Attachment to Therapist: A Primer

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.

Countertransference Problems

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

Preventing Disasters

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.

Version 2/28/18

Copyright, Jeffery Smith


  • Your work is genius. I hope one day you become a trainer of therapist. I am sure many therapist get locked up and the key thrown away because they themselves didn’t know how to deal with a “pretty” girls inner child. When the truth is an inner child is dealing with another inner child. We are all human. Therapist NEED your wisdom and guidance. You have a gift. Your wisdom is second to none.

  • This is such a helpful and very clear explenation. Thank you SO MUCH.
    I just started studying MSc in PersonCentred and Experiential Psychotherapy and recognised something what happened to me with my previous therapist and I am hopefully just starting to get over it with help of someone who is a lot more experienced.

  • Hello Jeffrey,
    I have one comment and one question. My comment is in response to this: (please let me call you patients, as that is what is most natural to me, and in no way disrespectful). Your book and blogs have been very helpful to me and I will read what you write whether you call me a client or a patient, just as I read books and articles from an earlier time that refer to me, a woman, as “man” or “he.” But I would prefer to be called a client because that puts us on equal footing. If you call me a patient, in my perception it means that you see me as sick. That might feel ok if I had cancer but it does not feel good in the case of mental health. The word implies a power differential – I am the lesser, and you are the greater, because of special knowledge or training, a certain expertise that you claim. That seems to me to be a throwback to the paternalistic and holier-than-thou attitudes of a century ago. If I call a computer geek to come fix my computer problems, he does not call me his patient! That would feel awful. He’d be lording his special knowledge over me in my vulnerable, needing his help, situation. Humility calls for client, not patient, in my opinion. We’re all in this being human thing together. No one has all the answers. Client signifies a working relationship between equals, a provider and a consumer of services.

    And that leads me to my question. Because of my upbringing, my relationships have followed a pattern – me taking care of the other person in return for them liking me. I’m becoming very aware of that pattern as a result of therapy, and some of my relationships are changing as a result. I’m not willing to put myself second. I’m not willing to be “understanding” if someone is treating me badly, “Oh he had a difficult childhood,” etc. Recently I called an old friend on his reluctance to pay me back some money that I lent him years ago, realizing that a “friend” would actually pay me back. I wonder if this relationship will last as I start standing up for myself. Ok, sounds healthy, right? But then I began to think about therapy and how very expensive it is (I don’t have insurance) and how the minute I stop paying, my therapist will no longer “be there for me.” She acts like a mother sometimes, she acts like a good friend sometimes, she behaves like a professional, I trust her boundaries. She acts like she cares about me, and I believe she does, but I know that the minute I stop paying her it will all end! So it feels exactly like all the other relationships where I sacrifice something in order to get someone’s love and attention. I will bring this up with her next week, but I wonder if you can offer any insight into my conundrum.


    • Hmmm, Sarah, Your point about client is well said, though I think by the content of what I write, our equality is clearly there. It feels strange for me to change a professional tradition that goes back quite a few centuries, and to do so after over 40 years of following that tradition. So for me, the word has evolved to a different, non-paternalistic meaning. I can see, though, how it rubs you the wrong way. I guess the issue relates to your other question about payment.

      In truth, the relationship is equal but not symmetrical. A Geek Squader “takes care of” her clients, and they pay money for her time. Your therapist “takes care of you” by putting aside her emotional needs and attending to you alone for a period of time. What equalizes or balances the relationship is payment. That financial arrangement justifies (makes balanced) an unusual emotional relationship, not unlike that of mother and child, where one person doesn’t have to “take care of” the other. It is asymmetrical, and that is what makes it work. If therapists were to derive their emotional needs from their relations with clients, as friends do, then the relationship would be symmetrical, but you wouldn’t be able freely to say what you feel or think. You would need to be tactful or risk damaging the relationship. That is different from your lending money. There you are “taking care of” a need of your friend, and your friend would be expected to feel an obligation to “take care of” you back. The friend didn’t and left an imbalance. I hope that is clarifying. JS

      • Good answers. I have to let the second one sink in, see if it satisfies all the parts of me, but logical mind is satisfied. As for your first answer, I was thinking, but didn’t say, that the content your writing does indeed contain a very definite, comfortable, and encouraging feeling of equality. And a client really does have to be very “patient” with the process of therapy, so I’ll think of it that way. I’d like to hear more about how the word has “evolved to a different, non-paternalistic meaning for you.” Sometime, if you ever feel like writing about that. Thanks again.

      • Having sat with your responses overnight, I find something still sticking in my craw. You wrote, about using the word patient instead of client, “It feels strange for me to change a professional tradition that goes back quite a few centuries, and to do so after over 40 years of following that tradition.”

