1
W. Donald Ross, M.D. and Frederic T. Kapp, M.D. (1962) A Technique for SelfAnalysis of Countertransference—Use of the Psychoanalyst's Visual Images in
Response to Patient's Dreams. J. Amer. Psychoanal. Assn., 10:643-657
SINCE FREUD'S original mention of "the countertransference" in 1910 (16) there
have been many contributions to the literature on the phenomena associated with this
term. At that time Freud considered that countertransference arose in the physician
"as a result of the patient's influence on his unconscious feelings, " and he stressed the
need for the analyst to "recognize this counter-transference in himself and overcome
it." We propose a method to facilitate the self-analysis of countertransference which,
at least to our knowledge, has not been published previously. This method is an
innovation in technique in line with Freud's principle that "the interpretation of
dreams is the royal road to a knowledge of the unconscious activities of the mind"
(15, p. 608). It consists of self-analysis by the psychoanalyst of his personal visual
associations to his patient's dreams, in order to reveal previously unconscious
countertransference.
Orr has made a thorough and thoughtful historical survey of the literature on
countertransference up to 1954 (34). His review considers the various definitions and
technical methods of handling countertransference. Some contributions which
appeared after Orr's survey, and which we do not specifically discuss, are included in
our bibliography (21), (23), (32), (33), (41), (48). The separate definitions of
countertransference have led several authors to use
Awarded the Franz Alexander Prize for 1960 by the Institute for Psychoanalysis,
Chicago. Presented at the Annual Meeting of the American Psychoanalytic
Association, Chicago, May 5, 1961.
From the Department of Psychiatry, University of Cincinnati College of Medicine.
Submitted April 6, 1961
- 643 other terms to label some of the related phenomena which do not fit with the more
usual specific definitions of countertransference as either the analyst's unconscious
reactions to the patient's transference, or the analyst's unconscious transference to the
patient. Some of these terms are: "counterresistance" (19), (36),
"counteridentification" (14), "the emotional position of the analyst" (18), "R" (the
analyst's total response to his patient's needs) (28), "normal countertransference" (31),
"the experiences of the analyst" (43), and "the analyst's personal equation" (2).
Regardless of the different ways of viewing countertransference and related
phenomena, the technique described in this paper is applicable to the analysis of
unconscious components in the analyst's reaction to the patient or in his reaction to the
patient's transference.
Method
A number of methods have been described previously for the recognition of
countertransference. For example, Maxwell Gitelson (18), Mabel Blake Cohen (9),
and Karl Menninger (30) have described several clues which suggest that a
countertransference problem is present. They cover a large number of situations
which should alert the analyst to examine his own involvement with the patient.
2
One of the methods accepted for resolving countertransference problems is selfanalysis (28), (39), (47). There is little written on specific techniques for
accomplishing this task, presumably because the analyst uses his own free
associations, and at times his dreams, in a manner familiar to him from his own
analysis, training, and experience with patients. Annie Reich, in discussing some
"acute forms of countertransference" writes: "frequently a bit of self-analysis can
reveal what is going on and bring about a complete solution of the conflict" (38).
Colby refers to the generally accepted phenomenon that "patients' descriptions
produce echo responses in the analyst and often he spends a few moments of each
hour silently exploring his personal associations" (10). He suggests a "time-spacing"
method of self-analysis.
In this paper we present a technique of self-analysis of the
- 644 countertransference which seems to provide a further tool of value for the analyst.
Essentially it consists of using the analyst's associations to his visual images of his
patient's dreams. The technique appears to have the merit of providing a simple
spontaneous starting point which can be applied either when a countertransference
problem has already been suspected or, routinely, to test for countertransference, even
without other clues. Our method was developed as the result of the stimulation
provided by a talk given by Kanzer on image formation during free association (24).
This led the authors to pay attention to the visual images which came to mind while
listening with "evenly suspended attention" (17) as patients told their dreams.
