Analyzing The Transference: Critical or Over-stated?

“The ability to understand and handle transference is perhaps the single most important aspect of psychodynamic psychotherapy, and the subject that separates the truly skillful therapist from the adequate therapist,” says my local colleagues Drs. Thompson and Cotlove in their book, “The Therapeutic Process,” which by now, many of my readers have probably guessed,  I am reading in an effort to begin teaching my class tonight on psychoanalytic technique. With all due respect to my esteemed colleagues, this sentence disturbs me greatly. Understanding how the past impacts the present is the basis of psychodynamic psychotherapy. Transference is an inherent aspect of that inquiry. However, I do not think that one can identify any specific understanding which separates out the “skillful therapist from the adequate therapist.” Therapists have different skills to offer different patients. Each dyad brings out different material which, in turn, creates a different therapeutic process. The complicated nature of the patient/therapist relationship does not lend itself to focusing in on one aspect of the relationship. At the same time, I do agree that shedding light on issues in which past important and critical relationships are interfering with the present relationship may save a therapeutic relationship which is otherwise about to fail. These “transference interpretations” are what some colleagues call “high risk, high gain comments,” since they could make the patient feel humiliated in that they are repeating a past abusive relationship with their therapist, or it could make the patient develop deep insights into why difficult relationships are a pattern for them. I have a new class tonight. I hope I can make this distinction in a clear and meaningful way. The adage that if one wants to really learn, then one should teach, might be true. However, and I know I am a skeptic, I think that also depends on the students. Easily stated phrases always make me question. Our need for simplicity must fight with our desire to explore complexity. Exploring complexity wins when the stress is not too great. I hope my students will agree.

Idealizing Transference

 

“This (idealizing) transference expresses the need for a calm, strong, wise and reliable therapist whose ‘properties’ and presence can be made use of by the patient in order to foster of sense of safety, self-esteem, and well being; self-worth and value are enhanced in the glow of the idealizing transference,” says Mark Thompson MD and Candace Cotlove MD in their book entitled “The Therapeutic Process”.   Becky, forty-four, a psychiatrist, glows when she speaks about her therapist, Doctor Holzberg. Her tone makes me think that she is speaking of a passionate love relationship, but she will tell you that she loves her husband and her three children very much and she did not seek psychotherapy because she was feeling unloved or unloveable. Becky, also known as Dr. S. has seen Dr. H. for over three years and she has yet to feel she has had a difficult session or a disappointment. “Could you be idealizing him?” I ask Becky, in casual conversation, as it is hard for me to believe that any psychiatrist, any psychotherapist,  does not present frustrations and grievances during the course of a treatment.  Becky is not sure, but she responds astutely. “Idealization prevents further growth, so if I am, then I have a pretty shallow relationship with him,” she says, hitting my point head on. Glowing reports about a psychotherapist are always suspect, given that too positive a point of view might suggest that the narcissism in the therapist does not allow for the relationship to have its fair share of interpersonal struggles and minor ruptures. It is through these struggles that relationships deepen and people grow internally. The trained ear tries to separate the need for the “perfect therapist” from the “good enough” therapist who provides support and trust, within the framework of divergent points of view. The “perfect therapist” may have too high of a need to be loved to allow for enough discourse. Given that, it is hard to plunge into therapy, as too great an endorsement may suggest a very self-centered therapist. The layers of meaning are endless. Diving in takes great courage.

Feeling Soup

Glen Gabbard, a noted psychoanalyst, likes to say that “there are two patients in the consulting room. The two complex human beings who are interacting in the course of psychotherapy are mutually influencing one another all the time and evoking a varied of feelings toward one another.” Now, a case example, you, the reader, I can hear, is asking and so a fictional case pops to mind. Patient A makes Doctor B bored. Doctor B wants to “leave the room” in his fantasy life when Patient A enters. Patient A talks about his writing career, but Doctor B does not feel engaged. Doctor B, before medical school, wanted to be a writer. His envy of Patient A makes him “tune out” to tales of his writing career. Doctor B goes to therapy with Doctor C. Together Doctor B and C begin to unravel the complex feelings that Doctor B has in regards to deciding to go to medical school. Doctor B begins to see, in his mind, that patient A, is not only a writer, which Doctor B dreamed of being, but also that patient A reminds him of his demanding mother who insisted that Doctor B become Doctor B. Doctor B’s newly discovered understanding of how patient A has triggered so many negative feelings helps Doctor B become more engaged with patient A and kicks Doctor B into his second psychoanalysis. As Daniel Stern taught us, the famous infant/mother researcher, not only does the mother influence the baby, but the baby influences the mother. So, the obvious is stated, but the complexities are uniquely compelling.

