COUNTERTRANSFERENCE AND THERAPIST SELF-CARE

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COUNTERTRANSFERENCE AND THERAPIST SELF-CARE

• Diane A. McKay, Psy.D., P.A.
• 1845 Morrill Street
• Sarasota, FL. 34236
• [phone]

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The Irony Of It All?

• As therapists, we use our education, training,
  and skills to help our patients to live more
  rewarding and healthy lifestyles, independently.
• Ironically, many of us are reluctant to offer
  ourselves the same kind of understanding and
  care.
• Yet, in reality, it is this self-care, personal
  and professional, that ultimately is the most
  important not just for us, but for our patients.
• It is possible that we are one of the few, if not
  the only profession, that does not purchase or
  utilize its own product?

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Resistance?

• Why is it so hard to attend to our own needs for
  nurturance, balance, and renewal?
• External stressors
• Perfectionism
• Narcissism or a Narcissistically gratifying ideal
• Another should to resist
• Fear of criticism, judgment, or penalty.

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Not Me!!!

• Many factors influence the effects of stressors
  on individual therapists. Our personal history,
  developmental state, and personality as well as
  the potency of the individual or cumulative
  stressors, affect our susceptibility to stress.
• An accumulation of stressors together in some
  critical mass (Kottler Hazler, 1997, p. 194)
  can conceivably happen to any psychotherapist in
  the course of a personal and professional
  lifetime and can knock even the physically and
  mentally healthiest of therapists off balance.

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Emotional Overload/Depletion

• We witness and vicariously experience a
  cumulative barrage of raw emotion.
• Emotional overload or depletion is not disabling.
• Can include many symptoms such as
• disrupted sleep
• depleted physical and mental energy
• emotional withdrawal from family
• less interest in socializing with friends
• fantasies about mental health days or paid
  vacation
• fantasies about being taken care of.

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Therapist Distress

• Therapist distress describes conscious discomfort
  of suffering
• Distress per se does not necessarily imply
  impairment (OConnor, 2001)
• It might be seen or used as a warning signal
• Has the potential to affect the quality of
  patient care
• Many personal and professional sources
• Over 60 of therapists reported having been
  seriously depressed at some point during their
  career
• Others experience marital/relationship
  difficulties, inadequate self-esteem, anxiety,
  and career concerns (Pope Tabachnick, 1994)

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Work Related Distress

• (National Survey by Pope Tabachnick, 1993)
• Eighty percent reported feelings of fear, anger,
  and sexual arousal at various times in their work
• Ninety-seven percent feared that a client would
  commit suicide
• Almost 90 had felt anger at a client at some
  point
• Over half admitted to having been so concerned
  about a patient that their eating, sleeping, or
  concentration was affected.
• Like their patients with a corresponding
  diagnosis, therapists exposed to a patients
  trauma can develop
• emotional distancing or insensitivity
• loss of trust in others
• increased alcohol use
• and/or ultimately burnout.

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Burnout

• Terminal Phase of Therapist Distress
• Freudenberger (1984) defined the term as a
  depletion or exhaustion of a persons mental and
  physical resources attributed to his/her
  prolonged, yet unsuccessful striving toward
  unrealistic expectations, internally or
  externally derived.
• Symptoms include fatigue, frustration,
  disengagement, stress, depletion, helplessness,
  hopelessness, emotional drain, emotional
  exhaustion, and cynicism.

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PURPOSE FOR PRESENTATION

• It is not my intent to be able to teach todays
  attendees how to care for themselves, personally
  and professionally, especially in less than one
  hour.
• It is also not my intent to provide an in-depth
  review of countertransference.
• It is my HOPE that today by revisiting the
  concept of SELF-CARE, we create a renewed,
  positive, focus on its necessity throughout the
  lifespans of our careers and our personal lives.
• Today, we readdress the elusive and conflictual
  issue of SELF-CARE, from a psychological
  perspective, regardless of our age, level of
  experience, orientation, and histories.

