Friday, July 21, 2017
Transference, Reality, or Error?
For my readers concerned about any alleged excessive political focus, I write today about a distressing clinical encounter.
The incident troubled me for weeks. I hope describing it will offer me some clarity and thereby help the patient. Also, I intend to educate colleagues and the lay public about the concept of transference and counter-transference.
Please note I am completely and totally fictionalizing the details of the patient I soon describe. The story demonstrates some of the fine points of psychoanalytic processes. It bears no resemblance whatsoever to any actual clinical encounter.
Before proceeding, a few definitions:
Transference refers to any constellation of thoughts, feelings, or interpersonal patterns projected onto the psychoanalyst; counter-transference refers to the reverse, namely the process of psychoanalysts projecting onto their patients.
When using the word psychoanalyst or the phrase, psychoanalytic psychotherapist, I am referring to any kind of depth psychotherapist. In contrast to the cognitive behavioral therapies (CBT), the psychoanalytic or psycho-dynamic psychotherapies help enhance self-awareness and personal freedom through uncovering unconscious material.
For example, a person feeling depressed would be guided by a CBT therapist to uncover negative “automatic” thoughts and correct them; a psychoanalytically oriented psychotherapist would probe deeply into the emotional state, looking for reasons for the distress lying outside of the patient’s conscious awareness.
Perhaps a particular patient never fully mourned the loss of a parent; perhaps he or she suffered abuse during childhood, has been repeatedly rejected in relationships, or negatively values him or herself. Psychoanalysts would uncover, explore, and strive to resolve these underlying themes.
Whereas CBT therapists tend to guide patients in an educational way, psychoanalytic ones essentially facilitate a transformational relationship. And, since a relationship develops — bounded, limited, professional — complexities often arise.
Last May, a patient, John Doe, surprised me with a negative reaction I didn’t see coming. He works as an executive at Parsons Engineering. He sought help three years ago for chronic interpersonal conflicts with his 22-year-old adopted son. They had not spoken in over a year.
On the one level, John felt great love for his son, missed him, and wanted the best for him. On another level, John felt angry at him. The young man had barely finished high school, dropped out of college, and spent most of his time smoking marijuana. He was underemployed and unmotivated. John felt helpless to intervene.
John struggled with a other issues in the twice-weekly psychotherapy sessions with me. He felt his wife was emotionally distant. He was unhappy with his work.
Partially a result of our conversations, he developed a much more fulfilling personal life. He began reading voraciously and joined a weekly reading group. He ran four times a week, lifting weights at a local gym on other days. At the time of the breach in our relationship, he was readying himself to address the problems in his marriage.
Unusual for John, he brought up a dream on that fateful day in May. It related to a colleague — barely an acquaintance — who had committed suicide a year earlier. The fellow employee killed himself by taking an overdose of opiates in addition to alcohol.
John dreamed of the colleague’s suicide — but, in the dream, the victim was his son.
Common for more relationally-oriented psychoanalysts like me, I began the dream interpretation by asking for John’s own ideas about the dream. He thought the dream reflected his sense of loss about his son. He suggested that, perhaps, the dream also revealed how his son had been “dead” to him — a reference to the year of no contact.
I carefully waited for John to relate the various elements of the dream that came to his mind. I then had a thought, and said,
“I have another idea about the dream.”
“Oh, what is it?” he asked.
(Here, I might have made my first error. I consider it crucial for patients to understand that their dreams, as well as their thoughts, feelings, behavioral patterns, are theirs; I offer ideas and reflections — consonant with my job description — but patients remain the final authority on their subjective experiences. I shall elaborate on this later.)
“I wonder if the dream could also represent anger, perhaps even homicidal anger, towards your son.”
My previously excellent relationship with John was instantly disrupted.
“How could you possibly think that?” he asked in anger. After a pause, I said,
“I know how angry you’ve been at him. We’ve discussed it at length. I’m thinking that, perhaps, the dream could also be speaking to you, on one level, of the intensity of the anger you feel towards him.”
A silence ensued. The session was nearing its end. Anxious about the reaction, I attempted to repair the disruption:
“Please remember that I only offer ideas about your inner world. It is ultimately yours.”
“Yep, I get that,” he said dismissively. John left, looking visibly shaken.
In the second session that week, John’s anger was more overt.
“I feel like you’ve pulled the rug out from our relationship.”
I felt myself tensing up, wondering how one idea could have felt so disruptive to him. I offered my professional service as usual, attempting to keep my personal reactions to myself. I said,
“I think I understand how upset you feel. I’m sorry to see it. I’d like to hear some more about what’s going on.”
Another short silence ensued, and John continued:
“As an engineer, you know, I’m very scientifically-oriented. I didn’t know you were such an old fashioned Freudian. And, besides, who the hell do you think you are to know my motivations?”
“You felt invaded by me.”
