Note on transference and counter transference - types definitions and other details and clinical applications
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I now have extensive material from Kaplan & Sadock's Synopsis and Comprehensive Textbook of Psychiatry. Let me compile the comprehensive notes.
Transference and Countertransference: A Comprehensive Note
Sources: Kaplan & Sadock's Synopsis of Psychiatry; Kaplan & Sadock's Comprehensive Textbook of Psychiatry
I. TRANSFERENCE
Definition
Transference is the unconscious displacement of feelings, attitudes, wishes, and expectations from past significant relationships (primarily parental figures) onto the therapist or analyst in the present. As Alessandra Lemma defines it, transference reflects "the human predisposition to see current interpersonal experience through the largely unconscious lens of selected forms of past experience" - but importantly, it is not a photocopy of the patient's childhood.
In the modern psychoanalytic view, transference is not merely a distortion - it is a working ground for interpersonal growth and one of the greatest sources of therapeutic leverage. "Transference demonstrates vividly that the past lives within the present and exerts a powerful force upon it."
Historical Background
- Sigmund Freud first coined the term, recognizing how patients transferred feelings toward past love objects onto the analyst.
- Classical analytic literature used transference to promote "transference regression" or "transference neurosis" based on infantile wishes and conflicts.
- Over time, theories of object relations, self-psychology (Kohut), and intersubjectivity broadened the concept from a simple distortion to a rich interpersonal phenomenon.
Mechanisms of Transference
The two core mechanisms are:
1. Displacement
The basic mechanism of classic transference. An object representation derived from early developmental experience is displaced onto the representation of the analyst. Displacement underlies libidinally based transferences (positive and erotic) as well as aggressive/negative transferences. It plays a dominant role in neurotic disorders, where phallic-Oedipal dynamics are central.
2. Projection
Qualities or characteristics of the self-as-object (introjects, self-representations) are attributed to the therapist, and subsequent interaction is shaped by those projected characteristics. For example, the analyst may be perceived as sadistic because the patient has projected their own disowned sadistic self-aspect onto them.
- Projections from destructive introjects fuel negative and paranoid transference reactions.
- Victim introject: patient sees therapist as victim, assumes hostile/aggressor position.
- Aggressor introject: patient sees therapist as aggressor, assumes weak/masochistic position.
- Projection plays a more prominent role in primitive character disorders.
3. Projective Identification
First proposed by Melanie Klein - projection of impulses into another person, bringing about an identification with that person based on those attributed qualities. Unlike simple projection, projective identification evolved from a one-body to a two-body phenomenon, describing an actual interaction:
- The projector behaves toward the recipient in a way that induces the recipient to experience the projected feeling.
- Particularly relevant in Kleinian theory and in understanding transference-countertransference interactions.
- Key distinction: projection involves displacing onto the external object; projective identification involves the object being drawn into experiencing or enacting the projected role.
Types / Classifications of Transference
By Valence
| Type | Features |
|---|---|
| Positive Transference | Feelings of affection, warmth, trust, admiration toward the therapist; fosters the therapeutic alliance; can be erotic if intense |
| Negative Transference | Feelings of anger, hostility, suspicion, resentment, or fear toward the therapist; often a resistance; must be interpreted |
| Erotic / Eroticized Transference | Sexual or romantic feelings directed toward the therapist; a specific form of positive transference requiring careful management |
| Ambivalent Transference | Coexistence of positive and negative feelings; common in the transference neurosis |
By Developmental Origin
| Type | Description |
|---|---|
| Parental Transference | Patient reacts to therapist as child to parent; most classically recognized form |
| Peer / Sibling Transference | Expressions of experiences from nonparental relationships (siblings, spouses, friends); therapist is cast as a sibling or peer |
| Son or Daughter Transference | Common in middle-aged and elderly patients; therapist cast in the role of patient's child, grandchild, or in-law; themes include defenses against dependency, dominance/submission, reworking unsatisfying relationships with children |
| Paternal Transference | Father-figure feelings transferred; often authority, discipline, prohibition |
| Maternal Transference | Mother-figure feelings; nurturing, holding, dependency needs |
| Sexual Transference in Older Adults | Frequent and intense; requires therapist to manage countertransference carefully |
By Structural/Dynamic Type
| Type | Description |
|---|---|
| Transferences of Impulse | Drives and wishes are directly transferred - the classic form |
| Transferences of Defense | The ego's defensive functioning is what transfers; not drives but the defense against drives; attention shifts to ego functioning |