        But you had no trouble answering my question and using the pronoun “she” in referring to the Geek Squad person, even though most Geek Squaders are not hes, and even though the literary tradition of the generic he goes back quite a few centuries. You may have written papers in graduate school using only “he” for a pronoun – this change has come about in my lifetime, I’m guessing yours too. So what’s the difference? That’s a rhetorical question – I don’t need an answer. I’m just asking what your attachment to using a word that makes some people uncomfortable is really about. Maybe there’s more to it than what you’ve said.

        • Oh my gosh, I just realized what this is about for me! I don’t trust anyone. I can’t let a therapist be an expert. I don’t want to give them any power. I can’t allow myself to be a patient. I have a horror of the medical profession – I never go to doctors. I am too proud (ashamed, scared) to admit how much I do in fact want and need help. Ah, maybe now I can surrender to this process a bit more. 🙂

  • This is so beautifully and informatively written and with such compassion for both the therapist and the patient. It’s personally very helpful to me, and I imagine will be extraordinarily helpful to anyone who stumbles across it via google searches.

  • An important piece of goal #1 has been omitted. Acting out will cease when the child feels safe. The first goal must always be to build an environment/relationship of safety for the child part (Judith Herman). It is not necessary to focus on the acting out, but rather on the safety needs that underlie the behaviors. Creating safety leads to containment, the holding environment (Winnicott).

  • “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 also hard for shame-ridden patients to admit to having an inner child.”

    I was finally the one who brought up my attachmentv(in an email) to my therapist. He was okay with it– he said he understood it and we discussed it in person for a red hot minute. But that is it– we’ve never talked about it again. I’m completely full of shame on this one. I cannot bring it up again–right? Or is that the only way I will ever be able to let go, do you think?
    Right now my thoughts are, I’m just gonna quit going and see if he even notices– which I know he probably will. But then my true “fear” is, that will be that and I’ll feel pain and he’ll feel little and that will just suck. He’ll move on and not contact me and I will know that although he cares he really didn’t care “enough”. All sounds pretty childish…

    • Dear TLC, I believe that acting as if your attachment is shameful has a way of confirming the foreign belief that it is not OK. Perhaps showing the post to your therapist could be a help in opening up the subject. It is very sad to decide to move on, leaving in place an attitude against oneself that came from neglect and should not be allowed. JS

      • So, a crummy dad who never really seemed to love or even like me, a crappy uncle who took advantage, and a mom not able to stand up for me- yup we’ve talked about it, and talked and talked. I’ve wept about it. It makes me understand the longing for a father figure and I know how not having one can screw up some. I understand better how all of that crap shaped me. But…I have been going to see him for nearly 3 years. I should be done–
        I know you’ve probably answered this a million ways, but I am just trying to figure out again how discussing my feelings for him and my longing for him to be a part of my “real life”, is helpful.

        Plus, whenever we end our sessions lately he says, “Call the office to make another appointment, if you want to.” I know I am so sensitive and he is probably just letting me know I am in control, but it bugs me. He seems to be cutting me loose– maybe. Of course he’ll never do it. I’ll have to be the one, but I think he thinks it is time and I’m too attached. So that’s why I’m thinking of stopping appointments– it’s totally a test. Mr. Therapist…do you really care???? But even just writing about quitting makes my stomach go flip,flop, glug.

        Maybe I just try a 6 month hiatus, which sounds like like hell to me.

        • I’ve noticed that inner children are quite action oriented. They tend to think that the answer is taking some dramatic action that will solve everything. Usually it ends up kicking the can down the road. A manipulation to get your therapist to indicate that he cares is not going to solve the problem because the next question is, does he REALLY care. What really makes the work go forward is both therapist and patient asking why it is so hard to accept the ample evidence that he he demonstrates “good enough caring.” Is it because of a belief that one has to be perfect for anyone really to care? Is it protection against the devastation of learning that someone important actually did not care? The real answer is more likely to be deep in those kinds of questions. JS

          • Interestingly enough, I have that “does he REALLY care” thought pattern a lot, in nearly every venue. For example, at work I’ll do something well and I will think my boss believes I am doing a really great job and I am really valuable to him, but then a day or two later I am sure he thinks I suck. At home I never really believe my husband really cares about me or wants me and if he was just a less honorable man he would have ditched me by now. There are other examples, but I’ll leave it at those. I’ve never thought about it like that before.

            The perfection piece also rings true, but my therapist and I have explored that one. No matter how good I was, no matter what I achieved, no matter how well I did in school or in sports I pretty much went unnoticed at home– particularly by my dad. I kept thinking my next accomplishment would be the key, but it never was– not when I would be the best on the team, not when I graduated with honors from college, not when I got married, not when I got pregnant with my first child. Nothing… and then he up and died and all my chances to prove myself were gone.

