Transference in therapy occurs when the patient unknowingly is transferring feelings about someone from their past onto the therapist. Freud described transference as the deep, intense, and unconscious feelings that develop during the therapeutic relationship with a patient. Over the years, the field of psychoanalysis, most likely influenced by attachment theories and early cognitive psychology, has adopted concepts such as templates or patterns of familiar feelings, implicit cognitions and habitual behaviours, which are manifested in the therapy relationship, evidently a common ground with the field of cognitive and behavioural therapy.
Psychologist and author Jonathan Shedler recently wrote in The Psychologist (2023) that “psychotherapy is a relationship and patients bring their templates and patterns into it. As psychotherapists, we enter the gravitational field of our patients’ problematic relationship patterns, experiencing and participating in them. Through recognizing our own unavoidable participation in these patterns, we help our patients understand and rework them.“ Dr Shedler feels this is the very heart of psychoanalysis and, he would be right.
But where does that leave the typical cognitive-behavioural therapy alliance? Could CBT approaches deal much more effectively with attachment issues when and if time allows it, and if true, then how is this so, and why? Because indeed, unlike with other psychotherapies, the expectation from the patient or referring agency would be that the presenting issues and health complaints ought to be addressed rapidly, within very few hours of CBT, as opposed to months or years. This presents the typical CBT therapist with unique challenges when collaboratively setting up realistic therapy goals. The therapy environment (the physical space), coupled with the need for flexible boundaries and challenging ‘working’ conditions (e.g., real life exposure) is precisely why the traditional therapy relationship had to evolve towards an empathic, yet dynamic and collaborative, relationship – the type that you might have with an inspirational but compassionate personal trainer or a motivational life coach. This brings a whole new meaning to the traditional therapeutic relationship that relies much more on transference and countertransference to explain patients’ relationship patterns over years of work. ‘Time’ is a privileged resource as far as the CBT therapist is concerned.
Cognitive-behavioural models (of which there are many), propose that, based on our early experiences, through various associations and learning processes, we develop emotional and cognitive templates, which call for specific behavioural actions or ‘defences’ in a crisis. For example, I know I am unlovable (this is a felt-sense, rather than a verbal expression, supported by historical evidence), however, I can manage a difficult situation if I act in very specific ways, without error or exception (i.e., I must always be cheerful, available and helpful).
As such, we have at our disposal very specific and very well-rehearsed repertoires or responses to a variety of triggering social situations, which we keep repeating throughout our lives. Such patterns, shaped by early poor attachment problems, often coupled with our biological inheritance (Beck and Bredemeier, A unified model of depression, 2016) lead to long-term psychopathology which is maintained by very rigid and specific cognitive, affective and behavioural templates meant to support and sustain relationships with significant others, in spite of a deeply rooted felt-sense that one is being flawed and/or vulnerable.
NA-CBT investigates neuroaffective research, evolution theories, mammal behaviours and emotions studies, and suggests that our brain is the organ solely responsible for controlling the body, whose principle mission is to keep the whole organism alive. Ymmordina and Damasio’s 2009 study and research on emotions and learning, over the last thirty years, adds to the earlier research on social-learning by Albert Bandura, and points towards the neural basis of emotions, which play a central role in social cognition and decision-making. Given how incredibly social and interdependent our species is and since our biology is inherently a social one, we are directly dependent on other people for the translation and formulation of our own sense-of-self. And so, when we interact with one another, we construct a sense-of-self and assign meanings and roles to ourselves, in order to accommodate each other, both mentally and physically. This process of survival, or learning how to relate in order to improve our chances, begins at birth with the mother, and continues with the main care givers, whoever they may be.
In that respect, the latest generation of behavioural therapists, unlike in the beginnings of the last century, acknowledge that within the therapeutic space, besides the practical and dynamic component of the change process, the therapist also acts as a sounding board, often needed for more accurate reflections of The Self.
A brief parenthesis here, the development of the original school of behaviourism into so many different methods and approaches, from exposure, to cognitive psychology and attention training, imaginal rescripting or mindfulness and acceptance, is a testimony to its true nature, its ability to adapt, integrate new theories, and evolve. Relying on research and evidence from all domains of psychology and psychotherapy, physiology, or philosophy even, has always created an advantage for the typical CBT clinician, with very popular results over the years such as SIT, DBT, Compassion Therapy, Mindfulness and Acceptance.
