See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/258312764

Transference, countertransference, and

reflective practice in cognitive therapy

Article in Clinical Psychologist · November 2011

DOI: 10.1111/j.1742-9552.2011.00030.x

CITATIONS READS

6 1,862

1 author:

Claire Cartwright
University of Auckland
47 PUBLICATIONS 277 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Training therapists to manage countertransference View project

Survey of antidepressant users in New Zealand View project

All content following this page was uploaded by Claire Cartwright on 17 January 2017.

The user has requested enhancement of the downloaded file.

Clinical Psychologist 15 (2011) 112–120
Transference, countertransference, and reflective practice in
cognitive therapy cp_30 112..120
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: c.cartwright@auckland.ac.nz
Received 23 March 2011; accepted 21 August
2011.
doi:10.1111/j.1742-9552.2011.00030.x
Key Points
1 The concepts of transference and countertransfer-
ence 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
Abstract
Background: The concepts of transference and countertransference devel-
oped 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, cog-
nitive analytic therapy, and schema perspectives. Two aspects of counter-
transference 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 psycho-
dynamic 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 super-
vision. It seems important that cognitive therapists do not dismiss these con-
cepts because of their origins but rather investigate the potential applications
of these concepts within cognitive frameworks.
The therapeutic relationship can be viewed as hav-
ing three components—the therapeutic alliance, the
transference–countertransference relationship, and the
real or personal relationship (Gelso & Hayes, 2007;
Horvath, 2000). The therapeutic relationship and espe-
cially the transference–countertransference relationship
are viewed as central to therapeutic outcomes in psycho-
dynamic psychotherapies (Gabbard, 2004). In cognitive
therapy, the therapeutic relationship is considered impor-
tant as a necessary underpinning to the effective imple-
mentation 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

Muran, 2000). However, there is less focus on transfer-
ence and countertransference, although there are excep-
tions 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 clini-
cal supervision. This, in turn, may assist in the manage-
ment of countertransference responses and thereby
protect the therapeutic relationship from what psycho-
dynamic therapists refer to as countertransference enact-
ments (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 (“subjec-
tive” 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 pro-
vided as an illustration of the application of these con-
cepts. It is important to note, however, that this article is
not suggesting that cognitive therapists adopt a psycho-
dynamic approach to treatment. Rather, it considers ways
in which these concepts can be understood from cogni-
tive 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 cog-
nitive 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 combin-
ing the keywords “cognitive therapy or cognitive behav-
ioral 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 rela-
tionship between therapeutic alliance and therapy out-
comes, and concluded that the alliance is moderately
related to therapy outcome (r = 0.22) regardless of
© 2011 The Australian Psychological Society
Transference and countertransference
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 consis-
tently, 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 cogni-
tive 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 alli-
ance significantly predicted subsequent improvement in
depressive symptoms after controlling for prior improve-
ment 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 thera-
peutic alliance, may provide the optimal treatment.
In order to ensure a good therapeutic alliance, thera-
pists 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 thera-
pists may benefit by using the concepts of transference
and countertransference in the process of reflective prac-
tice in self-supervision and clinical supervision. In order
for this to be meaningful, however, it seems important to
be able to conceptualise countertransference using cog-
nitive 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 situ-
ations; however, the term is generally used to denote
clients’ reactions to therapists. Greenson’s (1965) defini-
tion is often used by psychodynamic theorists (Andersen
& Baum, 1994). This definition refers to transference as
113
Cartwright
“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 dis-
placement 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 behav-
ioural activation (Leahy, 2008).
Andersen and colleagues (Andersen & Berk, 1998;
Miranda & Andersen, 2007) have investigated and
demonstrated the existence of transference in non-
therapeutic 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 repre-
sentations 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 motiva-
tional elements. Andersen and Berk argue that transfer-
ence 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. Indivi-
duals play roles and in so doing seek out or elicit reci-
procating responses from others. These reciprocating
procedures are learnt early in life through communica-
tions 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 “reper-
toire 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 adoles-
cence (Levy, 2005). These mental representations shape
expectations and behaviour within interpersonal rela-
tions (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 gener-
ally do not use the term transference or discuss transfer-
ence 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 per-
spective, 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 dis-
cusses 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 repeti-
tious 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

