Tuesday, October 13, 2009

Who's It All About?


In my last post, You May Leave Now, an anonymous commenter talked about how his/her psychotherapist steers the conversation to looking at the therapeutic relationship. She asks the patient if he/she feels abandoned during vacations or rescheduled sessions. The patient says "No, I understand you've got a life," and feels dismissed when the therapist doesn't take this at face value and continues to drift back towards a discussion of feelings that are (or are not) arising in the therapeutic relationship.

In traditional psychoanalytic practices (or those influenced strongly by psychoanalytic thinking) the "analysis of the transference" is a central theme to treatment. It means looking at and understanding the relationship with the therapist as a way of understanding feelings the patient carries with him from past relationships that continue to play a part in his present concerns.

None of the Shrink Rappers are psychoanalysts-- so this is my disclaimer. I ramble, but it's not clear I really know what I'm talking about.

What do I think of this technique? I guess I think it's important in the realm of someone who is inclined to look at the relationship and who likes to think this way. Many of my patients come to see me because of problems with their moods or anxiety, and to focus the discussion on the therapeutic relationship often feels forced. The discussion described by Anonymous feels kind of forced. It's not one that I personally am always comfortable with--- it assumes a degree of narcissism by the therapist-- that everything comes back to this one particular relationship. It's also just an uncomfortable discussion for me, unless some version of distress/disappointment or concern about the relationship is brought up by the patient. But for the average patient talking about their work or their family, or their distressing symptoms, it feels a little weird to inject the idea that it's about the relationship.

Lots of things in medicine are a little weird. There are personal questions and all sorts of body parts being palpated and fluids being infused or withdrawn from the oddest of places. It's not about the usual interpersonal transactions. It's about diagnosing and healing. So if analyzing the transference is part of what cures illness, improves functioning, or makes life go smoother in anyway, then I'm all for it, even if it's a bit awkward.

I haven't fully brought myself to that place for a patient who isn't initiating (unless it's otherwise obvious that this is an issue). My sense is that probing into the patient's feelings for the therapist in a repeated and unwelcome way may put some people off or may foster a dependency that can then become it's own focus of treatment. In people with personality problems, sometimes this is necessary, but it's not usually fun. It puts a lot of pressure on the therapist-- it's much easier to call a vacation a vacation and not deal with at a major abandonment theme.

My sense is that for the average patient with a psychiatric problem, focusing on the therapeutic relationship in a major way probably does not make people better. I don't usually do it, and people still seem to heal.

Any thoughts?

34 comments:

HappyOrganist said...

I think this can be fun to do (potentially) - discuss with a therapist some dynamic of the therapeutic relationship. However, I'm certain I only say that (and only find that potentially interesting) b/c I had Such a crush on a practitioner (not a therapist) a while back.
I suppose it could be awkward - but it would depend. I'm usually pretty open (and honestly very narcissistic, myself), so I would probably see such a conversation as still focusing on myself and maybe be fine with it.
(Is that weird or what.)

That said, however, I did abandon therapy with the one doctor (psychiatrist) I saw who would probably have been very likely to engage in such conversation.

I do find it fascinating - the whole phenomena of transference. And I believe there is plenty to be learned from it. However, the therapist I currently see (and she is pretty good for me) is all about CBT (and she is not into talking about transference or that sort of thing).

HappyOrganist said...

I do think that if I were seeing a psychoanalyst-type instead of the therapist I am seeing right now, I would not really be focusing on the real issues (and getting to useful skills to deal with the challenges I'm facing today). I'm sure I would enjoy seeing a psychoanalyst, but I don't personally think it would really be helpful for me. Entertaining - but probably not productive.

Alison Cummins said...

Transference discussions - no, I don't think I would want to have them. Just like Anonymous I would feel really dismissed if I had a therapist who wanted to make things all about them. I don't think I'd mind the asking, but I would mind the persistent refusal to accept my answer.

WRT "That didn't work," that happened most with me in psychotherapy, not with a psychiatrist. Psychologists often have something that they think is important and they just don't believe you when you say it isn't. I signed myself up for CBT at an outpatient clinic once because I knew that CBT was evidence-based for depression, and I'd already done any insight-based homework I needed to do. (At least, as far as I was concerned and also as far as my close friend the clinical psychologist was concerned.) I was assigned to a therapist who transferred me to her private practice so that we could talk about my mother, precisely the waste of time I went to the CBT clinic to avoid. She never believed me when I said that there was nothing there, that I wanted CBT for major depression. It was discouraging that she never even pretended to take me at face value.