“More than you can believe. I don’t want to kill my son. And, he’d never kill himself,” he exclaimed.
I watched as John’s anger gradually dissipated for the rest of that session. It re-emerged in the following session, however, including more questions about my psychoanalytic approach. Also, he reiterated his feeling that i had “pulled the rug out” from under our relationship.
I listened to more of his anger and disappointment at me. Towards the end, I added with some tremulousness,
“I am struck, though, by the degree to which you feel our relationship has been harmed. I may well have awkwardly offered the idea of hostility. I may well have clumsily proposed it. But why would it place the entire psychoanalytic relationship in peril?”
John remained angry, but he seemed impacted by my words.
Towards the end of that session, and guarding against my being defensive, I briefly educated John about the history of psychoanalysis. I advised him that, yes, Freud had created the profession called “psychoanalysis.” However, I continued, the field went through a “relational turn” during the mid-20th century. And, I was firmly on the wave of that transition.
I explained how the initial physician as active authority relating to passive, ignorant patients had been replaced by much more of a co-participant viewpoint of psychoanalytic relationships. Psychoanalysts paid more attention to their part in them. Further, psychoanalysts offered their patients observations and ideas, but the patients clearly retained authority over their subjectivities.
(Herein lies the second potential error: Rather than let John fully experience his angry feelings at me, I perhaps aborted them by adopting an educational and defensive stance.)
One of my all-time favorite papers in psychoanalysis, written by Thomas Szasz, represents one small contribution to the relational turn. The pioneers of psychoanalysis had assumed that any negative feelings towards psychoanalysts indicated a transference process. In other words, these negative feelings consisted of anger towards a father, or a brother, or even a mother, projected onto the psychoanalyst. They had nothing to do with the reality of the psychoanalytic relationship.
Not so, shouted Szasz. He boldly suggested that psychoanalysts could use negative transference as a defense. He asked, “perhaps the patient just doesn’t like the psychoanalyst?” (See references)
Transference is the pivot upon which the entire structure of psycho-analytic treatment rests. It is an inspired and indispensable concept; yet it also harbors the seeds, not only of its own destruction, but of the destruction of psychoanalysis itself. Why? Because it tends to place the person of the analyst beyond the reality testing of patients, colleagues, and self. This hazard must be frankly recognized. Neither professionalization, nor the ‘raising of standards’, nor coerced training analyses can protect us from this danger. Only the integrity of the analyst and of the analytic situation can safeguard from extinction the unique dialogue between analysand and analyst.
John was entirely correct that, had he been consulting a psychoanalyst during the 1940s, the practitioner may well have told him, with authority, what his dream meant. For many decades now, however, that sterile, medical-model based approach has evolved into one barely resembling its origins. Psychoanalysts offer their patients observations, ideas, interpretations and more; patients remain the authority on their own subjective experiences.
Psychoanalytic psychotherapy is vastly different than medicine. Physicians have data bases on health and disease, objective ways of measuring pathology, and access to a variety of interventions like medication, physical therapy, immunotherapy, or hormone replacement.
In contrast, psychoanalysts’ expertise lies in their ability to facilitate transformative relationships. They have knowledge of common human feelings, thoughts, relational patterns. They have one or many metaphors for unconscious structure, i.e. the Id, ego, and superego. Their “tool” is the relationship, the conversation, their influence in enhancing self-understanding.
As John and I continue to work our way through this recent disruption, the situation provides an example of the endless complexities of psychoanalytic work. The conflict with John lends itself, quite literally, to an infinite number of interacting possible meanings.
Perhaps the relationship has run its course, and John sincerely feels I don’t understand or support him.
Perhaps my interpretation of hostility was ill-timed. I might have been insensitive to how distressing the dream had been — just for its images of loss and sadness — to allow for the additional interpretation of anger.
Perhaps the anger is, as John argues, completely absent.
Perhaps, as John also suggested, my interpretation had something to do with me. Despite our striving to retain professional neutrality, psychoanalysts inevitably have their own feelings. I certainly have felt angry at John’s son on his behalf; it is certainly possible that I was seeing, in the dream, my own anger.
Perhaps the interpretation is entirely correct, but it is extremely disturbing to John, and he therefore ejects it entirely into me.
Perhaps I overreacted to John’s anger, and it struck the nerve of my own abandonment fears.
Perhaps the disruption results from many, interacting factors — the influence of the other stressors on John, the dominance of sadness over anger at that particular point, or an infinite other possible causes.
I feared John would summarily terminate our work.
I am heartened at his desire to continue the conversation.
In the final analysis, Simon and Garfunkel captured it best in their song, “The Dangling Conversation.”
The refrain goes:
In the dangling conversation
And the superficial sighs
The borders of our lives
Ain’t it the truth?
Szasz, T.S. (1963). II. The Concept of Transference as a Defense for the Analyst. International Journal of Psychoanalysis, 44:435-443
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