Why CAM Should Pay Heed to Potential Transference and Counter-Transference

Ongoing debate continues about the so called ‘placebo effect’ [1-6]. the range of effects of complementary and alternative medicine (CAM) and the way that particular CAM modalities might work [7-10]. Interest lies not just in identifying whether a modality has its intended, or any, effects, but also in uncovering the possible factors that may arise within the therapeutic encounter between practitioner and client and, in particular, to the nature of the client-practitioner relationship [11].

The assessment, treatment and care process entails intimate client-therapist interaction and the building of a therapeutic relationship. The notion of 'therapeutic' is itself imbued with meaning. In essence, a relationship is therapeutic by the very nature of its quality; it is also a subjective relationship. More broadly, it may span connotations of a relationship enabling healing, being restorative and beneficial [12]. The way that this human encounter occurs, and is structured, has consequences for the ongoing relationship and effectiveness of the modality and, more generally, a potential for healing [13]. CAM research and discussions over its practice have not, to our knowledge, paid much heed to or understanding of or indeed interest in psycho-analytic concepts. Two concepts of potentially powerful significance for this human engagement, and thus CAM interactions and treatment effectiveness, are those of transference (T) and counter-transference (Ct). Indeed, the operation of either/or both T and Ct may have a significant impact on the process and outcome of an interaction, and, by implication, identification of the full effect of a CAM modality.
These concepts have their roots in Freud [14] and his growing realisation that the concept of T and Ct could be of therapeutic use in recognising, in particular, the unconscious drive to repeat past events. In modern day thinking, transference relates to sub-conscious feelings or thoughts related to an individual's experience with a time, place or other significant association. Positive transference (T) brings with it a 'feel good' factor and often creates a feeling of wanting more so that these positive feelings will remain. In contrast, a negative transference (Ct) frequently creates avoidance and can lead an individual to develop complex plans in order to avoid a specific experience. The origins of the word transference remain within the Greco-Latin meaning, to 'carry across' [12].
T and Ct are thus two important psycho-analytic concepts to describe the process through which entities may be become 001

Abstract
Complementary and alternative medicine (CAM) research and discussions about its practice have paid little, if any heed to or understanding of or interest in psycho-analytic concepts. Two concepts of potentially powerful significance for the therapeutic relationship, so central to CAM human engagement, are those of transference (T) and counter-transference (Ct). Presence of either/or both T and Ct may have a significant impact on the process and outcome of an interaction, and, by implication, identification of the full effect of a CAM modality. Consequently much can remain invisible within the treatment process. This short piece outlines their significance for CAM research and implications for practice, drawing on a study exploring the potential to identify these two concepts within the provision of CAM treatment, and the derived four-staged model, with a small set of clients receiving palliative care. Clients may express and feel a positive transference towards those therapists who they perceive as providing the best therapy for them and a negative transference towards those that do not. Moreover, knowing or at least realising that clients, or their therapist, have processed and carried their T or Ct associations throughout the four stages of the model are likely as a result to be better placed to either benefit from the treatment or be a partner in their treatment and care.

Journal of Complementary Medicine & Alternative Healthcare
aroused and brought to the conscious level during a clienttherapist interaction and thus affect the process of care and treatment. In essence, the more the client and the practitioner have an understanding and ability to recognise and identify the concepts of T and Ct, the more the client's care and treatment will be enhanced. Recognising when and knowing how, and why, a certain situation or person may invoke transference will ultimately empower both the client and the therapist within the CAM relationship; otherwise, much can be lost, and invisible, within the treatment process and assessment of its effect. Moreover, this understanding would undoubtedly result in better patient and practitioner outcomes To cast further light on T and Ct in CAM, Hynes [15] studied a small number (n=10) of clients, who were receiving complementary therapy as part of their palliative care, and their CAM therapists (n=3). The study aimed to make explicit and demonstrate the possibility of identifying T and Ct through exploring the ways that clients and their therapists 'talked' [16] about themselves and exploring the impact, if any, these concepts have on the feeling of well-being that the client may or may not experience within CAM interactions. The clients, all diagnosed with a life-limiting illness, were receiving complementary therapies as part of their care and selected using a purposive sampling approach to ensure diversity in age, gender and social background. They took part in in-depth interviews, undertaken at three occasions. Clients were asked to tell their stories and therapists to talk about their feelings about the client when giving the therapy sessions. Such talk was the primary data source for the analysis of possible transference.
Data analysis of their 'talk' revealed a four-staged T and Ct model (triggers, awareness, self-analysis and response), with implications for CAM practice. At its base are triggers; their identification is the essential first step for uncovering, and understanding, potential T and Ct. Analysis and re-analysis of the data during the interpretation process identified familial memory, sensory input and physicality in the shape of language and words and the environment as areas that initiated a trigger response. When triggers occurred they brought about an association from a repressed memory and enabled the individual to associate with that memory, which would likely impact on the CAM experience.
How the individual, client or therapist, responds to the trigger is the focus of the other three stages of the model. In Stage Two, the client chooses, or not, to allow this trigger to enter awareness. Transition from Stage One to Stage Two is a relatively quick one. Journeying through this awareness may take the person to Stage Three, where a process of self-analysis takes place, involving personal and often deep reflection brought up from the trigger and awareness, giving meaning to associated feelings and thoughts about the trigger. The process of reflexivity in Stage Three enables the person to make a further choice and move on to enter Stage Four and make a response to the processes already achieved. Should she/he enter the responses stage, then she/he remains in a position to accept their own selfanalysis as to why she/he may think and feel in this way, or to reject those thoughts and feelings. For insight into the detail of the model and supporting client and therapist evidence, readers should consult Hynes [17].
This research reinforces the need for CAM, in both research and its practice, to pay heed to the two psycho-analytical concepts of transference and counter-transference. Implications for CAM practice are multiple. For example, while different therapists could be doing a similar/identical therapy session, the clients might relate to the triggers differently. Clients may express and feel a positive transference towards those therapists who they perceive as providing the best therapy for them and a negative transference towards those that do not. Further, knowing or at least realising that clients, or their therapist, have processed and carried their transference or counter-transference associations throughout the four stages of the model are likely as a result to be better placed to either benefit from the treatment or be a partner in their treatment and care [16,17].