Misch 2018 Great Expectations

Great Expectations:
Mistaken Beliefs of Beginning Psychodynamic

Psychotherapists
DONALD A. MISCH, M.D.*
Beginning psychotherapists often have mistaken assumptions about what it is

that constitutes good psychotherapy and a good psychotherapist. These
mistaken beliefs are counterproductive and may inhibit the development of
appropriate psychotherapeutic skills as well as delay, or even prevent, the
acquisition of an appropriate identity as a psychotherapist. This paper explores
six common mistaken beliefs on the part of neophyte psychotherapists,
providing a basis for exploration and discussion of key developmental issues
in the genesis of a competent psychotherapist.
Took with favor upon a bold beginning.

Virgil
A hard beginning maketh a good ending.
John Heywood
It is not easy to be a beginner, a neophyte, a novice, a tyro. This is true

whatever the area of enterprise, but it is especially true for the field of
psychotherapy. The beginning psychotherapist has a difficult task confront-
ing him, for master psychotherapists, like experts in other fields, do not
magically appear intact and ready to go, like fast food. Each master
psychotherapist was once a beginning psychotherapist, a usually eager,
typically befuddled, and not infrequently entirely overwhelmed individual
with a wish-a wish to become a psychotherapist (1). Confronting the
enthusiastic beginner is a multitude of knowledge and skills that must be
^Director of Education, Medical College of Georgia, Department of Psychiatry and Health

Behavior. Mailing address: 1515 Pope Ave., Augusta, G A 30912.
* I have taken the liberty in this paper of referring to psychotherapists by use of the male gender and
patients by use of the female gender. I fully realize that there are at least as many beginning and expert
female psychotherapists as there are male psychotherapists; and, similarly, there are large numbers of
both male and female patients. M y use of these gender stereotypes is solely in the service of simplifying
the language.
A M E R I C A N JOURNAL O F P S Y C H O T H E R A P Y , Vol. 54, No. 2, Spring 2000
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Mistaken Beliefs of Beginning Psychotherapists
assimilated and refined in order to become expert at the craft of psycho-

therapy.
One of the important steps in the transition from beginning psychothera-
pist to competent clinician, especially for those who wish to practice more
intensive (expressive, exploratory, or uncovering) types of psychotherapy,
involves the recognition and modification of unrealistic beliefs that are
typically held by inexperienced psychotherapists. The beginning psycho-
therapist usually brings to the task a set of assumptions about what
constitutes a "good" psychotherapy and a "good" psychotherapist. These
idealized conceptions may be helpful in that they provide the novice with
goals and ideals to which he aspires in his quest to become an expert
psychotherapist. Unfortunately, these assumptions may be counterproduc-
tive as well. To the extent that such beliefs are unrealistic and unattainable,
they may evoke in the beginning psychotherapist great anxiety and distress.
Feelings of guilt, shame, disappointment, and anger towards himself or the
patient may result from the mismatch between the novice psychotherapists
expectations and the difficulty in practicing good psychotherapy. Indeed,
the failure to live up to his unrealistic expectations may lead the beginner to
become disillusioned with regard to the value of psychotherapy itself or to
give up altogether on the goal of becoming a psychotherapist. Hence, one
of the key tasks of the beginning psychotherapist, and a difficult one at that,
is to identify and relinquish those beliefs about psychotherapists and
psychotherapy that are, indeed, more wish than reality (2).
The beginning psychotherapist is often aware, at least intellectually, that
some of these beliefs and conceptions are untrue. Even so, emotionally it is
difficult for beginners to truly accept the realistic limitations of psycho-
therapy and psychotherapists, for many such beliefs are not the result of
pure cognitive distortions or errors resulting from insufficient didactic
training or experience. They are, in addition, the product of a psychothera-
pist s underlying psychodynamics. Thus, a therapist's conscious or uncon-
scious needs to be loved, be responsible, be perfect, be omnipotent, and the
like, all contribute to his beliefs about what constitutes a "good" psycho-
therapy and a "good" psychotherapist.
In this paper, I shall focus on some of the typical wishes, fantasies, and
mistaken beliefs held by beginning psychotherapists. My intent is to
identify some of these mistaken beliefs so that they can be placed in a more
realistic perspective. It would be naive, however, to believe that simple
intellectual corrections will be sufficient, in and of themselves, to change
the thinking of all beginning psychotherapists. The reality is that these
mistaken beliefs must be resolved by a tripartite approach: didactic instruc-
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A M E R I C A N J O U R N A L O F PSYCHOTHERAPY
tion and review of the relevant literature, clinical psychotherapeutic experi-

ence with good supervision, and personal exploration (e.g., in psycho-
therapy supervision and/or in personal psychotherapy) of a given therapists
underlying psychodynamics. Nevertheless, there is value in clearly describ-
ing and examining these mistaken beliefs so as to help dispel some of the
misconceptions.
To this end, this paper will outline six of the more common mistaken
beliefs held by beginning psychotherapists. It is hoped that this paper will
be of benefit to neophyte psychotherapists in allowing them to pursue their
work and career to the point that they will, indeed, exhibit competence and
mastery of their craft.
I must ask the more experienced psychotherapist to forgive the simpli-
fied clinical vignettes used to exemplify key points; my goal is specifically to
simplify what is, in reality, an immensely complex undertaking in order to
make it more understandable to the novice.
MISTAKEN BELIEF #1: "I SHOULD COMPLETELY SEE AND UNDERSTAND

EVERYTHING, AND I SHOULD D O SO IMMEDIATELY WITHOUT HAVING
TO STRUGGLE."
The understanding that a psychotherapist comes to have of his patient is

the result of a long-term, continuously evolving, often difficult process, one
that involves serious, sustained, and dedicated collaborative work on the
part of both therapist and patient. To the extent that expert therapists seem
to "see" more and understand more of their patients more quickly than the
beginner, this is not the result of some magic, idiosyncratic intuition. It is
based on years of didactic education as well as training and experience in
which a therapist takes his natural empathy, understanding of people, and
interpersonal skills, and carefully hones them with repeated practice in the
course of therapy after therapy.
It is important to remember that the life of any individual is a very
complicated, multifaceted entity. No one-patient, therapist, family member-
can possibly "know" or "understand" a human life easily or completely. To
really come to know another person requires learning about that person
from multiple perspectives, in multiple situations or contexts, and over the
course of time. How one individual reacts to a given person may not reflect
how she reacts with other persons. And how one individual feels about, or
relates to, her parents or siblings or spouse or children today may not be
indicative of the thoughts and feelings and behavior towards those persons
in the past. One must learn about the person's "outer" or observable
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thoughts, feelings, and behavior, as well as her "inner" life-thoughts and

