Thursday, March 2, 2017

Transference and Countertransference in Working with Eating Problems

Transference and Countertransference in Working with Eating Problems – Part 1

By Susan Gutwill, LCSW
(This is the first of a 2-part series on the issues of transference and countertransference. Part II will continue next month in our April ENewsletter.)
The way one has been treated and the feelings it engendered in our formative early histories are repeated in every therapy couple. This is called transference. It is not a conscious process. But it is inevitable. If our patients have been abandoned, denigrated, abused, terrified, blamed, rejected, or taken over in their histories, they will transfer their learning from such relationships past, onto their expectation of us in the important intimacy of their current therapy relationship. Paying close attention to these patient expectations tells us a great deal about our clients’ early lives. ([1]Freud)
Freud established that transference was a critical piece of psychotherapy, similar to dreams, another “royal road to the unconscious”. He considered countertransference the therapist’s response to transference of the client, something about the person of the therapist, which should be explored in the therapist’s personal psychoanalysis and supervision. Many theorists/practitioners have changed and added to that original idea. Today, psychodynamic psychotherapists believe that transference and countertransference are both important tools within psychotherapy proper, as well about the therapist’s private life. We have learned from object relations, relational psychoanalysis, interpersonal, and inter-subjective theories, as well as from evidence based studies, that countertransference is equally inevitable and important to good treatment as is understanding transference. ([2]Racker, Wooley, Mitchell, Gill, Gill & Hoffman, Hoffman, Burke, Tansey & Burke) Feminist psychology, with its emphasis on nurturance, and equality and the anti-authoritarian stance the of the 1960’s and 1970’s have both impacted upon psychodynamic thinking positing that therapy should be based on a real, but bounded relationship. This relationship itself is a major part of the healing and growth our clients need, just as it is the base of all human needs for growth from babyhood throughout our adult lives.
Client’s feelings towards us inevitably pull for our own powerful countertransference feelings as well. Bion, Ogden and Racker, for example, teach us that the therapist’s countertransference response can be concordant or complementary ([3]Bion, Ogden, Racker).
For Racker, concordant countertransference feels like empathy, e.g. “oh how horrible that must have felt for you.” As therapists, our bodies and hearts may feel shaken, like we are sinking into the feelings our clients have. Often, when we share our concordant feelings, our clients feel understood, and grateful for our empathy and recognition. ([4]J. Benjamin)
Additionally, however, clients, (most especially, guarded anorexics), also may feel afraid of being deeply known and, therefore, open to being reinjured in ways they felt earlier in life. The theory of object relations by Ronald Fairbairn is particularly useful in working with eating and body image problems and trauma. He argues that when early dependency experience is very frustrating, even rejecting, we psychically split ourselves in order to accommodate the reality that we still have to depend upon the only caregivers that we have. We adapt by splitting our own ego, and unconsciously fantasize and imagine that we are the failures, ourselves. So, for example, we binge because we are afraid to admit to ourselves how hurt we are. It feels too dangerous to know our only caregivers are not reliable. We fantasize that if only we were better, they would love us, reliably enough. So, if we were only thinner, for example, we might yet be accepted, loved, and noticed. However, we further imagine, and the other side of the split screams at us, that we will never be good enough. There is really no hope. Thus, bad experience is internalized and split in two equally false options, an enticing part (if only I was thin) and a rejecting part (I’m hopeless, I want to shrink away, I am fat and ugly). This then becomes an inner relationship which is isolated, split off, and shut away from real human relationships in a deep freeze of profound fear. Fairbairn’s work in psychodynamic thinking, following earlier work by Ferenczi, opens us to the notion of the dissociative nature of the mind born of severe trauma. ([5]Aron, Ferenczi, Fairbairn, Hainer, Howell)
  1. W. Winnicott, writing at the same time, reminds us that being fed and held at the very beginning is the foundational relational experience required for life itself. Remember, that babies ([6]Spitz) which are fed but not related to, fail to thrive. Eating is a relational experience.
Winnicott, like Fairbairn’s ego objects, talked about an isolated part of self which he called  “the false self.” He meant that we accommodate to early caregiver’s needs to be safe in our dependent attachment. Hence, the goal of therapy is to find the potential to be a “true self,” never fully attainable, but the animus of a rich life which in itself is dependent on a safe early relationship of dependency. ([7]Winnicott)
In Therapy
In treatment, clients may show their fear of being known right away or more slowly and subtly, and they do so repeatedly at different stages of therapy. However and whenever these frightened warning signals become known to client or therapist, therapists may feel either concordant or complementary counter-transference.
