Psychiatry & Psychotherapy Podcast - What is Transference and Countertransference?

Episode Date: April 1, 2019

What is transference? Historically the term "transference" refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients' past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist. It is "a mixture of real characteristics of the therapist and aspects of the patient's figures from the past—in effect, it's a combination of old and new relationships." (Gabbard) How does transference work? The patient's early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist's actual behavior is always influencing the patient's experience of the therapist because of this. When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience. There is often misattunement to painful circumstances that can't be integrated into a person's emotional world. For example—a child who can't demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new "ideal self" so they can interact with others and no be rejected. The child then doesn't know how to deal with strong emotion, even moving into adulthood. Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states. To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization. That "ideal self" will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you. This is where it's important to understand transference, and to be able to give your patient a safe place to express their emotions. When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience. Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puder, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. I'm your host, Dr. Puter. And today I'm going to be going through the The Therapeutic Alliance Part 4, it'll stand alone, but it'll also build on the previous episodes,

The Therapeutic Alliance, the introduction, the second episode when I went through Meaning and Logotherapy and Victor Frankel's work, and the third episode, I went through empathy, the how-to of empathy, and this will be part 4, and I'm going to be talking about the therapy relationship and really therapy and countertransference. So I'm really excited to go through this with you. These are topics that are a little bit deeper. If you have an introduction to them, then hopefully this session will be building on it and reminding you of some of these topics and how to approach them. And if you don't have an introduction to transference and countertransference, hopefully this will open up your eyes to some of the deeper things going on psychologically. So here we go.

Okay, so transference and countertransference. Historically, what transference meant was it was the feelings, fantasies, beliefs, and assumptions that a patient would experience towards the therapist that originated in past relationships. So, for example, their dad was abusive and so they project on you that you were an abuser, or they were sexually abused, so they project on you that you will sexually abuse them, in some way. Or let's say their mother was very angry at them all the time, then they may feel that you are angry at them, or if their mother was neglectful, then they may feel acutely aware when you neglect them, or they may feel like you are not paying attention or focused or concentrating on them.

So historically, it was thought that all of those emotions and feelings that patients had towards their therapist were originating from past relationships. And so they would look at these and just kind of with the assumption that this was only from past relationships. But realistically, a lot of what goes on in the relationship is also related to the here and now aspects of the relationship. For example, if you're a therapist who does maybe feel a therapist. a little bit more emotionally detached,

and the patient is experiencing that, that may elicit real emotion in them related to your relationship with them and not just their past experience of neglect. And so more recently, we view transference as the here and now subjectivity that is the valid experience that the patient experiences of the therapist.

So it's not just, you know, oh, this is, to your past experiences, but also there's an aspect of the therapist that's eliciting this. And so it's a valid, they're entitled to their experience of you. Now, that being said, we understand that there's kind of like a mixture of both going on in the room. You as the therapist or psychiatrist or physician are eliciting things in the patient. based on the way that you are, the tone of your voice, the way that you dress, the smells in your office. All of those things trigger past representations.

So we know that patient's early experiences develop organizing principles. It constructs frameworks for how they will relate in future interpersonal interactions. And so transference is that continuing influence as a way of organizing and giving meaning to current experiences, while, you know, it's crystallized a bit in the past, it continues in an ongoing way in the here and now. So I hope this makes sense. Here's another quote from a Gabbard's psychotherapy book, a mixture of real characteristics of the therapist and aspects of the patient's figures from the past and affect a combination of old and new relationships. So a patient is seeking new developmentally needed experiences.

So this is happening unconsciously all the time. Some patients come to me and they wonder why they end up with people like their mother or like their father. Why do I always end up in abusive situations? And the patient is looking for these old repetitive experiences in the current life that they're living. but they're hoping that it changes. They're hoping that they have a new developmentally needed experience out of something that is similar. So they anticipate the past and the past continuing,

but they also hope that this new relationship will give them new developmentally needed experiences to repair those past experiences. So why someone ends up in an abusive relationship over and over again, is because perhaps there's characteristics of that new partner that is repetitive from their past. But they're hoping that that new partner can give them developmentally needed experiences, which are going to be healing of those past relationships. So another example is sometimes someone will end up in a relationship with a boss who is somewhat similar

