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Some time ago I answered an E. Mail asking about being in love with a therapist. Bob wrote a comment about his therapist and some unfortunate events that evidently happened to him. The entire article and responses can be found by pressing this hot link. In that linked article, Bob discussed the topics of transference and counter transference. The present article centers on both transference and counter transference and the kind of expectations and client or patient should have about their therapist.

Transference refers to the fact that we act towards people in the present based on our experiences from the past, particularly with our parents while we were growing up. In other words, we repeat patterns of behavior in the present that we learned in the past. Transference occurs all of the time. One example is when newly weds react towards one another as though their spouse was their parent. They come to expect that the spouse will act to them as their parent once did. In psychotherapy, there are times when the patient behaves as though the therapist were the parent from the past. This transference behavior becomes tremendously important in the "talking" or psychodynamic therapies because it helps the therapist correct the misperceptions and reactions of the patient in order that the healthier behavior occurs. An example might be of a patient who was always criticized by disproved of by their parent with the result that they constantly expect the therapist to be critical and disapproving.

Counter transference refers to the fact that the psychotherapist also has feelings in reaction to the patient. The therapist's reactions to the patient could be based on things that happened in his own past or might be in reaction to the way a patient is behaving. For example, if a patient has a transferential feeling of sexual attraction towards their therapist, the therapist might find himself having a counter transference sexual feeling towards the patient.

Anecdote of a counter transference reaction: Many years ago, when I was working with a young man with some Borderline Personality features to his personality, I became aware, during the session, of wanting to throw him out of therapy. I said nothing, as I listened to him, but was mystified by my strange kind of fantasy or thought. After carefully weighing my response, I stopped him and asked him if he had any thoughts or feelings about therapy on the way to the office. It turned out that he had a bad argument with his girl friend last night, felt like an awful person for expressing so much anger at her and, on the way to see me, had the thought and feeling that I could not possibly like him and would want to get rid of him as a patient. Wow!!! Without my saying anything about my fantasy, we explored what his anger meant to him and how it was used against him when he was a child. Whenever he was angry he was informed that he was not acceptable. It was not that his expression of anger was not acceptable to his parents but that he was not acceptable.

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Ethics: It is important to remember that therapists are human beings and have thoughts and feelings just the same as the rest of the human race. However, the therapist is trained to absolutely never act upon the counter transference feelings. Under no circumstances is a therapist to act romantically or sexually towards a patient. When people come into therapy they are placing their trust with this professional mental health worker. Just the same as seeking treatment from a medical doctor or dentist, they expect to be treated with respect and dignity. The expectation of being treated with respect and dignity includes the fact that the therapy office be a completely safe place where people can learn about themselves and learn healthy new behaviors in order that they can move on with their lives.

Unfortunately, there are always a few mental healthy practitioners who lack scruples and honesty. These are people who take advantage of those who have placed their trust with them. I have heard of therapist who will actually try to convince a patient that it will help them (the patient) to have sexual relations with the therapist. When these unethical people are discovered they are investigated, lose their licenses to practice mental health and even go to jail. This holds true whether the mental health worker is a psychiatrist, psychologist or clinical social worker. All three professions are licensed and come under specific ethical rules and regulations of their profession and of the state in which they live and practice. Every state licensing board has a list of ethical rules and laws that are publicly available and can be found Online in your state.

This is why it is always important for people looking for psychotherapy to exercise the greatest of care in making a good choice.

1. A good starting place for selecting a therapist is taking a recommendation from a friend, family member, family doctor (Primary care physician), and from another mental health practitioner.

2. When you interview a therapist you have the right to ask their professional identity (psychiatrist, psychologist, clinical social worker). You also have the right to ask whether or not they are licensed. In most if not all states, practitioners are expected to have their licenses displayed. Never assume someone is licensed. If they are not, Beware!

