Working with Transference: Timing, Technique, and the Here-and-Now with Jonathan Shedler

Helping the patient to find words to describe their experience, you know, which is often metaphorical, or listening to the patient's stories and understanding them metaphorically. So for example, you know, a patient might talk about going to see their physician, or you know, they thought it was a minor issue and the physician — this actually literally happened — and you know, the physician actually got some very troubling test results and it turned out they had something fairly serious. I hear that metaphorically. Well, they're telling me about their doctor's visit, but they're telling it to me now, you know, during our therapy session. So I also hear it as a metaphorical commentary perhaps on the experience they're having here and now. So no, I don't bring a stockpile of stories to tell patients. I get curious with them and try to, you know, expand the space for the patient to notice and attend to more of their experience.

Yeah, that's a tough question. So first of all, we're always addressing the transference. The transference is never not there, right? And the countertransference is never not there. If there's two people in a room interacting and they're alive, there's transference and countertransference. So, I would rephrase the question as like, how do we make constructive use of the transference? Wow, that's such a potentially big question.

We try to create a relationship where the patient can talk as freely as possible. Maybe we like really the instructions to the patient are: whatever you notice here, whatever you become aware of here, whatever comes to mind, for our purposes it's important to try to say it. So we're not overly structuring what the patient has to talk about. And then I'm going to divide your question into two sub questions. As a practical matter, we have to be very, very attentive to negative transference. You can let positive transference ride. We'll deal with it later. But very early in treatment, I mean really from the first meeting, the negative transference, if it's not made explicit, if it's not conscious and talked about and acknowledged, can blow up a treatment before it even starts. So one version of a transference interpretation is you make some observation or comment or whatever and the patient starts defending themselves. So there's a negative transference there. You said what you said for whatever reason, whatever clinical reason you had, but the patient heard it as a criticism. So we have to make that negative transference explicit, right? It could sink the treatment, you know. So, in this case, it was really as simple as saying, you heard that as criticism. You felt like I was criticizing you, right? So, I'm just taking something that's pretty close to the patient's conscious experience and I'm putting it into words and I'm saying, you know, I can hear this. You know, there's room to talk about this. Let's talk about it directly. So that's one version of attending to the transference. You know, I mean any negative reaction that the patient has early on, we really want — we don't want to brush over it. Like we really want to recognize it, attend to it, put words to it, and invite the patient to discuss it. Now, there's another kind of transference interpretation, which I think is really your question, which is, you know, when do we — right, these are sort of the big, you know, the big guns of therapy — when do we bring this in. So there's the content of what the patient is saying. There's the transference of what they're doing with us and showing us in the room. That's actually more important. But what we're really listening for is when we can hear parallels, see parallels between the content of what the patient is saying about things that happened in other times, other places, other relationships, right? And what's happening here and now in the room. Right? So, that's the best kind of transference interpretation, the one that bridges the gap. So, I have a patient who it's been an ongoing theme. She's had a couple of like previous failed therapy attempts. She'll sort of get a little dysregulated and then somewhere in there she'll start to tell me about — right, her thoughts will go to a previous therapy when the therapist actually said in one way or another like, this is too much, I can't, I'm not like, I'm not up to handling this. So I make the link, you know, and I might say, you know, that came up, your thoughts went to this previous therapist just on the heels of, you know, of telling me about this overwhelming experience. You know, it makes me wonder, you know, whether you're concerned that you're going to be too much for me right here, right now. So, it's really very close to the patient's experience, but I'm making a link between something that happened in their past and then something happening in the room. So we want to listen for those links. And actually there's three links. It's the links between things that happened in past formative relationships, often parents or siblings or an important teacher; things that are happening in current important relationships, you know, with a partner, spouse, girlfriend, boyfriend, some, you know, important attachment figure; and the therapy relationship. So, past relationships, important present relationships, the therapy relationship. And when you hear the same pattern and you connect the dots and say, 'Oh, here it is. Here it is. Here it is in these three areas. Here it is right between us.' That's really the ideal kind of transference interpretation. It links it directly to things that are important in the patient's life. Is that a good enough answer?

