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Transference

Mark Dombeck, Ph.D.

If you're just tuning in, we're in the middle of a sort of series of essays concerning how psychotherapy works. I started with an essay about the importance of the trusting relationship between therapist and client, and followed that up with a sort of overview of four different approaches to therapy technique; the psychodynamic approach, the cognitive-behavioral approach, the family systems approach and the humanistic approach. The plan is to write about each approach in more detail over the next four or so essays. Going in order of first appearance in the history of psychotherapy, we're due for an essay on psychodynamic psychotherapy, which is, more or less, the descendent of the form of therapy that Sigmund Freud created over a hundred years ago.

Transference

One of the most important concepts associated with the psychodynamic tradition is the idea of transference. Transference is a simple appearing idea that has to do with the way people understand one another and form relationships with one another. As its name suggests, it involves the idea of transferring something from one place to another. What is being transferred in this case is an understanding of a person. Where it is being transferred to is onto another person. When transference is occurring, basically what is happening is that we are trying to understand someone (usually someone we don't know very well) by making an assumption that they are similar to someone else, and will thus feel and behave in ways that are similar to how that other person would feel and behave.

Transference is a very fundamental process that human beings are constantly doing for better and for worse. Like most fundamental things we can't help but do, such as being hungry, communicating via body language even when we do not speak, or finding one's self sexually attracted or repulsed to another, it is not at all dangerous in moderation, but can create problems when done to excess. More to the point, the act of transference, like these other fundamental human processes, reveals and illuminates our motives and our thoughts; thoughts and motives that would otherwise remain hidden away from others and often even from ourselves (especially from ourselves Freud would say). Our acts of transference provide an information rich window into what we are desiring and what we wish to avoid. What we read into other people reveals our secret prejudices and our unfulfilled wishes. What is particularly wonderful about transference information is that it reveals or illuminates motives that people are often themselves unaware of having, or loath to fess up to. Part of Freud's genius was to recognize not only that transference was something that occurred on a regular basis, but also to realize that the information about personal motives that a person's transference activity revealed about him or her could be used as a therapeutic tool to promote self-understanding and healing.

Some therapists would disagree with the characterizations I'm about to make, but this is how I see it: transference is something that people do most all the time. It is itself an instance of a more fundamental and general process of perception that all people do which is to read patterns into things that aren't there in an effort to make sense out of incomplete data.

A Relationship Illusion

 Consider the following illustration which, for those of you listening to this via podcast consists of the following things. Three circles are arranged so that they are more or less equidistant. Each circle has a pie-shaped wedge cut out of it so that it looks like a pac-man, or a pie with a piece missing. These circles are oriented so that the missing wedges face each other. That is the visual description of what is in the image, but that is probably not the first thing you see when you look at the image. The first thing you are likely to see is a single triangle. There is no triangle really there, however. There are just three circles with wedges cut out of them. Your eyes see the circles with wedges too, but your brain interprets these three independent things into a single instance of a triangle; in doing so it adds things into the mix that aren't there so as to organize a familiar pattern.

How is it possible to have such a strong optical illusion of a triangle present in the image when there is no triangle there? Basically, what makes this possible is that people viewing the figure have a lot of prior experience with triangles, and "instinctively" or reflexively read the whole figure of the triangle into existence based on features of the image that suggest features of triangles we've known in the past. This processing occurs at an automatic, unconscious and non-verbal level of perception within the brain; you have no choice but to see the triangle, just as you have no choice not to understand the words on this page (or the sounds in your ear). Optical illusions of this type illustrate what the brain is, which is a sort of pattern matching and pattern generating machine. Brains basically find patterns in the world and when things aren't already in patterns we recognize, we try to fit patterns that are familiar with onto the data we have in an effort to make a familiar pattern appear. This automatic tendency is the basis of optical illusions, and it is also part of the basis of paranoia and a whole lot of interesting psychological phenomena, among them transference.

If seeing the triangle is an example of an optical illusion, transference is a kind of relationship illusion. It occurs easily and effortlessly when we first meet someone and try to form an understanding of who they are based on first impressions. It is an unconscious process, in that it occurs without effort, and does not announce itself. You only know it has happened when the person you thought you had a handle on goes and does something completely unexpected.

Relationship Schemas

It is not easy to get to know another person. When we first meet people what we appreciate about them is their surface. By surface I mean, our first impressions of who they are, and not just how they look (although that is clearly part of it). A person's depths – for example, how responsible they are, how they treat others, how they carry themselves when under stress – are not immediately visible or knowable. Deeper appreciations of a person's character are apparent only over time and repeated contacts and opportunities for observing what that person does. In effect we have to explore and witness each part of the people we form relationships with before we can accurately say that we know them well. Though it is undeniably true that trustworthy knowledge about relationships takes time and exploration to develop, it is also true that many people fail to understand this. Older people who have "been around the block" (e.g., who have been burned and hurt by relationship failures) understand, but young and inexperienced people never do, and people in love especially never do.

