Counter Transference And Clinical Epistemology

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Playing With Fire: Countertransference and Clinical Epistemology Jeffrey A. Hayes

This article explores both theoretical and practical concepts related to the therapist’s use of the self in psychotherapy. Particular emphasis is placed on the potential clinical value of countertransference. It is argued that awareness and resolution of personal issues are required for therapists to draw profitably from their own experiences in working with clients. Specific steps in translating the concept of the wounded healer into clinical practice are offered, along with examples from the author’s own practice. KEY WORDS: countertransference; wounded healer; therapist factors; psychotherapy relationship.

Paul Jordan Smith (1995) recounts the story of a group of physicians who are arguing about the most important organ in the human body. They take turns presenting claims for the supremacy of the brain, stomach, heart, and lungs. A rabbi overhears their discussion and declares, “You are all wrong. There are two vessels of the body only that are important but you have no knowledge of them.” When the physicians inquire as to what they are, the rabbi replies, “The channel that runs from the ear to the soul, and the one that runs from the soul to the tongue.” These same two channels can be, and often are, critical determinants of psychotherapy outcome, although a vast number of therapists do not intentionally use them, thereby limiting or even diminishing outcome. In the following paragraphs, I will explore both the prospective value as well as the inherent danger in using these channels in psychotherapy, with an emphasis on how they affect the psychotherapy relationship. At the outset, definitional clarity is important, especially with a hackneyed term like “soul.” In this article, I am using the word “soul” to refer specifically to the aggregate of the individual’s personal history. In using the term in this way, it Address correspondence to Jeff Hayes, Counseling Psychology Program, Pennsylvania State University, 312 Cedar Building, University Park, Pennsylvania 16802; e-mail: [email protected]. 93 C 2002 Human Sciences Press, Inc. 0022-0116/02/0300-0093/0 °

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is not my intent to trivialize or secularize the construct but rather to emphasize the sacred nature of the individual. I recognize that the term “soul” has a collective, as well as an individual, component (e.g., the notion that each person belongs to a larger spiritual whole). Although this broader view of the construct is relevant to the thoughts contained in this article, adequate consideration of these ideas is beyond the page limitations of the present paper. CLINICAL EPISTEMOLOGY AND THE PERSON OF THE THERAPIST Regardless of one’s theoretical approach to therapy, it is a general truth that therapists’ overarching goal is to reduce human suffering. A pertinent question, then, is what therapists know about suffering. Or perhaps a more relevant question is “How do therapists know about human suffering?” Although a thorough treatise on clinical epistemology is not the focus of this paper, a brief examination of various sources of therapists’ professional knowledge may be useful nonetheless. The origins of therapists’ knowledge may be conceptualized along a continuum ranging from the personal to the impersonal. At the impersonal end of the continuum would be relatively public sources of knowledge, such as findings from scientific study and philosophical reasoning that are disseminated by others, or pronouncements made by authority figures. Knowledge obtained from these impersonal bases can be beneficial in terms of general guidance for clinical work, but rarely is it helpful when working with a particular client in any given moment. Closer to the personal end of the continuum would be more private sources of knowledge, such as one’s own clinical and life experience. The latter has been recognized to exert considerable influence on therapy, dating back to Freud’s (1910/1959) claim that “no psycho-analyst goes further than his own complexes and internal resistances permit.” May (1939/1989) similarly emphasized the role of the therapist’s well being in humanistic work: “The personal equation is all important in counseling, as counselors can work only through themselves. It is therefore essential that this self be an effective instrument” (p. 131). Even therapists who are more cognitively and behaviorally oriented are acknowledging the importance of the therapist’s self (e.g., Robins & Hayes, 1995; Singer, Sincoff, & Kolligan, 1989). Despite the importance that has been and continues to be attached to the person of the therapist, we actually know very little about the effects of the therapist’s life experiences on psychotherapy. For the most part, researchers have ignored Strupp’s (1958) assertion that the therapist’s “background, attitudes, experiences, and personality must be put under the microscope for careful scrutiny and analysis if valid knowledge about how to treat mental illness is to be obtained” (p. 34). Furthermore, whereas meta-analyses have demonstrated that the person of the therapist accounts for more variability in outcome than do treatment specific factors

