Janina Fisher

Janina Fisher
PhD

TRANSFERENCE/COUNTERTRANSFERENCE
DILEMMAS IN THE TREATMENT OF
TRAUMATIZED PATIENTS

Janina Fisher
Ps yc ho ther apist,
Consu lt ant, Traine r

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Janina Fisher
PhD

As we studied the impact and symptoms

of trauma over the past eight months,
we have talked about how traumatic
childhood experiences affect both
mind and body, including the ability to
perceive reality, the ability to tolerate
feelings, the ability to trust and hope,
the ability to feel and protect bodily
safety, the ability to care for self, the
psychobiological responses to internal
and external experience, the ability to be
in relationship , the ability to differentiate
past and present, and so on. It would
be unrealistic to think that this legacy of
trauma would not affect the therapeutic
relationship. In fact, we could argue
that it would be a bit narcissistic to
assume that, just because we know we
are well-intentioned and determined
to be trustworthy and helpful, we will
be experienced as such by our clients.
It is unrealistic that traumatized clients
will perceive us as the antidote to their
abuse, rather than as a continuation of
it. That they will wish to and know how to
work with us – that they will trust us and
be honest with us – that they will know
how to take responsibility for themselves
and for their share of the therapeutic
relationship – that they will not expect
more of us than is fair and realistic – that
they will be considerate – reasonable
– willing to negotiate – capable of
remembering all of the positive history
they have with us, not just the negative.

None of these qualities or abilities can be

presumed with any client who has grown
up in a hostile environment and has
been shaped by the challenge of physical

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and psychological survival without

protection or support.

As Judy Herman writes, “Patients who

suffer from a traumatic syndrome form
a characteristic type of transference in
a therapy relationship. Their emotional
responses to any person in a position
of authority have been reformed by the
experience of terror. For this reason,
traumatic transference reactions have an
intense, life-or-death quality unparalleled
in ordinary therapeutic experience…
The traumatic transference reflects
not only the experience of terror but
also the experience of helplessness. At
the moment of the trauma the victim
is utterly helpless. Unable to defend
herself, she cries for help, but no one
comes to her aid… The memory of this
experience pervades all subsequent
relationships. The greater the client’s
emotional conviction of helplessness and
abandonment, the more desperately
she feels the need for an omnipotent
rescuer.”

In turn, the more desperately the

client feels the need for an omnipotent
rescuer, the more likely he or she is to
be hypervigilent and demanding with the
therapist. “Because the client feels as
though her life depends on her rescuer,
she cannot afford to be tolerant; there is
no room for human error.”

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PhD

Last, but not least, the client’s “capacity the “good news” in all this is that,
to trust has been damaged by the when these trauma themes rear their
traumatic experience. Whereas in other ugly heads in the therapy, we have a
therapeutic relationships some degree perfect opportunity to teach the client
of trust may be presumed the outset. . a new lesson in trauma recovery. And,
.[the traumatized client will] scrutinize if we perceive the client’s anger or
the therapist’s every word and gesture, entitlement or self-destructiveness or
in an attempt to protect herself from the passive-aggressiveness as a trauma
hostile reactions she expects. Because theme or symptom, we are less likely
she has no confidence in the therapist’s to have unhelpful counter-transference
benign intentions, she [will] persistently responses. If we see that these are
misinterpret the therapist’s motives and all grist for the mill, rather than an
reactions”. impediment to progress, we are less
likely to become discouraged or feel
The core experiences of existential devalued or frustrated. In fact, “It is the
terror, helplessness and abandonment, failure to understand the interpersonal
and betrayal of trust will always be assumptions [which the abuse survivor
brought into the therapy, and we are makes] that most frequently leads to
better off if we assume that these empathetic failure on the part of the
themes resonate in every encounter therapists” (Chu, p.119). In turn, the
we have with a traumatized client. [That empathic failure confirms the client’s
includes telephone calls, encounters worst fears that either the therapist
with our colleagues’ clients when we are doesn’t ‘get’ it or doesn’t care or, worse
covering for them, encounters with lients yet, has a hidden malevolent agenda.
we are screening – every contact.]
So let’s look at the paradigms you
Today, we will look at the most common most likely encounter in a therapeutic
transference/countertransference relationship with a trauma survivor.
paradigms and impasses. Because