No, that is the case. And as you go into the borderline range of functioning, actually that shifts things. So what I just described we call psychoanalytically a genetic interpretation — not genetic in the sense of, you know, genes, genetics, but genetic in the sense of the person's developmental history. When you're dealing with somebody who's in the borderline range, they just — it takes it too far out of the here-and-now experience in the room. So generally we don't want to make genetic interpretations. We want to focus, you know, certainly through the early stages of the treatment, on what's happening like right here, right now, you know. So my first example about, you know, you felt like I was criticizing you — that was yesterday. It actually didn't go very well yesterday because the patient's response was, 'Well, you were criticizing me.' And then you get into what like people who are writing about mentalization-based therapy, Fonagy, Bateman and their group, you know, really very good at this. I mean, really staying in the here and now. Something like, you know, 'I couldn't understand why it landed on you that way or why you interpreted it that way. I wonder if you could imagine other reasons why I might have said that.' And it's like, 'Because you were critical of me.' Like, 'Well, yeah, that's certainly one way to understand it. Just humor me — like, what else could you imagine?' You're trying to sort of expand their capacity for mentalization, that is their capacity to think in terms of, you know, the other person's motives and, you know, intentions, right? And it stays very much in the here and now for quite a long time in the treatment.

Yes. Yeah. Exactly. Right. So the problem that you have when you're dealing, you know, primarily at the borderline level of functioning is if you look at it through a mentalization lens, there's really a deficit in their ability to, you know, imagine somebody else's internal states, motives, intentions, as well as a deficit, you know, in their recognition of their own internal state. You're really working on that. If you look at it through like a transference-focused therapy lens, they're really different sides of the same coin. What the patient is responding to is their projections rather — right, there's a certain rigidity to the projection where the projection isn't, well, you know, this is how I'm interpreting it. The projection becomes, no, this is a fact. So yeah, if I tried to make a transference interpretation that had the genetic component that linked it to something outside the room and the patient couldn't go there, I would say, oh, you know, that was a mistake on my part. Let's come back to the here and now, right? And then, you know, then it becomes, you know, how are you seeing me now? Like, what's your understanding of how I'm listening to you and, you know, what I'm thinking and experiencing when I respond to you? Who are you right now? Right? What are you experiencing on your end of the relationship? Right? So yes, short answer: you have to come right back to the relationship. And there's a general principle in all psychodynamic therapy, which is the process takes precedent over the content. The process meaning what's going on interpersonally right here, right now, between the two of you. So I mean, I really, really believe that the dividing line between a master clinician and not a master clinician is the ability to shift from being immersed in the content of what the patient is saying and shift attention to what's going on in the room right here and now between us and to address that. And any — like if you guys take nothing else away from today, like that's the issue. When — like take this away: when you're feeling lost, you know, or bogged down, or you know, you and the patient are not tracking with each other, or you're not understanding something, let go of the content and just think, what's happening here in the room between you and me? And you can even say it that way to the patient, right? Something just happened between us. Like something just shifted now. You know, I'm not really — if it's true — I'm not really sure what happened, but something changed. You know, did you notice it also? And, you know, help me understand your experience of what just happened. You know, who am I to you? Who do you think you are to me? Right? So we're inviting, right? We're inviting reflection of the process. Sometimes you get a lot of pushback from the patient. 'That's not what I came here for. You know, why is that of interest? You think you're the most important thing in the world. Like, why do I want to talk about the relationship with you?' And we need to know the answer to that. We need to be able to respond. And, you know, the answer is some version of: because by virtue of being human, this is how we're built. We tend to recreate and repeat relationship patterns throughout our lives, right? And we repeat them wherever we go. And in, you know, in your case, it's caused problems for you. And I'd link it specifically to, you know, why they're here. And, you know, what happens between us here is a window into these relationship patterns, right? If we could understand something about, you know, how they repeat here with us, right, that understanding would then spill over into your other relationships, right? So that you had some freedom, you know, so you don't have to spend the rest of your life repeating the same painful or self-defeating patterns. So when we make these kind of transference interpretations or we shift the focus to the interaction in the room, we really need to know why we're doing it and we need to be able to explain it transparently to the patient.

