This very long post is intended to replace the previous one on transference disasters and give patients and therapists a sense of how attachment to one’s therapist can come about and what to expect. It is also intended to clarify what is required of the therapist and what can go wrong. I hope this might embolden patients to have confidence in their instincts and rights and to initiate discussion of these issue as early in treatment as possible. (Photo: Allison Day, Flickr, CC BY-ND 2.0.)
On Attachment to Your Therapist
Jeffery Smith MD
What I have Learned
Eight years ago, a reader wrote, “I have a very strong attachment to my therapist and have come to see him as a father. I struggle with this on a constant basis, because he’s not my father, he is my therapist and is one hell of an ethical one at that and would never ever stretch the boundaries (which of course are some of the things that I wish for…).” I responded with a post and since that time, hundreds of reader comments and many more posts have created a trove of collective experience and a place for discussion of the best and worst that can happen in intensive therapy. I am writing now, to summarize what I have learned in the hope that it may help patients and therapists be successful in their work together. Of course the ideas here may not apply to all situations and are not a substitute for working with a credentialed therapist. These pages are made to be shared with therapists and to be of use to patients/clients in getting an overview of what to expect and what problems may be encountered.
Causes of Intense Attachment to One’s Therapist
As best I can tell, these feelings are the result of experiencing a shortfall of “primal love,” that is, early, attuned, empathic attention from the primary caregiver. For different people it has different meanings, but it tends to be in the realm of the 24/7, total, unwavering devotion for which very young children experience an intense and very real need. The child has no doubt that the only possible solution to a shortfall is to get the grown up to take away the pain by fulfilling that need. This kind of loving connection is experienced as a life-and-death need, and when not met (or perceived as lacking), leaves a sense of something missing that must, somehow be fulfilled. If not that, then the child undertakes to satisfy the need with his or her own substitutes. This yearning can remain smoldering outside of consciousness for a lifetime. Therapy is like water to a dry seed. The yearning comes alive in the context of a relationship with someone who seems to understand and be willing to help.
Values as Defenses against Chronic Pain and Anger
When children carry distressing neediness day in and day out, in order to manage the constant pain, their mind eventually develops a value system that functions to suppress the constant ache. This system discourages conscious neediness by adopting an internal prohibition against it. “You shouldn’t need attention.” This is effective in pushing the yearning out of awareness, but further fuels its intensity. Another normal reaction is anger. Children can be thought of as consumers of parenting services. They know what is right and what isn’t, even if they don’t dare think it. So it is normal for children who have experienced neglect of some kind to feel anger. This too is a distressing emotion to carry, and can also be experienced as dangerous. By the same mechanism as the prohibition against neediness, the child also develops a value system prohibiting anger. “You shouldn’t be angry.” That only intensifies the anger, so we end up with a third set of internalized attitudes or values: “It’s your fault. You are no good.” Then the anger has somewhere to go and a pathway for it to be acted upon. It is not uncommon for a person who has experienced neglect to have a history of both overt anger (when it overflows) and anger turned against the self. Having these three types of values standing against one’s natural feelings and longings intensifies them greatly and leads to huge amounts of shame. Along with the unfulfilled needs, themselves, these internal defenses form significant part of the difficulty patients bring to therapy.
“Acting Out” to Soothe Emotions
This unconscious combination of unmet needs, angry feelings and the values that hold them in check, leads to a number of strategies for substituting for needs and soothing the distress. They may not fully blossom till the teens, when their power is discovered. Food, cutting, bulimia, all kinds of sexual acting out, drugs, gambling, are among the symptoms, as well as repeated, unsatisfying attempts to find comfort in relationships. These often combine soothing with self-punishment, which decompresses some of the rage. However, acting out is never more than a band-aid and must be repeated often to provide any kind of relief. The painful consequences of acting out only increase the anger, and with it, pressure to repeat the same maladaptive coping strategies.
An important principle of therapy is that acting out undermines the benefits of therapy. As the patient focuses on the consequences of self-defeating patterns, little energy is left to deal with what underlies them. Furthermore, the acting out takes energy away from the therapy, where there is a chance of actually working out the anger, and neediness that fuel the whole edifice. The mind tends to see this as too dangerous. After all, the therapist might be another source of disappointment and ultimate despair. So there is a strong tendency to favor acting out, even though it is guaranteed not to work.
Attachment to a therapist is one of the healthiest things that can happen to a person caught in such a tangle of feelings. It means there is hope of a real solution, hope that there is a way to have life as it should be. Therapy is all about channeling this healthy desire away from the old patterns and towards hope of healing and a better life. That said, we still need to recognize that the mind will naturally try to direct the therapy in the direction of repetition of the old patterns instead of examining and understanding them.
