transference in cognitive behavioural therapy

2. 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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3. • 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. 3

4. • 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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5. • 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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6. • These thoughts and feelings during the sessions
interfered with any effort made to let the patient
back to therapy road.
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7. 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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8. 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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9. 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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10. 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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11. 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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13. 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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15. The Therapeutic
Alliance
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16. 16

17. Common factors in psychotherapy
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19. TRANSFERENCE FROM THE COGNITIVE
BEHAVIORAL 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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20. 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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21. • 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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22. • 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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23. • 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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25. Some kinds of transference and plausible reactions
of the therapist.
Type
of transference
Examples of typical thoughts Emotional
reactions
Behavior Useful therapeutic reaction
Moderate
positive
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 a
person, he can advise me with
something, of course I can only
help myself.
Nice tune or
euphoria at
meetings
- Slightly competes
- Homework alternately
preparing and not doing,
- Emphasizes freedom of
relationship
- “normalization “ neither
of us is more unique than any
other man
- insist on homework
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26. Some kinds of transference and plausible reactions
of the therapist.
Type
of transference
Examples of typical
thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
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 tune
changes with
anxiety about
being 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 advantages
and disadvantages of the
dependent attitudes.
- Advice , affirmation and
further explanation should
not be given.
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27. Some kinds of transference and plausible reactions
of the therapist.
Type of
transference
Examples of typical
thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
Erotic Therapist is a perfect
(ideal) partner.
Relationship with him
will 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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28. Some kinds of transference and plausible reactions
of the therapist.
Type
of
transference
Examples of
typical thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
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 therapist
should express his attitude by feedback (to take
patient’s behaviour separately from his personality
as such).
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29. Some kinds of transference and plausible reactions
of the therapist.
Type
of transference
Examples of typical
thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
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 of
threat
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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30. Some kinds of transference and plausible reactions
of the therapist.
Type
of transference
Examples of typical
thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
Competitive Can’t let him overtop
me, I am better in many
things than he is. I will
show him, don’t let
him humiliate me.
Tension, changes of
feelings of euphoria
anger, envy,
frustration, according
to the subjective
“score“
Secretly or openly
competes, where expects
“competition”, rationalizes
noncompliance 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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31. Some kinds of transference and plausible reactions
of the therapist.
Type
of transference
Examples of typical
thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
Possessive He is here for me, he
has to be there for my
disposal anytime.
Feelings of euphoria
Change with anger
according to the
behaviour of
the 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 verbally
aggressive.
Investigate thoughts and
attitudes, find their origin
in the past (the need of
possession instead of the
fear of being left by someone),
thoughts, emotions and
behaviour in various
relationships including the
therapeutic one, advantages
and disadvantages.
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32. Some kinds of transference and plausible reactions
of the therapist.
Type
of
transference
Examples of typical
thoughts
Emotional
reactions
Behavior Useful therapeutic reaction
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 stops
attending the therapy
Give the feedback about the particular
behaviour, investigate thoughts and
attitudes, find their origin, find how they
work in different situations, the
behaviour they lead to, advantages and
disadvantages for the life and
relationships, what they mean for
the therapy.
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33. 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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