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(Ahn & Wampold, 2001), the bulk of therapist variables that have been studied to date are rather superficial constructs that are fairly distal to the therapy process (Beutler, Machado, & Neufeldt, 1994). It is also true, however, that a line of research on countertransference (CT) has begun to emerge since 1980. Building on the pioneering studies of Fiedler (1951), Cutler (1958), and Yulis and Kiesler (1968), researchers have started to investigate the origins, triggers, manifestations, and management of CT (e.g., Fauth & Hayes, 2002; Gelso, Fassinger, Gomez, & Latts, 1995; Hayes & Gelso, 1991, 1993; Hayes, McCracken, et al., 1998; Hayes, Riker, & Ingram, 1997; Latts & Gelso, 1995; Peabody & Gelso, 1982; Robbins & Jolkovski, 1987; Rosenberger & Hayes, in press; see Gelso & Hayes, 1998 and Hayes & Gelso, 2001 for reviews of this corpus of research). By and large, in these studies CT has been defined explicitly in a manner that integrates elements of Freud’s (1910/1959) classical definition and subsequent totalistic definitions (e.g., Fromm-Reichmann, 1950). That is, researchers have focused on the therapist’s unresolved conflicts as the source of CT (consistent with Freud’s classical definition) while acknowledging that CT may be a useful source of insight into the client, treatment dynamics, or both (in concert with the totalistic definition). Despite nominal acknowledgement of both the vices and virtues of CT, researchers have concentrated their efforts to date almost solely on the deleterious consequences of CT and how to avoid or manage them (e.g., Van Wagoner, Gelso, Hayes, & Diemer, 1991) while disregarding the potential therapeutic value of CT. COUNTERTRANSFERENCE AND THE WOUNDED HEALER I would like to propose that the key to using CT therapeutically, to return to Paul Jordan Smith, is to travel the channels from the ear to the soul and the soul to the tongue. What do I mean by this? To understand a client’s communication, we need a reference point. In one sense, it is impossible for us not to see the world, including the client’s world, from our own point of view. Even when we strive to understand the client’s frame of reference, we require an internal place from which to connect. Spence (1982) makes this point eloquently: “Sensitive, empathic listening can probably take place only if the words spoken by one speaker are invested with private meanings by the other. Unless some kind of internal elaboration takes place, the listener hears only words—we can imagine our response to a long monologue in a completely foreign tongue—and communication fails. To listen with understanding and involvement requires the listener to be constantly forming hypotheses about the next word, the next sentence, the reference for a recent pronoun, or the color of the bride’s eyes, because it is only in the midst of this kind of activity that words take on some kind of meaning” (p. 117). Spence’s description of the internal elaboration and hypothesis generation that take place within the therapist hint at how the therapist might make use of the

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channels that run to and from the soul. Doing so involves the therapist intentionally calling to mind—or at least intentionally being open to—a personal experience that somehow relates to the client’s experience and making therapeutic use of this. Schroeder (1925, cited in Mahrer, Boulet, & Fairweather, 1994) referred to this process as “empathic duplication.” To be sure, empathic duplication is a dangerous enterprise, somewhat akin to use of touch in therapy. It is a potentially powerful practice wrought with the risk of misuse and abuse that requires judiciousness and keen clarity about whose needs are taking precedence. Concerns about Type I error predominate in the current professional zeitgeist, and perhaps rightly so, but Type II errors are errors nonetheless. Just as it is a clinical mistake not to touch a client when doing so would be appropriately comforting, reassuring, or otherwise healing, not using the channels that run to and from the soul unnecessarily limits the instrumentality of the therapist’s self. As therapists, it is altogether possible to keep ourselves safe, practicing comfortably behind the shields of authority and expertise, limiting our involvement in the client’s work and thus, in all likelihood, our effectiveness. As Jung (1963/1989) wrote, “When important matters are at stake, it makes all the difference whether the doctor sees himself as a part of the drama, or cloaks himself in his authority” (p. 133). On the other hand, when the therapist makes use of the channel that runs from the ear to the soul, it opens up the possibility of deep empathic understanding; the therapist’s own personal experience becomes an epistemic well from which to draw. What does it require of the therapist to draw effectively from her own life experience? First, the therapist must be familiar with the internal pathway from her mind to her soul. One cannot draw therapeutically on personal experiences without an active and ongoing interest in one’s own history. Whatever form such introspection assumes, it ought to increase selfawareness, including awareness of one’s wounds. Acknowledgment of the therapist’s own woundedness is critically important to using the self as an instrument of healing. Therapists who disavow their wounds run the risk of projecting onto the client the persona of “the one who is wounded” while introjecting the persona of “the one who heals.” In truth, both poles of the wounded healer archetype exist within the person of the therapist and the person of the client (Whan, 1987). “There is no essential difference between the two people engaged in a healing relationship. Indeed, both are wounded and both are healers. It is the woundedness of the healer which enables him or her to understand the patient and which informs the wise and healing action” (Remen, May, Young, & Remen, 1985, p. 85). When the therapy relationship is dichotomized into one who is wounded and one who heals, the therapist becomes locked into a position in which her own wounds cannot be used in service of the client, and the client’s inner healing capacities are denied (Guggenbuhl-Craig, 1970). Problem awareness, of course, is a necessary but insufficient condition for using countertransference beneficially. As Nouwen (1972) succinctly put it, “Open

