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Transference, countertransference, and reflective practice in cognitive therapy Article in Clinical Psychologist · November 2011 DOI: 10.1111/j.1742-9552.2011.00030.x

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Clinical Psychologist 15 (2011) 112–120

Transference, countertransference, and reflective practice in cognitive therapy cp_30

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Claire CARTWRIGHT Department of Psychology, University of Auckland, Tamaki Campus, Private Bag, Auckland, New Zealand

Key words cognitive therapy, countertransference, reflective practice, therapeutic relationship, transference. Correspondence Claire Cartwright, Department of Psychology, University of Auckland, Tamaki Campus, Private Bag 92019, Auckland, New Zealand. Email: [email protected] Received 23 March 2011; accepted 21 August 2011. doi:10.1111/j.1742-9552.2011.00030.x

Abstract Background: The concepts of transference and countertransference developed within psychodynamic paradigms. While there is an increasing interest by cognitive therapists in the therapeutic relationship, there is less discussion of the relevance of transference and countertransference. Understanding these concepts may be useful to cognitive therapists as part of reflective practice, especially in regard to understanding and managing countertransference responses. Methods: This article briefly examines the concepts of transference from a number of different perspectives, including social-cognitive, attachment, cognitive analytic therapy, and schema perspectives. Two aspects of countertransference that are sometimes termed “subjective” and “objective” are also examined. A case example is given to illustrate a cognitive conceptualisation of countertransference. Results: There is some evidence that therapists’ countertransference responses can provide insight into clients’ experiences and patterns of relating to others. Cognitive therapists may therefore benefit from applying psychodynamic perspectives of countertransference in reflective practice. Conclusions: Transference and countertransference can be understood using cognitive perspectives. These concepts may be helpful for cognitive therapists to consider during reflective practice in self-supervision and in clinical supervision. It seems important that cognitive therapists do not dismiss these concepts because of their origins but rather investigate the potential applications of these concepts within cognitive frameworks.

Key Points 1 The concepts of transference and countertransference developed within psychodynamic traditions. These concepts, however, can be understood from alternative perspectives. 2 Understanding the concepts of transference and countertransference from a cognitive perspective may aid cognitive therapists in the processes of reflective practice and clinical supervision.

Funding: None. Conflict of interest: None. 112

The therapeutic relationship can be viewed as having three components—the therapeutic alliance, the transference–countertransference relationship, and the real or personal relationship (Gelso & Hayes, 2007; Horvath, 2000). The therapeutic relationship and especially the transference–countertransference relationship are viewed as central to therapeutic outcomes in psychodynamic psychotherapies (Gabbard, 2004). In cognitive therapy, the therapeutic relationship is considered important as a necessary underpinning to the effective implementation of cognitive and behavioural interventions rather than a main focus of therapy (Gilbert & Leahy, 2007). In the last decade, there has been an increasing focus on the therapeutic relationship and the therapeutic alliance in cognitive therapy (Leahy, 2008; Safran & © 2011 The Australian Psychological Society

Transference and countertransference

Muran, 2000). However, there is less focus on transference and countertransference, although there are exceptions to this, as will be discussed. Given the potential for countertransference responses to impact negatively on the therapeutic relationship (Gelso & Hayes, 2007), it may be important for cognitive therapists to understand and consider transference and countertransference as part of reflective practice in self-supervision and in clinical supervision. This, in turn, may assist in the management of countertransference responses and thereby protect the therapeutic relationship from what psychodynamic therapists refer to as countertransference enactments (Gabbard, 2001). In this article, I examine the concepts of transference and countertransference in order to consider their usefulness for cognitive therapists as part of reflective practice, both in self-supervision and clinical supervision. Two potential aspects of countertransference (“subjective” and “objective”) that have been studied by some psychodynamic therapists are discussed. These concepts are examined from a range of different perspectives, including cognitive perspectives. A case discussion is provided as an illustration of the application of these concepts. It is important to note, however, that this article is not suggesting that cognitive therapists adopt a psychodynamic approach to treatment. Rather, it considers ways in which these concepts can be understood from cognitive perspectives and how they can be used to reflect upon countertransference.

