Ethics of therapist-client interpersonal relationships

Countertransference and Professional Misconduct

The relationship between transference, countertransference and the APA's ethics code is one fraught with challenges and ambiguities. However, understanding the synergies and linkages involved is one of the key aspects to a successful therapist/client relationship.

By means of introduction, transference occurs while the patient does not know why he feels this way or why he does what he is doing. During transference, people convert into "biological time machines." (Conner, 1) A present action strikes a nerve and reminds a person of his past in a very tangible, forceful manner. The occurrence actually creates something of an "emotional time warp" that brings that past moment or memory quite realistically into the present for the person. The person reacts to a present situation while actually reacting to one from the past; he may treat a present-tense person one particular way owning to a past experience, when - in reality - he knows very little about the present-tense person.

In countertransference, the psychiatrist treating the patient actually becomes involved as well. The psychiatrist has her own emotional time warp with regard to her patient's descriptions, and rather than being able to perform a detached diagnosis and treatment, she falls into the trap of this counter-reaction. That is why, in fact, there are so many examples of therapists falling in love with their patients.

In the extreme, transference meltdowns are situations in which transference turns into a full-blown obsession if they go untreated. (Conner, 1) These meltdowns can result in accidents, violence, nightmares, stalking, fantasies and many other undesirable outcomes. Meltdowns are not common in therapy itself, but they can happen in a patient's personal life.

The American Psychological Association's Code of Ethics deals with transference and countertransference. It is a code which must be adhered to by all practicing therapists and students: "Membership in the APA commits members and student affiliates to comply with the standards of the APA Ethics Code and to the rules and procedures used to enforce them. Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct." (APA Code, 1)

Self-disclosure is another very important and related concept to transference and countertransference. According to Psychology Today: "Do you tend to open up to and confide in the people in your life, or do you keep tight-lipped? The inability to share ourselves with others can prevent us from reaching high levels of intimacy. If we bare our soul at the drop of the hat, however, we can put ourselves in a vulnerable position. Self-disclosure and communication skills overall are important components of any healthy relationship, whether with family, friends or in romance." (Psychology Today, 1)

These concepts must be tied together to develop a helpful understanding of countertransference and professional misconduct.

Transference

Transference is defined - broadly - as the patient's total emotional reaction to the analyst: reality and fantasy, rational and irrational, intersubjective and interpsychic.

The actual definition of transference is as follows: "The main characteristic (of transference) is the experience of feelings to a person which do not befit that person and which actually apply to another. Essentially, a person in the present is reacted to as though he were a person in the past. Transference is a repetition, a new edition of an old object relationship.... The person reacting with transference feelings is in the main unaware of the distortion." (Greenson, 151-152

But often, the metapsychology definition of transference is considered even more helpful: "Transference is reacting to a person in the present as though he or she were a person in one's past." (Bisbey, 1)

Freud originated the concept of transference and it is commonly used today in psychology and psychotherapy. Freud observed that some patients reacted to him as though he were a parent and that female patients often tended to "fall in love" with him. Freud pronounced that, during the therapy sessions, patients were unconsciously "transferring" the feelings and attitudes they held or had held toward early significant figures in their histories onto the analyst, in his cases, himself. At first, Freud simply observed the phenomenon but did not comment on it within the therapy sessions. Later, he arrived at the conclusion that addressing the transferential synergy between analyst and patient was in reality the curative factor in psychoanalysis, and turned interpreting the transference the cornerstone of the theory and practice of psychoanalysis.

Because today those in the profession use very structured techniques and strict rules in facilitation, transference may not seem to develop in or affect the facilitator/viewer relationship, but it still may do so. "From other facilitators and technical directors, and from personal observation, it has become clear to me that transference reactions in viewing are exceedingly common. I think it important, therefore, that we pay attention to transference and explore the area thoroughly. Moreover, we need a program to deal with transference when it arises in a viewer/facilitator relationship." (Bisbey, 2)

Most in the field can recall glaring examples of transference (in the sense of the metapsychology definition given above) which occur when a patient is triggered into an unresolved traumatic incident. For example, a husband and wife have an argument about the house. The wife has an unresolved traumatic incident in her history in which she was beaten by her father for forgetting her clothing on the floor. The husband begins to harp about her clothing and thus restimulates this particular past traumatic incident. The wife then curls up in a fetal position, crying: "Please don't hit me!" Here, it is eviden t that she is reacting to her husband as though he were her father.

Transference becomes a particularly critical issue if a therapist has a dual relationship with the. "Dual relationship" means any type of relationship other than a facilitator/viewer relationship. Because facilitators cannot always completely avoid social relationships with their viewers, and because we occasionally facilitate for friends and family members, it is likely we will have viewers who experience transference reactions towards us. Therefore, we need ways of recognizing and handling such reactions.

Transference reactions can also develop during the course of facilitation even when we don't have dual relationships with our clients. If a transference does develop, it can cause the viewer to have difficulties with other relationships: with other viewers, with our partners and colleagues, and with us, after facilitation has ended. A facilitator must recognize that feelings a viewer has toward him may well be partly transferential and therefore, even after the facilitator/viewer relationship has ended, the facilitator must realize that the relationship may still not be on an even footing." (Bisbey, 3)

Disclosure ties in closely with transference. Autonomy in disclosure represents that therapists should foster independence and self-reliance and that they should respect individuals' rights in their decisions on how to live their own lives.

Committee on Psychoanalytical Education commissioned a study co-chaired by Melvin Lansky and Gerald Melchiode. The study looked at the relationship between self-disclosure, autonomy and transference.

