Did I Mention I Was Teaching Transference Tonight?

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Freud initially thought that transference was an impediment to treatment, but as the years went by, he began to “discover” that understanding transference was the holy grail of treatment, meaning it is the part of psychotherapy which creates personality change. In other words, how we feel about ourselves, based on early relationships is often recreated in our meaningful relationships and if we form relationships which are harmful to our self-esteem, then we need to reformulate our opinion of ourselves, based on a new relationship. This new relationship, in the form of psychotherapy, allows the patient to examine how he projects on to others ideas from his past, and in so doing re-affirms his previous notion that the world is mean/cruel/withholding towards him. If the patient can see his own projections then he can open himself to new possibilities which includes relationships in which he feels valued/loved/cherished. This is a simple notion, which in practice, requires many hours, in fact, at times, many years of treatment to see how deeply held beliefs can be faulty and damaging.

Joe, thirty-two comes to mind. “I am going to disappoint you,” he tells me with great certainty. “Why do you say that?” I ask, thinking about his declaration. “I disappoint everyone in my life. I just do.” He says with little elaboration. “You mean you disappointed your mom,” I say, thinking that he is referring back to his earliest relationship in which he felt terrible sorrow for not making his mother happy, and in fact, disappointing her by not becoming a doctor or lawyer. “It must be terrible to feel that you disappoint people,” I say, thinking about what it is like to think that you will cause a significant other deep pain. Joe starts to cry. His tears speak volumes to his sense of inevitability that he disappoints; that is just what he does. “Maybe you disappointed your mom, but that does not mean you disappoint everyone,” I say, stating the obvious, but also knowing that it needs to be stated. “The issue is that you feel like a disappointment, and that is a terrible burden to bear,” I say, trying to help Joe understand that he carries around this painful feeling that he cannot shed, since he is so attached and identified with his mother. “I wasn’t abused,” Joe says protecting his mother. “Not in the traditional sense, “I say, “but you weren’t cherished for who you are, and that is a different kind of trauma,” I say, trying to help him understand the childhood feelings he carries forward into adulthood. “I don’t get it,” he responds impatiently. “Yes, we have more work to do,” I say, knowing that this is a painstaking process.

Transference: Continued

Distortion is another word for transference in that we mis-read social cues based on past experiences and not based on current interactions. Barb comes to mind again. She is the 50ish year old woman who suffers from always feeling persecuted and treated poorly. She tells me that I “make her go to her appointments with me,” as if somehow I have that power over her. Her issue is that she attributes to me, as an authority figure, the power to condemn her if she does not coöperate. She fails to see that it is her decision to be in treatment, and it is her decision to stop or decrease the number of our sessions. How she managed to recreate her experience of feeling persecuted with me, is how Freud described this phenomena called transference. At first, he saw it as an obstacle to treatment, but over time, he came to “discover” that understanding the transference was the holy grail of treatment. In other words, if I can help Barb see how she makes her world play out such that she always feels boxed in, then I can help expand her mind such that she can see the situation  in new and meaningful ways. Eventually, I believe, Barb will see me as someone who offers her a safe space to examine the inner workings of her mind, but for now, I am another persecutory figure who makes her life feel frustrating and that results in chronic feelings of anger. As we examine this repetition of feeling which occurs in my office, we can begin to understand how she unconsciously makes her life such that she feels she is a slave to other people, a repetition of childhood feelings of being a slave to her mother. As Freud said, we repeat in order not to remember, and so with Barb, understanding this repetition will take a great deal of time, because remembering her childhood feelings is going to feel deeply sad and despairing. The safety of our relationship allows for those feelings to bubble up, but it will still take time and care, on both of our parts,  for her to allow herself to get there. Transference is a simple concept, but in the therapy room, it is complicated by very challenging feelings. Still, privileging the transference as the key to therapeutic gain is the concept, we, as mental health professionals, must hold on to, as this is where we need to guide treatment for psychic pain. I never tire of saying this, as the importance cannot be overstated.

 

See also…https://www.youtube.com/watch?v=PD5iyGBVASU

Teaching Transference

Trans·fer·ence

transˈfərəns,ˈtransfərəns/

noun

1. the action of transferring something or the process of being transferred.