The Therapeutic Relationship and Cognitive Therapy As mentioned previously, there appears to be an increased interest in the therapeutic relationship in cognitive therapy (see Gilbert & Leahy’s (2007) edition that presents several different cognitive approaches to the therapeutic relationship). On the other hand, there is less interest in transference and countertransference. For example, a search of the PsycInfo database between 2000 and 2011 found only 16 references combining the keywords “cognitive therapy or cognitive behavioral therapy” and “transference,” and 13 references combining the keywords “cognitive therapy or cognitive behavioral therapy” with “countertransference.” The increased interest in the therapeutic relationship may be due to the empirical support for the importance of the therapeutic alliance to therapy outcomes (Leahy, 2008). In their meta-analytic review of 79 studies, Martin, Garske, and Davis (2000) investigated the relationship between therapeutic alliance and therapy outcomes, and concluded that the alliance is moderately related to therapy outcome (r = 0.22) regardless of © 2011 The Australian Psychological Society

variables such as the treatment approach, the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study. Similarly, in their decade review of process-outcome studies, Orlinsky, Ronnestad, and Willutzski (2004) concluded that the alliance is consistently, though not invariably, associated with positive outcomes in psychotherapy and that few findings in process and outcome research are better documented. DeRubeis, Brotman, and Gibbons (2005) point to some inconsistent findings for the role of the alliance in cognitive therapy and suggest that symptom improvement may lead to a good working alliance rather than the reverse. However, there is evidence that shows that the alliance is not the result of early improvement and that subsequent improvement can be traced to the alliance rather than early improvement (Wampold, 2010). For example, Klein et al. (2003) treated 367 chronically depressed clients with the cognitive-behavioural analysis system of psychotherapy and found that the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and client characteristics. In contrast, neither early level of the alliance nor change in symptoms predicted the subsequent level or course of the alliance. Hence, as Leahy (2008) points out, assuring the use of effective cognitive therapy techniques, along with a good therapeutic alliance, may provide the optimal treatment. In order to ensure a good therapeutic alliance, therapists need to be able to understand and manage their own responses to clients (Gelso & Hayes, 2007; Safran & Muran, 2000). In this article, I argue that cognitive therapists may benefit by using the concepts of transference and countertransference in the process of reflective practice in self-supervision and clinical supervision. In order for this to be meaningful, however, it seems important to be able to conceptualise countertransference using cognitive perspectives. The next section examines transference from a number of perspectives. These include a social cognitive model (Miranda & Andersen, 2007), an attachment model (Bowlby, 1988), the Cognitive Analytic Therapeutic (CAT) model (Ryle, 1998), and a schema-focused model (Leahy, 2007).

Transference Transference occurs in everyday life in interpersonal situations; however, the term is generally used to denote clients’ reactions to therapists. Greenson’s (1965) definition is often used by psychodynamic theorists (Andersen & Baum, 1994). This definition refers to transference as 113