| Narcissistic Transferences (Kohut) | Based on projections of archaic narcissistic configurations. Two main subtypes: mirror transference (therapist represents grandiose self) and idealizing transference (therapist represents idealized parental imago). In idealizing transference, all power and strength are attributed to the idealized object; union with this object restores narcissistic equilibrium |
| Transitional Transferences | Overlap with self-object phenomena; involve more explicit projective elements |
| Self-Object Transferences | Draw the analyst into meeting the pathological needs of the self |
By Severity / Regression Level
| Type | Description |
|---|---|
| Transference Neurosis | Recreation of the patient's neurosis enacted within the analytic relationship, mirroring the infantile neurosis. Develops in the middle phase of analysis; the transference emotions become more compelling than symptom relief. Governed by the pleasure principle, ambivalence, and repetition compulsion. Subsides only as the original infantile conflict is sufficiently analyzed and interpreted. Contemporary opinion is divided about its necessity for cure. |
| Transference Psychosis | Occurs when failure of reality testing leads to loss of self-object differentiation and diffusion of self and object boundaries. May reflect a bid for fusion with an omnipotent object. Negative elements may include fear of engulfment/loss of self, precipitating paranoid transference reactions. |
By Relational Theory
| Concept | Description |
|---|---|
| Transference as Psychic Reality | Transference as the patient's subjective experience - equally real as external reality, not simply distortion |
| Transference as Relational/Intersubjective | Transference seen through a two-person lens; reflects co-constructed dynamics between therapist and patient, not solely the patient's past; "a mixture of real characteristics of the therapist and aspects of patient's figures from the past" (Gabbard) |
Series of Transferences Through Treatment
A series of transferences typically unfolds over the course of treatment, each reflecting:
- Particular relationship conflicts in the patient's outside life
- Situations arising with the analyst that recall dynamics from early family life
- The stage of the treatment itself
II. COUNTERTRANSFERENCE
Definition
Countertransference refers to the therapist's emotional reactions to the patient, originally understood as the analyst's potentially idiosyncratic/personal response to the patient's transference. It was initially seen as an obstacle to treatment - something to be worked through in the analyst's own analysis.
The modern understanding has expanded significantly: countertransference is now recognized as a critical and informative part of the analytic process, offering valuable data about the patient's inner world.
Historical Evolution
- Freud's original view: countertransference as the analyst's unresolved neurotic reactions to the patient's transference; a disturbance to neutrality that must be controlled.
- Dramatic early examples: Carl Jung violated boundaries with patient Sabina Spielrein; Josef Breuer terminated abruptly when a patient developed a delusional pregnancy in conjunction with an erotic transference (acting out of countertransference).
- Modern view: The "relational turn" in psychoanalysis shifted from a one-person psychology (analyst as objective outside observer) to a two-person psychology of intersubjectivity. The analyst's own emotional life is now seen as a fundamental aspect of psychoanalytic understanding.
Types of Countertransference
| Type | Description |
|---|---|
| Classical / Narrow Countertransference | Analyst's unconscious reactions specifically triggered by the patient's transference; originally seen as interference; must be recognized and controlled |
| Totalistic / Broad Countertransference | All of the analyst's emotional reactions to the patient, including those induced by the patient's behavior and personality (not just transference); includes both neurotic responses and empathic resonances |
| Complementary Countertransference | Therapist identifies with the internal objects of the patient (i.e., takes on the role assigned by patient's projective identification) |
| Concordant Countertransference | Therapist empathically resonates with the patient's own self-experience (identifies with the patient's ego) |
| Objective / Induced Countertransference | Response that any reasonable therapist would have to a particular patient's behavior; reflects something real about the patient |
| Subjective Countertransference | Arises from the therapist's own unresolved conflicts, irrespective of the patient |
Countertransference in Specific Populations
With elderly patients (Synopsis, p. 2863-2864):
- Countertransference challenges arise because the therapist must confront issues of aging, illness, loss, death, and limitation that they may prefer to avoid.
- Therapist's reactions to the older patient's sexuality can be particularly disorienting (e.g., a younger female therapist uncomfortable with an elderly male patient's erotic transference, rooted in her own conflicted attitudes about parental/grandparental sexuality).
- Supervision and personal therapy are vital aids in resolving these countertransference reactions.
With suicidal patients:
- Countertransference feelings can be empathic but also ambivalent, aggressive, and even hostile.
- Requires understanding of one's own attitudes and values, and the origins of the patient's positive and negative feelings toward the clinician.
With borderline patients:
- Intense projective identification drives powerful countertransference reactions.
- Therapist may be pulled toward complementary countertransference roles (victimizer or victim).