3. You have every right to ask about a practitioner's background and experience. If they do not have experience in helping people to cope with a particular mental illness or behavioral difficulty you can go elsewhere to find the right professional.

4. If any practitioner refuses to answer these types of questions then it is time to leave and seek someone else.

5. Some patients are "squeamish" about asking questions. They fear offending the therapist. You have a right to know the person you are placing your trust in. Leave if they do not want to answer the very reasonable questions in this list. It is not your job to protect the feelings of the therapist. Ask the questions you need to know about.

6. Today, many people look for therapists Online and that is OK if you are careful. One excellent place to find a licensed therapist Online is http://www.psychologytoday.com/. They carefully check each practitioner's credentials before listing them on their site.

7. It is always possible to call the local chapter of each of the professional organizations that regulate the mental health professions. For psychiatrists, there is the American Psychiatric Association, for psychologists there is the American Psychological Association for social workers there is the National Association of Social Workers. These are places where you can check the credentials of anyone you are considering seeing as well as learning whether they have ever been convicted for unethical practices.

Summary:

In psychotherapy as in life, patients have transference feelings towards their therapist and the therapist, from time to time, may have counter transference feelings towards the patient. The idea is to teach what it all means so that you, the patient or client, can learn to live in ways that are happier and more fulfilling.

Readers in the Boulder, Colorado metro area (or Denver area people willing to drive) may contact Dr. Schwartz for face-to-face consultation and psychotherapy. Email him at dransphd@aol.com for details.

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Thank you!

What do you believe? - Kristene - Jun 24th 2009

Hi... I had a therapy session not to long ago with respect to CBT. I forgot my workbook, apologised and he said " ah yes we we were upto "Hot thoughts" with that in mind , I thought it was pretty sexy when he reponded "didn't you have enough hot thoughts" What do you believe Dr. Schwartz, I have known this man socially, worked with him for sometime etc etc . It's kind of difficult in a smaller town where access to therapy is minimal. Regards Kristene

thank you - kristene - Jun 20th 2009

Hi Dr. Schwartz, thank you for that comment. Regards K

Feeling ill? - Allan N. Schwartz, PhD - Jun 19th 2009

Dear K.,

Please do  not feel ill. I am very, very pleased that things worked out successfully between the two of you. There are no absolutes in this life. I also personally know a couple who met in a professional relationship and it worked out well.

Also, keep in mind that all relationships start out as transference, and that is normal and nothing to fret about.

Dr. Schwartz

sorry too - Kristene - Jun 19th 2009

Kathryn, I'm sorry too K

makes me feel a bit ill - Kriistene - Jun 19th 2009

Thank you, lucky my Surgeon-Husband and I waited for the appropriate time frame, however later we discovered  we loved each other and wanted children. Life can be to rigid and constructed AT TIMES based on theories. Certainly rules are in place to protect all, however the meare thought of my relationship with my husband  labled as "transference, co-t" makes me feel a bit ill   LOL K x

Transference - Allan N. Schwartz, PhD - Jun 18th 2009

Hi Kristine,

All the examples you gave: parents, teachers, psychiatrists and others, are all transference. Yes, there are those who step over the therapy-patient boundary and become personally involved but that is considered to be highly unethical and I will explain why:

Whether the doctor is a dentist, surgeon, internist, psychiatrist, school teacher, lawyer, professor or even your boss, they hold power over you. We, the patient_student are at their mercy because they deliver a service we need and are dependent on them. If things become sexual, there is always the question of whether they (doctors, etc.) are taking advantage of our vulnerability. That is why it is unethical. To have attraction and sexual feelings are fine, to act on them is not fine, not for the doctor.

However, the law and ethical principles, in most places, states that, if patient and doctor are attracted, they must wait one year, without having a professional relationship any longer, and, then, they can become involved.

Look, Kristine, in the news, we hear of many tragic examples of people in power taking advantage of and exploiting vulnerable people. The rules are there to protect people.

