Countertransference and the Therapeutic Relationship

Over sixty years of research has led the field of substance use disorder (SUD) treatment to conclude that the therapeutic alliance between counselors and clients is one of the key determinants of treatment outcome, accounting for 30 percent of all identified change (Hubble et al., 1999). Aspects of any therapeutic relationship include the well-studied “transference” and its less-studied partner “countertransference” (Valerio, 2017). Up until the last decade or so, countertransference was considered to be a simple outgrowth of clients’ transference, but it is now viewed as its own phenomenon and not necessarily connected (Wiener, 2009). Furthermore, both these facets exist regardless of the treatment approach used (Devon, 2017).

Transference, which refers to clients’ unconscious views of us as clinicians and often related to unresolved issues of power and authority, is often based on the power differential of the therapeutic relationship (Lacey, 2021). Countertransference, which is the clinicians’ counterpart, has developed from what was initially defined as the reaction to clients’ transference and has broadened in scope to the completeness of clinicians’ reactions to clients (Shafran & Gardner-Shuster, 2016). Failure to recognize clients’ transference reactions is often a lost opportunity to effectively apply it as a clinical tool, while failure to recognize, understand, and effectively use countertransference can have a significant negative impact on the therapeutic relationship (Lacey, 2021). The lessons of being aware of our own reactions, and even understanding them, allows us to look into our own personal experiences and see how they play into our ability to build and maintain therapeutic relationships with appropriate boundaries, to make sound clinical decisions, and to be of best service to our clients (Notaras Murphy, 2013). To assume that clinicians do not experience countertransference is foolhardy, as being immersed in the difficulties and suffering faced by our clients without being moved by it is simply unrealistic (O’Crowley, 2020).

Clinicians’ countertransference responses are not only information about ourselves that must be managed, but also useful tools in gathering information about clients (Gabbard, 2020). The implication is that interpersonal issues, not uncommon in those with SUDs (SAMHSA, 2019), play out in common relationships as well as in the therapeutic alliance. This provides a tremendous opportunity to use the strength of the therapeutic alliance to elicit behavioral change in clients.

It is not uncommon to hear clinicians tell clients some form of “It’s not about me, it’s about you” in response to questions about recovery status, requests for specific guidance, or simply as a response to “What would [the clinician] do [in the same situation]?” In such situations, it is clearly not about us as clinicians (and quite possibly just the manifestation of clients’ transference), but the same is not true in all situations. If the goal is to be attentive to our clients and present in the moment with those we serve (Greenberg, 2016), then there may actually be times, as Drexel University lecturer Thomas M. Baier points out in The Scope of Practice podcast, that it may be about us, but not in the way we commonly assume (Lacey, 2021).

Clinicians must begin with the realization that we are not value neutral (Baier, 2017), and be aware of any potential value imposition on clients. The understanding that our own values come from a lifetime of emotion-laden experiences that guide all aspects of our lives (Buechler, 2004) is a necessary tool in recognizing that client values come from the same process. Buechler also identifies this as one of the signs of mature clinicians. Interestingly, the failure to recognize our biases and value imposition in the therapeutic alliance may not restrict client growth and change, although that may be attributed to the 15 percent of change related to the placebo effect (Double, 2006; Hubble et al., 1999). If we as clinicians are able to truly listen to clients and get a picture of their specific values and beliefs, it affords us the opportunity to gain insight into the specific perspectives of each in the here and now.

It is important for clinicians to avoid focusing simply on relationships that exist outside of the treatment environment; they also need to address what happens in the treatment space (Gunzberg, 2011). We do not need to make generalizations about the presenting problems clients bring to treatment because we can actually experience and help work on them through our own countertransference (Gunzberg, 2011). The importance of our own experiences, if and when shared with clients, applies strictly to remaining in the present and expressing it clearly (Yalom, 2008). There is no evidence to support the notion that sharing information about our own recovery status has a positive or negative effect on the work of the therapeutic relationship. It has been theorized that the most powerful tool of treatment is clinicians’ ability to stay in the here and now through the sharing of honest thoughts and feelings about what is presently happening in the therapeutic relationship (Howes, 2010).

