“It is only by analysing the transference situation to its depth that we are able to discover the past both in its realistic and phantastic aspects”. (Klein, 1952). In this essay, I shall attempt to define the psychoanalytic terms transference and countertransference. I shall begin with definitions and Freud’s discovery of transference, and go on to explain how the idea of transference and its utility in the analytic process has changed with time. Change came with later psychoanalysts, but the most profound impact may have been that of Melanie Klein, and so I consider her work, and the impact of theories based on projection and projective identification. I then attempt to review what transference is when it is in the clinic, referencing several post-Freudian analysts. Before discussing what countertransference is, I consider the term negative transference, in order to distinguish it from countertransference. I go on to think about transference in the analytic session, how it works, and also to reference the importance of erotic transference. I consider if transference is used outside the clinic given that psychoanalysis is not just a form of therapy. Lastly, I make a few short conclusions.

How does one define transference, which I regard as fundamental to the analytic process? Laplanche and Pontalis (1967) give one of the best definitions, in my opinion: “A process of actualisation of unconscious wishes. Transference uses specific objects and operates in the framework of a specific relationship established with these objects. Its context par excellence is the analytic situation. In the transference, infantile prototypes re-emerge and are experienced with a strong sensation of immediacy.” Transference, whilst unconscious can be brought into consciousness and enacted. Many analysts believe that how the analysand reacts to the frame i.e. the fixed timing and location of the session, is a form of transference. Lateness is interpreted as a punishing anger, and early arrival as something revealing anxiety. Transference might come into a session as (attempted) manipulation or as a provocation. Frosh (2012, p.192) cites Spillius et al (2011) in considering how transference became central to psychoanalysis from its early beginnings. It now seems to be much more about externalising unconscious fantasy, informed by the past and developed in the relationship in the analytic sessions, whereas Freud held that it was a displacement of an unconscious idea from a person in the analysand’s past, on to the analyst in the room. Having originally thought transference interfered with the work of analysis, he came to see value in the analysand’s feelings, believing that they had value as a means of understanding a neurosis. In his 1914 paper “Remembering, repeating and working-through” he explored how primitive emotions could have free expression and become useful for self-exploration.

The origin or discovery of transference is attributed to Freud. However, in 1917, in letters to first Sandor Ferenczi, and then to Karl Abraham, he draws their attentions to the work of Georg Groddeck, with whom he had just started corresponding and who may be regarded as the first ‘wild analyst’. Groddeck eventually stayed outside of the psychoanalytical organisations, but was famous for his work on somatic and psychosomatic illnesses. Groddeck had emphasised the importance of transference, particularly negative transference, which I explore later in this essay, which had impressed Freud. Freud originally thought of transference as an obstruction and that it inhibited a patient from free associating. Transference was discovered by Freud, when thinking of the difficulties that caused Breuer to stop seeing his patient, known as ‘Anna O’. Breuer was worried by the unconscious emotional charge in the room, as it was erotic. It complicated the work. It was a little later that Freud himself came to understand its efficacy, as a tool for ‘working through’. The analysand brings buried feelings and thoughts from past relationships and ‘transfers’ them to the analyst.

Freud identified its more positive influence (1905, p.116) as part of what became known as the ‘Dora case’. He wrote of “new editions of the impulses and phantasies” which was about how feelings were transferred into the room when they properly belonged elsewhere. Freud came to see himself as the recipient of ‘transferred feelings’; things that were unresolved from past relationships and a window into the unconscious of the analysand. Although ‘Dora’ ended her therapy with him, and he came to see it as a ‘failed case’, it is one of the landmark moments in the development of psychoanalysis. He thought if analysands could be helped to identify what was being transferred, especially how patterns of past maladaptive relationships tended to repeat, then they could be helped to moderate the impacts. Freud went on to note that it was the most difficult, as well as the most important, part of analytic technique. In 1914, he was writing that the analytic setting was a playground where the repetitions could take place and in his 1915 paper, “Observations on transference love” he noted “there can be no doubt that the outbreak of a passionate demand for love is largely the work of resistance”.

