countertransference

March 31, 2018

Why Therapists (and Others) Don’t Always Understand

How often we hear someone say, “I understand.” How often we think, “I only wish it were so.” Beyond the imprecision of language, I want to consider 10 reasons why true comprehension – recognizing the other person as he is and in depth – is difficult.

  • The fog of appearances: We instantly react to the individual in front of us, even before he makes a sound. Beauty (including a lovely voice) or its absence rose with the dawn of man. Sometimes revealing, sometimes obscuring; sometimes enhancing, sometimes diminishing. Sometimes all of the above.
  • Stereotypes: Beyond what we take from the person’s facial symmetry, shape, and size, other factors can cloud deeper comprehension. Gender, age, race, religion, and nationality interfere with vision beneath the surface.
  • Secrets and history: Polite conversation sets boundaries around self-revelation. Many of us believe we have been misunderstood – judged to the point of harm – and hesitate to reveal much. Even in therapy this is an issue, though with time and growing trust, significant secrets are often divulged. Without exposure, the job of comprehending you is far harder.
  • Our limited access to important data: Think about what information you might need to understand someone else. No one can access to all three sources below:
  1. The individual is the only person who perceives his life from the inside. He does not, however, see himself from the outside and will be shocked the first time he hears a recording of his voice. His grasp of his own motivations cannot be assumed accurate and may not reflect the work of the unconscious. Similarly, he interprets his life without the benefit of external perspective; except whatever is received, understood, and accepted of the other’s body language, tone of voice, praise or criticism. Most of us would be unsettled to know what others say about us in private.
  2. Friends and acquaintances hear what the same individual says about himself, what he reports of life apart from the observer, as well as experiencing his behavior in real time. Even his intimates must contend with the fact that “a mask of him roams in his place through the hearts and heads of his friends.” (Nietzsche, Beyond Good and Evil).
  3. Finally, the therapist has the most limited exposure to the client in real life. Ideally, however, the patient is more open to the therapist than perhaps he has even been to himself. The counselor has the training to “figure out” who is facing him, and the opportunity to ask the most essential questions with some expectation of penetrating to answers not offered in the public world. He sees not from the inside and not only from the outside, but,  from closeup, below, and through.

  • How remarkable are you? Though I evaluated and/or treated well over 3000 people, I encountered only a handful who were unique. Such individuals represent an enormous challenge to one’s understanding.
  • Countertransference: We can have reactions to our patients that grow out of our own unfinished issues with persons of consequence who they resemble in appearance or personality. This is called countertransference. Objectivity and unbiased analysis flees the evaluator under those conditions.
  • The limits of our experience. One who hopes to grasp the essence of another will not have encountered the whole of humanity. If, for example, most of his contact is with like-minded people (let’s say small town residents of one religion) he will be at a disadvantage with those whose backgrounds are different. On the other hand, therapist and non-therapist alike can meet an individual with whom he is “in sync.” In that event, both might find friendship and sympathetic intuition effortless and uncanny.
  • The listener who wants to be right. Insecure counselors can be troubled, sometimes unconsciously, by their own uncertainty. They tend to find it more comforting to put people in a box than to recognize when someone doesn’t fit. The job of evaluator (not a judge) calls for two qualities not often mentioned. First, enough confidence to say to yourself, “I don’t understand yet.” Secondly, “I can do better and I’ll work until I get this right.” Therein they offer an odd combination of humility and security. From time to time the therapist must clean the slate and start over.
  • The observer’s own emotional wounds and defenses: Our personal wounds (we all have them) place a limit on the ability to absorb, accept, and seek the truth of all humanity. Indeed, who is to say there are not many truths. The best of us never fathom all we encounter.
  • The listener’s capacity and willingness to endure the other’s pain: Hearing personal stories, even with the therapeutic distance healers work hard to achieve, still creates vulnerability to the most poignant encounters. Too many such episodes close in time risk either overwhelming the counselor or making him callous. To understand the human condition one must recognize his limits.

Final thoughts. Treatment by someone who opened-wide your self-understanding can make you believe no one on the planet will ever know you so well. I’ve long believed that if you then allow yourself to take more real-life personal risks, other satisfying and close relationships are achievable. Nonetheless, the special nature of a therapy relationship may include a hard-to-duplicate quality of perception and acceptance “as you really are.” You then will want a friend or lover who is psychologically-minded, a patient and dedicated listener, and one who makes the effort to approximate what an expert analyst can manage. This might be a tall order.

Do remember this: you and the therapist might not have much in common beyond his comprehension and kindness. Interests, compatible temperaments, and world view count for a lot. He exists, as well, in a fantasy world of your creation: literally, too good to be true. Were the light-reflecting cellophane of illusion to come off the package, you’d find his unshaven, distracted, and ill-tempered alter-ego – occasionally.

