1 article(s) will be saved. To save, please use your browser's save option. Be sure to save as a plain text file (.txt) or an HTML file. Record: 27 Title: Transference-countertransference issues with adolescents: Personal reflections. Subject(s): TRANSFERENCE (Psychology); COUNTERTRANSFERENCE (Psychology); ADOLESCENT psychotherapy Source: American Journal of Psychotherapy, Winter94, Vol. 48 Issue 1, p64, 11p Author(s): Sarles, Richard M. Abstract: Presents personal reflections on transference-countertransference issues with adolescents. Presentation of two cases; Transference and countertransference as a result of all and everything in the therapist and patient as a part of the therapeutic relationship; Induction of the stimuli by the therapist and the patient. AN: 9410250987 ISSN: 0002-9564 Note: This title is not held locally Full Text Word Count: 4595 Database: Academic Search Premier TRANSFERENCE-COUNTERTRANSFERENCE ISSUES WITH ADOLESCENTS: PERSONAL REFLECTIONS The theoretical concept of transference-countertransference in the psychotherapeutic work with adolescents is approached from a more global, inclusive interactive view developed by tracing various modifications of Freud's original theory by Jung, Fromm-Reichmann, Klein and Sullivan, among others. The two case vignettes highlight the author's position that the transference-countertransference phenomenon is the result of all and everything in the therapist and patient as part of the therapeutic relationship induced by external stimuli by the patient or from the therapist (and vice versa) as well as internal stimuli from the patient or by the therapist (and vice versa). INTRODUCTION Psychotherapeutic work with adolescents is usually fascinating and often frustrating, always creative and frequently confusing. There is no doubt that many adolescents require psychotherapeutic interventions due to developmental stress or due to emotional turmoil of illness. There is some question as to why certain professionals seem drawn to patients of this particular age, however. Equally perplexing and troubling is why and how most adolescent patients get well and grow with psychotherapy and yet many do not. What happens and what does not happen remains a mystery in spite of erudite theories by brilliant scholars and clinicians. The phenomenon of transference countertransference is one theory that attempts to address some of these questions. Using clinical examples coupled with a historical overview of various theorists' view of the transference-countertransference phenomenon, a more inclusive, global, interactive view of this phenomenon will be presented. Case 1 Cheryl, an almost 16-year-old girl, was hospitalized on the adolescent medicine ward because of severe weight loss unresponsive to pediatric interventions in her home town. History, physical and laboratory data all led to a clear diagnosis of Anorexia Nervosa. Cheryl was seen just prior to her discharge from the adolescent medicine unit in order to establish contact for twice-weekly outpatient psychiatric treatment. The first hospital meeting in October went well as did a second visit. On Cheryl's fifth visit she asked my opinion of her parents. When asked what she thought, she said I probably found them to be bright, attractive, nice people; I responded that on first meeting I would probably agree with her thoughts. Cheryl did not talk with me again in her twice-a-week therapy from Thanksgiving to Easter. She always showed up on time in my office even though she came alone after she got her driver's license, and the drive was a three-hour round trip to my office. Cheryl's weight also never dropped below her medical limit. I learned from the social worker who was seeing ethe parents that Cheryl continued to do well academically. She developed several new close friendships, had a part-time job at a fast-food store, and her spirits and behavior at home were fine. I was very pleased to learn this because I felt frustrated, weary, puzzled, angry, disappointed, and stumped. All my attempts of interpreting and penetrating her silence seemed to be in vain. I wondered if she felt I had sided with her parents. I asked her could her anger at me be a way of relieving her anger at her parents. I wondered if I had said something stupid. Cheryl remained silent. I wished Cheryl and her parents would stop driving all the way to receive therapy. Why not let me refer them to a therapist closer to their home, I thought. Silence with an adult patient generally stimulates anxiety which, in turn, often leads to verbal production. Silence with an adolescent or child patient generally stimulates anxiety which usually stimulates greater silence. Also, therapists working with adolescents need to be active and involved so I started reading to Cheryl. I read books on repair of Volkswagens as Cheryl's parents had bought her a used "Beetle." I read books on horsemanship, Time and National Geographic, and even Hilda Bruch's The Golden Cage. One day Cheryl stood up hitting the arm of the chair, "Okay, that's