What therapists can make of their feelings within the session

At least since the seminal paper on countertransference published by Paula Heimann in 1950, it is quite well known in dynamic psychotherapy that the emotional reactions stirred up by patients in their therapists, together with the thoughts which go along with them, may be a relevant source of information.

However, there are broad divergencies among the different schools and authors about the relevance to be given to these elements for understanding and treating patients. This wide array of opinions goes from those authors who think that therapists’ feelings are expressions of the therapist’s intrapsychic dynamics and unresolved conflicts that need to be controlled by self-analysis [Freud (1910) and Melanie Klein (1957)] to those who thinks that they are a particularly sensitive tool for understanding patients’ unconscious [Heimann herself and Henrich Racker (1968)]; from those who think that there are “objective” emotional reactions to some patients in some phases of their therapies (Winnicott, 1949), to those who believe that countertransference (as well as transference) is inevitably a co-construction of both the patient and the therapist – an intrinsically intersubjective and idiosyncratic “co-transference” (Donna Orange, 1995). Which is the position of Control-Mastery Theory in this debate?

In How psychotherapy works, Weiss (1993, pp.80-84) talks about the therapist’s affective responses to a patient as one of the elements which may contribute to the understanding of the patient plan, and his clinical examples show how these feelings may be:

1)      Something that patients may push us to feel because of their pathogenic beliefs, but that they hope we won’t need to feel (for example, out of his survivor guilt a patient may push us to feel brighter and more effective than himself);

2)      Something that patients felt during their traumatic experiences and that they hope we could teach them how to better manage (for example, a patient who had to take care of a very suffering mother and felt overwhelmed by her pain can make us feel overwhelmed by the task of relieving her suffering);

3)      Something that patients hope that we will feel and show so as to disconfirm their pathogenic beliefs (for example, a patient who needs a relaxed and casual interaction because he needs to have disconfirmed the belief that people need him always to work hard and be productive may relate to us in a funny and informal way);

4)      Something that patients are afraid that we (also) will feel, because if we will, this would be a confirmation of their pathogenic beliefs (for example, a patient with strong feelings of self-hate may test us in such strong ways that we are tempted to reject him).

As it is possible to see from these brief examples, if on one hand a CMT therapist may use his/her feelings for understanding patients’ goals, pathogenic beliefs, traumas, and testing strategies, on the other hand therapist feelings are a slick tool if taken in isolation. In fact, they can push us to act both in a pro-plan and in an anti-plan way even though they typically say something about what is happening in the patient’s mind.  In some cases they are mostly an expression of our idiosyncratic way of reacting to some part of the patient material or some facet of his personality. I can easily recognize in myself, for example, an idiosyncratic irritation when I deal with passive and complaining patients. For these reasons, we can say that our own feelings may be useful for understanding patients, but we do not have to be guided by them in our responses to patients without considering also our own psychic functioning and the patient plan.

Clare, a patient in her twenties afflicted by a strong self-hate deriving from severe mistreatments at the hand of her mother, often behaved in session in a quite chaotic and aggressive way, stirring up in her therapist feelings of irritation and the impulse to reject her; the therapist thought that these reactions were similar to the reactions that the patient said her family members and high school friends often had with her, and it was clear that if the therapist had acted out these feelings he would have re-traumatized the patient. The therapist’s emotional response in those moments provided a useful hint for hypothesizing the patient traumas, pathogenic belief and testing strategy (transference test by compliance); but they were a very poor guide for his conduct. However, in other moments she was so sincere, open, and engaged that her therapist felt a deep affection and admiration toward her, feelings that when communicated to the patient, were a powerful disconfirmation of her self-hate (transference test by rebellion). They were something that the patient wanted the therapist to feel and show.

Alexander, a patient in his forties afflicted by  strong separation guilt, used to complain and claimed to be very distressed any time his therapist had to miss a session; this behavior stirred up in his clinician a mix of guilt and rage but showing these feelings would have re-traumatized the patient as they would represent a failure of his passive into active test. They were something the patient had often felt in his life, and he was hoping to learn from the therapist how not to be overwhelmed by these feelings. On the other hand, when the patient seemed to be pleased that the analyst had enjoyed his vacations, he stirred up in the therapist very pleasant feelings, which made the patient happy because he experienced it as a disconfirmation of his separation guilt (passive into active by rebellion). He was giving to his therapist something he wanted to receive for himself.

From these very short and schematic examples, we can easily see how patients’ traumas, pathogenic beliefs and testing strategies may affect therapists’ emotional responses with the mediation of the therapist’s idiosyncratic functioning. For this reason, therapist feelings and idiosyncratic thoughts may be very useful for understanding patients only when taken within the broader context of all the therapist knows about the patient and his treatment and without neglecting the peculiarities of her/his own psychic functioning. In other words, we do not have to neglect what we feel and think while being with a patient, but this should not be the basis of our clinical decisions. The patient plan, and the clinician understanding of the elements of the plan the patient is working on in each specific moment of the treatment, should be the main guide of our clinical decisions.

Toward our own and our patients’ feelings we should be as sensitive as a well-tuned violin string, but we must make sense of our vibrations within the overall symphony of the patient material. Our brains are wired to be pre-reflectively attuned with other peoples’ emotions and intentions (Rizzolatti, Sinigaglia, 2006), and our reciprocal interpersonal motivational systems are structurally paired (Liotti, Fassone, Monticelli, 2017), but as therapists we must make sense of the emotions we feel working with a patient within the context of our own idiosyncrasies and, above all, within the context of the patient’s plan.

We should be aware and accept anything we feel and think, but we have to tame our reactions so that they will be pro-plan.

 

 

References

 

Freud, S. (1910), The future prospects of psycho-analytic therapy. Complete Psychological Works of Sigmund Freud, Vol. 11

Heimann, P. (1950), On counter-transference. The International Journal of Psychoanalysis, 31, 81-84.

Klein, M. (1957), Envy and gratitude. London (UK): Tavistock Publications Limited.

Liotti, G., Fassone, G., Monticelli, F. (2017), L’evoluzione delle emozioni e dei sistemi motivazionali. Raffaello Cortina, Milano.

Orange, D. (1995), Emotional Understanding: Studies in Psychoanalytic Epistemology.  New York: Guilford, 1995.

Racker, H. (1968), Transference and countertransference. London: Hogarth Press.

Rizzolatti, G., Sinigaglia, C. (2006), So quel che fai. Il cervello che agisce e i neuroni specchio. Raffaello Cortina, Milano.

Winnicott, D.W. (1949), Hate in the counter-transference. The International Journal of Psychoanalysis, 30, 69-74.