Another thought. A psychologically profound understanding of your inner workings isn’t always essential for a happy relationship outside of the office. Love and acceptance, even without full knowledge of all your moving parts, can go a long way. Not even your counselor has a total grasp of himself or anyone else. That said, his success at his work doesn’t require perfection.

Anyone close is “out of this world.”

—

The first image is called Rorschach-like Inkblot by Irion. It is sourced from Wikimedia Commons. The painting that follows is Vassily Kandinsky’s Composition VI, 1913. Finally, just above, is Honore Daumier’s Couples Singers, as sourced from Wikiart.org/

July 23, 2017

Interview with a Therapist

Who knows what a therapist might say under the influence of truth serum? Well, upcoming are unguarded words from this writer, a counselor retired, but not retiring from the challenge of interrogation. No drugs were necessary, but some background first.

I recently was named one of the 2017 Top Therapy Bloggers by Online Counseling Programs. How nice, I thought. Yet mingled with my gratitude came a second nagging question: why not the one and only Top Blogger of 2017? And then, why just 2017? Why not the top therapy writer of the decade? Or top blogger in the universe? Ah, well, I’ll have to make do. Life is tough.

Oh yes, the interview. The kind folks at Online Counseling Programs asked me nine questions. If you’d like an overview of my perspective on sexual attraction to patients, the training of psychologists, the challenge of maintaining boundaries, how the therapist (not the client) is changed by therapy, and the specifics of my career, you’ll find a good deal in my interview responses.

Another therapist would give different answers, although those currently in practice are careful not to share much about themselves. My retirement gives me the freedom to say a few things active counselors are wise not to touch. Please don’t assume they’d respond in the same way even if they were retired. What I offer is my perspective only, not unassailable truth.

Here are the questions:

  1. When and why did you originally create your psychotherapy blog?
  2. What do you hope to achieve by maintaining it?
  3. We highlighted your recent post, “The Arc of a Therapist’s Emotional Life,” because you offer such insightful musings on the therapist’s emotional life as it informs and is shaped by his professional work. One of the points you make is the difference in sympathizing versus empathizing with clients’ emotional states. How would you recommend that mental health professionals in training maintain emotional boundaries with their clients?
  4. Can you walk us through what motivated you to become a psychotherapist, as well as the educational journey you took to get there?
  5. How have you seen your blog and profession evolve over the years?
  6. During your nearly three decades as a practicing psychotherapist, what would you say were your most challenging and rewarding experiences, and why?
  7. What advice would you offer to aspiring psychotherapists?
  8. Music plays a major role in your blog. What has been the value and influence of music in your practice of psychotherapy?
  9. Is there anything else you’d like to add?

My answers? Click here.

—

The top image is a still photo of Harold Lloyd from his 1920 silent movie, High and Dizzy.

April 9, 2017

What Does Your Therapist Dream About?

Therapists tell you little about themselves, especially their dreams. Why would they? The woolly, wild world of the unconscious might suggest the counselor is a rapist, murderer, or thief.

Looking at him through the lens of the dream makes the treatment about the practitioner, not about the patient. It cripples the client’s ability to project his own long-standing issues onto this person: react to the counselor as if he were a father or mother identical to the real dad or mom.

A crucial part of classical psychodynamic treatment relies on the client playing-out his long-standing relationship problems and historically driven expectations of trauma or rejection within the session. The patient is unaware, at first, of the “mistaken identity” going on, where his reactions are more about his own past than the practitioner. If the therapist reveals too much about himself, he risks becoming the man of his chaotic dreams to the patient, not a benign, but blank canvas upon which his client throws the paint of his own internal life.

Dream interpretation is an art, not a science. Its value is difficult to demonstrate, though some therapists swear by it. Too many possible interpretations, no way to validate them. Yet they can be helpful. Certainly they may enlighten. Regardless, dreams are hard for the patient to resist discussing. An open therapist needs to take in all the uncensored data provided, the better to serve him.

Though I claim no specialty in dream interpretation, what I offer here is a partial explanation to those who wonder about the kinds of dreams therapists have.

The simple answer is, I doubt they are much different from those of people of similar upbringing, temperament, and overall life experience. I might add two exceptions:

  • Certain kinds of dreams are recognized as symptoms within the diagnostic framework developed by the American Psychiatric Association. For example, one possible symptom of Post Traumatic Stress Disorder is: “Recurrent distressing dreams in which the content and/or affect (emotion) of the dream are related to the traumatic event(s).”
  • Conventional wisdom tells us that high achievers have recurring dreams dealing with things like being late or unready for tests. Since people with advanced degrees prepared well for examinations (and took so many of them), the unconscious disquiet of discovering you are not ready or present for a test, a crucial appointment, or a presentation requires no leap of insight. Many of us were either driven to succeed, afraid of failure, or both.

Ah, but this discussion is rather impersonal, so I will offer an actual dream of one person I know well and present you with two interpretations. Moreover, I invite you to take the interpreter’s role yourself: be the therapist.

