What Happens Between Therapist and Client? A Contemporary Psychodynamic Perspective

I didn’t decide that. My editor at Guilford contacted me and asked if I would be interested in doing a second edition. It was now 15 years since the first edition, and I asked him the very question you are posing:  Why now?  His answer was that interest in the psychodynamic approach was broadly increasing, resulting in greater interest in the book. That was music to my ears, of course, since the original purpose of the book was to make psychodynamic theory and practice more accessible for early career therapists.  I am always interested in updating my knowledge of research and practice, so I was happy to do that.  And I very much wanted to revise the chapter on regression, given the updated neuroscience-based perspective that there is no such thing as emotional experiences frozen in time, as Winnicott suggested.  Although some people fail to adequately process intense emotions, particularly in response to trauma, they have not literally stored these emotions away without modification.  Each time a feeling or memory is triggered and brought into awareness, it is modified. 

I did not include a chapter on transference in the fist edition because I thought it was too basic—that everyone knew what it was since almost all theoretical orientations mention it.  But after years of supervising therapists across the country, including early career psychoanalysts, I realized this wasn’t true.  Many of the therapists I worked with blamed themselves when their patients criticized or berated them, even when the person had described themselves as having these issues with other people. Perhaps because of the emphasis on each therapist-patient dyad as unique, it seems as though awareness of longstanding patterns of feeling and behaviors can sometimes be overlooked. I find that therapists often take their clients’ criticisms personally and either become defensive, overapologize or some combination of both.  A deeper understanding of the transference countertransference dynamic can help keep the focus on exploring the client’s emotional experience instead of guiltily shutting it down.  I am fond of saying that one of the biggest struggles for early career therapists is distinguishing between conflict and rupture.  Just because the client is upset doesn’t mean we necessarily did something wrong.  But I agree that keeping an open mind about our participation, and taking responsibility for it, is essential.

As you may know, this is something I have written quite a bit about.  In my 2022 book, The Analyst’s Vulnerability: Impact on theory and practice, I outline my observations that clinicians  often feel undue guilt and shame about negative feelings toward clients, which I believe is rooted in  therapists’ histories as parentified children. In our early roles as soothers and peacemakers, we tried to “cure” our mothers or other family members of depression or chronic distress—an impossible task. Carrying such outsized responsibility for others’ happiness from childhood naturally creates anger, along with a sense of being “special.” Searles and others have described the frustration and anger that often emerge, especially in adolescence. These negative feelings toward suffering family members produce guilt and shame in the parentified child. This same dynamic often repeats in clinical work, with therapists struggling to work effectively with their negative feelings. The reality that little to no training on this issue is provided in most programs adds to the therapist’s fear that what they are feeling is unusual and inappropriate. 

The key to working with negative countertransference is self-awareness: recognizing that negative feelings are inevitable and are not reasons for guilt or shame. I believe therapists often need their own treatment to develop this capacity. With greater self-awareness, it becomes easier to notice and explore negative feelings before they escalate into enactments, such as angry outbursts or criticism of the client. The biggest obstacle to expressing frustration constructively is waiting until the feelings have become so intense that therapists are having very negative, even violent, fantasies about the patient—fantasies that feel too inappropriate to voice, and shameful to have, so they shut them down. I advise therapists to step back, process their anger, identify what they are responding to, and then offer specific feedback that includes emotion without attacking or insulting the client. The focus should remain on the feelings and on what is happening in the moment. I remind therapists that honest negative emotional responses are rare in our society, yet people often need them. Offering such responses is one of the most difficult parts of our work, but we must overcome our fear of conflict and harm in order to provide this essential therapeutic response.

Yes.  I think it’s natural for all of us to identify areas where our clients could change or improve their functioning that would be better for them. Yet in the 40 years I have been doing this job, I can honestly say that I have never succeeded in getting a client to change something that they have not identified as problematic themselves.  They may give lip service to agreeing with me, but the change never happens unless it’s something they really want. And this is how it should be.  I think it can be hard to accept both how long change takes and that it is necessarily limited in scope.  Again, I go back to the notion of therapists wanting to cure their family members, and themselves.  This attempt at redemption, and sometimes rescue, is operative with our clients and can create unrealistic expectations for them. 

Therapists can then feel frustrated with the slow progress and feel like failures when the client doesn’t change the way they think they should, e.g. staying with a spouse they no longer love, or one who is not sensitive to their needs. I recall treating a young woman early in my career who was very dependent, including having her partner and friends drive her everywhere.  I asked her about getting a driver’s license and she said she was afraid to drive.  I gently tried to help her see that she was keeping herself dependent on others and possibly burdening them with this chore.  She made excellent progress in many areas of her life and became much more independent, including becoming expert at navigating public transportation.  But she never learned to drive.  Why?  Because she didn’t want to.  It’s that simple.  And it’s why we need to have agreed upon goals for treatment. 

