Category: Transference/Countertransference

Countertransference to Sexual and Developmental Trauma in the Psychoanalysis of a Disabled Patient

Posted on by Psychotherapy.net Team

Our First Meeting

Referred to me by a colleague, Tanya was an elementary school principal who had polio as a child. When I initially asked my colleague how severely Tanya had been affected, she told me, “It isn’t too bad.” When I opened the door to my waiting room to greet my new client for the first time, I was shocked to see that Tanya had a deformed arm and leg. She struggled to get out of the chair and when she stood up, I was struck by the contrast between my colleague’s description and the reality before me. I wondered what made my esteemed colleague deny the severity of Tanya’s deformity.

Tanya settled into the chair in my office and was silent. Although she was in her late thirties and a successful professional, she was dressed like a pre-adolescent in short white socks and sneakers. When I asked what brought her for psychotherapy, she said she wanted to feel sexual.

“Everyone else has somebody,” she said. “They have a husband, they have children. I have nothing. I hate my life. I need something, help me, help me,” she cried. “I need something. I want someone to love me. I want to get married. I want a family."

In her third session, Tanya began talking about her deformity.

“Nobody can see it,” she said. “Nobody knows I had polio, that’s why nobody says anything about it. You can’t tell, can you? Can you?”

Shocked that she could be in such a state of denial, I hesitated a moment.

“Yes,” I said as softly as I could, “I can tell you had polio.”

“I’m sorry. How can you say that?” she yelled. “You’re horrible. I’m sorry. I’m not coming back.” She hugged her purse but did not leave.

Tanya’s pleading for me to deny her deformity and the repetition of “I’m sorry” continued for many months. It grated on me. I wanted to yell at her: “Stop it, I can’t stand it.” Session after session as the same scene unfolded over and over, I felt tortured by her, and I felt guilty for feeling tortured.

““I think my mother couldn’t stand me,” she said. “She wanted me to go away.””

Finally, to my great relief, I realized that this was an enactment of her experience with her mother.

When Tanya was ten, she complained that she had intense back and neck pain, but her mother told her “it was nothing” and to go to sleep. But Tanya could not sleep. Finally, when she was in such pain that she couldn’t walk, her parents took her to a doctor, who said she had polio and needed to be hospitalized immediately. Her parents did not explain it to her. The doctors explained it to her parents, but not to her. She did not understand that she would have to remain in the hospital for several weeks. Her parents did not visit every day because the hospital was far from their house, and when they did visit, they only stayed for an hour. Tanya was filled with anxiety and rage.

When she was finally released from the hospital, recuperating at home, Tanya often pleaded for her parents to tell her she would not have to go back to the hospital. Her parents said, “No, don’t worry.” They knew that was not true, but they could not bear her reaction to the truth. When she had to go back a second time, she was enraged that her parents had lied to her.

“Tanya felt betrayed and unprotected”. Her parents said they would visit and didn’t come; they said she would be fine, and she wasn’t. After a while she felt that she could not trust anything they said. Later, when she went through puberty and the curvature of her spine worsened, her mother assured her that no one could tell she had had polio.

I knew that telling Tanya that I could see her deformity would enrage her. But if I had tried to avoid it when she communicated “Don’t you dare say you can see it,” I would have communicated that I was unable to deal with the reality of her polio—just like her mother.

Nevertheless, I continued to feel I was between a rock and a hard place with Tanya. I did not want to lie to her as her mother had, but telling her the truth enraged her.

“Do you think I’ll get married?” she pleaded over and over.

I felt a wave of meanness. The lyrics to “Que Sera Sera” came into my head:

“When I was just a little girl
I asked my mother
What will I be
Will I be pretty
Will I be rich
Here's what she said to me.”

I knew any answer other than “yes” would result in her fury and threats to quit treatment.

“I cannot predict the future,” I said. “I don’t know if you will get married.”

“You’re horrible,” she yelled, picking up her purse from the floor and embracing it. “How can you say that to me? I’m sorry. What’s wrong with you? I’m sorry. I’m not going to come back anymore…”

“What would you like me to say to you?” I asked. My head throbbed.

“That I’m going to get married like everyone else. What’s wrong with you?” she yelled.

“Do you want to get married?” I asked.

“Of course, I want to get married. But who will want to marry me?” she cried.

“I could hear my heart thumping. What am I going to say to her?” She was right to feel her chances were diminished because of her disability.

“You’re right,” I said. “There are some men who will not be interested in you because you had polio. But there are some men who don’t have perfect bodies either or who are more interested in finding someone who they can feel close to than whether her body is perfect.”

She was quiet.

“You had polio, and it affected your arm and your leg,” I said. “That is part of who you are, but that is not all that you are.”

Tanya had not been able to accept that she had polio and tried to cope with it by joining in her mother’s denial that it was visible. I realized that my referring colleague had also been drawn into the denial.

Being a Sexual Person

As the treatment deepened, it became clear that Tanya’s overwhelming anxiety was not simply the result of her polio. One session was a turning point in our understanding Tanya’s level of anxiety and confusion. She began by talking about seeing her doctor for dizziness.

“I went to see Dr. Roberts, and he took my blood pressure,” she said. “It was lower than it has been since this whole thing began. But then he took it ten minutes later and it went up. But it still wasn't as high as it has been in the last few weeks.”

Tanya sat with her legs spread apart. Her crotch was in full view. She did this often when she was wearing a skirt. I was trying not to look at her crotch while she was talking to me, but I thought she was not wearing underpants. I thought to myself that perhaps she was just wearing dark underpants. At first, I questioned whether I was imagining things, but I knew what I was seeing. I started thinking about how to handle it. If I ignored that she seemed to be exposing herself to me, I would be denying the reality. On the other hand, I knew that however I said it to her, she would be mortified and furious at me if I brought it up. In the past I felt the mortification would be too much for her, but this time I felt I could not ignore it.

“Are you aware of how you're sitting?” I asked.

Tanya immediately put her knees together.

“What are you talking about? What are you saying? I'm sorry. You hate me. You think I'm bad. What are you saying? You want me to leave?”

“I don't hate you,” I said. “I don't want you to leave. You were sitting with your crotch exposed to me, and I think that has some meaning. Don’t you?”

“I'm sorry. I like you and I respect you. I don't know what you're saying,” she cried. “You think I'm bad. I'm sorry. You want me to leave.”

“I know you like me and respect me, and I don't want you to leave,” I said. I leaned forward in my chair. “I don't think you are bad. You don't need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”

“I'm sorry. Sitting like that doesn't mean anything. I just don't think it matters how I sit.”

“You mean it doesn't matter if your crotch is exposed or not?” I asked.

“”I just don't feel like a sexual person. I don't feel like a woman”. Look how I dress. Look how I take care of myself. I just don't feel like a sexual person; that's why it doesn't matter how I sit.”

“You mean you feel like there's nothing between your legs?”

“That's right. What's between my legs is dirty and smelly and bad and disgusting. You don't want to see it.”

“So you think that I am pointing out how you're sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”

“I offended you. I'm sorry. I won’t do it again. Don’t worry about it.”

“You didn't offend me. But I think exposing yourself is a way of telling me something.”

“You know, you're really inappropriate sometimes. I can't believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”

““You mean you would rather I act like your mother and make believe that there's nothing between your legs or that it's too disgusting to talk about?””

“Maybe it's like the polio. I don't want you to see that I have it. I want you to say you can't tell I have it. But I also don't think I have anything. I am completely out of touch with my body,” she said, crying. “I don't feel connected to it. I can't touch myself still. I don't feel like a woman. Even now with the operation, I still don't really have breasts. Sometimes I don't even bother to wear a bra.”

“What about underpants?”

“What do you think is wrong with me? Do you think I don't wear underpants? Of course I wear underpants.”

“If you don't feel you need to wear a bra because you don't feel you have breasts, I wondered if you don’t wear underpants because you feel you don't have a vagina or clitoris."

“Of course I wear underpants, what do you think is wrong with me?” she yelled. “How could you say that. I can’t believe it. You must think I’m disgusting.”

She got up and walked out of the office. I was not sure she would come back.

When Tanya did come back for the next session, she was angry for the first few minutes. But then she told me that after the session she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.

“You mean your mother was masturbating in front of you?” I asked.

“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”

Tanya explained it was like listening to her older brother masturbate. She told her mother that her brother was making strange noises and she didn’t want to share the same room with him, and her mother told her it was nothing and she should just go back to bed. Tanya grew up in a dark, one-bedroom apartment. Her parents slept in the living room, and she and her older brother shared the bedroom. Her parents could have afforded a larger apartment and were even offered one for modest cost in the same building, but her mother did not want to move.

Her mother and brother overstimulated Tanya, and her mother’s denial gave Tanya no protection from the anxiety created by it. Tanya was forced to develop other ways of coping—being confused, not knowing if she was hearing things or not. Her anxiety was so overwhelming it interfered with her thought processes and her reality testing. Years passed in therapy before Tanya brought in a dream she identified as sexual.

“My car was damaged, someone hit it and the door and fender were all bent. I looked underneath, and it was perfect. I felt surprised and happy.”

“When did you have the dream?” I asked.

“I had the dream after our last session. I think it’s about myself. I am finally accepting that I am damaged on the outside, but I am all right inside.”

“Yes, it sounds like a positive dream. What comes to mind about looking underneath?”

“It was underneath the hood. Inside. But it sounds sexual doesn’t it? Maybe I realize that I am damaged outside, but I am not damaged sexually.”

“And you're surprised?” I chuckled.

“Yes, I have always been afraid of sex. Something is wrong with me. When I go to the gynecologist, she can’t even examine me.”

“Because you are so frightened that you have a spasm?” I asked.

“Yes,” she said. “”I have always been terrified of touching myself or someone touching me”. I’m terrified. I just see a man with a suit eating pizza and I think he’s cute and I feel terrified.”

“I think you have sexual feelings,” I said, “and then imagine he wants to have sex with you right there in the pizza store and then you are terrified.”

“Yes, I only feel the terror, but I must be having sexual feelings,” she said.

“I think you become overwhelmed by your sexual excitement and project it onto the other person and then feel terror. You know when you would lie in bed listening to your brother masturbating and coming, that was overstimulating. You knew it and went to your mother, but she denied the whole thing and told you to go back to your room. You couldn’t get any help protecting yourself from the overstimulation.”

“It was normal for him to masturbate. I know kids masturbate, but I shouldn’t have been in the same room. I should have had my own room, and when she just told me to go back to bed and ignore it, I must have felt flooded.”

“Exactly,” I agreed.

“You know, she said, “I had another dream last night. “I was watching somebody teach somebody how to dance. This young girl was very graceful, and she was moving very well. She knew how to dance. They were getting ready for a wedding.”

“How did you feel in the dream?”

“I felt good,” she chuckled. “I felt I could learn to dance. You know, they had dancing at my beach club on July 4th, and I didn’t dance. But next week, they’re having a DJ and they are doing line dancing, and I’m going to get up and learn how to do it. I’m going to join in.”

The following session, Tanya came in saying she had a dream about tongue kissing the night after the last session.

“I was eating dog food, and my mother was telling me I was eating dog food. I was licking the bowl like a dog and I got nauseated after she said that, and I threw up in the dream and, in my bed. I was gagging and choking.”

“What comes to mind about dog food?”

“Dogs go right for sexual gratification, they’re animals. They can’t delay gratification. Maybe I’m the one who’s bad because my mother tongue-kissed me in my dream. I was acting like a dog.”

“Maybe we're acting like a good dog—a loyal dog does whatever the master wants,” I said.

“Dog food looks like shit. I was eating shit. All my life I was eating shit. I was an obedient dog. Every day I was choking and gagging before I went to school. In the dream I said, ‘I must get it out of me.’ Something was stuck in my throat. It’s a feeling of fear. You know, my brother can’t swallow pills; he gags also.”

“Really!?”