Whose dream shall I speak of?

My own.

Get ready. Prepare yourself for the unexpected nature of the story. The partially unclothed aspect, too.

I was sitting in the smallest room of my old office suite. Yes, the washroom. Some vulnerability here, don’t you think?

The door to the W/C led to the waiting room, the lobby of the office suite. I shared the workplace with other therapists. Unexpectedly, one of those counselors opens the door to the washroom. A man. He walks through a side entrance I hadn’t noticed and was never there before. I pushed him out and spoke with him soon after.

The extra door was installed without my knowledge, he informed me. Even though all the other counselors rented the space from me, they somehow did this unilaterally, without discussion with me, and with no warning.

Several of them were in a meeting which I joined. I talked to them. I spoke of the danger to our patients, our duty to protect, and our professional liability. Since our clients all used this facility, I stated this unlockable entrance would constitute malpractice. The head of the group argued back, though I can’t recall the details of her rejoinder. The assembly of counselors was mostly docile and unpersuaded by my logic. In the end I went off, saw my next patient, and did my job.

What should be made of this, if anything? Well, I can recall failed attempts at rational persuasion dating back to my childhood. Mom ran the roost, like the female leader of the other therapists. My mother was a tough cookie and dad worshipped her. No amount of logic or effort were enough to effect changes in the family dynamic. Should I leave the interpretation at that or try another tack?

Let’s visit recent events as possible triggers of the sleepytime return to my professional practice. I read two disturbing books in the days before the dream. As Dr. Michael Breus notes, some believe dreams are “a means by which the mind works through difficult, complicated, unsettling thoughts, emotions, and experiences, to achieve psychological and emotional balance.”

The Souls of Black Folk by W.E.B. Du Bois and The Revolt of the Masses by José Ortega y Gasset both carry profound messages about the dark side of humanity. The first deals with American slavery, the second with the growth of a naïve, destructive, anti-intellectual “mass man” who may destroy the pillars of Western civilization. Du Bois led me to watch Slavery by Another Name, a superb, but equally unsettling documentary on the color-line that existed in the South even after the emancipation of blacks. Their forced-labor and imprisonment by legal and extra-legal means was new to me.

I was powerfully affected, but not, I thought, to the point of emotional distress. Still, these books and the movie offered a larger vista on what happens when reason fails and men know only rights and not duties to something virtuous and greater than themselves.

One more feature of my dream was a lack of control. Being interrupted in the washroom by a stranger is profoundly threatening. One is literally caught “with his pants down,” though I felt more surprised and angry in the dream than in danger.

The books also might have amplified my personal concerns about the current state of Western democracy: another possible precipitant of the strange story. If this is so, then perhaps I should alter my life: dip a toe into the ocean of earthly woe, not bathe in it. Rather ironic, in light of what I did during my career, which on some days was a daily if not hourly immersion.

Other interpretations are possible, of course, but I hope you get the idea.

Your own analysis might tell you about both yourself and me. Do remember, that the therapist must remove himself from his issues when doing therapy, including his investigation of dreams. Freud was a notable exception who performed a self-analysis.

So, you now get to be the psychologist. Complicated, isn’t it? Give it your best shot.

—

The first image is called Think Different by Neotex555. It includes within it a statue plus a portion of Kandinsky’s Fugue, the entirety of which makes up the painting that follows. Finally comes Sean Foster’s Cloud Frenzy. All are sourced from Wikimedia Commons. For more about the function of dreams, you might want to visit a very fine post by Dr. Michael Breus.

May 22, 2016

Why You Want “More” From Your Therapist (and Why He Can’t Give It)

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You think of your therapist as a special person, at least some of you do. His kindness and attention can not only generate gratitude, but affection. You are aware of his boundaries and you can be frustrated by a professional stance limiting the kind of contact you’d like: a favored position, not someone put into a time slot with a financial transaction attached.  Perhaps, however, there is more to this than an ethical code. Why might his viewpoint as a therapist make what you want difficult to obtain? And, no, I’m not talking about sex.

Consider the role you play and the role he plays. You are likely talking about emotionally charged issues. Your feelings are front and center. His are not. Indeed, he is thinking about what you are feeling and doing.

You come to the clinician because of problems on which you are intensely focused. Thus, you are internally directed to your issues. The counselor, on the other hand, is not attending to his concerns, but to yours. He is looking outward, you are looking inward.

The counselor is not exposed. While you can find out some things about him, the treatment is not about him. You do not keep his secrets, but he wants to keep yours. You are encouraged to open yourself in order to heal. He is closed, assuming a relative position of safety and authority no matter how much he tries to be gentle and helpful.

Your session is of singular importance to you. It is one of many sessions for him, focused on you and a full complement of other patients. That makes him more important to you than you are to him. It does not mean he is indifferent to you. The doctor may well have tender feelings for you and enjoy your company, care genuinely, and approach you somewhat differently from the way he approaches others. Still, he is your only therapist, while you are not his only patient.