I’m glad you brought that up.  As you know, I have been writing about self-disclosure since I wrote my first book The Power of Countertransference in 1991, relatively early in my career. Being in my own analysis right out of training helped me to understand the therapeutic process firsthand, particularly one that is intense and deep.  While I was wishing my analyst would be more forthcoming with me when I could read what she was feeling, I saw that my own patients were feeling this way about me.  I began the process of looking at not just what they said they wanted to know about me, but what was going on in the relationship--what I was feeling, and thinking about the critical role of emotional communication in the relationship. I also began reading whatever I could find in the neuroscience literature about emotion and its functions, as well as researching the process and outcome literature to see what was being said about self-disclosure outside of the analytic world. I have continued to do this throughout my career and updated the chapter on self-disclosure as well as adding a brief chapter on ethics and self-disclosure that provides some basic guidelines on what is therapeutic to disclose and what is not.

Although a brief summary does not do justice to the topic, the basic guidance I provide includes identifying basic emotional responses to the client, expressing them briefly while in control of your emotions, and avoiding any judgments or criticisms. Repetitive scenarios where both client and therapist feel stuck, with little changing with each retelling of the story, serve as a strong indicator that some type of feedback via self-disclosure is needed. Again, the focus is on the client. Avoid talking about yourself and your own issues.  Providing basic emotional feedback is crucial and is the essence of a therapeutic disclosure. In this section of the book I also outline what not to disclose and who tends to benefit or not benefit from disclosure.

Extratransference has also been referred to in the analytic literature as “displacement.” The general idea is that some clients will form an attachment to the therapist that they are uncomfortable with.  The reasons for this vary, but basically it is usually because they think it is inappropriate to have strong loving or sexual feelings for the therapist, or because they cannot come often enough or be able to process them adequately, or they just seem overwhelming. For some it is the intolerance of asymmetry. “I cannot love you unless I know you also love me.” Whatever the reason, as the transference heats up the client will develop an intense relationship outside of the treatment instead of having it with the therapist.  Thus the term “extratransference.’ In traditional analysis this was labeled as “resistance’ on the client’s part—something that needed to change for the treatment to be successful.  But I have discovered that this is not generally true. And many others hold the same view.  If you take the position that emotion processing in the session is at the heart of therapeutic change (something that virtually everyone agrees on these days from EFT to EMDR to IFS and DBT) then you can see how processing the emotion that the client feels toward this new person can be extremely therapeutic if they are experiencing it in the room with you. 

In the second edition of the techniques book I provide a long example of a client who developed a strong, loving and intense attachment to a person in an online chat group during her treatment with me.  She had trust issues and had declined earlier to come twice a week, even though it was obvious that she was having very strong feelings on many fronts.  At first I was disappointed when she developed this outside attachment, but then quickly saw how she immersed herself in the details of their communication and expressed strong feelings that arose for her.  As she continued to do this, and to become more emotionally honest with her husband and other family members, it was clear that she was changing in very meaningful ways.  Instead of seeing extratransference relationships as merely a defense, despite the fact that there is an unquestionable defensive aspect to developing them in the first place, we can take the position of wanting to explore the depths of feeling within these relationships, rather than trying to change the subject to the here-and-now with the therapist.  Though there is less narcissistic gratification for us when the extratransfence appears, it can still  provide a fertile path to processing deep emotions and resolving conflicts.

Psychoanalysis proper is not for everyone, including therapists. But clinicians do not need to identify as psychoanalytic to appreciate what the psychodynamic approach can offer. My early training was in behaviorism, and I have consistently incorporated it into my analytic work, especially the basics of assertiveness training. Helping people learn to assert themselves constructively—while continuing to improve this capacity in myself—has been invaluable in shaping my approach to self-disclosure and in helping clients express themselves more effectively. I often quote the philosopher Deleuze (1977), who said:

A theory is exactly like a box of tools…It must be useful. It must function.  And not for itself. If no one uses it, beginning with the theoretician himself..the theory is worthless or the moment is in appropriate…It is strange that it was Proust, an author thought to be a pure intellectual, who said it so clearly: treat my book as a pair of glasses directed to the outside; if they don’t suit you, find another pair; I leave it to you to find your own instrument (p.208).

I don’t believe in imposing any theory on clinicians, despite my unwavering commitment to the psychodynamic approach.  It works for me.  But I am not so myopic to assume it will work for everyone.  The interest must be there.  The motivation must be there.  The clinicians who come to me for supervision and consultation have varying backgrounds and training.  What they all have in common is that they have been practicing for at least several years and have come to the realization that many patients stay longer and develop strong positive and negative feelings toward them that don’t know how to navigate.  They also typically say that they have tried all the approaches they learned in their training but feel they are missing something.  They cannot really grasp the big picture, including what is really happening in the therapeutic relationship.  Often they have read some of my work on the advice of a colleague and find what I have to say useful.  Then they contact me to see if could work together. Most of these therapists become well versed in the psychodynamic approach and learn to use it well, without discarding other types of interventions that they have learned along the way.  They typically do not go on to become psychoanalysts, but they appreciate the breadth and depth of psychodynamic theory that is unmatched anywhere else.  I advise anyone who is feeling that they are bumping up against the limitations of what they have learned in their training to at least explore what the psychodynamic approach has to offer. I believe they will inevitably find a new pair of glasses with which to view the world.