“What could be stuck in my throat? Do you think this is at the bottom of why I can’t touch myself or have sex?” she asked.

“Yes, I think that your mother was crazy, and she masturbated in front of you and acted like nothing was happening and kissed you sexually and acted like it was normal. When you told her your brother was masturbating and you didn’t want to share a room with him, she said it was nothing and you should forget it. I think this is only the tip of the iceberg. I think there’s a lot you haven’t been able to tell me yet. Maybe you’re afraid I’ll think you’re bad.”

“Yes, I think so. You know, she would sit with her legs spread apart and pull her underpants to the side and play with herself. She did it while we were watching TV. My father was there sometimes, and he never said anything. My brother was there. If I asked her to stop, she would ignore me.”

Homosexual Feelings

Tanya was angry because I did not hear the doorbell—she had to ring twice, and the clock in my waiting room was four minutes fast. Anything that questioned reality (e.g., what time is the session) threw her into questioning everything. I also thought it might make her feel that I was out of control or her feelings toward me could get out of control. Maybe she felt I was like her mother if the time was wrong and I didn’t hear her. It threw her into a panic attack and made her question reality.

The next session, Tanya came in saying that she was upset and sad after our last session. It might have been from talking about how sexually stimulating her house was and that she might have felt aroused by it, or it might have been about my clock being wrong. She said the erroneous clock made her feel crazy. Then she moved on to talk about being angry at a teacher with whom she worked. She thought he was gay but that he could not deal with it because he was religious. Then she talked about being angry at her friend’s husband, who always talked about women he wanted to screw. Tanya thought it was a defense against his homosexual feelings.

“It’s interesting that in both cases you’re angry at people who are denying their homosexual feelings,” I said.

“Do you think I’m homosexual?”

“No,” I said, “but I think you might be afraid that you have sexual feelings about me.”

“That would be inappropriate, wouldn’t it?”

“No, I don’t think feelings are appropriate or inappropriate—they just are what they are. We don’t have control over our feelings, only our actions. Considering your mother’s sexually provocative behavior toward you, I don’t think it would be surprising if you had sexual feelings about me.”

“How would you feel if I had sexual feelings toward you?” she asked.

“I would feel happy for you that you were able to be in touch with your sexual feelings, whatever they are. You haven’t been able to experience them at all.”

“After the last session I had this tension in my inner thighs. Do you think that was a sexual feeling?” she asked.

“Yes, I think that was sexual tension.”

“How do you get rid of sexual tension?” she asked.

“Well,” I said, “you could masturbate or have sex with someone else. Sexual tension gets built up and then released when you have an orgasm.”

“I have to get a Pap smear on Wednesday. I’m afraid I won’t be able to do it. I feel like canceling it.”

“Are you afraid of having sexual feelings during the exam?” I asked.

“Yes, what if I have sexual feelings during the exam? What should I do?”

“You don’t have to do anything. You can just have them, and eventually it will pass.”

“Oh,” she said, seeming relieved.

Fear of Driving Me Away

Tanya walked into my office and sat down clutching her purse on her lap.

“I couldn't find a parking spot. It's getting harder and harder to find a spot around here. It makes me so frustrated,” Tanya said.

“What about that?” I asked.

“It makes me feel so annoyed and angry.”

“Maybe you're annoyed and angry at me?”

“No, I just can't stand how hard it is with all the traffic and it's so hard to find a spot. It makes me not want to come.”

“Maybe you had some feelings about coming today?” I asked.

“I was thinking about stopping,” she cried. I have too many feelings about you. I'm sorry, my feelings are too strong…”

“What are you sorry about?” I asked.

““You don't want me, you wish I'd go away,” she said angrily”.

“What is it about you that makes me want you to go away?”

“I'm sorry, I have too many feelings about you.” She picked up her purse and hugged it.

“You mean I can't stand your feelings about me?”

“I'm sorry. I want too much; you won't want to give it and you'll want me to go away.” Tears flowed down her cheeks.

“Why would your feelings be so intolerable to me?”

“I want to talk to you all the time. I'm sorry.”

“If you want to talk to me all the time, do I have to do it?” I asked. “Why can't you want whatever you want?”

Tanya looked surprised. “Because I want you to do it!”

“If I felt I had to do whatever you want, I wouldn't be able to stand your feelings. But I don't feel I have to do things just because you want them, so I can allow you to want whatever you want.”

“I don't think my mother could stand my feelings,” she whimpered.

“No,” I agreed, “because she felt she had to do something about them and she couldn’t, so she wanted you to go away.”

Transference and Countertransference

Tanya’s transference changed during various times in the treatment. At the beginning, she experienced me as if I were her mother who wanted her to go away. But this was not a neurotic transference onto me; rather, she induced in me the feelings her mother had about her. She pleaded for me to lie to her but wanted to believe me. She wanted me to feel what her mother had felt but be a better mother than hers had been. It was a struggle for me; I felt harassed by her pleading and guilty for not feeling empathic. I found it difficult to bear her pain and her rage at the hand she had been dealt. Her demands for reassurance made me feel helpless, which is probably how her mother felt. I had to find a way to help her accept reality but also console her.

Later in the treatment, when she was finally able to deal with her sexual feelings, the transference shifted. She was not able to tell me what had occurred with her mother. Rather, she created an enactment of it so that I would understand what she had felt as a girl. I became confused about reality just as she had—e.g., is she wearing underpants?

Final Thoughts

Tanya would remain in treatment with me for over ten years. When she terminated, she was a much more integrated person. She felt like a sexual woman and got over her social phobia enough to develop close friendships with both men and women. Tanya was able to accept the gaslighting, denial, and lack of boundaries in her family. She became closer to her brother and convinced him to seek treatment.

Of course, there were many other issues in her treatment that I have not dealt with in this article—e.g., her envy of me for not having a misshapen arm and leg. I have only highlighted the issues of denial of her disability and the lack of boundaries and sexual overstimulation in her family.

I think it was important that I told Tanya her disability was visible for two reasons. First, she knew that it was. If I denied it, it would imply that it was so horrible that I couldn’t deal with it. I would be like her mother – distorting reality because I could not tolerate Tanya’s pain. Second, Tanya did not trust her parents because they consistently lied to her. She called me constantly to confirm our appointments. And when applying for a handicapped license and being told she would have to wait 60 days, she called them daily to confirm it. So I had to be truthful to build her trust, even though it enraged her.

Some therapists might have avoided confronting Tanya about exposing herself to me. It was awkward and uncomfortable for me, and it enraged her. However, I think it was a major turning point in the treatment. As a result, she was able to tell me about her mother’s exhibitionism; she became more able to identify and process her own sexual feelings, which reduced her projection of them onto men. She also made progress in being able to comfort herself.

Although Tanya was not able to have a sexual relationship with a man, she bought a dog and named him “Sigmund” as a testimony to how much psychoanalysis had helped her. She did the macarena with the husband of her friend and felt sexually aroused. She understood that her sense of sexual abnormality had more to do with her mother than polio.She also made progress in being able to find comfort. Although she was not able to have a sexual relationship with a man, she was finally willing and able to treat herself to massages regularly and was able to masturbate. Overall, Tanya had come a long way. Her social and sexual anxieties were greatly diminished and she had a much more fully developed sense of self. It was very hard work for Tanya, and in a different sense, for me as well. 

Standing Up to Microaggression: A Clinician’s Experience

Posted on by Psychotherapy.net Team

Microaggressions (noun)—Definition: Everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership. (1) Looking back, a racial enactment between myself, a person/clinician of color, and my white therapist seemed inevitable. In our very first session, my therapist made some statements that revealed what I perceived to be her “White Savior” complex. I was taken aback by my therapist’s apparent lack of awareness of her own racism, as she had explicitly advertised herself as working through a critical post-colonial lens, and so I called her out on it. My therapist was quick to own her racist statements and take full responsibility. Despite the initial wounding and because of the subsequent repair, I continued to work with her because she did model a good relational and clinical holding style in following sessions, and I felt that she was helping me with the issues for which I was seeing her. Towards the end of our sixth session, I was sharing with my therapist how someone had explicitly sought me out for clinical supervision, mentioning familiarity with some of my work and writings, and how that had filled me with professional pride and confidence. My therapist’s exact reply is now hazy, but she said something along the lines of, “I think they chose you to be their supervisor because, as a white person, they can learn how it is for you—from your experiences as a person of color”. These words landed on me like a bolt out of the blue, and I instantly felt objectified. My therapist had unnecessarily racialized my experience, my whole identity reduced to that of “a person of color.” I had a vivid mental image of Black and Indigenous people literally being put in cages and zoos to be “observed,” and another of a laboratory rat being poked and probed—an object to be studied, “an other” whose experiences (painful or not) were being observed. A part of me still wanted to deny that it was I who was feeling the pain—to mask it as simply identifying or empathizing with those who have suffered racism. My heart began to beat fast, while my mind was trying to digest what I had just heard. Knowing very well that I have historically tended to minimize or deny micro-aggressions committed against me in the past, I resolved to be present to this current painful experience. Curiously, my heart wasn’t pounding but rather flapping—like a weak fledging trying desperately to fly away, but not having the strength or ability to do so. Instinctively, I put my hand to my heart to calm and hold the young, hurt thing, a part of me afraid that it was actually going to fly away. Anger has always been easier for me to own, so I told my white therapist with visible anger, “I am trying to calm myself before I speak.” My heart was ready to flee—and escape the pain—the pain of the blow which was multiplied in its effect, having come so hard and unexpectedly in a place that was supposed to be safe. The rest of my body, however, was ready for a fight—“I will not back down!” For the whole week, I allowed myself to fully stay and experience what had occurred in that painful therapy session. Paradoxically, this experience of staying with the pain of the micro-aggression pushed me into a spiral of transformative growth and healing, with the words of Rumi now resonating with me:

“If you desire healing, let yourself fall ill let yourself fall ill.”

It broke through my thick wall of defenses which had protected me from feeling or expressing my painful feelings in the past—especially those feelings when I had been “put down” or been the target of hate. Until then, I had vehemently denied and protested ever being cast in the role of a “victim.” Now I owned and allowed myself to feel them ALL—the feelings of indignity, humiliation, sadness, hurt, and fear—some of which were being held by very young parts of me. I became my own therapist, healing these young parts, unburdening them from the pain and hurt they had carried for years—simply waiting to finally feel acknowledged and validated, but more importantly, to be held and healed with self-compassion.

“We are healed of suffering only by experiencing it to the full.” Marcel Proust

In the next session, I clearly let my therapist know how her racist words and projections had negatively impacted me. To her credit, she took full responsibility for her racist remarks without trying to defend them in any way. This time we agreed that this was not a rupture that could be “worked through” or repaired to allow the therapeutic relationship to survive or grow stronger. Basic trust and safety had been violated by my therapist’s unexamined racist views and beliefs, and we agreed to terminate our relationship. However, having my therapist witness and listen to the impact of her words on me and take full responsibility for it was healing to me, and I did communicate that to her. In those moments, I recognized that as a therapist, irrespective of race, I have an ethical obligation not to perpetuate individual and systemic modes of oppression and racism, especially with my clients, and to pay attention to asymmetric power dynamics and intersecting identities to provide a safe relational context in therapy. I see how I have been guilty of protecting the status quo of white supremacy in my defensive denial of acts of aggression towards me (within and outside therapy settings) in the past. I have now vowed to directly challenge and dismantle oppressive thoughts and systems of power by speaking up against such micro-aggressions. Here is a list of defenses based on Internalized Racial Oppression from the People’s Institute for Survival and Beyond workshops shared with me by Nalini Kuruppu, LCSW, that I have found useful in my own self-reflections. My own defenses are highlighted. Defenses of Internalized Racial Superiority (for white-identifying people): White = Normal (unconscious understanding that white is the standard of humanity), White Denial, Intellectualizing, Individualism, White Distancing, Perfectionism, Entitlement, “Professionalism”, Expect Comfort, Rationalize, Minimize, Dominance, Demanding, Tokenism, White Saviorism, Self-Congratulations, Appropriation/Theft, Color Blindness, Addictive Behaviors, Defensive White Anger, Paternalism, White Tears, Dismissive, Arrogance/Expertism, Silence, Indifference, Need to be in control Defenses of Internalized Racial Inferiority (for Black-Indigenous-Persons-of-Culture BIPOC): Distancing (from race/ethnicity), Mimicking, Assimilation, Code Switching, Denial, Shame, Worthlessness, Fear/Hypervigilance, Guilt, Self-hate, Hopelessness, Ethnocentrism, Colorism, Protectionism (of whites), Tokenism, Invisibility, Exaggerated visibility, Addictions, Tolerance, Avoidance, Exceptionalism (the “model minority” myth). What about you? Do you directly speak to the asymmetry in power and the dynamics due to intersecting identities in sessions? Can you identify how you may be perpetuating oppression and racism? References: (1) Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons Inc.