Finally, when I complained loudly enough, she told me I could pick the topics for discussion. I would plan all week the things I wanted to talk about, then I would get there and she would say "What's new this week?" I would tell her what was new, but the important things I wanted to work on with a CBT therapist were never "new." Then we would spend the rest of the session with me trying to change the subject to what I wanted to talk about, and her insisting on probing into the deep significance of the beets I'd bought on the weekend.

After a few weeks of that she concluded that I didn't actually have anything to work on in the present, thus proving that my issues really were with my mother just like she'd been telling me all along. Aaargh!

I think many talk therapists (though I think less so with MDs) discount how fragile their clientele really is. If someone who doesn't trust their own judgement is depending on you to keep them alive, it's not good enough to say, "Well, they should articulate clearly what they want." They probably need help with that. A person who doesn't need therapy and is very comfortable with manipulation could probably say to the therapist, "You know, when you say "Really?" like that I get the feeling that you don't believe me. What would it take for you to accept that I don't have a problem with my mother/your vacation? If there is nothing that could change your mind about this, maybe we aren't a good fit. (Or) If there is nothing that could change your mind about this, then I have a problem because you are the only therapist in town."

But most people who are in therapy, who require a therapist, or who don't have superb negotiation skills, can't do that. Sometimes one gets the feeling that the therapist is there smugly thinking, "Well, they should." Well, yes, they should. But they can't, and it's not reasonable to expect them to, and it's not fair to set someone up for failure when they've come to you for help.

Back to the specific example of transference. I can think of times when transference discussions could be valuable. For instance, if the client is ranting away about how the therapist always does this or that, it might make sense to say something like "Is this really about me?" And then accept the answer.

William said...

It's interesting to me that in any other medical specialty, folks seem to intuitively realize that doctors have to do relatively uncomfortable things in order to provide care - but in Mental Health people seem more eager to dictate thier care. Then again, perhaps MH professionals do a poor job of inspiring confidence, as was somewhat evidenced by the therapist that continually kept asking if the patient felt abandoned. I would question not the therapeutic philosophy itself, but the lack of elegance in its delivery! Continually asking someone the same question again and again is usually a surefire way to provoke frustration and anger - I think most folks would know that - so when I ask my patient a question and, I either don't believe the answer, or I sense resistance, then I would point that out, rather than simply repeating the question. I'll even go so far as to explain my rationale and include my patient in the exploration - if they really don't want to discuss something, then of course we'll put it away for later - there's really nothing to be gained by forcing the issue.

In fact, the mention of manipulation in Alison Cummins' post intrigued me - I use precisely that word when teaching my residents that: If all you're doing is trying to get your patient to act/feel/discuss what you want or think they should, that's not therapy, that's manipulation.

Ultimately, it's important to recognize other people's autonomy, and accept that if they don't want to discuss what I think is important, then they won't. Instead of trying to make them, it's my job to inspire enough professional trust that they'll let me drive, in spite of the discomfort.

Anonymous said...

i can relate to this!! Unfortunately, though I fought as hard I could for years to fit into her train of thought, I wasn't getting any better, I still didn't really care when she went on vacation, and ultimately, the only solution was to find a new therapist. (do you think she felt rejected? ;)

Alison Cummins said...

William,

Two comments about patients "dictating care."

1) It's not just a mental health issue. When my ex saw a GI specialist for her Crohn's disease they would argue about whether it hurt when he pushed "there." She would say it did, and he would say it didn't. She accepted that she would be subjected to invasive testing and expensive drugs and possibly surgery as part of her treatment; she did not accept that being told she was wrong about the location of her pain was part of her treatment. This is what we're talking about here. About the credibility of a client or patient who says "No, that's not where it hurts."

