Clinical Rewrite

Clinical Social Work Journal Volume 14, No. 1, Spring 1986

THE CREATED RELATIONSHIP: TRANSFERENCE, COUNTERTRANSFERENCE AND

THE THERAPEUTIC CULTURE

Carolyn Saari

ABSTRACT: The concepts of transference and countertransference are ex- amined in the light of current knowledge about the unconscious. These are rede- fined as action patterns which are not conscious because they have not become in- tegrated into the individual's meaning system. It is proposed that the process of therapy consists in part in a mutually interactive construction of the client's "re- ality". In order for this construction to take place another construction, that ofthe therapeutic culture must come first.

Although it has now become common for clinical social workers to use the concepts of transference and countertransference, these were not originally utilized in discussions of social work treatment. In fact, ini- tially it was thought that social workers did not and should not focus on the transference in treatment. That was reserved for psychiatrists and analysts. Instead, social workers were presumed to rely on the "therapeu- tic use of the self". Times have changed and today there is a tendency to believe that psychotherapy is essentially the same process no matter which of the helping disciplines may be practicing it.

In recent years social work clinicians have gained some increased recognition for their ability to practice autonomously, a recognition which is perhaps symbolized by the legitimacy of utilizing the concepts of transference and countertransference in discussing their work. This in- creased recognition is both necessary and long overdue. It is, however, of equal or greater importance that social workers not forget the fundamen- tals of a social work identity in the process of achieving that status. Within this spirit there are a number of questions about concepts related to the treatment relationship which need to be raised. Now that social workers can choose to talk about transference and countertransference, is it desirable to do so? Are these concepts compatible with a traditionally social work point of view which places emphasis on the person/situation

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configuration? How does an understanding of the therapeutic use of the self fit with concepts of transference and countertransference? Is it possi- ble that a theory including the notion of the therapeutic use of the self is particularly useful in capturing the essence of our experiences as practi- tioners?

The concept of transference was a critical part of Freud's initial for- mulation of the manner in which analysis worked. An understanding, therefore, ofthe nuances of meaning of this concept, or of its companion countertransference, can not be achieved without some examination of the total theoretical context within which it was housed. Freud's theory of the nature of the unconscious was, of course, the cornerstone of his ex- planatory system. Derivatives ofthe primitive and unsocialized instincts gave the unconscious content which was basically universal in mankind. The instincts, through their associated affects and need states, could in- terfere with the ability to perceive the true essence of reality, thus caus- ing neurosis.

Transference consisted of the instinctually caused distortions in the patient's perception ofthe reality ofthe analyst and ofthe treatment situ- ation. The function of analysis, however, was to free the patient from these transference distortions so that an accurate picture of reality could emerge. Analytic treatment was understood to assist the individual in learning about and coming to terms with the nature of his own instincts and unconscious such that their effects could be controlled. The prac- ticing analyst, then, would presumably already have achieved an ability to view reality without distortion through his own analysis. The analyst would, therefore, be in a position to assist the patient in comprehending this same reality through the technique ofthe well-timed interpretation.

Freud did not write extensively about the concept of countertransfer- ence. However, he viewed it as the analyst's counterpart of the patient's transference. Countertransference was the analyst's distortion ofthe pa- tient's problems based upon the effects of his own instinctual drives. It is apparent here that countertransference would occur only when the ana- lyst was not fully in touch with the nature of reality. This would neces- sarily mean that the therapist's analysis had been somehow incomplete. Since analysis was thought to be highly effective, it stood to reason that the unwelcome and destructively pathological intrusion of countertrans- ference would be considered to occur only relatively rarely.

Due to this formulation ofthe nature of countertransference, the con- cept received relatively little attention for quite a few years. After all, to acknowledge that one might have a problem with countertransference was to admit publicly to personal pathology, to cast some suspicion on the competence of one's analyst and possibly even to raise question about the overall effectiveness of analysis as a treatment endeavor. In 1950

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when Margaret Little (1981) read a paper entitled "Countertransference and the Patient's Response to It" before the British Psychoanalytical So- ciety she caused a tremendous furor over her radical suggestion that an analyst might do such a drastic thing as acknowledge to a patient that he had made a mistake.