When a Client Resists, I Persist

Posted on by Psychotherapy.net Team

When it comes to client resistance, I should know better than to blame the client. The burden is on me, the clinician, to adjust my approach, search for my hidden personal biases, repair a therapeutic breach, and empathize more effectively with the client. It is my job to remedy clinical stuckness, to take that responsibility head on, and for good reason. I am the service provider. I am in the position to help. It is not the client’s job to transform my deficiency or blind spot into effective help. I get this on an intuitive level. So why do I get stuck personalizing resistance and harboring secret negative judgements of my clients? Psychiatrist David Burns, author of Feeling Good, suggests that counselors struggle with client resistance because their egos get in the way. He says we are too fragile, therefore strive to protect our pride and identity, forcing us to match the client’s resistance with our own. Thus, to help the client and enhance the clinical work by taking their critical feedback, we must, according to Burns, “put our egos to death.” What he means by this is that I, as a clinician, need to drop my defensiveness so I can truly hear what the client is trying to communicate. Once I am no longer defensive, I am then free to see the client’s resistance for what it really is—information, rather than a personal attack, although it may feel like one. And I can use that information to adjust my approach and hopefully enhance the overall clinical work. In my experience, ego doesn’t go down without a fight; it doesn’t even like surrendering. When I have felt slighted or diminished by a client, my first impulse is to prove them wrong; I want to show them I’m right or that I’m superior, or smarter. This is the dark side of my clinical self. I find it far more clinically useful to expose this darkness to the light. This is no easy task, but the pain of putting my ego to death is worth it. A dead ego means I can engage with the client’s criticism and defensiveness without taking it personally, without being threatened, without having to argue back. The client can no longer offend or wound me. I can harness their criticism and use it as information that changes the therapeutic work. That’s empowering! But this is easier said than done, so below I provide 5 suggestions from my own clinical experience on how to do this: Reframe the client’s criticism/resistance: It is my work to reframe the client’s resistance and criticism as information. They aren’t resisting me; they are, in fact, communicating with me. And what they are saying is valuable information uttered in the hopes of making the relationship better. I try never to ignore this useful information because of my ego. The stakes are too high. Take responsibility: I am the service provider. If the client is resisting, the responsibility falls on me, not them, to remedy the situation. I will not become a defeatist or a helpless blamer of the client. I can make things better. I can directly change the situation. I am not powerless. In order to serve the client, I will own the situation and take concrete steps to address the client’s resistance. The client is a person: The client is in a vulnerable position. They aren’t trained mental health professionals with high-powered degrees, certifications, and letters after their names. How are they supposed to tell me that counseling isn’t working? Their main vehicle for feedback is resistance. Therefore, I strive for compassion for my client and for their need to resist. The client could be teaching me something: It is possible that resistance is the result of venturing into an area of my weakness or ignorance, which is not the client’s fault. I am not all-knowing and comprehensively skilled—becoming a competent clinician is a life-long endeavor. I learn just as much from my clients as they learn from me. Counseling offers me the potential to expose my ignorance. And the possibility of that shouldn’t threaten me; rather, it should excite me. Exposure of ignorance can be gentle; it can also be harsh; but within are lessons that can be used for my growth and the client’s benefit. Modeling: I can demonstrate health to my clients by receiving their resistance in a respectful manner. My goal is leading my clients and modeling healthy give-and-take. The client’s resistance can be a teaching moment where I show them how to offer feedback in a more kind and respectful manner. I recall working with a young man who taught me how to see the benefit of resistance. I remember that anytime we tried to discuss the content of his assigned workbook exercises, he would do everything in his power to change the subject, to mock the content of the workbook, to say it was boring or that it didn’t matter. He would say the exercises were “stupid.” And when he did complete the assigned work, he would write down one-word answers. This always came as a surprise to me, because our conversations at the beginning of sessions were usually engaging and positive. At the beginning of our relationship, we could spend an entire session hour talking about why he didn’t do the homework. I grew tired of the run-around and finally asked if he thought the homework was helpful. He answered honestly. He said doing the homework felt like school. And when it came time to discuss it in session, it ended our positive conversation. He added that I was the only positive male figure in his life. When he was young, his father had abandoned his family, and his mother dated a series of angry and controlling men. All of his teachers at school saw him as the “problem kid.” So it was a huge relief and comfort to be with a man whom he liked and with whom he could have fun, lighthearted conversations. In that moment, I realized that working through the content of a workbook was secondary, and what this young man really needed was a caring relationship from a man with whom he felt safe. I thanked him for his honesty and feedback and adjusted my approach. I focused more on relationship building and made the workbook exercises completely optional. I would only discuss them if he brought it up. From then on, the young man’s resistance was gone, and he voluntarily put more effort into the workbook. Understanding my client’s resistance helped me understand him at a deeper level and, in turn, improved our therapeutic relationship and its outcome. His resistance offered us both the opportunity to grow in our respective roles.

Countertransference: How Are We Doing?

Posted on by Psychotherapy.net Team

The subject of countertransference, or the sum total of our conscious and unconscious emotional responses to our clients, has fascinated me since I first learned about it in graduate school. Our instructors repeatedly emphasized the importance of self-care, but their focus was more on burnout and compassion fatigue than active engagement with our countertransference.

Most clinicians have some way that they unwind after a day of intense sessions. Perhaps they get some exercise, read a book, binge watch their favorite show, or spend time with loved ones. All these activities feel good, help us to rest and stay connected to our sense of peace or calm, and keep us stable enough to continue to do the hard work of being a therapist. For many practitioners, this will be enough to sustain them for many years in the field.

But how do we therapists continually manage our own emotional responses to the myriad of clients and stories we hear day in and day out? Should we have better systems in place specifically for the management of countertransference? “Traditional self-care activities, which are usually focused on relaxing, reducing stress, and increasing our joy, may be inadequate in and of themselves for managing countertransference”.

That we would have emotional responses at all to our clients is natural. Human beings are social and relational animals, and when we work in such proximity to one another, dealing with such intensely personal subject matter, countertransference is inevitable. These responses in clinicians can be constructive when they are recognized and contextualized, but they can become obstacles to good treatment when they are ignored, devalued, or isolated in our psyches. Countertransference has valuable lessons to teach us if we pay attention. The question is… are we?

Unrecognized Countertransference

Unrecognized countertransference may not be just a barrier to doing great clinical work; perhaps it is the barrier. I should ask myself: Who am I attending to? When I do or say anything in session, For whose benefit is it? I have found that when I can quickly answer, “For the client,” I am generally on the right track. If that answer comes more slowly or with more hesitation, it usually cues me to look inward at my own feelings and motivations.

We have all had clients who trigger an emotional response in us. If I am working with someone who is intimidating to me, I may be more hesitant to challenge that person or hold professional boundaries when appropriate. If I am working with someone who is experiencing something similar to what I have gone through, I may suggest that they do what I did, or do the thing that I failed to do. This is one of the most classic examples of countertransference, wherein I attempt to resolve conflicts in myself via my work with the client. In another example, when I am more interested in a particular aspect of the client’s story, I will probably focus on it more, and when I am less interested, that experience will receive less focus. In all these instances, the direction I take is informed by my own feelings rather than the client’s needs.

To use a real example from my own practice, some months back I found myself feeling impatient with one client in particular and was frustrated that he was not applying the skills and concepts we were practicing in session. I had a very difficult time getting him to engage with nearly anything I thought was indicated. He would almost exclusively recount stories in which he was the hero. In his narratives, he always did the right thing, made the hard choice, and overcame the villains. I was aware of my impatience and frustration, but at the time I still attributed my feelings to his lack of engagement and insecurity. In other words, with all my education, training and experience, I was inwardly blaming the client for my emotional state. “I began to dread sessions with him” and engaged in avoidant behaviors while working with him. I fell into a pattern of offering tepid, half-hearted validation instead of addressing his avoidance and hesitation. My approach served more to make the sessions bearable to me by reducing my frustration, and less to help him reduce his chronic PTSD symptoms. He didn’t seem to be making progress, so what did that say about me? Sound familiar?

Is Self-Care Enough?

At around this time, I attended a workshop on trauma treatment. I asked the facilitator how he stayed calm and well-adjusted while doing so much trauma work. He responded that positive self-care was critical to this process; he did not elaborate further. He clearly knew something, because he has been doing trauma treatment for decades. He was a wonderful clinician and trainer and I suspect that at that moment, he just did not want to get sidetracked on that issue. But I found the response for my own training and understanding to be inadequate. You might be surprised to hear how many times I have received this response from the numerous professionals I have asked. As clinicians, I think we need to have a collective strategy for countertransference, and one that has an active dialogue around it.

There are many skilled clinicians who specialize in working with countertransference issues; the problem for me is that they are not getting much notice or airtime in the profession. When I have spoken about this issue with colleagues, I have encountered a wide range of responses. Usually, what I find is that they have a basic familiarity with the concept of countertransference but no actual working tools for recognizing, addressing, and resolving it. We teach our clients that we are emotional beings, and that we are experiencing some level of affective response throughout the day. Is it possible that countertransference is taking place with our clients all or much of the time, whether we notice it or not? The critical aspect of this is how and when we begin to notice that it is occurring.

In Ernest Hemingway’s novel The Sun Also Rises, the character Mike Campbell is asked, “How did you go bankrupt?"

“Two ways,” he replies. “Gradually, and then suddenly.”

So, “it is in that way countertransference starts to impair our clinical work: gradually, and then suddenly”. Like any problem, it is always best to catch it early, when it is a small and manageable issue.

The Solution Must Be Social

Experienced clinicians can teach and model that self-care is not the miracle cure that will resolve countertransference. Taking a bath or watching Netflix will not resolve countertransference, because these activities do not address some of the underlying mechanisms through which it takes place. Stress and fatigue are important factors, but they are not always the principal engines that drive our experience of countertransference. It arises from a very complex set of interpersonal and neurobiological factors. As such, simply relaxing more often or more effectively is not always an appropriate solution by itself. A close friend and colleague of mine once said to me that “social problems require social solutions.” Much of my self-care is not sufficiently social in nature; being in such a social job, my reset button often involves solitary pursuits like playing music, writing, and woodworking — all things that I do by myself. Perhaps a social phenomenon like countertransference can only be resolved in a social situation. We need other people to help us get through it.

Given the appropriate limitations of confidentiality in our profession, this leaves the earnest clinician with a few viable options. Much has been written about the benefits of social relationships, personal therapy, supervision, and consultation, and I agree with many of these points. All of these provide a social experience to solve a social problem. There are, however, some limitations to regular socializing, supervision, and therapy for resolving countertransference.

Social Relationships

Our social relationships with friends and family should provide us with outlets to find support, reduce our stress, and feel a sense of community. Sometimes our friends and family are not as equipped to hold the enormity of what we might have to share. Therapists tend to develop a fairly thick skin for hearing about truly awful human experiences. It is not that we are numb to them, it is probably more the case that experience in the profession has allowed us to develop the proper cognitive and emotional mechanisms to deal with them on a daily basis — just as the trauma surgeon is not probably too distressed by what she sees on a regular day, but her neighbor might not be able to handle the details of what her job requires her to see and experience. This leaves us with the option to share some feelings, perhaps, but not the intimate aspects of our experience with our friends and families.