feelings that may not be obvious to either the patient or the therapist.
Furthermore, even the "facts" of a person's life are elusive (3-12). Who
is the final arbiter of what actually happened, who said or did what when,
who really was angry or abusive or depressed or erratic? All of these are
subjective, as much as objective, assessments. How the "data" of an
individuals life are understood and construed is not a neutral scientific
process; rather, it is an interpretative, narrative enterprise (6, 12-17) in
which what one "observes" and the conclusions one comes to are them-
selves influenced by who is doing the observing and what preconceived
thoughts, feelings, and ideas he or she brings to the very process of
observation (13, 16, 18,19).
Roy Schafer (20) reminded psychodynamically oriented therapists of
Erich Fromm's three key questions to be asked of both themselves and their
patients: "Were the parents so guilty? Was the patient so innocent? What
was so traumatic about the traumatic situation?" One may add: What did
actually happen to the patient when she was a child? Was her father truly
cruel, or merely a strict disciplinarian, or, in fact, none of the above? Even if
we could go back and directly observe a patient interacting with her
parents, each of us would likely see something different and come to
different conclusions about the participants and their motivations. Thus,
even a patient may not know "the truth" about her past and the significant
people in her life. Adds Schafer (20), "as the [therapy] progresses, the
pictures of parents tend to change radically, especially in the direction of
complexity and conflictedness" (p. 151). The same can be said for other
past and present interpersonal relationships as well. Indeed, one outcome
of exploratory psychotherapy is that a patient often modifies her views of
herself and others as she employs new powers of observation and comes to
consider her life from new, more nuanced perspectives.
If, indeed, the "facts" of a person's life are elusive, the thoughts and
feelings about her life are likely to be even more so. A person's "true"
thoughts, feelings, hopes, expectations, fears, and fantasies may not be
readily available to herself or to others, including the therapist. As Sigmund
Freud demonstrated time and again, the unconscious exists and, by
definition, it contains thoughts, feelings, and fantasies of which an indi-
vidual is partially or completely unaware (6, 21-25). How frequently have
each of us discovered that our feelings about something or someone were
not what we had previously thought? How often do we learn new "truths"
about the thoughts and feelings of ourselves or others, new truths that may
even be incompatible with our previous conceptions?
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Thus, the beginning psychotherapist's belief that he should completely

see and understand everything about his patient is an impossibility. Or, as
Irvin Yalom (26) puts it: "The major task of the maturing therapist is to
learn to tolerate uncertainty" (p. 410).
Nonetheless, a psychotherapist often comes to know a great deal about
his patient, including the patient's thoughts, feelings, fantasies, behavior,
symptoms, and so forth. How does a psychotherapist accomplish this task?
The master psychotherapist takes his personal life experience, his
observations of others (family, friends, coworkers, public figures), his
didactic education in normal and abnormal human psychology, his clinical
experience as a psychotherapist with many patients over time, his psycho-
therapy supervisors' wisdom and insights, and the lessons and insights from
his personal psychotherapy; and he combines these with objective, subjec-
tive, and empathic observation (17, 27-38) of his patient over the course of
time. These observations include what the patient says about her past and
present life and interpersonal relationships, information that may be
obtained from other sources, such as family members, friends, and teach-
ers, and, very importantly, objective and empathic observation of the
patient in therapy with the therapist.
The patient's relationship to the therapist-the transference in part-as
well as the feelings engendered by the patient in the therapist-the counter-
transference-are crucial observational tools that allow the therapist to
come to know his patient more deeply. Indeed, although the patient's
transference-her thoughts, feelings, and fantasies about the therapist-is
not identical to the patient's relationships with significant others in her past
and present, it is, nonetheless, an important analogical window into such
information (39). The psychotherapist has the invaluable opportunity, if he
chooses to use it, to directly observe some of how his patient feels about and
interacts with others; he does this by observing his patient's transference
reactions to him, the therapist (40,41).
By using these various tools, the master psychotherapist begins to
construct theories about what makes his patient tick, how his patient views
and relates to herself and the world; in short, the therapist begins to make a
formulation (42-44) about his patient. But this formulation is only an
educated guess or set of hypotheses. The master psychotherapist is keenly
aware of this fact, and he repeatedly tests his hypotheses to see if they are
true. Because of the complexity of any given human life, it is invariably the
case that the formulation, the hypotheses about what makes the patient
tick, will need to be constantly modified over time. Never will any
psychotherapist completely know and understand his patient; never will he
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have a fully complete and accurate formulation. But, with time, the
psychotherapist will have an increasingly accurate and clinically useful
understanding of his patient.
It is also important to remember, as alluded to above, that no therapist
can deeply and accurately understand his patient without his patient's help;
the work must be collaborative. While the patient's behavior and interac-
tions with the therapist may be directly observed in the therapy session, this
represents no more than a small portion of the patient's total interpersonal
relations in various contexts and situations with different people. And even
in the therapy setting, without the patient's willingness to talk, disclose
thoughts, feelings and fantasies, and interact with the therapist, the possibil-
ity of deep understanding is limited. Thus, the patient and her psychothera-
pist have to work together over time, observing the "data" inside the
therapy and outside in the "real world," making hypotheses, testing them,
and revising them as indicated.
Not only is rapid and complete understanding of a patient in psycho-
therapy an impossibility; in reality, it is often an undesirable goal (13, 14,
45). The necessity for therapeutic action may demand a nascent formula-
tion; but the therapist who is too sure too quickly, who has "all the answers"
and understands his patient "completely," is most likely a therapist uncom-
fortable with uncertainty and frightened of his own limitations (17). Such a
person feels compelled to come to early closure on issues of diagnosis,
formulation, and treatment plan. Other therapists come to premature
understanding of their patients because of their own narcissistic needs to
know all or, at least, to appear to other persons that they do (46). Still other
impatient therapists rush to understanding and judgment because of their
sincere wish to help their patients at the earliest possible moment. Noted
TheodorReik (47):
I have been teaching and training young analysts for many years and I know
that nothing is more difficult for them than to control their impatience. The
temptation to help quickly and-what must necessarily precede every therapeu-
tic effort-to understand quickly, is a strong one for the inexperienced. Looking
back upon my own early analytic work, I realize how impatient I was myself,
how ready to form judgments and to make premature interpretations, how
hasty sometimes in my conclusion, (p. 127)
Kottler (17) puts it nicely: "If at some time every week (or every day in some
cases), therapists do not feel stuck, at a loss as to how to proceed, confused
and unsure about what is happening with clients, then they are probably
neither very honest with themselves nor very open to confronting the limits
of their capabilities" (p. 96).
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Whatever the cause, if the therapist knows too much too soon the
outcome is not favorable; indeed, the usual result is that the therapist
prematurely closes off both himself and his patient to other unexplored
possibilities. An open mind and a willingness to consider old hypotheses in
the light of new data is the essence of a scientist, including the "scientific"
psychotherapist.
MISTAKEN BELIEF #2: "I SHOULD ALWAYS SAY OR D O JUST THE RIGHT
THING, AND IT WILL PRODUCE A MAGIC C U R E . " COROLLARY: "IF I DON'T
SAY OR D O JUST THE RIGHT THING, IT WILL DESTROY OR IRREPARABLY
HARM MY PATIENT."
The words of the psychotherapist are analogous to the scalpel of the

surgeon: they are one of the key tools of his trade and, just like the scalpel,
they can relieve illness and suffering or they can cut and wound (48). It is
important that the psychotherapist be as skilled as possible in his use of
words, just as the surgeon is skilled in the use of his scalpel. What is said,
how it is said, and when it is said are important variables in the success of
psychotherapeutic interventions (40, 49-55).
Having noted this, however, the novice psychotherapist needs to recog-
nize that psychotherapy is a very complex process. At every moment in
psychotherapy, the therapist, like a chess player, is faced with innumerable
possibilities. He may choose to speak or he may choose not to speak; and if
he chooses to speak, there are innumerable things he could say, innumer-
able ways in which he could say it, and innumerable other interventions he
might make as well. It is always easier retrospectively, with the comfort of
time and distance, to go back and criticize and then conceive improvements
on one's earlier interventions. Thus, in such a complex endeavor, and one
further colored by various countertransferential pressures, the reality is that
psychotherapists relatively infrequently say "just the right thing."
Another important point is that psychotherapy is not a "single best
answer" endeavor; often, there are multiple appropriate or useful responses
on the part of the therapist in his work with a particular patient at a
particular time. Ultimately, the key issue is whether one's patient is
improving in terms of thoughts, feelings, behavior, or symptoms; and any
nondestructive path that leads to improvement is a clinical success. Further-
more, even if there were only one "right" verbal response or interpretation,
psychotherapists quite likely would not agree on what it was. One need
only listen to two or more psychotherapists discussing virtually any patient
to realize that there is hardly a universally recognized "right response" to
any given clinical situation.
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Moreover, beginning psychotherapists also need to recognize that the