The counselor spends a limited time with you. He will then meet with someone else and switch his concern to the newly arrived individual. In a sense, however much he is concentrating on you while you are with him, he must develop an ability not only to be “in the moment” with you, but switch to another person after a brief interval. You do not switch. When you leave, your concern is still on yourself and the relationship with the therapist. A mental health professional is like an athlete in this way. After the game is over, he quickly puts the contest behind him so he is able to bring all his skill and attention to the next game.

To the extent that the therapist makes himself a blank slate and reveals little about his life, it is thought you will play out your emotional issues in the form of transference: experiencing him, to some degree, as similar to an important person or persons in your life, especially if your parental relationships are unresolved. Your transference toward him provides important material which he will help you work through. In doing so, you cut the trip wires of the past that continue to harm you in the present.

The counselor, of course, can also have countertransference toward you: experiencing you and reacting to you as if you are someone about whom he has unresolved feelings. However, to the extent he gets to understand the intimate details of your life, he is likely to be less prone to such emotions than you are in response to him. You are not a blank slate to the therapist. Thus, his likelihood of projecting his issues on you is at least a bit less probable.

Now let’s switch focus. Imagine what therapy would be like if these conditions were not typical of a therapeutic interaction. In which case:

  • The therapist would reveal as many of his issues as you do of yours.
  • He would be focused on himself as much as on you.
  • He would have less control over his emotions in session.
  • You might come to know disqualifying things about him.
  • The counselor might break down in session when you are overwrought or because of his own life problems outside of the office.
  • Consolation from you may well be required to stabilize him.
  • When you are in session he could be preoccupied with the last patient he saw before you.
  • Your relationship to him would approximate the kinds of contact you have with friends and co-workers.

I wrote this essay for the purpose of helping you understand a therapist’s perspective, his limitations, and his boundaries. Without those walls, little benefit comes from treatment. This is not to say your therapist doesn’t care about you. It is to say his care must remain within limits. In the absence of those limits, no matter how much you believe you’d like something more, counseling leads to something less.

Sometimes in life we do not know what is best for us. Then we are lucky — very, very lucky — that our wishes are not granted.

—

The photo of the 45 rpm disc was sourced from Wikimedia Commons.

January 31, 2015

The Answers to More Questions You’d Like to Ask your Therapist

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Last autumn I wrote a post in response to Spacefreedomlove’s five questions she’d love to ask her therapist. I will try to answer a few more now, those from Jay at Who are You Calling Sensitive?

1) Do you ever dream about me like I dream about you? 2) Is it really easy to limit your thoughts and feelings (both positive and negative) about me to our one weekly session or do these spill over? 3) What do you most love and loathe about our therapy relationship? 4) Is being a therapist just a job or is it a big part of who you are? 5) How on earth do you manage to get all your needs met outside therapy with long working hours and don’t you just want to chat the ears off your friends and family because you’ve been relatively quiet during the day? 6) Do you feel lonely as a therapist, working alone and not being able to chat about the day freely and limiting where you go out in case you bump into a client?

1. Yes, I certainly had dreams about my patients when I was in practice. (I retired three years ago). Clients who weren’t progressing were the most frequent visitors during slumber. Not, you might be wondering, sexual fantasies or friendship themes. Whatever countertransferential feelings I had occurred while awake. In that time I found myself thinking about how to improve the therapy process and reconsider the diagnostic and treatment formulation. The blackboard needed a clean wipe to look at my patient afresh and discover something I missed.

2. Yes, feelings spilled over, but not about everyone. If treatment advanced, then I didn’t find myself drawn to think about you much outside of a session. If the course of therapy was rocky, however, questions and problems grew arms and threw stones at the door to my mind. I didn’t avoid thinking about anyone, but my process was as described.

3. What did I most love and loathe about my relationship with clients? I will admit I didn’t like my patients equally. Some drained the fuel cells, some energized me. We are human, therapists and clients alike. No two people match up in an identical way. For those who gave inadequate effort, I addressed this in session. All experienced counselors understand the patient must give everything if he is to improve.

When the metaphorical cellophane wrapper of my professional life had been removed, I found the “detective work” especially captivating. That is, trying to figure someone out.

I’d sometimes get frustrated and go too far in expressing frustrations. This occurred more near the beginning of my private practice, as well. A bad idea for both my client and myself. I then had work to do on my own psychology. Increased therapeutic distance was required. And, I tried to unravel any bubbling resentments about issues in my own life, old or new, that slipped past my receptionist into the office.

With respect to what I loved, I enjoyed hearing close to everyone’s life story. Even now, I continue to do oral histories of retired and retiring musicians for the Chicago Symphony. My fascination with such things assisted, I think, to communicate a genuine interest in helping. People recognize your sincerity if you are hanging on almost their every word. I also enjoyed laughing with clients.