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“the experiencing of feelings, drives, attitudes, fantasies, and defenses toward a person in the present, which are inappropriate to the person and are a repetition, a displacement of reactions originating in regard to significant persons of early childhood” (Greenson, 1965, p. 156). This definition is situated within a psychodynamic paradigm and emphasises the unconscious, drives, and defences. On the surface, this seems incompatible with a cognitive perspective, which emphasises the here and now, problem solving, and using rationality and behavioural activation (Leahy, 2008). Andersen and colleagues (Andersen & Berk, 1998; Miranda & Andersen, 2007) have investigated and demonstrated the existence of transference in nontherapeutic situations using laboratory settings. They explain transference using a social cognitive model. According to this model, transference presupposes that mental representations of significant others exist in memory and are triggered by relevant cues in any context. When a transference is triggered, the person views the other through the lens of pre-existing representations of significant others. This model also assumes that representations of significant others are linked with representations of self, so that when a representation of other is triggered, the corresponding representation of self is also triggered and vice versa. These representations of self and other are developed in relation to significant others and lead to interpersonal patterns of relationships that are superimposed onto new individuals (Andersen & Berk, 1998). The transference response that occurs is viewed as a cognitive-affective response with motivational elements. Andersen and Berk argue that transference is basic to social life and therefore deeply relevant to clinical theory. While transference is seen as a normal process, superimposing old interpersonal patterns on relationships in everyday life (and in therapy) can be problematic and is linked to psychopathology. Ryle (1998) has conceptualised transference and countertransference according to the CAT framework. Briefly, individuals in CAT are viewed as organising their experience and behaviour through the development of “procedures” made up of self-confirming sequences that include cognitive processes (e.g., perception and appraisal), enactments, evaluation of consequences, and modification or confirmation of the procedure. Individuals play roles and in so doing seek out or elicit reciprocating responses from others. These reciprocating procedures are learnt early in life through communications with caretakers (Ryle, 1998). According to Ryle, transference refers to the process by which the client enacts a procedure that is part of the established “repertoire of reciprocal roles” (p. 304) available to the client, and in so doing seeks a response from the therapist that 114

matches the role. Alternatively, the client may seek to identify with the therapist’s role and characteristics (Ryle, 1998). Transference has also been considered and investigated from an attachment perspective (Brumbaugh & Fraley, 2006). According to attachment theory (Bowlby, 1988), individuals develop mental representations of self and others, and inner working models of relationships, based on repeated experiences and transactions within primary relationships during infancy, childhood, and adolescence (Levy, 2005). These mental representations shape expectations and behaviour within interpersonal relations (Levy, 2005). According to this perspective, inner working models of relationships provide templates for the therapeutic relationship. More recent developments in attachment theory over the last decade have focused on the psychobiological findings regarding the impact of early emotional transactions with the primary caregiver on the maturation of brain systems involved in affect and self-regulation (Schore & Schore, 2008). As mentioned previously, cognitive therapists generally do not use the term transference or discuss transference from a cognitive perspective. Robert Leahy’s (2007; 2008) work is an exception to this. Leahy (2007) argues that the transference relationship consists of “personal and interpersonal processes that occur between the patient and the therapist” (p. 229). According to his perspective, the client’s transference is based on personal schemas about the self, interpersonal schemas about others, and relationship schemas, along with intrapsychic processes (such as repression or denial) and interpersonal strategies (such as stonewalling or clinging). Leahy discusses the ways in which client schemas manifest in therapy behaviours; for example, a client with a helpless schema is likely to seek reassurance, not have an agenda to work with, call between sessions, want to prolong sessions, or be upset when the therapist takes a vacation. A narcissistic client with a schema of superiority may come late or miss sessions, forget to pay, devalue therapy and the therapist, expect special arrangements, and feel humiliated to have to talk about problems (see Leahy, 2007). In their cognitive approach to personality disorders, A. Beck, Freeman, and Davis (2004) also briefly comment on the importance of “transference” responses, which they define as the client’s emotional responses to the therapist. They argue that it is important to explore these reactions and bring them into the open as they “often provide rich material for understanding the meanings and beliefs behind the patient’s idiosyncratic or repetitious reactions” (p. 76). They also discuss the schemas and core beliefs about self and others that underlie the different personality disorders and the ways in which © 2011 The Australian Psychological Society