it!" Great, I thought. She's talking. Now we begin. But Cheryl left the office with me in pursuit and she never returned. The parents remained in therapy for the remainder of the school year and we elected to allow Cheryl to manage on her own. Her weight never dropped, she graduated high school and she sent me a graduation announcement. About seven years after Cheryl abruptly terminated "therapy," I was awaiting the arrival of an adolescent male patient with my office door partially opened. Out of the corner of my eye I saw a very attractive young woman pass by. Shortly, my secretary came in to inform me that my patient had arrived. Send him in I said. "It's a her," said my secretary. "She said she was an old patient who just stopped by and her name is Cheryl." Surprised and delighted, I greeted her warmly, informing her that I had another scheduled appointment but we could talk until the appointment arrived. This was one of those times when I was absolutely delighted that my adolescent male patient did not keep his appointment. Cheryl talked continuously. She laughed, she recalled everything, so it seemed, of our many months of "therapy." Cheryl said "I really tried to get to you, and sometimes I did, I know I did." "Yes, you did at times," I acknowledged. "But you always let me come back." "Why did you come back?" I asked. "I don't know," she said. "Maybe because it gave some control to my life. My weight stayed in control without severe anorexia and my parents were in control because of their own therapy and my therapy." I added that I controlled the appointments and she controlled me and the therapy by her silence. Cheryl said, "You gave me a chance to look at my family, at myself, at my friends, or lack of friends then. You could have gotten very angry, but you didn't. You were tolerant." What happened in the transference-countertransference? Did I provide the "holding environment?" Did the empathetic therapeutic structure give Cheryl the time and space to egrow? I never demanded things of her. I did help Cheryl toward her independence by reading the Volkswagen repair manual. I fed and nourished her without her needing to put on weight. What happened on the last day, I asked Cheryl. Why did she get angry? Why did she leave and return seven years later? Interestingly, Cheryl could not recall any real issues that last day. Nothing different was happening in therapy, I had not said or done anything "stupid." Did she sense my frustration, I asked. "Sure, but it was no different or greater than usual." Did Cheryl think I was going to run out of things to read? Did Cheryl take control and determine that "our therapy" was over? Did Cheryl terminate because I would not or could not? Did Cheryl resolve or work through her transference? Did my countertransference help her resolve her conflicts and developmental problems? Transference-countertransference exists within the therapeutic alliance and accounts for, at least in theory, (1) the working, or (2) nonworking, relationship of the patient and therapist in the therapeutic alliance, and in theory, the resistance encountered in this working, or nonworking, relationship. Transference is a concept, a theory, developed by Freud to help him understand certain aspects of the psychoanalytic dyadic relationship. Freud believed that the patient "transferred onto the analyst feelings and thoughts resulting from a reactivation of previous psychological experiences, usually a recapitulation of early unconscious libidinal impulses." The interpretation and the working through of these transferences was thought to be the sine qua non of analytic treatment. Countertransference is a concept which describes the unconscious reaction of the therapist to the patient's transference. Let us look at definitions for other terms important to the therapeutic work with adolescents: therapeutic, alliance, and contract. Therapeutic: from the Greek, therapeusis meaning treatment of, or related to the treatment of diseases or disorders by remedial agents or methods, (psychodynamic, psychotherapy, cognitive, behavioral, pharmacological, analytic, etc.). Alliance: the state of being allied, having or being in close relationship, a bond or connection, an association to further the common interests of its members, a union by relationship in qualities. Contract: from the Latin, contractor meaning to agree upon, to establish an understanding by contract, to acquire involuntarily (pneumonia), to bring upon one's self, to reduce in size, to shorten, to shrink.