dyadic affective regulation. Thus, one of the therapist’s goals is to be able to identify the different projections and to help the client regulate the affects that otherwise are being projected. In proceeding toward this goal, if the therapist is able to identify the kind of personality disorder that is involved, then the therapist may be able to better predict the kind of projections the client will begin to put onto the therapist.

James Masterson’s research (1981, 1988), which is based on a developmental self and object relations perspective, helps to clarify this. Masterson presents three main clusters of personality disorders — narcissistic, borderline, and schizoid. (Psychopaths generally don’t seek treatment on their own.) Each of these disorders has their own pathological attachment style with the underpinnings based on their own object relation units. In childhood attachments, the relationship between the child and caregiver becomes internalized in the form of object relation units. These object relation units comprise a self representation (internal self image of the child), object representations (internal image of the caregiver) connected by the affects. In pathological attachments, where the child’s real self is not adequately attuned, regulated, or acknowledged by the caregiver, the child develops a false defensive self designed to deny this reality and create an illusion of a connection. These object relation units are the spawning grounds for projections, which then are essentially the unprocessed and excessive affects that spill out from the client’s internal world of internalized self and object representations. Thus, identifying the personality disorder can help the therapist to understand the specific object relation units and be more attuned and prepared to identify the projective identifications more quickly and potentially use them in a therapeutic way. Below are some clinical vignettes that may help illustrate how countertransference may impact therapy with clients with personality disorders who also have addictive behavior (Reed, 2000).

Mr. J
Mr. J, a 38-year-old male, was referred for substance abuse. He also had a narcissistic personality disorder. In the initial stage of treatment, he began to talk to me about his recent inpatient drug rehabilitation experience. He boasted that within a week of being in the hospital, he had become somewhat of a self-appointed guru in drug rehabilitation. He was giving other patients advice about how to manage their addiction and depression, and he even had some staff members beginning to listen to him. As he was telling me this, going “on and on” about it, I felt myself bored and distracted, and yet pulled into a mirroring trance like I was interested, listening attentively, and even felt pressure to provide a smiling nod. The session ended with me feeling my interaction with Mr. J was more “false” on my part than helpful or real.
The next session he came back angry and disappointed. When I asked him why, he said he was disappointed in me because he had fooled me. He had taken my ostensible smile as evidence that he was smarter than I am and that I couldn’t see through his facade, just like he had fooled the patients at the drug rehabilitation center. If he was smarter, how could I help him. I had fallen from being a hero to a zero with that one smile, which caused a massive narcissistic injury. Mr. J then talked about how this facade was a coverup for his profound sense of being defective to the core. He was describing his abandonment depression and how drinking excessively served as a way of numbing out his interior sense of being inadequate and allowed him to inflate his grandiosity.

As I began to acknowledge his inner pain, the impaired real self (Masterson, 1993), he stated, “When I get people to admire my performance, it’s like cotton candy — sweet but empty, versus when my real pain gets acknowledged, it’s like broccoli — it nourishes my body.” This is an example of how my countertransference eventually helped to reveal how active his false narcissistic self was as a coverup for his impaired real self.

Miss D
The task of telling whom exactly we are interacting with, whether it is the real self or false defensive self, is complicated in that the clients themselves are often not aware of the difference, especially in the beginning stages of therapy. An example of this was Miss D, a closet narcissist who had a spending addiction in that every time she would feel depressed, she would go on a spending spree. This had pushed her into financial difficulties and her marriage to the brink of divorce. Miss D also had a narcissistic personality disorder and had a bad case of asthma, which she was hoping could get cured in therapy as well as her spending problem.

There was a point, at which I thought treatment was going quite well, when I saw disappointment flash briefly across her face when I coughed during one of our sessions. I vaguely sensed her disappointment, but paid little attention to it until it grew into an angry hopelessness. I asked her about her reaction. Apparently, one of her idealized fantasies about me, being younger and healthier than she, was that if I could help her get better emotionally, she might be more invulnerable to her asthma. My coughing ruptured her idealization of me and strangely left me ashamed for having a sore throat. I knew my feeling of shame, which I had experienced often with Miss D and therefore was able to identify quickly in myself, was really shame she was projecting or parking into me because it was too painful for her to contain. This awareness of the projective identification that came out of her underlying narcissistic object relation units led me to offer a mirroring interpretation of her narcissistic vulnerability (Masterson, 1988). I said, “I sense that your disappointment in my humanness reflects how unacceptable and shameful it is for you to have an imperfection in yourself, even if it’s a physical weakness. The way you manage your vulnerability is to idealize others in hopes of them rubbing off on you.”