Supervision

A supervisory relationship offers support, is social in nature, and is often accepted as the place for clinicians to deal with countertransference. Numerous therapists receive effective support and leadership from very capable and experienced supervisors. For everyone to work through countertransference in this way presumes every therapist’s having access to a very competent supervisor. For my colleagues who place their trust in statistics, an analysis of any bell curve should suggest that supervisor competency follows the same statistical rules as nearly anything else in the natural world. There will be exceptional supervisors who can hold and handle anything, and there will be supervisors who are not equipped for the challenge of addressing therapist countertransference effectively. In many situations, the supervisee often does not feel free to authentically share an experience of countertransference, and for good reason: it could easily be perceived as a limitation, and therefore hinder advancement opportunities. It can result in very real consequences.

Imagine a supervisee reporting experiencing a romantic attraction to the client. The supervisee finds her or himself trying to impress the client, or to be seen as funny. He or she notices that being liked has suddenly become a distraction and wants to work through this. In clinical work, scenarios like these happen from time to time. In the best-case scenario, the supervisor would help the supervisee address this countertransference, work through it, and hopefully resolve it. It is possible that they would agree that referring the client out to another therapist is necessary; it is also possible that they would not come to this conclusion, if the supervisee can effectively work through their emotional responses to the client. But what if the supervisor is incredibly stressed out because his agency is currently being sued for malpractice? What if the supervisor is dealing with the same issue with one of her clients? What if her name is on the building? A supervisor, by definition, is in a position of power which is greater relative to that of the supervisee. It is not hard to imagine scenarios where a supervisee could be negatively affected by sincerely trying to seek out help in resolving countertransference, which is an ethical thing to do.

There is a time in most clinicians’ development where supervision often sounds like, “Have you tried this intervention? Have you tried that technique?” As clinicians progress in their skill development, if and when they get stuck, supervisors can assume that they have tried their usual go-to stock of interventions and tools. While training therapists in new techniques and interventions has a large role to play, they may also search for emotional barriers in their supervisees to carrying out good clinical work. The Discrimination Model of supervision in particular allows that sometimes, the supervisor will act as your counselor in the process. As stated above, many experienced and skilled supervisors can expertly help their supervisees navigate countertransference issues. The problem is that supervisees will not know who can and cannot do this until they have truly put ourselves out there. “Revealing our struggles with countertransference can be a deeply vulnerable experience”. It must be held in a safe and supportive environment. While supervision is enormously helpful, it has limitations for addressing countertransference. I write this as a supervisor myself, and someone who has had some truly phenomenal supervisors.

Personal Therapy

Doing our own personal therapy will certainly help us recognize our patterns of relating and certain triggers that may set us off. It is invaluable for our overall health and well-being. It seems fair to say that anything I do in my own personal therapy is about me, and therefore when I bring things from that personal therapy into my working sessions with clients, I will at least sometimes be dealing with my own issues. This is not black and white; some countertransference is diagnostic in the sense that I may infer that if I feel a certain way around the client, then others likely feel the same. From there, I can make educated guesses about the client’s social world and ways of relating. I may gather additional psychosocial information based on this. And then there is the kind of countertransference that has little or nothing to do with the client but is based on my own history and experiences. In short, just because I am frustrated in session with a client does not mean that everyone gets frustrated when interacting with this person. It is critical that we are able to separate these two ideas.

A psychologist whom I greatly admire once told me that he works through countertransference in his own personal therapy. While I do not begrudge him that preference and have done so myself, there is potential for us to muddy the personal and professional waters there. I may end up setting goals in my own personal therapy, such as being more assertive or holding better boundaries, and I may then bring those ideas into the professional session with my clients. These are fine things to work on and have obvious application in therapy. But there will be times when those pursuits have absolutely nothing to do with my clients. I will refer to earlier questions I asked in this article: Who am I attending to? For whose benefit is this? In my previous example about the client who only wanted to tell stories that bolstered his sense of personal power, suppose my well-meaning therapist encourages me to name this behavior and challenge it, even if gently. Perhaps I will return and in the next session challenge the client on his avoidance. In response, he stops showing up to sessions with me. On one hand, I overcame my own hesitance and mustered the courage to challenge him. On the other hand, a traumatized client who was in therapy is now not in therapy. Have I, in a stroke of clinical genius, revealed the client’s lack of readiness for treatment? Is it possible that if I were simply more patient, this client would come around in time, even absent any challenge or confrontation from me?

Consultation

Consultation, in my opinion, holds more promise than supervision or personal therapy for addressing countertransference, for several reasons. These groups can be set up so there are not marked power differentials. Given the reduction in power dynamics in a consultation group, it follows that each attendee incurs less risk by sharing authentically. In addition, the group’s diversity of experience, perspectives and opinions can offer any therapist increased response flexibility for countertransference when compared with the judgement of almost any lone supervisor or therapist. A consultation group of peers can be more objective, explorative, and therefore helpful, given that they also do not incur any personal risk based on what they hear. I should note the exception, of course, is when unethical or negligent behaviors are revealed in a consultation group. Then the members of that group will need to decide if they should report that behavior to their state licensing board, just as a supervisor or therapist might.

Returning to the example discussed earlier, simply experiencing a romantic attraction to a client is not in and of itself unethical. Whereas a lone supervisor with a large personal stake in the clinician’s performance may have a disproportionate reaction to that, a consultation group made up of peers is less likely to have the same response. They are more likely to consider the times they may have experienced this and what might have been helpful to them at the time. “The consultation group format also provides a social solution to the social problem”.

As part of this exploration, some colleagues of mine formed a consultation group that was focused on countertransference. I have found it enormously helpful to share my own internal conflicts in the profession with a group of trusted professionals. They help to normalize and contextualize my experience, while showing me where my blind spots are and where there is room for growth and development. Because these clinicians are not signing my paychecks, I feel a certain freedom to share openly. And in doing so, I have found that countertransference really can be addressed, processed, and resolved.

Regarding the client I was working with, the consultation group helped me to recognize that my impatience had more to do with my own desire to be competent and achieve some specific result. I needed to solve the client’s problem to end my frustration and thereby feel effective. How much more cliché could I get? My peers helped me to see that this client has lacked safety most of his life. As a result, he has crafted an internal narrative where he occupies a position of power and influence. I can reduce my frustration outside of session and work to increase my sense of competence on my own time. I now have more confidence that I can thread the needle by being patient and allowing him to establish safety and comfort with me, while also moving in the direction of gently prompting him to engage more with working to reduce his symptoms. My personal feelings are not all tied up in this client’s progress now. I was lucky to have a community of knowledgeable and supportive clinicians with whom I could consult. These friends and colleagues were able to create a helpful container in which I could safely discuss this issue and ultimately resolve it.

Flexibility is Key

Examining our own countertransference regularly and often is an important part of being an effective clinician.

I wholeheartedly believe that self-care is a critical aspect in maintaining one’s own wellness and longevity in the profession. We all encourage our clients to reduce their stress and to engage in hobbies and activities that bring them peace or joy, and we should absolutely walk the talk. When we are calm, healthy, and centered, we can do our very best work. As countertransference is a social and relational issue, the more solitary pursuits involved in self-care may not be of much help in recognizing and resolving it. This was true in my case.

“Friends and family can be an outlet for support, although we may feel limited in what we can share” by their lack of familiarity with the profession’s norms and difficulties. Capable and experienced supervisors can provide a wonderful space for working on countertransference. But there is usually a power differential, and with natural variability in supervisor’s competence, these factors can become limits. For those of us who examine countertransference in our personal therapy sessions, I hope we can recognize our patterns and responses, and apply those lessons to our work somewhat dispassionately. Otherwise we run the risk of inadvertently playing out our own therapeutic goals with our clients and will continue to experience unresolved countertransference. Consultation would seem to offer positive support in addressing countertransference, both in the variety of opinions that can be expressed and the potential for reducing or removing power differentials among the participants. I would recommend doing all the above. The important thing is that we keep looking at our countertransference and keep paying attention to what it is telling us.
 

Usha Tummala-Narra on Living Multicultural Competence

Posted on by Psychotherapy.net Team
Lawrence Rubin: I want to thank you very much, Usha, for being with us today and sharing your time and expertise with our audience of psychotherapists.
Usha Tummala-Narra: Thank you for inviting me.

Towards a Definition

LR: Multicultural competence seems to have become somewhat of a buzzword in the field of counseling and psychotherapy, defined differently by different clinicians; but since it’s the nexus of your own clinical and research work, can you tell our readers what you think it is and what you think it isn’t?
UT: Indeed, there’ve been many different definitions. I arrived at cultural competence from a psychoanalytic perspective. Given that, I think of multicultural competence as a way of understanding, a way of engaging with sociocultural context and how it shapes interpersonal processes as well as intrapsychic life and extending into the therapeutic relationship. How do the sociocultural context and dynamics that are evident in broader society get mirrored in the relationship between the therapist and the client? So, cultural competence to me looks at the various layers of an individual’s life, both intrapsychically and interpersonally.
LR: Irvin Yalom talks about the therapeutic relationship as a microcosm for the client’s interpersonal world, so I’m wondering if what you’re saying is that a multiculturally competent clinician strives to build a connection with the client’s broader contextualized experience.
UT: That’s certainly a part of it. I think the other piece is the person of the therapist in terms of their own socio-cultural history. This includes their own history of social oppression – what they find as positive and identify positively with in terms of their cultural background, their religious background or linguistic background. It’s about how all those sets of cultural and socio-cultural experiences shape the therapist and their subjectivity and how that in turn interacts with the subjectivity of the client. There’s this kind of interaction between multiple cultural worlds happening regardless of who we’re working with therapeutically. And this is not specific to working with clients from a particular socio-cultural background, but rather I see it as broader than that. It’s about engaging our broader context within the therapeutic relationship.
And so for me, cultural competence isn’t a specialty, it’s just part of professional competence. I just really see it as a regular part of psychotherapy.
LR: So, it’s more than just two people coming together, but it’s almost like two worlds coming together in the therapeutic encounter.
UT: Yes, that’s right.

Revealing Full Personhood

LR: Traditional therapeutic practice, particularly dynamically-informed practice, is built upon the premise of therapeutic neutrality; so how can a clinician bring their full contextual personhood into the relationship with a client and still be faithful to the ethics and the tenets of psychotherapy?
UT: That’s a great question. We should consider what neutrality actually looks like and feels like for the client. We’ve been socialized as therapists to put everything about ourselves to the side so that we’re not imposing our agenda onto the client. And so, therapists have this idea that “if I was to initiate a discussion about race or culture or gender, that it’s really my personal wish that’s being filled in some way, or my personal longing to engage in those discussions rather than the client’s needs and what might be actually helpful to the client.” But in fact, what I have found is that so many clients in fact need to talk about issues of race and culture and religion but have been told all their lives in one way or another that they shouldn’t. As a result, people’s experiences of racism are often kept hidden, are kept silent, and are more often spoken about within somebody’s home or with a circle of friends.
But, we should consider that psychotherapy is actually a place where we can talk about things that we have been told not to because therapy is not an ordinary conversation, as Freud himself pointed out. For me, then, we must think about what’s not being spoken about when we neglect to address issues of sociocultural context and background. If we’re not talking about something like social class and how it impacts our clients, then perhaps neither will our clients. I don’t see those particular issues as being separate from what may be going on internally for a person – what they might be struggling with. I just see the two as quite intertwined in terms of a person’s suffering and conflicts and relational issues. They’re very intertwined for me.
 