A little after Freud, Strachey (1934) wrote about transference interpretation. Its weight and significance is conveyed by “that which the analyst most feared and most wished to avoid”. One of the reasons for the fears, are what is happening to the analyst. Money-Kyrle (1956) noted that “the analyst’s experience of the patient’s projections may be linked with the analyst’s own internal reactions to the material.” I develop this below when discussing projective identification and countertransference, which Money-Kyrle (ibid. p.361) called a “delicate receiving apparatus”. It was Fairbairn (1958) who best summarised the centrality of working with transference as part of the treatment: “psychoanalytic treatment resolves itself into a struggle on the part of the patient to press-gang his relationship with the analyst into a closed system of the inner world through the agency of transference” (my italics). The transference is of little use without acknowledgement, and more significantly, interpretation. Strachey understood it as a lengthy process, “modification of the patient’s super-ego is brought about in a series of innumerable small steps by the agency of mutative interpretations, which are effected by the analyst in virtue of his position as object of the patient’s id-impulses and as auxiliary super-ego.”

Around the time that Strachey was writing, Melanie Klein was developing her ideas and in 1946 produced the seminal paper on projective identification. She wrote, “projective identification involves projection in that it is an identifying of the object with split-off parts of the self. Projective identification has given an added dimension to what we understand by transference, in that transference need not now be regarded simply as a repetition of the past.”. Transference, from a clinical point of view was evolving. Sandler (1987) felt it gave an ‘added dimension’ to transference “in that transference need not now be regarded as a repetition of the past”. Arundale and Bellman (2011) wrote that the projection of “early infantile states of mind” are akin, clinically, to transference and countertransference in having both ‘communicative’ and ‘evacuative’ functions. Feldman (2009) described Klein’s formulation of projective identification as “an unconscious phantasy in which the patient expelled what were usually disturbing contents into another object”. He goes on to describe how the object is then transformed in the patient’s mind because it now contains the expelled material. He added that it was not just a “method of evacuation” but provides other comforts for the patient such as believing that they can possess or control the object. “The patient’s phantasies, expressed by gross or subtle, verbal or non-verbal means, may come to influence the analyst’s state of mind”. 

The modern and Kleinian work of analysis is to contain the projections, work them through until they can be handed back, ‘introjected into’ the analysand, in a tolerable form. Klein saw transference as feelings being remembered and used. Steiner (1993) described it thus “We have come to use countertransference to refer to the totality of the analyst’s reactions in his relationship with the patient. The recognition of the importance of projective identification in creating these reactions led naturally to the idea that counter-transference is an important source of information about the state of the mind of the patient.” However, he warns “self-deception and unconscious collusion with the patient to evade reality makes counter-transference unreliable without additional corroboration”. Brenman-Pick (1985) reminds us that “constant projecting by the patient into the analyst is the essence of analysis”. Feldman (2009) describes projective identification as using an ‘omnipotent phantasy’ to defend primitive anxieties. He also highlights Bion’s work on containment to note “the mother’s responses to normal or pathological varieties of projective identification, emphasised the mother’s crucial function of taking in and allowing herself to be affected by the infant’s projection of severe anxiety or distress”.

The analyst also has his or her own transference. One thing the analyst has to be aware of, and be able to analyse, is the possibility of an analysand working through an enactment, sometimes called an ‘actualisation’. This is when something unconscious affects the participants and the responses cannot be contained and become part of the behavioural responses. Often these can lead to damaging and inappropriate responses known as ‘boundary transgressions’. The analyst needs to isolate the analysand’s responses and to understand when they might be acting out something informed by past relationships. If done well and appropriately, it becomes something to discuss, to ‘work through’ and can be explored as part of the therapy. Auchincloss and Samberg (2014) describe it thus: “Enactment is a co-constructed verbal and/or behavioural experience during a psychoanalytic treatment in which a patient’s expression of a transference fantasy evokes a countertransference “action” in the analyst. Enactments are “symbolic interactions” … in that they carry unconscious meanings for both patient and analyst, unconsciously initiated by the patient and evoking unconscious compliance in the analyst.” What is happening is exemplified by Brenman-Pick (1985), describing the clinical temptation to be a maternal figure, “we may act out by becoming excessively sympathetic to the patient”.