Dr. Schwartz

attraction - Kriiiistene - Jun 18th 2009

Can't wait for next Monday, or any day. Seeing a gorgeous man blush is so wonderful and benign. Transference and Co-transference" as it's put, is a little confusing, maybe it does exist, but not for us LOL

attraction - Kriistine - Jun 10th 2009

What's the difference between a teacher and parent, another dr. not involved in therapy and a patient ( my Surgeon years ago and I became attracted to each other, we are married and have 4 children....? answer that. I have had therapy with a Psychiatrist, and quite frankly he's a gorgeous, bright, horny head shrinker that needs to be ...........   senseless. And Freud can shove theory.

attraction - kriistene - May 20th 2009

MY Psychiatrist is hot... he thinks I'm hot, however we remain in the ethical, moral and professional boundaries. It will stay that way, however you can't get done for your thoughts!!!

Therapist Direcories - dheeru - Jan 4th 2009

There are various good site to find a counselor and psychologytoday.com is one of the best but one can also check the best therapist directory at goodtherapy.org.

Editor's Note: Mental Help Net also has a therapist directory which can be accessed here. 

The goodtherapy directory worries me a little bit in that it seems to reject cognitive behavioral therapy and potentialy other forms of empirically derived psychotherapy (usually behaviorally derived forms of psychotherapy) that it seems to suggest are superficial in nature and therefore somehow uncaring and unuseful.  Any group that wants to throw empirically (scientifically) derived psychotherapy out the window becuase it mistakenly thinks that it isn't able to provide a depth of experience hasn't got an accurate picture of what that therapy is about, IMHO. 

The goodtherapy website also seems to suggest that good therapy is always therapy that wants to draw out emotion.  For instance, consider this quote from their page "What is Good Therapy"

our experience is that healing takes more than insight about a problem, cognitive countering, and surface behavior change. Rather than turning away from, countering, or compensating for our suffering, healing requires an exploration into the depth of the wounds which fuel extreme beliefs, feelings, and behaviors. To counter and turn away from the deeper suffering is 'more of the same' and often leads to more suffering. Also, healing requires feeling. As it is said, "If we can feel it, we can heal it." Many of our extreme beliefs, feelings, and behaviors are maintained because we have, in an effort to survive, avoided the paionful wounds and burdens which lurk beneath. Good therapy helps one to process and complete whatever hidden and unhidden wounds one has harbored.

This is, to my mind, a romantic vision of psychotherapy that can be tragically wrong at times, even though it is often also correct.  For instance, in anger management therapy, it is generally a mistake to encourage people to dwell on the sources of their anger. It might be better to say that there are people who are overcontroled emotionally, and those who are undercontrolled, and you need to adapt your therapeutic position to fit the nature of the person's problem you are confronted with; not apply a one-sized fits all approach. 

I think there is room for a lot of approaches to psychotherapy, and I bear the goodtherapy people no ill will.  I just hope that they will come around to seeing that cognitive therapy is not bad therapy.  

Should you tell your psychologist you have feelings for him? - - Nov 30th 2008

You noted: "It can be really useful to discuss these love feelings in therapy in order to promote patient insight and awareness."

If a patient tells her psychologist she has feelings for him won't that just make the therapist very uncomfortable and the patient very embarassed? How is this helpful? How do you know whether you should tell your therapist or not?

What is the waiting period? - - Nov 24th 2008

What is the waiting period after the therapy has ended that is okay to have sex with your therapist?  Is it 1 year, 3 years?  What does Law say about that.  Not what the APA says, but the Law.  APA says that it is NEVER okay.

Editor's Note: To the extent that law regulates this at all, it will vary from state to state.  Whatever the law may be, having a sexual relationship with a former therapist is almost always going to be a bad idea.  

where is the ethical line? - Interested - Oct 25th 2008

Should a therapy be terminated if the therapist has a romantic/erotic countertransference toward the client?

