I attended a very good lecture this week on contemporary views of countertransference. It inspired me to write a brief overview of the concept here, with more to follow.
To understand countertransference, it helps to tackle transference first. As I’ve discussed previously, transference was a word coined by Sigmund Freud to label the way patients “transfer” feelings from important persons in their early lives, onto the psychoanalyst or therapist. Psychoanalysis was specifically designed to encourage transference. Intentional opacity and non-disclosure by the therapist promotes transference; the patient naturally makes assumptions about the therapist’s likes and dislikes, attitude toward the patient, life outside the office, and so forth. These assumptions are based on the patient’s experiences with, and assumptions regarding, other important relationships, such as childhood relations with parents. In this way the patient’s formative dynamics are re-created in the therapy office for both participants to observe. Patients discover that some of their assumptions about others, and themselves, are unfounded or outmoded and do not serve them well. This is an important type of insight that can lead to lasting psychological change.
Freud realized that transference is universal, and therefore could occur in the analyst as well. He did not write much about this, except to say that “countertransference” could interfere with successful treatment. The analyst experiencing countertransference should rid himself of these feelings by having further analysis himself.
Since the 1950s, psychoanalysts and psychodynamic therapists have held a more benign view of countertransference. It is no longer seen as an impediment to treatment (at least not inevitably), but instead as important data for the therapist to use in helping the patient. Countertransference can serve as a sensitive interpersonal barometer, a finely tuned instrument in the field of social interaction. For example, a therapist who feels irritated by a patient for no clear reason may eventually uncover subtle unconscious provocations by the patient that irritate and repel others, and thereby keep the patient unwittingly lonely and isolated.
In using countertransference this way, the therapist must consider multiple sources of his or her feelings. Some feelings, positive or negative, may be evoked by the patient. These are particularly helpful ones to notice, especially when the cause is not immediately obvious, as in the example just given. Often, however, feelings may be stirred up by irrelevant characteristics in the patient (e.g., the patient physically resembles the therapist’s sibling or spouse), by the prior patient, or by factors unrelated to therapy (e.g., bad traffic getting to the office, a quarrel at home, an upcoming vacation). This strongly argues for dynamic therapists to pursue such therapy themselves: It “tunes the instrument” to better distinguish countertransference evoked by the patient, versus similar feelings that arise from other causes. Freud’s advice for analysts to seek additional analysis themselves in the face of countertransference is wise, although not for the reasons he gave.
I teach psychiatry residents to go through a mental checklist whenever they become conscious of possible countertransference:
(1) Is this feeling characteristic, i.e., does the resident have it much of the time? If so, it may say a lot about the resident, but probably nothing about his or her patient.
(2) Is the feeling triggered by something unrelated to the patient? Feelings caused by hunger, one’s personal life, bureaucracy in the medical center, and so forth are not useful data for helping the patient.
(3) Is the feeling related to the patient in an obvious way? Feeling irritation toward a patient who is screaming obscenities and viciously destroying the office is countertransference of a sort, but not very illuminating. And finally,
(4) Is the feeling uncharacteristic of the therapist, a reaction to one particular patient, and yet the exact trigger is not immediately obvious? These are the most helpful feelings to notice in oneself, as they often shed light on subtle yet important dynamics in the patient.
Countertransference is not always helpful. Particularly when it is unexamined — or, worse, unrecognized — it can indeed interfere with effective treatment. This can occur even with positive countertransference, as when a therapist is so entertained by a patient’s jokes that the underlying bitterness is ignored, or when an attractive patient is never challenged because the therapist desperately yearns to be liked. More often, though, countertransference is problematic when it is negative. The therapist feels bored, irked, paralyzed, or contemptuous in the presence of a particular patient. It is the therapist’s job to recognize these feelings and deal with them. Occasionally a therapist must refer the patient to a colleague when the original therapist’s countertransference is unmanageable. Fortunately, in most cases these uncomfortable feelings, once recognized by the therapist, can not only be understood but also used constructively in the treatment.
Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?
In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…
In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?
Great blog post.
This was a very interesting and enlightening post. i have read much about transference, but very little about counter-transferesce.
i often feel that my Psychiatrist/therapist is irritated at me and i can think of a few reasons he might be, however i am very afraid to bring any of this up. i am often way too sensitive and wonder if i am imaging all of this or even worse, projecting my own feelings on to him. (Perhaps because i had an excellent Resident as therapist whom i was very attached to and, after almost 2 years, have yet to “get over”). i like this Psychiatrist and feel we have made a good connection, with some “bumps along the road’, yet i still have yet to feel completely “right” with the relationship…i guess it is because of the third person in the room.