2) Where mental health and physical health can be different is in the weight given to subjective well-being. If I have cancer and chemotherapy is horrible and painful and makes me want to die but massage makes me feel better, that doesn't change the fact that chemotherapy treats cancer and massage does not. No matter how much better a massage might make me feel, I will still have cancer at the end of it. On the other hand, if someone with major depression is more or less getting by with the resources they have and they see a psychotherapist who makes them feel crazy and suicidal, they are getting worse. The therapist might define what they are offering as treatment, but a patient who kills themselves because they find interaction with their therapist too disorienting was not helped. Alternatively, an imaginary "therapy" like homeopathy or therapeutic touch might make them feel better. A depressed person who feels better is less depressed. In fact, doing nice things that feel good to make yourself feel better, and figuring out how to avoid unpleasant experiences that make you feel worse, are evidence-based treatments for depression. I am not sure how a therapist who subjects a depressed person to the kind of profound disrespect implicit in the statement, "no, that's not where you hurt" could possibly be seen as alleviating depression. When clients and patients reject that kind of interaction with someone who is supposed to help them cope, they may be very literally saving their own lives. When you deny that the patient could be right - because it's the doctor/ therapist who has the right to drive - you undermine the client/ patient's efforts to stay alive.

(Yes, I understand that manic people may have a subjective impression of well-being but still be ill. That's why I used the qualifier "may be different" above. However, please note that schizophrenics may be more tolerant of the symptoms of their illness than the side effects of their medications; that they really might prefer hallucinations to dystonia or diabetes. This too, needs to be respected. Those of us who can do really cool things with our minds tend to value them highly, and have trouble imagining preferring psychosis over a physical symptom. But when your mind is never going to work that well, your body might be what you have left. So even here, when someone is clearly schizophrenic, a clearly physical disease of the brain, there is considerable latitude for accepting someone's statement that "that's not where it hurts.")

serialinsomniac said...

After years of failed CBT, hypnotherapy, psychoanalysis and other types of therapy - the best if which was psychoanalysis, though it still failed - I am now working with a psychologist whose main focus is psychodynamic therapy. I have to say that I find the phenomenon of transference remarkably telling about my 'outside' relationships, both past and present. As is the traditional psychanalytic thinking, it allows both the therapist and me to spot deficiencies with which I need to deal.

I believe that it would be irresponsible if both parties in the dyad not to acknowledge the presence and nature of these feelings. I can see why it would be awkward if, say, the transference were erotic (which mine isn't), but then again psychotherapists are supposed to be trained to deal with that kind of thing.

So my shrink and I actually discuss our relationship quite a bit, and I find it really rather helpful, if admittedly slow (though that's more to do with my strategic defence moves, which are frightening less powerful than they were with previous therapists).

Does it give the therapist an ego-boost? Maybe so, but that's not necessarily narcissism. Having said that, in Anonymous' case, it does sound like his/her therapist was pushing the issue, rather than let it develop in a natural kind of way, as has been my experience. That could be considered narcissistic, but I don't think discussion of the alliance is per se.

Like anything, if the practitioner is skilled in the area then the particular practice cam be 'carried off' effectively; if they are untrained, unethical or just otherwise not very good at the skill in question, then it can be disastrous.

A further point of course is not just talking about the relationship, but the relationship itself. Although contested, many studies suggest the most effective work is done by a therapist and patient that have a strong alliance, regardless of the type of therapy. So I suppose, in short, if you don't 'click' with your psychotherapist, then you should perhaps consider seeking another.

jessa said...

Alison, I am totally with you on the fact that it is unreasonable to expect patients to be assertive and stand up for themselves because, so much of the time, they are in therapy precisely because they can't do that. I wish professionals would recognize that more. It is not enough to have a grievance process or patient advocates for that reason (and because patients don't necessarily know what "good" therapy is supposed to be like, so they can't know that what they have is bad therapy; because, if they are frustrated at not being listened to, they have no reason to expect that the people they should appeal to will be any more receptive to their critiques; and because there are many other symptoms of mental illness that might get in the way, like lethargy).

William, yes, patients in mental health care do make a bit more clamor to get involved in their treatment, but there things you failed to point out. 1. There is a push (by I don't really know who) for patients to be active participants in their care, and I feel this particularly strongly in mental health care. 2. With physical health, if you ask your doctor why he is recommending a particular treatment, the doctor is usually plenty willing to tell you why and what the treatment is supposed to do and how it works. With mental health care, whenever I ask that sort of question, the professionals tend to "redirect" me and otherwise avoid the question. So even if people were equally curious about their physical health care and their mental health care, they would be more vocal and frustrated about knowing about mental health care. And coupled with point #1, this is all the more frustrating/hypocritical/ironic. 3. With physical treatments, the problem and the solution tend to be comparatively clear-cut. There are objective tests to determine definitively if you have high blood pressure or a blocked artery, there are no such tests for mental illness, they are all subjective (even when they are quantitative).

Alison Cummins said...

serialinsomniac,
Yes!

Jessa,
Yes, yes and yes!

