MOTIVATIONAL INTERVIEWING: PROJECTION, TRANSFERENCE, COUNTERTRANSFERENCE
Even skilled therapists can find working with a client complex if they bring up in that client their own issues or if the client projects previous abuse onto the therapist. Divine Charura and Charlene Parker guide us through.
LET’S START WITH A CASE VIGNETTE
Roy attends for an assessment session. He shares how his life has been destroyed by drugs and alcohol. He has had many detox’s and rehabs. Although he had periods of abstinence, he has never maintained sobriety long enough to get his life back on track. After the death of his wife, his substance misuse increased. Social services became involved a few months ago and now his two children have been taken into care because of his domestic violence and neglect.
In the assessment with a practitioner, he appears to shift from ambivalence to being clear that he wants to be abstinent but then reverts back to ambivalence. He states he has “nothing to live for and there’s no point stopping” because his wife is dead and children who mean the world to him are now in care for the rest of their teenage years. He blames his relapse on this and on other clients in his previous detox for being destructive and one female member of staff for being uncompassionate about his past.
1. What might be happening in this process?
2. What else should be considered alongside the usual motivational interviewing techniques employed?
This article explores a challenging perspective in psychodynamic ideas in order to help professionals who use motivational interviewing as a technique in their work. We aim to simplify both MI and the psychodynamic ideas we present, as they can often be quite complex and thus misunderstood. In doing this, we do not aim to minimise the complexity involved in these modalities but rather to illuminate some perspectives and concepts we believe are important.
We will start by giving an overview and critique of MI. Through the fictitious case vignette given at the start of this article, we will outline the psychodynamic concepts of transference, countertransference and projection which we propose are important in working towards shifting ambivalence in complex cases.
We would like to start by highlighting the importance of practitioners creating a therapeutic environment and having the competencies to offer facilitative skills of therapeutic change. These have long been cited (Rogers 1959) as empathy, unconditional positive regard (being nonjudgmental) and congruence (genuineness).
Charura & Nicholson (2013, see references) gave an overview of the importance of the facilitative conditions and the therapeutic relationship. They concurred that the curative factor of the therapeutic relationship can be ultimately found in its humanising, relational quality
When people feel judged or unaccepted and perceive that the care and support they are receiving is tokenistic – someone merely doing their job – they are likely to resist engagement and will ultimately drop out. We thus agree that the facilitative conditions for therapeutic change help clients to work through their ambivalence and promote positive outcomes. Alongside the facilitative conditions, it is important to employ micro-skills which include open-ended questions, affirmations, reflections and summaries.
WHAT IS MI?
Motivational interviewing has been described as a self directive, enhancing self motivational intervention (Lussier & Richard 2007). Exploring and resolving the individual’s ambivalence is the focus of MI (Miller & Rollnick 2002). Through engaging clients to clarify their strengths and aspirations, their motivation to change is evoked and this in turn promotes autonomy of decision making (Rollnick et al 2010). In this process, the practitioner concentrates on the clients’ desire to change more than their resistance to change.
THE FOUR MAIN PRINCIPLES OF MOTIVATIONAL INTERVIEWING
Ambivalence is the main factor in a person’s outlook and decision to change. So the practitioner’s role is to understand ambivalence and act on it in order to promote and encourage positive behavioural changes. There are four main principles of MI (After Treasure 2004):
1. To express empathy by the use of reflective listening, thus showing the client that you understand their experience and their point of view. An example drawing from the case vignette could be an empathic response like “Roy, I can see that it is so difficult to feel motivated when you can’t see anything to change or live for”.
2. Identify the discrepancies between the clients’ most deeply-held values and their current behaviours. An example of this could be “Roy, on one hand you say that you want to stop drinking and get some counselling, then work towards getting your children back – yet on the other hand, you say there is no point and that you will drink yourself to death. How can you achieve your goal if you are doing both?”.
3. Roll with the resistance by responding with empathy and understanding rather than confrontation. An example of this could be “Roy, through coming here today and through what you have said that this is hard for you but also that this is something you want to do... I am starting to ask myself how can you achieve your goal?”.
4. Uphold self-efficacy by building the individual’s confidence that change is possible (Shifting the decisional balance towards change). An example of this could be “How can I/we support you to change and to meet you goals”?
At this point, we advocate exploring with the client possible barriers and challenges to change and how they can be supported to overcome this. This then fits in with the MI concept of preparing the client for change-talk, which is often defined by the client’s consideration, motivation or commitment to change.
As already mentioned, throughout the session the facilitative conditions must be present. From our practice in addictions work over many years, and in line with good practice, at end of the session we ensure that:
>> to keep the client motivated and leave with a clear perspective, we collaborate with the client to formulate a clear plan; this might be about offering further appointments, detox, rehab, or further referral
>> we often ask clients to reflect to the practitioner their feelings about the session, their new found clarity and the plan
>> their commitment to the plan.
MI theory and techniques can be employed by most trained practitioners to satisfactory results. But our experience is that, when working with complex cases, the motivation for change fluctuates, and ruptures in the session can occur resulting in clients dropping out. This can often result in unsuccessful outcomes or a “relapse revolving door scenario” where clients return to the service time and time again with the same or other addictions.
There are criticisms raised about MI literature (Treasure 2004; Lussier & Richard 2007) but we believe that each practitioner is able to relate to the challenges and limitations of their idiosyncratic techniques and responses with clients. Here, we illuminate and focus more on the psychoanalytic ideas which will enhance practitioners’ knowledge and skills in motivational interviewing.
