First of all, we should realize that it is a virtue that a therapist can recognize and acknowledge to themselves  negative feelings towards a particular patient. One can’t expect to like every person you meet and just having some negative feelings isn’t necessary a contraindication to working with someone. If the feelings are minor it should not interfere with the treatment and the therapist would keep these feelings in mind but proceed with the treatment. In fact as will be described, the awareness of such feelings may actually assist the therapist in carrying out effective therapy.

Therapists are usually trained to reflect on their own feelings as they work with a patient, particularly when they are aware of strong positive or negative feelings. In the case in question, where the therapist is becoming aware that he or she doesn’t like the patient, the self oriented question is “Why don’t I like this patient?” The answer may  be obvious, such as the patient is inconsiderate, self centered, prejudiced , anti my political or religious beliefs etc. One doesn’t necessarily dislike a person who meets such criteria and therapists in their self reflection need to include the contemplation of “What do I know about myself that might help me to understand these feelings?” It may be that the patient reminds you of a significant person in your life or certain situations which have occurred to you. One more additional self directed question should be “Can I work with my own feelings and try to help the patient or are these feelings too strong for me to objectively work with the patient? Also, am I just not inclined to work with the patient even if I understand why I feel this way?”

If the awareness of the dislike for the patient comes during the initial consultation and the therapist is not inclined to work with the patient,  it may be relatively easy to refer the patient to a a colleague. A therapist not uncommonly will refer a patient to another therapist after the initial consultation if a therapist with special expertise might be better suited to treat the patient or if the therapist and the patient’s schedules don’t mesh for setting up ongoing therapy. On occasion, the consulting therapist might feel, after an initial consultation, that the therapy should be by a person of another sex, background or age. While these situations are less common, it may happen. Therefore referring the patient to someone else whom you feel will work better with the patient after you have initially examined the patient is ethically proper. Our guideline is to do no harm to the patient and do everything in the patient’s best interest. Therefore it most likely would only be hurtful to the patient to explain that you don’t like the them and that is why you are making the referral, therefore you shouldn’t do that. This may put you in the position of having to tell a “white lie” by saying that your schedule doesn’t work or that you are sending them to another therapist whom you feel is better suited for them (although this may technically be the truth). The therapist has to make the decision whether to discuss the reason for the referral. If the reason was one which there was a good possibility that another therapist might have the same problem ( ie. The patient was a member of the Klu Klux Klan or was a psychopath etc,) it would be best to discuss this with the potential new therapist in order to find someone who could separate their own personal feelings and work with the patient. When the reasons were totally personal  (the patient reminded the therapist of someone or some personal situation ) such a discussion would not be necessary. In such case, a general reason or a scheduling problem could be given for the referral or you could share this information with the new therapist.

When the awareness of the dislike for the patient occurs during ongoing therapy, referring the patient to someone else becomes more complicated as interrupting the therapy would have to be weighed against the therapist concluding that they can’t help the patient due to their own feelings. Psychodynamically  trained therapist are usually trained to recognize and work with their own countertransference and this would be the preferred mode of operation. This approach not only facilitates insight into self but also has the opportunity to facilitate the ongoing therapy. The therapist should always have the option to seek the assistance through a consultation with a colleague, a clinical  supervisor or their own therapist and certainly if they themselves are in ongoing therapy – this situation should be closely examined. Therapists should be constantly monitoring their own feelings and the awareness of some negative feelings about the patient is not unusual.

In fact the experienced therapist knows the kind of issues which push their own buttons and an emotional reaction to the patient may be the first opportunity to identify some conflict within the patient that both the therapist and the patient may not have had a conscious awareness.

After treating  patients with psychoanalytic or psychodynamic psychotherapy for a period of time we usually have a fairly good understanding of their personal and family dynamics. We come to understand their  relationships as well as their culture and customs which may be quite different than our own. If the the therapy has gone on for several years, we have seen how the patient and his or her environment interacts with important life events such as going to college, pregnancy, tragedies and even epic historical events such as war and 9/11. This is one of the privileges and great pleasures of being a therapist. In addition to helping our patients  have a more gratifying and forfilling life, we have learned a great deal, been enriched all the while sitting in our offices ( hopefully remembering to take time for exercise and other things.)

As Well As Reading A Good Novel

I recently was reminded how we can get a similar rewarding experience by reading a good novel.  I just completed such a book titled Shanghai Girls by Lisa See . As best I can tell  from supplementary reading, the author is not explicitly writing about her own life and family. She has researched her subject and her characters quite well by conducting many interviews and reviewing  oral histories in order to convey a very authentic story.  She also appears to have very good insight and empathic understanding of the emotions that the protagonists of novel could have.

Shanghai Girls

As the story opens the reader is introduced to two “beautiful” sisters age 18 and 21 who are living somewhat of an upper class exciting city life in Shanghai, China in 1937. We get a feel for their family dynamics which are embedded in the Chinese customs and culture of the time. We see devotion to parents but yet a struggle when an arranged marriage is imposed upon the sisters. We follow these girls and their family as they confront the Japanese invasion of their country, their attempt to flee, the death of family members and most poignantly, a brutal rape and the consequences of it. The story covers a time span of about twenty years which allows for a maturation and evolution of the characters as well as the effect of new historical events. The sisters come to the United States and struggle with the problems that  immigrants had to face in trying to make this transition. They confront cruel discrimination against the Chinese. Family secrets fester. We see the impact of parental values surface. Religious views, issues of conscience, teenage rebellion , the effects of previous traumatic experiences are all interwoven in this story. There are insights into the thoughts and feelings of immigrants trying to live in a new culture which can easily be reapplied when we look at the plight of the undocumented Latinos in the US today or reflect back on the experiences of the Jews as well as other groups who have tried to become part of the melting pot which is America.

I strongly recommend this book and contend it will  provide useful clinical insights for therapists as well as good reading for everyone.