these manifest within therapy. Despite noting the impor-
tance of these processes, however, the reference to them
is brief.
Finally, transference could also be considered using
Judith Beck’s (1995) cognitive conceptualisation frame-
work. 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 representa-
tions of self and other, and working models of relation-
ships, as well as relationship schema. A particular
viewpoint emphasised more strongly by psychodynamic
theorists, and more recently in the social cognitive per-
spective, is the pairing of particular self and other repre-
sentations 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 dis-
cussed earlier have a number of aspects in common.
These include the importance of the learning that occurs
during formative experiences, which leads to the devel-
opment 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, cog-
nitive, 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 cog-
nitive 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 counter-
transference that have been termed “subjective” and
“objective.” Within cognitive therapy, as will be seen,
there is acceptance of the notion of subjective counter-
transference but no focus on what has been termed objec-
tive 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
Transference and countertransference
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 “coun-
tertransference” 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 conceptuali-
sation 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 countertransfer-
ence. 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 per-
sonality or extreme behaviour. According to this view, a
client’s maladaptive way of relating to the therapist pro-
vokes responses in the therapist that are similar to the
responses of others in the client’s life. Hence, counter-
transference 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). Accord-
ing 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 counter-
transference. 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 counter-
transference emphasise an intersubjective perspective in
which countertransference is seen as “jointly created” by
the client and the therapist (Gabbard, 2001, p. 984).
115
Cartwright
While the terms subjective and objective countertrans-
ference may be redundant in a totalistic definition of
countertransference, it seems important to have syste-
matic ways of thinking about both aspects, even if in
reality the two are intertwined (Gabbard, 1997; Shafran-
ske & 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 counter-
transference, it is important to briefly consider the evi-
dence 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 self-
criticism (Swann, 1997).
There have also been a number of clinical studies that
have examined countertransference responses to differ-
ent 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 protec-
tiveness towards clients with suicidal depression. Simi-
larly, 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, sex-
ualised, 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 Psy-
chiatric 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 prob-
lems, 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 repeti-
tive interpersonal patterns, thereby supporting the notion
that countertransference is potentially a valuable source
of information about the client.
However, as stated previously, when cognitive thera-
pists 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 sub-
jective 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 emo-
tions as distracting or self-indulgent may communicate
negative attitudes towards clients’ emotions and emo-
tional expression. Therapists who respond from their
own emotional philosophies may inadvertently model
emotional avoidance, which in turn reinforces the cli-
ent’s own emotional schemas, such as “My feelings are
not important and they overwhelm others.”
© 2011 The Australian Psychological Society

While cognitive therapists do not discuss objective
aspects of countertransference, this notion has been con-
sidered useful by some psychodynamic therapists and
may benefit cognitive therapists in the process of reflect-
ing 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 strug-
gling 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 person-
alities” and “looked out for her” throughout her child-
hood 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
Transference and countertransference
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 inad-
equate 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 rela-
tionships 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!” Fortu-
nately, the therapist once again recognised this as a coun-
tertransference response and did not act out on the urge.
Objective Countertransference
The therapist’s responses to the client (initially support-
ive 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 uncondi-
tional 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
Cartwright
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 enact-
ment of countertransference responses can have negative
consequences for the therapy and the therapeutic rela-
tionship. 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 with-
draws 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 over-
whelming 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 relation-
ship 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 comple-
mentary to cognitive therapy. This article has argued
that understanding transference and countertransference
from within cognitive frameworks may enhance reflec-
tive practice in self-supervision and clinical supervision.
While some attention has been given to subjective coun-
tertransference by cognitive therapists (e.g., Bennett-
Levy & Thwaites, 2007; Haarhoff, 2006; Leahy, 2007),
objective aspects of countertransference are not dis-
cussed. 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 asso-
ciation with psychodynamic therapies, but rather inves-
tigate 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