Anonymous said...

Thanks for writing this post, Dinah. I’m the anonymous commenter from yesterday and I’m a “her”, BTW. :-) My diagnosis is major depression not a personality disorder, as I specifically asked her if I had one when I realized that she was using the “analysis of transference”. I refer to your blog or the links you have listed whenever I have questions/concerns, so when the frequency of these questions increased I decided to look into it. It’s funny that happyorganist mentioned having a crush on a practitioner because I originally felt that my psychiatrist thought that I had crush on her. That made me really uncomfortable. I was relieved when I read about transference until I read about it being the treatment for personality disorders. That really freaked me out. It took me about a month to work up the courage to ask her if I had a personality disorder and was relieved to find out that I don’t. So, I’m not sure why she’s doing this. Like I said in my previous post, she has helped me quite a bit but we probably spend 10-15 minutes of each session just spinning our wheels with inane questions. I have nothing to say about our relationship. So frustrating!!!

William – sometimes I wonder if she’s trying to piss me off just to get a reaction out of me. If that’s the case, it’s definitely the wrong approach with me. When I’m angry, I the last thing I want to do is talk.

HappyOrganist said...

Acupuncturist. very attractive. LOTS AND LOTS of transference. Piles and piles of it. But in the end I learned a lot (about myself and about my relationship with my parents and forgiving them, and so forth). She was quite a catalyst for me to work through issues I had about accepting myself and forgiving my parents.
I WISH I could talk to her now and tell her what I learned/accomplished by meeting her. Unfortunately, I am no longer her patient and we didn't officially 'hit it off' in any kind of social or platonic way, really, either (which is fine - it's not like you're supposed to in a doctor-patient relationship).
Transference is not a bad thing. It just happens - and it can be useful for learning things about oneself and about other people, as well.

I am enjoying this entire thread. ;D

Anonymous said...

Sounds like it's countertransfeence that's the problem. For whatever the reason, the therapist seems to have a need to believe the patient has abandonment issues when she's away. Maybe it makes the therapist feel needed/important.

Anonymous said...

It's interesting... I can discuss a situation in my life, with 15 different people, and get 15 separate opinions. Reading a certain passage, fish oil, waking up at a certain hour, taking a certain medication, trying yoga, trying a certain therapy, or multiple therapies...

I can easily dismiss the idea of reading a passage, or sitting in a specific pose, or even now, taking a specific medication, and yet..

when it comes to therapy... my belief in science and school and knowledge, has me going in, assuming another person knows best, trying to fit my life into the specific treatment, it's in a psych journal, it must be work, right? and if it fails the problem must be me, no?

How easy it would be, for someone, anyone to look at a therapy, to attempt it on a person, then blame (or have the person infer) blame for its ineffectiveness...

Instead, I need to work with my therapist, I need to know our agendas meet, that when I place my trust, allow decisions and help in my life to be made, it is based on what is good for me, not good for what the therapist wants for me.

This involves alot of talking. If the talk isn't there, I will bounce from one therapist to another, adding what they say is wrong with me to the list, feeling more and more lost...

I think that's part of my illness. So today, I try to listen for assumptions, assertions, and judgements, and ask why? ask for concrete examples, ask how something helps or hurts... and try to enhance my life...

Of course... it doesn't always work... sometimes my perceptions are accurate, sometimes they are not, same for my therapist - we both have bias's, let's admit them, see them and move forward, or i will remain stuck...

Will said...

This is a wonderful discussion. I would like to comment on the power of transference and make some distinctions. First of all, my disclaimer is that I am a psychoanalyst.

The theory of transference is basically: the past plays out in the present. I see this everyday in my office. Take for example the woman who finds herself habitually dating the same type of man, the young man who keeps quitting his jobs because he finds his bosses to be unreasonable, the college student who feels that people are always telling him what to do, or the employee who lives in fear that she will be fired. The theory of transference is that whatever one plays out with people in one’s life will be played out with the analyst, or put another way, the patterns in one’s life will become a pattern in the treatment.

Freud’s genius lies in the discovery that addressing these patterns to a person as they are happening in the present with the analyst is profoundly more effective than intellectually addressing a pattern in the past (how you acted with your boyfriend, your boss, etc.).

The comment reported by Anonymous doesn’t sound like transference; it sounds like bad technique. Transference is something that is happening, not something that the therapist suggests is happening. I would never ask a person if he were angry with me for going on vacation; however, if, in fact, he was angry with me, I would definitely ask about it and see if it reminded him of anything. This could lead to a wealth of information.

mysadalterego said...

