Countertransference Issues in Treating Depression

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.

With this client, understanding the difference between empathy vs sympathy is crucial. For instance, a depressed client may come to session and complain about how hard or unfair life is. She may run through a list of grievances, criticize other people or implicitly blame them for what she’s going through. He may subtly communicate a demand that you “save” him from his experience. In all sorts of quietly “unsympathetic” ways, the client may ask for your sympathy and you probably won’t feel that way. Maybe you’ll instead feel a bit guilty that you don’t. This person in front of you is obviously suffering; why don’t you feel more sympathetic to his or her plight? At times like this, we may feel compelled to express sympathy in ways we don’t actually feel, and which make us sound like bad parodies of ourselves: “I hear you saying you’re in a lot of pain. I’m really sorry that you’re suffering so much.”

If, on the other hand, you rely on your countertransference in the broad sense, you’ll understand the client more deeply. Rather than expecting yourself to have sympathy, you might instead examine your own feelings and accept that you feel surprisingly annoyed or even angry with your client. For many therapists, such a recognition would be shameful. We’re mental health professionals and caretakers, after all — we’re not supposed to feel hostile toward those we care for! If you can leave yourself room to feel that way and wonder about it, you might find that it tells you something about the way your client is feeling. Of course, you have to know yourself well and feel confident that you can tell the difference between your own issues and those of your client.

Assuming you do, what might your own anger tell you? It could be many things, and you’ll need to listen carefully for clues in the material to give you more insight. Here are some possibilities I’ve seen in working with depressed clients:

1. The client is enraged and doesn’t know it. I have often found this to be the case. In the professional literature, depression has been discussed as “aggression turned inward”; along those lines, I think of some cases of depression as the result of internal raging, where the person’s mind is laid waste by the violence of his destructive feelings and fantasies. You may be resonating with that rage.

2. The client wants to control you, or is quietly demanding that you take care of him or her. For me, a feeling of irritation sometimes comes up that tells me to look for covert manipulation, often masquerading as helplessness. (I discussed this phenomenon in an earlier post.) The client who feels unable to address the extent of the internal damage may believe instead that the only viable solution is to absorb the qualities they want by controlling you. Growth by annexation, as I called it, in my discussion of the film Cracks over on my Movies blog. They want to possess the mental health and emotional capacities you represent by merging with you.

3. The client is projecting a sense of despair and impotence into you; the communications cause you to feel as if there’s nothing you can do to make things any better, that you’re helpless to help your client, you just want to put them on meds, etc. This dynamic often comes up with clients who struggle with powerful feelings of envy and jealousy, but also with those in a state of disintegration. They may feel so overwhelmed by the degree of internal damage, so full of unbearable shame that they evacuate it into you. You might also consider it a communication of the mother-infant type I discussed in my post of the development of mind and meaning.

In all of these cases, I have found that understanding the particular dynamic leads to an emotional transformation within me so that I’m able better to empathize with the client’s pain. Instead of feeling the anger or irritation, I empathize with their shame and their sense of despair about the internal destruction. As a person who has wrestled a lot with issues of rage and anger during my own analysis, I truly empathize with the pain those feelings produce. That’s quite different from feeling sympathy for what is consciously expressed.

The work then becomes about helping the client to bear those split-off emotions. It’s not easy work. Hardly anyone wants to feel rage. Few people will admit to poisonous envy. Clients can easily feel criticized when you show them the ways that they’re manipulating you. Then there’s often a long phase where the rage becomes acknowledged and explosive during session, when all that anger is now overtly directed your way. I have found this to be the case with depression in borderline personality disorder. Very hard work, to remember (in a feeling way) that you care about someone who is assaulting you. But that’s the job, as I discussed in one my earliest post — returning a kind of love in the face of hatred.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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24 comments

    countertransference has grown to include all of the therapist’s reactions to the client

    I have problems with the ‘all’. Are therapists really incapable of a real relationship with a client? If so I find this a worry.

    Or is ‘countertransference’ just a word for ’empathy’ or ‘common humanity’? If so why not say so? Perhaps ‘countertransference’ is a resistance.

    Hi Evan. I agree that when you use the word “countertransference” this way, it becomes kind of fuzzy. Maybe we’re better off with another word altogether. Certainly empathy is a very large part of it. It’s really about using your emotional reactions and responses as information during the session. Sometimes your reactions have more to do with you than the client (maybe that’s countertransference in the old sense) but sometimes they tell you a lot about what’s going on unconsciously for your client.