In the clinic, it is often this relationship, with the primary carer, that is transferred, and the analyst that needs to do the maternal containing, usually because it had been absent in the past, through reasons of a mother being overwhelmed and neglectful. Brenman-Pick (1985) described a state of mind which sought another state of mind “just as a mouth seeks a breast as an inborn potential.” The analysand may make assumptions about the analyst’s personal life and therefore thoughts, even though she has no information on which to base such assumptions. The analyst uses these fantasies rather than dismiss them. Winnicott (1947) goes so far as to describe ‘exploiting’ the transference. An analyst might note how the analysand is prone to assume something about them especially if it feels judgmental. This may be because of a past where judgment, particularly if it was from a parent, has been common. An analyst can illustrate that the analysand is responding as if she was attacked, and yet there was no attack from what is likely to have been an open ended, perhaps ambiguous comment. It might manifest as a need to impress, perhaps by listing achievements, which might reveal an insecurity about not being respected, by a teacher or an employer. It might be a hastiness to agree with an interpretation, which is little more than speculation, but is transferred from avoiding conflict in other relationships, often a spouse.

Arundale (2011) reflects on Feldman’s work in this area and writes “As he understands it, the historical objects from the patient’s past are alive in the present moment as internal objects, so that they are available as transference objects”, she goes on to add that when the transference relationship is understood and properly experienced it allows the past to become clearer and for internal objects to be modified. She credits Strachey (1934) with creating a template for psychic change for future generations of analytic schools by identifying “mutative transference interpretation”. In the work, the relationship with the analyst is a foundation; a template for how future relationships might be formed to break the patterns of the past. Ultimately the aim is to reach a Bion moment of significance, when the analysand can be introduced to his or herself. Frosh (2012, p.190) puts it very concisely “…the reality of the analyst’s behaviour. Why should the analyst’s silence be interpreted as hostile judgment rather than supportive listening? The answer here is ‘because of the transference’”. Sandler (1976) considered the manipulative element of the dyadic relationship and wrote that “in the transference…the patient attempts to prod the analyst into behaving in a particular way and unconsciously scans and adapts to his perception of the analyst’s reaction”. He writes about the analysand resisting the impulse to be aware of any “infantile relationship” that he/she might be trying to impose. Separately Sandler (1990 p. 869) wrote about how an analysand might try “to impose on the situation a role relationship with the analyst”, which is the enactment described above.

What to do with all this transferential material, though? Roth (2001) observes that the transference has different levels of interpretation in the clinic. At one level, it links what is happening in the clinic with the analysand’s past, but moves to a level linking events in the analysand’s life outside the clinic and on to interpreting unconscious phantasies about the analyst and the analysis. The deepest level is to “enact phantasy configurations”. Roth opens her paper referencing another analyst’s material about a dream, but what is being considered is transference. She goes on to use other clinical examples of her own, to consider the multiple ways a transference can be interpreted and what the clinician needs to be aware of. How to separate layers of material and how to identify working with transference on the countertransference. I write about countertransference in more detail below. Roth notes how she is reviewing “complex transference manifestations” as she attempts to maintain the analysand’s trust and interest, but to get her to understand the links between what she is saying and what it means, and how it is being brought into the clinic. She guides us through her work deeper, by transference interpretation level, past an aggressive projective identification to a level four enactment which is a kind of seduction scene. Her conclusions summarise the importance of transference, which I regard as the foundation of the analytic work; “our sense of conviction about our patient’s internal world comes ultimately from our understanding of the here-and-now transference relationship between us”.

What happens when the analysand is transferring something from a difficult past relationship, or needs to project aggressive, hostile and unwanted, intolerable feelings into the analyst? This is the realm of negative transference; hostile feelings that the analyst’s presence elicits in the analysand. Analysts often have to start their work by demonstrating a caring side to become a ‘good object’, so that there is trust. This is the ‘therapeutic alliance’, but most often the effective work is done when the analyst becomes the ‘bad object’, and can show the analysand that the clinic is a non-judgmental space, and that difficult feelings can be contained and worked through. Understanding a phenomenon such as negative transference and more importantly, appreciating its utility, was largely the work of Melanie Klein, who had developed the ‘good breast/bad breast’ understanding of infantile love and hate, and she noted that the analyst was often split by the analysand into a good figure and a bad one, often in the same session. The demand of the analyst is to contain the anger, to ‘work through it’ and to behave as the nurturing mother of early infancy, and once again, to not judge the person from whom the hostility has come. The gentlest of questions, the most ambiguous of references, the calmest of silences can all be interpreted as hostile by an analysand with a negative transference. In Klein’s 1952 paper she wrote “we can fully appreciate the interconnection between positive and negative transferences only if we explore the early interplay between love and hate, and the vicious circle of aggression, anxieties, feelings of guilt and increased aggression, as well as the various aspects of objects towards whom these conflicting emotions and anxieties are directed.” And “I became convinced that the analysis of the negative transference, which had received relatively little attention in psycho-analytic technique, is a precondition for analysing the deeper layers of the mind.”