TK: Thanks for your comment. I have a lot to say about this, so I’ll address some of your points in another post. My short answer is that feelings about money loom large both in transference and countertransference.
t: I hope you’ll be able to share your concerns with your psychiatrist. After all, you just shared them anonymously with the whole internet.
Seriously, it’s better to shine a light on such feelings than to let them linger. Perhaps a short discussion will put your mind at ease, or at least clarify the situation. Thanks for writing.
Am looking forward to your post on money and (counter)transference. Love your blog.
Dr. Reinbord,
i apologize for taking so long to thank you for your reply. i really do appreciate it and your writings.
i will bring up my concerns with my Psychiatrist-scary-as i know it’s the only way to work through it all.
Thank you again,
t
in your opinion, what does it mean when transference fails to take place? when the therapist is so “successful” at presenting a blank slate that he manages to persist as a cipher throughout the process? is there a time when he should begin allowing some of his personality to show through (assuming he has one) to engage his patient more fully? to avoid the patient losing interest in the process?
Hi Anon, thanks for writing. Transference is not unique to therapy or psychoanalysis; it happens all the time, every day, in all sorts of interpersonal situations. Any time we lack emotionally important information about someone, we fill in the blanks with assumptions learned from our previous experience with people. Seen in this broad way, it’s hard to imagine that “transference fails to take place” in therapy when it happens everywhere else.
An apparent lack of transference suggests two possibilities to me. One is that the therapist is too disclosing or too structured, leaving nothing to the patient’s imagination. This is sometimes a good strategy with very disturbed, e.g., psychotic, patients. Such patients already imagine too much. However, in most cases therapists try to encourage transference by being less disclosing, and by structuring the interaction less. Being a cipher is a good way to promote transference, although it can be taken to absurd extremes.
The other possibility is that the patient is resisting feeling or expressing transference. This happens quite often in my experience, particularly in highly rational people who want the world to “make sense.” As I like to tell my patients, feelings aren’t rational. Emotional assumptions about the therapist may be immediately dismissed as unfounded or irrational, and not even consciously entertained. But they’re there. If nothing else, the feeling that the therapist is overly withholding (or has no personality) is a type of transference, one that can be usefully discussed in therapy.
All that being said, I believe good dynamic therapy, including transference work, can be conducted by a therapist who allows some of his or her personality to show through. I certainly do.
so i am too rational? i know that he’s purposefully not disclosing, so i purposefully block the feelings that i’m having toward him? or i know that they’re not real feelings– that they are just transference– so i block them for that reason? it sounds sort of woo-woo
Since I don’t know you, I don’t presume to know what’s happening in your therapy. It sounds woo-woo unless and until it makes sense for you personally. To take the two possibilities you mention, purposefully blocking feelings tit-for-tat may be a way of expressing anger about your therapist’s cipher-like approach. Conversely, blocking feelings because they are just “unreal” transference may suggest anxieties about being humiliated or ashamed — duped into reacting to something simulated. Either of these ideas are plausible, and there are surely others… maybe contempt for a therapist who lacks a personality? This is the essence of therapy: to pay attention to one’s own reactions and learn from them. You don’t have to like your therapist to have very useful therapy.
You wrote…
“Transference is not unique to therapy or psychoanalysis; it happens all the time, every day, in all sorts of interpersonal situations. Any time we lack emotionally important information about someone, we fill in the blanks with assumptions learned from our previous experience with people.”
This is a great point.
It leads me to this question: Why, then, in dynamic psychotherapy, is the assumption made that the transferential feelings of a patient expressed or externalized toward a therapist are in some way of mirror of the patient’s feelings toward early-life objects like parents/siblings, etc.? Those folks self-revealed, and the patient as a child learned to adapt and shape himself or herself in synch with their emerging understanding of the those objects.
Isn’t it more likely that what you’re seeing in the room is how a patient deals with the unknown, and especially with unknown people in positions of power? While there’s some value to that, certainly, it’s a highly artificial situation and relationship. Most people — okay, CIA interrogators are an exception! — reveal with some degree of reciprocity as relationships unfold. Not many therapists, though.
TK,
As I replied to the anonymous commenter above, in my opinion some therapists take the cipher thing too far. A silent, unrevealing therapist is acting abnormally in a social sense. Typical patient reactions include curiosity and frustration — normal reactions to an abnormal social situation. These reactions aren’t particularly helpful therapeutically (unless they are notably absent), and if anything, they may interfere with the “working alliance” needed to conduct therapy. However, this abnormal social situation does set the stage to maximize transference: the thoughts and feelings brought from important relationships in the past. You might say that dynamic therapy has to be (socially) weird to work, but not so weird that the weirdness itself interferes too much.