Mrs. B
This is an example of where countertransference can become informative to the therapist, particularly if there is an understanding of what kind of personality disorder the therapist is working with. This is very helpful in understanding the motive or function behind the addiction. As the meaning of addictions will vary from client to client, it involves different therapeutic understanding and potentially different interventions. The meaning of the addiction will vary intrapsychically and therefore require different therapeutic understanding and potential interventions.

For example, Ms. B, a 38-year-old female who had a drug addiction to cocaine and marijuana, had a history of dysfunctional relationships, poor work history, and regressive behaviors. I diagnosed her with a substance abuse addiction as well as a borderline personality disorder. When she brought in her story of being addicted, I was trying to listen to my own countertransference. One thing I noticed was this pull to have me reassure her, to provide advice, to try to ease her fears of never getting out of her addiction, and that she would potentially be able to keep on using the addiction without it really being a serious consequence. In short, she wanted to use me in the same way she had been using substances for caretaking and regressive functions. Her borderline false defensive self was pulling for regressive caretaking from me. As my countertransference was informing me of the “type” of projection she was placing onto me, this led to the intervention of choice for regressive caretaking projections. The intervention was a confrontation of borderline regression (Masterson, 1988) with me saying, “I wonder why you are wanting me to collude with your helplessness by giving you advice and reassurance, when you are more than competent to begin to discover some of those answers for yourself. This pattern of looking to the other person to supply the answers for your life may also reinforce your helplessness, depression, or low self-esteem when you act as if you are not competent.”

As I began to confront her borderline regression with similar confrontations, over time she integrated the confrontations and contained her acting-out behaviors. At the same time, her projections onto me began to subside as a therapeutic alliance was developing between the therapist and Ms. B’s real self. As the therapeutic alliance consolidates and the client begins to “own” this therapy and works through core issues, such as the abandonment depression, these projections are no longer needed.

Ms. N
Another clinical example is Ms. N, who was a highly successful, 50-year-old interior designer, and yet plagued with suicidal thoughts, low self-esteem, anxiety, and a sexual addiction. As she began to unfold her story in treatment with me, I began to feel a lot of performance anxiety, as if she was looking to me to be the expert to solve her problems with some magic answer and insight. With this performance anxiety, I had grown accustomed to identifying within myself a countertransference reflective of narcissistic fusion. I began to interpret Ms. N’s core dynamic behind the sexual addiction, which was for her to feel special and to have her grandiosity stroked by the mirroring she would receive from the male partners.

For the narcissistic false defensive self, the intrapsychic motive behind addictive behavior is not one of regression like the borderline self, but one of inflating one’s grandiosity. This grandiosity performed the function of covering up Ms. N’s core feelings of being inadequate and unacceptable as a person, much like Mr. J. I began to provide mirroring interpretations of Ms. N’s narcissistic vulnerability, such as, “I am beginning to understand just how threatening it is to focus on your self and deeper feelings and that you soothe yourself by being the sexual star where men admire you sexually, but they really never get to know the real you. Perhaps you never get to know the real you as well.” As Ms. N took in the mirroring interpretations and increased her desire to really know herself, her sexual acting out subsided, as well as her projections onto me and thereby my performance anxiety.

Ms. S
Ms. S presented initially with high social anxiety, depression, loneliness, social withdrawal, and emotional detachment. In a crisis as her husband had been killed a year earlier, a police officer on duty, she had resorted to alcohol to manage her pain. Ms. S was using alcohol as a means to be self-sufficient so she would not have to depend on others. In her words, “When I’m all alone, I feel so isolated I get panic attacks, but when I get close to people and have them help, that also terrifies me. It’s a catch-22. I felt alcohol was the best compromise because I could numb out my aloneness.”