    Have you ever fallen in love with a patient? My first therapist ended therapy with me because she fell in love with me and it completely shook my world. Whilst she still wants to stay in touch (and continues to message me though I’ve been clear about not wanting contact), I want nothing to do with her and I’m incredibly angry. I am seeing another therapist now who is helping me with this, amongst other things. When she was telling me her feelings for me, she told me that she even checked with her supervisor to make sure that her feelings weren’t my projected feelings towards her. This makes me furious, because it makes me feel responsible, as though its my own fault for losing this. It just feels really unfair. So I don’t know what transference/countertransference applies or what it means or whatever, but if you are going to use it to “better to empathize with the client’s pain” please please do so carefully. I hate that this experience has made me guarded towards therapists and therapy, mainly because I still need it.

    Your therapist must have had a really bad supervisor. When I was in my first year of training as a psychotherapist, I had client who I thought I had romantic feelings for. I took session notes to my supervisor, who helped me see that the client was being subtly seductive toward me, to engage me in a romantic way as peers rather than turning to me in a state of true need. This isn’t uncommon, in my experience. I’m NOT suggesting that this is what you were doing. It sounds like your former therapist had some countertransference issues in the original sense: her feelings for you reflected some unresolved difficulties of her own, rather than informing her about your state of mind.

    Joe, as always your post really spoke to me. Personally, I have a heard time with dysthemia and the negative affect that goes with it. It feels very stuck to me and I really dislike my own stuck-ness and my own negativity. I would like to split off that part of my personality forever. I have the urge to fix the client by showing how great life really is. I know this is how others feel with the client and I know it is certainly not helpful for them for me to deny their pain and world view. So I resist doing it and just stay with them but it is very hard work for me. I think that counter-transference is really all we have as therapists. How do we feel when we sit with another? This provides us powerful information about how the client is perceived by others. Again, thanks for writing about this. I am always reminded of important information when I read your blog. Renee

    Thanks, Renee. I think this is one of the reasons why so many professionals like to prescribe anti-depressants — they don’t have to sit with the client and his or her pain. A 15-minute med eval and they’re out the door!

    Thanks again for an interesting post that’ll keep me thinking for days… I’m not a therapist, and my mother-in-law not my patient, but this post, and especially what you wrote about growth by annexation, got me thinking about our realtionship. My mother-in-law is a sweet, old, helpless lady who’d drop everything to help us with anything and never says a bad word about anybody. Still, everytime I’m near here, I find myself being irritated and angry. My husband and I are pretty sure that she’s depressed, and she obviously has next to no self-esteem. She’s always changing her preferences and opinions to suit ours, and epsecially mine, and I’ve told my husband that it reminds me of having an insecure friend in high-school (the woman is in her seventies and went out and bought the exact same shoes I’d just bought, for instance. She also started using the same perfume – and there are a lot of other examples).

    I’m really freaked out by this, and I feel like keeping my distance with her, but she keeps following me (if we’re on a weekend-trip, I mean this in a literal way). I know she’s insecure and doesn’t have any close friends, but I feel like she’d suck me dry if I’d let her. I’ve felt bad because I’m more confident and well-functioning and should be able to be nicer to her, and I couldn’t understand my irritation. But now I got some new food for thought, thank you!

    Christina, it sounds like dealing with your mother-in-law is a trial. Just remember it’s not your responsibility to take care of or “fix” her. Being kind to her is one thing, and you obviously do that. But what she really needs is professional help.

    She needs help, but I can’t see how that would come about, as there is no therapy in her world, she is totally unfamiliar with it, in her mind, therapy is for crazy people. I was in therapy for three years to stop me from helping people instead of living my own life. It really helped, but this is a test (I’m not always nice, when she followed me to the bathroom once, I screamed at her to go away, I was so freaked out). You can’t get someone into therapy, can you? Even if it’s obviously needed? And is it possible to change that much when your in your seventies? I never met my late father-in-law, but appearently, he was her rock until he died. Maybe me being nice is keeping her from dealing with her own life (or from suicide, I sometimes fear). Thank you for your kind and understanding words!

    You’re right, you can’t get someone into therapy if they don’t want to go. I think there’s a place between nice and screaming, where you can firmly protect your boundaries before you get to the point where you’re that frustrated. There’s nothing mean about setting limits. Not easy to do, of course. You do have a lot on your plate!

    You were so right. I’d forgot my limits completely. Your answer woke me up to find myself miles and miles down a detour road. Back to meditating, back to boundaries. Thank you!