And yes, the therapy relationship is highly artificial. It is unlike other relationships, not only by virtue of its asymmetry, but in many other ways as well. The therapist does not aim to act like a parent (except in certain types of “reparenting” therapies, not our topic here), nor to re-create the relationship the patient had with a parent. The aim is to see what aspects of the parental relationship “rub off” on other relationships, like the relationship with the therapist, where they don’t apply or serve the patient well.
TK, you’ve now given me yet another topic for a blog post. I hope to have time one of these weeks to write them up.
maybe that’s why i bolt– it’s not that great being set up to have feelings for someone (transference), and then watching him cooly watch me have them, all the while hearing him tell me that he’s not allowed to reciprocate and that anyway they’re not really “real”, but that i should keep coming back to endure more of the same (therapy). it seems pretty sadistic. if i were describing this to you as my relationship (outside of therapy), wouldn’t you, as my therapist, suggest that i reconsider and possibly even recommend that i walk away?
Have you read my post on therapist disclosure?
http://blog.stevenreidbordmd.com/?p=11
Your comments really apply more to that post than this one. The one-sidedness of dynamic therapy is not inherently sadistic, although some patients experience it that way. A competent, ethical therapist takes no pleasure in making the patient uncomfortable, and aims ultimately to be helpful. Feeling victim to a sadist may be transference from prior important relationships. Of course, it always needs to be said that a (small?) number of therapists out there really are incompetent, perhaps even sadists. But what you’ve described so far sounds like typical therapy, except for the “not allowed” to reciprocate part, and the “not really ‘real’” part. I’d frame these differently. Not reciprocating is ultimately in your best interest (and I’d explain why), it’s not that there’s an arbitrary rule against it. And feelings in therapy are absolutely real, as real as feelings anywhere else. I hope you can raise these issues with your own therapist.
yes, i have read that. i guess that i just don’t find therapy very therapeutic.
Not wanting to change this thread from an examination of countertransference to an examination of the theory of transference, BUT…
I get the theory of transference. I really do. I even get it’s origins in Freud’s discussion of the Anna O. case, and Anna O’s love for Freud’s colleague Breuer. I understand the notion, as you wrote above, that “Any time we lack emotionally important information about someone, we fill in the blanks with assumptions learned from our previous experience with people.”
What I don’t get is how dynamic psychotherapeutic theory makes the leap to patients filling in the blanks on the basis of their relationships with their parents or siblings etc. — people who as a rule self-revealed to their child and were not time-limited relationship, and with whom self-revelation deepened with the operational maturation of the child, as opposed to other relationships which were and are much more akin to the therapist’s room.
Example? Nursery school. Elementary school. Where you have a certain kind of interaction with an adult in a power position, the student knows practically nothing of the teacher’s personal life or feelings, the relationship is time-limited by the duration of the school day, and — like psychotherapy! — the relationship is created with the idea and goal that it will end (with promotion to the next grade).
Now, I ain’t saying Freud was wrong. But I have a feeling the paragraph above is just one example among many. And if you’re going to blog on this subject at some point, I’d love for you to address it.
Thanks again for this forum.
Hello
Countertransference/transference…for this very reason, many times I wish I never began therapy. Has it been helpful to me? yes. Have I grown? yes. Did it ‘work’? well, kind of.
The problem lies in the artificial relationship aspect. I can imagine a psychotherapist would insist that I still have unresolved issues that need to be worked on…. but it seems very common sense to me–almost sad for the therapist–when taking on a client who has never experienced “love,” or has never been cared for…the therapist should be on high alert. I somewhat agree with the poster who called the practice ‘sadistic,’ because in cases of major emotional deprivation or maltreatment/dysfunction, the client may perceive the therapuetic process as hurtful.
It’s just kinda like, Oh–for the first time, here is someone who actually wants to help, who acts like they care, who is available consistently, who has great qualities (within the therapy hour), and who is (of course) smokin’ hot.
Then comes the loooonnngggg pause and the “BUT.”
But, the relationship is aritificial. This person doesn’t really care–er, they care within professional boundaries. Which is nice, but really…how much self-control can people be expected to have ? It’s like smoke and mirrors, it’s like a mirage, it’s like a fantasy. Let’s be wide-open and loving and caring and sharing for 50 minutes a week, but as soon as you walk out that door, forget about it. your therapist is forgetting it, they almost have to.