I think the unbearable part of it is when, because of their analytical viewpoint, they don't take your answer as truth. That's what finally got me to fire the last guy - it was like, if I said anything he didn't agree with, I really *meant* what he thought, just was denying/repressing/un-self-aware. It got to be almost like a bad joke.

"Don't you think you cannot understand that you can both love and hate your father at the same time?"

"No, I think when I was in high school I came to grips with that pretty well. I spent a lot of time thinking and reading about forgiveness, people as imperfect but always wanting to be better..."

"Well, you just think you did."

When it spun around to "Why is it so hard for me to admit that you love me?" (after me openly saying, when pushed, that sure, I did feel an affection for the relationship - true, but it wasn't anything unusual or that demanded attention - I liked the guy, I think he liked me, whatever), I realized that enough was enough. Psychoanalysis is bullshit, and no matter how much secret sauce you put on it, it doesn't change what it fundamentally is: a non-predictive pseudo-science.

moviedoc said...

Transference is a theoretical construct relevant only in psychodynamic and psychoanalytic treatments. My family systems psychotherapy supervisor, Tom Fogarty, MD, used to say it doesn't exist. To a psychoanalyst it means more than just the way the patient feels toward the analyst, but analysts tend to see the patient pschoanalyst relationship as the most important one. And many analysts tend to view the whole world as functioning according to their particular brand of psychoanalytic theory.

I have yet to find good evidence the psychoanalytic treatments are effective in treating any mental disorder, but maybe they can help you learn about yourself, if that's what your goal is. The downside is that individual treatment of any kind can isolate you from the really important people in your life: family and friends.

sandy said...

moviedoc, what is your experience with psychoanalysis? It honestly doesn't sound like you have had a close relationship with the field, based on your comments that it's about having the analysand learn about him/herself rather than the alleviation mental disorders. There's enough evidence that psychoanalysis does so, but that doesn't fit in with people's preferred perception that it's all about a lot of solipsistic talking.

I also take issue with the assertion that individual treatment (as opposed to... group therapy?) isolates you from the ones who are really important ones in your life---family and friends. It seems more likely that many people go into therapy because their relationships with others (i.e., family and friends) are problematic and they want to understand what the problem is by examining their selves and their past.

Anonymous said...

Great topic. My pdoc is psychoanalytically trained, my tdoc is not. My mother is a real piece of work, so I have some pretty deep-seated issues and I've been in therapy for a few years. (No, I do not have a personality disorder.)

Transference has never been the focus of my therapy, not with my tdoc and not even when my pdoc acted as my tdoc. TBH, I would be uncomfortable focusing on the therapeutic relationship in that way. I need the therapeutic relationship as a solid base, so to speak, so we can work on the trauma issues.

Yes, when transference interferes with therapy, we may discuss it (after I calm down). Or we may not, although I'm sure it's useful to them to recognize that that's what's going on. I do have trouble when my tdoc goes on vacation, and it's such a classic transference reaction that my pdoc will point it out to me. (Doesn't make things any easier, of course. Other than to know it's time-limited.)

For my part, although I prefer not to talk about the relationship, I do find that since my tdoc takes care of her "stuff" (countertransference) so it doesn't affect our relationship (or almost never), if I see something difficult in the relationship, it's probably my "stuff" and something to talk about. Not so we can talk about the relationship but so we can look at those feelings, beliefs, or perceptions. Although I might have identified the issue within the therapeutic relationship, we take it right back to my other relationships, where it might have been harder to spot because of having to distinguish my stuff from someone else's stuff.

Anyway, my point is transference can exist and you can even learn from it, without the therapeutic relationship being the focus of therapy.

serialinsomniac said...

I have to agree with Sandy's comments vis a vis those of moviedoc. As stated I am presently in psychodynamic therapy (though there are some other elements), which of course is derived from psychoanalysis. It is by far the most effective therapy I've ever experienced, and I've experienced c. 13 years to date.

I would also be mortified if I were forced into group or, in particular, family therapy. It does not mean I want to isolate my family and friends; it simply means that I am a private person, who needs to speak in detail about my issues on a one-to-one basis. I am certain that I would not stay in therapy of that nature.