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Janina Fisher
PhD

First, The Therapist is This paradigm arises from the abused

child’s repeated experiences of
Perceived as Critical humiliation and rejection. Her survival
or Shaming. in childhood depended upon her ability
to anticipate judgment and scorn
so that she was prepared to defend
herself against further psychic injury.
For example, many trauma survivors
experience any kind of feedback as a
potential threat, whether that feedback
is negative or positive. Typically, the
therapist’s interpretive comments
triggers anxiety which the client
perceives as confirmation of her fears
that she will be judged and humiliated.
It is important to remember that
compliments or positive comments or
even reassurance can have this same
effect because, in an abused child’s
experience, “nice” words were only a
manipulation by the abuser to relax her

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PhD

guard or “groom” her. It is crucial to be learning how to re-stabilize when things

able to talk about these issues with our go wrong, rather than believe you are in
borderline and trauma clients because danger, and I know it’s very hard for you.”
otherwise both client and therapist can
become more and more frustrated. Then I go to the next prong of my
Each time the therapist attempts to say intervention: to frame the problem as
anything, positive or negative, the client’s a dilemma for all trauma survivors – so
strong reaction disrupts the therapy, and I might say next: “The dilemma is that a
no work gets accomplished. Since the survivor may feel criticized or belittled
client has been “trained” to experience if the therapist tries to teach her safety
being talked about as dangerous, s/he skills – but, on the other hand, I would
will instinctively resist or defend herself. fail in my obligation if I didn’t keep talking
about safety. I don’t want anyone to feel
Perhaps this fact alone accounts for put down, and I don’t want to just ignore
why the bulk of my verbal interventions safety issues. I wonder how you and I
with clients are psychoeducational first can deal with this dilemma – I don’t want
and only secondarily about the client. you to feel like I don’t “get it”, but I also
Typically, what I will start with a piece want to help you to get to a different and
of psychoeducation: “Trauma survivors better place in your recovery.”
become so used to instability being
normal or so used to things being Notice, too, I always use the term, “your
unsafe that it is very hard for them to be recovery” or “trauma recovery” – not
comfortable with stability or safety. And the term “therapy” – because I want to
when things go wrong – even little things emphasize that the goal of treatment
– it automatically cues them to danger. is not us having a therapy but having a
In recovery, we are working toward recovery.

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The second paradigm will This paradigm most often occurs when
clients bring their rage or their despair
also be a familiar one: into the therapy hour and dump it in
The Therapist the therapist’s lap or even direct it at
the therapist. My client, Diana, let me
Becomes a know about 3 months after we started
“Container” for work that she didn’t plan to live out the
Intolerable Affect. year. Clara walked into my new office
last week and was upset and furious that
an office change had taken place during
my vacation: she dumped her rage into
my lap by announcing, “Well, I’m not
staying – I’m done with therapy – and,
by the way, I took an overdose of my
medication while you were away.” In the
case of Diana, I became the container
for her anxiety about how unsafe she
felt. For Clara, I was the container for her
rage – rage fueled by all the arbitrary
changes, all the instability, all the
disruptions of her traumatic past – rage
that she lives with every day and that,
on this day, poured into my container.
I am embarrassed to say that I had an
unhelpful countertransference reaction
to Clara: angry and discombobulated
myself by the office change, I replied,
“Do you want to leave now or stay and
talk?” Although coming from frustration,
the question gave her time to think. . . “I
guess I’ll stay and talk,” she said huffily.
It would have been more helpful if I had
been able to say, “You know, trauma
survivors are understandably sensitive
to change, especially when they get
no say or no notice – it makes them