Countertransference and Intersubjectivity
Contemporary understanding (Bion, Ogden, Stolorow, Mitchell, Kohut) holds that:
- The analyst's reveries, associations, and felt bodily/affective resonances during sessions provide knowledge about the patient's inner world.
- Daniel Stern's "interaffectivity" - the mutual sharing of affect states in the mother-infant pair - is seen as a forerunner of the analytic intersubjective process. The analyst's responsiveness mirrors the mother's responsiveness to the infant's affect states.
- Stolorow notes that when a child's affect states are not met with requisite responsiveness, they become vulnerable to self-fragmentation; the analyst's attuned responsiveness can repair this.
- The analyst must monitor their own projective identification reactions when working with patients who use this mechanism extensively, as the analyst may begin to experience emotions that "belong to" the patient's projected material.
III. CLINICAL APPLICATIONS
1. Therapeutic Alliance
Transference contributes to the real relationship and the working alliance in treatment. The positive transference, when not eroticized or resistive, is the engine that drives the therapeutic work.
2. Resistance Analysis
Negative and ambivalent transferences are major sources of resistance. The patient may fail to improve, act out, miss sessions, or devalue the therapist as a way of avoiding painful transference work. Interpreting the transference resistance is a central analytic task.
3. Transference Interpretation
The cornerstone of analytic technique:
- Therapist identifies and names the transference reaction occurring "here and now"
- Connects the present experience of the therapist to early object relationships ("then and there")
- Allows the patient to understand that their current relational patterns are continuations of past experiences
- Promotes insight, self-understanding, and new relational possibilities
4. Working Through the Transference Neurosis
In formal psychoanalysis, the development and resolution of the transference neurosis is considered the vehicle for deep structural change. The original infantile conflict is re-enacted and progressively interpreted until it loses its compulsive power.
5. Using Countertransference Productively
- Signal function: countertransference feelings alert the therapist to what is happening in the patient's unconscious
- Empathic tool: attuned countertransference responses deepen understanding of the patient's inner state
- Supervision and personal analysis are essential to distinguish personal neurotic reactions from induced countertransference
- The therapist must never act on countertransference (especially erotic or hostile feelings), which would constitute a boundary violation
6. Transference-Focused Psychotherapy (TFP)
A specific evidence-based treatment for borderline personality disorder (BPD) developed by Kernberg and colleagues:
- Uses the transference relationship as the primary vehicle for change
- Therapist sets clear limit-setting structure and interprets splitting, projective identification, and identity diffusion as they manifest in the transference
- Randomized controlled trials support its effectiveness in reducing suicidal behavior and improving personality functioning in BPD
7. Mentalization-Based Treatment (MBT)
Also developed for BPD, addresses how deficits in mentalizing (reflecting on one's own and others' mental states) are re-activated in the transference; also supported by RCT evidence.
8. Child and Adolescent Therapy
Transference in children and adolescents is more complex than with adults - the child has ongoing relationships with original objects (parents), creating overlap between transference and real relationships, requiring modified technique.
IV. PRACTICAL RECOGNITION CHECKLIST
Signs of Transference in a Patient:
- Sudden shift in affect toward the therapist
- Idealization or devaluation disproportionate to events
- Making assumptions about the therapist's inner state
- Testing limits or boundaries
- Disproportionate reactions to minor in-session cues
- Displacement of feelings clearly belonging to a past figure onto the therapist
Signs of Countertransference in the Therapist:
- Strong emotional reactions to specific patients (positive or negative)
- Dreading or over-anticipating sessions
- Rescue fantasies or overidentification
- Difficulty setting limits
- Boredom or distraction
- Erotic feelings or personal disclosure
- Acting to reassure or gratify rather than interpret
V. SUMMARY TABLE
| Feature | Transference | Countertransference |
|---|---|---|
| Origin | Patient's past relationships | Therapist's past + patient's induced reactions |
| Direction | Patient → Therapist | Therapist → Patient |
| Mechanism | Displacement, Projection, Projective ID | Projection, Identification, Resonance |
| Original view | Resistance and distortion | Obstacle/interference to be eliminated |
| Modern view | Vehicle for therapeutic change | Source of clinical data; to be monitored and utilized |
| Key theorist | Freud, Kohut, Kernberg | Heimann, Winnicott, Bion, Stolorow |
| Clinical use | Interpretation, working-through | Signal function, empathic attunement, supervision |
- Kaplan & Sadock's Synopsis of Psychiatry, pp. 2863-2864; 3277-3285
- Kaplan & Sadock's Comprehensive Textbook of Psychiatry, pp. 2827-2829; 8334-8340
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