I’m not saying this is the case for most therapy patients, but there is a small minority who (I’m speaking for myself, minority of one), perhaps should just be told to take heavy medication and long walks. Because give them an inch and they will need a mile, a nice therapist is like 3 drops of water in the desert, and only makes things worse.
I’m not trying to be a downer here, just wanting to express these things. It’s kind of like, you cant wish for something you have never experienced.
Hopefully I’ll work through this in a few months.
I fully agree with marymac. I have found therapy to be sadistic too. More painful than anything else I have ever experienced. If you have experienced multiple abandonments, extreme neglect and other horrible things throughout childhood and have spent most of your life trying to bury the pain, severing off parts of yourself to help you survive…. opening up to someone creates a transference that so blindsides you with the extreme pain that you buckle to your knees. I too often wish I never began. I didn’t sign up for this. I didn’t understand it would happen and would never have begun if I had known. I’ve come to call this experience the transference trap. You can’t go backwards, you’ve lost all your defense mechanisms that have enabled you to survive and function thus far and yet the pain is too intense to move forward… It’s as if you have to go through a violent storm to just allow yourself to trust enough to open up. You land in some surreal world (why not call it Oz) where you no longer control what you think or do. You’re completely at the mercy of emotions you hardly recognize. Only to realize that the Wizard is a fraud and the only way out is through a storm of pain that you feel might just kill you. So where does that leave you? In a far worse place than when you began as far as I’m concerned. Is there any way out of this trap? Is there any release possible? Without the storm of pain.
When you get to talking about money and transference/countertransference, I have heard therapists say that they hope that financial concerns won’t enter the realm of the therapist-client relationship. But seems to me that is like hoping that sex won’t enter the realm of the husband-wife relationship!
What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?
To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.
Cynthia, thanks for writing. You rightly note that financial concerns are an inescapable part of the therapy relationship. But I would no more agree to report my weekly patient schedule, and thus my weekly income, than any other hired professional would. Your plumber and electrician won’t supply this information, nor will your lawyer, music teacher, or physician. And yet in all these cases the information might help you “determine how important it is” to them to have you keep coming back. The missing factor here is trust. Not blind, gullible trust, but trust based on evidence and one’s personal experience. If you feel your therapist is just filling an hour and taking your money, no weekly report will quell this concern. If you trust that your therapist has your best interests in mind, the weekly report would make no difference.
See also my reply to the comment below.
My therapist can be a too much of a blank slate. He allows me to ask a certain amount of questions regarding his personal life. Very basic stuff. I do get very curious about him though as with every therapist, because I wonder if they really get it. If they really do understand what I am going through on a personal level. Not just on an analytical level. I feel like my therapist has no personality sometimes. It’s extremely frustrating. it would be helpful to see an honest reaction once in a while. He seems nervous sometimes lol. He is too into patient centered therapy. He definitely goes by the old adage ” I want to help you help yourself” Sometimes i need to be told what to do, and sometimes I need to know what he thinks is important in terms of treatment. It’s annoying when I really need his opinion, and he asks “what do you think?”. Do you think transference could fail to happen, because a therapist doesn’t want it to?
Thanks for commenting. See my post on therapist self-disclosure. Therapists are entitled to some privacy. Your accountant asks your income, but you do not ask his or hers. Your primary care doctor asks you to take off your clothes, but you can’t ask the same of him or her. Likewise, your therapist asks about your personal thoughts, feelings, and fantasies, and yet is not open to sharing his or her own. Your curiosity is perfectly natural, but the relationship is inherently asymmetrical. Part of a therapist’s professional judgment is deciding when, and in what fashion, to satisfy a patient’s curiosity. (Or to tell a patient what to do, even if she asks.) Part of a patient’s “job” in dynamic therapy is to tolerate some anxiety and frustration in the service of learning more about oneself.
I totally understand that. They are entitled to a lot of privacy. I am not asking for his life story, nor would I ever do that. I am fine with the amount of personal questions he has allowed me to ask. I know he doesn’t have to do that. I keep my curiosity to myself. It’s not like a burning need to know. Just a natural curiosity like you said. Just a simple wondering what he is really thinking? Does he really get it? Sometimes therapists seem to be reading a script. that is when I start to wonder.
I know you are exactly right about the patient tolerating anxiety, and the therapist using his judgement. What if you really feel his judgement is wrong, and the anxiety is really becoming too much? Is it reasonable to tell a therapist that, and emphasize your need for an answer relating to treatment or a particular struggle I am having? I don’t expect him to indulge my every curiosity or alleviate my anxiety by just telling me what to do.
Thanks,
~Catrenia