(Co)-Transference

Transference is everywhere. When you meet someone at a party and something about them puts you at ease, maybe their mannerisms are like your cousin. Or you have a boss that brings out those old insecurities you had of disappointing your parents and you never feel quite recognized. It can be the inspiration for a snap judgment you have of a stranger you see crossing the street; what colors you feelings for your kids 3rd grade teacher. Transference is when you are directing your feelings from one person onto another new person. 

Understanding Therapeutic Transference

Transference is an important part of psychodynamic therapy. There isn’t one set definition of transference, but for the purpose of this discussion, let’s say it is when the patient redirects feelings about their early life relationships onto the therapist. This transfer of feelings about parents, friends, love partners or even adversaries can help illuminate previously unarticulated patterns of relating. The transference can feel positive or negative, or a mix- there is no right or wrong.  It can feel familial, friend-like and/or erotic. Even though transference refers to the the  patient's feelings- the therapist contributes to its formation with their explicit and implicit communications. The image of the opaque therapist with no personality has gone out of style, but therapists should think about what kind of personal boundaries and behaviors will ensure a safe space where patients can let their imagination and fantasies develop.  

A common TV therapy trope is the therapist who answers questions with questions. Truth is, it’s actually an effective technique that I use. When I get asked a question about myself, I am curious about what is behind the inquiry. Typically, I find it helpful to explore before deciding if answering is going to be helpful to them. This is because when a patient asks me something like “Are you married?” or “Do you have kids”? They might be wondering if I can understand them or if I will judge them. They are really sharing something about their own desires, fears, ambitions. Their question has more to do with their early experience of being understood and seen than a true need to know something about me.

Understanding the Therapist's Countertransference

Another question I ask myself is: “Why would I answer this question?” Am I thinking about what is best for the patient? Am I thinking about my own privacy or desire to share? Did it catch me off guard and I impulsively answered or shut it down? Acknowledging my feelings allows me to re-focus on the person behind the question. Their fears, curiosity, desire to connect, ambition. This is part of understanding my countertransference. 

Counter-transference is when the therapist directs their own feelings onto the patient. These may be unresolved issues from the clinician’s past or feelings that arise in reaction to their patients' transference. Countertransference is neither good nor bad. Transference and countertransference are happening at the same time and it takes an observant and reflective mind to acknowledge the different forces at play. And just like transference, it is shaped by real qualities in the patient.

Co-Transference and Intersubjectivity

A key component of intersubjective therapy is believing that all dynamics are co-created. This does not mean that each participant contributes equally, but only that they each impact the relationship. This is immensely important because of psychoanalysis' history of mistreating  patients based on sexist and racist cultural assumptions as well as troublesome power dynamics. Co-transference, is a term that connects and highlights the co-creation of a therapeutic dyad and de-emphasized the perfectly objective therapist who knows all. It empahsizes that transference and countertransference are happening at the same time and shaping each other. This encourages the therapist to  reflect on their own conscious and unconscious feelings and biases that will shape their patients' treatment and seek supervision when necessary.   

Empath(y)

What is an Empath?

As an elder millennial (thank you Iliza Schlessinger ) whose working hours provide limited internet access, I am often introduced to new words by my younger, hipper patients. One of those words, which I have been seeing everywhere is empath.  My first thought  years back when I heard it was “isn’t that a sci-fi term?”. And indeed it is.  A Scottish author JT McIntosh wrote a story called “The Empath” in 1956 about supernatural beings who could sense other people’s emotions only to be exploited by the government. Since then, this concept of the empath has existed in a number of science fiction stories and even in Dungeons and Dragons. In our current zeitgeist, an empath is described as a person “highly attuned to the feelings and emotions of those around them. Their ability to discern what others are feeling goes beyond empathy [and] extends to actually taking those feelings on”. And I’d argue that, similar to their sci-fi counterparts, this ability happens unconsciously and can feel like a psychic superpower or a burden. This level of empathy can help these individuals develop deep connections with others, but at times may also be overwhelming and overstimulating. The latter reaction may induce a need to retreat and isolate. These varying responses, both relatable to me, inspire a teasing apart of the differences and overlaps between empathy and empath. In doing so, I hope to explore a happy union between unconscious and conscious processes. 

What is Empathy?

Empathy is defined as “the ability to understand and share the feelings of another''. However, in psychoanalysis, the definition tends to be more complex than the dictionary definition. I believe that empathy requires curiosity and humility, because although we can never truly walk in another person’s shoes, we can try. We acknowledge the commonality of human experiences while making space for difference. That’s why it is often more accurate to say “I can imagine how you are feeling” rather than “I know how you feel”. 