There is something in the word ‘counter’ that suggests resistance and even an aggressive return, as in ‘counterpunch’. Negative connotations perhaps, so is it related to negative transference? No. Countertransference has more than one definition, but is not negative transference. It might be a psychic response to it, though. Laplanche and Pontilis (1973, p.92) define “the whole of the analyst’s unconscious reactions to the individual analysand – especially to the analysand’s own transference”. Also, “some authors take the counter-transference to include everything in the analyst’s personality liable to affect the treatment, while others restrict it to those unconscious processes which are brought about in the analyst by the transference of the analysand.” This is difficult because if, as in some definitions, it is to be used as a tool in the analytic work, how can we deploy something that is unconscious? Nonetheless, prominent post-Freudians such as Winnicott (1947) thought it played a central role in the analytic work. He described it as “the analyst’s love and hate in reaction to the actual personality and behaviour of the patient”. For Freud, it was the analyst’s transference, how she had been affected by what the analysand had brought to the session. He regarded it as the neurotic response of the analyst, not a good thing, and something to be resolved by more analysis for the analyst. Sandler (1976) notes that Freud saw it as impeding understanding, because it clouded the mind, which was the tool needed to do the work; an interference with the work of interpretation.

More lately, with a Kleinian influence, it has come to mean the specific response of an analyst to the analysand’s transference. It is about taking in the analysand’s projections and being able to contain them. The analyst, in this way, comes to feel what the analysand is feeling and her ability to absorb and reflect helps the analysand when the projections are passed back and reintrojected. The analysand starts to feel things are more manageable and to be able to master integration, shifting from paranoid-schizoid positions to a depressive one. The working out of transference and countertransference go on together as a relational event – the feelings in the analysand become the data to analyse, upon which interpretations and reflections can be based. The analysand will be looking for signs that what she has projected into the analyst is being contained and perhaps cared for, or alternatively what is happening, if it is causing some panic or discomfort. In this understanding of countertransference there is a view that it signals to the analyst what is happening in the analysand’s unconscious life; rather different to the Freudian sense that it was exclusively an issue for the analyst. So, it is both the analyst’s own transference and her response to the analysand’s transference. Not only does an analyst feel her own countertransference but must then productively and subsequently analyse it.

Heiman (1950) was the first analyst to consider the positive influence of countertransference, “an instrument of research into the patient’s unconscious” – she describes it as the “patient’s creation” and that it is a part of the patient’s persona. Therefore, the analyst can use it as a guide to understanding the transference the analysand offers. She noted that the analyst has to sustain the feelings stirred within her, and not to let them go as the analysand does, but to “subordinate them to the analytic task” functioning as a “mirror reflection” to the analysand. Her definition was “all feelings which the analyst experiences towards his patient”. Her paper was the first to suggest that countertransference was ubiquitous. All feelings and everywhere makes it a complicated tool to use. To what extent is one dealing with the analysand’s material and to what extent might it be more about the analyst’s own past? Being able to engage, and yet analyse the situation with detachment, is a critical skill. Heimann wrote that the analyst “has to perceive the manifest and latent meaning of his patient’s words, the allusions and implications, the links to former sessions, the references to childhood situations behind the descriptions of current relationships”. She best summarised it as “in the comparison of feelings roused in himself with his patient’s associations and behaviour, the analyst possesses a most valuable means of checking whether he has understood or failed to understand his patient.” 