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wounds stink and do not heal” (p. 88). The therapist must not only acknowledge her inner conflicts but also work to resolve them. Keeping the channel as clear of obstacles as possible allows the soul to be accessed more readily. I do not think that complete problem resolution is either possible or essential; to help, the therapist needs to be only a step, not a mile, ahead of the client in the healing process. A continual willingness to work on one’s own issues simultaneously decreases the possibility of countertransference-based reactivity with clients and increases the pool of experiences that might be drawn upon in therapy. According to Maeder (1989), the therapist’s decision to tend to personal wounds “leads to a painful confrontation with his own problems and weaknesses, and ultimately to self-knowledge. Ideally, he can overcome the difficulties; at worst, he may be forced to resign himself to insuperable handicaps. In either case, though, the end result is a clearer perception of his ambitions and needs and their relationship to the task at hand. He can approach others with honesty, compassion, and humility, knowing that he is motivated by genuine concern, not by some ulterior motive” (p. 77). FILLING A GAP IN AN ANCIENT LITERATURE Though it may not be widely practiced among therapists currently, the idea of using one’s wounds in the service of healing others is hardly new. The archetype of the wounded healer can be traced back to the mythological character of Chiron. Abandoned by his father, Saturn, and rejected by his mother, Philyra, who preferred to be transformed into a tree rather than raise a creature who was half human and half animal, Chiron was emotionally wounded from the outset. As he matured, he became skilled in the healing arts and mentored Asclepius, the founder of medicine, as well as Hercules, who subsequently injured Chiron accidentally with an arrow. Chiron’s suffering was so extreme that he asked to trade places with a mortal, Prometheus, so that Chiron might die and Prometheus be granted eternal life (Reinhart, 1989; Snodgrass, 1994). The parallels are evident to the Christian notion of salvation through the death of Jesus. The concept of the wounded healer also is embodied in the ancient practice of shamanism. In a number of cultures, shamans may be called to their roles because of some physical or emotional wound they have suffered (Eliade, 1974). The wisdom underlying this tradition is that in older healing practices such as shamanism, woundedness is seen not as evidence of vulnerability but as the mark of knowledge . . . The wound validates the healer’s ability to move “between the world’s”—the world of the well and the world of the ill, for it is in the bridging of these world’s that the healing power lies. (Halifax, 1982, p. 84)

Despite the long-standing nature of these ideas, and their occasional discussion in the psychotherapy literature (e.g., Buie, 1981; Schafer, 1959), to the best of my knowledge, the specific mechanisms for translating them into actual clinical

