Psychotherapy © 2018 American Psychological Association

2018, Vol. 55, No. 3, 222–230 0033-3204/18/$12.00 http://dx.doi.org/10.1037/pst0000148

Origins of Countertransference and Core Conflictual Relationship Theme

of a Psychotherapist in Training as Emerging in Clinical Supervision

Irene Messina and Carolina Solina Alice Arduin

University of Padua Centro Psicologia Dinamica (CPD), Padua, Italy

Virginia Frangioni Marco Sambin

University of Padua University of Padua and Centro Psicologia Dinamica (CPD),
Padua, Italy
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Charles Gelso
University of Maryland, College Park

Therapists’ unresolved conflicts might be the source of countertransference phenomena. To investigate

the origins of countertransference, the aim of this supervision single-case study was to identify conflictual
areas that characterize private life relationships and therapeutic relationships of one therapist in training.
With this aim, we applied the core conflictual relationship theme method to the analysis of the therapist’s
relationship episodes with patients, as emerged spontaneously during clinical supervision sessions, and
to the analysis of relationship episodes concerning his personal life, collected using the relationship
anecdotes paradigm interview. Quantitative data showed that core conflictual relationship theme perva-
siveness scores concerning private life relationships and therapeutic relationships were significantly
interrelated. Qualitative examples of these associations are provided in the paper, and the implications for
supervision and training are discussed.

Keywords: countertransference, supervision, CCRT, origins, triggers

In 1910, Freud wrote, transference (CT), ranging from the classical Freudian definition of
CT as a conflict-based, unconscious response to the client’s transfer-
We have begun to consider the ‘counter-transference,’ which arises in the
ence to a totalistic definition that includes all of the therapist’s reac-
physician as a result of the patient’s influence on his unconscious feel-
tions toward the patient (for a review of CT definitions, see Gelso &
ings, and have nearly come to the point of requiring the physician to
recognize and overcome this countertransference in himself . . . we have Hayes, 2007). These different definitions reflect the existence of acute
noticed that every analyst’s achievement is limited by what his own forms of CT, which occur only under specific circumstances with
complexes and resistances permit. (Freud, 1910/1959, pp. 144 –145) specific patients, and chronic forms of CT that are more typical for a
specific therapist (Reich, 1951; Singer & Luborsky, 1977).
Since this early conceptualization, various psychoanalytic psycho- Among these different definitions, most of the research in this area
therapy approaches have provided different definitions of counter- has been based on the integrative conceptualization and operational-
ization proposed by Gelso and Hayes (2007), which retains the
classical view of CT, giving more emphasis to the therapist’s unre-
solved conflicts as the origin of CT reactions. According to Hayes
This article was published Online First August 2, 2018. (2004),
Irene Messina and Carolina Solina, Department of Philosophy, Sociol-
ogy, Education and Applied Psychology, University of Padua; Alice Ar- This definition is less narrow than Freud’s classical perspective in that
duin, Centro Psicologia Dinamica (CPD), Padua, Italy; Virginia Frangioni, countertransference may be conscious or unconscious and in response to
Department of Philosophy, Sociology, Education and Applied Psychology, transference or other phenomena. Nonetheless, unlike the totalistic defi-
University of Padua; Marco Sambin, Department of Philosophy, Sociol- nition, it clearly locates the source of the therapist’s reactions to the client
ogy, Education and Applied Psychology, University of Padua, and Centro as residing within the therapist. This encourages therapists to take re-
Psicologia Dinamica (CPD), Padua, Italy; Charles Gelso, Department of sponsibility for their reactions, identify the intrapsychic origins of their
Psychology, University of Maryland, College Park. reactions, and attempt to understand and manage them. (p. 23)
We thank Jillian Lechner for her contribution to the editorial work.
Correspondence concerning this article should be addressed to Irene Hayes and his colleagues developed this view into a CT structural
Messina, Department of Philosophy, Sociology, Education and Applied model with five components (Hayes et al., 1998): (a) Origins refer
Psychology, University of Padua, via Venezia 14, 35131, Padua, Italy. to therapist’s areas of unresolved intrapsychic conflict, (b) Trig-
E-mail: [email protected] gers are therapy events that touch on or elicit the therapist’s
222
 COUNTERTRANSFERENCE: A CCRT CASE STUDY 223

unresolved issues, (c) Manifestations are therapist’s behaviors, private lives and with their patients. However, they were not
thoughts, or feelings that result from the activation of his or her informative regarding how therapist’s conflictual themes may con-
unresolved issues, (d) Effects are the ways in which CT manifes- cretely influence CT in every day clinical practice.
tations influence the therapy process and outcome, and (e) Man- With this regard, one way by which the therapist will come to be
agement factors are abilities of the therapist to regulate and pro- aware of CT dynamics is clinical supervision, which is considered
ductively use CT reactions. CT management is associated with the core of psychotherapy training (e.g., Hess, Hess, & Hess, 2008;
positive psychotherapy outcomes (Gelso & Hayes, 2001; Hayes, Messina et al., in press). The effectiveness of supervision in
Gelso, & Hummel, 2011; Hayes, Nelson, & Fauth, 2015), and improving trainees’ efficacy has been demonstrated in several
within the psychotherapy process, clinical errors occur when a investigations (Freitas, 2002; Wheeler & Richards, 2007). In ad-
clinician fails to adequately respond to a patient’s emotional sig- dition, supervision is strongly recommended to therapists to en-
nals due to CT reactions (Sharma & Fowler, 2016). For these hance their awareness of personal conflicts and to prevent the
reasons, the identification of therapists’ intrapsychic origins of CT potential influence of these conflicts on the therapeutic relation-
is encouraged in psychotherapy training to improve trainees’ man- ship (Hayes et al., 2011). For the purposes of the present study, it
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

agement of internal CT reactions, in ways that prevent their be- is important to mention that supervision is a setting in which CT
This document is copyrighted by the American Psychological Association or one of its allied publishers.