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feel helpless and powerless – and that work for these clients because the
powerlessness makes any person angry.” therapist’s role is too passive. If we take
a trauma perspective, we do not want
Why do traumatized clients make to encourage the use of the therapist
us containers for their affects? First, as a container of affect. Instead, we
their experience of relationships has want to treat the intense affect (the
been that they were the containers rage, the despair) the same way we
for the unbearable feelings of their would any other symptoms. That is, I
abusers. It is as if they learned that would interrupt the client after a little
either one is the giver or the recipient bit of venting time to check whether it
of intolerable feelings. Secondly, it is is helping to vent the feeling or whether
an indirect way of asking for help or it’s making it worse. Then I would offer
communicating feelings, necessary some psychoeducation – with Diana, it
because traumatized children rarely was to say, “So, you have a bail-out plan
learn to communicate feelings directly in case you feel so overwhelmed with
because it was never safe to do so. the pain that you can’t face another
Lastly, the autonomic hyperarousal of a year?” We began to look at the triggers
traumatized nervous system cause any and anticipate the situations in which
emotion to escalate to such an intensity she might activate the bail-out plan. The
that it becomes overwhelming and moment of anger I felt when she casually
unbearable. In traditional psychodynamic dumped this threat on my lap passed
psychotherapy, we as therapists offer because I was able to help both of us
ourselves as a container for affect, and start thinking about the problem for
it is helpful for clients to utilize us in which death represented the solution
that way. When we work with borderline rather than colluding with her focus on
clients or trauma survivors, that offer suicide as the only possible solution.
to be a container becomes problematic A favorite line passed on to me by an
– it is not safe for us or for the client old supervisor is to respond to threat
because we are likely to have very (whether it is suicide or homicide) by
negative countertransference reactions saying, “Okay, now you’ve explained
if we are frequently used as vehicles for the solution to me, but I still don’t quite
dumping. understand the problem the solution is
intended to correct.”
As all of you have heard from me
repeatedly, I think the traditional
psychodynamic approach does not

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A third paradigm is Having never experienced soothing

or reassurance or encouragement,
trauma survivors are unable to provide
The Therapist is Seen themselves with adequate self-soothing
As Soothing Person or self-reassurance. To make matters
worse, they have to try to tolerate
unbearably intense levels of affect with
only limited resources and abilities. It
is understandable that they would seek
soothing from us, especially as we seem
to offer it, and as we clearly discourage
them from their more usual avenues
for self-soothing such as drinking and
drugging, cutting, hypersexuality, etc.
The clients with strong dependency
needs will tend to lean on the therapist
excessively when they need soothing
– with many phone calls, requests for
extra sessions, and decompensations
during the therapist’s vacations. The
counter-dependent survivors will pose
a different kind of challenge by asking
for soothing through acting out, missing
appointments, withdrawing when they
most need support. Both styles can
produce intense countertransference
reactions in the therapist: frustration,
anger, numbing, distancing, or trying
harder and harder to be the soother.
Again, the psychodynamic model
presumes that the client knows that
she should not distance under stress or
intrude on the therapist’s life and other
responsibilities. But trauma survivors
have never lived in environments with

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reasonable and consistent expectations, One strategy that can be helpful here
so we have to be active in teaching them is to use transitional objects to help
how to use therapy and the therapist, traumatized clients begin to learn self-
how to help themselves through the soothing. A small symbol of hope
overwhelming emotions. It is crucial to or comfort or a symbol related to
give them the psychoeducation that will the therapist is usually the best kind
help them understand why the feelings of transitional object. Because their
are so overwhelming and why they are achievement of “object permanence”
underequipped to manage them. has been so compromised by the
trauma, transitional objects often are
It is also crucial to explain to them very a way to teach object permanence
very empathically that, unfortunately, and self-soothing at the same time.
there is no one who can be there A typical transitional object might
enough of the time to provide them be the therapist’s business card or
with enough help and soothing and an inspirational greeting card with a
reassurance – that this is very unfair message from you or a postcard of
because if they had had adequate something you know has meaning for
protection and nurturance when they the client or a stone or seashell from
were children, they would not now be a collection you keep in your office or
faced with having to learn how to provide some silly putty or a slinky which the
it for themselves. I often tell the survivor client can use for tension release. I keep
that, if there was enough of me to go a pile of 4x5 cards nearby which I use to
around, I would want to be available write inspirational quotes or homework
to her whenever she needed me, but assignments or words of reassurance
unfortunately what I would want and she or a piece of psychoeducation. Having
would want is just not possible. I tell her a card in my handwriting serves as a
that I want someone to be there for her very helpful transitional object, and
24 hours a day, and the only person who the message often helps the client to
can take on that round-the-clock job is remember what we are working on!
her and I will teach her how to be there.

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Next we come to a group of paradigms that relate to fears and safety issues which
all trauma survivors bring to the therapy:

First, The Therapist is Next, The Therapist As

Seen as a Threatening Seen As A Potential
Force. Violator of Boundaries.