It is paradoxical that in orthodox psychoanalytic theory the concept which dealt with the possibility of an error on the part of a therapist was actually couched within a context that made clear that the therapist should normally be omniscient. Today, it is generally recognized that no individual can achieve a totally accurate picture of reality and further that even the most advanced scientific systems of measurement can not do so. It is probably true that Freud and the early psychoanalysts saw their position as highly positive in relation to an understanding of man- kind as perfectable through knowledge and science. No doubt they, them- selves, took for granted the features of the highly authoritarian Ger- manic culture of the time and thus were unconscious of the extremely grandiose implications of the notion that a therapist could achieve cer- tainty about the nature ofthe inner life of another human being.

In more recent years, of course, psychoanalytic theorists have modi- fied the understanding of countertransference considerably. In fact it has become so commonplace to interpret any countertransference on the part of the therapist as being an understandable and appropriate response to the patient's pathology that one begins to wonder if there is not still an attempt to preserve the notion of the possibility of the omniscient thera- pist. Countertransference has received much attention in the last few years, but nevertheless remains a controversial subject.

It has for some time been clear to many theorists that there is no uni- versal unconscious symbolic language (Rycroft, 1956). The meaning of symbols in dreams can not, for example, be understood outside ofthe con- text which those particular symbols have for the particular dreamer. Current developmental research is much more supportive of Piaget's (1976) notion that the content ofthe unconscious is constructed over time, than it is of Freud's notions of a shared unconscious. One current psycho- analytic theorist (Lacan, 1981) refers to the unconscious as the unreal- ized. Additionally, Piaget's idea that what the infant actually inherits is in the form of action patterns through which the child will actively con- struct the meaning of his environment and his experiences now seems much more in concert with observational data. These basic changes in the overall theory of human functioning necessarily mean that an under- standing ofthe concepts of transference and countertransference must be revised. However, adjustments to practice formulations following basic theoretical changes inevitably take time. It appears that much ofthe cur- rent controversy over countertransference has roots in a gradual shift in the direction of making these adjustments.

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COUNTERTRANSFERENCE AS UNCONCEPTUALIZED ACTION PATTERNS

The present, then, is a good time to review the entire notion of the treatment relationship with the hope that this might lead to a more help- ful perspective. I wish to begin the current consideration with an example which would normally be called countertransference. It is something of an extreme example and, although it actually occurred a number of years ago is an experience I expect I will never forget. It is, in fact, so extreme that if I were not aware from colleagues and from the writing of talented clinicians such as Searles (1965) that incidents like this are not unusual in the course of intensive work with very severely disturbed individuals, I might myself have some hesitation to talk about it openly.

I was driving home after a work day which had not struck me as especially unusual. I was tired, having not too long before begun working in an in-patient unit for severely ill adolescents and young adults and not being quite yet fully ad- justed to the demands of the job. I was very much enjoying the work, however, and was very pleased with what appeared to be tremendous learning opportunities. Tbere were no other things in my life which were especially upsetting at the time. I was not concentrating my thoughts on anything in particular, but was rather "decompressing" from the job during the drive.

The road crossed a country railroad track which had a warning light for cars but no barrier. Now it happened on this particular evening that a train was com- ing, making it necessary for me to stop. Mine was the only car at the crossing. When the speeding train was perhaps 100 feet down the track, I suddenly experi- enced a tremendous urge to put my foot on the accelerator with the accompanying thought that if I did this I would be killed and that no one would know if I had done it on purpose or not. I did not, of course, act on the impulse, but I had experi- enced it as so powerful that when the train had passed I continued to sit, almost in shock, quite terrified of what had occurred and shaking so badly that it was diffi- cult for me to start the car on its way again. The most terrifying part of this was that I had had no warning that I might have such an impulse and I had no com- prehension of why it should have occurred.

