Transference in cbt

Transference in cognitive behavioral

therapyCol. Dr. Ehab Elbaz

Psychiatry and addiction treatment hospitalMaadi military medical complex

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Case vignette•Mrs. (N) is a 52 years old housewife . She is the mother of 2 daughters and one son. Her husband is retired . She graduated from a college and worked for a while at an embassy as she can speak three languages. Currently she lives with her husband and son as her two daughters had married and have children.

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•Her first contact with mental health service is due to the substance abuse problem of her son , as she used to come with him to the follow up sessions. • In one of the visits she decided to talk about some psychological problems she had and asked for a professional help. •Her main complaint was about the overwhelming feelings and the pressure she felt in facing the demands of other people including her mother , husband , daughters and son.

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•Her family background revealed that she is a single daughter with four brothers . Her dead father and her 4 brothers work in same field in prestigious governmental positions. Her upbringing was very conservative and her behavior was always assessed by her family.

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• Her case conceptualization was because of her conservative family and her tough parents she had the core belief of incompetence and had poor social and communication skills and the agreed goal of treatment was to build an assertive skills to face the unjustified demands of other people including her family members. • During the first few sessions she frequently deviated from the roadmap of treatment and start to idealize the sessions and the therapist with few progress made as regard her skills training and incomplete homework made . She continued to acknowledge the therapist as a rescuer and that he resembled her brothers.

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•These thoughts and feelings during the sessions interfered with any effort made to let the patient back to therapy road.

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Discussion• What is going wrong ?• Why these thoughts erupt suddenly ?• Could the therapist do something that the patient interpret it wrongly ?• What are the automatic thoughts and the core beliefs behind these

emotions ?• What to do when the therapeutic relationship is not straightforward ?• How can we apply the principle of collaborative empiricism and

preserve the therapeutic alliance in such a situation ?• Is this patient not candidate for CBT (wrong choice) ?• Could it be transference ??• Can CBT adopt the concept of transference ?

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What is Transference ?• A tendency in which representational aspects of

important and formative relationships (such as with parents and siblings) can be both consciously experienced and/or unconsciously ascribed to other relationships . (Levy, 2009)

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Historical Overview• Transference first appeared in Freud’s neurological writings in 1888 .• In this early writing, Freud used the concept of “displaceable energies”

to indicate the transfer of strong feelings developed within a particular relationship to another person who was independent of the origin of those feelings.• The concept of transference was further elaborated later in Case

Studies in Hysteria in 1895 (Breuer & Freud, 1895). Here, Freud talked about a false connection where the patient transfers unconscious ideas about a figure from the past onto the physician, and also noted that this illusion melted away with the conclusion of the psychoanalysis.• By 1900, transference was ready to stand as it does today as the core

psychoanalytic theory.

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Social cognitive model

• Mental representations of significant others exist in memory, and such representations can readily be triggered by relevant cues in any context, which then leads people to view new others through the lens of pre-existing significant others.

(Andersen & Cole, 1990; Andersen & Baum, 1994; Andersen & Glassman, 1996).

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Social cognitive model• The self and significant others are linked in memory (Andersen et al., 1997). • Individuals develop unique representations of themselves as they are with

each of their significant others. Thus, when relevant cues are encountered particularly cues coming from a new person that are similar (even minimally) to the representation, this will activate the representation.

• This representation may then be applied in interpersonal perception in the process we have termed transference.

• Triggering a significant-other representation in this way can also shift one's view of the self in the direction of the self-when-with-the-significant-other, while at the same time activating a host of affects, expectancies, motivations, and behaviors typically experienced in relation to the significant other

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Does Transference Exist in NonDynamic Treatments?

• (Gelso and Bhatia ,2012) review 16 studies that have addressed transference in nonanalytic treatments and describe how transference unfolds. • Their description of the highlights how transference

is evident, even when nondynamic clinicians do not attend to it. Interestingly, they describe how nondynamic therapists are extremely reliable when it comes to assessing transference , but that research suggests that they do not always choose to address it in their sessions.• This is an important distinction—that nondynamic

therapists are able to reliably assess transference and identify it in their clinical work even if they decide not to explore it with their clients.

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The Therapeutic

Alliance

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Common factors in psychotherapy

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TRANSFERENCE FROM THE COGNITIVEBEHAVIORAL POINT OF VIEW

• Although the word “transference” is not part of the language of cognitive behavioural therapy, examination of the cognitions related to the therapist is an integral part of assessment and treatment within CBT.

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Signs of transference• These are the same signs that suggest the presence of

automatic thoughts during the session. • e.g. Sudden change in the patient’s nonverbal behaviour:

sudden change in expression, abruptly switching to a new topic, block, pauses in the middle of a train of statements, clenching fists, tapping foot and so on.

One of the most revealing signs is a shift in the patient’s gaze, especially if he/she has had a thought but prefers not to reveal it.

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• The therapist should pay attention to any negative or positive reactions to him/her that arise but should not deliberately provoke or ignore them. • He/she should be vigilant for signs of disappointment,

anger, and frustration experienced by the patient in the therapeutic relationship.• Similarly the therapist should be alert to excessive

idealization, praise or attempts to divert the attention of therapy onto the therapist. These reactions open windows into the patient’s past and actual relations outside the therapy.

