Countertransference

Working With Perception: Learning Counter-Transference

 

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.

Boundary Check: No No…

 

All interactions have both conscious and unconscious layers. This is the premise of psychoanalytic theory and treatment. As such, fantasies, erotic and otherwise, are likely to grow in both directions, with the major vulnerability and hence, safety valve, is that fantasies led themselves to words and not actions. In other words,  fantasies must mutate into a narrative, but not into an action.

The cartoon above illustrates the point. That Dr. James (fictional, of course), wants to jump on the couch with Edna, is a rich area for exploration, but jumping on the couch is the source of cartoon and mockery. The caption illustrates that Edna, the patient, might indeed fantasize about James jumping on the couch, but narration in replace of action, leads to understanding and healing, as opposed to repetition and re-traumatizing.

This, again, is the fundamental principle of therapeutic action. Patients get better because unspeakable fantasies are speakable, and in so doing, analyzable, and in so doing, amenable to forgiveness and mourning. Edna, in this example, needs to mourn the loss of a parent who saw her as a sexual object and not a child that needed love and nurturing to grow up and flourish in the world.   This is not the loss of the death of a parent, but rather the loss of a parent she never had. Only through fantasy, both in patient and analyst, can these traumatic pasts be explored and worked through.

Fantasy, as opposed to  check-lists must be open to exploration and hence must not be limited by time. The open-ended nature of this exploration is critical to getting at deep unconscious material which troubles and disturbs functioning. These are the basic tenets of psychoanalytic psychotherapy. We must cherish these techniques and not abandon them for what sounds like a faster cure, but in fact, is a quick change to the check-list.

 

 

Countering Transference or Just Havin’ Feelings?

 

As I re-enter into the blogging world, I am reminded that one purpose of this blog is to focus my attention towards teaching about psychoanalytic concepts. In this way, this blog serves as my notepad, my preparation to stimulate a dialogue about the human condition in a psychotherapeutic setting. In that light, I want to focus on the notion of countertransference; a notion which is vague but generally means the unconscious and conscious feelings that the therapist has towards his patient. Edna and James, the therapeutic dyad, struggle together to make sense of Edna’s past and present anxieties. Edna, seen four times a week, for many years, is often angry and frustrated with James. She feels stuck and guilty, for no apparent reason, except she thinks that James could be doing a better job. At the same time, she comes regularly and reliably to her appointments and it never occurs to her to switch psychoanalysts.

James likes Edna, looks forward to seeing her, but feels that his feelings towards her are shallow, despite the many hours they have spent together. He assumes these shallow feelings are a result of both Edna keeping her emotional distance and James, not wanting to be drained at the end of each day. Still, of all of James’ patients, Edna, he would say is the one he feels the least connected to. James come to me for consultation about this troubling realization. “Maybe you have just not gotten close to her because she is so defended? And/or maybe she reminds you of people from your past who you spent a lot of time with, but who really never had emotional meaning for you?” I say, expressing layers of understanding to begin a discussion with James as to why he is seeking consultation with me, with regards to his therapeutic relationship with Edna.

The parallel process between trying to draw James out, via free association, follows James attempt to understand Edna, by the same means. Yet, my relationship with James is a teacher, or  a supervisor, as the psychoanalytic world likes to call me. My job is to help with his concern, not about his life, or his personal relationships, but with his psychotherapeutic dilemmas. At the same time, I teach a class, struggling with the idea of countertransference, and in particular, struggling with the word “counter.” This, as I will talk about in class, is a major misnomer. There is nothing “counter” in countertransference, but rather, feelings go both ways, and the dyad changes over time-both sides, of course.  This changing dyad is a result of the struggle to understand what happens when two people come together, hour after hour,  trying to heal, trying to understand, with an attempt to offer up many answers, to seemingly unanswerable questions. These answers, are ideas, not definitive conclusions, and yet ideas help soothe anxiety, and create forward momentum,  given the limitations of our own biology and the stressors in the world around us.