When attachment to a therapist is sexualized, I usually think that the drive comes from the yearnings and emotions described above, but that premature exposure to sexuality, in some form, has most likely occurred, leading to expression in sexualized form. This can be challenging because it also engages mammalian biology in a powerful way, adding to the drive to find fulfillment of unmet needs.
When patients/clients come to therapy, the child in them wakes up. Traditionally, this is called transference, meaning that the person reacts as if the therapist were a figure from the past. Unfortunately, this term is far too dry and technical to even hint at the real life experience, both for patient/client and for the therapist. (please let me call you patients, as that is what is most natural to me, and in no way disrespectful) To put it simply, transference just feels like life. Patients feel upset when the therapist seems not to care. Therapists feel the patient’s loving attachment or criticism in the here-and-now. These feelings do not come with an asterisk saying that they are not really about the present.
Why is this? Emotional interactions in therapy are the domain of our mammalian, emotional brain, which operates automatically outside of consciousness and has been designed through evolution to take care of needs and keep us from danger—as our non-conscious mind understands it. So in the therapy room, we have not just the conscious adult patient, but, for all practical purposes, a young person as well, with a different way of seeing the situation and different ideas about how to make things better.
Children solve problems differently from grown ups. Their solution to any serious problem is to motivate the big person to solve the problem, meaning to take away the pain. Adults have a different approach. It is to analyze the problem and personally to take required steps to solve it in whatever way will work best. In the case of early life deprivation, the childlike solution is for the therapist to take away the pain by giving the love that was missing. On the other hand the adult therapeutic solution is to grieve what never will be and make peace with reality. This is obviously, not the answer a child would think of or accept.
Transference refers to times in therapy when the patient’s words and actions reflect the child’s perceptions and methods for solving problems. Usually this is (unconsciously) filtered to make it seem reasonable. For example, the patient might think, “I just want help feeling better.” The feelings surrounding that thought would be more consistent with, “I want you to take away my pain.” Hopefully later, the patient might feel safer and more comfortable and might admit that “I want you to hold me and be there all the time.” That would be a more accurate rendition of the inner child’s true wish. I hope it is apparent that characterizing this a distorted perception is far too limited. The young version is actually an alternative and age appropriate way of understanding life and solving problems. Because this isn’t just perception, but embodies goal directed behavior, I have personally, abandoned the term, transference, and simply think of an “inner child” with his or her own agenda. It is far more accurate to picture a being who seeks to feel better through methods that are appropriate for a young person. This is so much more true to life than thinking of transference as an adult with errors in perception. In addition, thinking in terms of an inner child encourages compassion and understanding rather than judgment.
What patients react to is their perception of the therapist’s inner motivation and intentions. They observe words and actions, but their emotional reactions are to what they imagine to be the therapist’s motivations. In fact, knowing other people’s true motivation and intentions is difficult at best and extremely subject to error. Husbands and wives do it all the time, mistaking the other’s intentions. “You only said that because…” We look at actions and say, “the only reason he/she could have done that is…” That proves it! There is no other possible explanation. Actually there are other explanations, but, under the pressure of emotions, the range of possibilities seems to narrow. Patients develop an unshakable rationale for their interpretation making it very difficult to show them that transference conclusions are in error. Their conclusion feels right, makes complete sense to them, and there is “no other possible explanation.” Furthermore the therapist’s defense is only an additional proof that he/she is trying to cover up bad intentions. So, helping patients understand the child in the room is really challenging, even for therapists skilled enough to see it themselves.
The biggest source of trouble in therapy is the therapist’s failure to recognize or correctly deal with the presence of the child. It is when the therapist reacts as if the patient were a difficult adult. This misinterpretation is the therapist’s responsibility because the patient doesn’t have a fair chance of recognizing what is happening and can only be expected to experience transference as simple reality. It is also hard for shame-ridden patients to admit to having an inner child. Transference can feel like ordinary reality to therapists, too, so those who treat these patients need a lot of knowledge, training, and experience to handle the interaction as it really is, the result of what appears to be an adult with an active, but not obvious, child in control of much of the surface behavior.
In the comments on this blog, there are far too many painful accounts of disastrous errors by therapists. I will try to discuss them here, both for patients’ awareness and for therapists.