[1] Transference-countertransference is a concept critical to the psychotherapeutic work with patients. However, it is not that I do not find this concept helpful in my everyday work with patients or in the training of general psychiatry residents and child and adolescent psychiatry fellows, and not that I do not believe in the existence and occurrence of transference-countertransference. Like my intuitive belief in the unconscious, I cannot prove transference-countertransference any more than I can prove the unconscious. Therefore, I wonder and struggle with these clinically useful theories. Throughout the history of mankind, curious people have developed theories to explain things they could not understand; theories of the heavens, sun, moon, stars, gravity, electricity, relativity, time, the body, the brain, the mind. Freud developed his psychoanalytic theory to help him understand difficult, perplexing patients. Theories, by definition, should be subject to constant scrutiny and revision. Theories that are not revised in light of current knowledge and understanding become rigid, stultified belief systems. It is not surprising, and very encouraging, to note that curious followers, disciples, and critics of Freud have refined and revised and sometimes refuted his concept of transference-countertransference. Carl Jung felt that the "wealth of the meaning of transference went far beyond what Freud theorized and that by virtue of the collective content and symbols, transference transcends the individual's personality and extends into the social sphere."[2] Thus, Jung acknowledged the sociocultural aspects of transference. Frieda Fromm-Reichmann questioned the universality of Freud's oedipal complex and therefore she did not consider the therapist/patient relationship to be based on a recapitulation of oedipal issues. Rather, FrommReichmann said, "Transference in the therapeutic process means transferring onto the therapist as a present-day partner, early experiences of interpersonal relatedness."[3] Harry Stack Sullivan emphasized the reciprocal dynamic transaction between the therapist and the patient, which was often a manifestation of parataxic distortions and could be understood on the basis of past experiences.[4] Sullivan believed that in any therapeutic situation "two more or less simply human than otherwise persons come together to deal with the issues of one." A further refinement of a definition of a therapeutic situation is that the therapist and patient come together to engage in a cojoint field of inquiry which is defined and colored by the two-person nature of the situation. The assets and liabilities both contribute to whatever the therapy is to become and what it is not to become. Thus, the essence of the therapeutic encounter, shifts in some theories, to be less exclusively dependent on the transference neurosis as a recapitulation of unconscious oedipal issues than on the coparticipation and cooperation of the therapist and patient in a reciprocal relationship. There is also a shift toward a more totalistic view of transference-countertransference which comprises the total emotional reaction of the therapist and patient including past and present experiences and important other figures (parents, teachers, peers, girlfriends/boyfriends, spouses, boss), and important events (marriage, death of a friend/parent college applications, acceptances, rejections, financial problems and decisions, denials, dictation, divorce, utilization review, managed care, new job, etc.). All and everything in the therapist and patient are part of the therapeutic relationship induced by external stimuli by the patient or from the therapist (and vice versa) as well as internal stimuli from the patient or by the therapist (and vice versa). Melanie Klein wrote that "no new relationship exists without traces of the past."[5] As human beings, developing and aging, we are modifying and being modified by the very process of living. Life is a series of experiences from which memory results. It is doubtful, however, that memories, as experiences of life, can maintain the purity of the moment. Memory is subjected to individual interpretation so that the reactivation of memory is never in its exact original form. Thus, in our psychotherapeutic work with patients the transferential aspects are subject to screen memories and distortions. Even when the parents are available, or other reliable sources of information help to clarify and understand some aspects of the transference, these resources often contain areas of inaccuracy or omission due to the distortions of memories of the event as it actually occurred. Accuracy is important, if available, but it is not as important as the working through the information and material and the affect this generates in the therapeutic relationship. The relationship, the therapeutic alliance, coupled with a sound theoretical approach is the basis of the "cure" or the ability of the child and adolescent to grow healthier and change. In the mid-1970s, 130 types of psychotherapy were identified, and in the mid- 1980's the number had expanded to 450. A comparison-outcome study of many of these types of psychotherapy revealed that psychotherapy works better than no therapy at all. However, nonspecific factors such as a good relationship between therapist and patient were far more crucial than either the theoretical orientation or the technical innovation, i.e., the kind of patient and therapist fit, not the kind of treatment was the best predictor of a favorable outcome.