havioral manifestations, improve empathic responses toward the phenomena can be examined and where the comprehension and
patients, and reduce anxiety in psychotherapy sessions (Gelso & utilization of CT deserve special attention (Shafranske & Falender,
Hayes, 2007; Hayes & Gelso, 1991; Messina et al., 2013). How- 2008). Thus, the supervision process offers a natural setting for the
ever, very little research has been conducted on the origins of CT observation of therapists’ conflictual areas (CT origins).
and how therapists’ unresolved conflicts are triggered in psycho- In the present study, we used a naturalistic single-case design
therapy. aimed at the investigation of one therapist’s CT reactions, as
A useful method to measure individual areas of personal conflict spontaneously disclosed in clinical supervision, as a means of
is the core conflictual relationship theme (CCRT; Luborsky & identifying the origin of CT. In line with previous studies that have
Crits-Christoph, 1990). Although this method was originally de- applied the CCRT method for the investigation of CT origins, we
veloped to study transference, its use has been extended to the explored the hypothesis that therapists’ central relationship themes
investigation of personal conflicts emerging in therapists that characterize both the therapeutic relationship and private life re-
produce CT (Tishby & Vered, 2011; Tishby & Wiseman, 2014). lationships in similar ways. In contrast to previous studies, we
The central principle of the CCRT method is that repetition across based our investigation on the analysis of verbatim transcripts of
psychotherapy relationship narratives is useful for assessing the supervision sessions. Namely, we collected one therapist’s rela-
core relationship pattern of the person. Namely, the CCRT de- tionship episodes with his patients, as these episodes spontane-
scribes the relationship pattern by the combination of the most ously emerged during supervision sessions, and we compared them
frequent (a) wishes, needs, and intentions expressed by the person with interview-based collections of relationship episodes in his
(W); (b) expected or real responses from others (ROs); and (c) personal-life relationships. The use of a naturalistic design aimed
emotional, behavioral, or symptomatic responses of self to others’ to extend the results of previous quantitative studies by providing
responses (RSs). These components should reflect an underlying a view of the CT dynamics of the therapist and to reflect on
schema, partly conscious and partly unconscious, of how to con- possible influences of such dynamics on the therapeutic relation-
duct relationship interactions, including therapeutic relationship ship. Our general aim was to contribute in bridging the gap
interactions. Two studies have focused on developing a method to between quantitative research and clinical practice concerning the
identify the origins of CT based on applying the CCRT to inves- influence of the therapist’s personal issues on the therapeutic
tigate CT themes in therapists, who were interviewed about rela- relationship by providing examples of the actual manifestation of
tionship episodes in their private lives and with their patients CT in everyday supervision processes.
(Tishby & Vered, 2011; Tishby & Wiseman, 2014). In the first
study, Tishby and Vered (2011) applied the CCRT method to
Method
investigate CT in 12 therapists treating adolescents, asking them to
relate narratives about their parents and about two of their clients.
The findings showed that all three components of the therapists’ Participants
CCRTs with their parents (W, RO, and RS) also appeared in their
narratives about their patients. In the second study, Tishby and Psychotherapy trainee. Dr. I.1 was a 28-year-old clinical
Wiseman (2014) confirmed the results of the first study when psychologist attending the second year of a 4-year psychodynamic
considering different phases of therapy in a systematic manner. psychotherapy training program. He had two years of experience
Thus, therapists’ unresolved conflicts, in interaction with patients’ doing psychotherapy. Dr. I. received individual supervision as part
behavior, may produce several CT dynamics, and the CCRT of this training. The therapist was unaware of our research hypoth-
method was useful in capturing these different dynamics. This esis during the supervision sessions. The consent for the use of
interaction of therapists’ unresolved conflicts with patients’ behav- audiotaped sessions for research purposes was obtained after com-
ior to produce CT reactions in the therapist has been referred to as pletion of the supervision sessions. The study was approved by the
the “countertransference interaction hypothesis” by Gelso and ethical commission of Padua University, and Dr. I. gave his
Hayes (2007) and has been viewed by these researchers as the informed consent for participating in the study and for the publi-
most effective way to understand the phenomenon of CT. These
quantitative studies provided evidence concerning the statistical 1
We used a pseudonym to comply with the ethics code concerning
correspondence between therapists’ relationship episodes in their de-identification.
 224 MESSINA ET AL.

cation of extracts of verbatim transcripts of supervision sessions cluster “To feel good and comfortable.” The responses from oth-
and Relationship Anecdotes Paradigm (RAP) interview. ers, which include “Don’t trust me,” “Don’t respect me,” “Are not
Supervisor. Dr. A.2, a 41-year-old female clinical supervisor, understanding,” “Rejecting,” “Dislike me,” “Distant,” “Unhelp-
was a staff member of the psychotherapy training program at- ful,” and “Oppose me” are all part of the cluster “Rejecting and
tended by the trainee. She was asked to participate in the current opposing.” The responses of self, such as “Angry,” “Disap-
study because she had formal training and extensive experience as pointed,” “Depressed,” “Unloved,” and “Jealous” are all part of the
a supervisor. Moreover, she typically explored CT phenomena as cluster “Disappointed and depressed.”
part of clinical supervision. The approach followed by the super- Raters were two students in clinical psychology trained in using
visor was transactional analysis (Berne, 1961). According to this the CCRT method as specified in the manual (Luborsky & Crits-
approach, to address CT management, supervisors should establish Christoph, 1998). Such training included a practical training in
an effective emotional contact with the trainee aimed at the pro-
scoring at least four to five sessions before the autonomous appli-
motion of the exploration of the CT reactions that the therapist has
cation of the method.
had internally experienced in psychotherapy and that were ex-
Evaluation of therapist personal relationship. To collect
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

pressed during supervision sessions, to allow the subsequent rec-

relationship episodes concerning the therapist’s private life, the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ognition and conceptualization of such reactions (Mazzetti, 2007).