to a past relationship with their father, and hoping that their boss will give them a new sort of relationship that will be healing of their past. Okay. So we can understand transference as people are both projecting those past relationships into the present relationship and also transference as everything that you are bringing to the table

in terms of how you interact with someone. Now you may ask, does this occur outside of psychotherapy? Absolutely. And this is how people construct schemas or construct understandings of how the world works and relationships and they are putting these types of ways

that they understand people and relationships onto their new relationships. and also the new relationships are uniquely recreating and creating new types of schemas and frameworks that then they'll go forward in future relationships with as well. So I would say, you know, healing relationships, relationships where, you know, the person is loving and caring with boundaries and for the other person, not only for themselves, those types of relationships can be healing and actually sort of change the way that someone will interact with other people in the future. Okay.

So sometimes people experience really painful transferences, and these are built out of maybe experiencing early on pain, deprivation, and trauma from a significant caregiver. There's often a very strong misattunement to painful affects, which therefore can't get integrated. So an infant, maybe one or two years old, experiences a lot of anger. And the mother or father doesn't know how to tolerate the anger. So just detaches and maybe moves away from the child in the midst of that anger. Therefore, that anger can't get integrated and it will sort of get associated with that person and sort of get associated with the transference as well. So, you know, the transference that they'll experience in the future.

So unintegrated affects become lifelong emotional conflicts and vulnerabilities to future traumatic things. What happens later is people who have unintegrated affects develop defenses against the affect. So a defense, you know, psychological defenses are, you know, if they come up, you see the emotion flash on the face, and immediately someone will have a defense against that painful affect. For example, denial is a very sort of early on defense against affect, and in denial, they just deny the affect completely, push it down into the unconscious as if it never happened, and maybe go blank.

Or another more higher order psychological defense is intellectualization. In intellectualization, someone will feel the emotion, push it down and then come up with creative intellectual things that might be going on sometimes they're very very far from what might actually be the case with the affect or why they had the affect and so it's very like heady and these people live in a place of um sort of ideas detached from their emotion so when they have this misattunement uh it communicates an unconscious conviction that unmet developmental yearnings and reactive painful states are manifestations of a low-sum defect or an inherent inner badness. So associated with these feelings are often shame.

That's the easiest way to put it. I am bad. I am defective. And shame really shuts us down. It shuts us into more of a dissociative or a dorsal-vagal place. And being in more of that deep place of shame, it moves us from moving forward. And so often it requires when we feel shame to feel anger to move ourselves out of shame or to feel the emotion. But shame may be the first thing that is felt. Often when people come in, they have a very sort of narrow horizon of their emotional expression. And then you come along. Now they can express emotions towards and with you and often the first place that they feel safe in expressing emotion is towards someone like yourself who they feel safe with.

So, you know, when I see a lot of physicians without this type of training, I have compassion and empathy for them because when someone's attacking them or when someone's getting angry or frustrated at them, immediately they may get frustrated and angry back or very defensive. But instead, we need to realize that some of the negative emotion is really just that unattuned or unintegrated affect that is coming back from the patient having a transference reaction towards you because you are the safest, strongest person in the room. I've also seen this happen with pastors or religious figures. What will happen is as they get closer to people, either early on in the first interaction with a person or after several years,

the person in the congregation will start to have very strong emotions towards them, often negative. And the person doesn't really understand completely why they're having these negative emotions. And the pastor is getting barraged often with these negative affects and, you know, anger and criticalness, right? And part of this is because it's the unintegrated anger from early on in developmental relationships. And so anytime you have someone in a place of authority, a boss, a spiritual figure or a therapist who is getting to know someone in a long-term relationship and is a safe person or is registered as a safe person, then the transference will start coming up.