My first thought was that I was obviously in serious psychological trouble and that I had best get myself back into treatment again immediately. Then I re- membered that not long before I had left work, I had been meeting with a young patient of whom I had become rather fond. She was very ill indeed and had a se- ries of what might be called "sergeant's stripes" covering both arms where she had cut herself. She had recently cut herself again and in the hour we spent to- gether she had been struggling to explain to me that she experienced her im- pulses to hurt herself as coming "out of the blue", that she could never predict when these would occur or why they occurred at all, but that she found herself helpless to resist them. During the session it had occurred to me that I had never had such an experience. I knew what it was like to be full of murderous rage or to consider suicide, but the possibility of dissociated impulses was different for me and struck me as probably being incredibly horrible. I had, therefore, spent a good part of the hour actively trying to imagine what such experiences might be like for her. It seemed I had been more successful in learning about the patient's

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experiences that I really would have wanted. It was a case of clear overidentification with the client. The realization that this was what had occurred was tremendously relieving for me, returning to me a sense that my be- havior was understandable and therefore controllable.

In this instance the patient's pathology had certainly had an impact upon my unconscious. The problem with which this girl struggled and had been trying to put into words for me had basically been at an action oriented level. Through a communication process which I do not fully un- derstand because some of its features are unconscious, I had acquired some data about a type of human experience which had not previously been consciously familiar. I had not, however, received these data in a verbal or visual form which I might then have been able to contemplate in my own mind. Instead, the data remained in the form of action pat- terns. These action patterns needed to be converted into a more mature form of thought in order for them to become integrated into a knowledge base that could be useful to me as a person as well as to the work with the patient.

Experienced clinicians are actuely aware of how many people are continuously acting out unconscious memories of old experiences without being able to solve the problems inherent for them in those experiences. Freud, of course, called this "repetition-compulsion". Loewald (1976) has referred to it as "enactive memory". Yet as Klein (1976) has emphasized through his concept ofthe "active reversal ofthe passively experienced", the action based recall of a past experience is best understood as an at- tempt at the mastery of the meaning of that experience. What, then, makes the difference between a fruitless repetition-compulsion and the healthy achievement of mastery? In other words, how do action patterns become converted into conscious and conceptualized thought?

According to Werner and Kaplan (1963) objects in the environment which are utilized purely as "things-of-action" do not contribute to the ability to symbolize. Thus, the simple acting-out of impulses on my part or on that ofthe patient would not lead to any mastery ofthe situation. In order for conceptualization to take place the action patterns must be or- ganized into meaning systems through a contemplative attitude and a sharing of perceptions with a significant other. Human meaning systems are indeed both human and social. Our very ability to utilize thought as a means of understanding ourselves and our world is dependent upon our interactions with each other. From this perspective it is clear that the pa- tient, in her attempt at explaining verbally to me what her experience was like at the times she cut herself, was attempting to achieve some mastery over those impulses. I am pleased to be able to report that in time that young woman did succeed sufficiently to change from a very se-

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verely ill and hospitalized psychiatric patient to a reasonably happy and well adjusted college student.

Although at the time this incident occurred I could not have ex- plained it from the present theoretical perspective, I nevertheless knew that the manner in which I could deal with an action pattern that was not integrated into my meaning system was to get another human being to help me. That is why I first thought I would need to go into treatment again. When, through contemplation, I was able to locate this action pat- tern in a meaning system without assistance from another person, I knew that I did not need to seek further treatment. I knew that there was no reason to think that such an incident would necessarily occur again— and I am pleased to say that this had been the case. Once a person has achieved the capacity to conceptualize or to integrate experiences into a meaning system through practicing the sharing of perceptions with an- other person, this can occur through a sharing of perceptions with an internalized other. It is what has traditionally been referred to as an ob- serving ego. However, it is important to understand that this capacity can not be achieved without initial extensive sharing with another hu- man being. Throughout life all of us need to continue to share at least some of our observations with significant others in order to maintain our level of functioning.

GOAL-ORIENTATION AS THE CRITERION FOR EFFECTIVE INTERVENTION

The implications of the concept of countertransference lead to the question of whether my experience at the railroad crossing was the result of my own unconscious or whether it was the result of an appropriate re- action to a "real stimulus from the patient." In this regard certainly it can be said that the possibility of self-destructive impulses which appeared "out ofthe blue" came from the patient. That a train was approaching the crossroads at the same time I was on that particular evening was a pure coincidence, attributable neither to the patient's inner life nor to my own. However, I am well aware—and was at that time—that trains have a particular meaning to me, a meaning which has been constructed as a re- sult of life experiences that had nothing to do with this or any other pa- tient. Therefore, it must be said that the components of this episode of what has been called countertransference come from a combination in- volving a stimulus from the patient, an existing meaning system within the therapist and conditions within the external world.