Dr. A. gave her informed consent for participating in the study and RAP interview (Luborsky, 1990b) was utilized. This procedure has
for the publication of extracts of sessions verbatim transcripts. been shown to be a valid method of eliciting relationship narratives
(Barber, Luborsky, Diguer, & Crits-Christoph, 1995). A postmas-
ter’s student in clinical psychology conducted the interview in a
Instruments and Procedures research setting. The therapist was asked to relate meaningful
Supervision sessions. The supervision sessions were con- interactions with others. Instructions for administration of the RAP
ducted and audiotaped as normally done with no interference from interview are as follows:
the research team. The first five subsequent supervision sessions,
Please tell me at least 10 incidents or events, each about an interaction
starting from the first session of the actual year of training, were
between yourself in relation to another person. Some incidents may be
used for the present study. Supervision sessions were focused on
recent and some old. Each one should be a specific incident. For each
several patients. Both the supervisor and therapist trainee did not
one tell (a) when it occurred, (b) who the other person was, (c) some
know about the object of the study at the time of the sessions.
of what the other person said and what you said, and (d) what
Evaluation of therapist therapeutic relationship. To de- happened at the end. The other person might be anyone—your father,
scribe the therapist’s relationship pattern with his patient, the mother, brothers and sisters, or other relatives, friends, or people you
CCRT(Luborsky, 1990a) was applied to verbatim transcripts of work with. The accounts should be about specific incidents, not just
supervision sessions. amalgams of several incidents.
Rating procedures included several steps. First, two independent
judges identified narratives in which patients describe specific The interview was transcribed verbatim and then coded by two
interactions with other people (relationship episodes—RE). Sec- independent judges (different from the judges who rated supervi-
ond, the same independent judges read each relationship episode in sion sessions) using the CCRT rating form (Barber, Foltz, De
the transcript and identified each of the three components of the Rubeis, & Landis, 2002). The independent judges were two post-
CCRT: (a) wishes, needs, or intentions expressed by the therapist- master’s students trained in clinical psychology.
trainee (Ws); (b) expected or actual responses from others (ROs);
and (c) responses of self (RSs). Third, judges were asked to
translate Ws, ROs and RSs found in verbatim transcripts of super- Data Analysis
vision sessions into clusters following the procedures proposed by
For both supervision sessions and RAP interview episodes, the
Luborsky and Crits-Christoph (1998). For any given relationship
episode, the rater is required to identify which segments represent interrater reliability was calculated using Cohen’s K to obtain a
a W, a RO, and a RS and use the definitions provided in the measure of the independent judges’ level of agreement. Following
manual to attribute a cluster to this specific segment. Clusters the procedure proposed by Luborsky and Crits-Chrstoph (1990),
include eight Ws (“To assert self and be independent,” “To op- the pervasiveness scores for the Ws, ROs, and RSs variables were
pose, hurt and control others,” “To be controlled, hurt and not calculated by dividing the number of times each W, RO, and RS
responsible,” “To be distant and avoid conflicts,” “To be close and occurred by the total number of relationship episodes. Then,
accepting,” “To be loved and understood,” “To feel good and Spearman’s correlations were calculated to determine the degree
comfortable,” “To achieve and help others”), eight ROs (“Strong,” of association between the ranks of pervasiveness of W, RO, and
“Controlling,” “Upset,” “Bad,” “Rejecting and opposing,” “Help- RS scores in relationship episodes in private life (collected using
ful,” “Likes me,” and “Understanding”), and eight RSs (“Helpful,” the RAP interview) and the ranks of pervasiveness of W, RO, and
“Unreceptive,” “Respected and accepted,” “Oppose and hurt oth- RS scores in relationship episodes with patients (collected in
ers,” “Self-controlled and self-confident,” “Helpless,” “Disap- supervision transcripts).
pointed and depressed,” and “Anxious and ashamed”). For each
cluster, several categories of Ws, ROs, and RSs are described in
the CCRT manual (Luborsky & Crits-Christoph, 1998). For ex-
ample, wishes such as “To have stability,” “To feel comfortable,” 2
We used a pseudonym to comply with the ethics code concerning
“To feel happy,” and “To feel good about self” are all part of the de-identification.
 COUNTERTRANSFERENCE: A CCRT CASE STUDY 225

Results Example 1. In the first example, we report a typical negative

dynamic characterized by the desire of the therapist to be happy
Quantitative Results about himself, followed by a rejection or disconfirmation from the
other and negative feelings of helplessness, anger, and sadness as
A total of 26 relationship episodes with patients were found in response of the self. In the following extract of a supervision
verbatim transcripts of supervision sessions (patients’ RE), and 17 session, the therapist reported an episode where he wished to feel
relationship episodes in private life (private life RE) were collected well in the therapeutic relationship and to be happy about himself
through the RAP interview procedures. The interrater reliability as therapist (Cluster W “To feel good”), the RO of the patient was
for CCRT components was high for all components in both pa- a disconfirmation (Cluster RO “Rejecting”), and the RS was char-
tients’ RE and private life RE. See Table 1 for Cohen’s K coeffi- acterized by negative feelings of helplessness (Cluster RS “Help-
cients. less”). In the extract, Ws, ROs and RSs are boldfaced.
Wishes. As shown in Figure 1, the most frequent cluster of W
Therapist: At the end of each session, I gave a questionnaire
was “To feel good and comfortable” in both private life and
to the patient to evaluate the therapeutic alliance,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

patients’ RE. Also, in private life RE, the W “To be loved and
because to me it was very important to know that
This document is copyrighted by the American Psychological Association or one of its allied publishers.

