What is Parallel Process?

Introduction

Parallel process is a phenomenon noted between therapist and supervisor, whereby the therapist recreates, or parallels, the client’s problems by way of relating to the supervisor.

The individual’s transference and the therapist’s countertransference thus re-appear in the mirror of the therapist/supervisor relationship.

Background

Attention to parallel process first emerged in the nineteen-fifties (1950s). The process was termed reflection by Harold Searles in 1955, and two years later T. Hora (1957) first used the actual term parallel process – emphasising that it was rooted in an unconscious identification with the client/patient which could extend to tone of voice and behaviour. The supervisee thus enacts the central problem of the therapy in the supervision, potentially opening up a process of containment and solution, first by the supervisor and then by the therapist.

Alternatively, the supervisor’s own countertransference may be activated in the parallel process, to be reflected in turn between supervisor and consultant, or back into the original patient/helper dyad. Even then, however, careful examination of the material may still illuminate the original therapeutic difficulty, as reflected in the parallel situation.

What is Acting Out?

Introduction

In the psychology of defence mechanisms and self-control, acting out is the performance of an action considered bad or anti-social. In general usage, the action performed is destructive to self or to others.

The term is used in this way in sexual addiction treatment, psychotherapy, criminology and parenting. In contrast, the opposite attitude or behaviour of bearing and managing the impulse to perform one’s impulse is called acting in.

The performed action may follow impulses of an addiction (e.g. drinking, drug taking or shoplifting). It may also be a means designed (often unconsciously or semi-consciously) to garner attention (e.g. throwing a tantrum or behaving promiscuously). Acting out may inhibit the development of more constructive responses to the feelings in question.

In Analysis

Sigmund Freud considered that patients in analysis tended to act out their conflicts in preference to remembering them – repetition compulsion. The analytic task was then to help “the patient who does not remember anything of what he has forgotten and repressed, but acts it out” to replace present activity by past memory.

Otto Fenichel added that acting out in an analytic setting potentially offered valuable insights to the therapist; but was nonetheless a psychological resistance in as much as it deals only with the present at the expense of concealing the underlying influence of the past. Lacan also spoke of “the corrective value of acting out”, though others qualified this with the proviso that such acting out must be limited in the extent of its destructive/self-destructiveness.

Annie Reich pointed out that the analyst may use the patient by acting out in an indirect countertransference, for example to win the approval of a supervisor.

Interpretations

The interpretation of a person’s acting out and an observer’s response varies considerably, with context and subject usually setting audience expectations.

In Parenting

Early years, temper tantrums can be understood as episodes of acting out. As young children will not have developed the means to communicate their feelings of distress, tantrums prove an effective and achievable method of alerting parents to their needs and requesting attention.

As children develop they often learn to replace these attention-gathering strategies with more socially acceptable and constructive communications. In adolescent years, acting out in the form of rebellious behaviours such as smoking, shoplifting and drug use can be understood as “a cry for help.” Such pre-delinquent behaviour may be a search for containment from parents or other parental figures. The young person may seem to be disruptive – and may well be disruptive – but this behaviour is often underpinned by an inability to regulate emotions in some other way.

In Addiction

In behavioural or substance addiction, acting out can give the addict the illusion of being in control. Many people who suffer with addiction, either refuse to admit they struggle with it, or some do not even realise they have an addiction. For most people, when their addiction is addressed, they become defensive and act out. This can be a result of multiple emotions including shame, fear of judgement, or anger. It is important to be patient and understanding towards those who suffer with addiction, and to realise that most people want to break free from the symptoms and baggage that come with addiction, but do not know how or where to start. Thankfully, there are many preventative measures and programs than can help those who personally struggle with addiction, or for those who have a friend or family member that suffers with addiction.

In Criminology

Criminologists debate whether juvenile delinquency is a form of acting out, or rather reflects wider conflicts involved in the process of socialisation. Deviant behaviour is commonly associated with crime and social deviance. Many of those who are involved in crime, usually grew up in broken homes, or had no authority figure in their life. For some, a life of crime is all they have ever known. This could be a reason as to why there is a debate over whether or not juvenile delinquency is a form of acting out.

Alternatives

Acting out painful feelings may be contrasted with expressing them in ways more helpful to the sufferer, e.g. by talking out, expressive therapy, psychodrama or mindful awareness of the feelings. Developing the ability to express one’s conflicts safely and constructively is an important part of impulse control, personal development and self-care.

What is Acting In?