In R. Levy & S. Ablon (Eds.), Handbook of evidence-based
psychodynamic psychotherapy (pp. 179–198). New York:
Humana Press.
Bowlby, J. (1988). A secure base: Parent-child attachment
and healthy human development. New York: Basic
Books.
Brody, F., & Farber, B. (1996). The effects of therapist
experience and patient diagnosis on countertransference.
Psychotherapy (Chicago, Ill.), 33, 372–380.
Brumbaugh, C., & Fraley, B. (2006). Transference and
attachment: How do attachment patterns get carried
forward from one relationship to the next? Personality and
Social Psychology Bulletin, 32, 552–560.
Colson, D., Allen, J., Coyne, L., Dexter, N., Jehl, N., &
Mayer, C. (1986). An anatomy of countertransference:
Staff reactions to difficult psychiatric patients. Hospital
Community Psychiatry, 37, 923–928.
DeRubeis, R., Brotman, M. A., & Gibbons, C. (2005). A
conceptual and methodological analysis of the
nonspecifics argument. Clinical Psychology: Science and
Practice, 12, 174–183.
Downey, G., Freitas, A., Michaelis, B., & Khouri, H.
(1998). The self-fulfilling prophecy in close relationships:
Rejection sensitivity and rejection by romantic
partners. Journal of Personal and Social Psychology, 75,
545–560.
Gabbard, G. (1997). A reconsideration of objectivity in the
analyst. The International Journal of Psychoanalysis, 78,
15–26.
Gabbard, G. (2001). A contemporary psychoanalytic model
of countertransference. Journal of Clinical Psychology, 57,
983–991.
Gabbard, G. (2004). Long-term psychodynamic psychotherapy: A
basic text. Arlington, VA: American Psychiatric Association.
Geisler, R., Josephs, R., & Swann, W. (1996).
Self-verification in clinical depression: The desire for
negative evaluation. Journal of Abnormal Psychology, 105,
358–368.
Gelso, C., & Hayes, J. (2007). Countertransference and the
therapist’s inner experience: Perils and possibilities. Mahwah,
NJ: Lawrence Erlbaum.
Geltner, P. (2006). The concept of objective
countertransference and its role in a two-person
psychology. The American Journal of Psychoanalysis, 66,
25–65.
Gilbert, P., & Leahy, R. (Eds.). (2007). The therapeutic
relationship in the cognitive behavioral psychotherapies.
London: Routledge.
Greenson, R. (1965). The working alliance and the
transference neurosis. The Psychoanalytic Quarterly, 34,
155–181.
Haarhoff, B. (2006). The importance of identifying and
understanding therapist schema in cognitive therapy
training and supervision. New Zealand Journal of
Psychology, 35, 126–131.
© 2011 The Australian Psychological Society
Transference and countertransference
Hafkenscheid, A. (2003). Objective countertransference:
Do patients’ interpersonal impacts generalize across
therapists? Clinical Psychology & Psychotherapy, 10,
31–40.
Hayes, J. A. (2004). The inner world of the psychotherapist:
A program of research on countertransference.
Psychotherapy Research, 14, 21–36.
Heimann, P. (1950). On counter-transference. The
International Journal of Psychoanalysis, 31, 81–84.
Horvath, A. O. (2000). The therapeutic relationship: From
transference to alliance. Journal of Clinical Psychology, 56,
163–173.
Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D.,
Vocisano, C., Castonguay, L. G. et al. (2003). Therapeutic
alliance in depression treatment: Controlling for prior
change and patient characteristics. Journal of Consulting
and Clinical Psychology, 71, 997–1006.
Leahy, R. (2007). Schematic mismatch in the therapeutic
relationship: A social cognitive model. In P. Gilbert &
R. Leahy (Eds.), The therapeutic relationship in the cognitive
behavioral psychotherapies (pp. 229–254). London:
Routledge.
Leahy, R. (2008). The therapeutic relationship in
cognitive-behavioral therapy. Behavioral and Cognitive
Psychotherapy, 36, 769–777.
Levy, K. (2005). The implications of attachment theory
and research for understanding borderline personality
disorder. Development and Psychopathology, 17, 959–
986.
Martin, D., Garske, J., & Davis, K. (2000). Relation of the
therapeutic alliance with outcome and other variables:
A meta-analytic review. Journal of Consulting and Clinical
Psychology, 68, 438–450.
Miranda, R., & Andersen, S. (2007). The therapeutic
relationship: Implications for cognition and transference.
In P. Gilbert & R. Leahy (Eds.), The therapeutic relationship
in the cognitive behavioral psychotherapies (pp. 63–69).
London: Routledge.
Norcross, J. C. (2001). Introduction: In search of the
meaning and utility of countertransference. Journal of
Clinical Psychology, 57, 981–982.
Orlinsky, D., Ronnestad, M., & Willutzski, U. (2004). Fifty
years of psychotherapy process-outcome research:
Continuity and change. In M. Lambert (Ed.), Bergin and
Garfield’s handbook of psychotherapy and behavior change
(pp. 307–390). New York: Wiley.
Ryle, A. (1998). Transferences and countertransferences:
Cognitive analytic therapy perspective. British Journal of
Psychotherapy, 14, 303–309.
Safran, J., & Muran, J. (2000). Negotiating the therapeutic
alliance: A relational treatment guide. New York: Guilford
Press.
Schore, J., & Schore, A. (2008). Modern attachment theory:
The central role of affect regulation in development and
treatment. Clinical Social Work Journal, 36, 9–20.
119
 Cartwright
Shafranske, E., & Falender, C. (2008). Supervision
addressing personal factors and countertransference. In
C. Falender & E. Shafranske (Eds.), Casebook for clinical
supervision: A competency-based approach (pp. 97–120).
New York: American Psychological Association.
Storr, A. (1989). Freud. New York: Oxford University Press.
Swann, W. (1997). The trouble with change: Self-verification
and allegiance to the self. Psychological Science, 8,
177–180.
120
View publication stats
Wampold, B. (2010). The research evidence in common
factor models: A historically situated perspective. In
B. Duncan, S. Miller, B. Wampold, & M. Hubble (Eds.),
The heart and soul of change: Delivering what works in therapy
(pp. 49–83). Washington, DC: American Psychological
Association.
Winnicott, D. (1949). Hate in the countertransference.
The International Journal of Psychoanalysis, 30,
69–75.
© 2011 The Australian Psychological Society