Those weren't the difficult ones.

It's just another transference to explore. Right. So I mean everything gets really, really simple once you have an understanding of the concept of the therapy frame, right? The therapy — like people, trainees especially, often misunderstand. You know, they think the frame is a series of rules to follow, and it's not. It's not rules. The frame is like sort of the rules of engagement for the therapy relationship. You know, what we do here and how we do it. So part of the frame is, you know, what we do in therapy is we talk about things, right? Anything that you think, feel, anything is fair game for therapy discussion. In fact, it's something, you know, invited in that we want to hear about, right? Within the rules of engagement, which are: we will stay in the realm of thoughts and feelings and fantasies and not be acted on. Once you understand that as the therapist and you're like, you know, rock solid, this is what we do, right? Well, then it's thoughts and feelings and words like anything else and we treat it like any other transference. But I think behind your question is when you, as you start getting into the like borderline range of functioning, right, you start to get patients that really don't separate thoughts and feelings from actions. Right? Now we're dealing with those projections, you know, 'No, you really do want to sleep with me,' or, you know, whatever form it takes. I'm curious in, you know, regarding this question, people in the more neurotic range where they might have, you know, more of a sense of like, oh, this is inappropriate to this setting, and so disavow, you know, sort of have that part of them either it's, you know, too shameful or disavowed, and so it's there, but it's unsaid. And how if you're attuning to that, that might be something coming up, but how would you approach that?

I mean, this is when you think diagnostically — I don't mean DSM diagnostically. I mean psychoanalytically, case formulation diagnostically. Like this is a real dividing line between neurotic and borderline level functioning, like right? The neurotic level of functioning, I mean, the person typically feels guilty and ashamed and hesitant, and, you know, they're not going to come out with it directly. Especially these sort of, you know, cross-sex therapy pairs, right, where, you know, like the patient thinks it's inappropriate, but now you're dealing with, you know, old-fashioned garden-variety conflict and defense. You know, I feel certain things, I have certain, you know, desires, wants, and something inside of me says, but no, it's not okay, you know, you shouldn't feel it, you shouldn't talk about it. The borderline patient is more likely to act it out. Right. It's not buried under the surface, right? I mean, they're being maybe openly seductive, right? Or openly, you know, openly salacious, right? So the neurotic level is, you know, it's hard for the therapist to deal with because often the therapist also feels uncomfortable with the topic. But the way we deal with that kind of neurotic conflict for, you know, for anything is, you know, we listen to the derivatives, which is to say that, you know, the metaphor, we pick up on it and, you know, we really want to signal to the patient, you know, first of all we hear it, second of all unlike the patient, you know, hopefully we're not passing judgment on it, and third, like everything else, it's something to be curious about that we could think about, right? Like it might hold some meanings. So sometimes I use humor. Like I was treating a pretty high-functioning person. It was the situation you described, but she was pretty, you know, she was pretty straightforward about it. She's like, you know, 'Oh, you know, yeah, I mean, I could never tell you about — I could never tell you about...' Oh, I remember. She's like, 'Well, you know, I have some thoughts and feelings, but, you know, it wouldn't be appropriate for me to say because, you know, rules and boundaries and frame.' She had the idea of frame, but was misusing it here. She said, you know, 'It's not appropriate for therapy.' And I just used a little humor and I'm like, 'I think you misunderstand that the rules are for me, not for you. I'm the one who has to follow the rules. You get to say, you know, you get to say whatever you think or feel.' And so we just sort of broached the topic that way. And it took quite a while, but, you know, you really want to continually invite it into the room and communicate to the patient: yeah, this is just one more pretty normal, common human response and so much more grist for the mill.

Be brave. Be brave. It comes up all the time. Like, you know, look, you guys are — just from my take of your little postage-stamp windows on the screen, I mean, like, you guys are young and good-looking. It's going to come up. It is coming up. You may or may not be attending to it, but it is going on between you and patients. Do you want to give an — do you want to stay with this, give more of an example, David, or do you want to pivot to like the countertransference regarding sexual transference here?

