Crushed by the Counter-Transference: A Tale of Descent and Recovery

April 19, 2010

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his colleagues. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

In some unknown but dramatic way, I must have felt vulnerable the day I was suddenly crushed by counter-transference. I was obsessing about a new sports coat I’d just bought at Barney’s. It has Cashmere in it. I’ve never had a coat with Cashmere in it. I purposefully donned the jacket, and even a flashy orange tie, in preparation for the meeting with a new patient. The referral source told me he was an authoritarian, successful physician who had strayed in his relationship with his wife and strained the trust of his partners.

Just as I feared, the man proved to be “Mr. Perfection” himself. Aged around 40, 6’4” tall, sun-tanned and muscular, highly-educated and even better-compensated, articulate and charming—he was a perfect male specimen. And he was wearing a sports coat five times more expensive and ten times better-looking than mine. Worse, just as I prepared to hide behind my well-rehearsed professional role, Mr. Perfection hands me my signed informed consent form, downloaded from my website. He had attached a check for $1000 so he could “buy a number of sessions in advance.”

Reflexively I accepted the check and, in my best pre-adolescent voice, squeaked out my standard line, “Tell me something of what brings you and I’ll tell you about me and how I work.” He proffered various confessions, but they sounded more like conquests than failures. He showed little guilt or shame about his ethical breaches, and no anxiety or depression.

The first half hour was unbearable. I was drowning in feelings of inadequacy the likes of which I hadn’t felt for 45 years. I was in recess in elementary school, skinny and sickly. I was small weak unintelligent out of shape ignorant and even poor. He was so good-looking that I wondered if I was having homosexual longings. It wasn’t clear who was the patient and who the doctor.

Then, slowly, a few ideas broke loose from the swarm of self-doubt. He was no psychopath, but he clearly demonstrated that concept of externalization so popular in academic psychology these days. Rather than look inward at his intra-psychic dramas, he enacted them in the outside world. He was seeking my help because of problematic ethics, I told him, not because of mental pain. He admitted that, like a slight aching in a distant limb, he could feel guilt at the pain he’d caused his wife and partners only minimally. And even that discomfort was absorbed by the externalizing behavior of consulting me: he was seeking help, after all; he was actively solving the problem.

As we talked my gaze fell upon the informed consent form lying on my ottoman with the check neatly clipped onto it. Because he had paid for a number of sessions in advance, I suddenly realized that I was in truth indebted to him. He had turned the tables on me. Classic for those who externalize rather than internalize: he had projected the entirety of his vulnerability into me.

Adrenaline rushed through my system, and strength returned to my muscles (well, kind of). The dynamics suddenly became clear! Mr. Perfection here, just another wounded human being like all of us, had managed brilliantly to transform his internal emotional world entirely into external action. He had left no small number of burning wrecks in his past in the form of ill-informed patients, envious colleagues, cheated wives, and wounded children.  We had some serious work to do, and now I was finally engaged in it with him.

Counter-transference is always an interpersonal process, with your fault lines intersecting with your patient’s. Identifying these subtle reactive feelings ideally helps guide your work. But sometimes these feelings transport you to shadowy spaces long forgotten. My brilliant Mr. Perfection, with his dulcet voice and smooth rhetoric, carried me right back to painful elementary school years.  That Barney’s sports coat really was absurdly overpriced – all that Cashmere for protection against nothing.

The End


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