So early on in my training, I had a mentor who I expressed like, hey, this stuff is coming up. I don't know how to make sense of it. I'm feeling defensive. And they're like, whoa, this is actually like really good because this person really trusts you. and if they didn't trust you, then they wouldn't have this transference towards you. So the goal is to make this less fixed, more chosen. We want to be able to choose who we react to emotionally, more context dependent, right? Some people have this transference towards a lot of people, but as you do this kind of work,

maybe it can be more context dependent. Like they'll continue to have anger towards someone who's very narcissistic and psychopathic, but less so towards someone who is kind and caring and compassionate. They also may develop positive transference and develop ways of diffusing negative transference. So positive transference really quick is when they have positive feelings towards you as their provider because you remind them of someone positive from their past.

and so often, you know, people are not just experiencing negative transference, but also positive transference. And positive transference, especially with someone with like borderline personality disorder, can come on very, very quickly. And they may say to you something like, wow, you know, Dr. Puter, you are the best psychiatrist I have ever met. No one has cared about me the way that you care about me. And, you know, if you're a little bit narcissistic, that can be very inflating to hear that. but whenever I hear it, I think to myself, okay, what's going on here?

You know, I'll thank them. Thank you for sharing that. But also in the back of my mind, I may think to myself, you know, part of this may be an early positive transference towards someone who cares about them and is listening carefully. And I may say to them, you know, I want you to know that at times you may feel negative feelings towards me as well. And it's okay for you to express those things if they come up as well. well. So I'm starting to prime someone to be able to express both positive and negative experiences

that they have towards me. So when we listen to a patient's world, when we acknowledge their subjective perspective, resonate with their affect and look for meanings, then an alliance is formed with the patient's expressed experience. And through that, transference will come up. It's not that it is transference occurring, it's, yes, absolutely, it occurs in every relationship, right? And especially as you start to get close to someone, then the transference comes up quite a bit more. And one note on that that's going through my head is often when you see couples, you know, the transference is deep between them. I mean, they're having these sort of experiences towards each other and their past is coming up in their relationship. And they may not realize.

it completely and they may get defensive when one of them gets angry at the other one. And of course, it's very complicated and it can't be reduced to. It's always transference. But sometimes, you know, partners, people who are in relationship with each other for a long time will have transference towards the other person. Okay. So one of the key things here is to be open to interpersonal feedback. And by interpersonal, I mean the feedback that is coming to you from another person about your relationship with them. And to be open to that feedback from the very beginning of the relationship.

And we introduced to the patient, the likelihood that he or she will develop the feeling of being misunderstood. And I would like to know when someone feels misunderstood, the sooner the better. And sometimes they'll come back to me like a session and they'll say, hey, you know, like two sessions before I said this.

And I feel like you didn't really understand it because you said this, and I'll be excited, and they'll be fearing that I'm going to attack them or shame them, because that's maybe what's happened to them in the past. And instead, if I respond to them with gratitude, one, for sharing something, and two, an openness to learn and to be better in tune and better empathic with what they said, they feel connected to you, and it's like a really meaningful, like, heartfelt feeling of connection. that you often feel. So when that happens, I get excited with the person and I say, hey, thank you for sharing

with me that you, you know, were able to have the courage to bring this to me. And I really want to hear like what I might have misunderstood and thank you for allowing me to better understand you. So when someone brings this forth to you, there may be a doubt that you will meet them. and with a positive way. There may be a feeling of shame. Like, I am bad for bringing something up for being critical. So we need to be prepared for that.

And we can even say something like if there's shame, we can say, of course, it's hard to express these things and to put them out there. And I'm so glad that you had the courage to do that. The next thing is sometimes they'll have negative feelings towards you that come out. Sometimes they'll come out in very sort of subtle ways, like passive aggressive like like um i had one patient say to me um he he had found my podcast and he said to me oh you know your podcast it seems like you just have other people on and you just interview them

and you know you don't really have thoughts of your own it's really not about you and you know it could be very kind of deflating to think that i have no good thoughts and it's only other other people have good thoughts. And, you know, if it, if it was just that comment, then it probably wouldn't be something that I would consider as like, you know, kind of like a competitiveness or a little bit of that anger, frustration, trying to diminish me. But I've seen this with this guy, like now, about 10 or 15 times. And I said back to him, you know, I'm wondering if as you thought that, as you heard that and you were thinking that, if you had any other things, thoughts that came to your mind or if you had any feelings that came with that. And, you know,

