Therapy Story: Missing A Transference

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.

Follow-up

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.

7 Comments

  • Hi JS,

    This article is helpful, yet a bit disappointing. From my own experience in therapy, I can completely agree with you on many moments that seem insignificant are tangled roots of transference. I think, at times, the language of therapy, that is, its phrases, its wording of unconditional positive regard, its selective disclosure of support, its invisible hand holding… becomes confusing for clients. I think when we become confused, we, clients, lose our ability to communicate or articulate the “deprivation of childhood” we experienced from the past and/or in that exact moment. Possibly those states of confusion dissolve the safety we feel with our therapist? I think the language of therapy and our translation of its messages, at times, shifts both the client and the therapist away from seeing transference. This has been my experience when I have reflected back on sessions and have come to the belief that some sessions were missed transference exploring opportunities. What is disappointing for clients, I think, is that those missed moments build upon themselves, potentially causing therapy to end, either by the client or by way of the therapist. I think both clients and therapists are hurt by the lost opportunities.

    Snow

    • Dear Snow, and other readers, I’m a bit new to storytelling and hadn’t realized that I was leaving my readers in a bad place. Fortunately, the story has a much happier ending, which I have added as a “Follow-up” to the post. Thank you for your feedback.

      In addition, you point out how the language of therapy can confuse. You are so right. One of the arts we therapists need to work on is the ability to communicate what we see happening. The single best way I know to do that is to help us both picture how the world looks and feels to a child. This engenders compassion, rather than judgment and shame, and compassion is the main agent of healing.

      JS

  • Very interesting read and I definitely appreciate the addition of the “Follow Up.” There are two sides to the coin of transference, though. Firstly, by encouraging transference one can work through issues in a client’s life quite effectively. However, this is not recommended if you cannot follow through with working through the transference as well. It is important to recognize transference, positive or negative. In the absence of recognizing and acknowledging it, you will probably miss an opportunity or find yourself against a wall.

  • Hi, From my experience in therapy, I agree that it is very important to identify transference and that it can be easy to miss. Missing a transference could probably happen sometimes due to too formal therapy language, as Snow suggested, but I think it can happen even when a compassionate attitude is present in the therapy room and when simple language is used, that resonates with a client’s inner child. Transference can be easy to miss because as Dr Smith noted, it looks and feels like reality, there are no clear cut signs that it’s transference that’s happening; and also adult therapy clients don’t want to appear childlike and make immature demands as this can be very embarrassing and threatening to one’s ego. So it’s important that therapists, and even clients, be on the lookout for transference, and I resonate with the pointers in the article on what can signal transference – a touch of strong feeling, repetition, or a suggestion of something a bit childlike. I remember in my own therapy how every now and then I would bring up a particular wish/demand (the same thing every time) and my therapist, though well intended, wouldn’t recognize it as transference and would respond with “it can’t happen because of the boundaries of the therapy relationship”. This would silence my wish for a while, but of course it would surface again several months down the road since it was something deeply buried in my unconscious and could have only been resolved if looked at more closely out in the open.

    My therapy was long term, and my therapist was kind and compassionate and cared deeply about me and my inner child, and I did achieve a lot of growth and healing, but there were several areas where transference was not recognized that remained unresolved for me beyond the termination of that therapy. So while in some therapies not recognizing transference can easily lead to termination and failure to produce a positive result, in other (longer) therapies, in which things are otherwise progressing positively, not recognizing or addressing a transference might not necessarily lead to failure of the therapy, but it can leave the client with some unresolved issues that will probably need to be worked on at a later time or in another therapy.

    Great post, and educating therapists and clients about transference and its subtle tipoffs can potentially really help.

  • Why don’t therapists actual mention the developing/focusing of and subsequent analysis of transference as a key element in the kind of therapy they are doing!?

    If it is a key part of the “active Ingredient” in effective therapy, I think it is definitely part of a consent process. I feel like therapists wouldn’t think people would want to do therapy if they know how it worked, and then obscure the process until people are so dependent on therapy that their choice is to stick with it or leave much worse off.

    But why assume people couldn’t engage, knowing a bit about the process? They may be more prepared to engage with these issues if they are more prepped to handle them. They may be interested in this process, and while it may still be uncomfortable to experience, the experiencing transferential feelings that were talked about during consent/evaluation might be really validating and hope-inducing that therapy is working as intended.

    Experiencing transferential issues when it is NOT a way someone was interested in engaging in therapy can be very upsetting, trust eroding, and therapy ending. This could extend to future help-seeking behaviors and experiences of mental health professionals. I know that fears of therapy not getting started keep therapists from actually explaining transference to clients, but it is a right of clients to have some understanding of what they may be getting into.

    Therapy is not helpful for everyone, and potentially unhelpful to some. These are just facts. It’s important for clients potentially starting a therapy process to have a better understanding of the process before they consent to participate, it is the responsibility of the therapist to provide that understanding. It is also ok if clients, after learning more, are uninterested in such work and decide to pursue different kinds of help an for their therapists to support them in that process. That is a far more benign and trust-increasing series of actions than feeling duped into a destabilizing process and the resentment that brings.

  • Thank you for this post. I left a therapeutic relationship last June. One month lair I began the process of communicating why. I was mortified most of the time in the relationship. She knew this. I worked through a lot of the fear. It was strongly based in having to ask for a clearer sense of how she gets me and my world, and verbal reinforcement. To me, those aspects seem like a “basic” aspect of therapy, but apparently it is not the case with all therapists.

    I was severely shaken by the experience, but I had a part. I chose to re-enter the relationship after having left once, feeling that perhaps the very feelings that I was experiencing towards my therapist could be the groundwork, and to work through it with her was a true, in the moment experience, rather than a mental experience of speaking about an outside situation.

    My perception is that she did not know what to do with what I brought in, and I began to feel my impact on her. I began to feel more desperate to receive the reinforcement and seeing I wanted. It was excruciating, like a rat in a lab going for drugs. Intermittent reinforcement was what was taking place.

    I appreciated reading this post, it gave me some validation of the experience. Its amazing to me that more than 6 months later, a part of me is still processing it. I feel that the therapist was never able to recognize what truly happened, acknowledge it, and make it right. In this way, it has felt unfinished for me.

    Be that as it may, I have done the best I can, with other support, to work through it, and give myself as much of what I wanted now.

    Thank you.

    • Dear Renee, having perspective is an important part of the process of healing. It is good to see that, along with young feelings of yearning, you have an adult view of what happened. Keeping both points of view open is how we heal. Having support is a big help in keeping the adult perspective, too, as well as feeling you aren’t alone. Bravo!

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