P. MARCOS OSCAR REYES ALTAMIRANO DIRECTOR DE AUDITORIA

There are times when the therapist really feels empathy for or with the patient, either feels what the patient feels deeply or what patient doesn’t yet know he is feeling. At these latter times the therapist may wonder: is this in fact what the patient is feeling, or is it me? Him or me? At other times a therapist has to work hard at getting to empathy, and at still other times he may question his empathy altogether. All these are examples of where empathy veers into countertransference, which means that the therapist really has to wrestle with himself alongside the patient. Thus there are two kinds of empathy, uncomplicated and complicated. When it is complicated empathy, the therapist must actively ponder what is ^zv96 going on inside himself, and this moves him into the realm of countertransference, which follows empathy out into an act of closer selfexploration.

An example

A patient tells me her tortured feelings about seeing a dead cat beside the road as she

drove by. As I imagine this, I am not filled with the ghastly horror of this that she is. I am not happy about it but it doesn’t bother me. So here I have to work, trying to imagine the feeling state of a person, the sensibilities and delicacy, of a person who would be that upset by a dead cat. But I then find myself thinking, “Oh come on.” Next, I feel a little guilt and wonder if I am a hard case; I wonder about my own propensities for denial, but the dead cat still does not affect me that much. Perhaps it would if it were my cat, but I don’t have a cat and am not particularly a cat person. So I have to imagine being a cat person, or someone who is tremendously attached to their pets. To really empathize, I have to set myself- my typical reactions and personality—aside and try to be a cat person.

To work with empathy, at times one has to work against oneself.

But unfortunately my thought-feelings do not readily budge—this was not her pet after all, I think—and I continue to feel a mild impatience at what seems to me to be an overindulgence, perhaps a misplaced sentimentality. I feel something like, “This is immature, this is hysterical”; but then, having not ignored my internal impatience with her, I begin to think, “It’s okay, who am I to judge?” Then I think of this patient’s reported family history, recalling that she told me her father was cruel to animals. This patient feels for all the animals in the world, and despairs because she cannot—life cannot—care for all of them. The image of her father is the embodiment of this heartless world as a whole (or, the “mean world “is generalized from her experience with her father).

I therefore start to ask myself: is my impatient way of thinking and feeling simply my callousness, or is it a callousness in him (the father in her, projected into me by her), or is it her own (very unowned and projected onto him and me)? Me, him, or her—I cannot tell which. Or is it all of these: my character, her projection of her father’s character (which also links up with an aggressive internal critic in this depressed patient), and her own unconsciously sadistic character? Or is it none of these, just my response to hers and there’s no problematic counter-transference issue per se? It could even be an “objective counter-transference,” in which my natural reaction to a distasteful—in this case a childish, in the negative sense—aspect of the patient is appropriate (Winnicott 1949). Or,

in ^zv97 opposition to that, isn’t this an interesting melange of transference and

countertransference, a mix-up needed by the patient, about which nothing has to be clarified yet, just experienced? In empathy/countertransference, a therapist sometimes must simply contain and wait.

The difficulty, if difficulty it is, is my getting with the patient’s point of view vis a vis the cat. Actually, her general insistence on the overall hopelessness of everything is what makes me feel impatient, and this is the real countertransference issue with this patient. I am transiently depressed at times by her perpetual depression, and I resist it (and its implications about life and also about an unsuccessful treatment). Her internal persecutor constellates my internal persecutor, and in response I want to lash out. Occasionally I remind her (and myself) of the positive steps she has indeed made in her life. But she appears always to forget, or to fall back into this treatment-resistant depression. I sometimes wonder if she is sadistically (even if unconsciously) torturing me by not getting better. I’m like one of the poor little animals. They can’t do anything, I can’t do anything, and neither can she. We all feel the same way—helpless—caught up in this disheartening paradigm of victims and victimizers.

Countertransference challenges

Situations like the above are a muddle, made more complex by the apparent fact that all of a therapist’s ruminations may seem true at various times. Such ruminations, which occur in split seconds, may seem extensive to the outside observer. They are extensive, but the mind covers a lot of ground and, like anybody else’s, a therapist’s ongoing thoughts in a session move much faster than they read. (Thoughts are always thought faster than they are spoken, written, or even read.) These are part of the in-session flow of his mind, his psyche.

Thus a failure of empathy, a question or reluctance about empathy, or so-called complicated empathy may be indicators that a deeper countertransference issue is being engaged in the therapeutic relationship. The countertransference struggle then becomes not the end but the beginning of the therapeutic process. Now, as in the example above, the therapist and the patient are in it together. As was quoted in Chapter 2, “The patient now means something to him [the therapist] personally, and this provides the most favorable basis for treatment” (Jung 1946, p. 177). In other words, for a patient to

“matter” to a therapist, the therapist must have a countertransference.

Most countertransference writings exhibit the above type of scenario and then a resolution. In the above instance, for example, the therapist ^zv98 would realize that the patient has been projecting her aggression, her own guilt, or her bad internal father into him and that the therapist has resisted, enacted, or identified with it in his impatience. Then, having realized and metabolized this, a therapist might interpret it back to the patient in some healing way. In my understanding of the Jungian perspective, which is slightly different, the interpretive dimension is less emphasized. The above type of situation plays unconsciously on the therapist’s current wounds (his despair and torturedness in this situation) and perhaps some old wounds (existential despairs). Jung mentions that it is his own hurt that gives the therapist power to heal. So here it is: therapist and patient both have a problem—feeling persecuted and worthless—and it is currently unresolved. They will live through it together, though the therapist most likely has to work it out first because, according to the Jungian perspective, a patient can only get as far as his therapist has.

