SELF-AWARENESS THROUGH PLAY

International Journal of Play Therapy, 14(2), pp. 87-102 Copyright 2005, APT, Inc.

Current Practices

COUNTERTRANSFERENCE PLAY: INFORMING AND ENHANCING THERAPIST

SELF-AWARENESS THROUGH PLAY

Eliana Gil Multicultural Clinical Center

Lawrence Rubin St. Thomas University

Abstract: The study of countertransference among therapists working with children and adolescents is a relatively recent phenomenon, but the lack of attention paid to resolving countertransference that arises during the course of play therapy is surprising. The most commonly suggested way to address countertransference in the literature is through the development of therapist self-awareness during verbal discourse in supervision. This article addresses the rationale for, and provides examples of an active approach for dealing with potentially counter therapeutic reactions. This technique, known as countertransference play, derives from the field of art therapy and provides therapists with a logically derived means of understanding and working through countertransferential responses.

Since its introduction by Sigmund Freud nearly a century ago (Freud, 1909), clinicians have come to perceive the concept of countertransference as a valuable tool for enhancing therapeutic

Eliana Gil, Ph.D., is affiliated with the Multicultural Clinical Center in Springfield, VA. Lawrence Rubin, Ph.D., is a Professor of Counselor Education at St. Thomas University in Miami, FL. Correspondence regarding this article can be directed to Dr. Eliana Gil,emgil@earthlink.net.

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outcome. Countertransference has evolved conceptually from its origins in adult psychoanalysis to broad applicability in the area of child and adolescent treatment. Initially and narrowly defined as the therapist’s reaction to the client’s transference (Freud, 1909), the concept of countertransference has expanded to include any and all of the therapist’s thoughts, feelings, and behaviors that may undermine treatment, and that arise in response to the client, the client’s family, or even elements of the client’s ecosystem (O’Connor, 1991).

Understanding of the therapeutic impact of countertransference has also expanded beyond both psychoanalysis and the treatment of adults to therapeutic work with children and use in non-analytic treatment. In therapy with children and adolescents, the therapist’s blind spots, biases, and unrecognized emotional needs may result in inappropriate emotional and behavioral responses, intolerance, need to be liked by the client, and attempts to change the client (Landreth, 2002). Metcalf (2003) has even argued that countertransference responses in child therapists exceed those found among adult therapists.

Even in light of this expanded view of the impact of countertransference, the means of addressing and resolving it have been described simply as “talking about it.” Existing literature focuses on nonspecific verbal techniques designed to help the therapist develop awareness, insight, and self-understanding through reflection, supervision, or treatment (Robbins & Jolkovsky, 1987; Rosenberger & Hayes, 2002; Sarles, 1994). This emphasis on intellectual and verbal means of addressing and resolving countertransference is not necessarily a problem, particularly when the treatment is predominantly verbal or oriented to adults. However, traditional, adult-oriented, verbal therapies for addressing countertransference may not be optimal for those involved in the treatment of children and adolescents, and for those using play therapy in particular, because play therapy is not exclusively dependent on the verbal elements of traditional therapy, that is, discussion, inquiry, and interpretation.

Few efforts have addressed countertransference and the means of resolving it in this area. In looking at the possible reasons for this

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neglect, Schowalter (1985) posited that child therapists may be uncomfortable with the type of self-examination required for those involved in the highly active and hands-on therapeutic work that therapy for children and adolescents demands. Regardless of the possible reasons for this neglect, efforts must be made by child therapists to address and harness countertransference responses that arise in play therapy with children and teenagers. To do so, an understanding of the importance of these responses is necessary.

Countertransference with children and adolescents Traditional psychoanalytically-defined countertransference is

conceptualized as a reciprocal relationship between the client’s transference and the therapist’s unconscious. This is a linear and limiting conceptualization, particularly when working with children and teenagers, who bring their entire system into the therapy session. According to a number of writers in the field (Bernstein & Glenn, 1988; McCarthy, 1989; Wright, 1985), awareness of the countertransference that manifests itself in child therapy is the key to understanding the child’s psychological issues, the child’s family, and the relationship between child and therapist. This implies that the therapist’s countertransference is not limited to his or her unconscious responses. Instead, it may be a conscious cognitive, behavioral, or affective reaction to some characteristic of the child or the child’s family. Gabel and Bemporad (1994a; 1994b) suggested that the therapist’s countertransference response may be to the agency in which the treatment is taking place. Waksman (1986) warned child analysts that their persistent and unresolved childhood issues could contaminate their work with both their child clients and their clients’ parents. A recent book entitled A Shining Affliction (Rogers, 1995) chronicles how countertransference can affect the therapy relationship as well as a clinician’s professional and personal stability. Given the myriad of potential sources of countertransference in working with young clients, it becomes important to ask the question, “What is it about working with young clients that is so potentially evocative of countertransference?”