   “education involves the transference of knowledge”

   • PSYCHOANALYSIS

     the redirection to a substitute, usually a therapist, of emotions that were originally felt in childhood (in a phase of analysis called transference neurosis ).

   How do you teach this concept? I wonder. We repeat behaviors from the past and impose them in the present, and in so doing, our behavior is out of proportion to the present situation but our behavior makes sense in a historical context. In other words, all actions are reactions to past experiences as well as reactions to current experiences. So, if Barb feels that I am being mean to her in session, I may in fact be mean to her, and/or she may get triggered by something I said which reminds her when her mom was mean to her, and in that situation, I am the trigger, but she does not see that immediately, so she feels very hurt and disappointed by me. With time in psychotherapy, Barb and I can come to see how she felt my behavior was “mean” and she can also talk about how it reminded her of how her mother treated her when she had a boyfriend that her mom did not find suitable for her. As we unpack her feelings of hurt and disappointment, Barb comes to see how in other parts of her life, particularly in her close relationships, she often feels hurt and disappointed, and this may, in fact, be her carrying forward painful experiences she had with her mother. “Maybe I am too hard on my boyfriend,” Barb says with the suggestion that her insight into her behavior is slowly expanding. Helping Barb understand how she feels that everyone will treat her as her mom did, opens her eyes to the understanding that maybe she carries with her painful assumptions, which, when tested out, turn out not to be true, but without opening her mind to the fact that she is making assumptions, she then constantly feels hurt and disappointed. Through talking about the transference, Barb has the opportunity to grow emotionally, such that she can begin to understand how she can take a benign comment, such as “I wonder what you find attractive about your boyfriend,” and given her history with her mother, she hears “what on earth could you like about that man?” In her mind, she is prepared for a judgmental, critical attitude towards her boyfriend, such that she cannot entertain the possibility that my question is one of curiosity and not criticism. Clearly, tone is critical in this discussion, but even with a neutral tone, there is the sense that Barb is so convinced that the discussion is going to be antagonistic, and as such she must go on the defensive when talking about her boyfriend. This is a simple notion of transference, but one which I hope will illustrate the point. The point being that by reacting to our past and not our present, we, who have been hurt in childhood,  continue to feel the pain and we do not open ourselves to feelings of acceptance and love. In essence, understanding transference can  be transforming, creating a life-changing  and maybe even a life-saving experience.

    

See also…https://shirahvollmermd.wordpress.com/2014/02/03/teaching-transference-2/

Transference

Is A 20 Minute Appointment Worth Anything?

 

Suppose you could see a patient for 20 minutes, once every month or so, with the expectation that medications can be altered, stopped or started. What if the question is whether 20 minutes is better than zero minutes, returning to the overarching question of whether bad care is better than no care. The answer, as you can imagine, is “it depends”. For some patients, this periodic check-in serves as a touchstone towards wellness. The brief visit is seen as a means to transitioning from sickness to health. For others though, there is a tremendous sense of futility, in that, patients often express the sentiment, “how could you know what is going on with me, when you hardly ever see me.” The difference between these patients is their transference. Those who are helped by a touchstone generally have a positive view of authority figures and as such, they are leveraging that history to improve their lives. Others, with more traumatic backgrounds, are tremendously skeptical of those who “ought to know” and as such, bring so much suspicion to the appointment that the therapeutic benefit is lacking. This negative transference is a way that the patient communicates that they need more time to break down their preconceived notion of authority figures such that trust can be built slowly over time. Understanding the various kinds of transference allows for an individuality to treatment which is short-changed with the twenty-minute model. In other words, well-trained physicians should be able to decide who can benefit from short versus longer appointments. This decision should not be based on the number of medications a patient is taking, but rather on the ability to form trust with the patient. To be clear, going to see your psychiatrist  as the photo might imply, is not the same as getting a haircut.