- Brand of therapy: There are many types of therapy and not all of them recognize the existence of transference or include the concept in their vision of how therapy should be conducted. In these types of therapy, the therapist is usually seen more as a technician, brought in to correct errors of behavior or cognition. Some theoretical explanations discount the person of the therapist, creating an unnatural persona which can be used as a shield to hide behind. With such an approach emotional reactions to the therapist are not considered relevant to the transaction at hand, and, like personal issues in the workplace, should be kept out. If they intrude, it is the patient’s job to eliminate the distraction and get on with the work. Better clinicians in all types of therapy recognize that this is not a proper way to approach patients, but a number of the disasters reported in these pages show that such concepts of therapy do exist, and are not compatible with the kind of therapeutic work discussed here.Another problematic brand of therapy is the kind where the therapist is not supposed to show his or her emotions. This goes back to a 19th century ideal that the scientist was objective and had no effect on what he was observing. Hard science has abandoned that position, but some therapists still cling to it. It is not possible to avoid communicating one’s emotions. Modern Freudians have left this attitude behind, recognizing that affective interaction is part of what makes therapy work. On the other hand, there remain therapists who have been taught or believe that sharing their feelings is off limits. For patients whose problems stem from unmet needs, this is extremely depriving, and will tend to generate intense reactions simply to the repeated deprivation. It is not impossible that this deprivation might lead to doing the work of grieving for absent love and suport, but more likely, the child will simply go underground and wait for another time and place for needs to be met.An additional problem comes up in therapies that discourage disclosure of therapist feelings. The patients we are talking about are extremely sensitive to what is going on with the other person. Their lives have depended on it. When, as has been chronicled in this blog, they detect a reaction on the part of the therapist, at worst, they silently draw conclusions. At best, they bring up what they noticed and ask for help coming to a better understanding. A therapist who systematically refuses to clarify the truth leaves the patient hanging, forced to assume that their worst fears are correct. Another way to express this is that breaks in the relationship are inevitable and need to be repaired before the work can proceed. A therapist who is too vulnerable to tell the truth or has been trained not to, will be limited in his or her ability to repair breaks in the positive therapeutic alliance. A great deal of research in every school of therapy tells us that maintaining a healthy alliance correlates with a successful outcome.
- Institutional Problems: A number of accounts describe supervisors or clinics where either people or policies are not able to accept intense feelings on the part of the patient. When the therapist reports what is going on, there have been sudden discharges and legalistic blaming and rejection of patients. This, of course, leaves the patient devastated, wounded, and with no place to seek support in healing.
- The Therapist’s Inner Child: Traditionally this is called countertransference, but I would rather say that therapists have inner children like everyone else. Hopefully the therapist’s inner child’s needs are taken care of outside of therapy and there is harmony between the therapist’s child and grown up selves. This highlights what should be obvious, that therapists doing intensive therapy need to have had successful therapy, themselves. It is not even worth speculating that your therapist might have grown up so healthy as never to have been at odds with his or her inner child.
- Limited Experience: It is a great help to have a seasoned therapist who has experienced his/her own inner child and patients’ inner children before and is comfortable handling whatever might happen. Anxiety and uncertainty on the part of the therapist fuels anxiety in the patient. When sexuality is an issue, an older therapist or one of a non-problematic gender can make the work easier.
- Therapist Handling of Errors: None of us is perfect. In spite of our best intentions, we “miss the boat,” our inner children act up, we have preoccupying things going on in our lives, we get sick, we have changes in our circumstances, we underestimate our stamina or generosity. When these things intrude, they may be forgivable and it may be possible to heal the break in the relationship and the impact on the patient. What is required? Honesty. Too much disclosure may distract and make it “about the therapist,” but at least an acknowledgment allows the patient to avoid the pitfall of self-blame. The therapist’s willingness to acknowledge what happened and to feel the pain and distress it caused to the patient is the least we can do to allow healing from the consequences of our inevitable shortcomings and failures.
This is really challenging for patients, and a troubling problem for the field. So far I don’t know of an effective means of prevention. Licensing and credentialing may help keep the situation from being even worse, but in the pages of the blog, you will see that much remains to be desired. In some cases, it is hoped that sharing this document with a therapist might create a basis for dialog and clarification of therapist beliefs, qualifications, and experience.
Here are my thoughts about what patients can do: You may have been taught to ignore your instincts and override your sense that something is not right. You may have been taught to feel ashamed of your needs and wishes. But as a therapy patient it is important to respect your instincts and listen to your insides. It can be critical to take the risk of asking difficult questions and questioning things that don’t feel right. A therapist should take your concerns seriously and be open to how it appears and feels from your point of view. Therapists are used to being the one who knows, and may not really be open to questioning themselves. Answers that don’t satisfy should be suspect. Ask about the therapist’s understanding of transference and how it should be treated as a therapeutic opportunity. Ask about the supervisor and the clinic and their policies. Dare to talk about your feelings as early as you can. It is far better to cope with a treatment failure earlier than later. As I have often suggested in the blog, if you can’t talk about your feelings directly, then talk, instead, about your difficulty discussing your feelings. At the end of this primer, I’ll make another suggestion about what to do if something doesn’t feel right or if you are not making progress.
