transference – PsychiatryTalk

Psychodynamic Psychiatry in the Medical Setting

The following is an extended version of a talk given by Dr. Michael Blumenfield at the World Psychiatric Meeting in Madrid Spain on September 15, 2014

Introductory Case :

I would like to start off with a case history

The patient is a 21 year old woman who has some paralysis in the right upper extremity and partial paralysis of the left lower extremity, weakness of the neck muscles, periods of persisting sleep walking as well as many other symptoms including a cough.

The symptoms came on after the patient’s father of whom she was very fond had become ill and subsequently died.

The patient’s internist Dr. B noted that the patient seemed to have alternating states of consciousness, which developed with regularity every day, during which she would talk and tell stories. She would talk about her past and how it was when she was a little girl as well as things that happened in the not too distant past. She would wake up feeling quite calm and then would go back to her usual clinical state.

Her internist became very interested in this patient and began to see her on a daily basis. He began to assist her to get into these altered states of consciousness by using a hypnotic technique. During the states he asked her to concentrate on each symptom. Eventually, she began to tell him about the circumstances that had occurred the first time that each of her symptoms had developed. When she came out of the trance, that particular symptom was gone. For example she told him that she began coughing for the first time while sitting at her ill father’s bedside and hearing the sound of dance music coming from a neighbor’s house. She had felt a sudden wish to be there and became overwhelmed with self reproaches and guilt feelings. Thereafter, whenever she heard music, she developed a cough. After this was brought out in the hypnotic state, the symptoms of coughing disappeared.

In the same way, her paralytic contractions, her numbness, hearing problems and other symptoms all disappeared.

The internist completed his treatment. While it was not in his original write up, some subsequent fact surrounding the case were not documented. Since the patient was cured of all her symptoms Dr. B. told her that he was terminating treatment and said good bye to her. However, that evening, he was called back to her house to find her in the throes of an hysterical childbirth.

We now understand that this was related to the patient’s “transference” which had been developing for some time. When the internist came into the room and asked what was wrong, the patient said, “ Dr. B’s baby is coming!” The doctor was overwhelmed by the situation and he had no way of understanding what was happening. He became profoundly shocked and took flight abandoning the patient to a colleague.

In retrospect, we understand that the internist had developed strong “countertransference feelings for his beautiful patient. He had been spending a good deal of time with her away from his family. He was emotionally involved with the patient and interested in her case. In his own background, his mother ( who happened to have the same first name as the patient) had died in childbirth when he was 5 years old. Unconsciously, he had become for his patient, the father whom she had lost and she was in turn the mother he had lost as a young boy.

This case occurred more than 115 years ago. The internist was Dr. Joseph Breuer, who subsequently collaborated with a young neurologist by the name of Sigmund Freud who encouraged him to publish this case history. This case marked the beginning of psychodynamic psychiatry.

It is known as the Anno O case. In it we can see evidence of early childhood feelings impacting on neurotic symptoms, a conversion disorder as well as examples of transference and countertransference.

Internet Changes Therapy Referral Patterns

The Internet has changed referral patterns for psychotherapy. Whereas in the past many therapists tried to keep information about themselves hidden, now days with the Internet it would be very difficult to do this. Rather than rely on referrals by other doctors, patients locate doctors as well as information about them via the Internet. The relationship to transference issues is also discussed.

When I first went into practice more than 30 years ago in New York City, I had my office in Manhattan and I lived in the suburbs. My home had an unlisted telephone number and I was determined that my personal life would be completely separate from my professional life. Other than seeing my board certification certificate on my office wall, it would take a great deal of effort for a patient to check out my credentials or be able know where I went to school and was trained. My office phone number was listed in the Yellow Pages but no psychiatrist that I knew took out a box, ad. On the very rare occasion when a patient came to me because he or she looked me up in the Yellow Pages, it was because they were socially isolated or had some type of related psychopathology. Referrals to me almost always came to me via mental health colleagues, physicians, patients or through my contacts at the medical school where I was on the faculty.

Fast forward to the present. A few years ago I set up a new private practice in California where I have relocated. Patients are still referred by the usual sources but in addition the Internet has made it a whole new ballgame. Finding doctors on the Internet has become a common practice. I have a professional website and it is not unusual for people to find me through several Internet sources. They have reviewed my web site and also googled me. They are aware of books and papers that I have written. They have seen my Facebook page. They may have even read my movie review blog. Having an unlisted personal phone number is not necessary since I have had a home office for more than 20 years, originally in Scarsdale New York and now in Woodland Hills, California. It doesn’t take much skill to locate my home address or even my email. People can check my credentials online and find out if complaints have been made against me and even make comments about me online. They probably can find out more about my family members than I know. Why would they want to do that and in fact why was I trying to be anonymous in the first place?

