Countertransference

September 4, 1986

After reading the excellent series of papers on the topic of countertransference in Volume 34, Number 2 of the Journal, I would like to offer a few points which, to my knowledge, have been written about very little.

Patients come to every therapist, no matter the school, with ready transferences. The Balints, Winnicott, and Leo Stone have written of the basic transference of a supportive mother figure. However, the possibilities of early countertransferences before the patient arrives have not been addressed. The patient making an appointment can be influenced, for example, by the referral source. What the patient has been told about the therapist of his background, whether the appointment is made solely because of the patient's distress and/or under duress from employer, spouse, school, or court, makes a difference. Each will influence attitudes and fantasy formation.

The accepting analyst also has attitudes and fantasies. What will the patient be like—a manageable neurotic or a potentially violent and unpredictable psychotic, etc. The source of referral creates pressures—a referral from one's old therapist, a colleague whom one identifies with or despises, or one with whom one is very competitive Does the patient come from an untrustworthy colleague? Is the patient rich, powerful, or well-known to the public? All are potentially disrupting. Then there are the possibilities or prejudices from what one knows in advance about the patient, especially from the unconscious anxieties that come from knowledge of the presence of physical disease and/or disfigurement. Presumptive diagnosis of a perversion may induce a tendency to make an advance moral judgment.

The necessity of a successful treatment of a neurotic patient for graduation from an institute is in a class with the influence of third persons—supervisor, spouse of the patient, or others whose good will is important to the therapist. All of them may influence attitudes before the patient