See Also…http://shirahvollmermd.wordpress.com/2012/11/01/countertransference-come-on/

Teaching Transference

So, it is time again for me to embark on another psychotherapy class that is interested in learning about transference. We will discuss how the therapeutic relationship leads to change in personality structure. This is the fundamental principle of in-depth psychoanalytically oriented work. The notion of transference separates out the therapies which focus on behavior from the therapies which focus in on deeper issues of unconscious self-sabotage and deeply rooted pain. “New brain” therapies, I like to call it, in which by understanding transference, a new brain can be formed, whereas with behavior oriented therapies, limited improvement is inevitable, since only the surface is being addressed. As always, I eagerly anticipate how this class will feel, their transference to me, in other words. We will talk about transference and experience transference, all at the same time. The parallel process will give us a way to make the subject come alive.  It should be interesting. Stay tuned.

 

Countertransference: Come On…

Countertransference is the notion that therapists bring unconscious issues into the treatment. Duh. Is it counter to the transference? No, I say. Hence I am not content with the terminology. Sure, therapists have an unconscious which can provide an obstacle to nonjudgmental listening. Somehow, the analytic literature suggests that countertransference was “discovered” in the 1950′s, after WWII. This was the era when many European analysts fled to the United States. Is this a coincidence or related? I am not sure. During this era there were numerous papers written on the bi-directionality of the dynamics. The therapeutic dyad was, in fact, a dyad. Patient and therapist change in the process-just like every relationship. This seems so obvious to us now, but apparently, in the earlier days of psychoanalysis, this was seen as a “discovery”. Yes, maybe I look back not appreciating the development of our field, that hindsight is 20:20, but I still maintain that sometimes the obvious is over-stated.

Feeling Understood

Tea, http://shirahvollmermd.wordpress.com/2012/07/06/lost-years-stimulated-by-turning-50/,  was born with dislocated hips and club feet, discovered by her engineer father who after changing her older siblings’ diapers multiple times knew that Tea’s hip joints were not normal. The pediatrician missed the diagnosis, but no harm was done, as Tea’s dad saved the day. Tea’s parents took her to the local Orthopedic hospital, leading her to have casts on both feet and braces around her hips. When she started to walk, the braces on her leg made her walk like a Tin Soldier. Her knees could not bend. As Tea grew up, she knew that her body did not move right, although she looked normal. After multiple yoga classes, and discussing her skeleton with multiple teachers, one knowledgeable teacher guessed that because she walked at an early age without bending her knees, this caused the spine to have a different ”rhythm” or curvature. Finally, Tea got some mental relief. Finally, someone could explain to her that her spinal limitations were not simply because she did not “stretch enough” as almost every other yoga and Pilates instructor told her. Tea tells me this story with tears and sorrow. “It is so hard to talk to people who supposedly know something about the skeleton, and yet, they respond to me in ways in which I know does not make sense.” “What is hard about that?” I ask, knowing that her issues are rare and that it makes sense that most yoga teachers are not educated in the developmental pathology of the spine. As if Tea were talking about a psychotherapist and not a yoga teacher, Tea looks at me and says “I am just tired of being misunderstood.” The transference here was apparent. Tea was misunderstood about her spine, but the bigger picture is her deep craving for understanding. Her search for a “good yoga teacher” was partly about yoga, and partly a search for a nurturing, understanding parent, who could latch on to both her inner and outer struggles. Her skeletal deformities were, in addition to being an obstacle to greater flexibility, are also a stand-in for how she feels psychologically deformed as well, and yet, no one can see that at first glance either. This image of a “hidden” deformity was powerful for her. Her skeleton looks normal until she bends over, at which point one can see a curve that is abnormal. Likewise, her personality seems normal until she engages in deep relationships, at which point her inability to express sensitivities becomes an obstacle to close connections. Once again, the inner and outer issues converge. Tea cannot change her spine; at least not without surgery. Yet, she can change how she thinks about her abnormalities. She can also appreciate those who struggle to understand her issues in contrast to those who dismiss her as “everyone is different”. This nuance of interaction is critical to her. Those yoga  teachers who respond to her report of her congenital issues by saying, “gee, that is really interesting, I am going to have to think about how to help you,” versus those who say “well, everyone has something they have to work on,” are dramatically different interactions for Tea.  Likewise, Tea is searching from me, from her friends and family, a curiosity about the uniqueness of Tea, and she rails against those who try to lump her into a bigger group. Tea is searching for that feeling of specialness, even if special means, more deformed. She wants to be understood. Who can blame her?

