Shirah Vollmer MD

The Musings of Dr. Vollmer

Diagnostic Countertransference

Posted by Dr. Vollmer on February 10, 2014


The patient is crying. The analyst is bored. What is the problem? There is a lack of affective, or emotional, attachment. To say that the patient is split off from his feelings is going to generate “blame the patient” approach to psychotherapy. To say that the analyst is “burnt out” is going to “blame the lousy doctor”. The question, for my students, is how to tell the difference, or determine the gradient where there is some sense of how this discord has come about. Luis, seventy-one, comes to mind. He insists he is not worried about aging, and yet, he frequently reminds me that he is “doing pretty well for a man of my age.” This inconsistency triggers in me a sense of confusion and internal movement. I am not feeling for Luis as a result of my internal sense of being twisted, not in a manipulative way, but in a defensive way. He tells me how hard his life is, given his elderly parents, his sick wife, and his lack of contact with his adult children. I hear his challenges, but his presentation makes me think of lists, and order, and numbers, rather than the stressors of caretaking and the feeling of abandonment. My “diagnosis” if you will, is that Luis has split off his feelings from this words, such that in an unconscious ways, the way he copes is to flatten out his feelings but maintain the verbal narrative which conveys his distress like a shopping list. As I recognize this split, my job becomes to help him stitch together feelings with words, such that he has more compassion, both for himself and for others. The absence of my feelings point me towards his psychological split, and hence I am using my countertransference to help me understand his coping skills. In the case of Luis, the patient sounds bored, and the analyst is confused. The challenge is to help Luis be more engaged with himself, so that other people, in this instance, me, can be more connected to him. This work of engagement will ultimately help Luis deepen his relationships and thereby help him cope with his responsibilities. Luis would tell you that his problem is the external issues of his parents, his wife and his children. I would tell you that a deeper issue for Luis is his need to split off feelings from words, such that he is unable to get nourishment from others.

6 Responses to “Diagnostic Countertransference”

  1. Jon said

    You story of Luis brings to (my nonlinear) mind a sonnet. In particular it is Sonnet 43 of Sonnets from the Portuguese by Elizabeth Barrett Browning. By your report Luis makes lists to distance himself from feelings. As a counterexample to a distancing list, here is what Ms. Browning writes:

    How do I love thee? Let me count the ways.
    I love thee to the depth and breadth and height
    My soul can reach, when feeling out of sight
    For the ends of being and ideal grace.
    I love thee to the level of every day’s
    Most quiet need, by sun and candle-light.
    I love thee freely, as men strive for right.
    I love thee purely, as they turn from praise.
    I love thee with the passion put to use
    In my old griefs, and with my childhood’s faith.
    I love thee with a love I seemed to lose
    With my lost saints. I love thee with the breath,
    Smiles, tears, of all my life; and, if God choose,
    I shall but love thee better after death.

    Now the trick becomes how to turn the soul of the distancing Luis more into the soul of the romantic poet… Aye, there’s the rub…

    • The “rub” as you say, is a protection from the softer side, a defense, against intimacy with a subsequent need to assume his problems are from his circumstances and not his internal dynamics. is poetry the answer, as you suggest? It doesn’t hurt, is my answer.

  2. Shelly said

    Why is the therapist bored when the patient is crying? Because the therapist feels that the tears are not genuine? How can he be split off from his feelings if he is expressing himself by crying? On the surface, it does indeed look like the therapist is denying the patient’s internal experience. Is it indeed possible that the therapist is placing his or her own internal values on Luis? For example, the therapist’s fear of aging may be misplaced on Luis–perhaps Luis really, really has no fear of aging! I speak for myself…I am 51 and don’t deny it, nor am I afraid of growing older nor dying.

    • Yes, these are all very important questions, with no definitive answers. This post is meant to illustrate that the protest in “I don’t think about my age,” may, sometimes, reflect the opposite, but then again, as you say, it may not. It is something to think about.My question for you, who is very comfortable with your age, do you announce to others how comfortable you are? Typically speaking, when one is comfortable, one does not need to advertise hisr feelings in an unsolicited way.
      Yes, boredom is indicative that the therapist is not feeling like the emotions in the room are connecting, and of course, this could be a result of the patient speaking without feeling, or the therapist not engaged in that moment, or both. It could be that the therapist is denying the patient’s internal experience, and it could be that the patient is denying his internal experience, or, again, it could be both.

      • Roia said

        I imagine another perspective/possibility might be that the crying patient triggered something the therapist is having trouble coping with in her/his own life. Feeling bored might be a way to create some (unconscious, of course) distance. This isn’t to say the patient may not be connected with his/her feelings- it’s just to say that the therapist may well be playing a part in this as well.

        • Shirah said

          Absolutely Roia- boredom is a point of inquiry to see who is blocking what. Many ideas need to be explored and more than one may be at play. Thanks for chiming in!

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