This same combination exists in all instances of presumed counter- transference. Frequently it may be both impossible and of little useful- ness to sort out what behavioral stimuli originated with which ofthe par-

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ticipants within the interaction. From an experiential point of view the elements from the person, the other and the environment are integrated and therefore an attempt to sort them out may be a purely intellectual exercize. Perhaps an analogy to a chemical reaction in which different parts, following combination, take on characteristics quite different from those of any ofthe single elements separately would be appropriate here. The result ofthe interpersonal contact is a new and unique mixture ofthe three elements. Nevertheless that new combination exists as a part of a particular individual. The impulse to move the automobile to the path of the train was my own. In this and all instances of countertransference it is in the direction of maturity for therapists to take responsibility for their own behavior.

If the most primitive element of what has traditionally been called transference is now to be understood as the patient's attempt at growth through active mastery, then it does not seem reasonable to consider this to be pathologic. Loewald (1960) has pointed out that transference in the sense of the application of associations from the new experiences gives life its richness and its depth of meaning. Certainly these phenomena are not unhealthy. If, then, transference is to be considered to be normal and healthy, is countertransference healthy as well? After all, Searles (1979) has implied that at least in working with schizophrenics the counter- transference is the "royal road" to an understanding ofthe patient's inner life.

Although it is not at all clear that Freud actually intended it, there was in orthodox psychoanalysis an implication that the unconscious was a part of an almost beastly quality of man which needed to be surmounted in order for humanity to become socialized and to reach the utmost in po- tential. Increasingly, however, psychoanalytic theorists have been agree- ing with Winnicott (1975) that the unconscious is not at all an enemy but rather at least potentially a very good friend. If we think ofthe content in our unconsciouses as an inherited but primitive language which we share with all the other members of our species, it is easy for us to consider that content as an impersonal and perhaps burdensome albatross with which we must contend. If, on the other hand, we think of that unconscious con- tent as something that we have ourselves actively constructed over the course of our lives, then it is more reasonable to think of it as constituting something which is uniquely ourselves and an important part of our indi- vidual identities. It benefits us, therefore, to become as well acquainted with the specific content of our own unconscious as is possible. It is, in ef- fect, to become acquainted with ourselves. To the extent, therefore, that our clients help us to conceptualize content in our unconscious thought processes they help us as we are trying to help them.

In spite of the above, however, experience has taught that what has normally been considered to be countertransference can interfere with

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the work with the client. How, therefore, can this be understood? Green- son has provided an excellent illustration of countertransferential re- sponses during a treatment hour.

Greenson had experienced Mrs. N., a woman who had been in analysis with him for several years, as being in a long period of complaining, fault-finding and thinly disguised contempt. On one occasion when she seemed slightly more re- flective than usual she replied "I guess I am no pleasure to work with." Green- son's immediate urge was to respond with a rather sarcastic "You ain't just awhistling Dixie." Realizing, however, that she was a patient and not a social ac- quaintance, he amended this to an intense, but controlled "Yes, these hours of nagging and complaining and nagging and complaining are a pain." Greenson re- ported that Mrs. N. had a marked response to the idea of her being a nag which was a highly painful thought for her. He evaluated his intervention as having been effective since it forced her to examine her behavior in this regard. However, as he later considered his comment, he came to the conclusion that the ideal re- mark would have been a more modified "Yes, it is no pleasure to work with some- one who complains to the point of nagging" (Greenson, 1978, 509-513).

The statement which Greenson was first tempted to make to Mrs. N. was an action-level response. He did not, however, act upon this impulse but called upon that function of his self which can contemplate such impulses prior to the action. Much ofthe time this brief delay for contemplative ac- tivity is initiated unconsciously. It is the same type of activity which pre- vented me from actually putting my foot on the automobile accelerator and which differentiated me in this regard from my young patient. It is an activity which provides us with some ability to have a choice regard- ing our behavior. The proper functioning of this contemplative activity has traditionally been considered to be evidence ofa healthy ego.