understood” had a high pervasiveness score, whereas, in RE with

all was going well, and I want to know if some-
patients, high pervasiveness scores were found for “To assert self
thing is not going well, if the patient feels lack of
and be independent” and “To achieve and help others.” The
synchronization [W]. [. . .] So, I presented the
rankings of pervasiveness scores in private life and with patients
questionnaire to the patient, and she said that she
were found to be highly correlated (rs ⫽ .854; p ⫽ .006).
was not satisfied [RO]. And I said, “Ok, what do
Response of the others. In both private life and patients’ REs,
you need to be satisfied?” She said, “I don’t
the most frequent cluster of RO was “Rejecting and opposing.” In
know, I come here but I don’t know what I will
private life RE, the RO “Bad” had a high pervasiveness score,
talking about, I see what happens”. I said, “Ok,
whereas this RO did not appear in patients’ RE. In patients’ RE,
can you think about what would you like to talk
the ROs “Strong” and “Controlling” had high pervasiveness
about?” And she said, “No, I don’t want”[RO].
scores. Although a few correspondences between ROs reported in
Thus, I have been not able to repair the alliance,
private life and ROs reported in therapeutic relationships can be
I felt helpless [RS].
observed in our data (Figure 2), a statistically significant correla-
tion was not found (rs ⫽ .284; p ⫽ .50). A similar dynamic can be observed in the following episode of
Response of the self. In both private life RE and patients’ RE, the RAP interview. The episode regarded an interview with a more
the highest pervasiveness scores were found for the clusters “Help- experienced therapist for an internship. Again, the therapist starts
less” and “Disappointed and depressed.” In private life RE, the from the desire (implicit) to be happy and proud about himself
positive RS cluster “Respected and accepted” appears frequently. (Cluster W “To feel good”), the RO of the other was a disconfir-
As shown in Figure 3, RSs reported in private life and RSs mation (Cluster RO “Rejecting”), and the RS was characterized by
reported in therapeutic relationships were statistically correlated, negative feelings be incompetent (Cluster RS “Helpless”), angry
r ⫽ .850, p ⫽ .007. and without enthusiasms (Cluster RS “Disappointed and de-
pressed”).
Qualitative Data T: I showed something that makes me proud, because I
Beyond the statistical correspondence between RE episodes talked about my master thesis . . . I have done a beautiful
with patients and in private life, the observation of the qualitative thesis, I had the highest marks . . . I was proud because
data of verbatim transcript of the supervision session and in the I had done very extensive work but she treated it as
RAP interview allowed us to describe a typical dynamic that something without value [RO]. She said, “Is this some-
characterized the therapist in training. We identified as a main thing that you think or did you read it somewhere?” Also,
conflictual wish the desire of the therapist to be proud of himself, in the discussion about the trauma I felt uncomfortable,
and when the response of the other disconfirms this need, the I felt unappreciated [RS] because I was attending a
therapist showed very negative responses from the self. course concerning mentalization-based techniques of in-
terventions on trauma, using techniques such as hypno-
sis. This made me very irritated [RS] [. . .] I felt incom-
petent, without energy, without enthusiasms to move
Table 1 forward and irritated [RS].”
Interrater Variability for Each Core Conflictual Relationship
Theme Cluster in RE with Patients and RE in Private Life Example 2. The second example is focused on the desire to
help due to its relevance for the context of psychotherapy. In the
RE with patients RE private life following vignette, the trainee spontaneously reports a relationship
CCRT components K K episode that he had with his patient during the fourth session. The
Clusters W .81 (n ⫽ 75) .72 (n ⫽ 33) W regarded the desire to obtain results in treating a patient (Cluster
Clusters RO .82 (n ⫽ 50) .71 (n ⫽ 33) W “Achieve and Help”) by maintaining the rules of the therapeutic
Clusters RS .81 (n ⫽ 53) .67 (n ⫽ 28) setting (Cluster W “To assert self and be independent”). The RO
Note. K ⫽ Cohen’s K coefficient; W ⫽ wishes; RO ⫽ Responses from was a reject because of repeated delays and skipped sessions
Others; RS ⫽ Responses from Self; RE ⫽ relationship episodes. (Cluster RO “Rejecting”). The RS was characterized by feelings of
 226 MESSINA ET AL.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 1. Correspondences between frequencies of Wishes clusters observed in relationship episodes in private
life and with patients. Pervasiveness Scores are reported above the bar.

