Shirah Vollmer MD

The Musings of Dr. Vollmer

Working With Perception: Learning Counter-Transference

Posted by Dr. Vollmer on September 26, 2016

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What happens when a therapist needs to be liked, needs to feel like they matter, and/or needs to feel like they are nurturing and the patient does not meet the therapist’s need for such gratification? Often, the work grinds to a halt. The patient gets “busy” with other things. The therapist, suddenly, must cancel multiple appointments. These unconscious resistances on both sides of the couch is the meat of psychoanalytic teaching, and yet, the most challenging concept to grasp in psycho therapeutic work. In other words, the beginning therapist must put aside the layman’s notion that “this work is so gratifying” as the need for that gratification can impose a burden on the patient to say they are well, when, in fact, they are still suffering quietly. The therapist’s unconscious need for affirmation can replicate the patient’s role in his/her family to make sure that their parent is happy, at the expense of knowing their own true self. In this scenario, the patient is not only not getting better, but in fact, is being re-traumatized by the alleged therapeutic situation.

Ty, a forty-year old female patient, and Tro, a forty-four year old female beginning therapist start to work together. Ty keeps telling Tro how much she is helping her. Tro reports the gratification is seeing Ty develop and suddenly, after 6 weeks, Ty drops out of therapy, while Tro is aware that Ty remains in a difficult relationship and she has occasional substance abuse issues. Tro is bewildered. On the one hand Ty expressed gratitude at every session, and on the other hand, Ty stopped the work prematurely, according to Tro. “Could it be that Ty unconsciously had to tell you how much you were helping her,  because she sensed your need for affirmation, but that deep down, Ty knew that she was not finding her sense of agency, her sense of her own voice?” I say, to my student, to her amazement and somewhat alarm. “You mean that I am letting my own stuff get in the way?” She asks, astutely. “If by stuff, you mean, your need to feel validated by others, then yes, that could be getting in the way of Ty being more authentic. She may feel she has to care for you and make sure that your ego is intact, as she had to do that with her mom.” I respond, pleased that Tro is quickly grasping the concept of counter-transference. “It is hard to be in a field, where positive reinforcement can be a defense,” I say, trying to make light of this challenging topic. “The holy grail of reward is seeing a patient become less defensive, which does not necessarily translate into holiday cards, or presents. In fact, gifts become a complicated subject, layered with meaning, and sometimes, “you guessed it” I say, a defensive act.

2 Responses to “Working With Perception: Learning Counter-Transference”

  1. Shelly said

    Although I know you will say, “It’s a fine line between too much and too little,” how does a therapist know when he/she is beginning counter-transference or not? A therapist always wants to take care of her patients, cares for them and wants the best for them. They invest alot of themselves into the treatment and care about the outcome. I don’t believe therapists need alot of positive reinforcement, but seeing that they are needed is a self-fulfilling prophesy in treatment, isn’t it? That’s validation, is it not? What does, “Being overprotective with a client,” mean?

    • I am not sure I would give you my “fine-line” answer on this one. The issue of whether a therapist wants to take care of his/her patients is debatable. It is true that the therapist puts a large investment into his/her patients, but the outcome of that investment, and the need for particular outcomes, or voices of gratitude varies from therapist to therapist. My argument is that the space between therapist and patient is a space of projection from both sides, and as such, is ripe for distortions. Understanding those distortions is the work of intensive psychotherapy. We all have expectations and aspirations from relationships which have a long history, dating back to our childhoods, and as such, small disappointments, such as coming late, could have larger meaning, because it could trigger past experiences and disappointments in relationships. Having the luxury to look at those distortions, to understand how past influences the present, from both sides, requires tremendous impulse control and thoughtfulness, as the initial impulse is to feel victimized and blame the other. In this example, a therapist who wants their patient to thrive, could be acting out on a sense that they have failed as a parent, and so they put subtle pressure on their patient to prove that they are indeed a nurturing and caring individual. This pressure might replicate the pressure the patient felt as a child to make her mother feel good as a mother, and thereby sacrifice her own sense of herself. In other words, the therapist’s ability to tolerate negative feelings towards him/her could be the most therapeutic aspect of the treatment, in that the patient, for the first time, had the opportunity to express authentic feelings, as opposed to feelings designed to preserve the ego of the caretaker. Thanks, as always.

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