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these manifest within therapy. Despite noting the importance of these processes, however, the reference to them is brief. Finally, transference could also be considered using Judith Beck’s (1995) cognitive conceptualisation framework. It can be argued that her concepts of core beliefs of self and other overlap with the social cognitive and attachment concepts (discussed earlier) of representations of self and other, and working models of relationships, as well as relationship schema. A particular viewpoint emphasised more strongly by psychodynamic theorists, and more recently in the social cognitive perspective, is the pairing of particular self and other representations such that when one representation (self or other) is triggered, then the linked representation is also triggered. Extending this to Judith Beck’s approach would guide therapists to consider not only clients’ core beliefs about self during formulation but also the core beliefs about others that are linked to beliefs about self; for example, self as inadequate and helpless linked with others as judgmental, or self as inadequate and helpless linked with other as powerful. As can be seen, the definitions of transference discussed earlier have a number of aspects in common. These include the importance of the learning that occurs during formative experiences, which leads to the development of patterns of perceiving and experiencing oneself in relation to others. These patterns can be viewed as potential templates for relationships that the client brings to therapy and from which the client responds towards the therapist. A number of perspectives emphasise the mental representations of self and other that underlie the individual’s relationship patterns. The transference response is seen as having emotional, cognitive, behavioural, and motivational components. While transference is seen as occurring in everyday interactions, the term usually refers to clients’ responses to therapists. Finally, transference can also be understood from a cognitive perspective as the client’s responses to the therapist and to therapy, which are manifestations of the client’s core beliefs, schemas of self and others, and relationship schemas, developed as a result of formative experiences in relationships with significant others. The next section briefly discusses the evolution of the concept of countertransference. Some psychodynamic theorists and clinicians discuss two aspects of countertransference that have been termed “subjective” and “objective.” Within cognitive therapy, as will be seen, there is acceptance of the notion of subjective countertransference but no focus on what has been termed objective countertransference. Hence, the empirical evidence that supports the notion of objective countertransference will also be briefly examined in order to consider the value © 2011 The Australian Psychological Society

and applicability of this concept for cognitive therapists when reflecting upon their own responses to clients.

Countertransference The term countertransference is most widely used to refer to the therapist’s cognitive-affective responses to the client (Gabbard, 2004). Freud conceptualised “countertransference” as arising from the client’s influence on the psychoanalyst’s unconscious feelings, a manifestation of the psychoanalyst’s unresolved issues, and a potential impediment to treatment (Storr, 1989). This conceptualisation dominated until the 1950s when a new “totalistic” perspective emerged in which countertransference came to be seen as all of the therapist’s emotional reactions towards the client (Gabbard, 2001). In a classic article published in 1950, Paula Heimann suggested that the analyst’s emotional response to the client was not simply a hindrance but an important tool in understanding the client. She wrote that “the analyst’s immediate emotional response to his patient is a significant pointer to the patient’s unconscious processes and guides him towards fuller understanding” of the client (p. 83). Around the same time, Winnicott (1949) introduced the concepts of “subjective” and “objective” aspects of countertransference. The subjective aspect referred to the therapist’s responses to the client based on the therapist’s own personal issues. The objective aspect referred to the therapist’s natural or realistic reaction to the client’s personality or extreme behaviour. According to this view, a client’s maladaptive way of relating to the therapist provokes responses in the therapist that are similar to the responses of others in the client’s life. Hence, countertransference can be viewed as a “clinically meaningful experience” that can shed light on the dynamics of the client (Betan & Westen, 2009). Many therapists continue to use and explore the concept of objective countertransference (e.g., Geltner, 2006; Hafkenscheid, 2003; Shafranske & Falender, 2008). However, there continues to be a disagreement about the concept of countertransference (Norcross, 2001). According to Hayes (2004), for example, there is an agreement that the therapist must understand the feelings elicited in him by the client and not act impulsively on them and that both client and therapist contribute to the countertransference. Hayes argues that there is less agreement on the relative weight given to the client or therapist contributions and conceptualises all countertransference responses as due to the personal issues of the therapist. In contrast, some modern conceptualisations of countertransference emphasise an intersubjective perspective in which countertransference is seen as “jointly created” by the client and the therapist (Gabbard, 2001, p. 984). 115