oh, no, no, no. I was, no. And, you know, try to change the subject really quickly, right? And instead, I kind of stuck with it a little bit. And it's like, well, you know, I think, I think I'm wondering if you felt a little bit critical towards me or, you know, you know, blah, blah. And eventually he's like, you know, I think like it's just hard to be the patient here, you know, and be here and like you'd be there. And I feel like it's just hard, blah, blah, blah. And, you know, there was this kind of feeling that he had of there's kind of like he's wanting to be on the same level, or maybe even a little bit above me in sort of the power hierarchy and the dominance place, you know, or whatnot. And I said, you know, of course, of course it's hard to come

here and to share about yourself and to feel maybe as if by doing that you feel a little bit like you're needing help. And it's really hard to ask for help sometimes. So I try to like normalize this sort of idea of like being in a, asking for help is kind of like to some people being in a one down position, although I see it as a strength. And so I really spoke from my heart and saying, you know, I think it takes a lot of courage to come in here and do express things that are bothering you and to get the help that you need so that you can continue to thrive in your life. So I kind of tried to bring in my own personal conviction that getting therapy is actually a strength and not a weakness. So we really have to expect people to have hesitations to trust us, to

to even avoid us, to have feelings of reluctance towards sharing, to feelings of shame and guilt and embarrassment, it's uncomfortable to share what one feels ashamed of. You know, as people tell their story, it's hard not to talk about something that they feel, makes them feel small. And people have a hard time sharing things that might make them feel alienated. Or maybe when they've shared things,

in the past, it has alienated them. They're fearful of being rejected, of losing face, of not being loved or liked, and they fear not being loved and liked. And so when people are expressing things, I think if we can have empathy and warmth towards the difficulty in the sharing. And a lot of that fear comes from early transference. experiences in which they didn't have the safety of sharing how they really felt. So as people express to you that interpersonal aspect, we get excited and we thank them.

So at this point, before I get into some common types of transference, I want to go into some of the research on transference. One study by Levi 2006 of transference-focused therapy versus dialectical behavioral therapy versus supportive psychodynamic psychotherapy for borderline personality disorder found that transference-focused therapy had increased secure attachments, whereas the other two types of therapy did not. Specifically, they had increased narrative coherence and improved reflective function, both of which are thought to be related to attachment, how someone tells their story, how they reflect on their own internal states,

how they mentalize the thoughts, feelings, and goals of another person. Was one therapy better than another therapy for reducing symptoms? That's not what this study found. So, you know, if you don't have a choice of doing transference-focused therapy and you have borderline personality disorder, I still think that the other therapies are very effective. Transference focus therapy was written about by Kernberg in 1984, who hypothesized about the developmental sort of nature of borderline personality disorder coming from an idea that they needed to integrate

polarized affective states and representations of the self and the other into a more coherent whole. And by exploring and integrating these split-off cognitive affective units of self and other representations, patients will be able to think more coherently and reflectively. They will have more realistic and accurate thoughts, feelings, intentions, and desires about self and others. Integration will allow for increased modulation of affect, coherence and identity, increased capacity for intimacy, and improved functioning. Now, what all that means is that early on there's these sort of split-off affects,

these affects of strong anger that weren't integrated and that will come out in the therapy relationship and that through the processing of your relationship with them they are able to integrate these very, very strong affects from their early life. Okay. So I'm going to post in the article blog that goes with this podcast, the links to these studies.

and I recommend that you check them out. Okay, now I'm going to go through a list of common transferences and talk about what might be going on in some of them to give you an idea of types of transferences that come up. So first of all, sibling rivalry. In this transference, maybe they had some conflicts with one of their siblings. They always felt competitive with them, and so in the session with you, they start to feel this competitiveness towards you.

What does that look like? Well, they might try to diminish you in some way, with very slight comments about either promoting themselves or diminishing you. For example, they may constantly talk about their successes, and whenever you talk about, or whenever they may be discern that you are doing well or whatnot, they may try to make less of that. The next transference is maternal transference, where they see you as maybe a mother figure, or an all-good mother, or you remind them of someone who's very maternal and loving,

or it may be a maternal transference as in, like, it reminds them of their own mother, who they had a really bad relationship with. They maybe have some strong anger towards their mother, some strong feelings of, you know, their mother neglecting them. And so they may fear you doing this as well, or they may feel like you are doing this as well. Next would be a paternal transference. you remind them of a father figure. Maybe they want you to solve their problems.