Infants trust others’ observations more than their own. As they grow, they start to rely on their perspective more, indicating not only a unique learning process in infancy, but how much we rely on learning through experiencing and associations to produce emotions and filter actions. It is therefore natural to understand why our first relationships with our primary care givers are suddenly crucial in developing a safe and secure sense-of-self; relying on a safe and secure template will no doubt facilitate trusting and long-lasting relationships throughout life. On the other hand, when these early relationships are disrupted (with or without intention) a sense of insecurity and vulnerability will dominate the internal sense-of-self, and as such (and this is crucial), we have to create a series of cognitive, affective and behavioural templates that will help us navigate the complexities of life with our perceived vulnerability or weakness (i.e. I am unlovable.. I am useless.. or.. I am worthless, etc.). Once again, this would not only increase our chances of survival, but often ensure some degree of progress, and on a bigger scale is even facilitating evolution. Such neuroaffective templates are deeply rooted in our neural networks, where they can be activated with ease by triggering an autopilot system, when and if our brain, the survivalist expert, decides this is needed. An individual would not need to be aware of such embedded and well-rehearsed strategies and there is no need to make an effort to remember them. In that sense, emotions are nothing short of reactions the body has to specific stimuli – external (i.e., a large bear is chasing me) or internal (i.e., I imagine my friend broke his wrist).
An emotion may therefore be understood as a call for action. When we are afraid of something, our hearts begin to race and our muscles tense. This emotional reaction occurs automatically, and physical sensations known as feelings occur only after we become aware in our brain of such physical changes; only then we start experiencing the feeling of fear. So, our brain is constantly receiving signals from the body, registering what is going on inside of us. The brain will then process the signals in very well-designed neural maps, which it further organises into sensory centres. Feelings occur when the maps are read, and it becomes apparent that emotional changes have been recorded as snapshots of our physical state. All these processes happen at an incredible speed.
Without making it sound too complicated, CBT therapists excel at raising awareness by educating clients about the link between thoughts, behaviours, emotions, and our ‘inner templates’ also known as schemas, schema processes and schema maintenance. Dr Donald Meichenbaum calls such patterns or templates ‘tyrannical’. The tyranny of ‘shoulds’, ‘musts’ and ‘if–then rules’ maintains victimisation because of the relentless attacks that such rules unleash on individuals’ core needs, genuine desires or life values; for example, ‘I should always be perfect’ or ‘I must always prioritise Others over Me’… ‘If I let anyone down, then I am not a likeable person, and I will end up alone’.
I should… I must… I always have to…
Identifying the problematic patterns alone is only the beginning, because then an ample process of evidence gathering begins; new learning and new life experiences are collaboratively developed with the therapist, in order to challenge the original templates and create new ones that will serve victims’ needs and goals much better. And this would be the main difference between transference-based approaches and cognitive-behavioural approaches. A trusting and empathic therapeutic alliance is essential when explaining patients how these sets of patterns and templates (aka conceptualisations, formulations, or internal-working models) operate in the background all the time, and how it even impacts on the current therapist–client relationship. For instance, drawing attention to, how unnecessarily hard the patient is trying to be the ‘perfect client’, self-sabotaging the progress, procrastinating, filtering out successes, suppressing emotions, or telling the therapist, what the client thinks the therapist would want to hear. All such transferential processes would be exposed non-critically and empathically within the safety of the therapy alliance with a clear aim to learn and improve.
Once the true cost of early templates and patterns, defences, or rules for living, is exposed and evaluated, a shift towards new life strategies and coping would be negotiated. A lot of shoulder-to-shoulder teamwork, creativity and problem-solving skills are involved in designing new social experiences and real-life experiments that aim to undermine the inherited sense-of-self.
Clinical practice reflects time and time again, the need for adaptability and out-of-the-box thinking required to enhance learning and self-efficacy during the therapy process.
Young Jane was struggling with selective mutism, social anxiety and spells of depression when she came to therapy. She would not communicate her feelings, concerns, dreams or expectations until we changed the therapy location to her art studio. A very talented sketch artist, when she was asked to draw a self-portrait of how she feels right now and another of how she would like to feel in one year’s time, suddenly a new language and specific plans started to emerge.