sadness (Cluster RS “Disappointed and depressed”). In the vi- schema, too. Then, I think that you should do a
gnette, Ws, ROs and RSs are boldfaced. contract of change. Otherwise, she does what-
ever she wants. She is a rebel child.
Therapist: I would like to talk about L., that patient of the
last session. Last time we talked about her late- T: So, I should decontaminate3 her.
ness and moved sessions . . . she arrived late
again [RO]. [The therapist extensively de- S: Absolutely.
scribes the context è].
T: Yes, I think that she would like to use me as a
Supervisor: So, she understood that if she arrives delayed, self-object. On one hand, she wants to resolve
she cannot explore herself, and she is not re- her self-esteem problems, but on the other, she
spectful toward you. wants to use me as self-object. Ok, I understand.
T: Then, I asked her, “Which strategies can you Now we are at the point that maybe we have to
use to arrive on time?” and she says, “Well, for change the time of the next session because she
example, I can use the alarm clock to remember has travel plans for the holiday. I said that for
the time.” My priority is to maintain the rules the moment, we fix the session, and then we will
of the therapeutic setting [W], and also the see.
time.
S: How are you feeling? Are you worried? Agi-
S: Yes, but my question is how much is she really tated? Angry? How do you feel after this clearer
obtaining results? Are the sessions useful? What focusing?
can we do to give her something useful? To give
a structure not only for the lateness, but also T: I say to myself that I could have thought of this
regarding what you do together in this setting before [RS].
for her. So, how can we arrive at a better
S: Do you believe that you did not do so before?
formulation of a therapeutic contract?
T: I do not know, in the sense that there is nothing T: It is like having two parts of me. One part would
I know to do . . . I would not know how to do make the contract immediately. The other would
[RS]. If we have the time to do it in the Session do the contrary. The other would explore, but
I can do it, otherwise I cannot. . . . I was feeling overwhelmed because I had
many objectives beyond the food, and I was not
S: You could do it also in 35 min. prepared for these things [RS].
T: To do so, I should focus on something specific.
3
S: You are at the beginning of the therapy with this In transactional analysis model of psychotherapy, the term “decontam-
ination” refers to the therapeutic action aimed to the achievement of an
person, so it is normal that you are exploring integrated adult, which is not infringed by unprocessed experiences from
the situation. You could ask how she is benefit- the past (child), or by the introjection of significant others from one’s
ing from these five sessions, and you can do a history (parent; Berne, 1977).
 COUNTERTRANSFERENCE: A CCRT CASE STUDY 227
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 2. Correspondences between frequencies of Responses from Others clusters of relationship episodes in
private life and with patients. Pervasiveness Scores are reported above the bar.

A similar dynamic can be observed in the following childhood me in a very harsh way. He told me that I was a monster
episode of the therapist with his father based on the RAP inter- [RO], that I act like a monster. I remember this feeling of
view. Again, the therapist (in his childhood) starts from an ener- sadness because I became aware that I had broken the
getic position with the attempt to help and allow something pos- egg, and I was sad [RS] to see this embryo in the grass.
itive for others (Cluster W “Achieve and Help”) and to be proud of In the sense that I did not want. . . . I thought it was
himself (Cluster W “To feel good and comfortable”), but, despite empty, that nothing was inside; I had not understood that
his positive intention, the other strongly rejects him (Cluster RO I had broken the egg. And then he told me that I was a
“Rejecting”), and again the RS is (Cluster RS) “Disappointed and monster [RO], that I was bad. I remember that he was
depressed”. shouting [RO], and I was not allowed to respond, and I
felt misunderstood [RS].”
T: “I was four or five years old. I was playing with another
child. There was a nest in a tree, and she asked me if I Example 3. As the last example, we provide an example of
could take that nest. So, I climbed the tree, I took the nest, correspondence in positive relational episodes. In the following
and I gave it to her. However, while I was taking the nest, supervision excerpt, the conflictual wish of the therapist concerns
an egg fell. There was a pigeon’s egg that had fallen, and the desire to feel good about himself as a therapist (W “To feel
I did not become aware. I gave her the nest, and I felt good and comfortable” and “To Achieve and Help”), and the
proud because I had given this present to a younger response of the other is positive (Cluster RO “Likes me”). Also,
child [W]. But, when my father arrived and saw the egg, the response of the self is positive (RS “Respected and accepted”
and my sister said that I had dropped the egg, he insulted and “Self-controlled and self-confident”).

Figure 3. Correspondences between frequencies of Responses of Self clusters observed of relationship

episodes in private life and with patients. Pervasiveness Scores are reported above the bar.
 228 MESSINA ET AL.

T: I immediately felt a very good alliance, and I think that “Helpless” and “Disappointed and depressed,” which character-
the reason for this was that now I have more experience ized several private life and patient relationship episodes. In line
in doing therapy contracts and in giving clear informa- with previous interview-based studies (Schattner, Tishby, & Wise-
tion to the patient. I said, “I work so, so, and so,” “we man, 2017; Tishby & Vered, 2011; Tishby & Wiseman, 2014),
will do that, that, and that. . . . I give you the information these results may reflect a possible underlying relational schema of
in order to give you the possibility to choose con- the therapist that played out in the psychotherapy relationship. The
sciously.” Thus, I was very secure and precise [RS]. analysis of qualitative material allowed us to better describe the
Then I said, “I don’t give advice,” and in that moment, I specific dynamics of the therapist involved in the study, charac-
felt that something happened, that I had touched an terized by the desire to be proud of himself (as person in private
important issue. She said, “ah” [RO]. This is part of her life and as therapist with patients). Indeed, when a response of the
personal history, because usually everybody tells her other disconfirmed this need, the therapist showed a typical re-
what she has to do, especially her parents. They had sponse of the self, characterized by helplessness, depression, and
bought a house for her, and they had chosen where she anger. Considering the operationalization proposed by Hayes and
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

had to live with her partner. She was typically passive in colleagues (Hayes et al., 1998; Rosenberger & Hayes, 2002), these
This document is copyrighted by the American Psychological Association or one of its allied publishers.