There have frequently been suggestions that therapists are not sup- posed to get angry at their patients or to have self-destructive impulses. The problem, however, is that we are human and we do. But in fact it is not a difference in the content of our thoughts or impulses which should differentiate us in therapy from our clients. After all our emotions are not our enemies. They provide us with considerable information about our relative safety in the world around us (Basch, 1976). Strong emotions make us feel human (Seton, 1981). This is why we enjoy such things as music, art and drama. What's more this is the case even when the content of those emotions consists of wishes to harm ourselves or others. What frightens us about our own emotions and those of our fellow human be- ings is that we might act upon them impulsively without the intervention of a consideration as to whether or not this is really what we wish to do. While in therapy the client is encouraged to allow impulses to express themselves verbally, the therapist is expected to weigh remarks very carefully as to their possible impact.

Greenson continued to contemplate the nature of his response to Mrs. N. even after he had made it. He concluded that he had succeeded in con-

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trolling his countertransferential response only partially and thus formu- lated, in retrospect, his third and ideal response. Greenson also indicated that he considered this third response to be "realistic" in regard to the na- ture of the working alliance. It is worth wondering what the use of the word realistic means here. Greenson was presumably not intending to imply that he might be capable of totally accurate perceptions ofthe true reality of the interaction between himself and Mrs. N. Rather, it would appear that what he meant was that this remark was more in tune with the goals toward which he and Mrs. N. had mutually agreed to work. That is, it was more in tune with the purpose of the relationship. It was both conceptualized and goal-oriented.

Kohut (1977) indicated that human beings were as much pulled by their desires as they were pushed by their instincts. The idea that a ther- apist's interventions must be judged by the extent to which they promote the desired therapeutic goal rather than the extent to which they are de- termined by primitive instincts would appear to be compatible with Kohut's meaning. Therapeutic error may, after all, be caused by that which has traditionally been called countertransference, which has now been defined as the carrying out of action patterns that the therapist has not conceptualized or attuned to the treatment goals. Therapeutic error may, however, also be caused by a lack of information about the client, by a lack of adequate training or even by the conscious and reasonable selec- tion of the wrong one of several possible hypotheses.

A THERAPEUTIC CULTURE CONSTRUCTED WITHIN THE RELATIONSHIP

The character of a treatment relationship is defined by its purposes and goals. In order to create the most effective climate for the achieve- ment of these goals, the relationship should concentrate on an inclusion of whatever will further its purposes and should seek to exclude or elimi- nate that which is tangential or distracting. The maintenance of bound- aries around the relationship which will insure its efficiency is the re- sponsibility of the therapist. In other ways, however, the treatment relationship is a human relationship. Therefore, it is inevitably mutual and interactive. Beyond the defining characteristics in relation to pur- pose, each treatment relationship is a unique construction created to- gether by a particular client and a particular therapist.

It is important to understand that, since each therapeutic relation- ship is unique, what may be appropriate for one relationship may or may not be appropriate for another. There are today many sterile arguments over the details of treatment technique simply because of faulty underly-

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ing assumptions that the treatment relationship is constant and concrete. An understanding of diagnosis does, of course, provide some guidelines as to ways in which judgments about what our clients are likely to need can be made. These are, of course, too extensive and complicated to outline in detail here. However, clients with generally borderline personalities will need to have the therapist define herself relatively clearly and in some concrete detail whereas neurotic clients will not need and may well be- come distracted by such detail.

The initial formulations regarding transference implied the idea of the therapist as a total "blank screen". However, this has not been taken seriously even by relatively orthodox analysts for some time now. Thus, it has been recognized that the therapist's personality is inevitably a part of the treatment situation. The confusion surrounding the concept of coun- tertransference, with some continued uncertainty as to its possible patho- logical nature, has undoubtedly retarded the invention of new ways in which to consider how therapists can best use the natural features of their personalities to help their clients. Mature personalities are complex entities and the therapist invariably will have a choice as to what part of herself to share with any given client. This is, of course, the principle of the therapeutic use of self. The treatment relationship is created and the treatment process, at least when it is at its very best, is a creative venture for both the client and the therapist. Such a process is never impersonal and it need not be confined to a fifty minute hour or to the four walls of an office. It must, however, be confined to the greatest extent possible to ac- tions which will promote growth and problem-solving for the client.