Re-Posting With A New Comment: Transference

 

The Comment:

Subject: Transference
Conditions for challenges in the therapeutic relationship: Are the clients
ready? It is important to work with the material to gain an assessment of the
right time to intervene. Can they hear? Clients might have intense shame and
feelings of worthlessness. There might be a shock of being confronted by the
shadow. Clients might act out rather than work through the difficult
material. Research has shown that negative transference is best to establish
bond.

There is no magic wand. This is one of the great realisations a client can
have. The ideal is self-challenge. What is the story behind the story that
the client is bringing? Bodywork and meditation only give us images and these
must reflect the client narrative.

 

The Post:

My 24 year old male patient, who has entered my most recent blogs, looks to me to struggle with his issues, but he does not look to me for comfort. I characterize our relationship as one which involves a lot of mutual fondness. He sees me as an intelligent participant in his life who helps him think and reflect on his life, but he also experiences me as emotionally distant.

Transference, first described by Sigmund Freud, is a phenomenon in psychotherapy in which there is an unconscious redirection of feelings from one person to another. In his later writings, Freud learned that understanding the transference was an important piece of the psychotherapeutic work.

In the case of this patient, he has a distant mom and a warm dad who he does not see very often. When his parents divorced, he and his mom developed an intense, but in his terms, a “weird” relationship. By “weird” he means that she took care of him, but she did not want to spend a lot of time with him. He came to understand that he was not “worthy” of her time. Although it would be too simple to say that he has made me into his mother, it does appear that he assumes that I cannot comfort him based on his childhood experience of his mother.

I know that my critics are going to argue that perhaps I am a cold person and so this is not transference, but rather a repetition of his past. The question becomes how much is my patient responding to his past relationships and how much is he responding to the present connection. As with most things, the past and the present are now woven together and it becomes nearly impossible to sort out. Having said that, the idea that his childhood relationship with his mom has shaped his expectations of our therapeutic relationship may be worth exploring.

According to The Source  published in 2001, “During transference, people turn into ‘biological time machine.”‘ A nerve is struck when someone says or does something that reminds you of your past. This creates an “emotional time warp” that transfers your emotional past and your psychological needs into the present.

My client wants to grow and he wants to feel comfort. At the moment, he is able to access the growth and reflection aspect of psychotherapy. I am hopeful that by talking about the nature of our relationship, he will begin to feel the comfort that is embedded in the deep affection that we have for one another. We will start by looking at the transference.
http://shirahvollmermd.wordpress.com/2010/01/24/transference/

‘I Am Making Better Friends, Thanks To You’

 

Jennifer, twenty-four, http://shirahvollmermd.wordpress.com/2010/03/30/mother-figure/, looks to me as a mother-figure. She reports to me about her daily life: school, friends, roommates, job. She tells me about the people she meets and we talk about the quality of her friendships. As a high-school student, this kind of discussion made her defensive. Her pot-smoking friends were “cool”, she would tell me, as if to ward off her assumption that I would be judgmental about them. Now, to my surprise, Jennifer says “I really want higher quality people in my life. I want people with some ambition, some sense of where they are going. I did not realize how important that was, but thanks to you, I do now.” I did not expect this expression of gratitude. I began to wonder, why now, after all these years together, is this coming up? I begin to see that Jennifer is now transitioning to an Occupational Therapy Program, where she is on her way to a career. This is a marked shift from the girl a few years ago who could not imagine herself deciding on a career path. Jennifer went from being aimless to being focused and in so doing, she wanted to shift her friends from drifters to future professionals. She gives me some of the credit for this shift since she assigned me the role of wanting to see her grow and develop into an independent adult. It is true that I wanted this for her, but it is also true that she allowed me to encourage her in that direction. She entered into the relationship with me, wanting a nurturing person in her life. Sure, her parents also want to see her succeed, but Jennifer felt she needed more support for her development. She initiated therapy as a teenager. This drive for development was impressive. Jennifer was likely to succeed; she was determined. I facilitated her, mostly by allowing her to have this mother-transference. The love of a mother figure facilitates growth. Jennifer proved the point.

