Discussion – Transference Paper
Sigmund Freud opined that unconsciously, one could bring up experiences, emotions, and feelings from previous encounters or occurrences and transfer them to other parties and objects, especially therapists and counselors. Interpretation of these emotions and feelings and reacting to them affect the outcomes of the interview or therapy sessions.
In my mental health training and practice, I have encountered these incidences more than once. The purpose of this discussion is to explain one of these interactions, how the incidence occurred, why the incidence occurred, and the outcomes of the incidence.
Patient Interaction Incidence
In my initial months of practice, my second patient was called Molly (not her actual name). Molly was 9 years old and accompanied her mother to the office for psychiatric evaluation. Her mother alleged that Molly had been having trouble in school, at home, and one time when they visited their rural home for holidays.
During my interview with Molly, I tried to maintain a therapeutic alliance that I had created before the session. In the first session, I was building a health history for Molly. I had then suspected that Molly was most likely having attention deficit hyperactivity disorder (ADHD). As the DSM-5 requires, the ADHD symptom should be observed in two or more settings (American Psychiatric Association, 2013). I moved to assess the situation at school.
I asked the patient about his homework. Molly looked down for a few seconds, and when she lifted her head, she yelled out and said, ‘are we here to discuss my homework, or are we here because my mum thinks that am not listening to them?”
At this point, I thought that her diagnosis would change to oppositional defiant disorder (ODD). After a minute of silence, Molly later realized that her response was inappropriate and harsh. Therefore, she showed remorse and verbally apologized to the mother and me.
Nevertheless, I continued to interview her mother to understand the course of Molly’s reaction to my open-ended questions. The mother stated that since Molly changed grades, she had a new teacher who had not been kind to learners and had been more authoritarian with homework and classwork participation.
Other kids had complained of the same teacher who was replaced a year later. From her mother’s explanation, I learned about the reason for her reactions to homework and school life. This interaction with Molly revealed a type of transference that I will later discuss.
Case Analysis
Molly’s case is typically a case of transference. Various scholars have defined transference in psychology since its introduction by Sigmund Freud in 1912 (Sohtorik İlkmen & Halfon, 2019). Our daily lives are full of transference and countertransference. In transference, the subject transfers their past significant interactions, feelings, emotions, and relationships to their current or present relationship or interactions. These can be from childhood to current adulthood life experiences or relationships.
Therefore, it can simply be explained as a reproduction of repressed emotions or feelings. Transference can occur in any setting, including but not limited to therapeutic sessions, counseling sessions, and daily person-to-person or person to object interactions.
In psychotherapeutic sessions or counseling environments, various micro-associations determine the outcomes of these interactions. In Molly’s case, transference occurred during the process of psychiatric interview and building patient history. During this time, I tried to employ my best communication techniques to sustain a therapeutic relationship.
Freud described transferences as pathological, unreflective phenomena that patients use to adjust to their virtual reality. His earlier description of this phenomenon explained transference as deep feelings that are made under unconscious states. Developments in psychology and psychotherapy have recognized that transference can be harmful and beneficial depending on how the two parties handle and react to the situations (Kupfersmid, 2019). These developments have been used to influence therapy outcomes.
Transference work in psychotherapy seeks to address the problematic situations in a therapeutic relationship. This leads to insight and affects awareness that seems to improve the outcomes of the therapeutic alliance, according to Høglend & Hagtvet (2019). Reactions to transferences depend on the treatment orientation and setting of the interaction, as well as the parties involved.
Molly’s case reaction was determined by the parties involved. Upon realizing that she had made a mistake, her reaction was remorse. The initial emotional reaction is usually unconscious, and the doer does not realize it until there is an awkward reaction from the target party.
Transference can broadly be categorized as positive, negative, or sexual transferences. Positive transference occurs when the patient reproduces enjoyable experiences from their past and exhibits them in their current interaction (MacKenzie Rioch, 2018). This reaction makes the patient view the therapist or clinical as good, wise, and empathetic to them.
This scenario enhances the therapeutic process. On the other hand, negative transference involves the projection of hostile feelings or emotions or experiences from the patient to the therapist. This type of transference occurred between Molly and me in the psychiatric interview session. I reminded Molly of her hostile schoolteacher who used to keep bombarding them with assignments and was punitive when she failed to deliver the homework in time. Her reaction was, therefore, hostile towards me.
The concept of intrapsychic conflict also came up from our interaction. Molly viewed me as an authoritative figure just by me reminding her of her homework and school life. This seems to have been going on for some time, but she has not gotten an appropriate avenue to manifest her inner intrapsychic conflicts. Her reactions towards her parents may have been due to transferences due to repressed emotions from authoritative adults.