Introduction

“Acting in” is a psychological term which has been given various meanings over the years, but which is most generally used in opposition to acting out to cover conflicts which are brought to life inside therapy, as opposed to outside.

One commentator, noting the variety of usages, points out that it is often “unclear whether ‘in’ refers to the internalisation into the personality, to the growth in insight, or to the acting within the session”.

Patients

With respect to patients, the term ‘acting in’ has been used to refer to the process of a client/patient bringing an issue from outside the therapy into the analytic situation, and acting upon it there.

The therapist is advised to respond to the issue immediately to prevent further and more disruptive acting in.

Hanna Segal distinguished positive acting in from destructive acting in – both being aimed however at affecting the analyst’s state of mind, whether to communicate or to confuse.

Posture

The term was used in 1957 by Meyer A. Zeligs to refer specifically to the postures taken by analysts in a psychoanalytic session.

Therapists

Psychoanalysis also describes as ‘acting in’ the process whereby the analyst brings his or her personal countertransference into the analytic situation – as opposed to the converse, the acting out of the patient’s transference.

The result is generally agreed to produce a chaotic analytic situation which hampers therapeutic progress.

The term was used rather differently however by Carl Whitaker in the 60’s, so as to refer to the technique whereby therapists increase their involvement in a session in such a way as to ramp up the patient’s anxiety for therapeutic ends.

What is Body-Centred Countertransference?

Introduction

Body-centred countertransference involves a psychotherapist‘s experiencing the physical state of the patient in a clinical context.

Also known as somatic countertransference, it can incorporate the therapist’s gut feelings, as well as changes to breathing, to heart rate and to tension in muscles.

Refer to Countertransference.

Various Approaches

Dance therapy has understandably given much weight to the concept of somatic countertransference. Jungian James Hillman also emphasised the importance of the therapist using the body as a sounding-board in the clinical context.

Post-Reichian therapies like bioenergetic analysis have also stressed the role of the body-centred countertransference.

There is some evidence that narcissistic patients and those suffering from borderline personality disorder create more intense embodied countertransferences in their therapists, their personalities favouring such non-verbal communication by impact over more verbalised, less somatic interactions.

Orbach

Susie Orbach has written emotively of what she described as “wildcat sensations in my own body…a wildcat countertransference” in the context of body countertransference. She details her role responsiveness to one patient who evoked in her what she called “an unfamiliar body experience…this purring, reliable and solid body” to counterbalance the fragmented body image of the patient herself.

The Irish Experience

In Female Trauma Therapists

Irish psychologists at NUI Galway and University College Dublin have recently begun to measure body-centred countertransference in female trauma therapists using their recently developed ‘Egan and Carr Body-Centred Countertransference Scale’ (2005), a sixteen symptom measure.

Their research was influenced by developments in the psychotherapy world which was beginning to see a therapist’s role in a therapeutic dyad as reflexive; that a therapist uses their bodies and ‘self’ as a tuning fork to understand their client’s internal experience and to use this attunement as another way of being empathic with a client’s internal world. Pearlman and Saakvitne’s seminal book on vicarious traumatisation and the effect of trauma work on therapists has also been an important directional model for all researchers studying the physical effects of trauma work on a therapist.

High levels of body-centred countertransference have since been found in both Irish female trauma therapists and clinical psychologists.[16] This phenomenon is also known as ‘somatic countertransference’ or ’embodied countertransference’ and it links to how mirror neurons might lead to ‘unconscious automatic somatic countertransference’ as a result of postural mirroring by the therapist. Hamilton et al (2020) revisited BCT in a larger sample of 175 therapists (122 females) and that the a similar pattern of body-centred countertransference was reported as in the previous two studies. The most common being:

  • Muscle Tension: 81%;
  • Tearfulness: 78%;
  • Sleepiness: 72%;
  • Yawning: 69%;
  • Throat constriction: 46%;
  • Headache: 43%;
  • Stomach disturbance: 43%;
  • Unexpectedly shifting in body: 29%;
  • Sexual arousal: 29%;
  • Raised voice: 28%;
  • Aches in joints: 26%;
  • Nausea: 24%;
  • Dizziness: 20%; and
  • Genital pain: 7.5%.