A number of studies of the dynamics of visual imagery have appeared in the
psychoanalytic literature. Breuer and Freud drew conclusions from the visual images
of patients such as Anna O. and Frau Emma von N. in Studies on Hysteria(8). In his
1914 revision of The Interpretation of Dreams, Freud inserted some comments about
Silberer's observations on the transformation of his own thoughts into pictures which
occurred especially when he was in a sleepy or fatigued condition. Freud considered
such observations to be a way of studying one factor of dream work in isolation (15,
pp. 344, 503). Felix Deutsch pointed out that visual images of patients in the course
of analysis may act both as resistance and as communication (11). Bertram Lewin
referred to aesthetic reveries in his patients as resistance and as alternatives to the
verbalization of ideas (26). Ekstein and Wallerstein included imagery among the
phenomena observed in play therapy of children, in the transition phase between
verbalization and action (12). Kanzer gave several examples of the process of
analyzing his patient's visual images (24). It appears, from these authors, that visual
imagery, although a resistance to verbalization as secondary-process communication,
and in this sense comparable to acting out, is nevertheless much more available for
analysis than is acting out.
Discussions of the imaginative process in patients and analysts during psychoanalysis
have recognized the value of creative imagination in aiding empathy (7), (40).
However, the specific use of the imagery experienced by the analyst in response to his
patient's
- 645 verbal report of a dream has not been described. Our basic suggestion is that such
images can be used by the analyst for self-analysis in a manner analogous to the way
Kanzer and others have described using their patients' images during the course of
free association.
Such images appear to be an instance of the unconscious activity of the analyst's
mind, caught as a snapshot, in the process of responding to the unconscious activity of
3
the patient's mind. The verbal description of the dream by the patient represents the
final result of the patient's dream work including secondary revision. The form in
which the analyst conceptualizes it, however, is a new version of the patient's dream
to which the unconscious feelings of the analyst have contributed. The analyst's
visual images of the verbal representations of his patient's dream portray the mind of
the analyst as well as that of the patient.
Visual images experienced by the analyst while awake, rather than while sleepy or
fatigued, even when they occur during the state of "evenly suspended attention, " are
surely not exactly comparable to images formed while dreaming, or fully comparable
even to the images of the patient in the special analytic state on the couch. Medlicott
(29), discussing some relationships between waking imagery, dream imagery, and
hallucinations, pointed out distinctions as well as similarities. Some of the features of
the analyst's images arise from the special circumstances. If one considers that the
analyst is not free to verbalize his associations as is the patient, let alone act out his
feelings toward the patient, it is not surprising that the unconscious mental activity of
the analyst can include the changing of "involuntary ideas into visual and acoustic
images" (15, p. 102), as a phase in the analyst's response to his patient. Furthermore,
in Fisher's reports on his experimental study of the construction of dreams and
images, he has indicated that "Images associated with repressed unconscious
childhood memory content do not appear in all subjects but only in those who are
freer, less inhibited and less resistant" (13, p. 38). Consequently it seemed that the
visual images of the "less resistant" analyst, in response to the patient's dreams, might
be used for self-analysis of both dynamic and genetic unconscious elements in the
analyst's countertransference reaction.
- 646 In our experience such images may "pop" into the center of the analyst's awareness
while he is listening to the patient's report of a dream. At other times they appear
vague and fleeting and at the margin of consciousness, but they can be captured. The
scenes may be recognizable as pertaining to recent or past memories of the analyst.
Often several such images and memories occur in rapid succession.
Free association to these occurrences often reminds the analyst of his own analytic
insights which are pertinent to the particular patient. This self-analytic work may be
done within the hour in which the dream is presented or at some later time.
Obviously, the use of this technique presupposes, on the part of the analyst, his own
personal analysis, his psychoanalytic training and experience, and his motivation for a
continuing pursuit of insight.
What the analyst does with the increased knowledge obtained by this technique will
depend on the individual analysis. In general, this knowledge facilitates the aspect of
the analytic process in which that which was unconscious becomes conscious.
Specifically, the choice of interpretation by the analyst may be more discriminating
after the analyst is more aware of the nature of his own unconscious responses.
Occasionally the countertransference insight might be imparted to the patient. Further
discussion would be more appropriate after some individual examples have illustrated
how our technique has been applied.
Examples
Example 1. —A woman patient who had made considerable progress earlier in her
analysis had been in the analytic doldrums for several weeks before the dream to be
noted. Despite the fact that the analyst had interpreted the conflicts around her erotic
transference many times, she could not recognize these feelings. The lack of
4
movement in the analysis and the ineffectiveness of his interpretations were clues to
the analyst that there probably was some sort of countertransference resistance.
At this time in the analysis the patient dreamed she was sitting in her dinette with a
person whose identity was vague. A woman
- 647 friend of the patient, who was also in analysis, and who seemed to be living in the
same house, came into the room looking ill and said that she was planning to move
away. So the dream ended.