very attempt to determine whether one has said "just the right thing" is
fraught with difficulty. Indeed, it may take minutes, hours, weeks, months,
or, in some cases, even years to determine if a particular intervention was, in
fact, "right" or correct (i.e., leads to clinical improvement) (56, 57). A
patient's enthusiastic response to the therapist's interpretation may reflect
her need to submit to others or her wish to make the therapist feel
intelligent and important rather than the fact that the therapist's interpreta-
tion was useful or insightful. Analogously, a patient's angry response to the
therapist's interpretation does not, in itself, indicate that the interpretation
was incorrect or even inappropriately timed or delivered. While the latter
may be true, it may also be the case that the patient has been confronted
with a truth that she does not want to hear. Just as one may react angrily to
being told something by one's friend but later come back and say, "You
know, I thought about what you said, and while it made me very angry at
the time, I realize that you're right," so, too, may a patient come to such a
realization.
VIGNETTE 1
A professional woman in her mid-thirties had been in regular exploratory

psychotherapy for almost two years when she announced one day that she
and her husband were having financial difficulties and, as a result, she
would have to discontinue her therapy. After further discussion, the
psychotherapist pointed out that the patient had made various expensive
purchases recently, suggesting that sufficient money might be available to
continue in therapy if the patient so chose. The psychotherapist wondered
aloud if perhaps her decision to discontinue therapy was less related to
financial difficulties than to other issues. The patient became very angry
and accused the therapist of trying to prolong her therapy in order to
protect his own financial interests. The therapist, to himself, considered
whether his comments had been inappropriate in content, timing, or
delivery. Nevertheless, over the course of the next several weeks, and in a
nondefensive manner, the therapist continued to explore this issue with the
patient. The patient ultimately came to realize that money was, indeed, a
peripheral issue in her decision to discontinue therapy and that she had
become angry at her therapist's confrontation because he had prodded her
to focus on an aspect of her behavior that she would have preferred to
ignore. What had appeared, at first, to have been an inappropriate com-
ment on the part of the therapist ultimately was revealed to be an accurate
and highly useful therapeutic intervention.
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Thus, the answer as to whether a verbal intervention on the part of the

psychotherapist is clinically effective may be difficult to discern and a long
time in coming. In Necessary Losses (58), Judith Viorst quotes the humorist
Art Buchwald as saying, "A good analysis . . . is when five years later
something happens and you suddenly say, 'Oh yeah, that's what he meant' "
(p. 18). An important corollary is that the beginning psychotherapist
should be slow to judge any intervention as correct or not; the patient s
immediate positive or negative reaction to a psychotherapeutic intervention
must be taken with a grain of salt.
An entertaining and instructive reference in this regard is Irvin Yalom s
Every Day Gets a Little Closer: A Twice-Told Therapy (59), in which a
patient and Yalom both present the separate written journals they kept of
their work together. Of note is how differently, at times, the patient and the
psychotherapist interpreted and valued the therapist s interventions. Thus,
at times, Yalom would make what he considered to be a "brilliant interpre-
tation," only to subsequently learn from the patient s journal that his words
had had virtually no impact upon her; similarly, at other times, comments
or interventions by Yalom that he considered to be trivial were deemed by
the patient to have been highly significant.
Therefore, one can only make the best interventions he can as a
psychotherapist. Trying to say "just the right thing" may be a goal to which
the therapist aspires, but in real life he will usually fall short of that ideal.
Furthermore, it is important to realize that less-than-perfect interventions
are not only the norm, they are also efficacious. Just as no parent is perfect,
but he or she may nonetheless raise a healthy, happy, successful child, so,
too, may a therapist help a patient by "good" rather than "brilliant"
interventions. Michael Basch (60) makes the same point: "The therapist has
to get used to the idea that a session need not be ideal in order to be
productive" (p.27).
Moreover, to the extent that a therapist succeeds in a given instance in
actually saying "just the right thing," one such "brilliant interpretation" is
rarely enough in itself to cause significant change in deep-seated psychologi-
cal structures. Hollywood movies not withstanding, it takes more than a
few fortunate words to substantially affect serious emotional difficulties or
character deficits. Charles Brenner (56) notes "that important interpreta-
tions can exert their full effect only gradually and after many repetitions,"
adding that "[w]ith rare exceptions it is not this or that interpretation that
counts as much as the cumulative effect of many interpretations" (p. 51).
The beginning psychotherapist should remember, too, that most psycho-
therapeutic interventions do not have life or death implications. If the
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therapist says something less than perfect, something inappropriate, or

even something outright injurious, the odds are that the patient will survive.
Indeed, the situation is more complex, and more opportune, than one
might expect. It has been stated that therapy is a situation or context in
which mistakes are made useful. When working in the transference,
therapist "errors"-real errors occurring out of inexperience, misunderstand-
ing, distraction, and so forth-are often the impetus for some of the most
productive work in psychotherapy. Such "mistakes" on the part of the
therapist may represent potentially invaluable therapeutic opportunities //
they are handled correctly thereafter (61).
VIGNETTE 2
A clinging and demanding, personality-disordered young woman an-

nounced during her therapy session that she had forgotten to bring any
money with her so that she would be unable to pay the one dollar fee to
leave the hospital parking lot. The therapist was reluctant to give the
patient the needed dollar, fearing that this would unleash further difficult-
to-control demands for care on the part of the patient. Ultimately, the
patient was forced to borrow the money from a stranger in order to get out
of the parking lot. Upon subsequent reflection, the therapist concluded
that while there were important therapeutic issues embedded in the
patient's request for parking-lot money and that these issues needed further
exploration, he also felt that under the circumstances common courtesy
dictated that he should have lent the patient the needed dollar. After all, he
would still be able to therapeutically explore the patient 's clinging needi-
ness in subsequent sessions. Furthermore, he realized that in her relation-
ship with him, the patient demonstrated the very dynamic that was a crucial
component of her unhappiness in life: her maladaptive attempts to force
people to care for, and nurture, her, had precisely the opposite effect of
making people want to distance themselves from her. Upon their next
meeting, the therapist told the patient that he felt he had made a mistake
and that he should have provided the patient the dollar she needed. In
addition, however, he used this "mistake" on his part to explore with her
the way in which her manipulative neediness drove the therapist, and the
patient's family and friends, away from her because of their fears of being
overwhelmed.
Therapists, too, may benefit from their own therapeutic mistakes and
misadventures (17, 61) insofar as they are "able to accept their imperfec-
tions, to remain open to processing their mistakes and misjudgments, and
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to use them as a means of increasing their effectiveness in the future" (17 p.