My ex-patients will remember my fondness for telling stories. The therapeutic message has a way of sticking with you when it doesn’t sound like a line from a clinical text.

I was delighted when people grew from our process; and grateful when I was enlightened by the therapeutic interaction and grew myself, not only as a therapist but as a human being. There is a two-way interaction here. Always. Patients understand that the psychologist benefits financially, but might not recognize how much a therapist’s life and humanity are enriched by non-sexual, intimate contact.

4. Being a therapist was much more than a job. Were it only a vocation I would have phoned it in, sounding like a poorly recorded 78 RPM disc, with as little expression as its two flat, black sides. I don’t hide disinterest well and have a poor “poker face.” I am not the most energetic person on the planet — never even close. Had I not been a counselor by training, choice, and by nature, the job would have made everyone miserable. Some said they had never experienced anyone who listened as intensely as I did. Those were the greatest compliments I received.

And, no, it wasn’t always praise I heard! But usually it was. Therapists who fail to generate approval are called ex-therapists with short careers.

5. Yes, the hours can be long. I suffered some internal conflict during the first years of independent practice. I tried to balance my desire to be the best clinical psychologist I could be, working late to support my young family, honoring my love for my wife and children with face time, answering emergency calls, and being good to myself. I had to avoid having the life sucked out of me by competing demands. I got better at this juggling act as I aged, my nest egg grew, and the kids required my physical presence less.

My work day and work week shortened by choice as time passed. I gave up carrying the now antiquated pager (in the days before cell phones), partly to reduce the crazy-making, self-inflicted wound of being on call at all times. I also discovered that when my patients knew they could not reach me past 9 pm, they found reserves of patience and fortitude to endure on their own. It is foolish for a therapist to wear himself to a nub and believe he is simultaneously providing anyone with a model of good self-care. He needs to be at his best in session, which required, at least for me, enough rest.

With respect to chatting “the ears off (my) friends and family,” two things: first, if you are tired, you possess less energy to talk. Secondly, I’m an introvert, so when the fuel tank is empty I prefer freedom from intense social interaction, not more of it. The exception was when my girls were small. I couldn’t wait to play with them and love them up.

6. I never felt lonely as a therapist. Again, my basic introversion helped with this. Plus, I found intense therapeutic interaction stimulating, as both an intellectual challenge and as social contact. I’ve been the lucky beneficiary of a wonderful spouse, amazing children, and good friends. I never avoided activities or neighborhoods for fear of running into a patient. Indeed, I don’t think the idea ever occurred to me. I did, of course, say hello to people here and there. Occasionally it was uncomfortable (probably for both of us), but nothing of lasting impact. It is usually a pleasure when I encounter former patients now.

I cannot speak for all therapists. The answers you’ve read are mine alone.

Again, thanks to Jay at Who are You Calling Sensitive?, Life in a Bind — BPD and Me, Saving Mommy, Possibly Penny, The Empress and the Fool and others who have offered questions they’d like to ask their therapist. And my appreciation to those of you who reblogged my previous efforts to answer such questions, including Spacefreedomlove, Understanding Me and Her, and Sunshine After the Rain. If I failed to credit you, let me know and I will correct my error.

I intend to address more of these “questions to therapists” in the future.

November 2, 2014

Five Things You Wanted to Know About Your Therapist but were Afraid to Ask: The Answers

psihoterapie-validTherapists sometimes reveal themselves despite their training not to. For example, in psychoanalytic treatment, Freud made himself a blank slate. He thought the patient’s troubles would become evident if he didn’t intrude upon the process. Remember, Freud sat behind the patient lying on the couch. Sigmund’s facial expressions and body language could not be observed. He said little, instead encouraging the analysand’s free association of thoughts. Then, if the client displayed positive or negative feelings about Herr Doktor Freud, the psychiatrist believed it due to underlying unresolved issues, usually about mom or dad. The heart of the problem having thus been uncovered, Dr. Freud could begin his “heart” surgery.

Still, patients wish to know “personal” things about the mysterious humanoid who treats them and will comment on the imbalance in unfolding that which is most intimate: the therapist gets to ask, the patient mostly does not. Spacefreedomlove, a provocative and prolific blogger, raised worthwhile queries in her post, Five Things You Always Want to Ask Your Therapist but are Afraid to Ask. I will try to answer, speaking only for myself. I encourage other therapists and clients to add or subtract by posting comments.

Question 1. “Do you ever wish you never met me or that you referred me out after the initial consult?”

A therapist works hard to find the best in the people he treats. This is a cliché, but it is true. You otherwise make both yourself and your patient miserable. I rarely if ever wished I had never met a patient, but occasionally thought later it would have been best to refer them. Careful readers will distinguish two questions here:

A. “Do you ever wish you never met me?”  The reason I’m glad I came to know my entire clientele is because they enriched me in knowledge and experience. I grew because of them. Many are wonderful people with whom it was a privilege to work.