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Why young clients evoke countertransf erence Therapeutic work with young clients presents its own unique

countertransference challenges. Brandell (1992) observed that unlike adults, children (a) lack conscious motivation for treatment, (b) are far more action oriented, (c) are easily frustrated, and (d) are inherently regressive. According to Brandell (1992), for these reasons, and also because young clients readily act out, engage in primary process thinking, and tax therapists’ defenses more readily than adults, they evoke powerful countertransference. In a similar vein, Gabel and Bemporad (1994) observed that because children are behaviorally and emotionally unpredictable, have ready access to material of a sexual and aggressive nature, and may be embedded in unstable family systems, they are potential countertransference tinderboxes.

Several authors have addressed countertransference responses to clients with various pathologies and presenting problems. In discussing depressed youth, Bemporad and Gabel (1992) observed that preschoolers’ helplessness, teenagers’ confusion, and suicidal children’s anger and confusion can induce significant countertransference reactions. Similarly, powerlessness, anger, divided loyalty, and sadness that children of divorce experience can be emotionally taxing to their therapists (Garber, 1992). The treatment of adolescents with borderline traits who are in constant turmoil and who regularly practice splitting and projection can push therapists beyond their ability to control their emotions and responses (Mishne, 1992). Finally, abused children, the most vulnerable and fragile of all of a therapist’s clients, challenge therapists’ skills and boundaries, as evidenced by literature on treating abused children and the issue of countertransference (Cattanach, 1994; Gil, 1991; James, 1989).

Typical countertransference responses Specific countertransference reactions evoked by young clients

are as varied as the clinical problems they present. These reactions may be elicited by the client and/or the client’s family. According to Sarles

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(1994), “Countertranference is a phenomenon that exists in every encounter with a child and adolescent patient, and includes the full spectrum of emotions and reactions including anger, anxiety, dreaded waiting, envy, joy, love and hate” (p. 73). For Sarles, these responses and reactions are not so much a peril, but an inherent challenge in therapy with young clients. Similarly, McCarthy (1989) suggested that countertransference may be manifest in therapists’ avoidance of their own anxiety or their clients’ anxiety. This might take the form of avoiding certain issues in counseling that might arouse the anxiety of either of the participants. Schowalter (1985) noted that countertransference could take many forms: (a) preemptory diagnosis or discharge planning, (b) under-inclusion or over-inclusion of the parents in treatment, (c) competitiveness with the parents, and (d) excessively positive or negative feelings toward the client. Gabel and Bemporad (1994b) noted that young clients may lead therapists to over-identify with them. Therapists use the child in the service of their own needs, and therapists take on a “go-between” role in the family.

In exploring the relationship between countertransference and childhood depression, Brandell (1992) observed that therapists experienced a range of responses, including helplessness, futility, frustration with parents, desire to protect, confusion, rescue fantasies, boredom, and the need to relive their own childhood and/or adolescent experiences. Working with therapists of abused children, Marvasti (1992) found countertransference reactions that included reluctance to explore abuse-related issues, identification with the victim or the abuser, vicarious guilt and shame, and failure to report. In an analysis of countertransference responses to children with chronic illness, Sourkes (1992) identified therapists’ guilt over their own good health, inappropriate disclosure of emotions, powerlessness, and grief related to losses in their own lives. Finally, and writing specifically in the context of play therapy, O’Connor (1991) cautioned therapists to monitor their countertransference so that they could avoid frustration, savior fantasies, over identification with their clients, and burnout.

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Each of the foregoing countertransference responses is extremely powerful and threatens to undermine therapeutic efficacy and outcome, and each calls for a means of resolution that creates successful opportunities for self-processing in order to overcome obstacles presented by the countertransference. The authors suggest that therapists can address their countertransference by using strategies that are consistent with the mode of treatment they typically use with their young clients, namely, play therapy.

Addressing countertransference In traditional psychoanalysis with both children and adults,

countertransference is addressed and resolved through the therapist’s own analysis. In a review of the general empirical literature on countertransference, Rosenberger and Hayes (2002) found that anxiety management, self-integration, and clarification were the most widely cited means of countertransference resolution. Robbins and Jolkovski (1987) noted that the most effective ways to deal with countertransference included awareness, understanding, alertness, and implementation of a theoretical framework, along with an investigative approach to self-awareness; however, they did not specify how to use these means.