92). Indeed, Cormier (62), in his analysis of personal accounts of critical
incidents that shaped the subsequent development of therapists, found that
therapeutic mistakes and failures were the most common stimuli for growth
as a therapist.
Finally, it should be underscored that if a patient is devastated by
anything less than perfect statements or interventions on the therapist's
part, then that, in itself, is a crucial therapeutic issue. It is likely that the
patient feels just as disappointed, angry, or at a loss when others in her life
invariably fail to respond in just the right way. One life task for every person
is to learn to live with an imperfect world and imperfect people (e.g., family,
friends, coworkers). A persons inability to do so, his or her failure to
develop adequate coping mechanisms for dealing with such disappoint-
ments, leaves him or her dangerously vulnerable to a flawed environment,
with subsequent overwhelming anxiety, depression, confusion, rage, or
inability to function. The goal of the therapist with such a patient is not to
be perfect, which is an impossibility in any event, but to help the patient
learn to tolerate and cope with imperfect people in an imperfect world. In
the helpful language of self psychology (36, 37, 63-65), the patient needs to
learn how to respond appropriately to empathic failures on the part of
important selfobjects so as to prevent fragmentation of the self. What better
place to embark on such a learning experience than within the context of
psychotherapy with a competent and respected therapist?
MISTAKEN BELIEF #3: "IF MY PATIENT DOESN'T GET BETTER QUICKLY, I MUST
NOT BE D O I N G A G O O D JOB."
The beginning psychotherapist typically wants, and expects, his patient to

show rapid signs of improvement. He usually assumes, incorrectly, that
other therapists are obtaining swift results and, therefore, believes that a
failure to obtain similar outcomes in his work is the result of professional
inadequacies on his part. Such beliefs are exacerbated by various factors.
For example, the increasing prominence of "brief" therapies (66-71) may
lead the novice psychotherapist to assume that, therefore, all therapies
should, and can, be brief. Similarly, the explosive development of managed
mental health care, with its demands of rapid improvement, may result in
unrealistic expectations of immediate patient progress (72-77). These
factors often combine to cause the beginning psychotherapist to fear that
both patients and supervisors will find him wanting for his inability to
provide prompt amelioration of his patient 's difficulties.
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In reality, however, the wish or expectation of rapid psychotherapeutic

relief is simply not achievable with all patients or all emotional difficulties.
Certainly, some problems can be ameliorated or resolved rapidly; but, by
the time a patient comes to a psychotherapist (especially for exploratory
therapy), she has usually been struggling with difficult issues for a consider-
able period without success. The patient has typically spoken with family or
friends, perhaps read some books, or attended self-help or lay groups; the
"easy" answers have already been tried and failed. So it should come as no
surprise that change may not occur easily or rapidly, no matter what the
therapy or who the therapist. Thus, the beginning psychotherapist must
learn patience: patience with himself and patience with his patients (17).
Furthermore, it should be remembered that each patient, indeed each
person, has literally spent a lifetime developing his or her own personality,
defense mechanisms, and coping styles. It is hardly surprising, therefore,
that lifelong character traits and patterns of thinking, feeling, and behaving-
the very "stuff" of intensive or exploratory therapy-may require long
periods of time to undergo significant change. Indeed, it is not the
uncovering of unconscious material or the acquisition of insight that
accounts for the length of psychodynamic psychotherapy; it is the process
of working through (40, 78-80), of transforming intellectual insights into
real and lasting changes in thinking, feeling, and behavior.
In this respect, psychotherapeutic change is analogous to the psychologi-
cal growth of a child: development does not occur in a simple linear
fashion; instead, periods of relatively rapid change are interspersed with
periods of slow but steady progress, periods with little change, and even
periods during which the child experiences significant regressions. Just as a
child can only mature so quickly, so, too, can a psychotherapy patient
progress only at a pace that is consistent with her innate abilities, her
previous experiences and their impact upon her, her current environmental
circumstances, her desire for change, and whatever external help is avail-
able to her. The result is that psychotherapy with a given patient may, in
fact, be going quite well even though the work is progressing slowly.
There are other reasons why psychotherapy is often less rapid than both
patients and therapists would wish. Paradoxically, one such reason is that
consciously or unconsciously patients often oppose the very psychothera-
peutic process they have sought for relief of their difficulties; patients
typically work to defeat the objective of change even as they simultaneously
try to alleviate their emotional suffering or alter their maladaptive behav-
iors. Psychoanalysts have referred to this phenomenon as that of resistance
(40, 81); and, from their perspective, it is an inevitable part of every
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significant psychotherapy. Said Sigmund Freud (39): "the resistance accom-

panies the treatment step by step. Every single association, every act of the
person under treatment must reckon with the resistance and represents a
compromise between the forces that are striving towards recovery and the
opposing ones" (p. 103). Freud (82) added that the "overcoming of
resistances is the part of our work that requires the most time and greatest
trouble" but that "[i]t is worth while, however, for it brings about an
advantageous alteration . . . that will hold good in life" (p. 179).
Resistance, a patients opposition to meaningful psychological and/or
behavioral change, is not necessarily a bad omen for the patient, the
therapist, or the therapy. At the same time the resistance slows therapeutic
progress, it also presents an opportunity for the patient to explore, and
overcome, fears of change as well as other factors that might result in
conscious or unconscious wishes to be unhappy, unsuccessful, or unful-
filled (40, 83-85). Roy Schafer (20) recommends that the therapist handle
"what has traditionally been called resisting in an affirmative manner, that
is, to approach it not as resisting or opposing but as puzzling or unintelli-
gible behavior that requires understanding" (p. 155). He adds (20), "[R]ather
than setting oneself to 'break through resistances,' one should try to
elucidate their role in the life that is being studied" (p. 75).
Another key point: if a patient does change overnight, it is not necessar-
ily good news. Such dramatic alterations in mood, anxiety, outlook, or
personality are often evanescent and represent transference cures (86-88), a
"flight into health," a desire to terminate therapy, a need to please the
therapist, or a host of other motivations. The result is that often the
patient's psychopathology may go underground, but not for long. Typically,
the patient's problems will be back, not infrequently with a vengeance. Real
change takes time and is recognizable by the hard work and time invested,
as well as by meaningful psychological or behavioral modifications mani-
fested repeatedly over time and in various situations.
MISTAKEN BELIEF #4: "MY PATIENT'S FAILURE T O IMPROVE IS A PERSONAL

FAILURE O N MY PART."
A difficult issue for the beginning psychotherapist is the distinction

between the psychotherapy and the psychotherapist. Thus, a psychothera-
pist may feel that he is personally deficient if a patient fails to improve, even
though the therapist may have done impeccable work with that particular
patient. This distinction between the therapy and the therapist is perhaps
more easily understood if we begin with a similar situation.
A physician, for example an oncologist, is usually able to appropriately
184
distinguish between his efforts as a physician versus the success of the

medical treatments available to him (89). An oncologist may feel badly that
one of his patients has died, but he is typically able to recognize, assuming
that no malpractice has occurred, that his patient's death is the result of
deficiencies in medical science rather than a personal failure: " I did a good
job, the best I could; medical science just doesn't have the tools yet to cure
all cancer."
In contrast, psychotherapists find themselves in a more difficult posi-
tion because in psychotherapy the psychotherapist himself is, in many ways,
the instrument of both diagnosis and "cure." With respect to the latter, the
psychotherapists therapeutic tools are his words, actions, and even his
personality-the very essence of who he is (17, 46). Maltsberger and Buie
(90), in referring to psychiatrists, put it this way:
[I]n psychotherapy the means of "healing" is the person of the physician. His
own personality is the therapeutic tool, and for this reason the means of
treatment are more difficult to separate from the self than is the case in surgery
or medicine, in which the means involve instruments and drugs. The psychia-
trist is therefore prone to confuse the limitation of his professional capacity to
heal with his sense of personal worth, (p. 627)
Maltsberger and Buie (90) add that "[t]he most common points of vulner-
ability at which the patient may shoot his arrows are those areas of
unrealistic narcissistic self-over-estimation (or overaspiration) that are to
some extent universal among beginning psychotherapists" (p. 627). The
latter lead to "the three most common narcissistic snares [in the therapist,
which] are the aspirations to heal all, know all, and love all" (p. 627).
Brightman (91) seconds the notion of a narcissistic triad (omniscience,
omnipotence, and benevolence) in the typical beginning psychotherapist;
other authors (92), using different terminology, come to similar conclu-
sions. From Burton's (93) perspective, many psychotherapists harbor the
feeling that "something terribly important is involved in the psychothera-
peutic process, and that no one else-certainly not the clergy, the artist, or
the philosopher-can provide it. The psychotherapist thus feels that he is
the chosen one" (p. 121). Hence, a patients lack of improvement is often
experienced by the beginning psychotherapist as a personal failure on his
part.
In spite of this belief, therapeutic difficulties with a patient do not
necessarily mean that the psychotherapist is deficient either as a therapist or
as a person. Indeed, the reality is that not all patients can be helped, either
at a given time or perhaps ever. Some mental health problems remain
intractable and untreatable, given the current state of the art. Furthermore,
185
some patients fear the loss of their psychotherapist if their symptoms

