“Counter-transference to psychotherapy patients who come late”,  was previously published on Dr. Lynn Friedman’s blog for her Johns Hopkins graduate students.

Yesterday we talked about the two meanings of counter-transference and we said that we would apply these concepts to the reader’s question about how a clinician, new to private practice, might understand and deal with their feelings toward the patient who is late or, “no shows”. The writer was candid enough to admit that he found coming to work, only to be frustrated by the patient’s lateness, or “no shows”, irritating. He added that he found it particularly frustrating in that he was just starting his practice and he was eager to have patients.

Let’s examine this in light of the two kinds of counter-transference that were described, yesterday. Hopefully, the clinician will explore his feelings about the patient’s lateness/”no showing” in his own psychotherapy, psychoanalysis in supervision or in consultation. Obviously, knowing neither clinician nor patient, it’s impossible to know what’s going on between them but let’s consider some possibilities.

For example, in his own treatment, the clinician may lament how frustrating it is — to be new in private practice and to want patients and how diminished he feels at being stood up. Further exploration might reveal that the clinician is the youngest of several children and that he spent his entire childhood, tagging along and being taken for granted and easily dismissed by his older siblings whom he adored. The patient’s “no shows” may have evoked in him these very powerful feelings of feeling diminished, devalued and excluded. No wonder he feels angry and frustrated. If this is the case, his anger may be disproportionate to the offense. This is, in fact, how the term, “counter-transference” was originally used.

More recently, the term counter-transference has been used to refer to the reactions that the patient elicits from the psychotherapist separate from the clinician’s history.  For example, nearly anyone would be frustrated at driving to the office for a single session only to find that the patient does not appear, particularly if one is just starting out in private practice.  The clinician may be frustrated, disappointed, angry, relieved, or still worse, indifferent. There are several important things to consider here. Three in particular are: the meaning of the patient’s behavior, the therapist’s feelings about it and the need to establish a, “psychotherapeutic frame” through which these things can be analyzed.

Since the patient is new to the clinician, we do not know whether the, “no show” expresses a fear, a tendency to be disorganized, a hostile act in response to something that happened during the phone call or something that the patient perceived happened during the phone call or something else.

Still more frustrating, if the patient does not show there is no opportunity to learn about the meaning of the behavior. Hopefully, the patient will call to reschedule and there will be an opportunity to learn more. How, though, does the therapist address the situation so that this is not a recurrent pattern? It is this issue that we will explore in tomorrow’s post.

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