The authors reported how previous researchers did not find BCT because surveys have previously failed to ask specifically about it, and have focused on emotional and cognitive and relational CT. The authors finally called for larger longitudinal studies and also larger sample sizes to allow a comparison of gender and orientation effects as well as whether higher levels affect levels of burnout and therapeutic engagement and treatment outcomes 26. Hamilton, L., Hannigan, B., Egan, J., Trimble, T., Donaghey, C., & Osborn, K. (2020). An exploration of body-centred countertransference in Irish Therapists. Clinical Psychology Today, 4(2), 26-38.

Loughran (2002) found that 38 therapists out of 40 who had responded to a questionnaire (which was distributed to a sample of 124 therapists) on a therapist’s use of body as a medium for transference and countertransference communication reported that they had experienced bodily sensations (nausea or churning stomach, sleepiness, shakiness, heart palpitations, sexual excitement, etc.) while in session with patients.

Frequency of Symptom Occurrence

A list of the frequency of occurrence of body-centred countertransference symptoms reported by trauma therapists (Sample A: 35 Female Irish Trauma therapists[20]) and Irish clinical psychologists (Sample B: 87 Irish Clinical Psychologists[21]) in the previous six months ‘when in-session with a client’ is given below in order of frequency:

  • Sleepiness (A; 92%, B; 76%).
  • Muscle Tension (A; 83%, B; 79%).
  • Yawning (A; 65%, B; 77%).
  • Unexpected shift in body (A; 77%, B; 57%).
  • Tearfulness (A; 71%, B; 61%).
  • Headache (A; 54%, B; 53%).
  • Stomach Disturbance (A; 41%, B; 46%).
  • Throat Constriction (A; 34%, B; 36%).
  • Raised Voice (A; 29%, B; 33%).
  • Dizziness (A; 26%, B; 19%).
  • Loss of voice (A; 32%, B; 18%).
  • Aches in joints (A; 37%, B; 18%).
  • Nausea (A; 23%, B; 18%).
  • Numbness (A; 29%, B; 15%).
  • Sexual Arousal (A; 26%, B; 11%).
  • Genital pain (A; 6%, B; 2%).

Somatisation

A small but significant relationship was found between female trauma therapists’ level of body-centred countertransference and number of sick leave days taken, suggesting a possible relationship between uncensored body-centred countertransference and somatization. This relationship was not however found in clinical psychologists who were working mainly with a non-trauma population. Therapists have noted the connection between a tendency for some clients to express emotional discomfort by focusing on bodily symptoms rather than being able to put their emotional distress into words. It is thought that such processes are more common in people who have experienced childhood abuse and trauma.

Recent research which measured female genital arousal in response to rape cues found that women when listening to rape, consent or violence developed genital arousal more frequently than men. It also might explain the relatively frequent reported experience of sexual arousal amongst Irish female trauma therapists. Further validation of body-centred countertransference in psychologists and therapists is on-going in both NUI Galway and Trinity College Dublin.

Cautions

Therapists have been warned against assuming too automatically that their body-feelings always involve somatic resonance to the client, as opposed to being produced from their own feelings/experiences – the same problem appearing with countertransference generally.

What is Countertransference?

Introduction

Countertransference is defined as redirection of a psychotherapist‘s feelings toward a client – or, more generally, as a therapist’s emotional entanglement with a client.

Refer to Body-Centred Countertransference.

Early Formulations

The phenomenon of countertransference (German: Gegenübertragung) was first defined publicly by Sigmund Freud in 1910 (The Future Prospects of Psycho-Analytic Therapy) as being “a result of the patient’s influence on [the physician’s] unconscious feelings”; although Freud had been aware of it privately for some time, writing to Carl Jung for example in 1909 of the need “to dominate ‘counter-transference’, which is after all a permanent problem for us”. Freud stated that since an analyst is a human himself he can easily let his emotions into the client. Because Freud saw the countertransference as a purely personal problem for the analyst, he rarely referred to it publicly, and did so almost invariably in terms of a “warning against any countertransference lying in wait” for the analyst, who “must recognize this countertransference in himself and master it”. However, analysis of Freud’s letters shows that he was intrigued by countertransference and did not see it as purely a problem.

The potential danger of the analyst’s countertransference – “In such cases, the patient represents for the analyst an object of the past on to whom past feelings and wishes are projected” – became widely accepted in psychodynamic circles, both within and without the psychoanalytic mainstream. Thus, for example, Jung warned against “cases of counter-transference when the analyst really cannot let go of the patient…both fall into the same dark hole of unconsciousness”. Similarly Eric Berne stressed that “Countertransference means that not only does the analyst play a role in the patient’s script, but she plays a part in his…the result is the ‘chaotic situation’ which analysts speak of”. Lacan acknowledged of the analyst’s “countertransference…if he is re-animated the game will proceed without anyone knowing who is leading”.