her interactions with her parents, thus I surprised her by resultsprovide support for the hypothesis that personal themes also
saying that I do not give advice. reflected in the narratives about patients might represent the ori-
gins of CT. Thus, this relational pattern may correspond, at least to
A similar dynamic can be observed in the following childhood
an extent, to a chronic CT reaction (Reich, 1951; Singer & Lu-
episode of the therapist with his father based on the RAP inter-
borsky, 1977), which may characterize this specific therapist re-
view. In this episode, the wish is to feel good about himself
gardless of the patients that are in treatment with him.
(Cluster W “To feel good and comfortable” and “To be loved and
However, the presence of several differences between private
understood”), the response of the other is positive (Cluster RO
life and patient relationship episodes allows us to speculate that, in
“Likes me”), and the response of the self is positive (Cluster RS
addition, elements of the real relationship with the patient influ-
“Respected and accepted”):
enced the CCRT clusters observed in the present study. First, the
T: “When I was a child, I used to go to Sicily with my father W “To achieve and help others” was reported with high frequency
during the summer, because my father is from Sicily. He in relationship episodes with patients, whereas it did not appear in
taught me how to dive. First, he taught me how to breathe the narratives about the parents. This result, also reported in a
with the snorkel and then how to go under the water previous study (Tishby & Vered, 2011), is consistent with the role
without breathing. He taught me to relax, and he said that of the therapist in his real helping relationship with the patients
I had to slow my heart rate. I was very fascinated, I felt (Gelso, 2011). Second, the association between ROs in private life
good, and I was happy [RS]. [. . .] What I wanted in that relationship episodes and relationship episodes with patients was
interaction was for my father to be proud of me [W]. He not statistically significant. This component probably reflects the
taught me how to dive, and I felt that he cared about me trigger of the therapist’s CT reactions in the context of psycho-
[RO].” therapy more than its origins in therapist conflictual areas. Thus,
when the patient responds in some specific way, the CT response
of the self may be activated, such as in a case where patients talk
Discussion
about material related to therapists’ unresolved conflicts (Gelso &
In the present naturalistic single-case supervision study, we used Hayes, 2007; Hayes et al., 1998; Rosenberger & Hayes, 2002).
the CCRT method to describe the similarities between therapists’ Finally, in our data, we found a major presence of the negative
therapeutic relationship and private life relationships, as a mean to clusters of RO and RS in relationship episodes with patients. This
investigate CT origins. We evaluated pervasiveness scores of W, prevalence may be due to the existence of more negative CT
ROs, and RSs concerning relationship episodes with patients— reactions in response to individuals affected by psychopathology
spontaneously emerged in supervision sessions—and we com- (Aviv & Springmann, 1990; Lingiardi, Tanzilli, & Colli, 2015),
pared them with the same components in private life relationships. suggesting that the RO component is linked to acute CT due to the
Numerous relationship episodes were collected in supervision ses- influence of patient factors on therapists’ CT (Betan, Heim, Zittel
sions, supporting the notion that supervision can be the main Conklin, & Westen, 2005; Rossberg, Karterud, Pedersen, & Friis,
setting for therapist disclosure of CT reactions and a resource for 2007). However, we should take into consideration the possibility
dealing with them (Ladany et al., 1997; Rodolfa et al., 1994). that this prevalence of negative components may be a bias in our
Our results demonstrated the similarity of the rankings of per- results due to the possible selection of relationship episodes char-
vasiveness scores of CCRT components in private life and rela- acterized by negative experiences in supervision sessions (whereas
tionship episodes with the patient (especially for clusters concern- less difficult cases may be managed by the therapist without the
ing Ws and RSs). However, we also found important differences support of supervision).
that account for a complex view of the therapeutic relationship, in The present study allowed us to explore a potentially significant
which projective, countertransferential phenomena interact with hypothesis concerning CT dynamics. However, the study pos-
aspects of a real relationship with the patients. Countertransferen- sesses several limitations. First, our results concerned a single-case
tial phenomena emerged clearly with the manifestation of the and are not generalizable to all psychotherapists. Second, the
conflictual theme composed of the positive Ws “To feel good and naturalistic design allowed us to attain ecological validity, which
comfortable,” “To be loved and understood,” and “To achieve and was based on real-life supervision, but, at the same time, our
help others,” the RO “Rejecting and opposing,” and the RSs single-case design reduced the internal and external validity of the
 COUNTERTRANSFERENCE: A CCRT CASE STUDY 229

study. Finally, there are limitations regarding the CCRT method, Berne, E. (1977). Intuition and ego states: The origins of transactional
as its application would require separate judges for the identifica- analysis: A series of papers. New York, NY: HarperCollins Publishers.
tion of relational episodes and the rating of the components. Betan, E., Heim, A. K., Zittel Conklin, C., & Westen, D. (2005). Counter
Despite these limitations, the observation of CT dynamics as transference phenomena and personality pathology in clinical practice:
part of the supervision process has intriguing implications for An empirical investigation. The American Journal of Psychiatry, 162,
supervision and clinical trainings. In previous studies, the CCRT 890 – 898. http://dx.doi.org/10.1176/appi.ajp.162.5.890
Diener, M. J., & Mesrie, V. (2015). Supervisory process from a supportive-
has been described as a valuable tool for training in interpretation,
expressive relational psychodynamic approach. Psychotherapy, 52, 153–
with the identification and exploration of recurrent interpersonal
157. http://dx.doi.org/10.1037/a0038085
patterns in patients as described by the supervisee (Diener & Freitas, G. J. (2002). The impact of psychotherapy supervision on client
Mesrie, 2015). In the present study, we extend its use to the outcome: A critical examination of 2 decades of research. Psychother-
identification the therapist’s recurrent interpersonal patterns as part apy: Theory, Research, Practice, Training, 39, 354 –367. http://dx.doi
of the supervision process. The observation of numerous relation- .org/10.1037/0033-3204.39.4.354
ship episodes in supervision sessions suggests that the clinical Freud, S. (1959). Future prospects of psychoanalytic psychotherapy. In J.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

investigations of the CCRT method to find associations between Strachey (Ed. & Trans), The standard edition of the complete psycho-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