LR:  It’s interesting how you’re saying that people who differ from the so-called mainstream are taught to be invisible, to homogenize themselves and hide the rich context of their life. And the same seems to go for therapists who are taught to blend into the background, to neutralize the rich cultural, racial, gendered, religious aspects of themselves so they may be fully available. But you’re also saying that both client and therapist need to step out of that invisibility and reveal themselves to each other.
UT: Yes. If we’re interested in exploring a full range of experience within our client’s lives, then we must actually explore all of those different aspects of our own life. And I don’t see how we can separate the individual from their context. One other thing that comes to my mind is how we might even from the very start think about developmental history. When we do an intake assessment and ask questions about a person’s development, we typically ask questions about their family, school experiences, work and health history – things of the like. But we tend not to ask more specific cultural, racial and contextual questions like, was the family struggling financially, did they have resources in the community, what was it like growing up in this particular family?
It can be so important to ask about the immigration history not only of the client and their immediate family, but of the extended family. Deep and culturally-informed questions can be so valuable like, was there any bullying related to racism or to sexism or homophobia? These are the kinds of questions I think that could extend what we already do, but into a realm that considers the fact that development is occurring in multiple contexts and that we ought to know and learn about what’s happening in those contexts, especially for kids. But also for adult patients, who have been internalizing all sorts of things as a function of being in and living through those contexts. 

Becoming Culturally Competent

LR: It goes back to what we talked about before—the need to de-neutralize the relational encounter with our clients. What are some of the challenges that you’ve seen clinicians deal with, or that you want to caution clinicians to be careful of?
UT: Actually, something you said pointed to part of my response to this in that I don’t see cultural competence as necessarily an outcome, but as a process. It’s a journey, as you say. And I think one of the things that clinicians are challenged with is this idea that somehow cultural competence only relates to certain outcomes related to people of color, or people holding some kind of minority status, rather than this being relevant to all people of all backgrounds. And so, I think that an important challenge to overcome is the assumptions we make about what is cultural competence and who it is relevant for. If we don’t see it as relevant to all of us, then it becomes a situation for certain people at certain times rather than thinking more broadly. I also don’t see it as only a professional endeavor, but a personal endeavor as well, because if we are not learning to listen to issues of context and culture in our everyday lives, then it’s very difficult to know how to listen for that in our professional work. So, to think that we just need a set of competencies to apply in a technical way in the therapeutic relationship, that’s really not what I think of as cultural competence. To me that’s a mechanical way of being rather than investing the self into the work.
LR: A more fluid way of living multiculturally rather than simply turning on the multicultural switch when in therapy! What do you see as some of the blind spots clinicians may have in working with the “other,” basically someone who’s different from yourself in any regard?
UT: I think that’s a great way to phrase it because so much of the time, the assumption or presumption in our literature is that the clinician is white, and the client is the racial minority person or something like that. Whereas certainly in my case, it might be reversed or there are two racial minority people in the room. So, you can have any combination. I think one blind spot may have to do with our human tendency to overgeneralize about groups or our conceptions about certain, if not all, socio-cultural groups. It is the notion that if someone is affiliated with or identified with a particular group, then they carry certain characteristics or that they have this or that particular set of values. I do think it’s important to have some working knowledge about the history of different cultural groups and a good working sense of that. To me, those form just a beginning framework, a beginning sense, rather than a story or rather than really understanding what belonging to that particular cultural group means for and feels like to the person.
Everybody has a unique experience of their own culture or their own religion or belonging to a particular racial group or being multiracial. I think this is why for me, a psychoanalytic perspective is particularly well-suited to this line of inquiry, because it does allow us to think about experiences that are deeply embedded in relationships, within early life relationships, but also throughout one’s lifespan and one’s evolving relationship with the broader context as well.
Another blind spot that comes to mind has to do with working with somebody who is, in some way, of similar background and making an assumption of sameness, which can get in the way of differentiating ourselves from the other. This is the flip side of overgeneralizing about the other, sort of more about merging – two people whom you think might be similar in some dimension which may not necessarily be true. 
LR: Overgeneralizing about the other and undergeneralizing about someone we perceive to be like ourselves or with whom we share certain demographics. Like me working with a white Jewish male and not inquiring into their whiteness, Judaism or their maleness and as a result, missing out on a lot of potentially good information about what it is like for them.
UT: And sometimes the clients are making assumptions about the therapist, too. So, you might hear a client say, “Oh, you know what it’s like to be Christian,” or biracial, or gay? And I could say, “Well, I know what it’s like for me, but I’m still learning about what it might be like for you and trying to understand that more.” And certainly, with some of my white clients, I routinely ask about their ethnic background. I will ask them to describe it. Some of these clients will say, “Well, I’m just white you know; that’s just who I am.” And to me it always reflects how we’re socialized around race, particularly in this country, to believe that some people don’t have a history beyond just being white. So any previous family history is really kind of disavowed, which people may actually have a lot of complicated feelings about.
LR: And if we don’t allow that into the conversation, then it just continues to be a force of oppression. Just out of…
UT: Disavowal of some kind.

Bearing Witness

LR: Along these lines, what have you learned about social oppression, racism and trauma in working with immigrants and refugees that could help our audience of therapists along their own journeys towards multicultural awareness and competence?
UT: The journey I’ve had has been an incredible one. I feel very grateful for the opportunity to have learned from the people I’ve worked with in therapy. They have been an incredible resource in transforming my understanding of immigration and trauma. One of the things that I have learned along the way is how incredibly complicated the process of immigration is psychologically.
Immigration is rife with hope and optimism and resilience, but also with deep separation and loss. And the ways that people reconcile this are unique to that individual and depend on so many different factors. It depends on their families, the quality of their relational life, their own personalities and what they bring to those relationships. It also very much depends on the traumatic experiences, the support they’ve received and the willingness of people to listen to them and to hear their perspectives. So much of what’s happened in more recent years, certainly since Trump’s election, is we have enormous anxiety among immigrants and refugees.
This anxiety is not only about status, the fear of deportation and separation from loved ones, but also related to the underlying anxiety that immigrants have always felt around not belonging and not being wanted. You know, feeling as though one must find other ways to sustain the self. And that’s been important for me to understand and bear witness to. So, listening to the stories of immigrants and refugees is not just about hearing what happened, but about witnessing and bearing what is happening now and what has happened in the past. There’s tremendous transformation that occurs across the lifespan for immigrants and refugees, as well as developmental points and junctures where their kids and their grandkids are also challenged. And that itself transforms one’s own experience of what it means to be an immigrant or refugee. So, there’s a lot that we still have to understand and learn and research. Actually, I think about these changes that occur as a function of time and cultural shifts and political context and social oppression – all those things.
LR: On a more personal level, if I may, how has or is being an Indian, Hindu female, informed your own multicultural journey as a clinician and a researcher?
UT: Well, certainly it informs a great deal of my whole self, which you know, I bring to my work as well. I immigrated to the United States when I was seven years old from India and grew up first in New York City and then in New Jersey and then moved to Michigan. And we traveled around quite a lot while growing up in the US as well. So, I think that one of the things that stood out to me in that process of adjusting to being in America was how incredibly resourceful my family as well as people in my community — my Indian community, the Hindu temple — were. We really found ways to take care of each other and be very present with each other in one sense. And yet in another way, people also have difficulty talking about painful losses and traumas, so there was this really interesting paradox within the community where I grew up.
I think it’s true for many communities that there’s this sense of cohesion and an incredible connection that feels positive that brings a great deal of strength for people. And yet at the same time, when there are issues of trauma such as violence in the home, racism, sexual abuse, or political oppression that people might have faced prior to immigrating, these things become much more complicated to talk about openly and become stigmatized. So, I became increasingly interested in figuring out what can we do about that and why is that the case? A lot of what I do in my research and in my practice has to do with trying to figure out those gaps and try to make mental health care more accessible to people who typically wouldn’t seek it out or who may not trust the typical mental health professional to understand their context, their values and their families.
I think anything that’s not considered mainstream American is not necessarily considered positive or normal in some cases or normative. People within immigrant communities have a lot of concerns. Racial minority communities as well.
I have concerns that if an immigrant sees a therapist, are they going to be seen as abnormal, or are their families going to be devalued? Is their culture going to be devalued in some way because of the very theories that we use to conduct psychotherapy? And so, there’s a lot of concern around that for people in addition to around providers’ not having awareness of the impact of trauma or the impact of emotional suffering on individuals and families. This is one way I think about my own journey interfacing with and guiding my professional life and is clearly very important to me. 

A Different Worldview

LR: What are the elements of the Indian and Indian American worldview that psychotherapists need to understand?
UT: I think there are some common shared elements. But I think that it’s also important to point out that, as you say, there isn’t one worldview. Somebody may say something like, “what’s it like to be an Indian person?” Well, you can ask a million Indian people and you’ll hear different things about what that means. So, I would say that there’s no one thing that’s definitive. There are many things, but I will try to narrow it down to a Hindu Indian perspective — but again, it depends on how much a person identifies with a particular religion or a particular ethnicity, and even a region within India and language, all those things.
One of the things that comes to mind as a common or a shared element of Indian culture is the ways in which families interact with each other. There is traditionally a respect for older members of a family, in a way — a deference.
And this leads us to think about conflict within families. While there is the tradition of deference to older members of the family, younger members may want to do something that’s not approved of by the older members, but they may then go ahead and do it. But in this instance, they tend to avoid speaking about the conflict. So, there are ways of communicating that are more culturally accepted or valued.
From a Hindu perspective, there’s also a belief in Karma, or a belief in the inevitability of suffering in human life. This is very interesting to me because it parallels psychoanalysis in a particular kind of way in that there is an acceptance of the fact that suffering happens and that there’s value in bearing suffering, at least to a certain extent in service of others, in service of a greater good. So, this feeling of being a part of something greater than yourself or bigger than yourself is something that I think a lot of Indians more broadly, but certainly Hindus, tend to value as well.
These are a couple of more common types of shared elements. There’s also a third thing I could highlight, which is a different sense of ideology around parenting. Parents are typically pretty involved in their children’s lives throughout their lifespan. The Hindu Indian notions of parenting don’t necessarily follow the same developmental lines of being 18 and going to college or being 21 and experiencing a definitive separation from the family. And so, in a lot of Indian families the separation may happen later, or it may take a different form in some other way later in life. So, that can look a little bit different from Western notions of parent involvement. And sometimes it’s extended family too, like aunts and uncles who play a significant role in the attachment and separation experiences within families. 

