"It is difficult to talk to patients about the relationship in the room", said Teri. "It‘s scary, it‘s vulnerable, it brings out our humanness. Nonetheless, it is a powerful therapeutic technique".

The next ninety minutes were spent discussing why it is important, why it is challenging, and ways to make it a little less difficult. The importance of the relationship in psychotherapy is illustrated in an article published twenty-five years ago in the American Journal of Psychiatry entitled "Can We Talk".

A patient with schizophrenia gave an account of how her therapy had helped her, and given her hope in her desperate struggle with mental illness. She said, For a long time, I wondered why my psychiatrist insisted on talking about our relationship. Our relationship was not the problem. The problem was my life. But she came to understand that the relationship with her psychiatrist was her first real relationship. She was able to bring that experience into her life in such a way that she finally felt like a part of the world and felt safe in it. In other words, the key to success in her therapy was the relationship between herself and her therapist, and talking about that relationship.

Why is it so difficult for therapists to talk about the relationship? One reason is that it is hard to recognize transference and to acknowledge how thoroughly all our relationships are built on our own fabrications as much as on reality. Another reason is that the patient often does not want to talk about it. Teri recalled the time, years ago, when her own therapist asked her how she thought the relationship was going. "It was a straightforward question, and I remember feeling completely undone by it. The fact was that I had come to respect, idealize, and (by that time even in some respects) love my therapist. I felt seen, I felt tolerated, and I wanted to emulate her. But I also felt like a psychological cretin in her presence".

With a comedian‘s pause, she revealed to the audience the very brief answer she gave to her therapist‘s question. "I remember my answer in the moment. I think I said, "Fine", she dead-panned. The audience laughed appreciatively and knowingly. ?But that wasn‘t the truth of it--not by a long shot, she continued. The point is that talking about the relationship can be threatening to the patient.

Early on, Teri turned the audience into the familiar territory of a classroom, complete with small-group discussions, to explore what we do as therapists. Specifically, do we bring the relationship into the room; how do we do it; what are the difficulties; what is its impact? A show of hands among this audience gave the result that only a few discuss the patient-therapist relationship frequently. The large majority of therapists in attendance rarely, or only occasionally, discuss it.

It is a given that our patients have a relationship with us. Not only may a patient experience the first real intimate relationship with his or her therapist; but it may be multiple relationships, such as his mother, his wife, his sister, or his lover. Simply put, transference is the imaginary relationship that we all experience, especially with those who have power over us. It is imaginary because it is built more on our imagination than on how the relationship actually is. Transference is hidden in plain sight, discernible in the patient‘s anxieties.

Anxieties arise from the inevitable misses in the interactions between child and caregiver. Parents, even good parents, can only approximately ?get us?. We respond in a predictable pattern to those misses, and unconsciously carry that attachment style into adulthood. In one study, even in good enough homes, micro-misses were recorded at the astonishing rate of one in every 17 seconds. Nonetheless, in those homes, the misses are tolerable. However, in others, the misses are egregious and chronic, and can cause a range of anxieties that we handle by anticipating them and bracing for them, to a greater or lesser degree. ?All of us have been practicing our counter-moves since we were born, said Teri. We super-impose familiar ways of relating onto new relationships. We also, without being conscious of it, exert pressure on others to behave in ways that are familiar to us, especially on those persons upon whom we most depend, including our therapist. This makes us feel more secure because we know what to expect. From the first contact with us, our patients begin to have impressions of us, shaped by their own early relationship experiences. Those impressions can be startlingly disparate from one patient to another. An illustrative case: at the end of one quarter, Teri did an experiment by asking her students to each give a one word description of how they saw her. The diverse answers that came back were: wise, smart, controlling, open, elusive, kind, engaged, present and obsessive-compulsive.

The therapist can use these impressions, in other words the transference, in the therapy, because in one way or another, the patient‘s world outside replicates itself inside the room.

So instead of having to try to handle patients‘ problems remotely, the therapist can deal with them directly in the relationship that is in the room.

Since using transference and talking about the relationship is so important, and yet so difficult, how do we do this?

We can use both transference and countertransference, and ask ourselves these kinds of questions: What does it feel like to my patient to be in my presence? What is my sense of myself in this patient‘s presence? What is the feeling in this room? Are they deferential? Are they trying to obliterate the divide between us? What does it feel like to me to be on the receiving end of this patient? How does my body feel in his or her presence? This work is delicate and cannot be rushed. "We are inviting our patients to disarm in a war zone", said Teri. There must be a profound respect for what that client has had to deal with, and recognition that the set of assumptions they are using has saved their emotional lives. But in the end, as Freud said, "It is on the field of transference that the victory must be won".

It is not always necessary to inquire into transference, for example when the energy in the room is fine and secure. But if there is anxiety in the air, if something is different, or off, there is no option except to go to the relationship, because if you don‘t, you will not be able to do anything else. Also, if a patient does not respond to an overture to talk about the relationship, the therapist should wait for the right time to emerge. In Teri‘s experience, it always does, sooner or later.

Author: Michal Sadoff
Presented by: Dr Teri Quatman