This can be rough on a therapist, when he knows that he does not know and is unsure of the outcome. The distance between empathy and countertransference is not great. They are on a continuum that varies with the depth of the patient’s effect on the therapist. If empathy is vicarious experience, then countertransference occurs when the experience becomes not so vicarious. A therapist finds that a sticky countertransference has just happened. This is marked by the therapist’s unease with the situation, his unease with the patient. The countertransference has hooked him, and he is in it.

It is here that the therapist is dealing with a wounded-healing situation, which is a situation where his own wounds get healed or reactivated in conjunction with the patient’s. This has traditionally been thought of as undesirable, and, as noted, the therapist’s own therapy was the preventative measure. A wounded-healing perspective, however, assumes the reactivation or creation of anxiety and conflict in the therapist and the therapist’s working through of the issues generated in his contacts with the patient.

Jung (1963, p. 143) puts it well when he states that the therapist and patient must

“become a problem to each other.” The degree of such problem-creation varies with the particular chemistry of patient and therapist, the level of the patient’s pathology, and what the therapist brings to the table from present and past. A therapist, in other words, makes use of his own psychopathology. Not every patient requires this sort of complicity, but any longer-term therapy at some time or other will become difficult for the therapist.³ The healing situation seems to demand this from the psychotherapy. The following example highlights this idea.^4zv99

Example

A patient dreamed two dreams in the same night. In the first dream he has a “hard book”

under his mattress. This “object” is his “pain,” which is “wrapped up by day” but comes out at night. In the second dream the patient brings this dream to me, his therapist, but I am uninterested. Confused by this, he goes into my office building where he meets my partner (a dream creation), whom he likes. The patient then meets with me and again gets

“nothing,” but bumps into the other therapist on the way out. He finds this therapist to be

“ethnic,” friendly, but also “deeply troubled.” My colleague tells my patient a story about how he and I rented the offices together but he by chance got the smaller room. The patient doubts this was by chance. Their conversation stops and the patient is left “alone”

as the dream ends.

This second dream shows the patient seeking a more open, “troubled” therapist, and seems on the objective plane to show some not-too-veiled criticism of my lack of, or repression of, emotional vulnerability. It also indicates what the patient wants from a therapist, and perhaps suggests what the therapeutic relationship needs. Respecting the dream’s perspective, I felt anxious and embarrassed about this vision of me. So the dream did in fact wound me, insinuating that I closed out the deeply troubled. (Though not

“ethnic,” as that term is traditionally used, I did not usually consider myself disengaged or invulnerable.) Still, it suggested that more space needed to be given to that which is looser, even psychologically disturbed. In other words, the patient sought more contact with the wounded healer.

In terms of the therapeutic relationship—if the dream is taken as having outer as well as internal reference—it was now up to me, as therapist, to provide more space for this messier and more messed-up healer, which could be done in part by my personally wrestling with the implications of the dream. But the second dream also linked with the first dream: making a connection with an imperfect therapist might enable this patient to get into his own repressed pain. This patient was somewhat superficial and intellectual—

as his first dream possibly indicated, his pain only walked by night, hidden in a book under the bed. These dreams called attention to the considerable, bound-up feeling that he objectified and had hidden away, perhaps through intellectual defenses or bookish abstractions. For this particular patient to get at his pain, he needed a therapist to be involved with him in a deeper, similarly troubled way.

This example suggests two things: how a wounded patient needs a vulnerable therapist, and how a dream can provide considerable food for ^zv100 reflection on the status of the actual therapeutic relationship. As has been suggested, the therapeutic relationship has an inward as well as an outward component. One could say the external relationship is

internalized by the patient, though perhaps this would be too schematic. Internalization is a much more complex process than a blank-slate patient taking in an available external therapist (the same holds true for childhood internalization). In fact, it is almost a mystical process, in the sense that internalization is a subjective absorption by nonphysical means of both the real and imagined presence of another person over a long period of time. How this happens is a mystery. In any event, this patient was trying to get to the wounded part of the wounded healer, both externally (in me) and internally (in himself). The dream, as understood, seemed to suggest it was necessary for the external version to exist in some form in order that the internal side could constellate.

The two previous examples both show a progression in the therapeutic relationship as experienced from the therapist’s side. There is movement from empathy (uncomplicated) to counter-transference (where empathy becomes complicated) to wounded healing (where the therapist lives through a countertransference situation in a process of mutual transformation with the patient). To articulate this, Jungians invoke the archetypal idea of the wounded healer (see Chapter 3), meaning, for the therapist, the bipolar fluctuation between the healing or doctoring part of his experience and the vulnerable, “patient” side of his experience (Guggenbuhl-Craig 1971; Groesbeck 1975). These two poles exist in dynamic tension in both the therapist and the patient. In empathy, generally what is happening is that the therapist is trying to get to his own “inner patient.” He is moving to the memory or experience of his wounded parts as a basis for empathy.

Of course, there is not really a patient inside a therapist, nor is there a concrete, “inner therapist” inside a patient. These are ways of describing something that seems to occur within the participants. The therapist, in effect, is plumbing the patient’s woundedness either through his own prior wounds (an identification via empathy) or any dealt him by the patient now (countertransference, which often echoes early or other experiences).

Usually, empathy is light, because the issues are not unfamiliar and have been dealt with already; countertransference is heavier, potentially hurtful. Meanwhile, the patient is trying to get to the idea (or rather, the feeling and experience) of an inner therapist; that is, of the healing potentials within him, mediated by an actual therapist. ^zv101