Examples of complementary countertransference might look like the following. We sense our client is endlessly compliant and it begins to feel “off,” “unreal,” “impossible.” We ask ourselves, “What am I missing?” Therapists may feel pushed away from the relationship, like “who are you kidding? I don’t believe you.” And often we women therapists feel guilty for having such ‘non-idealized’ suspicious and angry feelings. ([8]Steiner Adair, Gilligan, Ruddick, Eichenbaum & Orbach, Chodorow) Women are supposed to nurture! And yet at this moment “if you keep kissing my rear end, I am going to go nuts!” This may be a case where empathy has flown out the window and a therapist feels controlled and as if they are being forced to live in a lie.
Complementary feelings are often dramatic and negative. Another example might be, “Do I have to hear you complain for the umpteenth time about how much you hate yourself for eating. We have been here so many times and you keep saying the same things, as if we had never worked on this.” Or we may ask ourselves “Why am I not buying this?” Or, “If I am so noxious to you, why don’t you go find someone else to work with?” Or, “You haven’t spoken in months. What are we doing here? Anything?”
Yet another countertransference response may indicate that we are swimming in the same soup as our clients, because of our own unresolved anxieties about eating and living in our bodies, i.e., I call this cultural countertransference and it is rarely discussed. I will expand upon this kind of countertransference in Part II of this series.
All therapists’ countertransference feelings are by definition, powerful. We alternatively may feel guilty, frightened, proud, fearful of confronting our clients, and more. But they all tell a story we need to enter and explore, again and again.
This critical and central piece of all our therapeutic work is carried out by what Harry Stack Sullivan, the father of Interpersonal Psychotherapy, called “detailed inquiries.” ([9]Sullivan) He meant that we “get into it” with patients, that we explore their thoughts, behaviors, and feelings in detail. In a sense, we need to hold the curiosity they do not yet have.
We therapists have to be able to join our clients, again and again and again when they come in telling us they binged, threw up, or ate without hunger. We need to investigate, in great detail, their many moments, or episodes, of hating their bodies, of shaming themselves because of their bodies. The complaints usually begin with the same ritual that sounds depressed and/or like a monotone or super anxiety and are all filled with despair: “I did it again.” “I hate myself.” “I am so fat.” “I feel disgusting.”  They may have eaten an entire pizza or a handful of grapes and a little bag of popcorn that was not on “their program.”
Our job is to bring these repetitive complaints that may sound like whining, alive. My definition of whining, by the way, is complaining without feeling entitled to the underlying pain. That is why they often sound annoying. But it is also hard to stay present when patients are super-anxious. These presentations regularly induce therapists into complementary countertransference responses.  Whatever the presentation, what helps is to ask questions like:
What had happened just before you felt so fat, this time?
What had happened on your way to feeling fat? How did it make you feel?
Do you feel you are entitled to feel that way? No? Why not? How were feelings and especially your feelings treated in your family, your marriage, your friendship group? How do you feel our society feels about these kinds of feelings? Where does that show up in your life?
And where do you feel that in your body? We need to bring our clients into their bodies, where all feelings reside. Sometimes I do an exercise where I ask my clients to close their eyes and feel the couch. I then do a progressive relaxation to help them focus and enter the space of feeling. Or, clients shaping themselves into body sculptures, for example, can enact in their bodies what the inner self looks or feels like. These methods are endless and are personalized to what the therapist knows about a particular client’s history.
A great deal of therapy time brings clients back to the feelings they had when alone, this time with the therapist in accompaniment as witness. After the intense focusing I have suggested, therapists might ask, “so how do you feel now?” This works with compulsive eaters and for binges.
With anorexics, the path is rockier. Their defenses embrace more of their being. In other words, there is less of a healthy central ego/self. Our job is less directive, educational yes, but more focused on their life story, trying to “hold” a space for growth of self-in-relationship.
In doing all this, there is an inevitable transference/countertransference dance that is very challenging and essential to the heart of good therapy. We work in a real relationship where our impatience, horror, love, empathy, and hate, registers and demands to be understood. When we become curious about the details of these feelings, it opens the door to compassion and finally, some dignity to otherwise entirely shameful feelings.
To help with this demanding process, the ethics of psychodynamic therapy ask us to have our own deep psychodynamic therapy as well as clinical supervision. These are required in order to notice and work with what is unconscious and embodied. It is essential that therapists know what this kind of therapy feels like and what it can accomplish. As my first long term therapist put it to me, “I need to be as clean as possible, to know where my own responses are coming from, so that I can help you.” How relieving that felt to hear! She could own her part of our relationship…“response-able.”

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