To say that one type of therapy trumps all is rather unreasonable. We are all individuals and as such will respond to different types of psychotherapy. Furthermore, with all respect to psychiatrists and psychologists everywhere, as far as I can tell, all mental health related work is pseudo-science, not just psychoanalytic therapy. My own psychiatrist (a different person from my therapist) freely admits that her work is based on trial and error, on educated guesswork.

jessa said...

I wish more professionals admitted that mental health care is based on trial and error. I have met precious few who do admit to that. It seems that most professionals have a pet therapy that they insist is THE cure, and if it doesn't work it is the patient's fault. Most books on mental health do that too. Not only is this simply false, but I think it is incredibly cruel to inflict that on patients. It is cruel to tell someone miserable with depression who is trying her best to feel better that it is her fault that she is not getting better. It is cruel to promise that any particular therapy will make her better (because if it doesn't, what will she think? and if she is serially disappointed, what do you expect?).

tracy said...

Interesting how many people keep saying "NO, i do not have a Personality Disorder". Like it's the shame of the century. It isn't...it just sucks.

itsjustme said...

Wow!! The EXACT same thing happened to me as Anon 2 only when I asked my psychiatrist if I had a personality disorder, she answered my question with a question (I hate it when she does that!!!) She asked my why would ask her that, what do I know about personality disorders, transference, etc. Eventually, she brought the conversation back around to my original diagnosis of major depression, so I’m assuming that is her way of telling me that I don’t have a pd. The following week, I brought it up again and told her that I couldn’t help but notice that she didn’t answer my question. She rarely gives me a straight answer, so I don’t ask her many questions because I find it very frustrating. Anyway, she gave me the same run around. I’m only on meds for depression, so I’m sticking with my assumption until she tells me differently.

Tracy – I can’t speak for anybody else, but I don’t think that having a personality disorder is “the shame of the century”. I’m just having a hard time dealing with my depression and really don’t want to find out that I also have to deal with a personality disorder. The few

jessa said...

For me, I only think of personality disorder (borderline, specifically) as being "the shame of the century" because the professionals I have dealt with have treated it as such. I do not have borderline personality disorder. I never did. But many professionals interpreted me as being manipulative, usually because I did things that didn't make sense to them (I can give specifics if you like). Once a professional interpreted me as being manipulative, the label, "borderline personality disorder" always followed soon after. From my perspective, that means borderline pd = manipulative, which certainly isn't something to be proud of, and was something I found shameful. Once I was branded with borderline pd, I was treated as a supreme annoyance and not much more. Since I trusted these professionals to know better than me, I tried to stop being manipulative, but found it impossible (because I couldn't be any less manipulative when I wasn't manipulative to begin with and because I couldn't stop the professionals from misinterpreting me as manipulative). When I asked a therapist who I had known for a while and who understood me better than the rest how to stop being borderline, she basically explained that I wasn't, and wondered how anyone could possibly think I was.

I don't think PDs are really shameful, but it seems to me that professionals use it to mean, "I don't like her." The real definition of PDs is nothing to be ashamed of, but the perverted definition of PDs is something I am invested in avoiding being branded with.

Anonymous said...

I would like to echo what has been mentioned here: people in therapy may be quite fragile, and that being said, the little slights of a therapist/psychiatrist may prove to be devastating.

I almost posted on the what can go wrong thread, but it would be a novel. My first psychiatrist was a resident in training. In retrospect, that got me off on a VERY wrong foot. I don't know how it is supposed to work, but I think that any patient of a shrink in training should also get to meet with the supervising physician once or twice..I saw my record after the resident left, and her notes were NOT accurate. that was not 20 years ago...water far under the bridge.

I had one psychiatrist who seemed to work at fostering a dependency. At first, that relationship provided a sense of safety, but then it became suffocating. I tried to create distance, the therapeutic relationship fell apart -- at a time that I had little energy to be worrying about that sort of thing. During that phase, I was labeled with a personality disorder -- another thing that REALLY bugged me, having read about them. When I asked a later therapist about the PD issue, her response, "I don't think so. You have relatively refractory depression, and practitioners become frustrated. Rather than think that they might not have found the right approach to help you, they label you with an axis II diagnosis so that they don't feel so inadequate." I don't know if that is correct, but that certainly helped my sense of worth and removed a lot of angst.

Dawn said...

Wow. Reading all these responses has been fascinating. It makes me appreciate my therapist much more!

I think she is psychodynamically trained, but I don't think we've once (in the almost 2 years) talked about our relationship. I KNOW there is transference going on on my part, and she probably does (she's hinted at it)...but she's never made me talk about it. Each time I go in, she patiently waits for me to talk about whatever I want.

