by Martha Stark, MD / Faculty, Harvard Medical School


The patient, Janet, is a 31-year-old married woman who has a history of difficult relationships with almost everyone in her life; she is particularly troubled by her lack of close women friends.  Janet has been working hard in the treatment, has made substantial gains in her professional life, and has very much improved the quality of her relationship with her husband. 


Janet and her therapist (a woman) have had a good, relatively unconflicted relationship; Janet clearly likes, and is respectful of, the therapist. 


Upon the therapist's return from a week-long vacation in Florida, Janet, at the end of the session, just as she is leaving, turns back to her therapist and, as her parting shot, blurts out:  "Great tan, bitch!"


The therapist, taken aback, says nothing, smiles wanly, and nods goodbye.


The therapist (after discussing the situation with a colleague) opens the next session with the following:  "We have talked a lot about how upsetting it is for you to have so few women friends.  I think that now, in light of what happened at the end of our last session, I am coming to understand something I had never before completely understood.  When you left last time, your parting words were `Great tan, bitch.'  I wonder if, by saying that, you were trying to show me what sometimes happens for you when you feel close to a woman and then find yourself feeling competitive."


Here the therapist is using her experience of self, that is, her countertransferential reaction, to inform an intervention that is reasonably authentic – although not particularly empathic.  Her intent is not to resonate empathically with the patient's affective experience in the moment; rather, her intent is to enhance the patient's understanding of what she enacts in her relationships with women when she begins to feel close (and, therefore, competitive) with them.


The therapist’s awareness of her own countertransferential reaction (of feeling taken aback and put off by the patient’s door handle remark) to the patient’s provocative enactment enables the therapist to offer the patient an accountability statement that challenges the patient to take ownership of her hostile competitiveness.