With respect only to my enrichment, however, I would even say I found value encountering some nasty folks outside of work. Of course, I didn’t love those who did me wrong at the moment of injury. Strong feelings of anger and dislike touch everyone, therapist or thespian, “butcher, baker or candlestick maker.” A psychologist realizes he learns from some lessons only pain offers. Thus, if you ask me, “Do you ever wish you never met me?” I can pretty much say no, because you taught me about life, work, and myself. Past your tutelage, however, I might say I’d rather not meet you twice! This last comment refers to only a few people I met in the office, however.

B. “Do you ever wish you referred me out after the initial consult?” The simple answer is yes, but read on before taking the statement to heart. First, a different therapist might have worked wonders I did not. I remember one intelligent and sweet young woman early in my career who I didn’t diagnose as Bipolar Disorder until she arrived at the clinic with a bunch of “gifts.” The package included a box of condoms for me! She was hospitalized soon after. Had I been quicker to make the proper diagnosis, she might well have avoided being temporarily institutionalized. The young lady had some bad feelings about me as a result and I deserved them.

Therapists don’t predict the future without error. Only in retrospect do we realize an earlier referral was required. That said, I think the real issue being raised by spacefreedomlove is found in her second question:

Question 2. “Am I too much? Do I wear you out?”

The answer is yes, counselors get worn out, but not necessarily because of you. Once the therapist realizes he is exhausted, two more queries should pop up: a) Am I trying to do too much instead of allowing the patient’s own energy to carry therapy forward? b) Do I have some countertransference issues? Countertransference refers to the feelings the therapist has about the client, negative or positive. These can go back to the therapist’s own unresolved emotional concerns, so I’ll address this in response to Question 4. “Do I remind you of anyone from your past?”

As a young psychologist, I was keen to heal the world. This delusion is common among new therapists. Experience informs you of your inability to save everyone and, indeed, perhaps you can’t save anyone! By that, I’m thinking of the lifeguard who tries to rescue someone trying to drown himself. In other words, you need a person who isn’t going to fight your efforts every session and who has the therapeutic integrity to endure the pain of treatment. He must do everything he can to wrest a good life from the wreckage of his previous existence.

Therapists can burn out if they don’t recognize and calm their own frustration when progress is stalled. A counselor might exhaust himself by meeting his patient too early or late in the day, discounting fees to the point of feeling ill-compensated, and by overworking. Phone availability is still another potential complication, especially in non-emergency situations. Private life stressors create a trip-wire, as do multiple late cancellations without strong reasons.

A wise doctor will discuss issues during appointments, but not before healing himself or seeking his own outside support if the problem is his, not the client’s. Psychologists need to set limits. Being “on call” day and night can feel like guard-duty in wartime, causing sleeplessness and fatigue to the point of being less good when it really counts, in session. Remedies might include talking about the patient’s level of determination; a change to the time, day, or frequency of sessions; renegotiating the fee or the cancellation and phone policy, etc. Without improvement, referral is another option.

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Question 3. “What do I bring up for you? What do you struggle with in our sessions?”

As stated earlier, I only speak for myself. The best answer I can give is a long one, so I will refer you to a post called, What is Your Therapist Thinking? In addition to what is contained there, I struggled with how best to be helpful. Were a patient decompensating (getting worse) as the session progressed, I considered how to get the train of treatment on track to a safe place. The post I linked illustrates the manner in which your “doctor” head can be in a number of different places depending upon the flow of the therapeutic encounter as it happens. After the appointment, the counselor needs to reflect upon his efforts and whether they helped, were ineffective, or indeed caused the decompensation.

An inexperienced healer risks identifying with his patient’s pain so much that both he and the client are adrift at sea, and he is unable to offer a steady hand from the shore. Experienced therapists, on the other hand, risk becoming jaded to the point of equally worthless emotional distance. I believe I was eventually able to find solid ground in the middle.

Question 4. “Do I remind you of anyone from your past?”

Much like parents who are better suited to raising one child than another, counselors are not equally well-suited to each client. This can be a matter of skill, temperament, age, experience, or background. The question, however, seems to suggest you (the therapist) suffer issues from your past impinging upon your relationship with your patient in the present: your patient’s resemblance to someone else is the trigger. I remember a 16-year-old victim of sexual abuse. Her face reminded me of an old girlfriend, who I met when she (the girlfriend) was only a year older — 17. In the session during which the abuse surfaced, the client’s pain contributed to my own. While this was not a unique experience (my eyes can moisten hearing such stories), I was more than usually touched because of the invisible presence of tender feelings toward someone I’d not seen in many years. Nonetheless, my emotions settled and did not appear to derail treatment progress.

A few patients reminded me of my mother, with whom I had a “complicated” relationship. Please do note the euphemism! Once, however, I resolved my “mom” issues, I observed such similarities without undue emotion interfering in treatment. So, at least, I told myself.