This has been a source of frustration, but as time has gone on--it is also pretty awesome. I don't have to talk about the last session, I can bring in something totally new. Whatever it is, she's fine with it.

William said...

Wow what a thread!!

The Personality Disorder thing is so depressing - and it depresses me even more knowing that so many pros will whip that out instead of just admitting they don't really know what to do next. It also appalls me how few people who throw around such diagnoses can actually define what they are when challenged. It's a great deal of work to learn enough about someone to confidently diagnose a full on Personality Disorder (almost everyone has traits all over the board ...) MUCH more than can be done in just a few visits.

Borderline PD is probably the most misused of them all! On my ward, "Borderline" is actually translated to "any woman my nurses hate ..." and I'm forever sitting my residents down with a textbook, discussing the true definition, symptoms and likely etiologies of Borderline PD. The result is that we actually see that diagnosis relatively rarely.

Anonymous said...

I'd say that talking about transference can be fine and productive-- so long as that transference actually exists. Too often, the issue being addressed is more likely to be a counter-transference issue on the part of the therapist. While the therapist may get something out of working through that, I'd rather it not be done on the time that I'm paying a great deal of money for, or in a way that harms me. (And having a therapist, who is somewhat of an authority figure, repeatedly tell me that I'm wrong about my own feelings certainly harms me! Especially when the reason for it is their issue.)

Anonymous said...

Jessa, the reason I clarified that I don't have a personality disorder is that there had been a couple of comments earlier to the effect that if you experience transference or need to work on it, it's because you have a personality disorder. My point was that transference can come up (as an issue, I mean) for a variety of reasons.

As to the point that transference doesn't develop for everyone, my understanding is that if the therapy relationship goes on long enough and if it involves talking (i.e. not 15-minute med checks with a pdoc), then transference develops. But transference can be either positive or negative (in the nature of feelings toward the therapist) or both. Even if it occurs, it doesn't necessarily need to be a point of discussion. Positive transference doesn't cause problems, it simply facilitates the work of therapy.

Actually, transference develops in all relationships, in the sense that basically we bring the sum of our previous experience of (and successes or failures in) other relationships to bear in what we expect of new relationships. Transference is how you believe another person will behave in the absence of evidence to support that belief, and sometimes in the face of contradictory evidence of their actual behavior.

Back to personality disorders, although BPD is currently considered a personality disorder, my understanding is that some regard it as more on the spectrum of trauma disorders. Also, it can be treated or at least ameliorated, despite the current definition of personality disorders as unchangeable.

Anonymous said...

Fabulous post and comments, this is great stuff.

Transference, its presence or absence, is incredibly important but in my experience it takes a long time for clients to get comfortable and trusting enough to talk about it openly. And discussion needs to be initiated by the client, not the therapist.

tracy said...

Dr. William,
i am sorry to see that your blog is open to invited readers only. You seem like a very caring and understanding physician. A side note. The very best treatment and most positive progress i made was with a Psychiatric Resident. It was very hard to leave him and i still miss him very much. i was only able to see him for 10 months, however , i feel during that time, where we did a great deal of Schema Based therapy, i learned more and put into practice more skills than ever before. He has since gone on to do a Fellowship. Needless to say, i would love to be in therapy with him again. Transference....? Oh yes, but in this situation, it did not hinder progress.
BPD Richmond

a psychiatrist who learned from veterans said...

All must have prizes. I have had a patient who abused substances and was described by a nurse as 'the biggest borderline' who seems to have done absolutely wonderfully and can have the most sensible discussions now that she is on 100s of mg of Seroquel and lithium. No transference discussion. I had a patient who had an erotic transference, probably I was replacing her alcoholic mother who she always had to cover for. Interpretation of her dystonic thoughts to harm her children as reflective of her putting herself in the maternal space and experiencing what felt at least emotionally intended for her (as a child) held her emotionally, was a kind of transference interpretation which was absolutely the way toward her getting well. At the most elemental level, psychiatrists are hired for their ability to handle 'transference.' There is nothing more common than a patient's family saying, for instance, in differing from the doctor's opinion, 'The psychosis is just due to drug abuse,' putting you down and then turning around and asking, 'Will he have to take this medication for the rest of his life?' making you this all knowing person. Of course, such things are a part of life and doctor's lives more generally.

Anonymous said...