While the patient was telling the dream the analyst suddenly visualized a certain
dinette from his own recent social experiences. Free association by the analyst to the
dinette he had visualized led to a woman the analyst often met socially and whom,
frankly, he would have liked to meet much less often because he considered her social
behavior to be that of a superficial flirt, a bore, and someone who constantly was
demanding various favors from him. He next recalled a woman who had been the
housekeeper in the home where he lived as a child. She had been devoted to him but
he had gradually come to dislike her because of her stubbornness and her excessive
demands on him to reciprocate her love. When she became unhappy in her job and
quit, he had been pleased.
Through such associations the analyst began to consider the possibility that subtly and
unconsciously he had been encouraging the patient to defend herself against the erotic
transference by leaving treatment. It now became clear to him why his previous
attempts to interpret the transference had been clumsy and unsuccessful. His
unconscious countertransference feeling was one of wanting the patient to leave
treatment. Before the analyst recognized these feelings, his interpretations, colored by
unconscious feelings of wanting to reject the patient, had been presented in a manner
which contributed to the patient feeling that she was being criticized and excluded by
her therapist. Once this was clear, the analyst was able to deal with the transference
neurosis in a constructive manner and the analysis progressed again. The patient
could now accept the nonrejecting clarification of her erotic feelings to the analyst.
These feelings and the defenses against them no longer constituted a resistance to
analytic movement.
Example 2. —A man reported several dreams, the locale of which included the back
yard and the driveway of his home during early adolescence.
The analyst found himself visualizing the locale described by
- 648 the patient in terms of the back yard and driveway of his recent home, a place where
his son had often played. He also associated the scene to the back yard of his home
during his own adolescence, and to the driveway of the home where he lived when he
was four years old. The last scene was associated with an experience when he had not
been able to keep an "Irish Mail" handcar bought for him by his father, who decided
he was not big enough to operate it. These associations made the analyst aware for
the first time that, in part, he had been equating the patient with his son, as well as
with himself when he was an adolescent, and with himself when he was struggling
with oedipal problems. This insight into previously unconscious countertransference
revealed that the analyst was competing to some degree with the patient's father.
Now the analyst could consider more realistically the actual characteristics of the
patient's father as contrasted to the distorted picture which the patient had presented of
his father and which the analyst had previously accepted. He realized that the patient,
out of his oedipal rivalry, had been presenting a somewhat erroneous picture of his
father. This clarification paved the way to more effective understanding of the
5
transference and its genetic precursor in the need for the patient to find fault with his
father and with himself for doing so. Then the interpretations were made, step by
step, of the resistance against recognizing critical feelings about the analyst and, when
these critical feelings became conscious, of their competitive nature, paralleling a
similar need to find fault with his father in childhood.
Example 3. —Early in the analysis of a young, self-assured, and successful
businessman who complained of only a few well-delineated neurotic symptoms, the
patient dreamed that he was at a restaurant with an older man who offered to treat
him. In the dream, the patient told the man that he was not hungry since he already
had had dinner at home.
The analyst realized that, in part, this dream pictured the early transference reaction in
which the patient was struggling with his feelings about getting more deeply into
analysis. The patient was presenting himself as reluctant to accept treatment since he
liked things the way they were and had no desire to change.
- 649 As the patient described his dream, the analyst visualized a scene in which he had had
dinner at an exclusive club where he had been the guest of an older man. Immediately
following this image, he recalled another one of a wedding banquet he had attended
when he was five years old. The first image of the club dinner reminded him of his
feelings at that time when he was conscious of envy at not being a member of the
"Four Hundred"; he recalled how he concealed these feelings by assuming an attitude
of nonchalance. The image of the wedding banquet brought back the feelings of
happiness and importance at being the cute little boy at the large family party where
everybody made a big fuss over him and fed him tidbits. Self-analysis of this material
led the analyst to realize that he had made a countertransference identification with his
patient. Reminded by this bit of self-analysis that some of his own character defenses
were similar to those of the patient, he was able to recognize the patient's feelings
behind the façade of self-sufficiency in the dream and to make a much broader and
deeper interpretation of the transference which gave recognition to the defensive
nature of the patient's superficial attitude to his analysis. The interpretation was
confirmed by the patient's expression of feelings of anxiety over competition with the
analyst and with his father.
Example 4. —A woman patient dreamed that she entered her apartment and found her
younger brother eating in her kitchen.