To complicate the question, what if the therapist is in denial of the feelings - at least denying them to the client - but the client has accurately picked up on them?  For example: 

Client who has intense erotic feelings toward therapist notices that the therapist blushes, starts to blink and breath rapidly whenever the client is in close physical proximity, or starts to discuss feelings of desire for the therapist. Therapist occasionally goes overtime with the client, waives or reduces fees for  extra sessions, allows client to hug him, hold his hand and sit at his feet or beside him during session.

This therapist denies feelings of attraction to the client when the client raises the subject, becomes defensive - client feels rejected and somewhat confused, and the therapy continues.

Would anyone disagree that this therapist is likely to have feelings for the client, based on the behaviour? Is it ethical for the therapist to continue therapy with this client, even though the relationship has not become sexual?

Kathryn's comment - Under the spell of transference... - Jun 14th 2008

Kathryn,

Your experience was (and is) so tragic.  I'm sorry no one has responded to your comments.  I don't have much to say except your story strongly moved me and I hope you are actively seeking peace (if not through formal therapy, then through some other healthy method of reducing stress and finding self-love).

I'm not a therapist but I have considered becoming one.   I am currently under the care of a psychiatrist whom I have developed a deep transference with (but no countertransference that I am aware of).  I cannot imagine what it would do to me if she proposed a sexual relationship, or if she responded positively to my romantic affections.  Of course it would feel immensely gratifying 'in the moment' (and I don't think I would be strong enough to resist it because i feel so much trust and affection for her right now), but I think it would have the power to psychically destroy me for the rest of my life, because ultimately it would be such a violation of my path to emotional growth.

Psychotherapy has so many potential dangers because it deals with the deepest levels of human emotion and desire, beyond most levels of rational thought.  I can completely understand why so many therapists and patients end up in illicit relationships because they are talking about feelings and desires that have never been revealed before.  This naturally creates a deeper sense of intimacy than any 'normal' relationship would, where each party has to consider the consequences of revealing their truest feelings to the other person.

I think your suggestions of therapists contributing to a fund to help those victimized by therapy would be such a huge step toward the acknowledgment and healing of transgressions that occur within the near-sacred walls of the therapist's office.  I think the professional organizations (APA, etc.) would be the logical choice to put together such funds and rehabilitation/care programs as part of their dues-paying systems.  The professional and licensing organizations should be actively involved in caring for victimized patients, the families of therapists who transgress, and the therapists themselves (who also suffer greatly, perhaps sometimes disproportionately, as a consequence of their own actions).

I cannot imagine the pain you must have felt during the shaming and suicide of your husband.  Undoubtedly the death of his father contributed to his weakend emotional state, and once the initial faulty decisions were made, it is easy and sad to imagine how things spiraled from there.

Thank you so much for contributing to this forum.  I sincerely hope you are able to find peace, hope, and personal triumph in your life, even in the wake of so much tragedy.

blessings,

sean 

Suicide As The Outcome of Boundary Violations - Kathryn - Mar 1st 2008

My husband,a psychiatrist, was sexually invloved with a patient. He subsequently committed suicide. I tried to get help for him when I learned of the affair but his hospital  allowed him  to resign without any reporting.

After reading Pope and  Bouhoutsos,Sexual Intimacy Between Therapists & Patients, which is replete with case studies of the consequences of patient-therapist relationship,  I am still appalled by the system's lack of rehabilitative programs and non-legal oversight.  Sadly, when investigating the sexual contact  matter, the hospital never interviewed me to learn how depressed my husband was and had been following the death of his father.  They allowed him to resign and thereby practically threw the patient and the therapist together by their actions, ignoring all negative outcomes, and demeaning me.  The only efforts made were to limit the hospital's liability. 