There are a couple of reasons why a psychiatrist might want conceal his or her private life , particularly one that does psychoanalytic or psychodynamic therapy. It is well known that a patient’s thoughts and emotional reactions to his or her therapist reflects important psychological insight into themselves. Therefore it is often the goal of a therapist to try to provide a gray or blank screen of themselves in order to make it easier for the patient to project or imagine things about the therapist. This would facilitate the formation of “transference” which is an extremely important part of psychoanalytic and psychodynamic treatment. The more the patient knows about the therapist, the less the transference originates with themselves and the more it is based on reality. While there is no doubt in the validity of this type of thinking, it is also true that just knowing some factual information about the therapist does not eliminate the development of transference. Experienced therapists can help the patient understand the meaning of their curiosity and whatever they have learned from the Internet about the therapist. Just knowing about the therapist’s life doesn’t mean that you have lost the opportunity to have transference be a vital part of the treatment. The patient’s interpretation and emotional reaction of the information that they have learned becomes useful data for treatment.

There has always been a concern that a patient might stalk a therapist after finding out where he or she lives or perhaps call or email the therapist (other than for administrative reasons). This might be precipitated by a strong emotional attachment or perhaps because of delusional ideas. While this may not be prevented in rare situations, it is the task of the therapist to help the patient to understand the boundaries between them and the value of discussing any such tendency in the treatment sessions.

Modern day technology offers much more potential benefits than obstacles to good mental health treatment. Information about the credentials and experience of therapists, education about mental conditions and various forms of therapy as well as information about psychopharmacology are available online. The state of the art now even makes it possible to provide therapy in locations where it hasn’t been available via Internet video technology. People who travel a great deal and where it is difficult to commute for regular therapy sessions may be able to use this modality. There are also many locations where trained therapists are in short supply. I have had some experience with telepsychiatry and I shall blog about it more in the future.

When the Therapist Dislikes the Patient

This blog examines that situation where a psychotherapist realizes that he or she doesn’t like a particular patient. The therapist needs to understand this feeling within him or herself. Referring the patient to a colleague is discussed as an option as well as getting help from a colleague or supervisor in sorting out these feelings. The awareness of negative feelings and countertransference by the therapist can helpful in doing effective psychotherapy.

What should psychotherapists do if they realize that they don’t like a particular patient who has come to them for help?

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.

60,000 Empathic Responses

There is a website titled Postsecrets to which people send artistic postcards with a secret on it. Recently someone from San Francisco wrote a postcard indicating an intention to jump off the Golden Gate Bridge.
There was an outpouring of responses which resulted in special page on Facebook linked to this postcard on which over 60,000 people have responded with words of support. This phenomena as a form of social empathy is discussed.

In a recent blog I wrote about empathy and how we might try to teach medical students to be empathic physicians. Psychiatrists, other physicians and therapists try to put ourselves into our patient’s shoes (or skin) in order to understand how they are feeling in regard to the things which are troubling them. When we do psychotherapy we often approach this with an added dimension. We know that the patient will usually experience the therapist in a similar manner to how they experienced important people in their early life, most probably their parents and/or siblings. Freud has dubbed this situation as transference and for certain types of psychotherapy understanding the transference and using it in the therapy can be very helpful. In fact, for psychoanalytic and much of psychodynamic therapy, it becomes the essence of the treatment.

Social Empathy

I was recently made aware of another aspect of empathy which I never thought about before and which I would now label “social empathy” . My consciousness to this form of empathy was raised when I read about a blog called Postsecrets which weekly displays anonymously mailed-in secrets on artistic postcards from across the country. It has been around for several years and has long been known for revealing suicidal secrets. It has set up a phone hotline in response since the blog began in 2004. Recently a postcard read, ” I have lived in San Francisco since I was young…I am illegal…I am not wanted here. I don’t belong anywhere. This summer I plan to jump off the Golden Gate Bridge.” According to a blogger Kristi Oloffson .within 24 hours nealry 20,000 people had signed up for a Facebook group titled “Please Don’t Jump, which was later linked beneath the secret on the Postsecrets blog , linking in thousands of supportive comments. On the group’s page, sympathetic users posted comments ranging from simply “I want you here” to “If I knew when you’d be at the bridge, I’d drive all the way from Ohio to meet you there, and hold you until you changed your mind.” A video about this phenomena has become the most viewed video on the Time Magazine web site. ( For information about the issue of suicide from the Golden Gate Bridge please see two previous blogs I have written on this subject , Suicide Jumpers From the Golden Gate Bridge and More on Jumpers, The Movie ).

I checked it out and sure enough and as of this writing there are more than 60,000 people who have tuned in to this secret and obviously felt an empathic response which they posted on the Facebook site. It may have been that this group comes from a populations which were drawn to the Please Don’t Jump Facebook page because they themselves are in touch their own secrets and feel for someone who has this one. Others without being aware of their own secret may also just want to reach out to someone else whose pain they can feel. It is also clear that people responding to the would be San Francsico jumper are not mainly other immigrants who are in a similar plight. They seem to come from all age groups, geographic areas and different backgrounds as best as I could tell scrolling through a sample of the now more than 60,000 responses. I believe that it is the identification with loneliness and isolation which is the universal piece that many people have felt at some time in their life which is connecting people with the San Francisco postcard sender.

Implications For Psychotherapy

I don’t believe that social medial will replace the role of psychotherapy. However, it does appear that there is a natural role that it is playing in the support of people who are feeling psychological pain. This new media is clearly interdigitating with other forms of psychological support and there is no reason whey they can’t overlap. We should be asking patients if they have had previous psychotherapy, whether they have been treated by any self help groups as well as including an an inquiry whether they have been interacting with the social media in regard to their current or other problems.