Although it is impossible to truly understand exactly what another person is feeling, especially if their life circumstances vary greatly from yours, it is a worthy endeavor to attempt. For example, I work with a diverse group of individuals including people from different races, ethnicities, socioeconomic backgrounds, genders and sexualities. To tell a Black patient that I completely understand the crazy-making experience of subtle racism and unarticulated microaggressions would be insulting. But I can use my own experiences of prejudice and being gaslit as a jumping off point and then admit what I can’t understand. Similarly, to equate my experience of sexism and misogyny with a transgender person who  faces daily hate speech and the constant violating stares of others would be disingenuous. Instead, I listen carefully and use a kernel of my truth that connects to theirs as a stepping stone. It helps me acknowledge what I can never know. Perhaps that is something helpful for empaths to remember, it is ok to accept our limits and differentiate from others..  An empath may feel the pain or the joy of another, but I suspect that they are also feeling their own pain or joy to a degree. Not believing that our personal suffering assuages the suffering of others is an essential part of being a therapist and human. It’s asserting a conscious effort to self-introspect and acknowledge triggers (verbal and non-verbal) that may encourage an intense reaction that is based on personal history. It allows a level of self-care that can be likened to the metaphor of putting the oxygen mask on yourself before your dependent. 

Is it Nature or Nurture? (Hint: Both!)

The good news is that although it’s unlikely someone can learn to be an empath, empathy is a skill that can be learned. And empaths can learn to hone and control their abilities. That scary crime show you saw with the sociopathic child and two loving parents is really the exception, and something I’ve never come across. In general, it is a learned behavior and our capacity for empathy is based on our early life experiences. We learn it from our parents, caregivers, teachers and other influential figures. Treating your children with empathy and modeling it in your interactions with others is going to improve their capacity to experience it. In fact, babies are first able to read non-verbal behavior before language, thus what we show them and how we respond to them has a huge impact. Psychotherapists,  as well as other professionals learn to attune to non-verbal communications in a very conscious way by observing and even discussing what they notice with patients. When I am working with a patient I focus on what they show me as much as, and sometimes even more than what they tell me. How are they sitting? What’s the positioning of their arms and legs? Does their body seem calm or jittery? Where do their eyes fall, what are they telling me with their mouth and eyebrows?  I pay attention to their tone of voice, cadence and language. It seems that those who conduct these processes unconsciously may identify more as empaths whereas those who are more conscious and directed in their interventions may call it empathy. However, empaths can also apply these conscious efforts to magnify and control their abilities. Another factor in understanding empathy and empaths is research in mirror neurons, which has helped demystify the aspects of each process that have seemed a bit like magic. We have visuomotor mirror neurons related to our body sensations of pressure, pain and warmth. We have audiovisual mirror neurons related to physical coordination and visual perception. We have somatosensory mirror neurons related to combining our sight and hearing. All of these activate and organize sensory information. Mirror neurons give us cues about what someone else may be thinking, what they are planning to do next and even anticipate their reactions. This is key in empathy and in creating the experience of feeling another person’s emotions. It also helps explain why when you see someone stub their toe or witness a loved one crying, you may feel the pain of the other person and maybe even want to cover your eyes and ears to self-regulate.  It has been suggested that empaths may have more mirror neurons which amplifies this capacity. For empaths, sometimes the ability to feel someone else’s pain or emotions may actually encourage us to behave in a way that is the opposite of empathic. We may shut down, isolate or disconnect because we feel flooded- and in some ways actually behave in a way that is less empathic. This is not always true of empaths, but certainly can be. Experiencing your world as if it is always on high volume can be exhausting and detrimental to your emotional well-being. This is where the more logical side of empathy can be beneficial because it encourages an acknowledgement that although we may feel someone else’s pain, it is not actually ours pain. Mirror neurons are fascinating and the research into them goes beyond the scope of this blog, but I suggest you read up on your own time. An article that I used in the writing of this blog is “I Feel Your Pain: Mirror Neurons and Empathy” by Lindsey MacGillivray, BSc (2009). There are a number of other books and articles that explore this topic in depth.

Finally, the impact of trauma, especially chronic relational trauma, can be significant in the development of empathy and the identity of the empath. For example, children who grow up in emotionally and/or physically abusive homes may grow up learning how to evaluate the moods of their parents to assess what to expect from their caregivers and even how to survive. Think about the codependent who needs to take care of others to feel safe, common in the adult children of alcoholics or narcissists. Noticing body language, facial expressions, tone of voice can become survival mechanisms to organize an unpredictable world and learn how to get what is needed from parents. Like a highly sensitive person that becomes overstimulated through some of the processes described in the section of mirror neuron, the empathy of individuals with trauma histories can feel adaptive or burdensome- encouraging behavior that is overly empathic or not empathic at all. I suspect many people who identify as empaths are survivors of trauma, and their superpower is a blessing and a curse.