Maybe they want you to make everything right. You know, if a patient wants you to solve all their problems and asks you for direct advice, I would recommend first you look at like the yearning there for someone to kind of move in and solve their issue. So help me understand what you would desire here. Would you desire for me to kind of come in and solve your issues? Or you might say, you know, it would be very normal to want me to be able to solve your issues. You know, and it's very hard knowing exactly how to do that because I'm not you and I'm not in your life 24 hours a day. But tell me more about what's going on or what you've thought about.

there can also be a god transference wanting to be all powerful all omnipotent right erotic transferences maybe the way that they've connected in the past is through being sexualized from a young age from one of their primary attachment figures and so they just expect that the way to connect is going to be sexually and so they they yearn for attention and connection, which are good things. Attention and connection are good things. But they think that erotically is how this is going to take place. And so one of my mentors talked about how like an early patient of his said,

at some point, I am going to seduce you and we are going to have sex because that's how it's gone for my past therapists. and my mentor said, he said to her, well, I hear that at some point you feel like we are going to have sex, but I assure you that that is not going to happen, and I don't touch any of my patients. We shook hands when we first came in, but at this point after, we will not be touching. If you have thoughts that are erotic, you can put them to words. And eventually came out that she was kind of in this erroneous. erotic early attachment, and this was how she got attention.

And so this was what she thought was necessary to gain attention. And my mentor, who was able to be present with her and give her attention, without there being an erotic component, was able to kind of loosen up and change the nature of that very strong transference. Okay, another type of erotic transference is a patient falling in love with you, you and maybe because they're not conscious of this, they find someone very similar to you, maybe a similar body type, a similar personality, and they start dating that person and having erotic feelings that get manifested towards that person, whereas they can't act it out

towards you, they acted out towards the person that looks like you or seems like you. So that's erotic transference. The next is idealizing or contemptuous. So they could either idealize you as the all perfect person, the all person that's going to save them, or they could be contemptuous towards you like in sort of an alternating or just contemptuous in general as in competitive and looking down on you and wanting to make you less than.

They could be passively hoping for. for a miracle, they could be seeing you as someone who may be able to save them, so to speak. A person who is prone to not trust may view the therapist with suspicion. You know, can I trust this person? Can I see this person as someone that I can put my faith in? I can put my trust in. And they may be very suspicious and see things that aren't there, you know, like, oh, you didn't, you shut the door very loudly last time.

that's because you were you were angry at me you didn't like me you were upset at me and you know when someone gives you that feedback you get excited with them once again you get excited that they're able to share that with you and you empathize with the distress first and foremost so you're not you know trying to counteract like no that wasn't me i didn't shut the door you're wrong i'm not angry at you the first thing you do is you say thank you for sharing that's that's really helpful for us to look at today. And I just want to like let you know that that would be really distressing to think that I slammed the door on you and that I was upset at you. And we do that because we want to be present and empathic with their distress. So I want to highlight that throughout

the whole thing. And we also want to show the adaptive function of the different transferances that they have. Like it would be adaptive for you to look at me as someone. who is untrustworthy because of how hard it's been for you to trust people in the past. So a person who struggles with anger will have anger towards the therapist often. This usually doesn't come out at first, but it comes out subsequently. Sometimes it comes out at first. Transference can be influenced by age, gender, clothing, body attributes, context, vocabulary, and choice of words, personality characteristics.

So all that you bring in to the relationship, you may sort of stir. up in the person, something unique, some unique remembrance of some past person. So practical pieces. What went well and what did not go well in your past therapy relationship? I often ask patients this and ask them this because I'm curious about what types of transferences were elicited, if any, in the past therapy relationship. You know, when you felt disappointed or misunderstood, were you? you able to share that feelings with your therapist? In what way would you like your relationship

with me to be like your experience with your last therapist? What are some of the worries about what you might experience in your treatment with me? So you're kind of trying to get some of the repetitive transferences that have occurred and put words to them early on and empathize with them early on. Wow, that must have been really difficult to not be able to connect with that therapist like you wanted to. When someone says that they didn't want to come into therapy, you say, you may say something like, it's normal to have mixed feelings about coming into therapy. So you normalize their feelings.