In the arena of countertransference resolution in non-analytic therapy for children and adolescents, Waksman (1986) discussed a note- taking technique, a departure from standard practice. Up until this time, all means of doing so were strictly verbal in nature. Several years later, O’Connor (1991) focused the discussion of countertransference to play therapy. He, like others before him, indicated that therapy for the therapist could be helpful. Self-awareness was also an important tool for O’Connor, who added consultation, supervision, and other techniques to the list of resources for dealing effectively with countertransference. In her review of countertransference patterns among play therapists, Metcalf (2003) noted that group supervision, consultation, and peer process groups, as well training play therapists to recognize signs of countertransference, could be helpful. However, like others before them,

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neither Metcalf nor O’Connor suggested direct use of play and play therapy to address countertransference by therapists. If therapists are relying on the medium of play in therapy, relying on the same tools of play therapy to inform and enhance their own self-awareness seems logical.

Informing and enhancing therapist self-awareness through play Use of play therapy tools to help play therapists address

countertransference has been seemingly absent from the child counseling and play therapy literature; however, in the related field of art therapy, art media in supervision has been used. In this context Rubin (1994) argued that “The therapist can use his/her artwork as an aid to self- understanding in addition to helping the patient” (p. 58). Rubin suggested that while in session, therapists could verbally interact with their clients by sharing their thoughts through art work and could also draw portraits of their clients outside the session in order to resolve countertransference. Similarly, Wadeson (1995) successfully encouraged art therapists to draw pictures of themselves with their clients, of the therapy hour; of themselves with their clients’ illnesses; and of the beginning, middle, and end of treatment.

Countertransference play The authors suggest integrating play therapy strategies as a way

to expand those techniques clinicians already utilize rather than proposing an either/or dichotomy. We also consider the possibility that therapists who are not practitioners of play therapy might explore or experiment with these ideas to further enhance their self-understanding. Should these ideas prove helpful, transferring them to supervision relationships might prove to be of interest. At the same time, personal familiarity with the curative properties of generic and therapeutic play will likely facilitate clinical experimentation personally or with supervisees.

For therapists to ask themselves or for supervisors to ask their supervisees to “check in” after therapy sessions is not unusual. This

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checking in process may or may not result in substantive insights or discussions, but post-session processing can be fascinating and noteworthy and can enhance introspection and understanding. The use of therapeutic play can augment perceptions, narrow or expand focal points, and access and use affect and energy in the therapy relationship.

In the following sections we demonstrate how various forms of play and play therapy can amplify self-awareness and countertransference awareness through both nondirective and directive means. As will be apparent, either or both of these approaches can be readily applied to therapists’ self-work and in supervision.

Countertransference art As mentioned earlier, clinicians have been encouraged to use art

to understand themselves and their clients. Many adults withdraw from art experiences because of feelings of performance anxiety or fear of being judged or evaluated as artists. The art task must therefore be user- friendly and inviting.

Most clinicians will not have time or energy to process countertransference responses after every session. These strategies may therefore be most relevant after frustrating, disturbing, or exhilarating sessions, or when clinicians begin to experience unexplained feelings of fatigue, irritability, emotionality, hypervigilance, or hyperarousal. This requires time management skills and a willingness to promote personal and professional self-growth.

Few tools are required: a box of Nupastels (colored chalks) available at any art or crafts store, white paper (standard 8-1/2-inch x 11- inch paper), slightly wet paper towels, and felt-tip black ink pens. Clinicians sit down in front of a flat surface and prepare to do the art process. The directive is: “Use these chalks to make lines, shapes, images, words, symbols, filling as much or as little of the page with whatever comes to mind.” The request for abstract art can decrease some of the self-consciousness associated with making representational art. Clinicians then allow themselves time to reflect on their process (physical energy, affective state, movement, intensity of line pressure,

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physiological changes), content (images, symbols, words, or shapes), and association (what thoughts and feelings from the art work do they connect to the client or session). A useful approach is to view the page from all directions, hold it close or near, leave it and return to it, and document initial as well as subsequent responses.

In addition to this kind of nondirective countertransference art, the therapeutic supervisor may take a more directive approach by suggesting to the therapist to use the art materials to “depict a particularly troubling or challenging therapy session…one that left you with a lingering, and perhaps bothersome feeling.” The therapist may do this for a supervision session of a similar nature. The supervisor may expand the directive instruction to “depict a troubling session, placing yourself, or your feelings, or even the clients pathology, in the artwork.”

As an illustration of this directive countertransference art approach, I (Rubin) directed a supervisee to draw a picture of the relationship between herself, her young female client, and the client’s mother. Figure 1 presents that depiction, showing the therapist and the client protected under a table from the raging mother, located on top of the table. Previously unaware of how she tended to protect, and thus isolate clients from angry and abusive parents, the therapist drew connections to similar patterns both in her own marriage and in the family in which she had been raised.