The reason why it is difficult to get to know someone quickly exposes a deep fact about the limits of human knowledge which is that all human knowledge is fundamentally indirect, based on potentially faulty perception processes, and subject to error. We interpret the world through the lens of our senses; we can't appreciate it directly. I take this position to be a fundamental truth about the nature of reality. However, people who believe in direct and literal revelation (such as revelation from God) will necessarily see this issue differently, at least as concerns knowledge about God. 

Though we cannot know things directly (at least with regard to other people), we can group together things that seem to belong together so as to form a sort of knowledge cluster, or mental map, or (as psychologists call it) a "schema". Once schemas have formed to organize knowledge about a thing inside someone's mind, those schemas are used as an aide in understanding and interpreting new information that concerns the things each schema is about. Think of schemas as a sort of reference book that sensory input can be compared against. The brain looks for a match between appearances out in the world (the way someone looks, acts, etc.) , and what is know about the world in the form of schemas. The brain does this because if a match can be found between something new and something old, then all of the stored knowledge inside the schema can be applied to the new situation without having to figure it all out again and again.

Let's make this all more concrete by giving an example. Suppose you get into a fight with someone you know who has a crew cut and you end up coming to blows. You learn about those blows from the evidence of your senses – you ache, you are bruised and you feel pain! You learn that this person is likely to be violent, and this knowledge about crew cut-guy's violence potential gets stored in a schema that represents and organizes your knowledge about this person. A week goes by, and there you are minding your own business when you happen to glance up and see a crew cut. Your immediate reaction is to get ready for a fight. This sense of urgency goes away quickly, however, when you realize that this new person is not the person you fought with but rather someone else. In this manner, knowledge taken from your senses is compared against your existing relationship schemas to aid you in quickly appreciating whether you are in danger or not. It's a good thing you have these relationship schemas to organize your knowledge and trigger an alarm, because otherwise you might have again walked into a punch!

People (by definition) form schemas about all manner of things they know something about, including themselves (which you've heard of before, labeled as the 'self-concept'), other people they know, and how they get along with those people they know. It is exactly these schemas concerning relationships that get transferred from one person onto another in the process of transference. You see that crew cut, and brace for a beating (or get ready to give one). It's a different person this time wearing that crew cut, but they were initially close enough in appearance for you to mistake one for the other and treat the new person as though he was the old person.

It's not just crew cuts that can lead us to confuse one person for another, and it's not just violence that we can respond to. Transference is far more general than this simple example. It's transference, for example, when you see someone who reminds you of a former lover you no longer see and you get sad for a moment. It's transference when you fall in love at first sight, because something about that person leads you to believe they are your soul mate. It's transference when the porn star dresses up as a French maid, or wears pigtails to suggest youth and innocence. It's transference when you assume that a doctor is competent because she wears a white coat and carries a stethoscope, when the banker's pin-striped suit leads you to infer wealth and stability, and when the neighbors appear to be richer than they really are because they have a (leased) BMW. It's a form of transference when a woman who was abused by her father, goes and gets involved romantically with a partner who also abuses her. It's also transference when a confidence man (or woman) leads you to trust him or her and then steals your money, or when a politician leads you to believe that he or she will act one way, causing you to vote for him or her, and then proceeds to act another way you didn't expect. We respond to characteristics that aren't really there, and what is more remarkable is we don't tend to notice that we've done it; we do it automatically and without thinking. The illusion is so seamless it appears to have been out there in the world such that anyone else looking would see the same thing. That's not the case, however. Transference is really an interpretation and an illusion that is generated inside the brain as the brain tries to organize the world.

As was the case with the triangle illusion, we try to make sense out of the things we are confronted with by matching their appearance to things we've known before. We organize things we see so that they fit the things we already know and we fill in the blanks that aren't there with the rest of the pattern we know from our schemas. We can set ourselves up for problems when we do this, for instance by extending trust or intimacy (sexual or otherwise) to people who haven't earned it. In this way, we end up harming ourselves some of the time by failing to appreciate dangers that are really present. The positive flip side of this equation is that we can also learn to benefit from transference by learning to accurately recognize novel situations as dangerous because they remind us of past dangers.

Transference As A Therapy Tool

Though transference happens automatically and unconsciously, it is possible to learn to become aware of transference Becoming aware of one's transferences is a good thing, because it can help you to become a more conscious and proactive person, more in command of your own destiny, rather than a passive, reactive person. Proactive aware people are better able than passive reactive people to influence their lives for the better, and to learn from mistakes so as to not repeat them again and again. They tend to have a better quality of life than passive reactive persons.

There are many ways to become more aware of your own transferences. One way is to write journal or blog entries about what is happening in your life and then to read them over looking for patterns that you have that get you into trouble; areas where your judgment is repeatedly poor and you make the same mistakes over and over (as chronicled some time ago in that bestseller book "Women who love too much"). Another way is to hire a therapist who can help you to become aware of what your transference are. The psychoanalytically oriented school of therapy was the first to identify how becoming aware of transference could serve as a tool for personal growth, and they are still the best trained professionals for helping to accomplish this goal.