therapists’ dynamic with patients and therapists’ dynamic in pri- logical works of Sigmund Freud (Vol. 11, pp. 139 –151). London:
vate life can be an important resource for dealing with CT reac- Hogarth Press. (Original work published 1910)
tions in supervision setting. Although in the present study the Gelso, C. J. (2011). The real relationship in psychotherapy: The hidden
interpersonal episodes with patients were spontaneously reported foundation of change. Washington, DC: American Psychological Asso-
in supervision, their systematic exploration using the CCRT ciation. http://dx.doi.org/10.1037/12349-000
method could be introduced as a useful tool to promote therapists’ Gelso, C. J., & Hayes, J. A. (2001). Countertransference management.
Psychotherapy: Theory, Research, Practice, Training, 38, 418 – 422.
reflection concerning their conflictual areas. Namely, the use of
http://dx.doi.org/10.1037/0033-3204.38.4.418
CCRT may help in disentangling countertransferential reactions
Gelso, C. J., & Hayes, J. A. (2007). Countertransference and the thera-
due to therapist personal conflicts (chronic CT) from reactions
pist’s inner experience: Perils and possibilities. New York, NY: Rout-
activated only in presence of specific patients’ features (acute CT). ledge.
For example, in the case treated in the present article, work in Hayes, J. A. (2004). The inner world of the psychotherapist: A program of
supervision on the therapist’s conflictual need to be proud of research on countertransference. Psychotherapy Research, 14, 21–36.
himself would be an opportunity to reflect on the influence of this http://dx.doi.org/10.1093/ptr/kph002
conflictual need with patients. Future studies should be directed Hayes, J. A., & Gelso, C. J. (1991). Effects of therapist-trainees’ anxiety
toward understanding if a similar use of the CCRT method could and empathy on countertransference behavior. Journal of Clinical Psy-
be applied to the understanding of parallel processes in supervision chology, 47, 284 –290. http://dx.doi.org/10.1002/1097-4679(199103)47:
(Hilsenroth & Diener, 2017; Raichelson, Herron, Primavera, & 2⬍284::AID-JCLP2270470216⬎3.0.CO;2-N
Ramirez, 1997; Silberman, 2015; Tracey, Bludworth, & Glidden- Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing counter-
Tracey, 2012; Waugaman, 2015). Different CCRT themes may be transference. Psychotherapy, 48, 88 –97. http://dx.doi.org/10.1037/
activated depending on the power/authority hierarchy in the rela- a0022182
tionship. For example, in the therapist’s relationships with peers, Hayes, J. A., McCracken, J. E., McClanahan, M. K., Hill, C. E., Harp, J. S.,
& Carozzoni, P. (1998). Therapist perspectives on countertransference:
he may be inclined to want to be helpful and achieve, whereas in
Qualitative data in search of a theory. Journal of Counseling Psychol-
his relationship with authority figures (parents and his supervisor),
ogy, 45, 468 – 482. http://dx.doi.org/10.1037/0022-0167.45.4.468
he may have a stronger wish to be loved and understood. In this
Hayes, J. A., Nelson, D. L. B., & Fauth, J. (2015). Countertransference in
sense, the use of the CCRT method may contribute to what has successful and unsuccessful cases of psychotherapy. Psychotherapy, 52,
been described as “a continuous and focused search for a more 127–133. http://dx.doi.org/10.1037/a0038827
comprehensive, nuanced and in-depth understanding of oneself Hess, A. K., Hess, K. D., & Hess, T. H. (2008). Psychotherapy supervi-
and others, and of the processes and phenomena that the practi- sion: Theory, research, and practice. Hoboken, NJ: Wiley.
tioner meets in his/her work” (Rønnestad & Skovholt, 2003, p. 29), Hilsenroth, M. J., & Diener, M. J. (2017). Some effective strategies for the
which constitutes a central developmental process for therapists. supervision of psychodynamic psychotherapy. In T. Rousmaniere, R. K.
Goodyear, S. D. Miller, & B. E. Wampold (Eds.), The cycle of excel-
lence: Using deliberate practice to improve supervision and training
References (pp. 163–188). New York, NY: John Wiley & Sons.
Aviv, A., & Springmann, R. R. (1990). Negative countertransference and Ladany, N., O’Brien, K. M., Hill, C. E., Melincoff, D. S., Knox, S., &
negative therapeutic reactions: Prognostic indicators in the analysis of Petersen, D. A. (1997). Sexual attraction toward clients, use of super-
severe psychopathology. Contemporary Psychoanalysis, 26, 692–715. vision, and prior training: A qualitative study of predoctoral psychology
http://dx.doi.org/10.1080/00107530.1990.10746686 interns. Journal of Counseling Psychology, 44, 413– 424. http://dx.doi
Barber, J. P., Foltz, C., De Rubeis, R. J., & Landis, J. R. (2002). Consis- .org/10.1037/0022-0167.44.4.413
tency of interpersonal themes in narratives about relationships. Psycho- Lingiardi, V., Tanzilli, A., & Colli, A. (2015). Does the severity of
therapy Research, 12, 139 –159. psychopathological symptoms mediate the relationship between patient
Berne, E. (1961). Transactional analysis in psychotherapy: A systematic personality and therapist response? Psychotherapy, 52, 228 –237. http://
individual and social psychiatry. New York, NY: Grove Press. dx.doi.org/10.1037/a0037919
Barber, J. P., Luborsky, L., Crits-Christoph, P., & Diguer, L. A. (1995). A Luborsky, L. (1990a). A guide to the CCRT method. In L. Luborsky & P.
comparison of core conflictual relationship themes before psychotherapy Crits-Cristoph (Eds.), Understanding transference: The CCRT method
and during early sessions. Journal of Consulting and Clinical Psychol- (pp. 15–36). New York, NY: Basic Books.
ogy, 63, 145–148. http://dx.doi.org/10.1037/0022-006X.63.1.145 Luborsky, L. (1990b). The Relationship Anecdotes Paradigm (RAP) inter-
 230 MESSINA ET AL.