Boundaries are protective in that they tell the inner child what can and can’t happen. When they are maintained consistently, this allows the child to relax and not have to keep testing over and over. If the testing must continue, it is not as intense and distracting. Boundaries lower the level of uncertainty but don’t take away the child’s drive to have the therapist fulfill his or her needs. The child’s wishes will not and should not disappear but will be channeled by boundaries towards doing the unfinished emotional work of grieving, acceptance, and finding more satisfying ways to approach life.
Boundaries also help the therapist. Therapists need alone time, time with other patients, time to recharge their batteries. They need some privacy in order to keep their needs met. The boundaries they set are not only to protect the patient, but to protect the relationship and the work by shielding the therapist as a person.
Boundaries need to feel reliable and predictable, but sometimes things happen. Unforeseen events and spontaneous reactions can give a glimpse of the therapist as a real person. So, on occasion, can a “failure” such as the therapist getting upset with the patient. These events may be, but are not always bad. They can cause a break in the alliance, but they can also cement it by showing the therapist as human. They do need to be talked about openly, and that is the therapist’s responsibility.
Good boundaries are also what protects the patient from being used to fulfill therapist needs. Doing therapy is often a satisfying profession, but therapist needs should never override what is best for the patient’s healing process. Sharing too much information about the therapist’s life is a minor example. The seriousness goes up from there.
One less obvious kind of therapist need is a therapist’s need to be helpful and loved. Patients may yearn for “tokens” of love, tangible, but ineffective substitutes for the understanding and compassion that are the gold standard of what therapists have to give. Extra time, giving in to patient’s wishes, and making promises never to leave are examples of therapist actions that encourage expectations beyond what the therapist may ultimately be able to handle or fulfill. The result can be painful disappointment and a another hurtful break in the relationship.
Finally, patients’ inner children often want “just one little thing” from the therapist. Maybe a hug or a bit of time outside the session. These are tests, but there are two kinds, and it is not easy to tell the difference. One test is to see if the therapist’s boundaries are reliable. If the therapist bends his or her boundaries to accommodate, then the child concludes that the therapist can be coaxed into taking away the pain. From then on, all effort is put into getting the therapist to give more and to bend the boundary further. This kind of boundary failure is very hard to come back from.
On the other hand, there have been reported a number of instances where the test was to understand if the therapist is really human. Once in a while, showing a willingness to be flexible about a boundary is just what has been missing to help the inner child really know that the therapist is a human being who cares. How can you know the difference? The only guideline I can be clear about is that the more innocuous the boundary bending, the less dangerous. Otherwise, unfortunately, the outcome can either be very positive or quite dangerous. What I can say firmly is that the rationale, often used by therapists and patients, that the therapist is fulfilling some childhood need, and that once fulfilled, the need will be taken care of, is not true. This is a comforting illusion, but facing and working with the painful feelings is the only thing that will actually put them to bed.
Healing the Needs
As implied in what has already been said, there are two basic healing processes involved in successful therapy. The first, in a nutshell, is for the child to accept that major aspects of the unmet needs of childhood will never be met, but that the pain of acceptance can heal, preferably in the context of an attuned and compassionate relationship. The second, and perhaps just as challenging form of healing, is learning to override those unfortunate values and prohibitions standing against healthy feelings of anger and neediness.
It isn’t possible in therapy or elsewhere, to ask a patient to give something up without something of value to replace it. The only way the child can accept the therapist’s accurate compassion as a substitute is by experiencing that the trade-off feels OK. In order to experience that feeling, the child has to accept deprivation of primal love and simultaneously experience positive compassion. How easy is that to engineer? Not!
Probably (because things don’t always occur in the order expected) the first thing will be to get over the anger. Otherwise, doing without a substitute for primal love feels like being punished. Punishment or purposeful deprivation supported by the therapist will generate anger, which will need to heal the same way a temper tantrum heals. That is, hopefully, you get held (metaphorically in therapy) and prevented from doing harm until the rage abates and tears start. Or if you are self-punishing (for having anger and neediness) you have to give that up. Only then, without the distractions of rage and destructiveness or self-condemnation, can the patient experience having a need, not having it fulfilled, and being understood with compassion. When those conditions are fulfilled, healing takes place.
