A positive transference is not uncommon in the early stages of therapy as the patient is mobilised by his wish to get better and usually hopes that we will be of help to him. Nevertheless, as with any relationship, the therapeutic one will also need to stand the test of the patient's hostility or his mistrust. These feelings are not always expressed at the outset. Some patients may find it very threatening to own such feelings in themselves and/or to express them. Consequently, they may be displaced onto other relationships in the patient's life so as to protect the therapeutic relationship. The patient will, for example, report arguments or conflicts with a partner or boss safely keeping their anger ''out there'' rather than in the relationship with us. Most of the time, negative feelings are more readily voiced when the patient trusts that we can tolerate their expression without retaliating or trying to minimise their significance. The experience of such feelings in the therapeutic relationship is referred to as the negative transference.
There are differences between the three schools as to how to work with the emergence, in therapy, of negative feelings and attitudes towards the therapist. Emphasis on the negative transference and its early interpretation are characteristic of Kleinian technique. Anna Freud and those who followed her argued, on the contrary, that interpretation of the negative transference should be avoided early on, prior to the establishment of a solid therapeutic alliance. Nowadays, there is more attention paid to the negative transference across the different schools and its interpretation early on in the therapy.
Interpretation of the negative transference is a risky intervention since it brings into focus the patient's hostile feelings and phantasies. Once exposed, such negative feelings may leave the patient fearing our retaliation. The anxiety that this generates could lead a patient to break off treatment and at the very least, demands of the patient, a capacity to bear his own aggression and paranoid anxieties. In light of these considerations, it is thus often preferable to interpret the negative transference in the context of an established therapeutic relationship in which the patient has felt supported and has had experience of relating to a helpful therapist.
Nevertheless, there are clinical situations in which the interpretation of the negative transference - even if in the context of a relatively new therapeutic relationship - may be necessary so as to help the patient to remain in therapy by giving him the experience of being with a therapist who can understand and think about more aggressive feelings without retaliating. In other words, even though the negative transference will often be apparent in the first session, whether we interpret this will depend on our assessment of how helpful it will be at that stage of therapy. In my experience, the interpretation of the negative transference in the initial sessions is justified where the patient's ambivalence about being in therapy is pronounced and could undermine the viability of the therapy, or where the patient's hostility is so evident that not interpreting it could be experienced by the patient as our inability to manage such feelings. This in itself could lead the patient to break off treatment as he would not have had the experience of us being able to survive, and think about the meaning of, his hostility. Managing the patient's negative feelings towards us with equanimity is important, but under their pressure we maybe tempted to seduce the patient away from their distrust or anger. This is another instance when supervision is vital as it supports us to stay with such uncomfortable feelings.
I Matthew was the eldest of seven children. He had been married twice when he started therapy. His second marriage was breaking down at the time and acted as a spur to seeking help.
In the assessment session, Matthew described the end of his first marriage in some detail. He had been very much in love with his wife, but he noticed that he became distanced from her when she was pregnant with their first child. Within a year of the birth, Matthew had moved out of the family home. As he was telling me this, we could hear noise outside my office coming from the waiting area. Matthew stopped talking and looked irritated. He said: ''It's impossible to think straight with all this noise outside. I guess the NHS can't afford soundproofing''. I thought to myself that Matthew was angry with me for not ensuring a space all to himself without any interruptions or intrusions. Although there was a lot of noise outside, and it was intrusive, the degree of irritation and the contemptuous tone in his voice as he referred to the NHS alerted me to the emergence of strong negative feelings in the relationship. However, since we were only fifteen minutes into the assessment, I did not comment on this as I did not have sufficient evidence to make an interpretation.
Matthew resumed talking and continued to describe his first marriage. As he spoke, I was struck by the fact that he referred to his child not by name but as ''the child''. It felt as though his child was an impersonal object in his mind that had somehow got in the way of his relationship with his first wife. When I later enquired about his second marriage, Matthew described his wife as a very beautiful, intelligent woman who had many interests, ''too many'' he added as an after thought. When I elicited an elaboration of this throwaway comment, he described finding it increasingly difficult to manage her hectic schedule. He hated coming home from work and not finding her at home waiting for him. As he was finishing off this sentence, there was a loud bang outside my office. Matthew abruptly stopped talking and grabbed his briefcase in one hand. He looked at me sternly and said: ''This is just not good enough. I can't hear myself think. It's like a circus out there''.
At this stage, I felt that Matthew would leave unless I took up with him why he had felt so perturbed and angry about the noise outside my office. Although taking up his anger felt risky, it seemed the only intervention that might engage him. I was guided at this point by the quality of the interaction between us, his relationship to the setting and the themes in his story as they had unfolded, and as I had tentatively formulated them in my own mind as the session progressed. Firstly, I noted that he was clearly disturbed by the noise. Secondly, his approach to this external reality was angry and indignant, as if he was saying to me: ''How dare you expect me to talk under these conditions''. Thirdly, his expression ''I cannot hear myself think'' made me wonder about the nature of his anxiety at that point: I speculated that he was in fact worried about whether I could hear him and whether my mind was uncluttered enough to give him undivided attention, that is, whether I could think about him. Fourthly, I speculated that being one of seven children probably meant that competition and rivalry were themes salient in his experience of relationships and, more specifically, relating to his experience of wanting undivided attention.
These strands formed the basis of my interpretation: ''I can see that the noise outside has disturbed you and that you feel very angry about it, so much so that you are ready to leave. You may well decide that's what you would rather do but I think there is something worth understanding here. It seems to me that every time there is a noise you experience it as an intrusion into my mind, as if you fear that in that moment you lose my attention and interest in you to the other noisy patients out there. When this happens, you feel enraged and you want to walk out. This reminds me of how you said that you found it difficult to feel close to your first wife after your child was born and the way you now also resent your wife's interests, which you feel take her away from you. I think that you are perhaps letting me know that it feels unbearable when you cannot be sure that the other person has space in their mind for you''.
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