The study's group members began by agreeing that they wanted to begin with discussion among its members rather than reviewing literature or interviewing experts on autonomy and self-disclosure. As a result, the study constituted more a gathering together of experiences than empirical work. Literature reviews and discussion with experts might have a place after the group has clarified some of its basic questions and concepts. According to Lansky, "A lively discussion on anonymity and self-disclosure ensued. These concepts are in need of clarification, yet, despite conceptual confusion, it seems that most analysts have definite opinions on the topic. The very notions of anonymity and self-disclosure hint at standards that encourage anonymity and question self-disclosure. It is not entirely clear what is meant by self- disclosure or what constitutes data that would allow us to refine the concept and test our assumptions. Not all self- disclosures are made by conscious decision. Finally, self- disclosures made by the analyst should be appreciated as compromise formations. The context of self-disclosure is important: 1) Does one do so to acknowledge a patient's criticism which is well taken? 2) Does one do so when giving short notice for time away from the office? 3) Does one do so to correct patients' inaccurate perceptions?" (Lansky, 5)

Self-disclosures may be viewed as in the service of diminishing the analyst's shame or guilt. The participants at the committee themselves gave examples. Though it has been established that self-disclosure may provide a vehicle for the analyst's acting out, "it is clear that excessive anonymity or adherence to 'the rules' may also serve as acting out, resistances, or inhibitions on the part of analysts or analysts who adhere steadfastly to 'the rules' in ways that avoid analytic scrutiny. It is not necessarily technically neutral for the analyst to always keep the spotlight on the patient and never to answer questions." (Lansky, 6)

Such a technical regiment if adhered to rigidly constitutes a large risk of shaming the patient because of the sheer lack of synergy between the analytic situation with the patient always exposed and the analyst constantly avoiding exposure. The committee noted that therapists do not have well developed and agreed upon ideas of when self-disclosure hinders and when it facilitates analysis. Therapists should have a context for discussing self-disclosure that recognizes disparities in analytical models -- for example those stressing the reparative needs of certain patients for 'new objects' as opposed to those focusing solidly on exploration of the patient's internal existence. The group finally attacked the discussion of evidence against and for self-disclosure. "Group members were in agreement that evidence for the usefulness of self-disclosing techniques based on the patient's sense of well being and exhilaration for a session or so after the revelation did not constitute convincing evidence of the benefit of such techniques." (Lansky, 7)

The gender influence of transference is also an area rife with examples and explanations. As Kalb has noted, "Psychoanalytical endeavor reflects some degree of culturally exaggerated normative roles, including tendencies for women to be more nurturing and containing and for men to be more authoritative and interpretive. Gender is merely one element washing into the undulating currents of the highly complex transferential space. At times gender plays a central role and at other times recedes into the background, at times echoing sociocultural prototypes and at other times becoming more fluid. (Kalb, 2002).

In essence, gender roles play a not insignificant role especially in transference and countertransference: Obviously, a patient is less likely to fall in love with a therapist (and vice-versa) if the genders are not such as they are accustomed to. But as Kalb mentions, gender roles are often not central to transference as well.

Countertransferece

As mentioned earlier, countertransference is when the therapist, during the sessions of therapy, begins to develop positive or negative feelings toward the patient. This is actually quite normal during therapy. However, therapists must not and cannot act on such feelings. (Kardas, 1) To act on them is absolutely unethical. Sections 4.05 and 4.07 of APA's Ethical Principles of Psychologists and Code of Conduct state:

4.05 Sexual Intimacies With Current Patients or Clients.

Psychologists do not engage in sexual intimacies with current patients or clients.

4.07 Sexual Intimacies With Former Therapy Patients.

A a) Psychologists do not engage in sexual intimacies with a former therapy patient or client for at least two years after cessation or termination of professional services.

Both of the principles above are, of course, designed with countertransference in mind.

Turning to actual countertransference, one may think of it as an arcane topic; it is certainly an unwieldy word, one which invokes the most abstract of latter-day metapsychological conceptualizations. Indeed, it arose very early and was very immediate: That is precisely why Freud's first collaborator, Joseph Breuer, gave up. He ran away from Anna O. because she aroused him. If transference is in fact projection, countertransference is projective identification -- something elicited by the patient in the therapist: this is called evocative knowledge. For example, here, Anna O. elicited in Breuer a sexual excitement which he found unacceptable and was unbearable to himself and his wife, so he abandoned the work (Gay, 1988, pp. 63-9).

For Freud the transference went from being an annoying interference to an instrument of great value to the main battlefield of the analysis. An analogous story can be told about the countertransference, but it is a story with profound implications. Now, to define countertransference. Freud rarely discussed the topic; he saw countertransference as the patient's influence on the analyst's unconscious. He said that no analyst could go farther than he or she had progressed in his or her own analysis, so the analyst's analysis was all-important. He first mentions the concept in 1910: 'We have become aware of the "countertransference," which arises in [the analyst] as a result of the patient's influence on his unconscious feelings, and we are almost inclined to insist that he shall recognize this countertransference in himself and overcome it. Now that a considerable number of people are practicing psychoanalysis and exchanging their observations with one another, we have noticed that no psychoanalyst goes further than his own complexes and internal resistances permit; and we consequently require that he shall begin his activity with a self-analysis and continually carry it deeper while he is making his own observations on his patients. Anyone who fails to produce results in a self-analysis of this kind may at once give up any idea of being able to treat patients by analysis'" (Young, 8, quoting Freud, 1910, pp. 144-5).