            I wish I could address my neediness for my therapist’s attention with my therapist. I wish I had guts to bring it up– or better yet I really wish he could be the one to bring it up. I guess if neither of us does nothing will get solved and I will stay stuck. Then again, if I stay stuck I won’t have to say good-bye.
            Just kidding–sorta.
            One thing that does make sense is when I start to think of this inner child as being a separate being from me. I don’t like this inner child so very much. She makes me quite embarrassed by her neediness and her craving for attention and her uncertainty about her looks and her abilities and… the list goes on. When you wrote about my inner child in the third person saying “inner children are quite often action driven” that style of writing kind of helped me look at this child from a more neutral position instead of always judgmental one. I hope that is healthy and a good idea.

            It just feels like I have been mulling this over and over and over and talking about it over and over and over with my therapist and although I have grown in three years time, I am also ready to not need my therapist or at least not have that constant desire for him to be my dad. I just wish I had met him in a different capacity, like as a neighbor or family friend– then I could always have him in my life. I’ve just never really felt like I have ever had an adult male figure in my life that really cared or felt a need to protect me. Sometimes I think that if I just knew my sessions with my therapist weren’t SUPPOSED to end, then I could just relax and go with it. I keep trying and failing a bit.

    • Hi TLC,
      Thank you for sharing your experience with us here. The very thing you are talking about happened with us, too, and I felt a tug at my heart. We, too, brought up the issue of attachment to our therapist after a long hiatus from therapy. We discussed it in one session, and felt satisfied for about a day, then swollen by shame storm. Felt the need to talk about it again, but felt like it was not acceptable to bring it up, like you. It took some time to muster up courage, but we did it again….. Then again for the third time. For us, each time discussion deepened, and we leapt different insights and learned something different. Just wanted to share our experience. Thank you again for your sharing.

      • Hi Echo,
        Yes! Exactly! Being swollen by the shame storm is a great analogy. The first time I brought it up it was terrible and then, you are right, I felt great for about a minute and then it was exactly how you described it.
        Then yesterday I met with my therapist after sending him a sorta, kinda generic email about my still constant search for a father– something I have been doing since I was around 10. He actually started to ask me some really pointed questions about what kind of men I looked for in a father and I shared with him how it usually happens. I told him that I usually pick men who are authority type figures, like ministers, doctors, bosses and that I usually get so incredibly embarrassed because I can feel myself trying to push my way into their lives too much–aka get too much attention. Sometimes I can get myself to step back and stop acting too needy around a male figure– like sending too many texts, or emails or trying to be in the same place they might be, because it is so very, very embarrassing. If I feel I overstep at all, I then avoid the person completely. But I still occasionally will send one more email or text as a test…to see if maybe they are really willing to fulfill that dad role; they always fail, always– of course.
        My therapist was very interested in this and asked me if I was going to start testing him– this question confused me a bit, but of course I didn’t ask what he meant because I was too embarrassed my the whole exchange. Even after he told me not feel ashamed and that what I was feeling was normal for someone who had experienced what I experienced, I could just not really continue the conversation. I just stopped talking.
        I am thinking that I am going to email him and tell him that we HAVE to please continue the conversation next time. I think…
        Echo, you say that you gained different insights and learned new things when you talked about it, maybe you can share what those were (if you feel comfortable doing that, if not that is perfectly fine too).
        I really just don’t know how talking about the attachment is going to help. It seems pretty black and white. I am attached–I shouldn’t really be and now what?? He is not in my “real” life and most likely never will be. The really cruddy part is that I feel that if I had met him in another capacity– family friend, church, or whatever, I could keep him around forever. Sometimes I think he feels that way too, but that may very well be wishful thinking on my part.
        My stomach hurts having to have another conversation about all of this with him. He has helped me figure out so much important stuff and part of the reason my stomach hurts so much is probably because I realize that talking about this probably marks the beginning of the end.

  • What a great post. It helps to explain so much about attachment to your therapist in easy to understand language. Thank you.

    One thing I am confused by however is where you write about sexual feelings for a therapist. You say;
    “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” I am a heterosexual female and I have had intense sexual feelings for my female therapist. Whilst my childhood was certainly unpredictable with verbal abuse and neglect I have no history or memory of any form premature exposure to sexuality. This paragraph thus confuses me…Is it wrong and I disagree with you or am I simply not remembering something?

    • Dear Janet, That’s why I hedged, “Usually” and “Most likely.” There is no way of knowing. In my experience, creating a safe place in therapy ultimately (usually) leads to the truth becoming clear, so I don’t think that digging for memories or worrying about knowing is helpful. One can ask the question whether, if something did come to light, one might be ready to face it. If not, then it is no surprise that memories have not surfaced. JS

  • I just came across your blog. Thanks for all
    of the information. I am currently attached to a former therapist that I have been emailing. He has retired, but has been trying to help me. I feel like I will die when I can’t communicate with him. I don’t have any sexual feelings toward him, only platonic. I wish he was my father. It all makes me feel miserable and hopeless.