Sitting with Suffering

LR: Along these lines of differences in worldview, I understand that in Hinduism, as in some other religions, suffering for the greater good is seen as a virtue, as aspirational. Western psychotherapy, in contrast, seems bent on eliminating suffering, resolving irrational thoughts, helping the person to regulate themselves, helping the person to change their behaviors so they don’t suffer. And even though the third wave of cognitive behavior therapy incorporates mindfulness and acceptance, do you still see a tension between traditional Western psychotherapies that are designed to eliminate suffering and therapeutic orientations that embrace suffering for growth?
UT: To see some type of suffering as a normative part of life feels very aligned to me with the reality of what I see every day. But the idea that somehow to live a happy, fulfilled life you must eliminate all suffering, just doesn’t add up. I think it’s sort of a setup for people to actually feel even worse, and it creates more suffering because there’s a way in which this expectation creates the unrealistic expectation that one should never feel bad or one should never have negative experiences. And in fact, we all do and we all will and that’s sort of a foundational idea. So, I do see it as a problem of trying to eliminate the suffering as quickly as possible rather than trying to understand what’s happening. I do see that as a big tension.
LR: I wonder then if Western psychotherapists need to be aware of the intrinsic pressure of our models to sanitize living. An example, perhaps, is our seemingly uncomfortable relationship with death, dying and grieving. We remove people to facilities. We don’t talk about death. We have special grief counselors, which is okay, but what about conversations in families around loss and death? I worry that many therapists in our audience may be too caught up in that need to sanitize and cleanse the person of suffering.
UT: I think we probably feel some pressure to have to relieve people of how bad it feels. And I understand that. And of course, there are certain situations where that suffering is so overwhelming that we do need to help and relieve people. But if it’s something that is a natural part of a loss or separation that happens, we can help people to bear those and know that they will come through it. And so, you’re certainly instilling hope. But you’re not also giving this false hope that somehow everything will be fine after this. Because in fact, it often isn’t, you know?
LR: I wonder if therapists working with refugees and immigrants who have been trafficked, tormented or brutalized simply find it so hard to be in the presence of someone who’s suffered that they try purge them (and themselves by association) of their suffering? Or might some therapists simply not be cut out to work with these clients for reasons related to countertransference?
UT: I do think there are certainly some types of suffering that feel too much to bear for therapists, but that varies for each of us. Some things are going to just feel harder. And perhaps it’s because we’ve been through something similar or that we just don’t want to imagine, you know, and bear witness to that. And certainly, that happens. I’m thinking also of situations where a therapist may not know what to do with that suffering, so they minimize it or push it aside.
LR: Ignore it.
UT: Ignore it. I’m thinking of a situation where clients will talk about experiences of racism at the workplace or at school and wonder within themselves, was that racism? Was that why I feel so badly?
LR: It goes back to something we were talking about earlier in the conversation — core competencies of a clinician who is aspiring to cultural competence. So maybe we should add to this conversation the willingness and ability to sit in the presence of pain, someone else’s pain, our own pain, and bear witness to it — to embrace it, to allow it into the conversation. And in doing so, honor the client who has been oppressed, who’s been trafficked, who’s been marginalized, who’s been hunted.
UT: You’re right. You’re mentioning situations of extreme trauma like trafficking that feel, in some way, so foreign to so many people, as though it’s happening out there somewhere. And in fact, it’s happening in our own neighborhoods and in our own microcosms. I think that it speaks back to that earlier point we touched on which has to do with our own personal investment in these issues. If we don’t take the time to learn about what’s happening to people within our broader society, then it’s going to be very hard to listen for these experiences.
LR: You speak about our broader society. I worry that some psychotherapists consider our broader society maybe a few states away, or “all the way” out to the Coast. But when you expand the definition of “our broader society” to humanity beyond borders, then it’s really a commitment to considering that there but for the grace of Allah or Brahma or Yahweh, go I — that we are all potential sufferers.
UT: Yes.
LR: I wonder if certain therapists would actually benefit from working with such clients and to consider doing so to be a gift of enlightenment for them. A potential gift of the opportunity for awareness and growth.
UT: I think it’s so pivotal to growth as a human being and as a therapist. It’s transformative when you listen to people’s stories from various places and contexts; it is unbelievably transformative.

Final Thoughts

LR: Given that patriarchy and the masculine worldview have historically infused psychotherapy and religion, how does male privilege impact the practice of psychotherapy for you? What are some of the learning lessons we need to learn?
UT: It’s a big framework kind of question. When I think about male privilege more broadly, I see it in the context of our traditional theories that I think hold so much weight over how we think today. I don’t think, oh, well these were some of the older theories or theorists and that was a long time ago. But in fact, I think about how we’ve all been and continue to be socialized under certain models of thinking. In the research world, for example, there is still a valuing of a certain type of research which is quantitative and includes randomized clinical trials as the gold standard. Only certain types of methodologies fall under that umbrella, whereas qualitative research such as case studies are actually more feminized and seen as less valuable. Storytelling and listening and witnessing and participatory action research, which is not valued as highly as quantitative research, is really rooted in community psychology and feminist psychology.

So, I’ve been really interested in using the feminized methodologies and rethinking the issue of being privileged, how it applies to our research paradigms and ultimately to our clinical practices. You know, what narratives and whose narratives are being privileged, and why? Not to say that there isn’t value in all these different paradigms. I see great value and I learn a great deal from each of them, but I do think that the issue of male privilege brings up a broader question about privilege in terms of what therapies are available to different communities. I think about what research is considered to be gold standard and acceptable, and how that all translates to public welfare and people’s wellbeing. I think there are many ways to challenge the status quo in terms of that.

LR: A dichotomy between quantitative and qualitative as masculine and feminine. It seems that the newer therapies are much more relational, inter-psychic, narrative and contextual than the traditional therapies. This makes me wonder about you as a psychotherapist. When a client walks into a room with you, a Hindu, Indian female, what can they expect from you based on the intersectionality of you, of your Usha-hood?
UT: When someone comes to me for psychotherapy, I think they can expect someone who is really interested, curious about their life, about their perspective, how they make meaning of things in their life, and what’s important to them. And I want to hear their story. I want to know who they are as fully as I can know them and as they will let me know them. I want them to understand that we’re all vulnerable in some way or another, but also that being in psychotherapy itself can feel really precarious and that I understand that. I hope to make it a space where they can connect with as much of themselves as they can and make decisions that feel more fulfilling.
LR: So, you are curious, and you are caring, and you are contextual, and you are collaborative.
UT: I would say so, yeah. That’s what I try to be.
LR: Well, it’s about the journey, not about the destination. Right?
UT: True. Very true.
LR: Do you have any questions of me before we stop, Usha?
UT: I have one question. I am curious about how you’re finding this mode of interacting with your audience and what you’ve been learning from that.
LR: This mode of communication, the interviews I conduct, is the pinnacle of the work I do for Psychotherapy.net, because each interaction expands me as a teacher, clinician and as a person. Learning from some of the experts in the field, those who are passionate and committed has ignited my own passion and commitment to learn and grow. It has also made me painfully aware of my biases and limitations, but also of my gifts and strengths. It has made me all the more sensitive to stories, to context, and to the importance of deeply felt personal experiences. I hope that answered the question.
UT: It does and very much aligns with how I’m experiencing you. So, I just want to say that. It’s really been lovely to talk to you.
LR: Same here, Usha. I hope we can speak again.
UT: Me too.

© 2020 Psychotherapy.net, LLC

How Self-Disclosure of Learning Differences Guides My Clinical Relationships

Posted on by Psychotherapy.net Team

Origins of Empathy

As a child, I remember the frustration of not being able to tie my shoes, ride a bike or grip a pencil. The fact that I needed extended time on tests and note takers throughout high school and college was no less discouraging. However, one of my greatest challenges was adapting to adult employment and social demands; a process during which few people seemed to care about my specific struggles. I still remember fearing the supervisor who would criticize my handwriting and the sting of rejection after a first date. Although my therapists were empathetic, I was often curious about whether they had similar personal experiences, and whether disclosing them would have strengthened the alliance between us. Now, as a therapist who specializes in working with young adults with learning differences, I have made self-disclosure not only a basic component of treatment, but also part of how I present myself to the outside world, as my personal story is published on my website as well. This dynamic has led to a transference and countertransference between my clients and myself that starts from our first session and strengthens our relationship in many ways, while also providing an opportunity for us to reflect on our differences.

Part of my initial interest in becoming a psychotherapist and coach stems from my personal experiences struggling with learning differences. I am interested in using some aspects of my life to help other young adults with similar diagnoses navigate their challenges. It is reported that 75 to 85 percent of young adults on the spectrum are unemployed, and although the exact statistics on unemployment among adults with other learning differences are not known, it is widely thought that they also face a variety of barriers.1 The clients that come to my practice often say that they are struggling to manage their workload, navigate interpersonal situations with colleagues and bosses, and establish friendships and romantic relationships. “Preserving the uniqueness of their challenges while drawing on my own experiences is a tricky balance as a psychotherapist”, but I have developed a few strategies for doing so.

Fellow Travelers

My clients frequently find me through my writings for the NVLD (Nonverbal Learning Disorder) project, a non-profit that disseminates research and builds awareness regarding this unique visual-spatial disorder. One of the first things I tell them is that everyone’s experience is unique, and that my job is to help them to navigate their lives while also drawing on some of my own personal experiences related to common issues such as self-disclosure in the workplace, creating organizational systems and finding mentorship. The key is to listen fully to their stories and experiences, helping them to brainstorm and find their own solutions, while also offering, when appropriate, some personal anecdotes that might be helpful for their specific situations. An example could be a client who states that he or she is not sure how to best self-disclose their learning difference to their employer. We may explore ideas about different times and places to self-disclose, and I can talk about what I have learned from my own experience. I have found that many clients often appreciate this approach, stating that when I speak from a personal viewpoint it helps them to trust me more and feel as if I can relate better to their experiences.  

If transference in psychotherapy normally consists of unresolved feelings and expectations that are placed onto the therapist–oftentimes in an unconscious attempt to recreate or approximate a past relationship, and countertransference is the therapist’s resulting conscious and/or unconscious feelings that are projected onto the client, “the therapeutic relationship between two young people with learning differences is ripe for the enactment of these feelings/experiences”. I often find that the clients I work with report a feeling of safety and security, perhaps seeing me as an older sibling or parental figure, especially when they describe feeling understood or supported by my being in a unique position to empathize with their learning differences.

Transference & Countertransference

One client, whom we will call Joyce, frequently contacted me after our therapy had ended in order to ask questions that usually began with “since you have and know about NVLD…” Because our work together had ended, I redirected her to another therapist who practiced in my office, but she did state that she had felt a sense of security and safety with me that she may have felt earlier with her mother, whom she used to call to help guide her with difficult situations. In some ways, she may have unconsciously seen me as a parental figure helping her to navigate difficult questions related to her job and personal life. 

While working with male clients, I have often found that the transference/countertransference relationship may take on a different form. This is due to the fact that there is an element of both bonding and competition; many of the young men I have worked with may have a complicated history with women, especially regarding rejection and feelings of emasculation, a topic about which they may look to me for understanding. While I do not usually disclose my romantic status or experiences, by validating the unique challenges of dating with a learning difference and providing some practical steps for managing these feelings, I establish a bond with these clients, who describe previous male friendships in which they discussed these issues. A dynamic of male companionship can often form between my clients and me. However, some of my male clients have also seen me as a source of competition, and have reacted strongly, stating “you don’t know anything” or “how can you understand me?” Admittedly, it may be uncomfortable for some of my clients who see me as a “success story,” especially when they are struggling to find work or build interpersonal relationships. This is also a dynamic that I try to work through with them, making space for it to be discussed in the therapy room.

I attempt to use my countertransference as an indicator of not only how I should respond to the client in the room, but also of when, if and how I should self-disclose. A dynamic of male connection may lead me to respond to a client’s disclosure regarding rejection in the dating world with a few suggestions for improving one’s strategies, perhaps with the caveat that I have learned from my personal experiences. Depending on my relationship with the client, I may also use my countertransference as an indicator of my familiarity with certain aspects of the client’s professional experiences. For example, I remember identifying with a client I will call Michael, when he described challenges figuring out certain aspects of his job, as I have had similar experiences. However, if a client expresses competition or hostility towards me, I may also notice a feeling of defensiveness that arises in me, which will cause me to be more cautious regarding self-disclosure. Again, “countertransference can be an indicator of when and how to self-disclose”.

In my clinical work, transference and countertransference are often sparked by the patient’s vulnerability in the therapeutic relationship, something that individuals with learning differences will sometimes go to great lengths to conceal. Sometimes, they will hide behind a veneer of competence, lest anyone discover their sometimes painfully embarrassing challenges. The transference and countertransference dynamics in a therapeutic relationship often emanate from these struggles becoming visible, causing relief, vulnerability and perhaps shame at the same time. An articulate and thoughtful client, whom we will call Jenny, recounted how she had transferred to a reputable private school to receive more academic support and was subsequently abandoned by her previous friends, who stated, “So you think that you are better than us?” Despite distancing herself from her new school’s perceived “preppy” culture, she was reticent to explain that she had enrolled there because the workload and lack of individual attention at her local public school had become too onerous to handle. Quite the opposite of feeling “better,” her true reasons for transferring were a source of embarrassment. Hence, she described feeling “invisible” to her former friends, as they had falsely assumed she must have chosen the school for its supposed prestige. Jenny’s story prompted me to reflect on how many of my peers had also judgmentally questioned my parents’ decision to send me to small private schools, with statements such as, “Wait! How many people go to your school!? That’s weird.” Not to mention, “Are your parents rich or something?” I stated to her, “It is so frustrating and somewhat ironic when people assume you attend a private school because your rich parents want to help you escape the chaotic real world of public education, instead of the reality that you would do anything to be able to thrive while attending a school with over thirty students per class, loud and confusing hallways, and overwhelmed teachers.” Jenny thanked me, and although I never disclosed my experience, the fact that I had made hers visible created a positive transference between us. In that moment, I may have seen her in a way she would have wanted to be seen by an empathetic friend.