I got as far as the therapist using his vacation to try to elicit feelings of abandonment, and when that doesn't work, begin to insist that the patient feels abandoned due to the upcoming vacation. I had to laugh, because as a former analysand, my analyst did this all the time. I was to discover a friend of mine who was also in psychoanalysis had her therapist pull this on her too. We decided that this is done by wrote. Whether it's true or not that patients unconsciously feel abandoned when the therapist goes on vacation, nothing is gained by pressing the point during the therapeutic hour. Since the patient is not willing to talk about their feelings of abandonment at that point in time (because they're there, regardless of vacation time or not) then the analyst can pathologize the analysand's resistance and write a paper about it. Thus, the therapeutic hour is all to the benefit of the analyst with none for the analysand who will be buried under layer upon layer of the language of pathology which the analyst will impose on the analysand. This way, they never get well. It could be contended that the analyst has no intention of being of any help from the git, but of course, this is all unconscious on his/her part. Don't even get me started on how a language (the language of psychoanalysis) is a science according to them. I live in a province where psychoanalysis is funded by government health care. I'll be dancing the happy dance when they finally wake up and pull the plug on that. There are people in this province who don't have access to a GP, but psychoanalysis is available!

Valjean said...

There is without a doubt a good number of bad practitioners. Psychology is also somewhat of a "soft" science, because the complexities of human behavior and thought make those of molecules, organisms, and animals look tiny. Research on the human mind will take longer because, well, we're dealing with humans. There are plenty of ethical boundaries and extraneous variables that we wouldn't have when dealing with rats in a cage. The "business" side of mental health, that of helping patients cope with their lives and problems on a daily basis, takes its practices straight from theories and results in the research area of psychology. It's premature, and as with physical medicine, there will be plenty of chiropractor and acupuncture types before we can get a good enough understanding of the human mind to deal with its problems.

Psychoanalysis depends on the psychoanalyst and the analysand. It works well for learning about yourself and your strengths/weaknesses, the patterns of your behavior and where they come from. It is also a very long-term procedure. That being said, it doesn't work well for people who want a solution to the problem soon. For that, behavioral modification therapiest, CBT, and DBT are good. Yet these forms of therapy also breach the very surface of the the problems and depend on a lot of client discipline and willpower. They don't really offer much in terms of self-understanding. Unfortunately, given the consumer and fast-past orientation of our society and economy, the CBT,DBT, and Behavioral options are often the best route to go to, because most people don't have money or the time to see an analyst three times a week, and may lose their patience due to its slow, patient-based pace. I've experienced both types of therapy, and I'm studying to become a psychologist. I can say that I nearly cut the cord once on my psychoanalytic therapist. It is frustrating because as a society we are used to getting things NOW. And when the therapy isn't modeled to give you a concrete answer, a magic pill, or overwhelming support at first, you tend to discredit the therapy and move somewhere else. However, I also noticed in CBT that much of the pep-talking and "you can do it!" can be superficial. It is what it is; a rough, assembly-line therapy procedure.

Anonymous said...

I stuck it out for five and a half years. I didn't have a clue what the process was about from the beginning, and I was so messed up after, I spent years studying it, as well as the anatomy of the brain, along with a deep and wide education about mythology. Of course you can't study myth without encountering religion, politics, and culture at large. By folding all this into my awareness I was able to apply it to gain further insights into myself. So really, you might say I stuck it out for 20 years, all told.

Psychologists should thank all these non rats in a cage for letting all y'all tinker with our minds, hearts, souls, lives, so that you can get a better understanding of how the human mind works.

And pay y'all to boot.

Considering the continuing, sharp incline in mental distress experienced by a growing population, it leads one to wonder if this profession is in any way equipped to help, or even if it is competent to unravel the psyche's secrets.

The heart of the profession is in the wrong place.

Although there are some with successful practices, this profession is doomed to fail - the writing is on the wall.

It's true that self recovery comes from self knowledge, but also it comes from people who truly care about you, or me. From friendship, family, community. Unfortunately, these institutions are also failing.

Between the lines of your response, I read that this is all about the therapist, and what's in the best interest of the profession, and not what's in the best interest of the people seeking help.

I would love to see data with respect to the people who have sought treatment for this or that distress, or as you like to call it, disorder, and who has actually been cured. Not medicated. Cured. Helped. Healed. Made whole.

Move aside shrinks. The Shaman are coming. Meh. Meh heh heh. Meh heh heh heh heh!