[6] Jerome Frank once conceptualized therapy as when " a person (client/ patient) having trouble visits a wise authority who has been delegated with special powers, the client/patient problems are explained by the authority within the context of an ideology accepted by both and a healing ceremony leads to relief."[7] Anna Freud said that treating adolescents was "a hazardous venture from beginning to end,"[8] and Donald Holmes wrote it is "an experience which constantly reminds one that there are many easier forms of livelihood."[9] Why is this? Certainly working with children and adolescents tends to reactivate in the therapists, or any adults, growing-up struggles, particularly with respect to the expression of sexual and aggressive impulses. E. James Anthony said that there is "at once a rekindling of old experiences or desires, or of lost opportunities, and envy of youth. The child and adolescent is on his way up while the caretaking adult is on his way down."[10] Little wonder George Bernard Shaw felt that it was a shame that youth is wasted on the young. In psychotherapy with children and adolescents two crises or reactions may be occurring concomitantly. The crisis of being a child or adolecent for the patient and a reactivated crisis for the parents complicated by addition of a therapist, the school, the court, and others. We must constantly ask how and why do children and adolescents get better with psychotherapy. Is it all transference-countertransference? Probaby not entirely, but it certainly is a good theory to help explain what happens between two people. Is it insight gained through working through transference-countertransference issues? Probably only partially. Insights never cured anyone. It is only when insights are put to practical use for growth and change that they are helpful and useful. The term, "the corrective emotional experience," but not necessarily the concept as popularized by Alexander best describes, I think, what goes on in a successful therapy. It describes the therapeutic alliance, the resistances in therapy, and all the things that are involved in the phenomena of transference-countertransference. The corrective emotional experience results from clarifying the transference distortions, both positive and negative, and dealing with countertransference issues. Transference-countertransference issues may be seen in several contexts of therapy, in the formation of the alliance, in dealing with resistance, and in every encounter with a child and adolescent patient. These transference-countertransference issues include the full spectrum of emotions and reactions: eager anticipation, dreaded waiting, envy, joy, anger, love, and even hate as described by Winnicott in "Hate in the Countertransference,"[11] pity, concern, and others. Therapists "sweat out" things with their patients, the upcoming date, the report card, a parent's visit or missed visit, foster home placement, SAT's, DUI's, college acceptance or rejection, and parental discord or divorce. Therapists work with the silent adolescent, the angry adolescent, the adolescent who wears ear muffs to, and through, therapy, the adolescent who picks apart a pair of smelly, rotting sneakers dropping the debris on your rug, the adolescent who cancels therapy to watch an "important" episode of an afternoon television soap, the adolescent who comments on "people with 10USV decorating taste" as they look around the therapist's office, and the adolescent who tells the therapist that they would not have been able to work with the therapist even if he/she were young and good looking! The therapist needs to deal with and use, at times, the idealizing transference as it fosters and cements the early therapeutic alliance, when the adolescent comments that "you are the best in town, even some of my friends say so," and then the adolescent begins to take interest in the therapist's political views, musical tastes or vacation plans. Therapists also need to deal with the adolescent who sarcastically asks if you sleep and swim in a coat and tie, or the young adolescent who seems quite surprised and shocked that you charge a fee that the parents pay. "Does my father pay for this?" a patient asked. Yes, I replied. "How much," he said. How much would you think? "A buck." "Actually more than that", I said. "Two bucks?" More. "Ten bucks?" Even more. "Wow, what a rip off!" The ability of the therapist to deal with these transference-countertransference issues in a manner other than that of other important people in their lives, for example, parents or teachers, is the therapeutic challenge. How to survive one's own countertransference feelings and reactions is the therapeutic challenge. Psychotherapists need to attend to the playfulness of therapy in a tactful, concerned, listening fashion. They need to attend to the transference-countertransference issues. This is where the art and skill based on training, a sound theoretical foundation, experience, and intuition are crucial. Timing is