SAEDNEWS: Hatred and aversion toward patients can arise in psychotherapy. In “Hate in the Counter-Transference,” Winnicott explores its roots in the mother–infant relationship and stresses the importance of therapists recognizing these feelings.
According to Saednews, It has probably happened many times in the course of our work as psychotherapists that we have felt an intense dislike toward some of our patients. If we look back, we can certainly recall patients whose sessions left us with a heavy sense of exhaustion, lethargy, and lack of motivation. Most of us have probably had at least one patient whose approaching session made us anxious or distressed, accompanied by the thought: How am I going to endure another 45-minute session with this patient?
At times, we may also have experienced a profound sense of relief, ease, or even liberation when the treatment of certain patients came to an end. In short, the experience of dislike, anger, or, more precisely, hatred toward a patient is a relatively common phenomenon in the therapeutic setting—one that most therapists are familiar with.
In this article, we revisit Donald Winnicott’s paper “Hate in the Countertransference.” In 1949, Winnicott attempted to trace the roots of the therapist’s experience of hatred toward a patient, explore its different dimensions, and provide a clear and comprehensive picture of the hatred that can emerge within the therapeutic relationship.
In Hate in the Countertransference, Winnicott acknowledges that therapists can also experience hatred when working with neurotic patients. However, he distinguishes the nature of this hatred from the hatred experienced in relation to borderline and psychotic patients.
He argues that managing patients experiencing madness is considerably more complicated, demanding, and exhausting. In other words, through this distinction, Winnicott suggests that hatred in the treatment of neurotic patients remains largely abstract, can be concealed within the therapeutic process, and does not necessarily become a significant problem.
To a considerable extent, these patients are capable of understanding ambivalence and distinguishing love from hatred. In contrast, in the treatment of borderline and psychotic patients, the absence of this capacity causes hatred to become more concrete. It takes on a tangible presence in the consulting room and consequently becomes problematic.
It is important to note that Winnicott essentially does not regard the mother and infant as separate during the first months after birth; he even considers them to constitute a single psychological unit. He applies a similar understanding to the therapist and patient, referring to the relationship established through transference and countertransference.
In other words, therapist and patient continually rediscover one another in the role of the primary object, and an interpsychic world emerges within the consulting room. Understanding this point is important because the hatred that Winnicott describes as emerging in the consulting room has its roots in the very hatred that the object experienced within its original relationship with the mother.
Through a process of making the familiar unfamiliar, Winnicott speaks explicitly about a mother’s hatred toward her infant. He implicitly challenges Melanie Klein’s idea that the death drive, annihilation anxiety, and aggression originate primarily from the infant, and in this paper he explicitly argues that hatred actually begins with the mother.
Of course, he continues to regard love as more ancient, but he acknowledges that the mother herself may experience hatred toward her infant at certain moments throughout the process of motherhood.
Winnicott gives 18 reasons for this experience of hatred. Among the most important are:
The infant does not correspond to the mother’s mental image of the baby she had imagined.
During birth, as the infant emerges from her body, the baby causes physical injury to the mother.
The infant behaves brutally toward the mother and causes her pain.
Once its needs have been satisfied, the infant discards the mother as if she were an orange peel.
The infant disrupts the peaceful life the mother had before motherhood.
The infant frustrates the mother and is sometimes unkind toward her.
And so on.
Winnicott concludes that the mother must distance herself from idealized and stereotypical images of motherhood, become conscious of her hatred toward the infant, and acknowledge it. Otherwise, she may develop feelings of guilt toward the baby and resort to masochistic behavior.
Winnicott clearly distinguishes between concepts such as holding and containing and masochistic behavior. He considers it essential for the mother to understand the subtle boundary between these two domains.
Winnicott goes on to point out that some maternal lullabies actually contain violent themes, and that this violence may represent the mother’s hatred toward her infant. The mother sings lovingly to her baby, who peacefully falls asleep, while the words of the lullaby nevertheless contain an unconscious hatred.
Winnicott emphasizes that, precisely through these lullabies, some of this hatred is discharged, and in a sense, the mother’s capacity to tolerate the hatred increases. In the paper, he gives an example of such a lullaby:
“Hush, my baby, up in the tree. When the wind blows and the cradle rocks. When the bough breaks and the cradle falls…”
By drawing a parallel between the mother–infant pair and the therapist–patient relationship, Winnicott argues that the same complex, multilayered dynamic involving hatred can also exist within the therapeutic relationship.
He explains that he personally experienced such hatred when working with psychotic patients. Because psychotic patients may have fragmented, incoherent psychological structures and limited capacity for ambivalence, they may be unable to grasp abstract concepts or differentiate love from hatred. Consequently, much of what they experience is discharged within the therapeutic setting.
This situation can leave the therapist profoundly exhausted and emotionally depleted. Such exhaustion may, within the context of countertransference, reveal aspects of the therapist’s own unconscious and may sometimes take on anxiety-provoking and guilt-laden qualities, ultimately obscuring the purpose of treatment.
For this reason, Winnicott concludes that, just as the mother must become conscious of her hatred, acknowledge it, and tolerate it, the therapist must do the same. The therapist may even need to make use of this hatred within the therapeutic process.
In Hate in the Countertransference, Winnicott describes a dream that has a close relationship to one of his psychotic patients.
He explains that, in one part of the dream, he was on a theater stage as an actor and had to perform in front of an audience. During the performance, he experienced a strange and disturbing anxiety: the fear of losing the right side of his body.
Winnicott understood this part of the dream as representing something he was experiencing in the consulting room with his psychotic patient.
The patient believed that he had no body and possessed only a mind. Winnicott explains that any discussion of the body was intensely anxiety-provoking and unbearable for this patient. The patient had asked Winnicott to communicate with his mind solely through his own mind.
Winnicott explains that such a demand from the patient was extremely difficult and exhausting for him, and that he had been attempting to repress this reality.
His disturbing dream represented something he had been experiencing in the consulting room with the patient. He writes:
“The night on which I had this dream I was a little annoyed with what my patient had said, in spite of all my preoccupations…. It took me some time to find myself and repair my lapses. The essential thing was that I needed to understand my anxiety, and this was shown in my dream: the loss of the right side of my body at the time when I was trying to play a part that people were watching.”
“The right side of my body was the part that was in relationship with this patient and, according to his wishes, had to be in a state of complete denial…. There may be other interpretations of this dream, but as a result of the dream, and by remembering it, I was able to resume the analysis and repair the damage that had been done—the damage rooted in my relationship with a patient who did not want to have a body.”
In this paper, Winnicott explains that the therapist must tolerate this hatred, just as he believes the mother must tolerate it.
He suggests that by understanding hatred and becoming aware of its different dimensions, the therapist can discover what is taking place within the patient’s psyche. In this sense, Winnicott believes that the therapist must tolerate the hatred that the mother was unable to tolerate—the hatred that contributed to the development of an unhealthy early relationship between the patient and the mother—and survive the experience without being destroyed by it.
He adds that, under certain circumstances, the therapist may even need to interpret this hatred to the patient. Winnicott acknowledges that such patients may, at certain moments, actually be seeking the psychoanalyst’s hatred, and that the therapist may need to place this hatred before them.
If the patient never comes into contact with this hatred, they may perhaps never fully understand love either.
Nevertheless, it is clear that the first step in this process is for the therapist to trace this hatred within their own personal analysis and become familiar with its various dimensions.