Not so fast. When rage and destructiveness are taken care of, there is still the barrier of shame about expressing or even having needs. As long as needs are not shared, they stay underground and acceptance can’t happen. So the therapy may have to overcome a lot of shame to allow needs to be felt and expressed out in the open. Then it is possible for the adult patient and therapist to help the child patient understand that some needs can’t be met, and to do so in a context of accurate empathy and compassion. With that, the two necessary conditions are met and healing happens.
Bottom line: Goal 1. Terminate destructive acting out. Goal 2. Recognize and manage need fulfillment by substitutes that prevents facing the pain of unfulfilled needs. Goal 3. Allow anger and/or shame and neediness to the surface and work with them. Goal 4. Find acceptance of therapist’s understanding and compassion as next best to having unmet needs fulfilled.
Healing Unhealthy Values or Prohibitions
Here I am talking about the prohibitions against anger and neediness. These values are internalized as part of the conscience. When we fail to fulfill the dictates of our conscience we feel shame or guilt. Shame is a sure sign that there are values involved. Usually these values are reflections of how the child experienced the attitudes of the primary caregiver. I won’t explain why here, but these values are internalized in a way that is permanent. For example, we never lose our shame about failures of toilet training. So the best we can do is actively to override unhealthy values. That means recognizing that they are dysfunctional and telling ourselves that it is OK to have needs and to feel anger. More important, it means acting as if it is OK to have those feelings. This is because acting according to unhealthy values reinforces them. Acting the opposite is quite hard to do, and needs to be kept up indefinitely. It takes work and active behavior to repudiate unhealthy values, but this can and must be done to free oneself from this aspect of the legacy of deprivation.
Moving On from Therapy and the Therapist
There has been a lot of discussion in the blog about the end of the therapy relationship. Traditionally therapists thought that “termination” had to be a final cut-off in order to reap the benefits of full independence. I think a more nuanced version is as effective and more humane.
Just as I think the inner child concept is the most accurate way of understanding transference, I believe that parents and children give us the best way to understand how therapy comes to an end. When children leave parents under healthy conditions, they don’t need to end the relationship. On the other hand, over-involvement with parents can interfere with the transition to adult life. The same principles hold with regard to therapy. Difficulty letting go is a problem to be dealt with specifically, rather than by a general mandate of complete separation. Personally, I see no advantage to closing the door. When former patients contact me I am always glad to hear from them.
Hopefully as therapy goes on, the patient will be finding more healthy fulfillment in positive adult relationships and activities. If this is not happening at an appropriate pace, then one should wonder if something is getting in the way. In my experience, patients often have a kind of loyalty to their family of origin and to the past. Completely outside of consciousness, they may hold onto wishes or yearnings for support from those who should have given it in the first place, but never will. Perhaps this is because of a stubborn (as children’s wishes are) tenacity about repairing childhood rather than moving on, or it may be due to a reluctance to let the original caregivers “off the hook.” The therapist may serve as a safe person half-way between family and the outside world. As the patient takes risks and gains confidence, relying on the therapist should naturally lessen.
When fulfillment of age appropriate needs is steadily being transferred to the outside world, the patient will increasingly find outsiders more interesting and rewarding, and the beloved therapist, a bit boring. Then it is time to move towards reducing or ending regular sessions. Sometimes it takes discussion of the idea of ending to bring out feelings like anxiety and loss, that need to be processed. Letting go is a big event, and needs to be respected like any other leave-taking. But the processing of emotions is something that, by that time, patient and therapist should have long since learned to do together.
When moving on seems impossible
In general I interpret these feelings as indications that the healing journey consisting of trading the childlike solution for the adult solution of grieving and acceptance has somehow been blocked and not completed. If that is the case, then the question for patient and therapist is how, exactly, has the inner child been able to avoid facing the dreaded pain of not having fulfillment. That is an excellent question for patient and therapist to tackle.
Earlier I promised a powerful source of help in case things get bogged down. When there is an impasse, let me recommend the technique of consultation for both therapist and patient. Bringing an experienced, but neutral third party into the conversation can often break up a logjam. Usually the answer is obvious to the consultant: Transference has been missed or, to say it in my terms, the inner child has not been recognized or given needed help. Having someone with a firm grip on the process is very reassuring for everyone and should be done more often than it is.
For More Information
I would refer everyone to the rich pages of the blog as well as to the several books I have published that cover many of these subjects. They are highlighted in the Bookstore area of the blog. To therapists in particular, let me say that I am an integrative therapist and not aligned to any one school. My way of looking at pathology and the processes of therapy is embodied in the Affect Avoidance Model, on which my professional textbook, Psychotherapy: A Practical Guide (Springer 2017) is based.
Copyright, Jeffery Smith