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• An idealized transference develops quite often, usually at the beginning of the treatment, whereas negative transference typically occurs later.• Acute intense transference and countertransference reactions may

serve as indicators of serious character pathology, such as Cluster B personality disorders. • Devaluation presents one of the therapist’s biggest challenges:

conducting therapy and managing resistance with patients who force the therapist into very aggressive and uncomfortable experiences. When these situations arise, the therapist has a twofold task. He or she must tolerate the transference enough not to engage in a countertransferential enactment. Additionally, he or she must help the patient understand both the meaning of and the consequences of devaluations of the therapist.

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• The goal of transference interpretation is sustained improvement in the patient’s relationships outside therapy. It seems to be especially important for patients with long-standing, more severe interpersonal problems. • Although the central tool of CBT is not interpretation of

transference, automatic thoughts and feelings related to interactions with the therapist are very much within the scope of exploration and may provide valuable opportunities for testing and modifying dysfunctional automatic thoughts.• One of the more common mistakes in CBT, is moving too quickly

away from the emotions being expressed about the therapist or the therapy

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Some kinds of transference and plausible reactions of the therapist.

Typeof transference

Examples of typical thoughts Emotionalreactions

Behavior Useful therapeutic reaction

Moderatepositive

The therapist wants to help me, understand me, is human and helpful, doing his job very well

Nice tune Cooperation, willingness to do homework

none

Admiring– Independent

Therapist is great like me.It’s nice to meet with such aperson, he can advise me withsomething, of course I can onlyhelp myself.

Nice tune oreuphoria atmeetings

- Slightly competes- Homework alternatelypreparing and not doing, - Emphasizes freedom of relationship

- “normalization “ neitherof us is more unique than any other man- insist on homework

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Typeof transference

Examples of typical thoughts

Emotionalreactions


Admiring -dependent

-Therapist is great. It is only himself, who is able to help me - I am lost without him. I can do anything with his support.

Euphoric tunechanges withanxiety aboutbeing left

-Try to put themselves into therapist’s place. -They bring presents, flatter, do their best to do the homework- need affirmation that they did it right, often require advice, explanation, support.

-To strength independent behaviors- Discuss the advantagesand disadvantages of the dependent attitudes.- Advice , affirmation and further explanation shouldnot be given.

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Type of transference


Emotionalreactions


Erotic Therapist is a perfect (ideal) partner. Relationship with himwill save me , it would be wonderful to be with him, make love with him.

- Fall in love with the therapist -"trance“ during the contact with the therapist

- Flirting or shy withdrawal

- wearing showy clothes, amorous looks towards the therapist.

- It is not necessary to solve it, as far as it does not affect the therapy. It flows away spontaneously.

- In case it blocks the therapy open the theme as a problem, go through the thoughts and realize their influence on the behaviour

- discuss sources of this need“ in the past, express clearly and in a sensitive way his/her own attitudes in the therapeutic relationship.

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Typeof transference


Emotionalreactions


Aggressive -I must show my power (dominance)otherwise I will be deprived of my freedom. - It is either him who wins or me. -- How dares he! I must put him down!

Anger, hate,fear

- Aggressive voice as well as his look- verbal rage, blaming, threatening

-Give feedback,-let the patient know you understand his feelings,-let him express anger . -When patient’s tension decreases, the therapistshould express his attitude by feedback (to takepatient’s behaviour separately from his personalityas such).

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Typeof transference


Emotionalreactions


Suspicious -Therapist does me wrong on purpose abuses me for his own needs or for the needs of somebody else, he is against me, has hidden motives.

Anger, fear,feelings ofthreat

He withdraws, does not speak about himself or only superficially, can be aggressive indirectly,does not do homework, drops out or stops attending the therapy.

Give feedback, discuss the situation openly, help to examine, where the sensibility comes from and to go through the relationships, where it also occurs. Mapping the sensible attitudes, their advantages and disadvantages, effects on the behaviour..

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Typeof transference


Emotionalreactions


Competitive Can’t let him overtop me, I am better in many things than he is. I will show him, don’t lethim humiliate me.

Tension, changes of feelings of euphoria anger, envy, frustration, according to the subjective “score“

Secretly or openly competes, where expects“competition”, rationalizesnoncompliance in homework

Give the feedback for the specific situations, investigate the competitive thoughts , their sources, where they occur, to which behaviour they lead to, ,advantages and disadvantages including their effects on the therapy..

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Typeof transference


Emotionalreactions


Possessive He is here for me, he has to be there for my disposal anytime.

Feelings of euphoriaChange with anger according to thebehaviour ofthe therapist.

He domineers, calls very often, does not visit the therapist at the time they agreed on and is angry when the therapist is not on disposal. He blames or is verballyaggressive.

Investigate thoughts and attitudes, find their originin the past (the need of possession instead of thefear of being left by someone), thoughts, emotions and behaviour in various relationships including thetherapeutic one, advantages and disadvantages.

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Typeof transference


Emotionalreactions


Contemptuous He cannot make it! He is weak, stupid, he is a fool, etc. How could he help me? I am the dominant one in our relationship

Contempt,impatience,anger

He despises the therapist, he cheapens what the therapist does, refuses to do the homework, drops out the lessons or stopsattending the therapy

Give the feedback about the particular behaviour, investigate thoughts and attitudes, find their origin, find how they work in different situations, thebehaviour they lead to, advantages and disadvantages for the life and relationships, what they mean forthe therapy.

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Conclusion • Transference is a normal human experience and can occur in any

relationship.• It may be positive or negative• In the psychotherapeutic encounter it may be severe enough to affect

alliance and cooperation , and the therapist should not ignore it.• CBT can adopt the concept of transference and deal with it in a

different approach than analytical and dynamic therapies

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Education

Transference in cbt