If I ask you, "what does therapy look like" and you had never had therapy before, you are likely to describe something like this image: "The therapist is a man with a beard who sits taking notes while the patient lays down on a couch. Neither patient or therapist look at each other. The patient drones on". This is the classical image of psychoanalysis – quite out of date of course, but still useful for illustration purposes. Did you ever wonder why the therapist and the patient aren't looking at each other? The reason is that this "no eye contact" arrangement was thought by early therapists to best promote the patient forming a transference relationship with the therapist. The therapist minimizes eye contact, and says nothing about himself and his life outside the therapy room so as to become a blank slate or canvas or screen onto which the patient can project his or her transferences, and the therapist can view these transferences happening, figure out what they are, and help the patient to become aware of what they're doing. In theory, the patient's behavior will change as he or she becomes more aware of what he or she is doing. In practice, such insight is often not enough to motivate real change in the patient's life. It is helpful, but something more is often needed to get the patient to actually behave differently then they have been. The map is not the territory, but some patients and some therapists can mistake the one for the other.

What does this transference-encouraging look like in practice? I'll give you an example from my own life. While on internship early in my career, I had to participate in my own therapy as a client. I had been reprimanded by a supervisor for being late to a meeting before this therapy process started and was feeling kinda paranoid about being judged unfairly. Very shortly after I started in with my therapist, I found myself feeling that he was judging me too and found myself getting pissed at him. I'm sure he would have picked up on this in short order, but I beat him to it in this instance, telling him, "This therapy relationship is going to work out fine - I hate you already".

I had the advantage of being educated about transference before the above exchange took place, so my ability to be self-aware about it shouldn't be taken as the norm. My anger towards my therapist, however, was classic transference. Another typical scenario is for a patient to develop a crush on a therapist or to feel ownership of the therapist's time (feeling jealous when the therapist is unavailable), or to respond to the therapist as though the therapist was acting like a parent used to act (judgmental, for example, or overly permissive, and getting upset or sensitive when opportunities for slights or limit setting occur.

The aware therapist recognizes over-reactions for transference (generally a safe assumption, but not one to be just assumed), and interprets these back to the patient, " I don't think you are a bad person – but you seem to think that is what I think of you. Am I perhaps reminding you of past relationships you've been in where you have felt similarly treated?" The occurence of transference then becomes an opportunity for growth of the patient's self awareness. If you can recognize the patterns you are succeptable to falling into, you aren't as much at their mercy anymore.

Counter-Transference

It's not just patients who are vulnerable to transference Therapists routinely (if grudgingly) also form transferences with their patients. This is called counter-transference when this happens, to indicate that it is the therapist's rather than the patient's issue and responsibility. A typical counter-transference might occur when a therapist starts feeling angry with a patient who describes doing something that is similar to something that previously harmed (or would harm) the therapist or someone the therapist cares about. A therapist I'm friendly with recently described a situation where a patient was talking about feeling good about not being expected by his elderly parent to take care of that parent. The parent in this case preferred the patient's brother to provide care, and the patient enjoyed the freedom of being the 'less responsible child'. The therapist found herself suddenly angry with her patient because she was herself a 'responsible child' with an irresponsible brother and she felt herself to be unfairly burdened with elder care responsibilities. It wasn't exactly fair for her to get pissed at her patient, and she didn't show it or let the anger feeling interfere with her duties, but she did feel it, and it was there because of counter-transference

Experienced and ethical therapists notice when they are forming counter-transferences and handle them appropriately. This means that they take steps to deal with their own issues so that they do not impose on their work. If they cannot manage their reaction on their own, they seek out their own therapy or supervision situation where they can get help in dealing with it. If they cannot deal with it, they must then stop working with the triggering patient if feasible and possible, recommending another comparable therapist who will not be so affected whenever that is possible. Therapists should strive to never abandon patients, but this doesn't mean that sometimes everyone isn't better off with a therapist recusing him or herself from working with a particular patient.

Recognizing counter-transference is as hard as recognizing transference, which is to say, very hard, and even good therapists may take a little while to figure out what is happening. It is ultimately the therapist's responsibility to figure it out, however.

Conclusion

So that brings us to the end of this essay on transference Transference is a truly amazing process, casting light as it does on hidden thoughts, feelings, wishes and motivations that would otherwise remain hidden and troubling. Freud's recognition and characterization of transference was brilliant in of itself (although I believe there were writers who recognized the phenomena before he did), but the thing that moves his contribution over the top to genius status was his recognition that transference could be used as a therapy tool. The psychoanalytic therapy he pioneered featured analysis of transference as a central element, and generations of psychoanalytically oriented therapists since his time have continued to recognize the importance and centrality of transference to the work of therapy. Awareness of transference is no cure-all. It is really best suited for problems that are relational in nature (such as anger or depression problems – where transference leads patients towards inappropriate and exaggerated moods and actions). It is not particularly helpful if you are working with a patient who is dealing with a primarily biological problem like schizophrenia or autism, for example. Nevertheless, it is a useful and brilliant tool and technique for most all therapists to know about and use appropriately to the benefit of patients. It is a major contribution of the psychodynamic approach to the universe of psychotherapy techniques.