What seems to be lacking in all the literature that I have read is the recognition and acknowledgment that the therapist has family, not to mention other patients, former patients, colleagues, students or support staff, and supervisees,  who  will be impacted by the sexual contact,  and most especially by a subequent suicide which is not uncommon according to the statistics reported. The consequences or impact  of the patient-therapist sexual involvement on this broader group may be just as debilitating as to the patient. Clearly, the professional associations, ethics committees and peer revue committees need help in formulating a rigorous non-legal theraputic approach when sexual intimacy occurs between therapists and patients. 

Finally, if sexual involvement with a patient is as common as the numbers in Pope and Bouhoutos suggest,yet it is established that it is unethical,  then perhaps, each therapist should contribute to a fund against which a harmed party may make a claim for the therapy needed to overcome the harm done by the therapist. Claimants should include family members of the therapist who suffer greatly. Once the sexual contact occurs, there is no malpractice insurance and threats of loss of license or prison  frighten colleagues and administrators into non-theraputic responses. The result might be that therapists will take  a more active role in this neglected area.  Additionally, "patients rights'" posted in conspicuos places might state the prohibition and hopefully, the more agressive patients will read it, although I have heard of Borderlines jumping over tables to embrace therapists. The therapist would be continually rememded of the ethical duty to the patient.

- therapist - Feb 20th 2008

i believe is not correct to have a dual relationship/sexual relationship with a client because it is empowering to client. Therapist has ethical problem issues. therapist are there to help client meet it owns needs such as reconstructing their own lives. A therapist is like a sailor navigating with its client. therapist are to guide you and live a better life.

Sex with Clients - - Dec 29th 2007

As a licensed psychologist I'll put my two cents in. The reason for the ban on sexual relations with clients is that there is a power differential and we, as the professionals, must always act on the side of caution in protecting our clients as a whole. It may be that in a particular instance it will not harm the client or therapist to have a sexual relationship, but who is to say that is the case for sure? Most people would not want a judge to decide. As for transference or countertransference, it is a moot point. Sometimes we just meet people that in other circumstances we might date. Regardless of the reason for the attraction, it is never okay. Period. This is a no-brainer.

reply - - Dec 29th 2007
Well, I beg to differ. I guess that's what you call free speech.

Sexual Relationship with Therapist - - Dec 29th 2007

I see no good reason why a person should not have sexual relations with their therapist, if it's a mutual attraction. Freud slept with some of his patients. I think it all depends on the patient (is he/she competent to make this decision), and the therapist (does he/she truly care about patient). I'm in love with my therapist, though the feeling is not mutual. If the feeling is mutual, I say why not? Life is short, and what's so terrible about feelings of love?

Editor's Note: Everyone is entitled to an opinion. However, no responsible professional group involved in psychotherapy shares your opinion and that ought to give you pause to think why that is so. Universally, therapist-patient sexual relationships are viewed as abusive and unethical transgressions. This is because therapists have more power within the relationship than do patients (who are after all seeking the therapist's help and assistance, not the other way around), and becuase combining romantic and therapeutic roles causes what is called a dual relationship to form. People who are having sex with one another cannot view each other objectively and this lack of objectivity undermines the quality of the professional service being offered. Finally, therapy relationships are almost always highly one-sided, with the therapist knowing a great deal about the patient and the patient not knowing much about the therapist. This one-sidedness is intentional (designed to keep the focus of therapy on the client and to promote transference) but it has as a side effect many patients falling in what they think is love with their therapists. This love feeling is not anything like a mature love, becuase patients simply do not know enough about their therapists to know them in that way. Such love is more like a crush, based as it is on the very limited sample of the therapist's behavior that patients get to see.  It can be really useful to discuss these love feelings in therapy in order to promote patient insight and awareness. To take advantage of them is to take advantage of the patient, even when the patient is experienced sexually and wants the relationship to happen.  The patient wants the fantasy of the therapist; not the actual reality of the therapist.  For these and similar reasons, therapists who have sex with their patients are seen as ethically and professionally compromised.