For the therapy consultant there is usually one easy answer. When therapy is stuck it’s a transference problem. Yes, there are exceptions. Enabling, whether from family or the an institution, can guarantee that no change will happen. I’m sure there are others, but in the vast majority of cases, the problem turns out to be the patient responding to a past reality and unable to see the true situation. In this post, we’ll look at some of the more challenging ways this can happen.
First, let me explain why, this time, I am using the term “transference.” I have championed the concept of the “inner child” as an alternative, precisely because it takes the emphasis away from cognitive distortion. But in this instance, recognizing the cognitive mismatch is often the key to resolution. Here, I’ll use both concepts as appropriate.
Need for the antidote
Whether the final mechanism of change is memory reconsolidation or extinction, the critical element for resolution is the antidote. By that, I mean a piece of new information or experience that surprises and contradicts what the inner child knows and is responding to. In treatment we hope that both the old way and the new will become activated and available to consciousness at the same time. Suddenly (we hope) there will be an ah-hah moment and the new reality, obviously correct, will put the old in perspective. A bubble of illusion will pop, and the transference distortion will be abandoned. Unfortunately, it’s not always that easy.
When the bubble doesn’t pop
Looking at the various ways a transference can be resistant to change, most happen when the antidote, the new information, is not accessible or not acceptable to the reactive part of the patient, that is, the inner child. Here are some examples of transference problems that can lead to a stuck therapy.
- The old perception is deeply nonverbal. Words describing the new reality simply don’t touch the right neurons. Clinical experience and the science around memory reconsolidation both say that a therapeutic collision needs to happen between new and old information in order to bring about a permanent resolution. The essence of such a resolution is that inputs formerly appraised in a certain way are now interpreted differently. They no longer trigger the same core emotion, and that emotion no longer sets off the same maladaptive response. We all know that intellectual knowledge alone fails to produce this kind of result. Both pieces of information need somehow to be active on the same playing field at the same time.
Usually for the clinician, this means that both views of reality need to be affect-laden. They need to be accompanied by feeling and the bodily changes that make affect more than just feeling. That’s how we know we are dealing with the right kind of activation.
This raises an interesting question for future research. Why is consciousness needed and what is the role of affect? Is conscious affect simply an indicator of the right kind of activation or is there some intrinsic reason why consciousness is necessary for change to take place. For now, I’m voting for the former. Perhaps instances of enduring change taking place without insight would be evidence that consciousness is not, in itself, necessary, but serves only as an indicator.
- The other person’s response is seen as confirmation. Here the patient acts in a way that triggers the significant other (or therapist) to respond in a way that is then interpreted as confirmation of the expected negative motivation. “Your failure to support me proves that you are against me.” In reality, the other’s response might be the only one available to a healthy partner: disengagement from the patient’s subtle aggression.
Guessing others’ inner motivation is exceedingly inaccurate. Perceived negative motivations are also a source of some of the most powerful conflicts between partners. When we have no way of knowing, it is human to fall back on deeply embedded schemas. That’s the mechanism of transference. So the patient thinks he is observing a trait, a static characteristic of the other person, when, in fact, what he sees is a dynamic response to his own behavior.
This kind of distortion is very hard to dislodge for several reasons. First there is confirmation bias. It’s what, the patient “knew all along.” Awareness may have been suppressed, but the misperception has been incipient from the beginning. Then there is the potentially positive instinct to re-enact unfinished business from the past. The patient instinctively interacts in such a way as to re-create unresolved relationship problems from long ago. This is why transference is so valuable in therapy. As Freud pointed out, the distortion that seems to thwart therapeutic progress is actually the vehicle that makes resolution of core problems possible.
What can we do in such a situation? Telling the patient he is wrong doesn’t work very well. The unconscious mind doesn’t have a place for negatives, so this truth doesn’t even compute below consciousness. Furthermore, the way it does compute is to confirm the therapist’s negative intent, reinforcing conflict with the patient and a break in the alliance.