Each individual must construct his own comprehension of the fea- tures of his environment. Pictures of reality are quite personal, since they are in a sense a record of an individual and unique perceptual history. These pictures are also absolutely essential to an ability to achieve any sort of adaptation. It is an ability to conceptualize reality, in both its in- ternal and its external aspects, which makes some conscious choice over behavior and a sense of self-determination. Developmental studies now make it quite clear that human beings have a fundamental need for a sense of understanding and organization (Donaldson, 1978). In fact, hu- man beings heed this sense of comprehension so badly that if an explana- tion of the elements and events in the environment is not immediately apparent people will make up such an explanation. Current scientific knowledge indicates that some explanatory theories are better than oth- ers. However, evaluative judgments about the pictures of reality can be made, not on the basis of whether they are true or false, but rather on the basis of whether they are more or less articulated, differentiated and in- tegrated.

The role of the therapist, then, is not to correct the client's distorted

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perceptions since there is no guarantee of accuracy in the therapist's per- ceptions. Instead, the therapist's role is to encourage the client to take a contemplative attitude toward his environment and his own actions and to encourage through a sharing of perceptions ofthe environment a more highly differentiated and integrated picture of the client's "reality". Treatment, therefore, works hoth by assisting the client in achieving a more comprehensive and complex picture of himself and his world and by helping the client to refine his own abilities to process conceptually the features of his reality. Spence (1982)), for example, has recently pointed out that psychoanalytic claims to be able to put a patient in touch with the actual historical truth of his biography are highly questionable. Rather, Spence indicates, treatment works through helping the person construct a sophisticated and plausible narrative of his life with which he can be comfortable.

The relationship is one essential feature of the treatment process. However, in order for treatment to work it is also necessary for the partic- ipants to have some sample of action to contemplate. Such examples often come from the client's memory of past experiences or from his perceptions of his inner life. However, Freud's concepts of transference and counter- transference have been absolutely invaluable in helping to place the fo- cus on the interaction within the treatment relationship itself. It is this sample of reality which the client and the therapist have both observed at the same time, though from different perspectives. In their sharing and contemplation of these perceptions, the client and the therapist construct a social agreement regarding what has actually occurred. This social agreement about the nature of the reality of the treatment situation and ofthe client's problems constitutes a therapeutic culture. The therapeutic culture is created mutually by the client and the therapist over the course of their interactions with each other and is therefore unique in the treat- ment of each client.

The therapeutic culture is an extremely important element in the treatment process simply because it is through practicing with the con- struction and conceptualization of this reality that the therapist assists the client in the increasing differentiation and integration of his compre- hension of his world. It is through interactions within the therapeutic culture that the client can gain the skills that he can then utilize in his functioning in the environment beyond the treatment situation itself. To date very little attention has been paid to the idea of a created context within which the therapist and the client do their work. Yet studying the events in treatment processes with this concept in mind may have consid- erable potential in helping to gain further insights in the constant quest for deeper understanding of the manner in which treatment works.

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CONCLUSION

The concepts of transference and countertransference can be invalu- able in understanding the process of therapeutic interaction, but only if they are divorced from orthodox psychoanalytic notions of instincts and defined as action patterns which have not yet become conceptualized or conscious. The use of these concepts, however, does not preclude the addi- tional use ofthe idea ofthe therapeutic use ofthe self. In fact, a redefini- tion of the concepts of transference and countertransference actually points to a necessity for a concept involving the therapist's conscious choice of what aspects of her self to share with a client. Traditionally so- cial work practitioners have not been considered to be master theoreti- cians, yet much of their "practice wisdom" has, perhaps unconsciously, been wiser than some ofthe more superficially elegant theoretical formu- lations.

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(1979.) Countertransference and related subjects. New York: International Universi- ties Press.

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Spence, Donald P. (1982.) Narrative truth and historical truth: meaning and interpretation in psychoanalysis. New York: W. W. Norton & Co.

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Loyola University of Chicago School of Social Work 820 North Michigan Chicago, IL 60626