But you're not doing psychotherapy under those conditions. You're doing — you're managing, right? I mean, this is psychiatric management. If you're doing psychotherapy, right, meaning you have an ongoing relationship, right, you are both expecting and planning, you know, to meet on a regular ongoing basis, and the purpose of the therapy is deeper self-understanding, self-awareness, right, and not for its own sake — I mean, deeper self-understanding so the person can free themselves from having to, you know, from being sort of destined to live out the same unhappy patterns over and over again. And so the person can be, you know, more whole, just say, you know, more right — if the person is, if there's like splitting or dissociation, you know, more whole and integrated. If the person is in, right, that's borderline range. In the neurotic range, the person is, you know, conflicted, right? Certain parts of their experience are, you know, welcome and, you know, get to be seen and heard from, others not, right? We want to hear from all of the sides of the conflict. Right. So when you say more whole, right, the person's sense of themselves encompasses more of their experience. Why am I saying that? If it's that kind of therapy, then sexualized transference is just one more kind of transference. What do we look for in the transference? Right? The person is repeating difficulties in their life. It's not a one-time thing. I mean, it's a pattern that we can see recur and ideally they can see recur. We're listening for that theme, but we're also looking for the convergence of that pattern with a pattern that's happening in therapy. I mean, this really depends on their capacity for insight and, you know, reflection. But that's a pretty fertile ground for interpretation. And, you know, the interpretation — you know, you think of it in terms of scaffolding up to the interpretation, and the scaffolding is clarification, confrontation, interpretation. In psychoanalytic work, you know, clarification is: this is happening. Let's bring it into focus. Let's recognize this. So I mean, there might be, you know, they might be telling you about one of these difficult triangular relationships with, you know, that they get into. You might — the clarification might be, you know, 'That sounds like another one of these triangular relationships that always involve some, you know, sticky situation with a third person.' The clarification doesn't ask the patient to do anything. It just — it's just sort of bringing something that we think is important into focus. Or if it is asking the patient, it's asking to elaborate and say more. And are you getting that right? Are you getting that wrong? Right. Can they clarify the experience? The confrontation is: what about that? Let's think about that. We want the patient — confrontation is not confrontation between therapist and patient. It's asking the patient to confront themselves with more of their experience, right? Basically, to pay attention to it. Let's pay attention. Let's really think about it. Interpretation is making a link that's not already apparent. And in the example you gave, it's, you know, I might say something like, see, once it's established, here's the triangular relationship that, you know, that you're describing. Here's the kind of — it's the kind of thing that gets you in trouble for, you know, this or that reason. You know, here it is. It seems to be happening again in this situation you're describing. Right? Once that's the scaffolding, once that's established, then you're in a position to say, you know, 'It seems to me that there's a way that that same thing is happening here between us,' right? 'What do you mean?' Say, 'Well, you're telling —' I'm just making this up, but, you know, 'you're telling me about how, you know, this person is in the position, you know, of having to see or hear about what's going on between you and this other person, and this third person is in, you know, right? This third person is, you know, seeing things that, you know, either trying to draw them into something or trying to let them know they're not included in something or whatever's going on. You know, there's something in the way you and I are talking about it, and it's like, it seems like I'm in that same person's situation. Do you see how there's something similar happening in what you're telling me about and what happens between the two of us right here as you tell me?' I now — I'm, you know, I'm the witness, right, to something. And then it becomes a question of how much curiosity — right, because what we're really after is curiosity, right? We're always sort of testing the limits of the person's capacity to get curious about themselves. Do you see how this is happening here and there? 'Oh, I never thought about it that way. I guess I am putting you in that position.' It's like, what about that? Let's think about that together. You know, help me understand what that means for you just right here, right now. So, that's a way of working with it. And I will add — I know there's other questions — but the thing that gets in the way for therapists, especially younger therapists, you know, we're like, we're uncomfortable with our own sexual feelings toward the patient. 'I'm not supposed to have it. I'm only supposed to have like benign physicianly or therapisty feelings toward the patient.' No, we're supposed to have the full range of all of the normal feelings that we have in all of human life, right? Within the frame, anything I think and feel is fine. But there's a frame about, you know, what we do and don't act on. Like, so then I'm like, I'm, you know, feeling attracted to this patient, or I'm feeling put off by, repulsed by this, whatever it is, more than I normally would, right? My internal process as a therapist is I want to notice that, say, okay, well, how much of this is about me, you know, my life situation, the kinds of things I'm attracted to or put off by, turned off by? How much of it is about something going on in the relationship with the patient? Right? Doing that internal work — and that's, you know, that internal work is what prepares us, right, to say something that's helpful to the patient. If we back away from it, 'Oh well, I'm not supposed to think that. I'm not supposed to be attracted to my patient. Bad thought. I shouldn't think that,' right? Then we close off a channel of information because our feelings are in part, you know, created in response to something happening in the relationship. I saw somebody wave a hand, Daniel.