For a trauma survivor, there is almost Because these clients have become
always the unconscious fear that the accostome total disregard of their
therapist will suddenly become an personal boundaries, they have to
unsafe and dangerous person. That is presume that the therapist may be
why the client’s level of hypervigilence a boundary violator too. Usually this
is so high – why our every word and paradigm gets manifested in one of two
piece of body language is always being ways: either difficulty with adhering to
scrutinized. If encouraged to talk about and respecting appropriate boundaries
what makes her feel safe or unsafe or a rigid need for boundaries that
in therapy or in her life, often we will precludes any closeness or intimacy.
hear that she cannot imagine feeling The first manifestation is the client
safe anywhere, even in therapy. Many who repeatedly tests the therapist’s
trauma survivors feel like magnets for boundaries: running over the time,
harm or “marked:” they are primed by being unable to leave the therapist’s
the expectation that, sooner or later, office because s/he is too upset,
something bad will happen. It might wanting to be held or hugged, wanting
be the fear of the therapist becoming to know personal details about the
angry or mean; or might be a fear of therapist’s life, complaining that the
abandonment by the therapist; or it therapist is too distant or “doesn’t
might be the fear of being so bad and care”, requiring proof of the therapist’s
destructive that the survivor herself will caring (usually in the form of more
destroy or burn out the therapist. If we availability). The client with the need for
are offering a lot of psychoeducation that rigid boundaries and greater distance
speaks to the difficulties of feeling safe usually presents with questions about
with others, and if we acknowledge that confidentiality or gets angry when
it is not unreasonable to prefer “being the therapist appropriately discloses
safe rather than sorry,” given his or her personal information or hypervigilently
history, we are much more likely to elicit watches the clock in anticipation of
information about the specific fears the the end of the hour. Many clients with
client might have and how they relate to fears about the therapist’s ability to
his/her history. remain safely boundaried will use a
combination of both approaches, which
can be particularly confusing because
the therapist feels “damned if I do and
damned if I don’t”.

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Next, The Therapist Is Next, The Therapist As

Seen As Untrustworthy Perceived As Judge and
or A Potential Betrayer. Jury.

This paradigm reflects the anticipation The trauma survivor continually projects
of violations of trust appropriate in an unto the therapist her worst fears and
unsafe environment that accompany beliefs about herself and then waits for
the client into the therapeutic the therapist to condemn her. Since
relationship. Typically, we see it in the traumatized children feel degraded
client’s expressing fears of becoming and culpable, guilty and ashamed as if
too dependent on the therapist or in they were responsible for the abuse,
premature termination as s/he begins they grow up to be adults who believe
to invest in the relationship. The critical there is “badness” or “evil” inside them
period is often when trust and closeness and who are anxiously awaiting the
are beginning to develop (whether that is time when others will see through them
five months or five years into treatment). and be shocked and repelled. This
We may be pleased and delighted that paradigm gets played out through the
things going so well and forget that this client’s repeated self-condemnation
“good news” may trigger the traumatized and expressions of the conviction that
client’s fear of closeness and stimulate eventually the therapist will “see through
impulses to distance from or sabotage her” and hate her as much as she hates
the therapy. It is important to remember herself. Or it can get played out in the
that getting close too quickly will always client’s acting or feeling self-destructive
result in a need to distance. Heed the and being afraid to tell the therapist for
words of wisdom of an old supervisor fear of judgment. Often these clients
of mine: “Always pursue a distancer, can try us to the point that we do made a
and distance from a pursuer.” Again, judgment or feel and sound judgmental,
psychoeducation about how trauma creating a self-fulfilling prophecy. As
has destroyed the client’s capacity to with the other paradigms, always start
trust and how important it is for her to with psychoeducation rather than
proceed cautiously in trusting anyone, reassurance. I explain that the trauma
even the therapist, usually helps to has created an inner prosecutor and
defuse these situations. an inner judge but no inner defense
attorney! Or I will say, “Let’s get clear
which of us is judging you because it is
not me.”

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The next paradigm is a

familiar one: The Next, the paradigm of
Therapist is Seen As The Therapist Is Seen As
Caretaker. Controller.