everything in life and in therapy. It includes: (1) when to comment, when to be silent, and at what level and dosage; (2) how to comment in an empathetic, tactful fashion, how to convey understanding, how to use humor; and (3) how to fill the vacuum as the patient leaves the parents y et still needs an adult. The therapist must attend to the playfulness of therapy and the tactfulness of therapy and to pay special attention to the very delicate balance of responding to the need to help the adolescent patient grow, but not push too much. The therapist should have a gleam or a twinkle in his eye for the patient and serve and act as a parent but not the parent. It is difficult to treat a patient you do not like, a patient for whom you do not have a gleam in the eve. Gleam is defined as "a flash of beam of light; the gleam of a lantern in the dark; a dark or subdued light; a brief or slight manifestation or occurrence; trace; a gleam of hope;" to appear suddenly and clearly like a flash of light."[1] The gleam in the eye" is especially important in the arduous, often hazardous, psychotherapeutic work with adolescents. The gleam in the eye serves as a metaphor for the developing adolescent with the curiosity, creativity, self-determination, and rebelliousness characteristics of this age group. The gleam in the therapist's eye should reflect back the adolescent's gleam of curiosity and creativity, but should also reflect the therapists creative involvement in the therapeutic process. The gleam in the therapist's eye is an affirmation that the therapist sees something good in the patient. It is a gleam of hope, of affection and pleasure. The gleam reflects a certain playfulness, a certain working together, a certain sense of joy and satisfaction within the therapist. Case 2 Bruce, a fourteen-year-old boy with Attention Deficit Hyperactivity Disorder and Learning Disabilities, was slightly oppositional and passive-aggressive. He was an electronic and computer wizard and a weapons expert. Yet, Bruce's grades were never good and were falling even further. He was referred for psychotherapy because of school suspension for bringing knives, pistols, live cartridges, Bowie knives, ninja knives, and other weapons to school. Bruce was cold, distant, and suspicious. It was hard to get to know him. He kept people at distance. It was hard to like him. Bruce's father was a highly successful computer expert and had served in the military as a munitions specialist. Bruce's mother was a school teacher. Bruce subscribed to several gun and weapon magazines. He had played computer games with his father, but his father "lost interest" as Bruce became more and more proficient. Bruce was also sneaking out of the home late at night to "hang out" at an all-night convenience store, but he had no real friends. To prevent Bruce from going out at night, his father had "booby trapped" the house with touch-sensitive carpet pads, infrared beams, and hair-wire trigger alarms on doors and windows. But Bruce learned to find these traps and "safe wire" them so as not to be detected. It was clear that Bruce and his father were at war. I knew Bruce was going to war with me. In the office Bruce was quiet and suspicious, not very giving. "Are you worried about electronic devices in the office?" I asked. Bruce and I spent most of our appointments down by the stream, by the ponds or in the woods at the edge of the hospital property. We mostly played was, building dams and destroying them with bombs, or long-distance shelling. One cold, damp, mixed rain-snowy day, typical of our in mid-February weather, we were down by the stream, but since the ground was muddy, wet, and slippery I remained up on the stone bridge while Bruce did his work down below. Bruce and I did "yelling" therapy that day, yelling directions for bombing, yelling clarifying comments, yelling therapeutic comments. We were yelling about war and how resistance fighters, often the underdogs," the "weaker," the "invaded," had to blow up dams and bridges to stop the more powerful enemy, often at great danger and cost to the resistance forces. While I was thus occupied, standing hunched up with my collar turned up, and my gloved hands stuffed in my pockets, the hospital security police emerged from their car and asked me to come down off the stone bridge wall and to identify myself. It seems that several passing motorists had seen me perched on the bridge and assumed, or feared, that I was a patient about ready to jump to harm myself. Bruce hid at first, fearful, or cautious like a good resistance fighter. Then he came up to my rescue, without explosives, guns, knives, or rocks. Bruce told the security officer that I was his doctor, his friend, that I was okay. As Bruce and I walked back to my office he told me that I was his only friend and that I had helped him feel good about himself and to better understand his father and what his father was and was not and what his father could give and do and what he could not give and do. We stopped going to the stream