Transference

“Psychoanalytic treatment does not create transference, it merely brings them to light like so many other hidden psychical factors.” Freud, 1905

 

“I am just not comfortable with your shoes,” a fictional patient, Trey, sixty-one tells me, to my astonishment. “What do you mean you are not comfortable?” I ask, feeling clueless about his comment. “I mean, they do not suit your outfit and they just make me uncomfortable, ” he protests. “Tell me more about this feeling of discomfort,” I ask, hoping for clarity, which never seems to come. “I know this sounds silly, ” he continues, “but I trust you more when I like what you are wearing.” Again, I am confused, but aware that this discussion is about his pre-conceived notions of authority. I sense that to him, being in power is strongly associated with a professional look, and as such, he was raised to associate appearance with wisdom. This superficial connection, as I suspect, has caused him great difficulty in his life, as he is a sucker for the polish without the substance. He never grew to appreciate the inner workings of relationship which involve loyalty and dedication because in his background, appearance trumped sincerity. As he focuses on my shoes, I am reminded of his traumatic beginnings where there was a confusion as people he was told to trust turned out to be disloyal, leading him to feel anxious and unhappy in his close relationships. He repeats these poor judgments by commenting on my shoes. He opens the window into his childhood in which I can now appreciate that the trappings of wealth were of such high value in his family that he became blind to the bonds of good relationship which depend on honesty and reliability. If I did not understand transference, I will tell my students, I would be completely taken aback by his focus on my clothing. With understanding this phenomena, I am still confused, but I know I am in a transference confusion and that is the area I need to pursue. Freud, once again, has guided my thinking so that although the path to helping Trey is not linear, I do have tools to help me.

Learning Patterns of Interaction

“The child tends to carry over into later situations the patterns he first learned to know. The rigidity with which these original patterns are retained depends upon the nature of the child’s experience. If this has been of a traumatic character so that spontaneity has been blocked and further emotional development has been inhibited, the original orientation will tend to persist. Discrepancies may be rationalized or repressed…..The little child who grows more and more negativitistic, because of injuries and frustrations, evokes more and more hostility in his environment. Some people are so injured that they are not able to make use of kindliness or decency when it does come their way. They meet the world as if it were potentially menacing…..Despairing of real joy in living, they develop secondary neurotic goals which give a pseudo-satisfaction…When the reference frames are made conscious, then reality gradually becomes undistorted. ” Janet MacKenzie Rioch MD

 

Nellie, sixty-three, comes to mind. She is ALWAYS angry, bitter and expressing stories of unfairness and persecution, be it about herself or a member of her family. She has no ability for spontaneity. Many might see her as dour. She is obese, which she attributes to those “dumb doctors which gave me medicines that made me fat,” despite the fact that she has been obese since childhood, long before she had to take chronic medication. She got into a fight with her sister because she was SURE that her sister wanted to harm her kids, even though she had no evidence for this. Nellie is not psychotic. In fact, she functions as a high-level executive, although she works independently and no one reports to her. Yet, when it comes to her personal relationships she is quite certain that all of her friends and relatives use her for their own needs, and have no feelings of love for her, while at the same time, she states she has no feelings of love for them either. Nellie’s emotional world is characterized by feelings of paranoia and victimhood. Going back to her childhood, she describes her mother as very similar to herself. The world, according to Nellie’s mother, was one in which everyone else was happy, but not her (meaning Nellie’s mother). Nellie’s mother raised her children to be financially successful, but she did not instill in them a sense of love for themselves or each other. Consequently, Nellie describes her relationship with her six siblings as distant, but in touch. She also tells me that she, and ALL of her siblings have expressed an emptiness, despite academic and financial success.

Nellie treats me like I am using her to make money. She comes, with ambivalence, and wonders aloud, saying “you obviously want to make money off of me, so it is not in your best interest for me to get better.” I respond, “it must be hard for you to imagine that I care about helping people and that might trump my need to make money,” suggesting that although making money is important, the satisfaction of people developing independence and autonomy is also important to me. I am also hoping to slowly instill in Nellie a sense that her bitter remark towards me could be symptomatic of her frame of reference, where no love was ever exchanged, and people were seen as objects to advance one’s standing in the world.

Nellie’s mother, apparently, seemed to use her children to reflect well on her, rather than allow them to develop self-empowerment and creativity, such that their accomplishments felt empty. Nellie, by my formulation, was an object to her mother, and as such, with that kind of emotional deprivation, she has carried the flag forward, continuing to see her relationships as objects, as people who can get her somewhere in life, rather than as people she can enjoy and cherish. Without consciousness, Nellie will continue her life repeating this pattern of seeing people who have no feelings for others, but only have the ambition which mandates that they use people to advance themselves. Psychotherapy and psychoanalysis are pattern busters. Patterns are exposed, allowing the person to see the pattern in which they are living, and thereby giving them an option to make new patterns, new kinds of relationships. Life does not have to be a repetition.