“Group therapy sessions necessitate a different kind of self-disclosure” and create a different stage for the expression and integration of transference and countertransference into the therapeutic work. I led a small group on developing dating skills for young men on the spectrum. The participants asked me, “Do you have a girlfriend,” and “What dating experience do you have?” I did not answer the first question but did confirm that I had faced some the challenges in this area. I added that I had developed some strategies and techniques of my own for finding success. My self-disclosure sparked an ongoing discussion of the struggles of dating between the group members, a discussion in which I was a participant in but not the expert leader. In other words, my self-disclosure leveled the playing field, so to speak, which facilitated a deeper and more meaningful conversation in the gruop. Because the participants acknowledged that they did not feel comfortable speaking about these issues with anyone else, the transference that may have developed was that of a relationship between intimate friends. Regarding my countertransference, I also felt a sense of kinship with the other participants.

Self-disclosure regarding around my learning differences and a careful monitoring of the related transference and countertransference relationships with certain clients has enriched my clinical work. My clients have had both positive and negative reactions to my self-disclosure, which has provided an important opportunity for deepening the clinical relationship. While not all my clients react positively to knowing that I also have a learning difference, the majority have developed a trust and willingness to explore how my self-disclosure may help them in treatment. Although I will continue to make sure that sessions focus on clients and not on myself, I believe that, overall, my decision to self-disclose has been a positive experience for clients.

Resources

Carley, J. M. (2017, April 13). The Employment Shift: Rethinking Autism Employment Initiatives. Fallbrook, California , USA.

Responding to an Immediate Negative Transference

Posted on by Psychotherapy.net Team

A Cold Opening

When my friend and colleague, Jessica, called to make the referral, she said, “She’s an analyst, really smart and a great person. You’re going to love her.”

Sally arrived in my office about ten minutes before her appointment began. When I opened the door to the waiting room to invite her in, I saw a tall, thin, woman with gray hair. She was dressed simply in a gray wool skirt and black turtleneck sweater, but there was something elegant, almost aristocratic in the way she carried herself when she got up from glancing at a magazine and entered my office. I felt instantly inferior to her.

I greeted her: “Hello Sally, why don’t you come in.” I invited her to sit wherever she was comfortable. Then I sat in my chair and faced her silently. I thought about the fact that she was a more experienced analyst than I was. If she had never been in treatment before, I might have waited a minute and if she was silent said, “So tell me what brought you to see me.” But since she was an analyst herself, I just waited for her to tell me why she came.

“You’re pretty cold, aren’t you–silent and cold. But maybe that’s not bad. Maybe that will be more analytic and help the transference come out faster than if you were warm and fuzzy.”

I was taken aback because I don’t imagine myself as silent and cold. I thought I was warm but giving her the space to present herself. Indeed, this was the first thing I learned in my first class in analytic training. So I was speechless when Sally accused me of not knowing how to begin a session properly; but before I had a chance to respond, she continued.

“Let me tell you about my history.” Her face was expressionless as she pulled aside her long gray hair that was partially covering her right temple and continued. “When I was five years old, I was in front of my house waiting for the school bus with my younger brother. A car ran me over and I almost lost my right eye. I was in the hospital for months. They saved the eye, but I have this scar.” She pointed to a slightly indented grayish patch of skin that started at the edge of her eye socket and extended to her hairline. I made an inaudible noise and grimaced to express my understanding that this was a traumatic experience. But she continued before I could utter a sentence. “Then when I was 15, my mother, brother, sister and I were going to California to see my maternal grandmother who was dying. My father dropped us off at the airport in Chicago and then before we got on the plane, a policeman came and told my mother that my father and his driver were in a car accident and my father was dead.” Again I gasped, this time in disbelief that so much tragedy had befallen her at such a young age. But she continued telling the story without affect as if she were giving me a chronology of what she did over the weekend. I wanted to say something empathic to her, but I would have had to interrupt her to do it. So I just decided to listen until she gave me an opportunity to speak.

When Sally finished telling me the history she thought was relevant for me to know, she turned to telling me about her present life. She told me she had a husband, son and daughter. Then she got around to why she came.

Are You Orthodox?

“I’ve come because I’m depressed. I was terribly depressed a few years ago and went into couples’ therapy with my husband John. It helped, but I’m depressed again and I’m also worried about my son. He doesn’t have a job and I’m afraid he’s not doing the right things to get one. Also, I’m going to be 60 and I feel terrible about it…”

I was about to ask her what was so terrible about being 60 when she continued;

“The thing is that I think there’s something wrong with my brain.” She started to get teary for the first time. “I used to remember everything. But now I take notes on every single session because I’m afraid to forget; I walk into a room and forget why I came. I go to get the car and realize I forgot the keys. I know something is wrong with me.”

I thought to myself, I constantly forget what I’m looking for and where I put my keys.

My impulse was to reassure her. I wanted to blurt out: Oh, that’s nothing. I do that all the time. If she were a friend, rather than a patient, that’s what I would have done.

Sally continued in a voice that sounded frightened. “I think I may be getting Alzheimer’s. I always remembered everything and now I have to make lists to remember things.”

I have to make lists to remember things too. I resisted the impulse because reassuring her might seem to her that I wasn’t really hearing her. I didn’t want to trivialize her anxiety. And, after all, “there could be something wrong with her brain”.

“I went to a neurologist and he said there was nothing wrong. But I heard about this cognitive test regimen you can take and I’m going to do it.”

I wanted to say: That sounds like a good idea. But she continued without skipping a beat.

“I don’t want anyone who knows me to know about this. Some analysts talk about their patients with each other. But I think that’s terrible. I came to you because you’re not involved in my circle. I won’t tell any of my friends except Jessica and I’m terrified of them finding out.” I felt stung by her pointing out that I wasn’t “in her circle.” But I knew I had to let that go. I knew what I should say was: “What’s the terror?” But I didn’t want to cut in. I looked at the clock and the session was over, but I would have had to interrupt her to tell her. But then, as if she knew the session was over, she said,

“You haven’t said anything all session. You just sat there like a silent analyst. I guess you’re quite orthodox or maybe you’re just inexperienced.”

I felt “put down” and misunderstood. I needed to say something, but the session was over and I was feeling furious at her. I was afraid I would blurt out something angry. I dug my nails into the palms of my hands to try and get control over myself. “Well, we’re going to have to stop in a minute. But I think it’s a good thing that you’ve come because it sounds like you’ve experienced a great deal of trauma and loss. Turning 60 seems to be a catalyst for re-experiencing those feelings again.”

I sat in my chair for a few minutes after she left and thought about what I was feeling about her and what my friend Jessica had said about her. “You’re going to love her.” But I didn’t love her; I was struck by how controlling and critical she was during the session. I wondered about the disparity in our perceptions of Sally. What’s was going on here?

A Transference Blooms

When Sally returned the following week, she seemed calmer and less frightened. My back relaxed. But then she began the session by noticing that my chair seat was higher than the other chairs in the office.

“No therapist has a chair higher than her patient. It’s such a basic thing.”

I felt like my mother had slapped me across the face. I could feel the sting in my cheeks. I wondered if my cheeks were red and if she could tell. It had never dawned on me to consider the height of my chair in comparison to the other chairs in the office. Sally’s criticism made me feel like a fool. Once again I dug my nails into my palms to try and get control of myself. I spoke very quietly:

“What does it mean if my seat is higher than the others in the room?”

“You must be insecure and need to be higher than your patient. I have never been in a therapist’s office with seats of different heights.”

I bit my lower lip, trying to control my rage. “You seem to equate the height of the chairs with differences in status.”

“Yes, I feel like you’re trying to be superior to your patients.”

After what felt like a long pause during which I was trying to tamp down my anger, I said: “To my patients, or to you?”
“Yes, of course, to me.”

Trying to keep my composure, I spoke slowly and quietly: “Are we competing?”

“Yes, I guess we’re competing. I don’t want to feel lower.”

There was silence for a moment. She seemed to immediately understand that her feelings about the chair were more about her than me. Then she went back to the story about her father’s death that she had told me about the prior week which indicated to me that we had come to some transferential understanding of the importance of the height of the chairs in my office. I could feel the muscles in my back relax.

“My father had a driver. They drove Mom and me to the airport because we were visiting Grandma in California. The driver hit a truck and my father wasn’t wearing a seat belt so he was thrown from the car. He was probably decapitated.”
I felt stunned and I’m not sure if I gasped. Part of what staggered me, aside from the inherent horror of what she was saying, was that Sally said it without affect as if she were saying: “My father was probably wearing his blue suit.” That amplified my shock because I was completely unprepared for it. “I had an image of her father’s bloodied head flying onto the highway” while his disheveled body was thrown to the side of the road. I was speechless and Sally went on to another topic.

“I’m really angry at John because he keeps saying my anxiety about losing my cognitive capacity is silly.” She's worried about losing her head, I thought.

“That must feel like he doesn’t understand how frightening it is for you…" I said. "Unfortunately, we are going to have to stop for now.”

The next session I was afraid to open the door to my office and invite Sally in. I could feel myself tightening up in expectation of her criticism. She was consistent.

“You know it’s really odd that your magazines are old and you cut off the address label on the magazines in the waiting room.”

I felt exposed. What did this mean about me?

“I’ve never seen such a thing.” She continued, “You must order the magazines for your house and then bring them here!” She was outraged at the idea.

It was true; she was right. I didn’t really understand what was wrong with doing that.

“What is it about taking the mailing labels off the magazines," I asked, "that is upsetting to you?”

“It means that you don’t subscribe for the office, you subscribe for your house.”

“What is it about that, that’s upsetting?”

She took a breath; she was trying to figure it out. “My parents had a very romantic relationship. Every night they had a cocktail in the living room together when my father came home from work and we weren’t able to talk to them or even go in the room during cocktail hour. I think it feels the same to me. Your patients are secondary to your real life. We get the magazines with the label torn off.”

I felt that something important was happening. Each week she came in criticizing me and I felt exposed and inadequate. Each time we were able to understand what these criticisms meant to her, but we had not talked about what it meant that she was always criticizing me. I felt a dread that reminded me of how I felt when my mother came home from work. There was always something I had done wrong. I wondered what it meant that I was dreading Sally’s next criticism of me. Was this my countertransference or was this what she felt about her mother? Or both!

Fits and Starts

The next session Sally came in saying she felt very depressed. She realized that she forgot to put on make-up or comb her hair before she came to my office. She analyzed it herself:

“That’s very interesting. I’ve never done that before. I seem to want you to see me without any decoration.”

I thought that was a great breakthrough; she wanted me to see how she really feels underneath her façade. I decided to take a risk and make an interpretation.

“You’re critical of me, but I think you’re hyper-critical of yourself.”

“You mean you think I’m projecting my own feelings of inadequacy on you?”

“Yes exactly. I think you’re treating me the way your mother treated you.”

“I feel so relieved. Yes, that’s right.”

I felt that was an important moment in our work together. I finally addressed how critical she was of me. I was much happier to see her when I opened the door to my office the next week.

Sally handed me the check to pay the bill for the prior month. I took the check and crossed off her name in my book to indicate she paid.

“What are you doing that for?” She said in an outraged tone.

“Doing what?”

“Writing down that I paid you. I’ve never heard of anyone doing that.”

“I don’t know what you mean.”

