The Relationship is Everything Part 2: Transference and Countertransference
In the previous article, I wrote about the importance of establishing trust as the basic foundation to any therapeutic relationship. However, the relationship is not only a means to start treatment, but an incredibly informative process that provides deep psychologic insight into the client.
The two most important concepts describing what occurs between patient and clinician are Transference and Countertransference. Transference is what a client unconsciously projects (feelings, expectations, and attitudes) from past relationships onto the therapist. This occurs because the human brain tries to understand current interactions by filtering them through past experiences. Countertransference is how a therapist behaves with their own emotional reactions, including biases and unresolved issues, toward the client in response to the transference. Transference and countertransference help explain why people experience similar patterns playing out across many different relationships. Freud, for example, noticed that many of his female patients developed intense feelings of love and passion towards him that had nothing to do with him personally. These patterns of relating are as varied and unique as the individuals who possess them such that there is no right or wrong way to relate to another human being. It is when these relationships cause pain in a person's life, that he/she may seek help.
Transference and countertransference are not used as much clinically now, not because they are less relevant, but because modern-day psychiatry has de-prioritized these skills to have a greater focus on pharmacotherapy. This means that psychiatry graduates no longer possess the ability or awareness of tending to the relationship as a way to better understand and tailor treatment to the individual. This is a huge loss. I make the greatest impact when I am aware of these phenomena and can speak to them, as they often explain what makes a particular patient challenging for healthcare providers. When neither party recognizes this, they risk acting out, compromising both patient care and clinician wellness. These issues are not so easily resolved with a procedure or medication, making many physicians feel out of their depth.
How it works in practice: Emily's Story
Emily is a 21-year-old woman who came to see me with concerns about her mood. An hour into the appointment, I noticed I was getting confused and annoyed. This was because I found Emily vague and evasive. Even with careful questioning, I could not figure out what was wrong and what she wanted. As a result, my countertransference had me wanting to tell Emily how difficult she was and that I would not see her again. These strong negative emotions are a red flag. If I wasn't careful, I could act out my frustration and any hope of helping Emily would be lost. I therefore turned my attention to the transference. She described how growing up, her father was a highly intelligent, charming person who could also be controlling. When she would ask for his help, he was very generous and always found a solution, only later to take credit and use any information she gave him against her. By being vague and non-committal in our assessment, she protected herself from asking me directly for help. Her transference was that she was experiencing me, a person in authority with expertise, as her father, and she was wary of my intentions.
Had I insisted she had an illness and needed medication, I would confirm what she feared: that I was not truly interested in her, but only in how she could help me get my job done. The transference/countertransference allowed me to see that the first step to helping her was to establish a therapeutic relationship where all information she shared with me would be in safekeeping. If she did not experience this, we would get nowhere.
Near the end of our appointment, I shared with her how I found it difficult to understand her needs and asked if she felt the same. She looked visibly relieved. I wondered aloud if this evasiveness was a protective habit formed in response to her father and this resonated deeply. The "treatment" we agreed upon was not a prescription, but follow-up appointments dedicated solely to helping her find her voice. After 6 months, she had moved out on her own and returned to college. Only this time, she chose the school and the major. When I asked about her father’s thoughts on these big decisions, she told me she didn’t know. She never asked him because she had learned to trust herself.