resolve. More obvious situations occur when patients are forced into
therapy, for example, by family members or the courts; unwilling patients in
psychotherapy are more likely to reject the therapist's efforts on their
behalf. And then there are patients who are determined, consciously or
unconsciously, to fail in therapy-the so-called "negative therapeutic reac-
tion" (94-102). Some may do so as a consequence of unconscious guilt and
a need to suffer: "Because I mistreated my mother over the years, I do not
deserve to be happy." Others may fail in therapy in order to defeat the
efforts of the therapist, to make him feel incompetent as the patient secretly
feels or in order to secure a "victory" over a perceived, authoritarian elder.
Such patients may have spent a lifetime honing their skills of subverting,
defeating, or embarrassing others.
VIGNETTE 3
A third-year psychiatric resident was presenting to faculty and colleagues at

his departmental Grand Rounds, when one of his patients, a young woman
with borderline personality disorder, appeared at the back of the audito-
rium. In a loud and plaintive voice she called out, "Dr. Smith, you wouldn't
return my phone calls and you know how suicidal I've been feeling; I
desperately need your help and you won't speak to me." Dr. Smith, an
excellent resident and one who had been carefully and appropriately
setting limits on the patient's manipulative parasuicidal behavior, calmly
replied, in front of everyone in the auditorium: "Ms. Jones, I can't speak
with you now; however, since you're feeling suicidal, I'm going to ask one of
my colleagues to escort you to the Emergency Room where you'll be safe
and you can be evaluated. I'll check in with you later after I finish my
presentation."
VIGNETTE 4
In spite of the fact that she had access to virtually any of many psychiatrists
in a large city, the 19-year-old daughter of a prominent psychiatrist on staff
at General Hospital presented to the outpatient psychiatry clinic for
psychiatric evaluation. In the course of her initial evaluation, she revealed
many "family secrets," including information relating to what she perceived
to be the many faults of her psychiatrist father. It became clear that she had
chosen to attend the psychiatry clinic at General Hospital where her father
was on staff precisely because she wanted to cause him great embarrass-
ment.
An important proviso, however, is that therapeutic impasses (103, 104)

186
do occur; and the honest psychotherapist must be willing to explore the

hypothesis that the impasse is partially, if not primarily, the result of a
deficiency on his part. Perhaps the therapist simply did not have sufficient
experience or empathy with a particular type of patient, or perhaps he was
unable to control his countertransference. The truth is that any therapist
can be a better therapist. The professional psychotherapist unabashedly
examines his potential role in therapeutic impasses or difficulties, and he is
willing to acknowledge those areas where, in fact, he can and should
improve his therapeutic skills (17, 61).
In a related vein, it is important to be alert for needs and fantasies,
especially common in beginning psychotherapists but not limited to nov-
ices, to save, rescue, or "cure" others (46, 105, 106). The neophyte
psychotherapist need not feel guilty about such fantasies; indeed, they often
appear to be developmentally determined and, ironically, may constitute an
important motive in the decision to become a psychotherapist (46). Thus, it
has been suggested that many current psychotherapists grew up in families
where they had been assigned the role of ensuring the happiness of their
parents (especially their depressive mothers) (107-110). Similarly, rescue
fantasies of psychotherapists have been viewed as attempts at reparation
(111)- "an attempt to reduce the guilt over having attacked the good object
[e.g., the parents] by trying to repair the damage, express love and
gratitude to the object, and preserve it internally and externally" (p. 30).
Health professionals typically demonstrate powerful reparative traits (112,
113) and their attempts to cure their patients may represent symbolic
restitution or atonement. Even without such personal histories, psychothera-
pists may succumb to the implicit or explicit demands of more regressed
patients that the therapist rescue them from a world of difficulties,
injustices, or personal inadequacies (114).
Rescue fantasies are not only unrealistic, they are also potentially
counterproductive. The psychotherapist with unbridled rescue needs may,
paradoxically, cause the patient to become more regressed and dependent.
The therapist's compulsive insistence on rescuing the patient, whether or
not such efforts are warranted, leads the latter to feel like a helpless child
who must be saved (114). The net effect, in spite of the best of intentions to
help his patient grow psychologically, is that the therapist may inhibit his
patient's development of personal responsibility, autonomy, and compe-
tence (105). In addition, the psychotherapist with unrestrained needs to
rescue others may unconsciously refuse to allow the patient to get better
and terminate the therapy (115). Rescue fantasies may also lead the
psychotherapist to insist that his patient improve or be cured. Some
187
patients may comply, to the best of their ability, with such demands by the
therapist; but they do so at the expense of true change and autonomy.
Other patients, who either cannot or will not improve at the rate or to the
degree demanded by the therapist, may become the target of vengeful
countertransference acting out including sadistic verbal assault and other
actions intended to drive the patient from therapy. Finally, a therapist who
believes that he, and he alone, is responsible for curing his patients
provides certain patients with an invaluable weapon with which to control
him (90). "Suicidal patients are surprisingly quick to recognize in a
therapist any lingering magical expectation that he personally should
provide a panacea. If his self-respect depends on production [sic] a 'cure,'
it is here that the patient will be likely to attack" (p. 627). Indeed, the
psychotherapist may become a masochistic victim at the hands of such
patients (116).
Thus, the beginning psychotherapist must be wary of excessive therapeu-
tic zeal (20, 117, 118). Declares Schafer (20): "[Psychotherapists] do not
view their role as one of offering remedies, cures, complete mental health,
philosophies of life, rescue, emergency-room intervention, emotional Band-
Aids, or self-sacrificing or self-aggrandizing heroics. It is more than likely
that each of these alternatives to a [sound therapeutic] approach manifests
countertransference" (p. 11). One's job as a psychotherapist is not to "cure"
the patient, but to give her the opportunity to work therapeutically on her
problems or issues (85).
One final point: a good psychotherapist must be willing to be a
"failure," at least at times. He must be willing to take risks, to be creative
and playful, and to be found by himself and others as less than perfect (17,
46, 61, 102). The psychotherapist who tolerates no mistakes, real or
imagined, on his part, who must be perfect at every juncture, is a rigid,
inauthentic, nonhuman therapist who, paradoxically, is likely to blame the
patient for any lack of therapeutic progress. Kottler (17) states the problem
well:
Consider, for example, the clinician who is so threatened by the possibility of
failure that he or she practices defensively and never takes risks-preferring a
safe, predictable, benign treatment that will not help all that much, but that will
not hurt either. When the client does not improve, it is because of "resistance,"
"family interference," "poor motivation," "unconscious sabotage"-anything
other than the therapist's own behavior or attitude. And because this stance
does not allow for accepting the possibility of failures, such a therapist is
destined to repeat them. (p.93)
188
MISTAKEN BELIEF #5: "NEITHER I NOR MY PATIENT SHOULD EVER HAVE