Yeah, and that's the work we have to do, right? The question becomes why is the patient doing that, and then, you know, how do we work with them so that they can start to get a sense of why, right? So you just put a hypothesis on the table. The hypothesis is either true or not true. We don't know in advance. You have to explore it, right? So one hypothesis is this is a — there's something performative, it's a defense against talking about, you know, it's a defense. If you — we say, if they weren't doing this, what else might they be talking about, right? So if there's something that starts to feel, you know, sort of repetitive or scripted, right, in how the person presents, then we think, oh, okay, you know, that's not free, right? We're looking for free association, which is, you know, just really say whatever comes to mind, be open to attending, right, to whatever we notice. But the person isn't doing that, so we could think of it as a defense or resistance, right? Another hypothesis — another hypothesis is they want to enact something with you, they're trying to titillate you, they're trying to get a response, I don't know, so that you should feel left out, not them, right? Or right, there's a whole lot of hypotheses. So, you know, one option, you know, might be just in a very wide-open way say, but, you know, there's a way that you're — you know, you've told me about this situation, this situation, that situation, you know, now again, you know, there's a way, it seems like it's — you're telling it, you know, in a way that seems like, you know — I would just say directly — in a way that, you know, seems like you want to tell it in a way that's titillating for me. You know, I'm curious about that. Help me understand that. And of course, when we say 'help me understand that,' what we really mean is, you know, let's hear more so that we both have a chance to understand it, right? We, you know, we ask the patient to help me understand it, but part of what we mean is let's look at it and think about it so that we can both understand it. So, you know, 'help me understand that.' You said, well, I didn't — the patient says, 'Well, I didn't really think about it that way.' Yeah, I know, but now that, you know, I've put it on the table and, right, right, it's out in the open as something that we can think about. I wonder what your thoughts are about this. And so that's part of the scaffolding. That's clarification. This is what, you know, here's something I want to bring into focus. Confrontation, which really — confrontation is just clarification plus an expectation that the patient should pay attention. That's really all it is. And then we see where their associations go and what comes up, right? We tune our ears to: is this taking the place of something else that they might be talking about? Is this repeating something else? Right? If it starts to sound like it's taking the place of — you say, you know, 'I notice there's, you know, there's a kind of pattern, you know, there's...

Almost to, to make one random example, like, almost like you feel like your role is to entertain me or to, you know, perform something for me or to keep me titillated, right? I wonder, I wonder what that's about. And then we listen to what they say and maybe we get to be able to say something like, you know, maybe it's easier to do that than to pay attention to, you know, whatever else might be coming up. Huh? Huh? I wonder about that.

So we're just continually inviting the patient to take things that they do pretty reflexively and automatically and slow down enough to pay attention to them and to recreate some space to notice more, just a bit more than they noticed previously, and to think about the bit more and to put that into words, right? And that's the process that's transformative, right? We're trying to create spaces, you know, pauses between things that otherwise happen very, you know, very quickly and automatically. Pauses to notice and reflect. And out of those pauses, right, comes the understanding and, right, the freedom and flexibility to maybe be able to do something else.