Martin, a dedicated teacher, developed PTSD after suffering a homophobic attack at the hands of two of his students. This led to social isolation and withdrawal from a lot of activities that he used to enjoy in the past, as well as significant autobiographical alternations such as, a different sense-of-self, more vulnerable, less appreciated and so on. It took more than 10 hours of therapy for him to learn to trust his male therapist and the process began with baby steps, increasing the length of each session from 10 minutes to a full 60 minutes and gradually accepting to take his coat off during sessions and, then the hat, followed by the sunglasses and the headphones. Having a handshake at the beginning and the end of every session was one of the early therapy goals. Besides the usual trauma and memory processing, real-life experiments and new social experiences were agreed on, helping him reclaim some of his pre-trauma hobbies; several realistic role-plays involving new coping skills were rehearsed during sessions in preparation. Eventually going out for a meal at his favourite restaurant with a friend he missed and had not seen in over two years was a game changer, according to Mark’s feedback months later during one of the final follow up sessions.
The above stories are not attempting to show off the range of techniques and instruments available to the cognitive-behavioural therapist, but simply to emphasise the creativity employed, the thinking outside the box, the problem-solving skills, and not least the dynamic and organic nature of the therapeutic alliance which constantly evolves with clients’ needs and goals.
Specialist literature explains how mental disorders are precipitated and perpetuated by psychological rigidity and lack of ability to adapt to new situations. Rigidity impacts on the ability to learn new coping skills and achieve a shift from a narrative and global sense-of-self to a much more fluid sense-of-self.
It seems therefore important to agree early, on the overarching goals of any form of psychotherapy which more than likely would include, improving clients’ psychological resilience, undermining mental health symptoms, and essentially helping individuals move on from a victimising role, in no particular order. Research is very clear, in order to achieve that, a shift from psychological rigidity to psychological adaptability would be required through new learning and skills acquisition in particular.
As such, it seems logical that the therapeutic relationship, whatever label it might have, ought to facilitate all of the above. Over 30 years of clinical and teaching experience, as well as a significant body of research data drawn from clinical supervision studies, point towards a few interesting findings. Here is the list of the top ten things that could influence the therapy relationship:
1. What the therapist believes would work within the therapeutic space.
2. Therapist’s own values – influenced no doubt by early experiences, personal narratives or inner-working models.
3. Therapist’s school of thought or therapist’s preferred modality (usually are the same).
4. Therapist’s beliefs in regard to their preferred school of thought, which they often feel they must represent.
5. Therapist’s assessment skills and ability to diagnose or formulate a case or the ability to develop an internal working model or conceptualisation (here is an example).
6. Therapist’s psychopathology knowledge or lack thereof.
7. Therapist’s ability to consistently update their knowledge and skills in line with recent research.
8. Therapist’s ability to reflect back, ask for feedback and change therapy course in line with patient’s feedback (aka listening skills with a plus).
9. Ability to work collaboratively towards goals and teach new skills.
10. The quality of clinical supervision and the clinical supervision modality.
Internal-working models are cognitive-behavioural formulations that present an ideal platform for an open dialogue about relationships and the need to change. When early experiences or a disrupted attachment leads to a negative sense-of-self, I am a victim or I am weak, or unlovable or flawed, this embodied sentiment is experienced in all situations with all people. The victim of a negative sense-of-self is forced during earlier years (by the survivalist expert, our brain) to adapt or die of neglect. And thus, the child develops sophisticated strategies, life rules or defences meant to help him or her navigate through life with the knowledge the felt-sense provides (i.e., the knowledge that they are unlovable). This is the cognitive-behavioural translation of what analysis calls defences, patterns or templates from the past. Such deeply rooted defences become over time important life values, rules or guidelines with direct behavioural implications for example: ‘I have to act (implicit behaviour) in a specific way in order to overcome this situation.‘
Whilst helpful to the victimised individual at an earlier stage in life, and at different times even functioning as very useful surviving tools, these defences also encourage psychological rigidity. As they decrease the need for new learning and they are repeated time and time again, in various situations in the here-and-now, with only a minor degree of success (e.g., ‘I should always be available to all of my friends in spite of how exhausted I am’… ‘I must never say NO to anyone’… ‘I should always hide my true feelings’… ‘I should never show my true emotions’…).