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While the terms subjective and objective countertransference may be redundant in a totalistic definition of countertransference, it seems important to have systematic ways of thinking about both aspects, even if in reality the two are intertwined (Gabbard, 1997; Shafranske & Falender, 2008). Shafranske and Falender, for example, in their competency-based approach to clinical supervision in psychology, guide supervisors to assist supervisees to reflect on both objective and subjective countertransference. This article also uses these concepts and aims to examine them from cognitive perspectives. Before considering cognitive perspectives of countertransference, it is important to briefly consider the evidence for the support of the notion of an objective (or realistic) aspect of countertransference. The clinical literature on objective countertransference is extensive, but the empirical investigation has been relatively limited (for an overview of the research, see Betan, Heim, Conklin, & Westen, 2005). Some laboratory and non-clinical studies have provided indirect evidence to support the notion of objective countertransference (Betan et al., 2005). These studies demonstrate the effects of an individual’s expectancies in relationships on the responses of others (Downey, Freitas, Michaelis & Khouri, 1998). There is evidence, for example, that depressed individuals “desire” and “invite” negative evaluations from others compared with non-depressed individuals (Geisler, Josephs, & Swann, 1996) and elicit criticism from others that matches their own selfcriticism (Swann, 1997). There have also been a number of clinical studies that have examined countertransference responses to different client groups. Colson et al. (1986), for example, found that the responses of professional staff to clients in an inpatient unit varied systematically across client groups. These responses included anger towards clients diagnosed with personality disorder, hopelessness towards clients with psychotic withdrawal, and protectiveness towards clients with suicidal depression. Similarly, Brody and Farber (1996) found that depressed clients evoked mainly positive reactions in therapists; borderline clients evoked anger and irritation, and the lowest levels of empathy; and people diagnosed as “schizophrenic” evoked the most complex mix of feelings along with the highest perceived need to refer. More recently, Betan et al. (2005) investigated the countertransference responses of 181 participating clinical psychologists and psychiatrists to randomly selected clients. The authors identified eight countertransference dimensions. These included overwhelmed/disorganised, helpless/inadequate, positive, special/over-involved, sexualised, disengaged, parental/protective, and criticised/ mistreated. These patterns of countertransference varied 116

across client groups in predictable ways. For example, there were significant correlations between clinicians’ countertransference responses and personality disorder symptoms. Clinicians tended to respond to clients with a diagnosis of personality disorder (including antisocial, borderline, histrionic, or narcissistic) (American Psychiatric Association, 2000), with an overwhelmed/ disorganised pattern of countertransference. Betan et al. concluded that these clients elicit what they called “average expectable countertransference responses” (p. 895). Clinicians from different orientations had similar response patterns to clients with different types of problems, and these emerged even if therapists did not believe in countertransference. The authors argue that the results support the view that countertransference is useful in diagnostic understanding of clients’ dynamics and repetitive interpersonal patterns, thereby supporting the notion that countertransference is potentially a valuable source of information about the client. However, as stated previously, when cognitive therapists talk about countertransference, as they sometimes do, they refer to the subjective form only. This focus is reflected in methods that guide cognitive therapists in self-supervision and reflective practice to consider subjective countertransference and the personal schemas that underlie responses to clients (e.g., Bennett-Levy & Thwaites, 2007; Haarhoff, 2006). Similarly, Leahy (2007), one of the few cognitive therapists who use the terms transference and countertransference, deals only with subjective aspects of countertransference. According to Leahy’s “social-cognitive model,” countertransference results from the therapist’s schema or core beliefs that underlie the responses to client behaviours. As he states, “The therapist is similar to the patient in holding certain personal and interpersonal schema” (Leahy, 2007, p. 239). Examples of personal schema given by Leahy (2007) include “demanding standards” by which the therapist feels he has to cure his clients and meet the highest standards; “rejection sensitivity” by which the therapist is upset by conflict and therefore does not raise issues with clients if clients might be bothered; and “need of approval” by which the therapist wants to like and be liked by clients. As part of discussing subjective countertransference, Leahy (2007) also notes the importance of the therapist’s “emotional philosophy,” that is, the therapist’s response to the expression of emotions. Therapists who view emotions as distracting or self-indulgent may communicate negative attitudes towards clients’ emotions and emotional expression. Therapists who respond from their own emotional philosophies may inadvertently model emotional avoidance, which in turn reinforces the client’s own emotional schemas, such as “My feelings are not important and they overwhelm others.” © 2011 The Australian Psychological Society

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While cognitive therapists do not discuss objective aspects of countertransference, this notion has been considered useful by some psychodynamic therapists and may benefit cognitive therapists in the process of reflecting upon their countertransference responses, either in self-supervision or clinical supervision. However, it seems important to have ways of conceptualising both aspects of countertransference from cognitive perspectives. In the next section, Judith Beck’s (1995) concepts of core beliefs about self and others are applied to a case discussion and used to consider countertransference.