The Coach Mom: Transference In Action

     Murray, 37, wants to run a marathon so he hired, Millie, 62, a coach, to help him. Inevitably, Murray starts to treat Millie as a mother-figure. He rebels against practicing. He is fearful of letting her down. He wants her to be proud of his accomplishments. “She has become a stand-in for your mom.” I say, pointing to the transference that is occurring as their relationship deepens. “Well, sort of. She has other students that she coaches and they don’t seem to have a problem telling her that they did not practice, but I feel so guilty about it.” Murray reports with a sense of anxiety and tumult. “Exactly,” I say excitedly. “Everyone has a different relationship with authority figures based on their past experiences and for you, disappointing your authority figure gives you internal disruption, as it reminds you of the pain of disappointing your mom.” “Yea, I see that, but it is still really difficult. I emailed Millie to tell her I was not going to practice with her Sunday and now I am on pins and needles waiting for her response, ” Murray says, as if he just had to tell his mom that he was not going to study for his math test.  ”Millie is bringing back a lot of old feelings for you. That is really hard.” I say, connecting the past to the present. “They don’t feel like old feelings, but I guess they are,” Millie says, somewhat confused by my line of thinking. “Your relationship with Millie is so intense that you bring past relationships into the present.” I say, trying to explain the universal nature of this experience. “Yea, but I wish it were not so intense,” Murray says. “Yet, at the same time, maybe you appreciate Millie as a mother-figure who can slowly change your relationships with authority figures. Maybe you are hoping that Millie will reshape your experience of trying to please someone.” I say, explaining that new relationships can sometimes mend the trauma of old relationships. “That is very interesting,” Murray says, as if the session was finally congealing for him.

Mother Transference

 

   Ray, sixty-five, was excited when his best friend, Lee, sixty, married Lizzie, age forty, because for the first time in his life, Ray felt he had found a mother figure. As in my previous post,  http://shirahvollmermd.wordpress.com/2010/03/30/mother-figure/, this transference, or these feelings of Lizzie being motherly to Ray were unconscious. Ray would call Lizzie to tell her about his “accomplishments” but he would never ask how Lizzie was doing. Lizzie reports to me “it was as if Ray wanted me to pat him on the back for cleaning his room. I felt foolish, like this was a relationship that was really uncomfortable for me, but really important to Ray.” Lizzie reports her feelings about Ray with anguish and uncertainty. “Maybe Ray needs someone to watch over him and he feels that you are really interested in him in a motherly sort of way.” I say, thinking about how one’s need for a mother never really goes away, and maybe we all do what Ray is doing with certain friends, although in a less obvious way. “Yes, but I don’t want to be Ray’s mother,” Lizzie says in loud protest, as if  fighting off this notion is a way of saving her soul. “I am curious,” I say, “what is so terrible about being motherly to Ray?” I ask, thinking that I probably know the answer, but I am curious how Lizzie will respond to my question. “I want to have friends with mutuality. I have kids. I don’t need any more. I want to spend my time with people where there is a give and take to the relationship, not, as I do with Ray, just listening to him report to me his strides since our last conversation.” Lizzie says with despair and disappointment, as if she hoped that marrying Lee would expand her social network, but over time, she has discovered that Lee’s social connections, which mostly consists of Ray, does not  suit her well. “Do you think that if you don’t respond to Ray in a maternal way, then maybe Ray will interact with you in a different way which might be more satisfying?” I ask, thinking that Lizzie may be encouraging Ray’s mother transference, and as such, Lizzie’s change in her behavior towards Ray may solve her problem. “Oh, I have tried that,” Lizzie says, continuing her despairing tone. ”In fact,” she continues, “Ray told me that I would be really interested in a story he wanted to tell me, and I cut him off and said, well, actually, maybe I am not as interested as you think. I thought I was being harsh, but I also wanted to let him know that I did not want to be a ’dear diary’ for him.” “How did he respond?” I asked. “Well, he just moved on, as if I did not hurt his feelings, but I felt like I did.” Lizzie reports, claiming that he knows Ray better than Ray knows himself. I thought that could very well be true. “You and Ray are engaged in a deeply unconscious relationship and it sounds like you are aware that this relationship is not healthy for you because it is so one-sided.” I say, trying to help Lizzie cope with her mixed feelings of wanting to make Lee happy by getting along with Ray, but at the same time, wanting relationships which feel growth promoting and mutual. “Yes,” Lizzie declares. I feel like Ray is our child and if I pull back, then both Ray and Lee will be hurt.” “That is interesting,” I say. “Maybe if you talked about your feelings towards Ray with Lee, he would understand.” “Right,” Lizzie says, “I need to do that. “I am glad that Lee does not treat me like his mother; that would be really bad.” Lizzie says, taking our conversation in a new direction. “It sounds like you allow people to use you as a ‘mother figure’ because you are willing to listen to them and not insert your own ideas when they are talking.” I say, stating that Lizzie’s good listening skills might be a liability when it comes to her relationship with Ray. “I never thought of it that way,” Lizzie says. “I just think it is rude to interrupt.” “Well, usually it is, but sometimes you have to steer the conversation away from a mother/child interaction.” I say, helping Lizzie navigate the waters of social interactions and civility. “That is interesting,” Lizzie says. “Maybe I will learn to abruptly change the subject, even though I hate when other people do that to me.” “Well, yes, sometimes you have to use a crude instrument to change course,” I say.