view as a versatile source of narratives. In L. Luborsky & P. Crits- Schattner, E., Tishby, O., & Wiseman, H. (2017). Relational patterns and
Cristoph (Eds.), Understanding transference: The CCRT method (pp. the development of the alliance: A systematic comparison of two cases.
102–116). New York, NY: Basic Books. Clinical Psychology and Psychotherapy, 24, 555–568. http://dx.doi.org/
Luborsky, L., & Crits-Christoph, P. (1990). Understanding transference: 10.1002/cpp.2019
The CCRT method. New York, NY: Basic Books. Retrieved from Shafranske, E. P., & Falender, C. A. (2008). Supervision addressing
http://psycnet.apa.org/record/1990-97984-000 personal factors and countertransference. In C. A. Falender & E. P.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: Shafranske (Eds.), Casebook for clinical supervision: A competency-
The core conflictual relationship theme method. Washington, DC: based approach (pp. 97–120). Washington, DC: Psychological Associ-
American Psychological Association. http://dx.doi.org/10.1037/10250- ation. http://dx.doi.org/10.1037/11792-005
000 Sharma, S., & Fowler, J. C. (2016). When countertransference reactions go
Mazzetti, M. (2007). Supervision in transactional analysis: An operational unexamined due to predetermined clinical tasks: How fear of love can
model. Transactional Analysis Journal, 37, 93–103. http://dx.doi.org/10 keep us from listening. Psychotherapy, 53, 302–307. http://dx.doi.org/
.1177/036215370703700202 10.1037/pst0000089
Messina, I., Gelo, O., Sambin, M., Bianco, F., Mosconi, A., Fenelli, A., . . . Silberman, E. K. (2015). Parallel process and the evolving view of the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Orlinsky, D. (in press), Trainees self-evaluation of their development as therapeutic situation. Psychiatry: Interpersonal and Biological Pro-
psychotherapists: An Italian contribution to an international collabora- cesses, 78, 199 –211. http://dx.doi.org/10.1080/00332747.2015.1069649
This document is copyrighted by the American Psychological Association or one of its allied publishers.

tive study on psychotherapy training. Clinical Psychology and Psycho- Singer, B. A., & Luborsky, L. (1977). Countertransference: The status of
therapy. clinical versus quantitative research. In A. S. Gurman & A. M. Razin
Messina, I., Palmieri, A., Sambin, M., Kleinbub, J. R., Voci, A., & Calvo, (Eds.), Effective psychotherapy: Handbook of research (pp. 433– 451).
V. (2013). Somatic underpinnings of perceived empathy: The impor- New York, NY: Pergamon.
tance of psychotherapy training. Psychotherapy Research, 23, 169 –177. Tishby, O., & Vered, M. (2011). Countertransference in the treatment of
http://dx.doi.org/10.1080/10503307.2012.748940 adolescents and its manifestation in the therapist-patient relationship.
Raichelson, S. H., Herron, W. G., Primavera, L. H., & Ramirez, S. M. Psychotherapy Research, 21, 621– 630. http://dx.doi.org/10.1080/
(1997). Incidence and effects of parallel process in psychotherapy su- 10503307.2011.598579
pervision. The Clinical Supervisor, 15, 37– 48. http://dx.doi.org/10 Tishby, O., & Wiseman, H. (2014). Types of countertransference dynam-
.1300/J001v15n02_03 ics: An exploration of their impact on the client-therapist relationship.
Reich, A. (1951). On counter-transference. In R. Langs (Ed.), Classics in Psychotherapy Research, 24, 360 –375. http://dx.doi.org/10.1080/
psychoanalytic technique (pp. 153–159). New York, NY: Aronson. 10503307.2014.893068
Rodolfa, E., Hall, T., Holms, V., Davena, A., Komatz, D., Antunez, M., & Tracey, T. J., Bludworth, J., & Glidden-Tracey, C. E. (2012). Are there
Hall, A. (1994). The management of sexual feelings in therapy. Profes- parallel processes in psychotherapy supervision? An empirical exami-
sional Psychology: Research and Practice, 25, 168 –172. http://dx.doi nation. Psychotherapy, 49, 330 –343. http://dx.doi.org/10.1037/
.org/10.1037/0735-7028.25.2.168 a0026246
Rønnestad, M. H., & Skovholt, T. M. (2003). The journey of the counselor Waugaman, R. M. (2015). Searles’s discovery of the parallel process in
and therapist: Research findings and perspectives on professional devel- supervision. Psychiatry: Interpersonal and Biological Processes, 78,
opment. Journal of Career Development, 30, 5– 44. http://dx.doi.org/10 225–230. http://dx.doi.org/10.1080/00332747.2015.1069643
.1177/089484530303000102 Wheeler, S., & Richards, K. (2007). The impact of clinical supervision on
Rosenberger, E. W., & Hayes, J. A. (2002). Origins, consequences, and counsellors and therapists, their practice and their clients: A systematic
management of countertransference: A case study. Journal of Counsel- review of the literature. Counselling and Psychotherapy Research, 7,
ing Psychology, 49, 221–232. http://dx.doi.org/10.1037/0022-0167.49.2 54 – 65. http://dx.doi.org/10.1080/14733140601185274
.221
Rossberg, J. I., Karterud, S., Pedersen, G., & Friis, S. (2007). An empirical
study of countertransference reactions toward patients with personality Received May 2, 2017
disorders. Comprehensive Psychiatry, 48, 225–230. http://dx.doi.org/10 Revision received October 5, 2017
.1016/j.comppsych.2007.02.002 Accepted October 13, 2017 䡲