Unfortunately, one of the most common ways that talk therapy goes off the rails is when the therapist doesn’t recognize transference. The story I’ll tell is a composite, so please don’t focus too much on the details. (Photo by The Mighty Tim Inconnu/Flickr, Creative Commons BY 2.0, cropped)
Gene started seeing Karen, his therapist at age 35 when his marriage was coming apart. That was stressful, but his main complaint was that every day of his life, he felt others didn’t like him. Even when he knew they did appreciate him, he felt it was only temporary, and that soon he would be rejected. In truth, as he was aware, he was a competent professional with a fine, if sometimes caustic sense of humor. He was well liked, though sometimes his constant joking was tiring to others.
Karen identified herself as a psychoanalyst and explained to him that she would do her part, but that ultimately it would be he who would have to do the work of getting better. She would listen and try to help him understand himself better and become more realistic in the way he saw his world.
With that very reasonable explanation, the stage was set for failure of what should have been a successful treatment. The problem was that Gene was the oldest of five children born to a mother devoted to her social standing and a father who would soon have an affair. When Gene was almost five, his mother discovered the infidelity and separated, leading to divorce. Gene was shaken, but ready to do his best to help his mother cope. She often complained of the difficulty of her life. When stressed, she would become critical and frequently hit her son. He helped out with the two younger children, changing diapers and comforting them as best he could.
By the time he was seven, his mother had remarried a man who was not abusive, but was better at admonishing his son than relating to him. Gene continued to be pressed into service taking care of the younger ones as well as two new half-siblings.
As you might guess, Gene was harboring a good deal of resentment, yet this feeling had nowhere to go. If he complained to his mother, she would respond with anger or tears over how hard her life was. His father would sternly tell him to bear up and show how strong he was.
So imagine what went on when Karen told him that he would have to do the work of getting better. Immediately, he reverted to his old ways of coping. He dutifully accepted her word and admonished himself to work hard at doing his part in the therapy. He was unaware that a younger part of himself was not at all happy with this arrangement. His healthy anger remained buried without an outlet or pathway to healing. Now both he and Karen wondered why he continued to experience the intense feeling that no one liked him.
As time went on, he had spontaneous thoughts that he would like Karen to offer more concrete help. Dutifully, he reported these thoughts and was told once again that psychoanalytic therapy didn’t work that way. With his intelligence and resourcefulness, he should be able to find his way without infantilizing guidance from Karen.
What Karen had missed, was that his wishes for concrete help were the only clear manifestations of the precious transference that her therapy was designed to bring out. Her abstaining from giving guidance or feedback was specifically aimed at frustrating whatever childlike wishes he might have so they would be expressed in his free associations. The technique worked. His transference was manifested as a re-enactment of his unmet need for parenting. Perhaps if he had insisted, she might have realized that she was seeing transference, and might have been curious about his wish for more help. But, Gene, already accustomed to grown-ups who were skilled at waving off a child’s demands, quickly reverted to his dutiful posture and joking manner.
A Common Tragedy
This failure of therapy should not have happened, but the truth is that transference is easy to miss. It doesn’t come with any flags. It doesn’t even feel special. It looks and feels like life, like reality. Part of the reason is that transference feelings and wishes are presented in the most normal looking way possible. Why? Because no adult patient wants to appear childlike or make immature demands. So patients do their best to ask only for what seems reasonable and justifiable. Gene’s request for more concrete help didn’t seem unreasonable, but was clearly not within the scope of what Karen considered good technique. She took his wish at face value, focusing on what she could not do rather than what it meant.
What should have happened is that Karen should have noticed a tiny bit of insistence, a hint of strong feeling. Those were the indications that she should take notice. His thoughts persisted and he mentioned them multiple times. That, too, should have aroused her curiosity.
How can patients and therapist identify transference? Any of those three things could be the needed hint: A touch of strong feeling, repetition, or a suggestion of something a bit childlike. Another hint was that Gene’s initial complaint didn’t get better. Any of those modest hints could have alerted a therapist to the presence of transference. Unfortunately, both Gene and Karen were lost in the midst of the therapy. Had they sought consultation, an outsider would have been much more likely to see what was happening.
How Transference Can be Handled
If Karen had taken notice, what would she have done? If she had asked if his thought might contain a message, Gene would probably have denied any strong feeling or important wish. Karen would have had to insist. If Karen had showed interest and persisted, that would have set the stage for spontaneous thoughts to keep coming, eventually trumpeting their message. Of course, as his anger and needs became more insistent, he would first have resorted to more ironic humor and joking behavior. Perhaps only with some scrutiny of this behavior, would his spontaneous thoughts have revealed their real origin. If the message had been noticed and his covert expressions of anger challenged he might then have been able to face and process the intense anger and frustration at his parents’ refusal to honor his feelings.
At the point of realizing that his anger was not really about Karen, he would have been able to experience the intensity of appropriate feelings attached to the real deprivation of his early years. He and Karen would find compassion for what he missed in childhood and help him seek healthy fulfillment for those needs that could be met in adult life.
Is That the Only Way?
An alternative, (one I would be more likely to follow) would be to listen carefully to the wishes expressed and not refuse on principle to provide concrete help. If the needs were appropriate, say for referral or information, I might simply agree, knowing that the young needs lying behind his requests would inevitably return later with more intensity and in a form more obviously related to his childhood. In general, I think that being as genuinely helpful as possible actually gives energy to the therapy. That doesn’t mean infantilization with aid that is desired but not needed.
Either way, resolution begins when the feelings come to the surface and can be identified as related more to the past than the present. At that point, facing feelings in a context of empathic connection is what allows them to be resolved, perhaps not overnight, but step by step. What about therapies that don’t recognize transference? Of course transference happens anyway, regardless of the brand of therapy. Childhood wishes, if ignored, go back underground, searching for the next opportunity for fulfillment.
How can we improve therapy for everyone?
Educating therapists and patients about transference and its subtle tipoffs can help. Talking with neutral third parties and seeking consultation are powerful ways to prevent failure. If a therapy that is important to you doesn’t seem to be progressing or questions remain, the SPSE, Scarsdale Psychotherapy Self-Evaluation, (under the resource tab on this site), may help to highlight problem areas.
Is this a helpful kind of post? I would love to hear your own stories of transference missed or not, from therapists or patients. Our community can be a source of clarification for those who are stuck.
This person did eventually question his therapy and started with a new therapist. So far, they are moving along well with a clear understanding of how understanding and compassion for the child left behind are the key to letting go of dysfunctional patterns of life.