shortly after that incident. Bruce began to bring in computer games to play on my personal computer. He was really good! He always beat me handily and soundly, often acknowledging in a teasing fashion that I really didn't know much about computers at all. He was correct, but then Bruce began to "teach" me his secrets, shortcuts, and strategies. One day, while walking down the hall to get a soda, Bruce stopped and looked over my head, informing me that he was now taller than me. "You certainly are," I acknowledged, "and you have grown in many ways. You have got to feel very good about that." Bruce is doing much better, so is his father. No more booby traps, no more war. Bruce has a job, trying to save money for a car. Still somewhat socially awkward, Bruce thinks he will go to college, maybe a military school and he thinks he would like to join the military some day. Bruce and I still occasionally share a twinkle, a gleam, of our eyes when we recall the cold, wet day at the bridge. What happened with Bruce? Why did Bruce "grow" with therapy? I did not compete with him. In some ways I could not. We were allies, not at war. Bruce taught me about weapons and computers. Adolescents feel good when they can "teach" an adult. Bruce rescued me from the security police, like I rescued him from his war. Transference-countertransference is a very important theoretical construct and critical for therapists to understand and utilize when working with adolescents. I hope these ideas will be helpful to you, the reader, in your work with those wonderful, full-of-wonder, frustrating, fascinating, hazardous, humorous, playful, punishing, seductive, sarcastic, sensitive, creative, confusing patients during their adolescent phase of development. And don't forget the gleam. May the gleam be with you! SUMMARY The concept of transference-countertransference is an important theoretical construct and critical for therpists to understand and utilize when working psychotherapeutically with adolescents. Freud introduced the concept, hypothesizing that the patient "transferred onto the analyst feelings and thoughts resulting from a reactivation of previous psychological experiences, usually a recapitulation of early unconscious libidinal impulses." Jung included sociocultural aspects by stating that "by virtues of the collective content and symbols, transference transcends the individual's personality and extends into the social sphere." Fromm-Reichmann viewed transference as "transferring onto the therapist as a present-day partner, early experiences of interpersonal relatedness," and Sullivan believed that in any therapeutic interaction "two . . . persons come to deal with the issues of one." It is my position that transference-countertransference is a phenomenon that exists in every encounter with a child and adolescent patient and includes the full spectrum of emotions and reactions--eager anticipation, dreaded waiting, envy, joy, anger, love, and hate. Working with and through this phenomenon creates a corrective emotional experience for the patient and the opportunity for him or her to mature in a more normative healthy fashion. [*] Director, Division of Child and Adolescent Psychiatry; Professor of Psychiatry and Pediatrics, Universitv of Maryland School of Medicine, Baltimore. Mailing address: 115 Forest Drive, Baltimore Maryland 21228-5119. REFERENCES [1.] Webster's New Collegiate Dictionary, Standard Edition (1979). G&C Merrian Co., Springfield, MA. [2.] Jung, C. (1954). The Practice of psychology: Essays on the psychology of transference and other subjects. New York: Pantheon Books. [3.] Fromm-Reichmann, F. (1959). Personality of the psychotherapist and the doctor-patient relationship. In D. Bullard (Ed.) Psychoanalysis and psychotheraphy: Selected papers. Chicago: University of Chicago Press. [4.] Sullivan, H.S. (1953). The interpersonal theory of psychiatry New York: W.W. Norton & Co. [5.] Klein, M. (1948). Contributions to psychoanalysis. London; Hogarth Press. [6.] Luborsky, L, Singer, B., and Luborsky, L. (1975). Comparative studies of psychotherapies. Archives of General Psychiatry, 32, 995-1008. [7.] Frank, J.D. (1971): Therapeutic factors in psychotherapy. American Journal of Psychotherapy, 25, 350-361. [8.] Freud, A. (1958): Adolescence Psychoanalytic Study of the Child, 1, 255-278, 261 . [9.] Holmes, D.J. (1964). The Adolescent in psychotherapy. Boston: Little Brown, p. 298. [10.] Anthony, E.J. (1969). The reactions of adults to adolescents and their behavior. In G. Kaplan & S. Lebovici (Eds.), Adolescence: Psychosocial perspective. New York: Basic Books, pp. 54-78. [11.] Winnicott, D.W. (1949). Countertransference. International Journal of Psychoanalysis, 30, 69-74. ~~~~~~~~ By RICHARD M. SARLES, M.D.[*] Copyright of American Journal of Psychotherapy is the property of Association for the Advancement of Psychotherapy and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.Source: American Journal of Psychotherapy, Winter94, Vol. 48 Issue 1, p64, 11p.Item Number: 9410250987