The post-Heimann approach continues to evolve and become more nuanced. Roth (2018) takes Heimann’s mid-twentieth century view as countertransference being something pathological, and something for the analyst to own for her own self-analysis, and shows how it moved into being accepted as a tool to help with an analysand’s development. How to utilise it has been subtly different in the techniques of many analysts and he cites Balint, Fairbairn, Tower and Winnicott. Nonetheless he emphasises Heimann’s view of it as a creation brought to her. What it meant was a shift from conventional analysis requiring the neutrality of the analyst, sometimes called ‘the blank screen’, to the analyst being actively involved in a process; a more dynamic therapeutic alliance, properly open to projection and introjection. To clarify this, he cites Money-Kyrle (1956) “as the patient speaks the analyst will, as it were, become introspectively identified with him and having understood him inside will re-project and interpret”. In Segal’s 1997 paper, “The use and abuse of countertransference”, however, there is a warning to emphasise the need of proper understanding. As Segal suggested, whilst it can be “the best of servants” it can also function as the worst of masters. One example might be ‘enactment’ – against which Freud had warned – as I highlighted above. Roys (2011, p.163) describes how the analyst shifts position back and forth between concordant (a sense of sharing the analysand’s experience) and complementary (when the transference has affected the analyst so that something is felt towards the analysand).

Freud’s early encounters with transference were noteworthy because of the erotic elements. Having explored the erotic transference as resistance, he wrote, “of the first kind (of resistance) are the patient’s endeavour to assure herself of her irresistibility, to destroy the doctor’s authority by bringing him down to the level of a lover”. What he understood was the need to work with it, having initially seen it as nuisance. “To urge the patient to suppress, renounce or sublimate her instincts the moment she has admitted her erotic transference would be, not an analytic way of dealing with them, but a senseless one”. He thought it would be bringing repressed material into the conscious realm, but then ensuring it was repressed once more by a fearful patient, who would “feel only the humiliation, and she will not fail to take her revenge for it”. For clarity’s sake, “analytic technique requires of the physician that he should deny to the patient who is craving for love the satisfaction she demands”. He added that the patient would have “what all patients strive for in analysis – she would have succeeded in acting out”, which is probably the first reference to what I refer to above as ‘enactment’. Freud’s patients were, of course, predominantly women and usually treated for hysteria, hence the slightly unbalanced gendered views; modern clinical work is consistent with transference from male, female and non-binary individuals. As he noted, though, ‘transference-love’ must be worked through in the therapy “and traced back to its unconscious origins”. An analyst must be able to demonstrate distance from the transference love as Mann (1999, p.7) observed, “the erotic connects people at deeply unconscious levels, driving them into relationships at least at the level of fantasy”. He thought that closeness activates erotic material in the unconscious, but also that the greater the activation of erotic material in the unconscious, the closer the bond two people develop.

Before concluding this essay, it is important to ask, ‘does transference exist outside the clinic?’ Klein (1952) was clear, “in some form or other transference operates throughout life and influences all human relations”. I think it is helpful to imagine walking into a room of strangers at a party or a conference. Does one want to be seen and not heard, or to be acknowledged, heard and visible? What is happening? We are seeing around us a number of people as hostile, or as potential allies. This is informed by our past relationships and some form of transference is underway. Sandler, Dare and Holder (1973) observed that it enters all relationships and these (e.g. choice of spouse/employer) are often determined by some characteristic of the other person who (consciously or unconsciously) represents some attribute of an important figure of the past. It seems highly probable that it goes on at all times in our lives. Psychoanalyst and historian Daniel Pick, suggests it is a form of transference that political leaders exploit to facilitate what the psychologists understand as ‘group processes’. Generations after generations this seems to be a constant, as we note today with the tragic manipulation of the Russian people.

This essay has discussed the psychoanalytic terms, transference and countertransference. It has described their origination and their development. It has asserted that they are fundamental to the work of psychoanalysis in the clinic, but also that they are ubiquitous and exist outside the clinic. It has considered how such an important concept continues to evolve as the theoretical baton gets handed on to each new post-Freudian generation, but has focused on what Melanie Klein and Object Relations Theory brought to developing Freud’s discovery, and how Paula Heimann was the critical developer of countertransference by seeing it as an important tool for the clinician. In conclusion, I suggest that psychoanalysis is only effective when the pillars of the clinical work, that are transference and countertransference, are properly understood and deployed.