Case Discussion—Illustration of Cognitive Conceptualisation of Subjective and Objective Countertransference A client, Ann, 35 years old, has presented with major depression triggered by the end of an 8-year cohabiting relationship. Assessment reveals that Ann has suffered from mild depression on and off for many years, but this has been exacerbated in recent months. Ann is also struggling at work with a demanding boss and tasks that she feels are beyond her. She presents for therapy 6 weeks before the therapist is due to have a 2-week holiday. A risk assessment reveals that she is not suicidal, although she is frightened by the strength of her own emotions and the belief that she cannot cope without her partner. Ann is the youngest in her family of origin and has three older sisters (living overseas) who are all “strong personalities” and “looked out for her” throughout her childhood and adolescence. If she had any problems, “they solved them.” Her parents, on the other hand, were “hopeless” at helping her when she was upset or having difficulties and were critical of her. Ann also had some experiences of some verbal bullying at school, when classmates became irritated with her because she was a “crybaby,” “a sook,” and “a wuss.” Teachers also became annoyed with Ann at times. She recalls one year when she was often sent to sit outside on the veranda until she had calmed down and stopped crying. Ann reports that she cried a lot at school because she hated the feeling of not being able to do things successfully. Ann also reports that she cries easily at work when her boss “tells her off” for making a mistake. She says that her ex-partner also said he could no longer cope with her “clinging and whining.” In therapy, Ann appears to respond initially in a warm and trusting manner towards the therapist, giving her feedback by the beginning of the second session about how great it was to talk to her and how much better she felt afterwards. The therapist tells Ann at the beginning of the sessions that she can see her but that there will be a © 2011 The Australian Psychological Society

break of 2 weeks in sessions after the sixth session. Ann happily agrees to this, but as time goes by, she begins to “fret” about the therapist going away, says she will miss her, and does not know what she will do without her. A full conceptualisation requires further information. However, from what is provided, we can hypothesise that Ann has core beliefs of self as being helpless or inadequate and core beliefs of others as strong and potentially supportive. These beliefs about self and other may have originated mainly from her relationships with her older sisters, who appear to have taken on a caretaking role for Ann and perhaps inadvertently encouraged her dependence on them. However, she also appears to have representations or core beliefs of others as critical and rejecting in relation to herself as helpless or inadequate. These representations may have originated in her relationships with her parents, who did not assist her when she was distressed, and with classmates and teachers who became angry or critical of her when she seemed unable to cope. These core beliefs about self and other may have contributed to her difficulties with her ex-partner and been reinforced by her partner’s rejection of her due to her “clinging and whining.” Ann’s response to the therapist is one that initially communicates helplessness, neediness, and admiration and trust. Initially, the therapist finds herself feeling warm towards Ann and begins to think that she cannot go away for 2 weeks at such a crucial time, as Ann might not be able to cope. She begins to wonder if she should shorten the holiday. However, the therapist recognises this as a countertransference response and does not act on it. As the holiday period draws closer, the therapist finds herself becoming irritated with Ann’s “fretting.” The “fretting” manifests as crying, rubbing her hands together anxiously, and beginning to catastrophise about what could go wrong at work when the therapist is away. The therapist’s countertransference manifests as twinges of irritation throughout the sessions and at one point in time, an urge to say, “For God’s sake, grow up and stop whining. It’s no wonder your partner left you!” Fortunately, the therapist once again recognised this as a countertransference response and did not act out on the urge.

