Early in my practice, a client said something that has stuck with me for the last 30 years. A trained dancer, she told me she avoided taking pain relievers because, in her view, pain was her body’s way of providing important information to her and she needed to “listen”. Although you’ll sometimes hear medical and body-work experts echo this view today, when you move from physical to psychological pain, it’s rarely mentioned. The idea that one needs to “listen” to one’s emotional pain gets short shrift, especially if that pain has been labeled depression, anxiety or an eating disorder. In the current mental health profession, dominated by cognitive-behavioral therapy and psychiatric medication, pain is something to be removed or eliminated. Take this drug. Try this CBT technique.
Last week, I reviewed an article by L. Alan Sroufe that had appeared in the New York Times, seriously questioning the effectiveness of Ritalin, Adderall and other stimulants used to treat children with ADHD symptoms. Two site visitors, including my friend Dr. Bob Dick, raised some strenuous objections to my post, and more importantly to Dr. Sroufe’s piece in the NYT. Both of their comments convinced me the issue deserved another look, and that because of my basic anti-medication bias, I’d been too quick to accept Sroufe’s report at face value.
Shortly after Sroufe’s article appeared, Harold S. Koplewicz MD, President of the Child Mind Institute, wrote a point-by-point rebuttal of it; if you’re interested in this issue, the article by Koplewicz bears reading. I won’t bother to summarize the whole piece, but suffice to say that he brings some fairly persuasive evidence in support of the effectiveness of stimulants to treat ADHD symptoms in children and raises important questions about the validity of the studies cited by Dr. Sroufe and the conclusions drawn from them.
Before I began taking on new clients for online counseling in November, it had been quite a while since I’d started therapy with someone new; for the most part, my practice had involved ongoing work with long-term clients who were no longer struggling with depression. A number of people have recently come to me with depression symptoms and I’ve been struck once again by how important it is to understand the role that anger and rage play in so many depressive conditions.
In an earlier post about different types of depression, I discussed severe cases that result from intensely destructive but unconscious rage; I believe unconscious anger plays a major role in less severe conditions, as well. You’ve probably heard depression described as “aggression turned inward”; accordingly to this view, depression symptoms are the result of unresolved and unexpressed anger that is turned inward upon the self instead of being directed outside, at other people. This might account for the apparently unjustified feelings of guilt that often accompany depression symptoms: while the depressed person has no real reason to feel guilty — that is, they haven’t actually done anything in the external world about which they might legitimately feel guilty — their (unconscious) enraged fantasies of wanting to hurt people around them nonetheless inspire feelings of guilt. As therapists, instead of treating the feelings of guilt as irrational and unjustified, we might instead wonder what the person has done (in unconscious fantasy) to justify those feelings.
Countertransference was a term originally used by Freud to describe a client’s influence on the analyst’s unconscious feelings. Freud believed that no psychoanalyst “goes further than his own complexes and internal resistances permit,” and for this reason, having a personal analysis as part of training was considered essential. In other words, Freud viewed countertransference as arising from unresolved and unconscious issues within the analyst. Since then, our conception of the countertransference has grown to include all of the therapist’s reactions to the client, including his or her conscious experience during the session. From this point of view, as a working therapist, your own feelings, thoughts and fantasies provide important information to further your understanding of your client. This latter view is exactly the way I think about countertransference; during sessions, I rely heavily on my internal process to help me understand the person I’m working with.
In my recent post on repression, I gave a simple example: a client who communicated a lot of pain to me during session (that is, I felt pain) but seemed not to be feeling it herself. I often have similar experiences in session, where I’m listening to someone talk; feelings will start to stir within me but my client doesn’t seem to be conscious of any particular emotion. Working this way, you have to be cautious not to assume that everything you feel comes about because of the client’s issues; you need to listen for other material that gives you a basis for believing that it’s a projection or unconscious communication. After a while working this way, you begin to trust your reactions (your countertransference in the broad sense) and feel confident about when and how to use them.
Part of that trust depends upon your comfort level with certain emotions. Remember Freud’s remarks about how unresolved complexes and resistances will limit a therapist’s effectiveness. If you’re the kind of person who has trouble bearing anger or grief, it may limit your ability to understand your client’s experience. This is especially true when dealing with certain types of depression. I’m thinking in particular of one type I discussed a while back, where unconscious and destructive rage plays a major role. Therapists who have a hard time acknowledging their own anger and aggression will struggle with this particular client because they don’t want to feel the emotions aroused by treatment. Therapists who believe they should only have kind and loving emotions toward those in their care will also have a hard time. Such therapists may often dislike the client without quite admitting it. Their interpretations may come across with an edge; or they may become much more directive and impatient because they want the client to “move on.” They may secretly dread that particular session in their day.
Thirty-five years ago, I received a phone call from my friend Lily about a car accident involving a mutual friend of ours, Terry. The three of us had just graduated from UCLA the week before. Terry, along with her sister, brother-in-law and niece, had gone on a trip to the Colorado River. En route, along a two-lane highway, another vehicle tried to pass them and the line of cars ahead. The driver mis-calculated the distance and as a result, a semi-truck coming from the opposite direction swerved to avoid the passing car, struck our friends’ car and instantly killed Terry’s sister, brother-in-law and niece. Terry survived but suffered severe and irreparable brain damage.
I had given up my apartment following graduation and was briefly staying with my parents before leaving on a long trip. When I came out of my room after the call, deeply upset and in tears, my mother immediately went to her bathroom and returned with a blue, 10 mg Valium tablet which she pressed into my hand. Her response to my grief was to offer me the same medication she used to keep her own pain sedated. I hadn’t thought about that incident in years, but recently, in considering some of the wrong reasons people take antidepressants, the memory came back to me.