What Do Patients Think About Their Therapist? What a Counselor Does About “Transference”

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Patients wonder what their therapist is thinking. Therapists wonder what their patients are thinking. It is not much different from what happens between husbands and wives, parents and children, bosses and employees — or is it?

I’ve written about what doctors think about their patients before: What is Your Therapist Thinking? But today I’ll focus on what the patients are thinking about their counselor and how therapists are “supposed to” handle that. I say supposed to, because we don’t always do it well. It is one of the trickiest parts of a counselor’s job.

Patients have feelings and expectations about a counselor, in part, because he resembles someone else. This is called transference. In other words, the client’s sense of this new person is transferred from someone else who is important to him, simply because the new acquaintance resembles the old one. It happens automatically and without thinking; a kind of mistaken identity.

No, you don’t think your therapist has red hair if his hair isn’t actually red. But you do see him through the lens of your past experiences, and react to him because of certain real or imagined similarities to others. All of us do this in all sorts of relationships. It occurs whenever we have unconscious feelings and assumptions about someone who reminds us of someone else; which is a lot, even if we don’t know it. The feelings toward the old person (be it a parent, a sibling, a boss, or a lover) can become quite mixed up with the real human qualities of any new individual, including a new therapist.

Indeed, this is made easier by the fact that the therapist limits how much the patient knows about his personal life. In effect, the shrink is a kind of blank slate upon which the client “fills in the blanks” left empty by a lack of real information. Not surprisingly, all of us are prone to repeating old behavior patterns in new relationships; and, to the extent that a new person evokes old feelings about what the relationship is and what it can become, the transference can play out the patient’s repeated relationship difficulties right in the therapist’s office.

Take a hypothetical situation. Let’s say that your dad was a hard guy. He was critical of you, didn’t give you enough attention, and seemed to favor your siblings. Now, many years later, you meet your new therapist. Is he any of these things? To some extent it doesn’t matter. For example, the fact that your shrink only sees you once a week can reopen the tender wound of your neediness — your failure to win your father’s time and attention. You might feel that your doctor isn’t as available as you’d like him to be, in person or on the phone. You might interpret some of his statements as being disinterested, even when they are not so intended.

The counselor can be more important to you than he would otherwise be because of your unresolved, unconscious desire to get the affection and approval of this admired authority figure, who, like all authority figures, can easily remind you of dad. The hurt and/or anger that you feel when the shrink does not fill your need for a “good” father is almost inevitable. You might want to leave therapy because of it.

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What is a therapist supposed to do when this happens? If he reacts defensively to the patient’s demands or disappointments, he is unlikely to do him any good. In fact, the counselor who responds angrily can create one more injury of the same kind that was inflicted by the patient’s father, thereby adding to the client’s mistrust and misery. Even if the healer tries hard to give him what only a father can give, the patient will still not be satisfied. After all, the therapist cannot literally fulfill the childhood yearnings that come from anyone’s vanished youth. The hunger of a 10-year-old for good parenting can no more be satisfied when he is 30 than can a literal hunger for a good meal at age 10 by a delicious dinner 20 years later.

What the therapist can do is the following. First, he can be compassionate and understanding. He often anticipates that the patient’s old losses and resentments (his past disappointments concerning his dad) are likely to play out in the therapeutic relationship. When they do, the psychologist will try to gently assist the client to see that the feelings bubbling up are not fully appropriate, but come from the historical emotions attached to the father that have been superimposed onto the shrink. If the patient is open to exploring this, he will gradually be able to purge his internally complicated connection to his parent. This is a grieving process, a cathartic expression and understanding of the sadness and/or anger that continue to live inside of him, even if the parent is dead.

If all goes well in therapy, the therapist will eventually no longer evoke the transferential emotions; no longer remind the patient of the parent. And not only will his relationship with the therapist be less complicated, but so will all those other interactions with lovers, bosses, or friends which used to unconsciously trigger the same feelings. Finally, the old injuries will be healed sufficiently to be set aside, clearing the way to better social interactions in the future.

I am certainly not saying that all of the feelings that patients have about their doctors are mistaken. Therapists have the same potential flaws as everyone else. They can be good or bad, attentive or unreliable, too easily hurt or too distant. Some want your admiration and some don’t much care. They have feelings about the patient that grow out of their own relationship history. This is called a countertransference. Regardless, the potential for the transferential issues I’ve described is always there, just as the therapist’s countertransference toward the patient must be carefully watched to prevent the damage that it can do.

Do you find all of the above some sort of psychobabble that doesn’t apply to you? Trust me, transference is real. The more that you believe your relationships are “logical” and that your past doesn’t reach into your present, the more that it probably does, unless of course you have dealt adequately with it in some sort of therapeutic process, whether in treatment with a professional or in your own self-analysis.

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Therapy and transference are much more complicated than I’ve described. What you’ve read is a simplification based on a hypothetical relationship between a father and his adult child who is in therapy. If you are not in therapy, even if your relationships are going quite well, it still may benefit you to take a look at patterns of connection you make with friends or lovers: the kind of people you are drawn to and the types of individuals who usually “push your buttons,” get you angry, or disappoint you in some way. We can all learn a lot by just connecting-the-dots of our life history, seeing the resemblances among the people who keep returning, even if their names are different the second or twenty-second time around.