Objective Countertransference The therapist’s responses to the client (initially supportive and protective, and later irritated and critical) can be seen as a realistic response to the client’s relationship style. The client, based on her core belief that she is helpless, initially aims to engender the type of unconditional support that she was given by her sisters, and thereby responds to the therapist from her representation of others as strong and supportive. The therapist finds 117

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herself responding in a complementary way to the client, feeling supportive and protective, and having thoughts of giving up part of her holiday. As the holiday approaches, the client begins to “fret,” “whine,” wring her hands, and catastrophise about work. At this point, the client may be unconsciously beginning to view the therapist as rejecting or unhelpful, more similar to her parents or her ex-partner (who abandoned her to her distress). The therapist once again responds in a complementary fashion by having fleeting feelings of irritation, and on one occasion, an urge to hit out verbally at Ann. Hence, the therapist—at least at some moments in therapy—has responded emotionally to Ann, as significant others have. By considering this, the therapist can understand more about the pattern of relationships that the client has experienced and now engenders.

Subjective Countertransference It is also important that the therapist considers whether some of her countertransference may be subjective and related to her own personal issues and beliefs. For example, a therapist with an emotional philosophy (Leahy, 2007) that values independence and feels uncomfortable with neediness may find herself feeling irritated with the client’s distress. As can be seen from the above, the therapist’s enactment of countertransference responses can have negative consequences for the therapy and the therapeutic relationship. If the therapist changes her holiday plans, she reinforces the client’s belief in her own helplessness and also increases the likelihood of further support and reassurance-seeking behaviour in the future. If she withdraws from the client’s neediness and distress because of her own personal issues, she reinforces the client’s beliefs that her emotional responses are unreasonable or overwhelming and that others are rejecting and critical. By being aware of the possibilities of different aspects of countertransference, the therapist can consider how to respond in such a way that the client’s distress is acknowledged, and the client is assisted to cope with the challenge ahead. Working from a cognitive perspective, the therapist may help the client challenge some of the negative thoughts that she is having about coping while the therapist is away, and may work with developing some coping strategies for this period.

Conclusions There is an increasing interest in the therapeutic relationship and the therapeutic alliance in cognitive therapy. Some cognitive therapists (e.g., Leahy, 2007, 2008) and researchers (Miranda & Andersen, 2007) have also begun 118

to use the terms transference and countertransference and to translate these into frameworks that are complementary to cognitive therapy. This article has argued that understanding transference and countertransference from within cognitive frameworks may enhance reflective practice in self-supervision and clinical supervision. While some attention has been given to subjective countertransference by cognitive therapists (e.g., BennettLevy & Thwaites, 2007; Haarhoff, 2006; Leahy, 2007), objective aspects of countertransference are not discussed. However, there is some evidence to support the notion of objective aspects of countertransference and to suggest that therapists may benefit from understanding and reflecting on both aspects of countertransference. Given this, it seems important that cognitive therapists do not dismiss these concepts because of the strong association with psychodynamic therapies, but rather investigate the potential applications of these concepts within cognitive frameworks. In time, it may be desirable to develop alternative terminology that represents these concepts and fits within a cognitive paradigm.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author. Andersen, S. M., & Baum, A. (1994). Transference in interpersonal relations: Inferences and affect based on significant-other representations. Journal of Personality, 62, 459–497. Andersen, S. M., & Berk, M. (1998). Transference in everyday experience: Implications of experimental research for relevant clinical phenomena. Review of General Psychology, 2, 81–120. Beck, A., Freeman, A., & Davis, D. (2004). Cognitive therapy for personality disorders. New York: Guilford Press. Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Bennett-Levy, J., & Thwaites, R. (2007). Self and self-reflection in the therapeutic relationship: A conceptual map and practical strategies for training, supervision, and self-supervision of interpersonal skills. In P. Gilbert & R. Leahy (Eds.), The therapeutic relationship in the cognitive behavioral psychotherapies (pp. 255–282). London: Routledge. Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162, 890–898. Betan, E., & Westen, D. (2009). Countertransference and personality pathology: Development and clinical application of the countertransference questionnaire. © 2011 The Australian Psychological Society

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