What we need, instead, is a positive antidote. We need to elicit the patient’s empathy in understanding the loving motivation of the significant other. It can also help to elicit empathy towards the patient’s own inner child, who is still trying to cope with the past. Even then, the job is not an easy one. In the end, the emotional work to be done is not simply to correct an error, but for the patient to discover a new solution to a centrally important but still unresolved problem from long ago. Using the earlier example of a disengaged partner who is seen as “unsupportive,” the antidote would be knowing that there actually was an unsupportive other, but that was long ago. Following confirmation of the archaic truth, the patient may be ready to open his eyes empathically to the real characteristics of a partner whose response was motivated by love and a desire to save the relationship.
- An additional twist on the above: The therapist’s role as helper and teacher can, itself, be compromised by transference. What if the primary caregiver from long ago would characteristically rationalize her depriving behavior by explaining that it was for the patient’s “own good?” Imagine as a therapist that you try to explain or “interpret” what is going on. Now you sound just like the parent. The patient instinctively sees you justifying your abdication of duty and blaming of the victim. As you come from your position of observer and use of metacommunication to clarify, you step right into the neglectful parent’s shoes. The patient’s observing ego disappears in an instant and you are left with a child who knows only that you are trying to blame her for your own failure.
I don’t have a great solution for this one. I have slogged through many angry sessions to the point where anger, originally aimed at the caregiver, has dissipated. The adult patient even agrees with my interpretation and realizes that the answer for her, the adult, is to go ahead and live her life instead of waiting for me to reform myself. But as soon as I open my mouth, the inner child still gets triggered, the observing ego goes to sleep, and any attempt to foster change sets off the same negative transference.
- Acceptance must come last: Unfinished business from the past is not just a matter of accepting today’s reality. What about the case where the inner child, at 11, was forced into premature adulthood by the parents’ failure to manage their marriage. He became a “good boy” and did what was expected. In fact, being a good boy became part of his values and identity. But all that time, a healthy revolt was brewing inside. At last, in later adulthood, as time was beginning to run out, he found an opening. The girlfriend seemed infinitely supportive of his youthful energy, while his wife seemed to embody everything repressive, just like the mother who robbed him of his childhood. The dynamic was the same as #1 above, but the bubble of transference didn’t pop. The intensity of the transference pattern seemed too powerful.
In fact, the problem was that the antidote was wrong. At first it seemed obvious that the antidote was for the patient to accept the new information that the wife was actually a loving, supportive partner and what appeared to be her repressive personality was actually a desperate attempt to deal with his bad behavior. The problem was that acceptance that truth was putting the cart before the horse. If he accepted the truth about his wife, then he would have to give up his youthful revolt. It put being a “good boy” ahead of the inner child’s wish to glory in childhood and taste the fruits of a time when parents might have shielded his innocence from the need for responsibility. Until his youthful rebellion gains recognition and is fully honored, if not acted upon, the processing of unfinished business will remain incomplete. In fact, it can’t even start. The need to accept adult responsibility will have to wait. Until then, admonishment to do the “right thing,” whether it comes from the wife, the therapist, for from the patient, himself, will continue to trigger for the old transference.
Perhaps this is the reason why patients discussing this website’s posts on “attachment to your therapist” so often report tremendous difficulty finally letting go of the therapist. All the therapist has to offer is the pain of loss. Accepting that empathic understanding is most of what the therapist can give is too painful, so the inner child waits and hopes. Attachment to the therapist needs to be transferred to someone in real life who actually can give more, and that is truly challenging. The difficulty is all the more dramatic when, as often happens, the therapist is idealized, while real partners, who are in fact better known, have clear limitations and flaws.
What’s the “Take Home?”
Transference problems are the essence of psychotherapy and the cause for most of our failures. What they really represent is unfinished business from long ago, seeking a resolution in the adult present. The simple truth is that children, whether young or “inner,” naturally assume that the solution is for the grown-up to change, while therapists seem to insist on the radical and misguided notion that the patient is the one who must do the work. Given this reality, we need to be very thoughtful, putting ourselves in the position of the inner child and imagining a genuinely positive pathway to healing. We can’t expect to take something away without first giving. We need to think of the antidote as one or more steps leading to the patient’s readiness to embrace an entirely different and better solution to a problem that once was truly insoluble.
Jeffery Smith MD
Photo: Vitolda-Klein, unsplash.
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