    I have a diagnosis of Borderline Personality Disorder. My question is, does this largely occur in people with this diagnosis or does it vary?

    Thank you

    • Judith Herman was the first to point out that “borderline” usually means trauma survivor. Unfortunately the term has gathered up a lot of negative associations, which is one reason I don’t like to use it. The other reason is that labeling doesn’t help, while working to understand what is going on is different for each individual, and is what really helps. So I usually skip the label and want to get to work on the unique experience that led to whatever problems we might be seeing. And by the way, the people who have commented on this blog mostly only show behavioral characteristics. The real, original concept of borderline were people who had trouble seeing themselves or others as “three dimensional.” They could picture people who are all bad or all good, or who switch back and forth, but had trouble taking in the nuances of humanness. That can be a real issue, having to do with early development, but is not at all as common as people who feel intense needs for something in the realm of what I like to call primal love. JS

  • Dear Jefferey,
    I am currently in therapy and have several significant issues to work through. I have been working with a therapist for about 10 sessions. We procured a contract identifying 5 issues that we would work on. We are on issue 5 of 5 and I’ve not heard any further talk about a formal diagnosis, or even some frank discussion about what the therapist thinks is going on with me. I thought at some point I would receive a diagnosis of some sort. I have asked the therapist about my diagnosis directly several times and I have gotten the response that the therapist “thinks my case is more complicated than that.” (‘That’ being the ADHD diagnosis) but with no further clarification.

    Initially I sought help for what I thought were attention issues and general scatter-brainedness moreso than usual. I think somewhere in my medical paperwork it mentions that I have ADHD inattentive type in addition to my 20+ year old diagnosis of dysthimia. However, my sense is that there is more going on with me, and that I may not even have ADHD. I suspect that the ADHD label was an easy diagnosis to use in order to secure insurance funds (not for shady fraud purposes, but for the purpose of trying to move things forward to provide me with treatment.)

    Knowing that I’ve directly asked the therapist several times and gotten the ‘your case is more complicated than that’ response, and assuming that my therapist is being straight with me in not clarifying the diagnosis for reasons I cannot know, is there ever an instance or set of circumstances that a diagnosis might be withheld at least initially, or that a diagnosis is withheld for fear that incorrect diagnosis may damage the patient in some way (e.g. not being able to get X treatments in the future, impacting the patient’s qualification for future insurance benefits, etc.)?

    Thanks for any insight.

    • Dear Allen, diagnosis has been co-oped by insurance and gives very little useful information. “Formulation” is a technical word for the therapists understanding of how problems came about and what is making them stay. Or you can ask in plain English what he thinks is going on and how you might get better. A good therapist might have only guesses but should be willing to answer. Personally I don’t believe that being mysterious has a place in therapy. JS

  • I love this blog and comments and to realise I am not alone is unbelievable. I have a question though which has tormented me all my life. I have been in therapy twice and now referred for a third time. It is exactly as you describe – like a seed that gets watered. I have these issues you describe, my attachment to my therapist a few years ago now was torturous- but I was never abused or neglected or in care. I know my Dad did not really want a child and my mum struggles to show emotion and I think I was left to “cry it out” but they both loved me. I am angry that my inner child thinks it has the right to feel so needy when nothing bad ever happened to me. It makes me feel ashamed, embarrassed and melodramatic. Why do I hand this attachment problem when nothing has ever happened to me?
    Also – should I go back to therapy- I have been referred for a phobia but it has triggered my inner child and as a result I feel like I am going mad and I’ve taken diazepam to help calm me down. I never want to go through what I went through before again but I’m scared it’s too late, the door has been opened and the seed is watered – help what should I do?

    • When children are upset they have a reason and need help, not blame. I think inner children need to be listened to with compassion. Not necessarily left to act as they want, but treated with understanding. When treated that way, they will do their best. JS

  • Thank you for this article.
    May I ask, when the therapeutic relationship does go wrong can it be fixed or is it time to move on? My Therapist possibly gave too much, then firmed up the boundaries we have been talking lots and they have taken full responsibility for what happened. If I move on this attachment pain will surely just end up in another relationship but if I stay I think what is being said is that we won’t have to say goodbye when retirement happens our relationship will enter another phase.

    • I can’t quite make out what your situation is, but in general there is a very important principle: working problems out in the relationship with your therapist is the same as working them out with your family of origin. Said another way we engineer a re-creation of our unfinished business from the past in our therapy, and working it out there is the way to heal. So definitely, when there is a problem with a therapist, if there is any chance of working it out in the therapy or with the therapist, that is way better than giving up and carrying our issues to another relationship. JS

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