'BAD' O R 'INAPPROPRIATE' FEELINGS (e.g., ANGER, ENVY, SEXUAL
ATTRACTION) TOWARD ONE ANOTHER; AND IF EITHER O F US DOES HAVE
SUCH FEELINGS, IT IS AN INDICATION THAT THERAPY IS G O I N G BADLY AND
THAT THERE MUST BE SOMETHING W R O N G WITH ONE O R BOTH O F US."
A patient always has feelings about her therapist. Such feelings may be
unconscious or conscious; and, if the latter, they may be overt or covert,
explicitly stated or purposely withheld from the therapist. Furthermore, a
patients feelings for her therapist may be positive ("I really like my
therapist; he's a very understanding person") or negative ("My therapist is
thoughtless and condescending") or more typically both positive and
negative. To complicate matters further, these feelings are dynamic, occur-
ring simultaneously and/or sequentially in an ever-shifting constellation of
emotions.
From the classical psychoanalytic perspective, when such feelings on the
part of a patient are distorted by past experiences with early significant
figures (e.g., the patient's parents), the process is called transference (39,
40, 119-121). These transference feelings are ubiquitous and inevitable,
present to a greater-or-lesser degree in every human relationship, including
the relationship between a patient and her therapist. The psychotherapeu-
tic relationship, however, represents an emotional vessel particularly likely
to be filled with transference feelings. There are at least two reasons for
this.
First, while feelings are inevitable in any significant relationship be-
tween two people, they are often intensified in the context of long-term,
psychodynamic psychotherapy. A patient meets frequently with the thera-
pist, often reveals intimate secrets, and depends on the therapist for
much-needed help. These factors work synergistically to magnify the
importance of the therapeutic relationship and, by extension, the feelings
that the patient has towards her therapist. Second, the therapeutic relation-
ship is reminiscent of the parent-child relationship insofar as the patient,
"childlike" in the particular respect of being unable to conquer a particular
difficulty, seeks assistance from an actual, or seeming, older, wiser adult,
namely the therapist, who then becomes "parentlike" in relation to the
patient. The result is that a patient may often view the therapist, con-
sciously or unconsciously, as a parental figure.
To the extent that this occurs in any given instance, a patient will then
"transfer" some of her feelings about her parents on to the person of the
therapist. The transference feelings thus elicited will very much depend on
the specific nature of the relationship between the patient and her parents
189
in earlier years. For example, a patient with a harsh, authoritarian father

may come to view the therapist, male or female, in a similar way. Yet,
another patient, with a different history of parent-child relationships, may
perceive the therapist to be understanding, kind, and helpful, just as she
experienced her mother or father to be when she was a child.
The therapeutic situation is further complicated by the fact that a
patient s transference feelings to the therapist are not solely derived from
early relationships with her parents; they may also spring from any signifi-
cant human relationship, primarily in the past but even in the present,
encompassing not just relationships with parents but also with siblings,
grandparents, teachers, friends, and innumerable others. As a conse-
quence, a whole gamut of transferentially derived emotions, based on
important relationships with significant others, may be aroused. As already
noted, the spectrum of feelings typically ranges from positive to negative,
from feelings of love, kindness, and closeness to anger, envy, competitive-
ness, and even hatred (39, 40); and, more often than not, both positive and
negative feelings are involved.
Transference, however, is only one source of a patient's feelings towards
her therapist; another is what has come to be called the "real relationship"
(40, 41, 122-125). The latter term represents an acknowledgment that a
patient and therapist have an actual, here-and-now relationship, and a
patient may have feelings about the therapist that are based not on
transference distortions but on a more-or-less accurate assessment of the
therapist as a person. Thus, the relationship between any two people can be
viewed, at a minimum, as a complex commingling of both transference-
derived and more accurate, reality-based feelings. Furthermore, even if a
patient accurately and realistically assesses her therapist's personality and
behavior, the patient's emotional responses to her objective evaluation of
the therapist may still be shaped by her early experiences with important
figures, i.e., transference.
The patient's feelings about the therapist, whether positive, negative, or
a combination of the two, cannot simply be taken for granted. The skilled
psychotherapist knows that he must decide whether, when, and how to
intervene therapeutically in the management of these feelings. Moreover,
perhaps surprisingly to the beginning psychotherapist, the patient's posi-
tive and negative feelings about the therapist can be of great diagnostic and
therapeutic value (39, 40, 80, 126). They provide a window through which
to observe how the patient feels, thinks about, and behaves towards other
individuals in her life.
Not unexpectedly, therapists generally prefer to work with patients who
190
exhibit positive emotional responses towards them. Therapists, just as do

other people, like to be liked; and they are pleased andflatteredwhen their
patients feel positively about them. A patient's positive feelings towards her
therapist, however, serve a greater purpose than simply helping the latter to
feel good about his work or himself. A patient who likes, respects, and
enjoys her therapist is also more likely to seriously engage in therapeutic
work than is one who has the opposite feelings towards the therapist.
Indeed, the strength of the therapeutic alliance (40), reflected in a patient's
positive feelings towards her therapist, is an important predictor of benefi-
cial therapeutic outcome (127-133). Psychoanalysts have referred to the
positive feelings of the patient that foster the therapeutic or working
alliance as the "unobjectionable" positive transference (39, 123).
While the unobjectionable positive transference typically requires less
management, negative feelings demand more active intervention insofar as
negative feelings towards the therapist, especially in the absence of a strong
working alliance, portend a poor outcome. Failure to address the negative
feelings towards the therapist often results in a therapeutic impasse or
premature termination of therapy.
When a patient's negative emotions towards the therapist are primarily a
manifestation of transference, the therapist must appropriately address
these distortions, not in a defensive manner, but in a way that not only
ameliorates the negative feelings but also helps the patient better under-
stand how early significant relationships adversely affect current ones (40).
As previously noted, in this respect the transference, and especially the
negative transference, provide both the therapist and the patient with an
invaluable opportunity to learn about the patient's past and present
interpersonal relationships. Indeed, "[OJnce a working alliance has been
established, the emergence of the negative transference can be an impor-
tant sign of progress . . . The reliving of hostility and hatred to the early
childhood figures in the transference is a most productive phase of the
analytic work as long as a good working alliance is present" (p. 235). Insofar
as the patient's negative feelings may reflect accurately perceived adverse
characteristics or behavior on the part of the therapist rather than transfer-
ence distortions, the therapist must have the integrity to honestly examine
his own real errors, mistakes, or inappropriate behavior and, depending on
the circumstances, alter his conduct and perhaps even apologize.
Surprisingly, a patient's positive feelings towards the therapist may
represent a troublesome therapeutic issue as well. This is not to maintain
that any positive feelings towards the therapist are suspect; rather, that
inappropriate, excessive, or unwarranted rosy regard for the therapist may
191
mask underlying, conscious or unconscious, feelings of a very different