As the patient told the dream, the analyst visualized a particular door and a particular
kitchen. He had, of course, never seen his patient's apartment, and the origins of his
visualization of her dream were sought in his own associations. The apartment door
was recognizable as a condensation of the door to an apartment where he lived early
in his marriage, and also of the door to a hotel room which was associated with erotic
fantasies stirred up in his own analysis. The kitchen visualized by the analyst was
recognizable as pertaining not only to the apartment of his early married life but also
to an apartment in which he had lived at the age of six, when he had oral and phallic
problems related both to his mother and to his older sister.
These associations led the analyst to become aware of the
- 650 fact that unconsciously he had been feeling toward the patient as he had toward his
wife early in marriage, as he had felt toward his older sister during childhood when he
displaced feelings from his mother to her, and as he had felt toward his wife during a
period in his analysis when he had displaced feelings to her from his woman analyst.
Thus, the analyst was able to gain insight into the countertransference by associating
6
to his visual images of the patient's dream. He was now able to see that not only was
the patient transferring feelings to him which she previously had to her younger
brother, but also that his countertransference was acting as a resistance and thus
blocking analytic progress. He decided that these circumstances warranted a limited
interpretation of the countertransference to the patient. He told the patient that not
only was she equating the analyst with her younger brother, as he had previously
interpreted, but that the analyst had facilitated this by tending to equate her with his
sister. This interpretation was followed by new material from the patient indicating
greater emotional insight into the brother transference, then by a shift to a father
transference, with further movement in the analysis.
Example 5. —This example illustrates an instance in which a modification of the
suggested technique might have been used to prevent a therapeutic failure. It is taken
from the supervision, by an analyst, of a resident doing psychoanalytically oriented
psychotherapy.
The patient was an attractive, young, married woman who was unhappy in her
marriage and had many phobias. At the time she had the dream to be discussed, the
patient was talking to her therapist about quitting treatment because she felt she was
getting worse rather than better. The therapist realized the patient was angry at him.
He thought that her anger was based on his frustration of her infantile dependent
strivings. At this point in treatment, the patient dreamed that she was the bride at a
wedding in a Catholic church and was standing next to a tall man whose face she
could not see and whom she assumed was the groom. During the dream, the patient
felt more and more disturbed because she did not want to marry a man she did not
know.
- 651 As the patient told the dream, the therapist visualized himself as the groom. Then he
visualized his own wedding which had actually taken place not in a church but
outdoors and had been in a different faith. He ignored his associations to the patient's
dream and went ahead to interpret to the patient his preconceived hypothesis of the
transference. He explained to her that she was angry at him because he was not
satisfying her excessive needs for attention which were like those of a greedy child.
He was disappointed, puzzled, and frustrated when the patient failed to come for the
next appointment.
Later, when he discussed this case with his supervisor, the therapist recalled the visual
images he had conjured up while the patient was telling her dream. After he told
these to the supervisor, it became clear to both of them that the therapist's lack of
awareness of his erotic countertransference had blinded him to the implications of
even the manifest content of the dream. His inability to see them, and therefore deal
with them, had played into the patients erotic transference and had aroused so much
anxiety in her that she broke off treatment.
Discussion
The history of the concept of countertransference in psychoanalytic theory has
followed a pathway similar to that of the concept of transference. In the earliest
period of psychoanalysis transference was not recognized. Later, after it was
recognized, it was considered an unpleasant contaminant and a dangerous resistance
that interfered with the treatment process. Still later, the concept of transference came
to be recognized as a most important and inevitable aspect of treatment which has to
be dealt with constructively in the physician-patient relationship.
7
A similar development seems to have occurred in the unfolding of the concept of
countertransference. Countertransference was at first unrecognized; then it was
recognized but considered a contaminant and an impediment to treatment. Only fairly
recently have analysts begun to look on countertransference phenomena as inevitable,
and even, at times, as useful tools in psychoanalytic treatment (4), (5), (22), (27), (28),
(31), (35), (36), (37), (42), (44), (45), (46). There is
- 652 some controversy about the interpretation of the countertransference to the patient, but
Margaret Little's discussion of the value of doing so under specific conditions (27) has
been essentially supported by other experienced analysts (5), (18).
The example given by Franz Alexander of telling a patient that his behavior was
annoying to the analyst can be considered an instance of interpreting the
countertransference to the patient. Alexander described the "corrective emotional
experience" as "a consciously planned regulation of the therapist's own emotional
responses to the patient's material … in such a way as to counteract the harmful
effects of the parental attitudes" (1). Leaving aside the controversial aspects about
role playing by the analyst, there is general agreement on the desirability of greater
conscious awareness of countertransference.