Life As a Repetition of Feelings

Love is experienced for someone today in terms of the love felt for someone in the past. as Freud would explain feelings. More recent psychoanalysts, such as Janet Mackenzie Rioch MD  has stated that relationships do not repeat, but they expand on prior relationships. New relationships feel so awesome, because, she would say, they extend the interior of the individual. Old relationships, from childhood, she likens to hypnosis, as certain repetitive messages become etched in one’s identity, such as “you are dumb, you are a nuisance, you always make mistakes, mother loves a good boy who does what I tell him.” Since the child has no other frame of reference about himself, he typically adopts the characterization which is repeated the most. This hypnotic “spell” as Dr. Rioch explains, becomes the transference in psychoanalysis. The adult patient feels like a nuisance, even though the therapist does not experience the patient in that way. Or, the patient makes himself a nuisance to the therapist in order to communicate that is how he is used to being seen. This is why the analytic work is to not be authoritarian, so as to allow the patient to display how he works with the idea of authority. In so doing, both the patient and the therapist can learn about the childhood hypnotic state which has shaped his view of himself.

Colt, forty-one, comes to mind. He comes from a family of published authors. Both his parents and his four siblings have achieved both financial and literary success with their writing, but he does not seem to be able to find his way. He teaches English, and he enjoys that, but he believes himself to be intellectually inferior, not just in terms of his family, but in terms of the world. He does not see that he was in a “hypnotic trance” as he was made to feel inferior because he did not pursue a writing career. As he explores his past, he relates to me, that in his family, writing was the only measure of intelligence, and since he did not have a passion for writing, he believed himself to be dumb. As he sits with me, he is “absolutely certain” that I see him as intellectually inferior, when, in fact, I am in awe of his wit, and his humor, which I take as evidence of his superior intellect. I cannot reassure Colt that I find him stimulating. I mean I could say that, and he would listen, but he would experience me as “trying to make him feel better, because that is what I am paid to do.,” as he has told me in the past. Instead my approach is to help him see how he thinks, to examine his own language, so that he can see that he is generating interesting ideas. Plus, I attack, gently, his certainty, about his intellectual inferiority, and propose a new way of understanding that the message given to him by his family, may, in fact, not be an adequate reflection of his strengths and weaknesses. Perhaps his family never studied him to know his intelligence, but with a high narcissistic endowment, the family thought that since he was not like them, he must be inferior. In other words, together, Colt and I can come to see that beliefs about himself which he has held on to tightly, may, in fact, be generated by people who did not really know him. “Consider the source,” I want to say early in our work together. As time goes on, our relationship strengthens, so  I do say it.  Colt gets it and opens his mind to a new look in the mirror. The work is slow, but over time, the change is huge.

Medication Transference

 

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“There is only so much you can say about Prozac,” one of my students says and makes me chuckle. “Yes, but there is a lot to talk about the meaning that Prozac has to that person.” I say, highlighting that themes in a person’s  life come alive when you ask them what the medication means for them. Without this discussion, the physician is at a loss as to how the patient integrates psychiatric medication into their schema of their world. This issue of what the diagnosis and/or the treatment means to that individual patient is what drew me into the world of medicine. Yes, diagnosing can be fun, and watching people get better by using your intervention is fulfilling, but for me, the excitement comes from understanding how the person is thinking about their circumstance, in this case the agreement to begin a psychotropic medication.

 

Clarissa, sixty-one, comes to mind. She feels that she needs medication “to function”. Sometimes this “medication” is Xanax, and sometimes it is alcohol, and sometimes she takes Zoloft. In her mind, each of these mind-altering agents serve the same purpose. They make her feel rewarded and worthy of enjoying her life. Without these substances, Clarissa feels lost, anxious, and unloveable. Yes, these medications help her feel loveable because they shut off the voice which speaks to her and tells her what a bad person she is. Her superego is very mean and loud, I say, explaining that the medications turn down the volume of her superego, thereby allowing her pleasure. “Wouldn’t it be nice if you could tame your superego without medication?” I propose, hoping that she will work with me to taper her Zoloft. “I am just not sure I can do that. I am an old lady and I have been this way for a long time,” she says, giving me hope that although we both agree that things get harder with age, slowly, change can happen.

