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

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.

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.

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.

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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.