PSYCHODYNAMIC PERSPECTIVES: TRANSFERENCE, COUNTER-TRANSFERENCE AND PROJECTION
In any therapeutic encounter there are multiple dynamics which impact on the process. Such dynamics can include unconscious/conscious processes, fantasies, wishes, feelings towards the practitioner from the client, influences from our past relationships and who the client reminds us of and vice versa.
The concept of ambivalence, which MI focuses on, could be argued to be embedded in unconscious processes hailing from attachment theories and primary relationships where clients first learned their decision-making processes. The ambivalence about whether to abstain from substance or not could thus be seen as a combination of physical addiction, psychological dependence, and as influenced by many other relational factors from the past. It then becomes clear that to look at the MI encounter as a simple process of employing techniques in stages is a limited view.
It is from this basis that we highlight the importance of having some basic knowledge and considerations for psychodynamic ideas to inform practice. The concepts we outline were first used by Freud in his psychoanalytic work with clients and have continued to be developed, challenged and critiqued (Crawley and Grant 2003). We believe that they are helpful in not only shifting the decisional balance in MI when working with complex cases but also in generic therapeutic work which we do with clients.
Before outlining some concepts, we stress that what we are advocating is the importance of the knowledge of these psychodynamic concepts rather than their psychotherapeutic use. This is mainly because psychodynamic/psychotherapeutic practice is specialist work which requires many years of training and close supervision. To work in a psychotherapeutic capacity without the adequate training and skills would be unethical practice.
Transference refers to the projection of past experiences with a significant figure onto a current relationship with the therapist/practitioner. It can be seen as mirror to the internal world of the client (Grant and Crawley 2002 p16). An example of transference dynamics could be where a client directs painful or repressed thoughts and feelings about their abusive father/mother or experience onto the practitioner. This would result in the client behaving in a particularly unpleasant way to the practitioner.
It is not hard to envisage scenarios where, when a particular client works with a certain practitioner in the team, conflict arises or the client becomes destructive/ lapses. In such cases of strong transference, even the most skilled MI practitioner could find working with such a client complex because they might be bringing up in the client their own issues about previous abuse which they then project onto the practitioner.
The way to work with transference in classic psychoanalytic/psychodynamic practice is to offer an interpretation of the client’s feelings towards the practitioner in the light of current patterns, and in the here-and-now and past memories (Grant and Crawley 2002).
This sounds authoritarian but what the process entails in practice is an empathic offer of what the practitioner is experiencing and sensing as meanings of the unconscious processes and dynamics in the relationship. Naming and exploring possible meanings and difficulty in the process will start to shift the decisional balance.
Countertransference is a process by which the practitioners’ feelings, thoughts and behaviours are stimulated by their client and results in a personal response without reference to processing the content and its meaning (Paul and Charura, in press). An example is when a client talks about his/her mother and the issues in that relationship. This can then stimulate issues about the practitioner’s own relationship with his/her own father and response from this personal perspective.
This is counter to seeking to understand and make sense of the client’s thoughts and feelings. Treasure (2004) concludes that the style of the therapist is a critical component in facilitating change; particular dynamics can be detrimental to the overall outcome. The countertransference expectations of the therapist on the client can reduce the client’s motivation towards change.
Projection is a psychological process which involves the attribution of unacceptable thoughts, feelings or behaviours to others. The disowned aspects of self are transferred onto another (Grant and Crawley 2002). In practice, practitioners can find that a client – such as Roy in the case vignette who blames others for stressing him out to the point of drinking – cannot look at his own destructive behaviour, because it would be too anxiety provoking, and defends against it by projecting it onto others thus giving what makes sense to him as a good reason for his behaviour.
This projection is an unconscious process, not deliberate, so the practitioner needs to be aware of the importance of treating it with sensitivity but at the same time be willing to work with the client as they become aware of their own destructiveness.
Grant and Crawley (2002) suggested that transference and projection are worked through by exploring the client’s responses to the practitioner and collaboratively trying to understand what the experience is about in relation to the present moment as well as in the clients’ past and present relationships.
In the therapeutic relationship, note the importance of transference, contertransference and projection from the perspective that:
>> the client’s experience of difficult past primary relationships is likely to come to the fore in the room as the work develops (transference and projections onto the practitioner); the practitioner must be prepared
to work with and through these with their client in a non-defensive way with a focused intention of helping.
>> the practitioner knows that their own relational patterns will have an impact on their own internal reaction to the client and so must ensure that they do not negatively affect the therapeutic process.
Supervision is helpful in helpful in managing practitioner reactions to transference and own countertransference (Charura and Wallace 2012).
Motivational interviewing is beneficial to people, helping them to identify their risky behaviours and motivating them to change But behavioural changes can be a long process and the practitioner must persevere and encourage clients to reach their end goal (Lussier & Raichard 2007). In this process, different dynamics interplay. Going beyond a simplistic view of MI, a higher standard of practice emerges when considering psychodynamic principles of transference, countertransference and projection when working with clients. This is increasingly important especially when working with complex cases in which our capacities as practitioners to use MI effectively becomes extended.
Divine Charura is a UKCP-registered psychotherapist and a senior lecturer in counselling and psychotherapy at Leeds Metropolitan university. He has many years experience of working in psychiatric and therapeutic settings, and co-managed a detox and rehabilitation service for five years. He has a private practice where he offers psychotherapy and supervision.
Charlene Parker is a specialist addictions nurse, using motivational interviewing techniques with complex cases. She is also interested in working with clients who present with dual diagnosis. Before clinical training, she worked with marginalised groups including homeless clients and in residential detox and rehabilitation services.
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