In this sense, the term includes unconscious reactions to a patient that are determined by the psychoanalyst’s own life history and unconscious content; it was later expanded to include unconscious hostile and/or erotic feelings toward a patient that interfere with objectivity and limit the therapist’s effectiveness. For example, a therapist might have a strong desire for a client to get good grades in university because the client reminds her of her children at that stage in life, and the anxieties that the therapist experienced during that time. Even in its most benign form, such an attitude could lead at best to “a ‘countertransference cure’…achieved through compliance and a ‘false self’ suppression of the patient’s more difficult feelings”.

Another example would be a therapist who did not receive enough attention from her father perceiving her client as being too distant and resenting him for it. In essence, this describes the transference of the treater to the patient, which is referred to as the “narrow perspective”.

Middle Years

As the 20th century progressed, however, other, more positive views of countertransference began to emerge, approaching a definition of countertransference as the entire body of feelings that the therapist has toward the patient. Jung explored the importance of the therapist’s reaction to the patient through the image of the wounded physician: “it is his own hurt that gives the measure of his power to heal”. Heinrich Racker emphasised the threat that “the repression of countertransference…is prolonged in the mythology of the analytic situation”. Paula Heimann highlighted how the “analyst’s countertransference is not only part and parcel of the analytic relationship, but it is the patient’s creation, it is part of the patient’s personality”. As a result, “counter-transference was thus reversed from being an interference to becoming a potential source of vital confirmation”. The change of fortune “was highly controversial. Melanie Klein disapproved on the grounds that poorly analysed psycho-analysts could excuse their own emotional difficulties” thereby; but among her younger followers “the trend within the Kleinian group was to take seriously the new view of counter-transference” – Hanna Segal warning in typically pragmatic fashion however that “Countertransference can be the best of servants but is the most awful of masters”.

Late Twentieth-Century Paradigm

By the last third of the century, a growing consensus appeared on the importance of “a distinction between ‘personal countertransference’ (which has to do with the therapist) and ‘diagnostic response’ – that indicates something about the patient…diagnostic countertransference”. A new belief had come into being that “countertransference can be of such enormous clinical usefulness….You have to distinguish between what your reactions to the patient are telling you about his psychology and what they are merely expressing about your own”. A distinction between “neurotic countertransference” (or “illusory countertransference”) and “countertransference proper” had come (despite a wide range of terminological variation) to transcend individual schools. The main exception is that for “most psychoanalysts who follow Lacan’s teaching…counter-transference is not simply one form of resistance, it is the ultimate resistance of the analyst”.

The contemporary understanding of countertransference is thus generally to regard countertransference as a “jointly created” phenomenon between the treater and the patient. The patient pressures the treater through transference into playing a role congruent with the patient’s internal world. However, the specific dimensions of that role are coloured by treater’s own personality. Countertransference can be a therapeutic tool when examined by the treater to sort out who is doing what, and the meaning behind those interpersonal roles (The differentiation of the object’s interpersonal world between self and other). Nothing in the new understanding alters of course the need for continuing awareness of the dangers in the narrow perspective – of “serious risks of unresolved countertransference difficulties being acted out within what is meant to be a therapeutic relationship”; but “from that point on, transference and counter-transference were looked upon as an inseparable couple…’total situation'”.

Twenty-First-Century Developments

Further developments in the current century might be said to be the increased recognition that “Most countertransference reactions are a blend of the two aspects”, personal and diagnostic, which require careful disentanglement in their interaction; and the possibility that nowadays psychodynamic counsellors use countertransference much more than transference – “another interesting shift in perspective over the years”. One explanation of the latter point might be that because “in object relations therapy…the relationship is so central, ‘countertransference’ reactions are considered key in helping the therapist to understand the transference”, something appearing in “the post-Kleinian perspective…[as] Indivisible transferencecountertransference”.

Body-Centred Countertransference

Psychologists at NUI Galway and University College Dublin have recently begun to measure body-centred countertransference in female trauma therapists using their recently developed “Egan and Carr Body Centred Countertransference Scale”, a sixteen symptom measure. High levels of body-centred countertransference have since been found in both Irish female trauma therapists and clinical psychologists. This phenomenon is also known as “somatic countertransference” or “embodied countertransference” and links to mirror neurons and automatic somatic empathy for others due to the actions of these neurons have been hypothesised.