This paradigm occurs most frequently Another frequently encountered

with survivors whose strong needs for therapeutic dilemma. Because of their
independence are a defense against childhood experiences of coercive
dependency needs. These clients have control, many trauma survivors assume
difficulty demonstrating any sign of that the therapist will try to dominate,
“weakness,” especially tears and sadness. change, persuade, or control them
They may rebuff or be uncomfortable against their wills, just as the early
with any signs of the therapist’s authority figures in their lives did. In
empathy or concern. Because they their world, there are two positions
grew up in environments in which no in the power hierarchy: under and
care or protection was available and over. They assume that we want the
where normal dependency needs were power-over position and want them to
exploited, they came to believe that their assume the powerless position, just as
dependency needs were unacceptable their abusers did, and, very early in the
signs of weakness, and they project this therapy, they play out this expectation
belief onto the therapist. These are the by trying to take control of the therapy:
clients who think the therapist is bored they need a different appointment time,
with them or tired of their complaints a different fee schedule, a different kind
or is just “doing his job”. They can be of therapy, more support, more answers,
infuriating because they seem to need better caregivers. Or, conversely, instead
continual reassurance. In fact, they need of fighting for control of the therapy,
to understand the dilemma: that they the client is utterly helpless and passive:
were taught to avoid ‘signs of weakness’ nothing we suggest is possible for her
which makes therapy extremely to do, but she can’t think of anything
difficult for them. If they open up to that would work better; we ask her
the therapist, they feel weak, “stupid” opinion and get back the passive-
and unsafe; if they remain numb and aggressive response, “I don’t know” or
detached from their feelings and try “It doesn’t matter – you’re just going to
not to “bother” the therapist, they will do what you want anyway”. Both of
feel safer but the therapy will not be as these manifestations of the power and
beneficial. control paradigm tend to make us, the
therapists, feel crazy and frustrated. We
want a level of mutuality in the therapy
work that these clients are simply not
capable of achieving. I think it can
be helpful early in therapy to bring in

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psychoeducation or discussion about In a way, these are two sides of the

power dynamics: to explain to them same coin: trauma survivors have had
that the best recovery work is done so little in the way of lasting meaningful
when the client and therapist can relationships that, when they begin
work collaboratively but that might be to feel a sense of connection to the
challenging for them because they are therapist, they either begin to feel
used to a model in which there is winner terrified of loss, or they begin to want
and a loser, not two equals. Often, I more contact, more friendship or more
find it helpful to sympathize with them intimacy. This paradigm gets played out
about how my inability to accede to in panic about therapist vacations, fears
their wishes may make them feel as if I of being suddenly terminated, fears of
have all the control and they have none. the therapist not liking her or wanting to
Or, conversely, to empathize with the work with her, and even anger at having
“helpless” ones about how hard it must come to care about someone s/he may
have been to learn how to play it safe (to now lose! The wish for more contact
not have opinions or feelings or ideas) or friendship often is manifested in the
but how it must have helped them to client’s wanting to be like the therapist:
survive. If we as therapists can correctly bringing gifts to the therapist, wanting
interpret the meaning of what feels like to know more about the therapist’s
controlling and manipulative behavior, values or politics or lifestyle. Often
then we are less likely to over-react to trauma survivors will try to extract a
it. When it feels manipulative, I get angry promise from the therapist to continue
and rebellious. When I remember that working with them “forever,” and it can
the behavior means that the survivor be extremely difficult to respond to such
views me as a powerful authority figure requests because our natural instinct
who holds all the control, while she is to say, “Of course, I will work with you
has none, that helps me to keep it in for as long as you like.” However, that
perspective. can be potentially less helpful in the long
run, no matter how helpful it is in the
short run. I find it more helpful to give
Last but not least, the last the client some psychoeducation about
two paradigms we the perils of being a trauma survivor in
frequently encounter: a good, caring therapeutic relationship –
The Therapist Is Seen As why she gets so afraid of people leaving
her, why she gets so preoccupied with
A Potential Loss and The the potential loss, that she can’t take
Therapist Is Seen As a advantage of what she does have now.
Potential Friend.