The Takeaway

Empathy may feel innate, but like so many other skills, it is also something that can be nurtured and developed. As a therapist I have learned that we are all have similar feeling words in our vocabulary (sad, happy, scared, angry etc) but that the way we embody them and express them has more nuance. Keeping that in mind can help the person struggling with empathy to find it, and the empath struggling with self-regulation to ground themselves. And for those who need a little help, there is always therapy!

TRIGGERED

When a mental health term used by psychotherapists and counselors crosses over into mainstream culture, I often have mixed feelings. First, a bit of surprise and delight that people outside the field are learning about terms and ideas and applying it to their lives. Secondly, some dismay and frustration at how the word gets used, misunderstood and even changed without acknowledgment. One of those words, which has actually been used for years and in a lot of ways is already almost unrecognizable is “triggered”.

What does “triggered” actually mean?

 Triggered in its simplest form is something that elicits a reaction but in the world of mental health is often when a person with a past experience of trauma (potentially with a diagnosis of PTSD but not necessarily) has a painful and overwhelming sensory and emotional reaction to something that they experience in the moment. As a therapist, I think this is an incredibly helpful piece of information for someone to have about themselves. It can make sense of strong reactions that don’t fit the current situation and even help the person ground in reality. 

An example: 

You are meeting a friend for dinner and she was late. You feel yourself shift from annoyance to seething,-thinking about how rude and inconsiderate she was to be late and make you wait for her. Maybe you want to yell at her, maybe you want to punch her in the face, maybe you want to storm off. This friend, who you love, suddenly became the cause of all your pain.

And then you stop and think. You remember how your mom would pick you up late from school or forget you were at a friend's house and you’d have to call her to pick you up. It made you feel unimportant and abandoned. You were never really able to talk about it, but to this day, people being late feels like they have forgotten you. It’s at this moment that you know you are not only upset, but you are triggered.

Sometimes knowing that is enough to let the feeling pass through your body. When your friend arrives, you can believe her lateness was an accident and enjoy the dinner. 

Or maybe that’s not enough. Maybe you need to talk to your about it. This is where I think the internet gets it wrong. If you use this information to tell your friend how rude she is and  make her take responsibility for the full scope of your pain, then you are misunderstanding the concept. You are forgetting that like all dynamics, to be “triggered” is an intersubjective act (occurs and is co-created by at least two people) and that you are bringing something to the dynamic. 

If you fully understand the meaning of triggered then the conversation may go differently. You will tell your friend you are aware you have a sensitivity to people being late  and that if there is a way to better communicate about delays when meeting up you’d appreciate it (if it’s a pattern). Sharing responsibility in the problem and the solution increases the chance that your friend will be responsive. And if the behavior does not change, you have a choice about if you accept it or let go of the relationship. This is a simple example of being triggered. 

Although each dynamic is co-created, the engagement is not always symmetrical and power differentials can impact the level of responsibility each party owns. An example of that may be when a professor misgenders a student repeatedly. Although as an older millennial I can imagine how a professor in the field for years may struggle with the new way of acknowledging student identities I also recognize their power in the dynamic.  As an authority figure the language they use with their students shapes the quality of all of the interactions. A classroom is not supposed to be a baptism by fire but rather a chance to incubate developing identities and instill confidence. After all, it is an arranged marriage in a sense. If possible I think it is always an interesting experiment to try to imagine a story about the other person’s behavior that is about their own history. A student being triggered here may want to think about their professor’s point of view as a coping mechanism, but they also have a right to ask for accountability and change from their superior.

Triggered is a word and concept that has a very important place in psychotherapy and in understanding a patient’s history, family dynamics, current relationships and relationship with the world. Outside of the therapy room, it often takes on a different connotation. Words change with use and with the cultural zeitgeist, (I’m still lamenting the acceptance of “literal” to mean “figurative”), and I don’t aim to police that. But when shifts happen to frequently used words, it’s important to acknowledge it. For many years, “triggered” has become closer to the word “upset” , a somewhat vague feeling word. It implies the other has wounded us and needs to apologize. It feels closer to “verbally assaulted” or “wounded”. These are important concepts and extremely common experiences and at times to use the word “triggered” actually undermines the ability to acknowledge an actual abuse. The shift in the connotation makes it an easy target for humor and mockery, connecting it to politically infused words like “snowflake” and “entitled”.

Being thoughtful and intentional in our language choice when discussing feelings is important as it increases the likelihood that we will be understood and responded to in a way that feels validating.