 

Clarissa illustrates the weaving together of medication and psychotherapy which can only be done with time and focus. A “med check” visit could not explore these meanings. A therapist visit could explore these meanings but they would not likely tie the exploration to the discontinuation of the medication. Being able to use medications to launch into a discovery of the internal mind is what I call “integrative care,” as distinct from that term which is now used to suggest that psychiatrists can do chart review while another clinician implements the treatment. Psychiatrists, as prescribers of medication, need to understand how these prescriptions are integrated into the mental interior, through Freud’s famous adage of “free association”. To do this, psychiatrists need to reflect on our history of understanding that meaning is derived from the past, influenced by the present.

Teaching Transference

“You have an empty life and that is why you are in this field,” an angry female patient, age fifty-four, says to me, causing me to pause and reflect about both how I feel and how I want to respond. “What gives you the idea that I have an empty life?” I ask with a calm tone, wondering what might have happened in the previous session that led her to that conclusion. “It seems like you are always working. I know you have early morning appointments, weekend appointments, evening appointments, so I was thinking that the reason you must do that is because you have no one you want to go home to,” Marni says with a degree of certainty that gives me deep pause. “It is interesting that you jump from the time of our appointments to the fact that I am working all the time, to the fact that I have no one I want to go home to,” I say, highlighting her assumptions which begin in the present, but maybe bring up her past important relationships. It is in these assumptions where I begin to wonder if Marni is confusing past from present. Whether I do work too hard, or whether I have someone to look forward to see when I go home, is not as critical as to how Marni created that narrative and why, at that moment, she wanted to share that story with me, as opposed to maintaining a private fantasy life about my non-working existence. The technique issue in the moment, is that Marni is so certain of her conclusion, that any pushback, might be heard by her to be defensiveness, such that we may not have the opportunity to pause and reflect over her narrative.

Now, I begin to think about the second half of her sentence. My motivation for being a psychiatrist stems from my “empty life”. How does having an “empty life” encourage someone to pursue undergraduate, medical school and residency? Does Marni think that the time commitment of medical training suited me perfectly because, after all, I had nothing else to do? I had a strong internal urge to point her to  my last post where I confessed to watching, and loving, ‘Breaking Bad’. Although this line of thinking was riveting for me, I thought it was wiser to focus on her anger. “Why do you think you have to put me down?” I say, thinking about the enormous hostility and meanness, I felt from her tone. In the moments before Marni answered, I thought about her relationship with her younger sister, and how she explained to me, that whenever Marni had a bad or difficult day, she came home and tortured her sister, leaving Marni to feel tremendous guilt and confusion as to why Lissa, her sister, was the object of her venom.

Marni began to cry. “I guess I feel empty. My kids have grown up and they are doing well, with little need for my attention, but the truth is, I hated being a mom, so I am not sure I can say that is the central issue. I had a career as an attorney, but my husband makes enough money that I quit my job two years ago, and so I thought that would give me relief, but I have not found anything to fill that void, even though I am happy not to be a lawyer any more.” Marni’s tears are painful and not surprising. Her anger towards me was quickly transformed into her own despair. “I wonder if your despair begins as anger, since that is how you lived your life as a child, when you came home and beat up on Lissa, when life presented unbearable challenges. It seems like you transfer your sadness, your fear, into a more active stance of aggression, and in the past it was towards Lissa, and today, it was towards me, but just for a few moments.” I say, reminding both of us that her anger was her first step on her journey towards sadness and fear. To put it in Freudian terms, her anger and aggression were her defense against despair. Uncovering her defense, put her in a sympathetic place that allowed both Marni and I to feel her pain, in a way which began a process of thinking together, how she can restore meaning in her life. Her word “empty” was the key to understanding that she feels a desperate need to “fill up” and yet she is painfully confused as to how to begin. By putting me off my center, Marni could feel the power that is so sorely lacking in her life in which she feels impotent and lost. Understanding transference allows us to work with her initial venom as the manifest content, covering up the latent material of uncertainty, with subsequent anxiety. Thinking in terms of layers is the difference between the beginning therapist who is unable to think, when attacked, and the more mature therapist who can feel the attack, but still  think about the multiple meanings, both in the present and the past.