“You mark it down after the patient leaves, not while I’m here.”

I was feeling speechless once again. I never noticed what Anna did after I gave her a check because I always turned around and walked over to the couch to lie down. I was barely able to utter: “What does it mean that I’m marking down that you paid while you’re here?”

“It’s unprofessional that’s all. Anyway, I’ve been thinking about whether I want to see you or not. It’s a big trip from where I live to get here.”

“Do you think there might be something more to it?”

“Well, I liked what you said last time. It made me feel much better to think that you’re not inadequate; I’m just projecting. But “I think I liked you better when you didn’t talk”. I want to know what you think, but when you tell me what you think it’s what I’d say if I were you.”

“Is that good or bad?”

“I don’t know. When you were silent it gave me room for my own associations.”

I felt damned if I did and damned if I didn’t. It felt just like my situation with my mother—whatever I did it would not be right.

“Do you think not wanting to see me might be related to my saying something that was helpful to you?”

“Yes, I think I’m competitive with you. I want you to help me, but I don’t want to feel you can help me. Especially because you’re so much younger than I am.”

Well, I thought, she’s certainly not like my mother. Sally’s able to consider my questions and look at her own behavior.

The next time I saw Sally she told me she was feeling much better about herself and about me. She realized that her family was very focused on status differences. Her parents were contemptuous of blacks and Jews.

“Do you think that’s related to your feelings about me?”

“Well, you’re probably Jewish and I seem to be competitive with you.”

In the next few sessions Sally told me she felt I was “too nice” and “not analytic enough.” Once again I felt like she was poking a finger at me. It took energy to find something to say to her that wasn’t defensive and angry. Finally, I was able to remove myself and see what this was about. I suggested that “analytic” was her term for cold and uncaring. I was the first female therapist she had and she was ambivalent about whether she wanted a mother who was cold and critical like her mother or warm and “too nice.” Of course, Sally continued to criticize me, but we had developed a working alliance and now the work could continue.  

Countertransference is not a Flesh-Eating Disease

Posted on by Psychotherapy.net Team

Among my varied clinical and clinically-related roles, I supervise master’s level counseling interns who are training in a variety of settings, from alternative schools to psychiatric hospitals. In our group supervision classes, we discuss a range of theoretical and applied concepts related to clinical practice. Frequently, countertransference takes center stage. Perhaps this is due to the nascency of their clinical skills, unpreparedness for or inexperience with self-reflection, lack of personal and interpersonal maturity, or all the above. In our meetings, we are never short on content for conversation or the inevitably painful role-play exercises that I inflict upon them. All in the name of their growth, of course.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

With few exceptions, my counseling interns have somehow latched onto the notion that countertransference is a flesh-eating disease; proof positive of psychological frailty inevitably resulting in psychic degradation, the inability to evolve into effective clinicians, and who knows, maybe contagion. I believe that these apocalyptic notions stem in part from the origin of the study of countertransference in psychoanalysis, with its emphasis on forbidden and deeply concealed libidinal urges, unresolved parent-child conflicts and other dark intrapsychic forces ever seeking sunlight and the opportunity to wreak havoc in the therapeutic sphere.

Try as I might to dispel this notion by deploying the most powerful tools in my arsenal of empathy, they cling tightly to the fear that countertransference is the enemy within, seeking to undermine, subvert and slowly erode their fortitude and confidence. And try as I might to demonstrate the opportunities countertransference presents for self-awareness, personal and clinical growth as well as healing, they recoil at the sound of the word! Maybe, I should just call it Steve.

Two examples might help explain what I and my student-interns have been experiencing. A student-intern who was a new mother to a 9 month-old was working in an alternative high school. She was assigned, ironically enough, a seventeen-year-old student who had given birth just months before. See where I am going here? My student was angry at this young woman who had abdicated her parental responsibilities to her own mother, refused to engage in attachment-related exercises, and had become increasingly depressed and withdrawn. My student seemed, at least temporarily, incapable of empathizing because she could not fathom how someone could neglect an infant when concurrently, she was in the process of building a deep bond with her own infant. When I suggested that her negative reaction to her client was rooted in countertransference, she initially recoiled and withdrew, but with encouragement and class support, opened herself just enough to consider how she was triggered by her client. Subsequent on-site and in-class supervision helped her to reconnect with the client.

Another counseling intern had taken on a new college-age student who had experienced several years of depression, family rejection, a profound sense of hopelessness, and who had a history of rejecting therapeutic intervention. When his own clinical supervisor made specific recommendations for how to work with this client my student resisted, arguing that the supervisor was not being sufficiently empathic, had disregarded his own ideas, and he planned to speak to the client about issues that the supervisor felt were premature. My student grew increasingly angry at his supervisor, more deeply intent on doing what he thought was necessary and walling himself off from the supervisor. This was the first rupture in the relationship between this student and the supervisor whom he had previously seen as supportive. As the class supervision unfolded, I suggested to the student and the group that this particular client could be triggering something in him related to past relationships or even experiences in his own life. As with the intern mentioned above, this young man felt embarrassed and disappointed in himself that he was perhaps being influenced by countertransference. I should have called it Steve.

As the conversation unfolded, this intern volunteered that just a year before, he too had experienced a severe depressive episode and felt misunderstood by friends and family who offered suggestions that he found destructive. “If only I had been a better clinician, I would’ve seen that coming”, he lamented. Well-intentioned as he was, this posture was unrealistic, and fortunately subsequent supervision and counseling helped this particular intern to continue along his own path to healing and professional growth.

***

In both of these supervisory moments, the interns better understood what countertransference was and was not. If our interns are always taking universal precautions to guard against the psychological equivalent of a flesh-eating disease, then caution and defense will win out over opportunity for both personal and professional growth. Sometimes, past and present painful and/or unresolved experiences and relationships scream out from within for attention, even for debriding if you will. Only in this way can clinicians, at any point in their evolution, build healthy psychological immune systems. 

Surviving Attacks in Psychotherapy – An Occupational Hazard

Posted on by Psychotherapy.net Team

The sound of gravel being ripped from my drive is that of an angry 25-year-old man leaving his session with me. He is furious, and though he sat through the final minutes of the session with his emotions firmly in check, they spilled out as soon as he left.

He is angry with me because I have tried to find out why he walked out of therapy with me three months ago with no warning, and why he wants to come back now. He is here because it is a requirement of his psychoanalytic training, and though he gets some satisfaction from working with me, I don’t think he would be here if he wasn’t required to be. He is frustrated by my asking about the premature break earlier in the year.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

We are caught in a difficult transference. His acting out, his anger with me, his resistance and refusal to want to find out more about what’s going on make things difficult. But it’s not going away. By coming back now he has drawn further attention to it. He could have stayed away, and then no questions would have been asked. Not by me! But he’s come back because he must for his training.

I find my practice can run very smoothly (a superstitious side of me prevents me from saying more), but every so often an issue will flare up and the atmosphere is changed. Often clients who are in training prove the most difficult, particularly when they are ambivalent about being in therapy. I think of these experiences as attacks on psychotherapy. Evidence that an attack has been launched is demonstrated by particular behaviors, and frequently these are behaviors that manifest themselves in terms of boundary or therapeutic frame issues.

In this example, someone breaks off therapy and then expects to come back with no reference being made to their previous actions. The challenge then is how to find a way of working and thinking these things through with the client without becoming caught up in the attacking behavior. And without, as D.W. Winnicott put it, the psychotherapist retaliating and attacking back.

When these kind of aggressive and attacking experiences are enacted in psychotherapy, the psychotherapist is tested. The psychotherapist must find a way to keep working with the experience. And as they try to, the client finds more ways of provoking the therapist to retaliate. But retaliation might be fatal to the therapy. It might prove that the client is as unlovable as they already think themselves to be. It might lead to the end of the work. It might prove very hard on the psychotherapist’s sense of their own professional identity.

So, in the sessions that follow I have to find ways, despite the provocations, of developing the therapeutic relationship, trying to develop the relationship so that the client may come to lower their defenses so that in time, the client may become interested in the complicated dynamics that are at work. If this can happen, and the therapy can survive the attack, then the client may develop the sense that this therapeutic relationship is not like other murky, unfair and repressive relationships that they have or had, perhaps with their father. They may come to see that in their therapeutic work with me, they are outside of that original destructive parental paradigm. The negative paternal transference might be resolved. This could then be the beginning of profound change.

The attack, however it comes, could be a gateway to change. A gateway out of the stuck world of unhappy relating that the client has lived in. This may be what the client has come to therapy to resolve, although they probably don’t know that yet. The only problem is that the attack is real and happening right now. And the client’s way of finding opportunities to provoke the therapist into an uncharacteristic act of rejection are very hard to predict and can be very hard to work with and survive.

In the case of this particular client, it took some time for his anxiety and his aggressive and attacking behaviours and defenses to be contained within the therapy so that we could think about them together. This seemed to coincide with a more measured approach to his driving.

I have gained from my experiences of surviving these kinds of attacks without retaliating- they are always very hard work. They are an occupational hazard.   

The Lose-Lose Comment: A Therapist

Posted on by Psychotherapy.net Team

In my years of practicing therapy, I frequently would not know what to say. Once, a woman made a classic doorknob disclosure as the session was ending: “When I was 14,” she said, “my uncle sexually abused me.” A male patient made fun of me for not following a story organized around economic theory. A woman wanted me to praise her for resisting temptation the week before. At these moments, I would typically frame my predicament as egalitarian (be spontaneous and gratifying) versus authoritarian (be withholding and rule-bound), and I would choose the egalitarian path. Other therapists, I’ve noticed, have other ways of framing therapy dilemmas.

I wish I’d known at the time how to make a lose-lose comment. For example, with the first patient, I might have said, “If I just say goodbye right now, I seem to be communicating that what you said is not that big a deal. But if I ask you about it, I seem to be communicating that it’s such a big deal that our relationship can’t take it in stride. I don’t think this dilemma is new to you in dealing with the abuse. Since both alternatives have disadvantages, I guess I’d like to keep our agreements intact, while assuring you that we will talk it over next time.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Two of the many ways of understanding therapeutic success make sense of the lose-lose comment’s effectiveness. First, Gregory Bateson, the anthropologist, observed therapy in a VA hospital and concluded that therapists teach patients how to metacommunicate. He meant that many people do not take advantage of their capacity for reflection before taking action, largely because they never learned to talk things over in a reflective space, much less in their own heads. He said that almost all therapies of every orientation excel at this because virtually all therapies talk things over. The dilemmas I mentioned above pressured me to act, and the lose-lose comment demonstrates that even intense pressure can be reflected upon.

Transference resolution seems outdated as a therapy construct, but it can be understood in contemporary terms. Jonathan Shedler has said that therapy teaches the patient, “That was then; this is now.” I have long maintained that successful therapy depends on the fact that the patient will mess up the therapy in the same way that they mess up other relationships, and the therapist’s job is to help resolve these relational conflicts. In this context, many therapy dilemmas arise when the patient promotes a characteristic mode of relating and the therapist is trying to promote a therapeutic mode. The lose-lose comment is intrinsically therapeutic, even when the alternatives specified by the comment are not, so it restores or maintains the therapeutic relationship.

To the economist, I might have said, “If I fight back, our relationship becomes a stag fight, but if I don’t, I will lose your respect. I get the sense that you might not be too familiar with other ways of relating.” If the last sentence seems like a putdown, I could have said, instead, “I’m not sure how we got to this point.” To the woman wanting praise, I might have said, “If I praise you, then it might cast you as a little girl, the very image that precedes your yielding to temptation; if I don’t, you might feel lonely, which we have also identified as a precursor to temptation.”

The structure of the lose-lose comment can become monotonous, but it lends itself to other forms. I could follow up the lose-lose comment with something like “Are those my only choices? I wish I could think of a way to show you how important I think that is while also showing you that I think we can take this in stride.” Or, with the economist, just holding my hands up in a timeout signal might have gotten us back on track.