You normalize their experience of their previous events and their previous therapists, if they've had them as well. You may say something like, this is a laboratory where we will look at what goes on between us, and when you tell me something like you are mad at me, I'm going to be happily excited at you sharing your feelings. So we kind of start to, you know, if we're doing this type of work, we start to put it out there early on that we want to look at what goes on between us, the interpersonal.

And if they have negative feelings towards us, we want to meet them and be excited with them in that. One study that's coming to my mind right now is when they looked at expert cognitive behavioral therapist versus expert psychodynamic therapists. And one of the commonalities between them is they both focused on the relationship and what was going on in the relationship. So no matter what type of therapy you're doing, good therapy is looking at what's going on in the relationship.

What are you feeling about leaving me? You know, if you can tell there's some people who give you. a little bit more distressed towards the end of a session when they know they're leaving you for the week. You know, have them put that to words. What are you feeling about leaving me? You know, and they may say, well, I feel like I'm going to leave and I'm going to be upset this week and I'm not going to be able to, you know, have anyone to talk to. That would be very distressing and not have anyone to talk to. And I want to let you know that, you know, if you bring those in next week, we can definitely talk about them. So I'm wondering if, if you're, you know, if you're going to be

you might be able to hold some of those thoughts until you come in next week. What did you do when you were young and something bad happened to you? So this is another way of looking at how someone interacted in their childhood when something bad happened. For example, did they go to their mother? Did they go to their father? Did they go out alone? You know, I went to my mother.

I went to my father. I went up into my treehouse when something bad happened to me. So you can look at that and then you can look at, well, how did your mother or father respond? Or what was it like to be alone? When you looked for help, were you responded to? Were you comforted? Did it help? How did it make you feel when you wanted somebody to help you in your upsetness?

Right? And what we're looking at there is we're looking at how. how they attach. This is actually a question in the adult attachment interview. And one thing that they grade in the adult attachment interview is narrative coherence. Like how clearly do they have stories about these things, about the examples of these things, you know? Can you remember a time you went to your dad when you were upset? What happened? Well, he hit me with his belt buckle because, you know and then you're like whoa like you've never told me about this before like what what's that and they're like well i guess that is kind of odd that they would that he would do that you know and if

so if they don't have like a narrative or a way to make sense of their childhood that's kind of a an indicator of an insecure attachment style so when you sense an empathic strain mending it is priority number one. Often I will say, help me understand what I might not have understood here. Or if I said something that makes you feel worse about yourself, then let's talk about it now. You don't have to use my exact words, and I don't exactly use these words, but the idea is that you want to catch these moments of strain early. And I'm going to refer back to my micro-expression episodes, which I'm actually remastering my audio engineer is going back through them and cleaning up a lot of stuff. So if you haven't listened to them or you want to listen to them again, it's a really good

series because the microexpression is one way that you can catch if someone is upset with something that you said. You know, if as the session goes on, they're experiencing more gratitude and connection with you, everything is great. But if as a session is going on, they're folding their arms, their flashing micro-expressions of anger or disgust, then it cues you into something, you may have missed something, there may be some empathic strain that you may need to attend to. And so putting it into words like, hey, I just want to check in with you if there's something that I'm not quite understanding. So that, when we are able to catch those empathic strains early on, they don't become an empathic rupture. An example of an empathic rupture would be that the patient

never shows up again, or that they don't show up for three or that they don't show up for three months. So one thing regarding strong emotions is be enthusiastic and curious about how the patients experience the strong emotions and how they cope with these intense feelings. And you want to really encourage them discussing these feelings and especially their feelings towards you. Whereas in the past, they may not have had a safe place. to get angry. They are entitled to want a different experience with you. So when they get angry at you,

allow it to be a different experience. Allow it to be a place where you meet them with gratitude, curiosity, and exploration instead of getting defensive. See if you can empathize with the anger that they feel towards you. Say explicitly that they have all of their feelings, including love and hate, and that they're entitled to put these into words even if they occur in the therapy relationship. It's your intention that the patient share their

feelings about you and with you, and that this will not jeopardize your relationship with them. So this is also great if you have employees and they come to you with, like, upsetness. I had such an experience just today and I said, hey, thank you for bringing this to me. And, you know, I really get that. It would be very upsetting that you felt like I asked you to do something that you didn't have time to do. And I just want to let you know that it's okay for you to tell me that you're busy and you don't have time to do it or you don't have time to meet. And, you know, that's fine because you're in a busy season right now.