Question 5. “What would you say to me if you were not my therapist?”

I am a pretty direct person. Not undiplomatic (most of the time), but direct. From childhood I found it almost impossible to be false. Should you care to know more, an amusing post on this congenital failure describes a kindergarten catastrophe: Gone in Sixty Seconds: How to Lose Three Girlfriends in a Minute. I don’t take full credit for my discomfort with being disingenuous (since I seem to have been born with it). Nonetheless, because of the trait, my client heard whatever I thought was most important to say. I tried to hold a mirror so that he might better recognize himself. If his vision was cloudy and it was essential that he perceive more (in my opinion), I often said more. I made good use of Socratic dialogue, asking questions designed to lead to self-awareness. Telling someone he is missing something is rarely helpful. A therapist says things like “What does that way of being cost you?” in the hope of allowing the patient (upon answering and thereby taking responsibility for his behavior) to grab the therapeutic initiative to change. The same comment in the form of a statement, by comparison, might cause him to feel scolded. It is easier to reject the therapist’s conclusion than your own.

No one gets to know every thought a therapist or a friend thinks about him. The truth of the previous statement does not mean, however, you would hear more from me as a friend than you would as your therapist.

In the end, as worthwhile as the above questions are, I believe it is most important a therapist know the truth of what Leo Tolstoy described in War and Peace — the role of medical doctors in early nineteenth century Russia:

“They satisfied that eternal human need for the hope of relief, the need for compassion and action, which a human being experiences in a time of suffering. They satisfied that eternal human need — noticeable in a child in its most primitive form — to rub the place that hurts.”

September 22, 2012

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.

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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.

January 20, 2012

The Pain of Counseling: When Therapy Turns South

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Turning points in therapy and in life are usually seen only in retrospect.

Sometimes — many times — therapy leads to a better life. But sometimes therapy creates pain in the process of trying to do its work. The patient can experience it as a necessary part of the process; or, as one more disappointment, frustration, failure, or betrayal in a life already filled with them.

It often depends on the type of discomfort that therapy is causing.

I’d like to describe four different categories of such therapeutic problems. Three of these involve failures of the therapist. But one (Item #3) is a frequent development in therapy that has to do with the nature of treatment and how people deal with emotional pain, rather than some shortcoming of the counselor.

1. Countertransference

Therapists can get frustrated or angry with patients, attracted to them or repelled by them, bored by them or fascinated by them. Therapists are human, so they are subject to all the same relationship issues as everyone else.

Of course, we are trained to keep a therapeutic distance and to know ourselves well enough to minimize all of the above. Unfortunately, self-knowledge is always less than complete and training can be an imperfect aid when faced with challenging relationships.

The psychoanalytic concept of countertransference was an early contribution to understanding these sorts of dilemmas within the doctor and patient dyad. It refers to the therapist’s feelings toward the patient, particularly those that may be unconscious and stem from unresolved relationship issues in his own childhood.

For example, does the patient somehow remind him of a mother who was insufficiently loving or too critical? Those are the sorts of feelings that can sneak up on the counselor without him fully realizing what is happening and why.

Therapists who are not aware of the shadow of their own past can be destructive toward the very people they are supposed to help. Similarly, healers who are themselves too needy or too stressed will not be at their best when someone else requires their undivided attention. Simply put, the therapist should be safe and stable — on land if the patient is at sea, so that he will not be sucked into a whirlpool of suffering and make things worse.

In other words, the therapist must be professional. And, if he finds that he is pulling too hard or being too critical, then damage to that person is likely.

How will the counselor react if he discovers that he doesn’t enjoy the patient’s company or thinks that the patient is too demanding or too dependent — too critical or cancels appointments too often — not improving fast enough? Will the therapist lash back, feel hurt, try too hard to win the patient’s approval? Under such circumstances, the patient can be harmed, even if he provoked the relationship complication himself.

Therapists are well-advised to reflect on their own feelings, work on their own unresolved issues, obtain advice or supervision about challenging therapeutic encounters, and sometimes refer the patient elsewhere; not to mention, get their own treatment if their issues are compromising professional responsibilities.

2. Therapists Who Cross Boundaries

There are two categories here. First, those therapists who mean well, but are not aware of their personal vulnerabilities and the necessity of inviolable boundaries between themselves and those they serve. These practitioners therefore fail to set firm limits on responding to the neediness (or attractiveness) of their patients. Second, there are those self-described “healers” who are frankly corrupt.

  • Let us begin with the first of these two categories. In an effort to help, some therapists simply do too much for the patient. A few examples:
  1. Discounting (or deferring) fees to the extent of feeling resentment.
  2. Agreeing to schedule appointments so early or late (or on weekends or holidays) to the point of wanting to help the patient more than the patient wants to help himself.
  3. Seeing patients outside of therapy in some sort of quasi-friendship.
  4. Giving patients a physical contact that they crave which leads to sexual contact.