Figure 1

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Countertransf erence sand world Although sand therapy has been used for a number of years, it

has gained popularity in the last decade (Ammann, 1996; Boik and Goodwin, 2000; Kalff, 1980; Lowenfeld, 1935/1967; Ryce-Menuhin, J. 1992). This countertransf erence technique will be more accessible to those already practicing sand therapy because it requires the following props: a sand box, fine white sand, a collection of miniatures, and water. Contemporary sand therapy includes the use of sand boxes of many sizes and shapes as well as the use of containers, such as Tupperware boxes, cat litter boxes, and shoe boxes. The formality and structure of the technique will vary, as well as the size of the miniatures collection.

Clinicians should prepare themselves to make their countertransference tray by making sure they will be free of interruptions, by giving themselves permission to take time without internal pressure to rush, and by making the environment as quiet and comfortable as possible. The directive is simple: “Allow yourself to check in and see what thoughts, feelings, and responses you have about the work you’ve just completed with … [a specific client or over a specific period of time]. Then review the miniatures in front of you and use as few or as many as you like and place them in the sand box.” Once clinicians feel that they have completed the task, they are encouraged to explore their reactions as they stand back and observe the sand scenario they have created.

In addition to the nondirective approach, supervisors may guide their supervisees to create a sand box scene that “depicts a particularly troubling session you had with a client or the relationship between you and a client who evokes strong feelings in you.” As an example, a therapist struggling with her own impending divorce, feeling overwhelmed, angry and depressed, conducted a session with a child who was neglected and who was extremely needy and dependent. She subsequently made two sands trays in supervisory sessions (Figure 2). The first tray, which represents the therapist’s sand depiction of the first half of a session in which she was unable to nurture the child, shows

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how she equated herself with the client by using the same animal to represent both of them. The only difference was that the therapist gave herself a boat to float in and used a traffic light in an attempt to control her anger. In the second sand scene, which represented the second half of the same session, the therapist regained control, using a turtle to slow herself down and trees to soften the scene, and thus her emotions. While both characters were spotted dogs, suggesting not equality but equivalence, the therapist’s character was larger, and therefore in a better position to nurture. Through this sand work, the therapist/supervisee developed considerable understanding into how her countertransference had played it self out in the session.

Figure 2

Note that creating images using art or sand can be evocative and powerful experiences. As informative and useful as these tools might be, they may also be disquieting in the type or level of affect that they generate. Clinicians may find processing their work with colleagues or consultants to be helpful, and may use other methods such as collage, dollhouse play, and metaphoric story-telling to enhance self-awareness and address countertransference.

CONCLUSION

The study of countertransference dates back nearly a century, with roots deeply embedded within the psychoanalytic tradition.

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Historically defined within that tradition as the therapist’s unconscious response to that of the client’s, early countertransference literature focused on traditional verbal therapies with adults. While clinical attention was later broadened to encompass therapy with children, even after it became evident that children could evoke powerful countertransference, little research or clinical discussion was directed at dealing with countertransference that arises in child therapy. Only recently has the clinical study of countertransference been untethered from the unconscious, and expanded beyond the therapy room to include the client’s entire ecosystem. While this represents a considerable advance in understanding of the phenomenon, the means of addressing and resolving it has been exclusively verbal. This article has taken a step toward remedying this deficiency by suggesting how the modality of play, the same modality used in therapy with children and teenagers, can be applied to countertransference awareness and resolution in self- work and supervision.

Countertransference play is a logical outward extension of play therapy, whereby any therapists experienced with play, can explore their responses to a client, as well as to members of the client’s system, or even to agencies involved in the client’s care. Therapists can use countertransference play before a session with a particularly troubling client or after a session that leaves them with strong, inexplicable, and/or uncomfortable feelings or thoughts. This technique may also lend itself to both individual and group supervision that is either directive or nondirective and that incorporates a wide range of expressive media including art, sand, and symbol work. Other possibilities may include collage work, role playing, and story telling.

While the development of countertransference play was both logically derived from our clinical work and based on our collective intuitive approach to play therapy and play therapy supervision, we are not suggesting that it is a simple technique that can be readily applied by anyone with a modicum of play therapy experience. Instead, countertransference play, like play therapy, is a potentially rich and complex resource for clinicians who have dedicated significant efforts to

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acquiring a firm foundation in the theories and practice of counseling children and teenagers in general, and of play therapy in particular. Just as the discipline of play therapy has increased its empirical foundation through experimental outcome study, we recommend that similar efforts be directed at countertransference play and readers are encouraged to use the examples provided in this brief article as a springboard for creative applications of their own.

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