References

Arundale, J. and Bellman, D.B. eds., 2018. Transference and countertransference: A unifying focus of psychoanalysis. Routledge.

Pick, I.B., 1985. Working through in the countertransference. International Journal of Psycho-Analysis, 66, pp.157-166.

Britton, R. and Steiner, J., 1994. Interpretation: Selected fact or overvalued idea? International Journal of Psycho-Analysis, 75, pp.1069-1078.

Carpy, D.V., 1989. Tolerating the countertransference: A mutative process. International Journal of Psycho-Analysis, 70, pp.287-294.

Etchegoyen, L., 2010. The analyst’s response to the effects of the transference: On Lacan and Bion. The International Journal of Psychoanalysis, 91(2), pp.399-401.

Fairbairn, W.R.D., 1958. On the nature and aims of psycho-analytical treatment. International Journal of Psycho-Analysis, 39, pp.374-385.

Feldman, M., 2009. Doubt, Conviction and the Analytic Process. Routledge

Freud, S. (1917) Letter from Sigmund Freud to Karl Abraham, November 11, 1917. The Complete Correspondence of Sigmund Freud and Karl Abraham 1907-1925 52:361-362 

Freud, S. (1917) Letter from Sigmund Freud to Sándor Ferenczi, June 3, 1917. The Correspondence of Sigmund Freud and Sándor Ferenczi, Volume 2, 1914-1919 26:211-212 

Freud, S., 1958. Remembering, repeating and working-through (Further recommendations on the technique of psycho-analysis II). In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works (pp. 145-156).

Freud, S., 1953. Fragment of an analysis of a case of hysteria (1905 [1901]). In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume VII (1901-1905): A Case of Hysteria, Three Essays on Sexuality and Other Works (pp. 1-122).

Freud, S., 1955. Notes upon a case of obsessional neurosis. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume X (1909): Two Case Histories (‘Little Hans’ and the ‘Rat Man’) (pp. 151-318).

Freud, S., 1958. Observations on transference-love (Further recommendations on the technique of psycho-analysis III). In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works (pp. 157-171).

Frosh, S., 2012. A brief introduction to psychoanalytic theory. Red Globe Press

Heimann, P., 1950. On counter-transference. International journal of psycho-analysis, 31, pp.81-84.

Heimann, P., 1960. Counter-transference. Part II. British Journal of Medical Psychology.

Katz-Bearnot, S.P., 2014. Psychoanalytic Terms and Concepts, edited by Elizabeth L. Auchincloss, MD, and Eslee Samberg, MD, Yale University Press, New. Psychodynamic Psychiatry, 42(4), pp.700-702

Klein, M., 1952. The origins of transference. International Journal of Psycho-Analysis, 33, pp.433-438.

Laplanche, J. and Pontalis, J., 1967. The language of psychoanalysis. London: Karnac.

Money-Kyrle, R.E., 1956. Normal counter-transference and some of its deviations. International Journal of Psycho-Analysis, 37, pp.360-366.

Roth, P (2001) Mapping the landscape International Journal of psychoanalysis 82 p.533-43

Roys, P., 2018. Two impulses to end an analysis: exploring the transference and countertransference. In Transference and Countertransference (pp. 157-179). Routledge.

Sandler, J., 1976. Countertransference and role-responsiveness. International Review of psycho-analysis, 3, pp.43-47.

Sandler, J. (1987) The Concept of projective Identification London: Routledge

Sandler, J., Dare, C., Holder, A. and Dreher, A.U., 2018. The patient and the analyst: The basis of the psychoanalytic process. Routledge.

Segal, H., 1977. Countertransference. International Journal of Psychoanalytic Psychotherapy, 6, pp.31-37.

Spillius, E.B., Milton, J., Garvey, P., Couve, C. and Steiner, D., 2011. The new dictionary of Kleinian thought. Routledge.

Steiner, J., 1994. Patient‐centered and analyst‐centered interpretations: Some implications of containment and countertransference. Psychoanalytic inquiry, 14(3), pp.406-422.

Strachey, J., 1934. The nature of the therapeutic action of psychoanalysis. Classics in psychoanalytic technique, pp.361-378.

Winnicott, D.W., 1994. Hate in the counter-transference. The Journal of psychotherapy practice and research, 3(4), p.348.