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work have not been described in detail. I will attempt to provide some of the particulars, followed by two examples from my own work with clients. The starting place is to adopt a posture of slightly bifurcated attention, concentrating primarily on the client, of course, while maintaining an openness to one’s internal experience. Sensations of almost any kind might naturally arise—visual, auditory, visceral—and these may serve as useful associations for understanding the client’s material more deeply. The sensation may be vague at first. I take comfort in Sedgwick’s (1994) notion that “Countertransferences often start off muddled and wind up, one would hope, bringing clarity” (p. 106). Alternatively, I sometimes find that distinct images of an exact location with which I am familiar or lyrics from a personally meaningful song will trickle into consciousness. What is their connection to the client’s communication, including the client’s covert messages? If I am able to find an association, and it is not uncommon that I cannot, I treat the insight tentatively, searching for evidence that supports or refutes it until the association itself loses meaning. I also examine the possibility that the sensation is more indicative of boredom or defensiveness on my part than a useful source of insight into what the client is expressing. Honesty is important to the endeavor. When information emanating from my own experience does not arise naturally, I might seek it out, especially when I am having difficulty empathizing with a client or when I want to understand the client more deeply. How do I connect with my client’s account of having been raped? Is there an event from my own history that I can draw from where I encountered or felt something similar to the client? If so, I check my arousal level to try to determine if my issues are sufficiently resolved that I will be able to recognize important distinctions between her experience and my own, between her emotions and mine, between her needs now and mine then. If using this channel to my soul is in the best interest of my client and not primarily an act of self-indulgence, I may allow myself to reexperience affect connected with the event, mindful of cues about the client’s possible feelings and vigilant about both the source and intensity of my feelings. I look to extract relevant lessons from my own experience that might deepen my understanding of the client and provide guidance about our work together. Again, tentativeness is the norm here; I cannot assume that what has worked for me will work for my client. But perhaps my own experiences can be used to facilitate the client’s healing process. I will conclude by sharing a couple of examples to help elucidate these ideas. One of my former clients had been trying to conceive a child for quite some time. When she announced the good news to me that she was finally pregnant, I shared her joy (as a father of three, this was easy to do). About six weeks later, my client disclosed that she had miscarried. An image came to mind almost immediately of my wife and me drinking chicken soup in bed, accompanied by a slight tension in my chest. Years earlier we had lost a daughter after a fairly advanced pregnancy, and one night shortly after the miscarriage, a friend brought us chicken soup. We ate in bed and wept. That image gave me a place from which to connect to the

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client’s grief. Having lost Kelsey and having worked through the associated pain and anger and disappointment, I understood the client’s range of emotions more deeply than I would have otherwise. Without minimizing the client’s experience, I also was able to offer her genuine hope borne out of my own experience that helped her through her grieving. Another client once was talking about getting pushed around by others, and in my mind’s eye I saw Barnegat Bay from a distinct vantage point, and my body relaxed noticeably. I searched for the association. This specific location on the shoreline is a place where I feel at one with myself, congruent, whole. When I am not myself, I feel anxious. I wondered if this might be how the client was feeling, although he had not been saying so. I became more attuned to signs of potential anxiety in the client, looking for evidence to confirm or disconfirm my hypothesis. He did not sound anxious, but he looked tense. I floated out my observation, which he took to, and in no more than a handful of seconds, our work had deepened. I became more empathic toward his experience of being pushed around, and I was able to offer the prospect of greater wholeness as a goal for our work together. ACKNOWLEDGMENTS I am grateful to the following individuals for their encouragement and support while I developed the ideas contained in this article: Susan Bowers, Charlie Gelso, Mary Margaret Hart, Janet McCracken, and Glenn Mitchell. REFERENCES Ahn, H., & Wampold, B., E. (2001). Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy. Journal of Counseling Psychology, 48, 251–257. Beutler, L. E., Machado, P. P., & Neufeldt, S. A. (1994). Therapist variables. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 229–269). New York: Wiley. Buie, D. H. (1981). Empathy: Its nature and limitations. Journal of the American Psychoanalytic Association, 29, 281–307. Cutler, R. L. (1958). Countertransference effects in psychotherapy. Journal of Consulting Psychology, 22, 349–356. Eliade, M. (1974). Shamanism: Archaic techniques of ecstasy. Princeton, NJ: Princeton University Press. Fauth, J. & Hayes, J. A. (2002). Therapists’ male gender role attitudes and stress appraisals as predictors of countertransference behavior with male clients. Manuscript under review. Fiedler, F. E. (1951). On different types of countertransference. Journal of Clinical Psychology, 7, 101–107. Freud, S. (1959). Future prospects of psychoanalytic psychotherapy. In J. Strachey (Ed.), Standard edition of the complete psychological works of Sigmund Freud (Vol. 20, pp. 87–172). London: Hogarth Press. (Original work published 1910). Fromm-Reichmann, F. (1950). Principles of intensive psychotherapy. Chicago: University of Chicago. Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship. New York: Wiley.

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