and you know i want you to know that i really value when you're able to express your boundaries to me so convey to them that they can feel secure and accepted and not reproached or rejected for having a voice you can work cooperatively to help them process and modulate their emotions and actually doing these things doing empathy and doing empathy repetitively really does help them modulate their emotions. They'll calm quite a bit down in session very quickly. And you can explore together what actions might be appropriate for them when flooding eruptions erupt, you know, and they're unsure about what might happen as a consequence. So complicated emotions are inevitable. And we have the opportunity to offer enhanced ways of coping.

with desirable as well as disruptive emotions. And sometimes when I say complicated emotions, I also mean mixed emotions. Often people will feel both happiness or desire and guilt. Or they'll feel anger and gratitude. Or, you know, they'll have a mixture of emotions. And because of the guilt or because of the shame, it's hard to express the anger or desire. You know, and so we want them to be able to put things to words in the most accurate way with us. So emotions may be congruent with experiences in the past, but not necessarily appropriate in the present context in which they recur.

This is like one of those Yoda mind shifts that really can occur if you're a therapist or a psychiatrist or a mental health practitioner or just some sort of mental health enthusiast when you realize that, that they're congruent with the experience of the past, but not appropriate potentially with the current context in which it occurs. That's why they feel the added guilt and shame in feeling it in here and now as intense as they feel it. So if they feel you as their therapist is a witch or an evil person, they may not be able to put that to words

because they don't get why it's so, so strong but it's necessary and powerful when they're able to. Because when they're able to, then it's like they're processing emotions that maybe they weren't able to even have when they were super young. And so, yes, they have those emotions, maybe the intense anger,

and maybe that emotion was appropriate, but they didn't have the ability to express it, but now they can express it, and it's super intense, and they don't know why it's super intense, and they feel it towards you, and they don't know why they feel it towards you. And so the sort of the Yoda mind shift that takes place is when you're able to be present with them in the midst of it without getting defensive and with actually seeing it as an adaptive mechanism that's occurring and as a helpful part of their process. So pivotalness is my underlying sort of thoughts on how people grow and change.

So they have distressing emotions from the past, from past memories, and from past attachment figures. And in the midst of that distress, they're unable to catabolize that emotional experience. And so when they pull out that memory or when they pull out that transference, It's very uncontabalized. It's very distressing. And what you can do is you can be a different experience for them, a corrective emotional experience. And then they put that back into their memory. And the memory or the transference is fundamentally changed.

Maybe they're able to loosen up the amount of anger they feel towards their past caregivers in a way that then allows them. to interact with every single subsequent person in a new way. That's where I get excited. I get really excited when I notice these changes occurring. Now on to transference. And what I'm going to say about transference is everything that I have just said can happen, but from you towards other people in your life and specifically towards patients.

So they used to think that countertransference was the experience the therapist had towards the patient's transference towards them. So the patient's having a strong maternal transference and you don't like being the all-perfect mother. So you have a counter-transference against that. Get away. I don't want to be this. You know, I want to, I don't want to be sucked dry. so to speak. But I would say

the newer sort of idea of countertransference is your total reaction towards the patient. And it's seen as a source of information about the patient, a major diagnostic and therapeutic tool. It's an instrument into the patient's experience and your experience.

So when a new trainee initially has a very strong negative reaction towards a patient, that's something I want to explore. I want to go there. I want to listen to them. I want to try to understand what's going on. I don't want to just fix the issue. I want to sit in it, sit in the emotion, explore it, see what else is there. See how it's adaptive.