Behavioural and cognitive approaches can deliver positive outcomes not only because interventions constantly evolve in line with new evidence and research, but also because therapists adapt and focus their attention on presenting complaints, maintenance and problem-solving, rather than constraining psychotherapy boundaries. The therapy relationship would not be authentic and responsive to patients’ immediate needs, if therapists would rigidly subscribe to a 50-minute session when going through reliving or imagery rescripting with a traumatised patient, for example. Not to mention real-life exposure programs that can last two or three hours outside of the boundaries of the clinic. The relationship adapts and adopts yet another tone, when the therapist shows willingness to swap roles with an OCD patient and touches unsanitised objects or goes on a spider ‘hunt’ in the garden shed with an arachnophobia patient.
Traditional psychotherapies on the other hand, seem to be less willing to redefine the therapy relationship boundaries and align it with their clients’ needs, in favour of clear and strict boundaries. However, there is no evidence to suggest that bonding, respectful and compassionate gestures such as offering a cup of tea, shaking a patient’s hand or gently touching someone’s shoulder in a reassuring manner, is likely to disrupt the therapy process or outcome. Equally so, there is no data to support the idea that silence gaps for prolonged periods of time during therapy, does anything else apart from increasing internal negative ruminations or worry, self-blame or self-critical thinking. Becoming a good object or a positive role model and even appropriate self-disclosure is acceptable and encouraged by the therapy alliance, just like displaying genuine sadness and empathy whilst hearing and ‘feeling’ a sad narrative; e.g., This is what it feels like to me, is this what is this what is going on with you? And… what would I remind you to do in this difficult situation?
If transference is nothing short of feelings triggered by associated thoughts, images or video reels, that can be traced back to early experiences and may result in questionable behaviours in the present-moment, I fail to see how this not exactly what CBT calls a contextual cognitive-behavioural conceptualisation, simply labelled differently in the psychoanalytic literature.
The cognitive-behavioural therapist relies on this type of conceptualisation, formula or indeed ‘inner working-model’ to help the victimised individual ‘verbalise’ their internal psychological pain and translate the untranslatable sense-of-self, thus exposing its true meaning and intention. In doing so, the therapist increases the victim’s ability to learn new coping skills and effectively proposes a way forward by ‘acting as if’; e.g., ‘What would my life look like if I was loved and appreciated by significant others – as opposed to holding on to a core idea that nobody accepts me no matter how hard I try’...
Within the safety of the therapeutic alliance, the CBT therapist will question the felt-sense and accompany the client on journey towards a new sense-of-self. This will often involve active and realistic short-term plans and essentially starting to live life as if the opposite of whatever the felt-sense is suggesting, is in fact the truth. And revealing that these defences bring more emotional pain, instead of opportunity and joy.
So, what about the question posed in the title? The answer simply does not matter, it seems that, what is needed is more cross-training and dialogue between different schools of thought, alongside a thorough review of data, in order to upgrade therapists’ views about what a therapeutic relationship ought to look like. Schools competing for supremacy does not seem to provide an answer, on the contrary.
All of the above therapy instruments would eventually lead to the best, healthiest and most independent version of the victimised client, irrespective of therapists’ personal beliefs about the intervention itself. Independence from the reliance on rigid defence mechanisms facilitates new learning, adaptability and not least psychological flexibility, which in itself, is one of the main ingredients for a pathology free life. If only, some therapists would also adopt more psychological flexibility themselves…
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According to my good friend and colleague Dr Donald Meichnebaum one of the founders of CBT, positive outcomes are further enhanced by developing resilience rooted in individuals’ culture, personal values and strengths. Meichenbaum has reminded us in his characteristic manner that we are not only homo-sapiens but also homo-narrans or story tellers or narrators, therefore the stories that individuals tell will determine if victimised individuals will fall into the 25% traumatised group or 75% symptoms-free group (Meichenbaum, lecture notes 2022).
[ proof reading and editing by Ana Ghetu ]
NeuroAffective-CBT 