It is easy to blame others when relationships fail. Relationships aren’t easy. But, the more unsatisfactory and repetitious your social life is, the more likely that something in you needs attention.

The top painting is called Therapy by Gerhard Gepp. Apparently, the patient (a soccer ball or football) is thinking about being kicked around. Might he have transferential feelings toward the therapist and feel badly treated by him, as well? The second image is a photograph of Sigmund Freud in Session with a Patient, from the Seventh International Sand Sculpture Festival in Portugal. The artist is RHaworth. Finally, a cartoon of Freud Treating Moses by Moa1. All are sourced from Wikimedia Commons.

16 thoughts on “What Do Patients Think About Their Therapist? What a Counselor Does About “Transference”

  1. I disagree with therapists believe about transference because I feel they’re so enraptured with theory, they’re not aware of what they actually do.

    The therapy dynamic is no more precious or magical than the Queen bee lady who “fixes” everyone else at luncheon and the stooge friends who hold her in high regard.

    Here’s how I experienced therapy as a client. I was the stooge. I took the sick role; the therapist took the well/evolved role. From there, he was a often-silent riddle-Spinx, one who knew THE ANSWERS, but withheld them in a game only he understood, The disclosure, the play-acting was all skewed to give the therapist the power and make me believe I was inferior to him.

    This unnatural relationship was a very real event and its artificiality magnified my reactions when the therapist was authoritarian or contemptuous.

    As you know, transference always exists in life. But therapists often fail to realize the real-time artifice and stagecraft they use in the treatment room. It’s no different than the dazzler who diminishes us at lunch.

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    • I would agree that some — I’d emphasize that word — therapists meet your description. Surely there is no magic. It sounds like your experience was a bad one and the therapist mishandled the admittedly skewed power relationship. As I’ve said elsewhere on my blog, therapists have to be very careful about what they do — sometimes it can be “for you” and (unfortunately) sometimes it can be “to you.” I’m sorry that you had a bad experience, but appreciate your comment very much. My link to your site remains on my blogroll because I think your description of your experience is an important cautionary message.

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  2. Interesting write-up Gerald. I can easily believe a patient would engage in transference, and I can definitely see it happening in other contexts. I believe I have seen it in a student or two of mine, sometimes with rather disruptive results.

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  3. drgeraldstein

    Thanks, Daniel. Another way to think about transference is in terms of something one learns in first year Introductory. Psychology: stimulus generalization. For example, responding to a person (or even a piece of food) because he/she/it looks like someone or something one has had previous experience with.

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  4. These feelings you’ve described here on paper can be incredibly strong. I have been in therapy for six years, and my therapist helped me to stay, to trust, to talk about my feelings, and to love. I have talked with him about these feelings, and because he normalizes them, this helps me to realize that I’m OK. I am not sure how termination will go, but I hope I will carry his voice and words inside of me. He helped me work through my past, and was there when I needed him. He helped the child inside to tell her secrets, and when she finally did, he reached out to her in empathy and compassion.
    This is why “she” sees him as her father. These feelings have been at times confusing, healing, painful, or the best feelings I have ever had. Now that I am not ashamed of these feelings, their intensity has started to level off, which I never thought would happen. I think, based on my experience, that therapy is about love, and helping clients to feel again. There’s a lot more work behind the scenes, but love is the central force. This is why good therapy works, provides healing, and helps clients to love themselves and others.

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  5. Is attachment to your therapist the same as transference?

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    • It depends on the sort of attachment. If one person seems kind and is helping the other, it is quite natural to have good feelings toward the helper. Transference refers to those feelings, however, that are superimposed on the counselor and go beyond this. The positive or negative transference is a set of feelings that usually derives from some prior relationship, often from a father or mother, and change one’s view of the therapist so that he is seen as something like such a person. The power of those feelings is strong and they are thought to reflect unresolved emotions in the relationship to the original person from whom the emotions are “transferred” to the therapist. I hope this helps. Thanks for you very good question.

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  6. My first rift with my beloved CBT psychologist, who has disappointed me. I was raised without a father, believe now (after reading this article) I had different expectations than what he delivered, and I am terrified he will discharge me. Afraid I will be seen as the “bad patient” and will be despised by him. He liked me until now. Scared, and yes…I have GAD.

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    • Your relationship with the therapist is grist for the mill, the sort of thing counselors deal with regularly. Of course, you aren’t bad. This kind of problem in the relationship can be used to make progress in resolving the transference.

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  7. Would a CBT therapist recognize the fatherless woman with transference issues?

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  8. If he is good at what he does, he should be able to recognize this, Nancy.

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  9. Note to self…do NOT post comments while in the midst of high anxiety. All is well, Dr. Stein and I am very lucky to have a kind and understanding therapist. There was never a rift, just my brain thinking and thinking.

    Liked by 1 person

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