Molly is a humble and soft-spoken child, but her school life has seemed to stress her a lot. In response to this, she has kept her cool by suppressing her anger and frustrations. Her remorse after the incident suggests that she didn’t intend to respond in that manner. Therefore, there could be a conflict between her conscious and unconscious self.
My Reaction to the Incident
This incident happened in my beginning year of interacting with patients on myself. It was not my first incident, but personal reflection when I went home enabled me to understand and attempt new techniques when interacting with patients that I had initially deemed violent.
Before this incident, I had tried to stick to the objective of the assessment sessions and sought to ignore their anger tantrums or inappropriate reactions because I thought they would distract me from reaching the goals of the interaction. As I gained experience and exposure to these kinds of patients slowly, either alone or with colleagues, I learned that they are humans with feelings too who require understanding and being listened to in-depth.
I took time to understand why Molly reacted that way. At first, I thought her reaction would result from her personality because she had complaints from her parents that sometimes she fails to listen. Despite meeting the DSM-5 criteria for ADHD diagnosis, her diagnosis was inattentive type and not hyperactive type.
The origin of her reactions could, therefore, be from somewhere else. I thought of a past traumatic experience that would be causing her to present as a posttraumatic stress disorder (PTSD) patient. This was ruled out because she didn’t meet those criteria.
He had no significant traumatic past. I, therefore, asked myself why her reaction was only to the assessment of her schooling and homework and not doing other things at home that she had responded to very well at the beginning of the interview. This is when I turned to her mother for an explanation. Internally, it was a milestone breakthrough for me in the profession.
My response to Molly was empathetic instead. My response to Molly’s question stated: “It appears that your school life and homework have frustrated you for some time now. Currently, how do you feel about going back to school?’ At this point, Molly seemed to open up about her school life, and the conversation continued smoothly before she lost interest again in the discussion later. Modern concepts in psychotherapy have modified many concepts in Freud’s theory (Kupfersmid, 2019).
Instead of seeing transference as pathologic, modern psychologists see these occurrences as opportunities to focus on the intention of the patient reactions and build positive relationships. I believe that I applied this concept unconsciously and perfectly well to Molly’s case. My subsequent interactions with Molly whenever she checked in for evaluations and assessments were based on this positive relationship that we built.
Plans for Future Interaction
The most appropriate thing I did for Molly was to continue to provide care whenever she was brought in. After learning my lessons through practical experience, I feel that interaction with future patients presenting similarly to Molly would require tolerance. Understanding them as they present without prejudice would be the next principle of interaction. I cannot deny that I never thought of countertransference when Molly lashed out at me.
Countertransference describes the therapist’s reaction toward the patient’s transference reactions. In this case, I would have reacted by either defending myself or transferring the issue back to the patient. Choosing to tolerate her enable me to affirm my diagnosis through exclusion and finding the precipitating factor for her presentation.
Conclusion
Transference is a daily occurrence that we see daily in clinical training and practice. We choose to understand the reason or the reaction or ignore it and stay focused on the goals of the session. In my experience with the patient in the described incident, I learned essential concepts that have helped me establish positive patient relationships.
Tolerance to patients transferring their feelings towards you makes you understand their reaction and use it to develop a positive therapeutic alliance if possible. Countertransference may seem destructive but allows self-reflect and improve your future techniques. Allowing no room for prejudices and stereotyping can enhance your empathy skills. Every patient case is unique.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.
Høglend, P., & Hagtvet, K. (2019). Change mechanisms in psychotherapy: Both improved insight and improved affective awareness are necessary. Journal of Consulting and Clinical Psychology, 87(4), 332–344. https://doi.org/10.1037/ccp0000381
Kupfersmid, J. (2019). Freud’s clinical theories then and now. Psychodynamic Psychiatry, 47(1), 81–97. https://doi.org/10.1521/pdps.2019.47.1.81
MacKenzie Rioch, J. (2018). The transference phenomenon in psychoanalytic therapy†. Psychiatry, 81(4), 311–321. https://doi.org/10.1080/00332747.2018.1540236
Rocco, D., Rizzi, L., Dell’Arciprete, G., & Perrella, R. (2021). The functional psychotherapy approach: A process-outcome multiple case study. Frontiers in Psychology, 12, 727497. https://doi.org/10.3389/fpsyg.2021.727497
Sohtorik İlkmen, Y., & Halfon, S. (2019). Transference interpretations as predictors of increased insight and affect expression in a single case of long-term psychoanalysis. Research in Psychotherapy Psychopathology Process and Outcome, 22(3), 408. https://doi.org/10.4081/ripppo.2019.408