nature (134, 135). Usually lurking not far below the surface of any
relationship between two human beings are feelings of fear, envy, competi-
tion, spite, and even hatred. The patient frightened of having such feelings,
or afraid of subsequent retaliation due to angering the therapist if she were
to express such feelings, or wishing to remain on the therapist's "good side"
for various reasons, may hide her negative emotions behind a mask of
respect, admiration, and even adulation of the therapist. In order to address
the patient's negative feelings towards the therapist and others, the thera-
pist may have to confront his patient's one-sided positive feelings. Timing
and context are crucial to the success of such a therapeutic intervention.
Indeed, it is as much a mistake to prematurely question an inappropriately
positive transference towards the therapist as it is to ignore or belatedly
address negative feelings towards the therapist (40).
Analogous to the situation with transference, the countertransference
(136-138)-the therapist's feelings about his patient-is ubiquitous, inescap-
able, and potentially of great therapeutic value. This dictum holds true for
the neophyte and seasoned psychotherapist alike. Nevertheless, the begin-
ning psychotherapist typically is disturbed by strong countertransference
feelings, especially if he considers them to be "bad" or inappropriate.
Typical among such uncomfortable countertransference feelings towards
patients are those of anger or hatred (90, 139-141), envy or competition
(142, 143), boredom (139, 144-146), or sexual attraction (147). Therapists
may even experience sadistic and murderous thoughts towards their
patients (90, 148). Notes Winnicott (148), "However much he loves his
patients he cannot avoid hating them, and fearing them, and the better he
knows this the less will hate and fear be the motive determining what he
does to his patients" (p. 69). Such feelings of hatred and malice conflict
with the beginning psychotherapist's fantasies and expectations of unadul-
terated benevolence on his part (46, 140, 141), often causing great psycho-
logical distress as a result. It is true that positive countertransference
feelings, such as a strong desire to take care of a patient, can also be
problematic for the therapist and the therapy, but the novice psychothera-
pist typically experiences such positive countertransference feelings as less
threatening than the negative ones.
As noted, however, countertransference is always present, to a greater or
lesser degree, in every psychotherapy and with every psychotherapist.
Indeed, a therapist can no more completely eliminate his own countertrans-
ference feelings than can a patient completely eliminate her transference
feelings (149). Thus, the beginning psychotherapist needs to have an
192
attitude of tolerance, and even curiosity, towards such feelings on his part.
The therapist s task is not to not have such feelings; but, rather, to be aware
of them, acknowledge them, explore their meaning, limit their negative
impact in his work with his patient, and, if possible, use them to therapeutic
advantage (85,125,139, 140,150-162).
Experienced psychotherapists, all of whom have had to struggle and
continue to struggle with their own countertransferential issues and feel-
ings, realize that the most dangerous position a therapist can take is that of
the denial of the existence of such feelings (90). The more a therapist denies
his countertransference, the more likely such feelings are to negatively
affect his work with a given patient. A crucial distinction to bear in mind is
that feelings are not equivalent to behavior. A therapist may have all sorts of
feelings about his patient; this is normal and expectable. But, conversely, a
therapist is not free to act on all of his countertransferential feelings. The
unfortunate truth, demonstrated time and again by experience, is that the
psychotherapist who minimizes or denies his countertransference feelings
tends to act them out with his patients, often in ways that are destructive to
the therapy and to the patient (90, 158, 163). Thus, there is no shame, and
there is great utility, in the therapist's recognition and acknowledgment of
his countertransference feelings.
VIGNETTE 5
A psychotherapist had been working in twice weekly dynamically-oriented

psychotherapy with a narcissistically disordered graduate student at a
renowned university. In the face of the patient's repeated devaluation of the
therapist, his methods, and his worth, the therapist began to increasingly
question his own abilities as well as to experience increasing anger towards
the patient. Unconsciously, the therapist felt compelled to revenge himself
upon the patient by counterattack, criticizing the patient in his work and
interpersonal relationships, and becoming competitive with him. Not only
did such behavior on the part of the therapist endanger the therapeutic
enterprise, it also prevented exploration of the important dynamic issues
underlying the patient's vituperative personal attacks: his deep sense of
personal inferiority and shame defended against by grandiosity of himself
and devaluation of others.
This is especially true for countertransferential thoughts, feelings, and

impulses when working with self-destructive or suicidal patients. Counter-
transference to suicidal patients is ubiquitous and especially dangerous (90,
164).
193
VIGNETTE 6
A psychiatry resident had been working weekly with a chronically suicidal,
personality-disordered 25-year-old woman. Not infrequently, just as it was
time to end a session, the patient would state that she was feeling suicidal
and unsure as to whether she would be physically safe after leaving the
therapist s office. The therapist, increasingly angered by what he consid-
ered to be the patient's manipulative behavior, began to simply ignore the
patient's comments about suicidality, a response he did not take with other
suicidal patients. In supervision, the resident came to realize that his
countertransferential anger towards the patient was not only preventing
him from exploring with her an important therapeutic issue (her use of
suicidal ideation as a means to manipulate others), but was also causing a
countertransference enactment on his part. The therapist learned that
not-so-secretly he wished this demanding and difficult patient would "go
away" (i.e., die), and his failure to respond to her suicidality reflected an
unconscious wish on his part that she actually proceed to kill herself. He
realized that under these circumstances, he might well fail to respond
appropriately at times when the patient was truly and imminently suicidal.
When the beginning psychotherapist becomes aware of such counter-

transferential feelings and fantasies, what should he do? First, he might
explore the feelings and fantasies on his own; if he feels he understands
what they are about and feels that they are under adequate control, then he
may go no further except to continue monitoring them. However, often
therapists, including experienced therapists, have difficulty understanding
or handling certain countertransference feelings towards particular pa-
tients. If so, then it is imperative that the therapist talk to someone he trusts'.
a colleague, supervisor, or personal psychotherapist (160, 161). With
respect to the latter, one of the myriad advantages of psychotherapists
undergoing their own psychotherapy is that countertransferential feelings
and fantasies can be safely and usefully explored in such a setting.
How can a therapist 's countertransference feelings about his patient be
used to therapeutic advantage? First, as already noted, the feelings must be
recognized and acknowledged. Second, the therapist must attempt to
explore the genesis of such countertransference feelings and fantasies and
mine them for key diagnostic data. The therapist who recognizes that
certain patients engender certain feelings in him is in a position to use the
existence of such feelings to learn something about the patient. Such
feelings also often provide a clue as to how other people, outside of therapy,
view, and react to, the patient. To the extent that the patient causes the
194
therapist to feel repeatedly frustrated and angry with the wish to be rid of
her, so, too, may the same dynamics be operative in the patient's relation-
ships with other important people in her life (family, friends, coworkers).
Third, the therapist must find an appropriate way to use the knowledge
thus gained in the service of the therapy. While in some instances this may
involve actually informing the patient of particular countertransference
feelings on the therapist's part, more often the feelings themselves are not
shared with the patient but are the basis of subsequent therapeutic
interventions. Each of these steps in the therapeutic use of countertransfer-
ence has been the subject of active exploration and voluminous exposition
(85,125,139,140,150-162).
VIGNETTE 7
A severely disturbed schoolteacher in her forties was in twice weekly

psychotherapy of about six months' duration. The therapist found himself
frequently confused as to the patient 's family members, their relations to
one another, and even their names. Such confusion was unusual for the
therapist, who was typically very attentive to such matters. Upon further
self-reflection and observation of the patient, the therapist realized that his
confusion was, in fact, countertransferentially induced by the patient who,
indeed, never gave a straightforward, coherent description of her large
blended family. The therapist used this information to explore with the
patient why she should present her family in such a confusing way,
especially insofar as she could be crystal clear on other matters. Both the
therapist and the patient came to understand that the confusing family
picture presented by the patient served at least three unconscious func-
tions: to distance the therapist and prevent him from truly understanding
the patient, to recreate in the therapist the utterly bewildering intrapsychic
and real interpersonal world in which the patient lived, and to recreate yet
again a situation in which the patient felt victimized by an "incompetent"
and uncomprehending authority figure.
A particularly noteworthy opportunity for effective employment of

therapist countertransference occurs in the context of a patient's use of the
mechanism of projective identification (151,163,165), a process by which a
patient induces her own feelings or behaviors in the therapist. As described
by Ogden (165), projective identification consists of a three-stage process.
The first step, analogous to the intrapsychic defense mechanism of projec-
tion, occurs when a patient represses unacceptable or unwanted parts of
the self and projects these on to the therapist. The second step of projective
195
identification is an interpersonal, rather than an intrapsychic, process. In