As with most other treatment concerns, the use of clinical supervision to process issues related to countertransference helps build confidence in clinicians (SAMHSA, 2014) despite the amount of research devoted to actual supervisor strategies that help clinicians address and understand countertransference (Ponton & Sauerheber, 2014). The parallel processes of transference and countertransference are also evident in the supervisory relationship as well (Sumerel, 1994), and provide more opportunities to develop clinical insight. Using the clinical relationship as practical training—as opposed to just guidance—helps to develop knowledge, skills, and abilities (Sumerel, 1994).

A strong awareness that countertransference is a normal clinical phenomena and neither “good” nor “bad” helps us look at it through a nonjudgmental lens and develop it into an effective clinical tool within the therapeutic relationship. In effect, the 30 percent of change related to the therapeutic relationship (Hubble et al., 1999) may just be about us with little regard to our recovery status.

References

Baier, T. M. (2017). Countertransference and the boundary of self: The use of self in the therapeutic alliance. Presented at the National Conference on Addiction Disorders on August 17, 2017, in Baltimore, Maryland.
Buechler, S. (2004). Clinical values: Emotions that guide psychoanalytic treatment. London, UK: Routledge.
Devon, A. (2017). CBT versus the unconscious: Ignore countertransference at your peril. In P. Valerio (Ed.), Introduction to countertransference in therapeutic practice: A myriad of mirrors (pp. 81–96). London, UK: Routledge.
Double, D. B. (2006). Clinician bias in diagnosis and treatment. In P. W. Halligan & M. Aylward (Eds.), The power of belief: Psychosocial influence on illness, disability, and medicine (pp. 189–204). London, UK: Oxford University Press.
Gabbard, G. O. (2020). The role of countertransference in contemporary psychiatric treatment. World Psychiatry, 19(2), 243–4.
Greenberg, B. (2016). The ten most frequent mistakes therapists make. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/the-teen-doctor/201604/the-10-most-frequent-mistakes-therapists-make
Gunzberg, N. (2011). Working in the here-and-now of the therapeutic relationship. Retrieved from https://www.psychotherapy.net/article/therapeutic-relationship
Howes, R. (2010). Yalom on the here and now. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/in-therapy/201009/yalom-the-here-and-now
Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association.
Lacey, B. W. (2021, March 10). Is it about me, or is it not? A primer on countertransference (episode 49.5) [Audio podcast episode]. In The Scope of Practice. Doctor Podcast Network. https://scopeofpractice.podbean.com/e/its-not-about-usor-is-it-a-primer-on-countertransference/
Notaras Murphy, S. (2013). Attending to countertransference. Counseling Today. Retrieved from https://ct.counseling.org/2013/09/attending-to-countertransference/
O’Crowley, M.- L. (2020). Transference, countertransference, and vicarious trauma. Retrieved from https://www.symmetrycounseling.com/couples-counseling-chicago/transference-countertransference-and-vicarious-trauma/
Ponton, R. F., & Sauerheber, J. D. (2014). Supervisee countertransference: A holistic supervision approach. Counselor Education and Supervision, 53(4), 254–66.
Shafran, J. D., & Gardner-Shuster, E. (2016). Psychoanalysis. In H. S. Friedman (Ed.), Encyclopedia of mental health (2nd ed.) (pp. 339–47). Amsterdam, NL: Elsevier.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Treatment improvement protocol 52: Clinical supervision and professional development of the substance abuse counselor. Retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4435.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf
Sumerel, M. B. (1994). Parallel process in supervision. Retrieved from https://www.counseling.org/resources/library/eric%20digests/94-15.pdf
Valerio, P. (Ed.). (2017). Introduction to countertransference in therapeutic practice. London, UK: Routledge.
Wiener, J. (2009). The therapeutic relationship: Transference, countertransference, and the making of meaning. College Station, TX: Texas A&M University Press.
Yalom, I. D. (2008). Staring at the sun: Overcoming the terror of death. San Francisco, CA: Jossey-Bass.

Jeffrey Quamme, MS, CAC, CCS, CNC, CNE

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Jeffrey Quamme, MS, CAC, CCS, CNC, CNE, is the executive director of the Connecticut Certification Board, a workforce development organization for SUD/COD professionals. He is an administrator, trainer, and podcast host and has served as a subject matter expert for legislative office at the federal level.