    Of course I took it first in the most flattering way: that I was a staggeringly powerful influence on him. And then I found it a charmingly modest statement, a suggestion to remember he could be wrong. Both of these are highly personal interpreatations, obviously.

    I needed my therapist to feel what I feel ie the huge screaming void of depression. She took a long time to open the door last week and said I didn’t realise what I had done to her. I know she has times when she can’t face anyone but she couldn’t look me in the eye last week and said she couldn’t carry on with this, which I took to mean the therapy. I don’t know what to do. Do I apologise and try to make reparation or do I terminate the therapy for now.

    You have no reason to apologize. Your therapist is telling you she lacks the emotional capacity to help you. My advice would be to start looking for a different therapist.

    Dr. Joe, thank you for all your posts. Just started reading them and they have been so helpful and enlightening. In regard to your response to Cathrine above (in Nov) about thinking you had romantic feelings for a client, but learned through your supervisor that the patient, in fact, was seducing you, how did you handle the client after this awareness? Was it easy to just switch off the feelings you felt? Or did you secretly continue to harbor these feelings for them but continued the therapy as a professional would? Just curious on how doctors handle their own feelings even after acknowledging the counter-transference. Sometimes it’s not so easy to switch feelings off and on when you want. Your honesty on this site is very much appreciated.

    With that particular client, I was “saved” from having to deal with it when she took a job in New York and moved. When other such feelings have come up, and it hasn’t been very often, I find that if I’m just skeptical about them and wait long enough, they eventually do fade as I come to understand the dynamics between us. I think the real risk is when the client’s admiration for us taps into our own narcissism; we run the risk of believing we’re every bit as wonderful as the client feels us to be.

    Hello Dr. Burgo,
    A devil’s advocate question for you: Transference and counter-transference occur in every type of relationship. Why can’t it be positive and healing? And when you cut through the psychobabble, could it not just be possible that client and therapist are meant to be together? It is not our fault we met under the conditions we did. By the way I am an MSW. We recognize some of the usual pitfalls but we also see the numerous positives. Once my therapy is done, we will likely enter into counselling ourselves to iron out the kinks BEFORE they become too problematic. While this therapist is wonderful he has been through a world of pain that he needs to grieve and deal with his own demons on his own time. Only then will we consider a relationship-friendship first to build a solid connection. So you know the old joke about just because you are paranoid does not mean people are not after you anyway? So then: Just because there is trans and countertrans does not mean you aren’t right for each other!
    Your thoughts?
    Lee

    I think that transference is inevitable and necessary; the transference relationship is where the healing occurs and not something that needs to be avoided or “interpreted away.” I also believe that therapists get their own needs met through their relationships with clients (call it counter-transference, if you will) and as long as it’s not an unhealthy or narcissistic need, that’s just fine. We’re not selfless beings, of course.

    What a helpful article. I am a trainee therapist, working with my second long-term client. She is very depressed with suicidal thoughts, and sometimes I find the countertransference after sessions so heavy – bits of the hopelessness get into me, and I’ve felt very preoccupied with the topic of suicide (though not actually feeling suicidal myself), which has been losing me a little sleep. I know I have some personal vulnerabilities around this as one of my parents has made suicide attempts, including recently. I know both my own therapy and supervision are important here. But what I’m wondering is, is this usually tough for trainees and does one usually progress to finding countertransference more bearable?

    Yes, I think it’s difficult for everyone starting out, and it most definitely becomes more bearable. For me, and I think for most psychodynamic therapists, what makes it bearable is learning how to interpret the unconscious projections and “give them back” to the client, as it were, so you’re not left with them. It’s when clients come in,”dump” all their pain into us and leave it there that it’s hard to bear. The work is to understand and somehow transform that pain into an interpretation that sheds light upon the unconscious.

    Hi I am out of psycotherapy , I was seeing my t for two years once a week. We had a lot in common close in age. I loved being able to let everything out to such a grounded wise person.he was honest, kind and very intuitive . A truly gifted person. We did a lot of projection , really talking about ourselves using other people , it wasn’t till therapy session was over and I was driving home that I concously figured out I was talking about him not my husband or I was talking about me not my father, he would do the same. Talking about his father but it was his feelings, we had great emotional release but I stopped therapy because I felt I wanted this in real life not the therapy room. I miss therapy it was my favorite day of the week, I never told him about my transference so I am healing alone, any tips on how to move forward.

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