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Now in describing the paradigms,

notice a theme that emerges: in every
paradigm, there is a victim and a
victimizer or a victim and a rescuer or a
victim and a neglectful abandoner. In
each paradigm, the client casts herself
in one role and us in another. Usually,
she is the victim, but sometimes she can
be the victimizer or even the indifferent,
neglectful abandoner. In an unsafe
world, there are no other roles. For
us, the result of being cast in roles
we haven’t chosen is that we may feel
intensely uncomfortable, confused,
resentful, disempowered, and angry.
These should be cues to us that we have
been invited to a therapeutic dance,
but most of the time, most of us will be
too busy feeling annoyed or bored or
helpless to notice that the dance has
begun.

I also think it is hard to notice because

we are usually focused either on our
goals and agenda for the session or
the client’s content – we think of our
feelings as “countertransference”, and
often we will feel apologetic for having
them, rather than seeing them as
valuable information. I encourage you
to begin thinking about your feelings
and reactions as a potential gold mine
of information about what the client is
experiencing transferentially.

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For example, I will use my client Clara

again. I often feel furious with her – eg,
when she walked into my new office and
announced she was leaving therapy. If I
think about the meaning of her reaction
and my reaction to her reaction, it is clear
that she was experiencing the paradigm
of therapist as “controller” – arbitrarily
and without notice “taking away” the one
place she had ever felt safe in the world:
the office where we met for six years.
Suddenly, for her, I was the victimizer
and she was the victim. She was angry
but couldn’t express it in an appropriate,
coherent way, so she turned the tables
by arbitrarily announcing that I could
change offices but she could change
therapists! So my anger was a sign of a
number of phenomena: first, that I felt
victimized by her; secondly, via projective
identification, she had communicated
her anger straight into me (I was the
container); and my anger was also a
reflection of my feeling miscast in the
role of victimizer. Most therapists
strongly to being cast in that role. If I
had sat with my anger a little longer and
thought about what it was signaling, I
would not have responded unhelpfully
by saying, “Do you want to leave now
or talk about it?” As she was able to
point out to me later one, that comment
triggered the therapist as potential loss,
and it raised her anxiety further. In a
sense, I turned the tables back on her: in
doing so, though, I actually became the
victimizer!

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My guess is that we could spend another Indifferent Bystander: “Do what you want
hour regaling each other with similar – I don’t care anymore.” If we hold the
anecdotes: because borderline and anxiety about whether the client will live
trauma clients have such intense feelings or die, and it’s hard to concentrate on
and reactions (remember they have a our children or the weekend’s activities,
dysregulated “emotional thermostat”), then we have ended up in the role of
because their traumatic experiences the victim. If we “go to the wall” for the
have shaped a set of relationship client while she continues to abuse
paradigms in which someone is always or undermine herself, then we have
a victim and someone is always a become the rescuer – the superman or
victimizer, their traumatic transference woman she has always dreamed of who
to us will inevitably elicit such strong would come when she cried for help.
feelings in us that we will unconsciously
find ourselves adopting one of those very I could go on and on with examples:
roles the client is so afraid of. If we have when we are relieved that we got fired –
to harden ourselves to defend against or feel hurt and misjudged – or when we
the client’s attacks or our own despair, have a moment of feeling glad that the
then we will have adopted the role of client had to go to the ER at 10pm after
insisting that she was “fine”. I want to

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stress that all these feelings area normal feeling and reacting in unhelpful ways:
reactions to being typecast and then we will become less involved, try less
misunderstood! hard to understand the “emotional
logic” of the client’s behavior; we may
I believe that this happens to all of dread the weekly appointment and may
us a lot in working with borderline harden ourselves just to get through it;
and trauma clients: by casting us we may begin to have a startle response
in the roles of abuser or indifferent or dreams and intrusive images related
abandoner or victim, they elicit strong to particular clients; we may feel
countertransference responses to which intimidated and try to placate the client;
we have a difficult time responding we may feel so helpless that we just
because we are taught that we are want to give up. If we understand our
not supposed to have them! I would emotional and physical reactions as data
argue that we are supposed to have about the therapeutic relationship or
them – they are there for a reason. The as information about how threatening
challenge is how to make these reactions the relationship feels to the client or as
clinically useful. If we can’t acknowledge evidence of how the client survived, our
them, and we don’t know how to use countertransference, even if negative,
them effectively, we will find ourselves can be a positive contribution to the
work.

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