When I began to see Ms. S, I saw her as a person with a schizoid personality disorder whose main need was to feel safely connected with another person; part of her dilemma was she felt terrified of being alone and terrified of being connected to people. Ralph Klein (Masterson & Klein, 1995) refers to the schizoid state of aloneness as “cosmic aloneness.” On the other hand, when she reached out to other people, she would be afraid that she would be hurt or attacked. In other words, this dilemma of being cosmically alone or dangerously connected left her stuck in fear. As Ms. S had a history of severe sexual abuse by different perpetrators throughout her life, connecting with people was too dangerous. The only solution in her mind was alcohol.

When she began to see me, my countertransference involved my feeling very detached or a sense of pity. These reactions were in response to both sides of her dilemma. Quite dramatically, within the first two sessions, Ms. S gave up alcohol altogether. This had little to do with me as a therapist (despite my wishful thinking to the contrary), as much as it was about a solution to her core dilemma in life. This solution was having a safe connection with another human being that replaced her need for alcohol. This case highlights the reality that Ms. S’s substance abuse was not only a symptom, but an expression of her false defensive self needing to manage her abandonment depression.

Some final reflections
These clinical examples underscore the importance of understanding the intrapsychic dynamics of the client that then allows the therapist to more precisely understand the main function that the addiction is serving, as well as the function and meaning of the projections being placed onto the therapist. It is with this understanding that the therapist is able to conceptualize his or her own countertransference and its therapeutic meanings in the transference-countertransference matrix.

The therapist can reasonably anticipate the different kinds of countertransferences he or she will have depending upon the differential diagnosis of the personality disorder — be it narcissistic, borderline, or schizoid. Additionally, a differential diagnosis potentially instructs the therapist on the best treatment plan to address the presenting addictions and interventions that facilitate developing a therapeutic alliance. As the client is able to manage his or her addiction and process the core affects from the abandonment depression, the degree of projection subsides, and so does the countertransference of the therapist.

Steven K. Reed, PhD, is a clinical psychologist in private practice in Bellevue, Washington. He is currently on the faculty of The Masterson Institute. Dr. Reed gives workshops and facilitates study groups for therapists learning the Masterson approach to personality disorders. He also has a special interest in traumatology, addiction, and spirituality. He can be reached at (425) 455-5189.

References
Balint, A., and Balint, M. (1939). On Transference and Countertransference. International Journal of Psychoanalysis, 20:223-230.
Benedek, T. (1954). Countertransference in the Training Analyst. Bulletin of the Menninger Clinic, 18:12-16.
Bollas, C. (1983). Expressive Uses of the Countertrans-ference. Contemporary Psychoanalysis, 19, 1-34.
Ernsberger, C. (1979). The Concept of Countertransfer-ence as Therapeutic Instrument: It’s Early History. Modern Psychoanalysis, 4(2), 141-164.
Gabbard, G.O. (1994a). Sexual Excitement and Countertransference Love in the Analyst. Journal of the American Psychoanalytic Association, 42(4), 1083-1106.
Gill, M. M. (1982). Analysis of Transference (Vol. 1). New York: International Universities Press.
Masterson, J. F., Klein, R. (1995). Disorders of the Self. New York: Brunner/Mazel.
Masterson, J. (1993). The Emerging Self. New York, Brunner-Mazel.
Masterson, J. F. (1981). The Narcissistic and Borderline Disorders: An Integrated Developmental Approach. New York: Brunner/Mazel.
Masterson, J. F. (1988). Psychotherapy of the Disorders of the Self: The Masterson Approach. New York: Brunner/Mazel.
Masterson, J. F. (1985). The Real Self: A Developmental Self and Object Relations Approach. New York: Brunner/Mazel.
Ogden, T. (1982). Projective Identification and Psychotherapeutic Technique. New York: Jason Aronson.
Reed, S. K. (2000). Countertransference to Patients with Personality Disorders and Trauma. Paper presented at 6th Annual Conference on Counseling Skills, Las Vegas, NV.
Schore, A. N. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Hillsdale, NJ: Erlbaum.
Siegel, D.J. (1999). The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York: Guilford Press.
Wolstein, B. (Ed.). (1988). Essential Papers on Countertransference. New York: New York University Press.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2003, v.4, n.5, pp. 39-43.

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Virgine De Paepe  - counter transference   |24.4.61.xxx |2008-11-05 22:16:34 hey Reply 0   0

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