Empathize with the distress of it. to every relationship we bring learned expectations from past encounters. I was a quote by Dr. Tar, my mentor. To every relationship we bring learned expectations from past encounters. That could be transference or countertransference, really. It's this how we feel towards the person. It's often a gut feeling. And what I would say is the more work that you in particular do towards your transferences,

towards your major attachment figures, the more work that you can do on that, the easier it is to see clearly what's going on in the patient's transference and the less clouded your vision of what is going on. One example I'll give is there was one therapist who would see almost every patient as a trauma victim because the therapist had been a trauma victim. And this patient came in, to the therapist with pelvic pain after being newly married. And the therapist started asking about all sorts of sexual abuse questions. You know, did your father do this? Did you do this?

I don't even want to repeat it because it was so distressing the questions that were being asked. And the patient came to me and was distressed and was like, I just feel so horrible thinking about this potentially happening. and maybe that horribleness is because this is happening. Well, it turned out that the patient had an IUD, and that IUD was placed soon after she got married. And there was something about that IUD, intrauterine device, that made sex painful.

And once she took out that IUD, the pain went away. So it had nothing to do with sexual abuse. She was perfectly normal before. she got married. They had a great honeymoon. She came back. She got the IUD and she couldn't enjoy sex after. And once I delineated the timeline of that in her story, it was like the lights went on and I said, well, let's just try to get that out and see if that changes things. And it changed everything. So most people, by the way, who have IUDs have absolutely no pain during sex. But what I would say, is that the timeline that I got was very, very specific to when it's happened. And I looked at

everything. Medication changes, changes in job, changes in other stress. Finally, it came back down to, you know, oh, how are you doing your contraceptives? And this kind of came out. My point in this is that the therapist had transferences towards what the story was. The story reminded them of their own story of abuse. And so everything that they heard fit in line with their story and the questions sort of were leading. And this is the type of work that we need to do is psychiatrists and psychotherapists, not to lead our patients. And I often tell patients, don't try to remember any trauma. If you have nightmares, bring me the nightmare. If you have memories, bring me the memory. but it's very easy to especially if you have a vivid imagination and if you're very suggestible

and people who are in a very difficult position psychologically are a little bit more suggestible and so we have to be careful in how we interact with people and not put our own stories on the patients we come to see so That's one of the big takeaways I want to give you. I'm also going to put in my handout here a list of the different types of countertransferences you can have. I put them specifically by disgust, you know, attraction, sadness, anger, dissociation, shut down, sensorium issues, and fear and anxiety. So I split them into there and I have different questions and I'll put that up on the website in my resource library for you.

and I think it's helpful to go through this list, especially early on in training, after every patient you see, just read down the list and just check in with yourself, did I feel any of these things during the session? Because often we can come out of sessions and we can be very sort of busy and not really reflect on our own experience. And so when I'm training a medical student or a resident and we see a patient together, after the patient leaves, I say, how did you feel differently with them in the room? did you feel more tired? Did you feel more confused?

Did you feel more anxious? Did you feel more angry? Did you feel competitive? Did you feel manipulated? Did you feel more sleepy? Did you feel any attraction? Like you wanted to treat this patient? I will be open to any questions you might have.

You can find me on social media at dr. david pewter on Instagram. I'm also on Facebook and Twitter. Links in the show notes. And if you haven't already and you've been listening to this podcast, shoot me a direct message. Just introduce yourself. And I would love to hear about who you are and where you're from and what's been helpful and what thoughts you have. If you have any other things you think I'm missing that I need to talk about in the future,

I love to hear that too. And specifically with that, I would say one of the joys that I've had recently is interacting with people in other countries, Pakistan, Kuwait, a psychiatrist. people in training. People have said, hey, if you're ever out here, I'd love to give you a tour of this place, and that's exciting. So, you know, as I'm interacting with these people,

I'm learning as well, and so I bring those things into subsequent sessions. And so I hope that this can become a community where we can share with each other and grow together and, you know, kind of foster the bond of, you know, we're in these trenches together. This is often difficult work. This can be draining work.

Some of the countertransference that you may feel is like sucked dry. And so my hope is that you're feeling a little bit less burned out through the equipping that you're getting through this podcast. That you're able to thrive a little bit, feel more confident in your clinical care. And I am looking to bring in some of the best minds in psychiatry in future episodes. I'm really excited about some of the future ones that are planned. So I would love to continue this conversation, continue this community, and really learn from each other and also connect with each other. So I will leave it there. Have a great day.