Diagnostic Countertransference

 

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.

Teaching Countertransference

Is there a pipeline from the unconscious of the patient to the unconscious of the therapist?  Imagining this pipeline is part of the psychotherapeutic  art. “Tell me what I should talk about.” Willa, forty-three, says with, what I perceive to be, a demanding tone. “I am feeling angry right now and I am not sure why,” I respond, suggesting that I am picking up on her anger, but not certain of that. “I do have some self-awareness” Willa says forcefully. “I am confused,” I say, interrupting her, when I should have waited for her to continue. “I do have anger,” she says, as if that should have been obvious to me. “Tell me more about your anger,” I say, not clear as to who or what this feeling is about for her. A dramatic change in tension ensues, where Willa and I begin a comfortable conversation about her husband and her resentment of his behavior. My feeling of anger, I guessed, was a perception which came from Willa’s anger, and yet I had no basis for this assessment, other than my own internal state. Using my feelings, my countertransference, allowed me to unleash Willa’s self-imposed strangulation, of her not allowing herself to be forthcoming about her marital problems. Willa communicated with me through a nonverbal pipeline, which in my early years of work, I would have sat there confused and uncomfortable, instead of harnessing my feelings to deepen our therapeutic work.

Sick One: Healthy One, No Way!

Heinrich Racker says “the first distortion of truth in ‘the myth of the analytic situation’ is that analysis is an interaction between a sick person and a healthy one. The truth is that it is an interaction between two personalities, in both of which the ego is under pressure.”

This concept of “egos in the ring” as I like to say, is often resisted, as Kathleen, seventy-one, likes to say, “well you are the expert,” to which I respond, “I can’t possibly be the expert about your internal experience, but together, maybe we can come closer to understanding that.” So, Kathleen, based on her upbringing, needs to see me as the omnipotent one, needing an idealized helper who guides her through her life, and I, the professional, educated for many years, and yet, still insisting that there is no one truth, only a way of understanding her psychic landscape. This struggle, as I like to teach my students, is the “working through,” the experience of re-framing long-held beliefs in which one feels anxious, dependent and insecure, rather than the confidence to gather one’s internal experience to make thoughtful and measured decisions. So, unlike other professional/patient relationships, the psychotherapeutic relationship has no expert, only a willing guide through the sometimes dark internal world, of the curious. The stripping of the expert job, again, does not sit well with massive systems which try to pinhole psychotherapy into small bits, as this “egos in the ring” is not a small bit, but a decisively nonlinear activity.

Boredom In Psychotherapy

 

“Do you get bored?” many friends ask, as if this is the shameful underbelly of psychotherapy. In fact, boredom, a countertransference, is, to use an overused phrase, grist for the therapeutic mill. Boredom is the window into emotional blocking, the common way in which people check out from themselves. Bari, forty-two, starts to give a lot of details about her drive to my office. Her monotonous tone, along with my trying to understand of her need to give me so many details, makes me think about what she is not telling me. “I wonder what is going on here, between us, right now,” I say, gently trying to point her to wonder together as to why she is telling me about her traffic. It is my job to move from boredom to engagement by helping Bari see her avoidance of something that is really bothering her. Eventually Bari gets to her fight with her teenage daughter, but the shame involved in that altercation, sheds light on why her driving difficulties was an easier, less emotional, topic. Lolly, twenty-six, goes on for a long time about how her wedding plans are going. Although interesting at first, over time, my mind wonders, leading me to believe that there is some underlying emotion that Lolly is dodging. Once again, tracing my mind leaving Lolly, I have a clue, a suggestion, that maybe Lolly’s mind also left Lolly, such that she is talking, but not really caring, or feeling anything about what she is saying. Emotional connection is never boring, such that losing interest is a sign of emotional distance. So, yes, I get bored, and then I wonder how to latch back on to that privileged space of shared feelings.

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…https://shirahvollmermd.wordpress.com/2012/11/01/countertransference-come-on/

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.