I’ve known therapists who took too many calls in the middle of the night for their own good or that of their family, counselors who brought patients who were down-on-their-luck into their own homes, and those who did not (I don’t think) intend for a comforting hug to become sexual, but who found that it did.

  • In the second category, some counselors — thankfully not a great number (although one would be too many) — take advantage of the power relationship in treatment. An attractive patient can be used for sexual purposes, or for the ego-boost that such encounters can provide, without conscience; or with some sort of rationalization that it is actually therapeutic. It isn’t, no matter how much the patient provokes it, desires it, or the counselor rationalizes it. More on the problem of “dual roles” and boundary violations can be found on a previous blog post about damaged therapists: When Helping Hurts.

3. When the Patient Has Improved Somewhat and Now Has Less Motivation to Continue the Hard Work of Treatment

Naturally, when therapy is working the person who came to treatment starts to feel better. Sometimes, in fact, he feels better even when therapy isn’t doing very much. Many if not most individuals come to therapy in a crisis. Eventually such a crisis will pass or at least begin to be more tolerable, even if the treatment isn’t the reason.

Once the patient is experiencing less pain, he now has less reason to stay in therapy. The pain is what brought him in and the desire to reduce pain was the motivation to do the hard work involved in treatment. Now that there is less motivation, there just might be less cause to suffer the unsettling thoughts and feelings that therapy stirs up, not to mention its financial cost and the amount of time that it takes.

Take a look at the graph below. The red line (AB) is the pain of “life,” the distress that the patient finds outside of the doctor’s office — the upset, unhappiness, and disappointment that brought him to consult the psychologist in the first place.

The blue line (PQ) in the graph is the pain or effort required by the therapy process itself. Therapy is hard work. It is often also intense and wrenching, since it asks people to change, stop avoiding frightening situations, and face the demons that might have been covered over until the therapist worked to address them: those incompletely healed psychic wounds that are still excruciating to touch.

intersecting lines

On the left side of the graph you will note that the red line (AB) is above the blue line (PQ). That is, when the person enters treatment, the pain of the person’s life is greater than the pain caused by therapy’s effort to make life better. But, as I indicated, at some point it is likely that the pain of life is reduced, while the discomfort (effort or difficulty) of therapy remains constant or might even increase. Why increase? Usually because the most tenacious problems are the hardest for the therapist to successfully address and might include taking the patient deeper into traumatic memories that he has tried to look past.

Once the patient has improved sufficiently (where the two lines intersect at point C), he now begins to find that staying in therapy causes more discomfort than getting out of it, as indicated on the graph by the fact that the blue line is higher than the red line (on the right side of the image). When the point of intersection of these lines is passed, the patient often wants to terminate treatment. Only those with sufficient “therapeutic integrity” or courage will stay long enough to resolve the most intractable of the issues that brought them to the doctor’s office in the first place. Or, they will wait until another life crisis brings them back to finish the job.

4. Therapists Who Haven’t Done Their Homework

It has only been in the last couple of decades that research has begun to point clearly to those treatments that are most helpful for some of the conditions therapists treat. Broadly defined, for example, Cognitive Behavior Therapy (CBT) has been demonstrated to be the “treatment of choice” for most people who suffer from Social Anxiety Disorder and Post Traumatic Stress Disorder.

Despite this, many therapists who claim to treat such conditions do not avail themselves of these treatment approaches or don’t familiarize themselves with the research upon which they are based.

Why?

Some weren’t trained in how to evaluate research or in how to engage in this form of therapy. Some stopped reading about progress in working with these conditions or “don’t believe” in the conceptual grounding of CBT. Some are too busy (or think they are too busy) making a living to afford the time and effort required to be up to date. Some trust their intuition to the point of rejecting anything that doesn’t match what they have come to believe is most important about how to deliver service to the people who seek them out.

The difficulty here is that therapeutic models should not be like religious beliefs, based on faith rather than evidence.

While a failure to follow “best practices” for which there is empirical evidence is not as egregious a violation of trust as sexual contact with a patient, counselors must keep learning and growing in their field of alleged expertise, just as much as they encourage their patients to grow personally.

In summary, therapists are not unique in having the capacity to do injury, but their position of authority gives them a vantage point somewhat like that which parents have with their children, making it easier to accomplish quite inadvertently.

The remedy? Obtain recommendations about counselors from those you trust. Read up on the treatment of your condition. Collaborate in your treatment, don’t just count on the therapist to do exactly what you need at every moment. Let him know about any concerns that arise. If necessary, get a second opinion. And keep your eyes open for the things I’ve described.

Not least, have the courage to stay in therapy even when the process touches on important issues that are sensitive.

As the old saying tells us, “when the going gets tough, the tough get going.”

And, no, I don’t mean “…going out the door.”

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The above photo is called U-Turn by Zipley is sourced from Wikimedia Commons. Intersecting Lines is sourced from onlinemathlearning.com