step two, the patient unconsciously attempts to manipulate or coerce the
therapist to act in consonance with the unwanted, projected parts of the
patient. It is at this step that the therapist often finds himself thinking,
feeling, or behaving in ways that are atypical for him, important clues to the
presence of countertransference-in this case, countertransference induced
by the process of projective identification. The third step of the process
consists of the therapist s holding or containing of the projected parts of the
patient, metabolizing or reconfiguring those projections, and then making
more healthy thoughts, feelings, or behaviors available to the patient for
introjection. Glen Gabbard (162) provides an illustrative example of the
first two steps of the process:
A patient says to the therapist, "You hate me, and I know it." The therapist,
taken by surprise, responds by asking, "What makes you say that?" The patient
becomes angry and glowers at the therapist: "Don't act like you don't know
what I'm talking about!" The therapist protests: "But I don't!" The patient
shouts at the therapist: "You liar! You know exactly what I mean!" At this point
the therapist, feeling enraged, says, " I don't appreciate being called a liar!' The
patient appears triumphant and says, "You see? I'm right! You do hate me.
Your face is red, and your eyes are filled with hate!" In this vignette, the patient
projects a hating internal object into the therapist. She then behaves in such an
infuriating manner that she coerces the therapist to take on the characteristics
of the "bad object." His obvious anger is interpreted by her as confirmation
that he hates her. (pp. 5,6)
VIGNETTE 8
A therapist was working in twice-weekly psychotherapy with a depressed,

borderline woman in her fifties. The therapist often found himself the
subject of attacks on the part of the patient, many of which focused on her
perception of the therapist's greediness. Time and again, the patient called
attention to the many ways in which she believed her therapist's greediness
was demonstrated: by his unwillingness to extend sessions beyond the
agreed-upon 45 minutes, by his "unreasonable" fees and requests that the
patient pay them, and by his unwillingness to return each of her many
off-hours calls. In the face of this constant assault, the therapist began to
wonder if, indeed, he were not being too rigid and greedy. The therapist
came to realize, however, that the greediness he felt had been induced in
him by the patient who had repressed her own great greediness. The latter
had derived from the patient's early years with a physically and emotionally
withholding and depriving family such that she had always felt that she had
to "fight for the measly crumbs that were left over." Armed with this
196
knowledge, the therapist was able to normalize such feelings on the part of
the patient and demonstrate how the patient 's greediness, while sometimes
inappropriate in current contexts, served a vital function in the atmosphere
of her home as a child where she truly had to fight for everything she
needed.
In sum, the beginning psychotherapist must learn not only to tolerate

uncomfortable countertransference feelings towards his patients and recog-
nize them as an inevitable concomitant of the psychotherapeutic enterprise,
but he must also appreciate countertransference as an important medium
of communication between patient and therapist which can be used to
great therapeutic advantage. In so doing, the neophyte therapist comes to
approach his countertransference thoughts, feelings, and fantasies with an
attitude of forbearance and curiosity rather than guilt and shame.
MISTAKEN BELIEF #6: "EVERYONE ELSE, INCLUDING NOT ONLY MY

SUPERVISORS BUT MY PEERS, IS D O I N G THIS BETTER THAN I AM."
Unfortunately, this is true, at least in a certain sense. Thus, at any given

time in any given situation with a particular patient, there is probably some
therapist somewhere who might have "handled it" more professionally than
did a beginning psychotherapist. Furthermore, it is definitely true that the
more one studies and practices psychotherapy, the better one will become.
However, psychotherapy is hard work, it is an art, and every psychothera-
pist, no matter at what level, could do better.
It is easy to look back (for example, in supervision) and say, " I , or
someone else, could or should have done that better." But one must
remember that as a psychotherapist innumerable decisions have to be made
every moment, often without a full understanding of what is occurring, and
often when under attack by transference storms and/or countertransfer-
ence feelings. In the middle of a psychotherapy session, one may not have
the luxury of sitting back and calmly considering one's options or words;
the therapist may have to act, or choose not to act, right at that moment.
The novice psychotherapist should not hold himself to impossible stan-
dards.
Thus, while the committed psychotherapist must recognize and work
on his psychotherapeutic shortcomings or deficiencies in order to become
more expert at his craft, he should also focus on the positives, including his
strengths and progress as a psychotherapist. The antidote to the belief that
everyone else is a better psychotherapist is to become a better psychothera-
pist oneself. Through didactic study, clinical experience, supervision,
197
continuing education, and personal psychotherapy, each therapist can

continue to develop and hone his professional skills in order to become the
best psychotherapist of which he is capable.
In conclusion, it is not easy being a beginning psychotherapist; but,
through hard work and the crucible of clinical experience, the novice can
become a skilled and effective psychotherapist. The work is hard, the effort
may be taxing; but the rewards, to both patient and psychotherapist, are
great.
So [said the doctor]. Now vee may perhaps to begin Yes?

Philip Roth, Vortnoys Complaint
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Great Expectations:

Mistaken Beliefs of Beginning Psychodynamic

DONALD A. MISCH, M.D.*

Beginning psychotherapists often have mistaken assumptions about what it is

Took with favor upon a bold beginning.

It is not easy to be a beginner, a neophyte, a novice, a tyro. This is true

^Director of Education, Medical College of Georgia, Department of Psychiatry and Health

A M E R I C A N JOURNAL O F P S Y C H O T H E R A P Y , Vol. 54, No. 2, Spring 2000

assimilated and refined in order to become expert at the craft of psycho-

tion and review of the relevant literature, clinical psychotherapeutic experi-

MISTAKEN BELIEF #1: "I SHOULD COMPLETELY SEE AND UNDERSTAND

The understanding that a psychotherapist comes to have of his patient is

thoughts, feelings, and behavior, as well as her "inner" life-thoughts and

Thus, the beginning psychotherapist's belief that he should completely

The words of the psychotherapist are analogous to the scalpel of the

Moreover, beginning psychotherapists also need to recognize that the

A professional woman in her mid-thirties had been in regular exploratory

Thus, the answer as to whether a verbal intervention on the part of the

therapist says something less than perfect, something inappropriate, or

A clinging and demanding, personality-disordered young woman an-

to use them as a means of increasing their effectiveness in the future" (17 p.

The beginning psychotherapist typically wants, and expects, his patient to

In reality, however, the wish or expectation of rapid psychotherapeutic

significant psychotherapy. Said Sigmund Freud (39): "the resistance accom-

MISTAKEN BELIEF #4: "MY PATIENT'S FAILURE T O IMPROVE IS A PERSONAL

A difficult issue for the beginning psychotherapist is the distinction

distinguish between his efforts as a physician versus the success of the

some patients fear the loss of their psychotherapist if their symptoms

A third-year psychiatric resident was presenting to faculty and colleagues at

An important proviso, however, is that therapeutic impasses (103, 104)

do occur; and the honest psychotherapist must be willing to explore the

MISTAKEN BELIEF #5: "NEITHER I NOR MY PATIENT SHOULD EVER HAVE

in earlier years. For example, a patient with a harsh, authoritarian father

exhibit positive emotional responses towards them. Therapists, just as do

mask underlying, conscious or unconscious, feelings of a very different

A psychotherapist had been working in twice weekly dynamically-oriented

This is especially true for countertransferential thoughts, feelings, and

When the beginning psychotherapist becomes aware of such counter-

A severely disturbed schoolteacher in her forties was in twice weekly

A particularly noteworthy opportunity for effective employment of

identification is an interpersonal, rather than an intrapsychic, process. In

A therapist was working in twice-weekly psychotherapy with a depressed,

In sum, the beginning psychotherapist must learn not only to tolerate

MISTAKEN BELIEF #6: "EVERYONE ELSE, INCLUDING NOT ONLY MY

Unfortunately, this is true, at least in a certain sense. Thus, at any given

continuing education, and personal psychotherapy, each therapist can

So [said the doctor]. Now vee may perhaps to begin Yes?

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