Lucia Tower has pointed out that earlier attitudes about countertransference tended to
keep it concealed (46). Therese Benedek has expressed the opinion that reluctance to
face countertransference has contributed to long and painful transference neuroses (6).
To Levine it seems probable that countertransference accounts for a large percentage
of mistakes and failures; Levine feels that the therapist need not be shocked if he has
countertransference problems since they are universal (25). Michael Balint stated that
in the Hungarian system of psychoanalytic training, "the interrelation of the
transference of the patient and the counter-transference of his analyst is in the focus of
attention right from the start, and remains there" (3).
The method for self-analysis of countertransference described in this paper provides a
further means of making the countertransference conscious so that it can be taken into
account. The adult ego of the analyst can then resolve the countertransference in
favor of the more mature response. This response can include more discriminating
interpretations. Other methods of self-analysis, of course, can achieve the same goal.
Furthermore, self-analysis can be applied to visual images which the analyst has in
response to material from the patient other than dreams. However, we have found the
use of visual images in response to patient's dreams to be a particularly pointed way
of assuring that self-analysis is done fairly quickly in a vivid and convincing
- 653 manner. The use of such fantasies in better understanding the analytic process is an
instance of regression in the service of the ego.
Our examples illustrate three applications of this technique. In some it was applied to
pinpoint a countertransference problem already suspected from other clues. In others
it was used to pick up previously unsuspected countertransference. The last example
suggests its possible use in supervision.
We would like to propose a means for assessing the validity of this method.
Procedures for validation of insight into previously unconscious countertransference
are not well established. We suggest the working hypothesis that the correctness of a
countertransference insight is indicated by the same signs that are well known when a
correct transference interpretation is made to a patient. These indicators include a
sudden change in level of tension, a sudden feeling of the individual understanding
himself better, and a subsequent spurt in the progress of the analysis. However, some
8
of these phenomena also occur with inexact interpretations (20). Hence, these criteria
are not sufficient.
The most accepted technique for the assessment of countertransference is by
supervision with an experienced analyst. Example 5 illustrates how attention to the
therapist's images of his patient's dream might have been used to advantage in the
supervision of psychoanalytically oriented psychotherapy.
We propose the following plan for the validation of the innovation described in this
paper. During the course of analytic supervision there are periods in which the
supervisor becomes aware of countertransference problems. At these points, before
the supervisor has communicated his impression to the analyst, he might write down
his opinion of the countertransference. At the same time, the analyst could take a new
dream of his patient and write down his impression of the countertransference derived
from his self-analysis of the visual images that occurred to him when the patient told
the dream. The two written conclusions from independent material could then be
compared.
A discrepancy between the two results would, of course, raise the question as to
whether the supervisor or the analyst was closer to the truth. This is a question which
arises at times in any
- 654 case during supervision. Usually the supervisor, with greater experience and less
involvement with the patient, is more likely to be correct. Other criteria, such as the
subsequent course of the analysis, can be used by both supervisor and analyst to
decide the issue.
Such testing of the method during supervision, besides validating or denying the
usefulness of the technique, would supplement present methods of supervision. This
would provide an additional means by which the analyst in training could increasingly
sharpen his ability to recognize his various patterns of countertransference.
- 655 SUMMARY
An innovation in technique is presented for the self-analysis of unconscious
components in the analyst's reactions to his patient and to his patinet's transference.
The visual images of the analyst in response to his patient's descriptions of dreams are
used by the analyst as the starting point for the uncovering of previously unconscious
countertransference.
Pertinent literature on countertransference, self-analysis, and visual imagery is
discussed with the explanation of the development of this method.
Four examples of the use of this technique in psychoanalysis are presented; in
addition, one example is given from the supervision of psychoanalytically oriented
psychotherapy, to illustrate how a modification of this method might have prevented a
therapeutic failure.
This technique is consistent with recent emphasis on the inevitability of some
countertransference reactions, and even of their being useful when they are
recognized, in contrast with earlier tendencies to consider them to be undesirable
contaminants.
A suggestion is made for the validation of this technique and for its use in analytical
supervision.
Although its use presupposes the skill and motivation of the analyst for the constant
pursuit of insight, the method provides a distinct and relatively simple procedure for
facilitating the self-analysis of the countertransference.
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9
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