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OBJECTIVES

• Stimulate and enable therapists, of all ages and
  stages, to develop and institute a conscious,
  ongoing practice of personal and professional
  self-care
• Advocate for the need and value of normalizing
  therapist self-care
• Foster communication among therapists on the
  subject of self-care to help them confront the
  loneliness and isolation of working in the field
• Organize and share information, resources, and
  various perspectives on the process of therapist
  self-care and thus to contribute to the evolving
  therapist self-care literature
• Support ongoing education and research pertinent
  to therapist self-care.

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SELF-CARE AS A CONCEPT

• Self-care is being widely discussed these days as
  a healthy and valuable process. The myriad of
  books available on the general market address the
  benefits of self-care, self-nurturance, and
  self-nourishment.
• Self-care is a responsible practice for all
  human beings and in disputably for those
  employed in the service and care of others, like
  psychology.
• Self-care is a lifespan issue, personally and
  professionally, whatever your theoretical or
  clinical worldview.

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Paradox Of Providing Therapy?

• We are rewarded for our choice of profession in
  so many ways, from intellectual, emotional, and
  spiritual challenges to opportunities for
  personal growth, social status, and material
  success.
• Nonetheless, our work is also intensely
  demanding, depressing, frustrating, terrifying,
  and even isolating at times.
• The very pains and joys of human existence that
  our patients experience, we experience.
• Most of us, when were honest or pressed, feel
  very human indeed.

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Paradox Of Providing Therapy? (contd)

• Masterful at helping others learn about and
  practice self-care, many of us struggle with
  conflicts and deterrents to our own self-care.
• Each of us brings our own personal and
  professional history to the practice of
  self-care. This history can both help and
  complicate the process.

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WHY TODAY?

• Isnt this seminar about the Assessment and
  Treatment of Sexual Offenders?
• The simple answer is No one likes a sexual
  offender or the associated concepts.
• There is universal agreement that this arena of
  behavior is the ultimate of taboos. That leads us
  to believe that working with this population is
  likely to be more challenging, creating a
  stronger need for self-care.
• Regardless of the view of countertransference you
  subscribe to, therapy by its nature involves the
  therapist.
• As the instrument of therapy, the therapist
  requires its own maintenance/self-care.

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Traumatic Transference

• The therapeutic relationship as a system includes
  the patient/therapeutic entity (couple, family,
  group) and the therapist. Therefore, one might
  conclude that in order for the therapist to have
  a countertransference, it must be triggered by
  some sort of stimuli, mainly the transference.
• Herman (1992) defined Traumatic Transference as
  life or death quality unparalleled in ordinary
  therapy experience.
• Spiegel and Spiegel (1978) defined Traumatic
  Transference as occurring when the patient
  unconsciously expects that the therapist, despite
  overt helpfulness and concern, will covertly
  exploit the patient for his/her own narcissistic
  gratification.

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Trauma Patient Data

• Survivors of trauma figure prominently in
  virtually every well-known therapeutic dilemma or
  disaster associated with strong
  countertransference reactions.
• They are over represented among those who
  self-mutilate or commit suicide (sometimes the
  reasons given suggest the event was related to
  countertransference errors).
• Trauma survivors (especially those diagnosed with
  BPD or having been sexually abused as children)
  show higher tendencies
• to terminate therapy early,
• fail to attach to the therapist,
• or to act aggressively in therapy.
• Their success rates are also lower, even with
  well-proven treatments, leaving the therapists
  often frustrated and/or confused.

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Trauma Patient Data (contd)

• Trauma Survivors are also highly overrepresented
  among patients who become involved in erotic
  attachments with their therapists either ending
  in enactment or termination.
• Trauma Patients reports include more likely to
• be disappointed or even betrayed by therapists
• experience episodes of therapy that they rate as
  making things worse.

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Trauma Patient Data (contd)

• The litany of difficult situations this suggests
  that by mere virtue of the symptoms that tend to
  occur with trauma history, the clinician will
  face more than the usual number and severity of
  opportunities to sort through difficult
  transference countertransference interactions.
• There is reason to believe that the traumatic
  transference often differs in form and character
  from the transference of other patients.
• Mismanagement of these transferences can place
  the therapist and patient in psychic and/or
  physical danger.

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National Vietnam Readjustment Study

• 40 of combat veterans engaged in violent acts 3
  or more times in previous year
• One or more violent act per month was 5 Xs
  higher in the combat sample than in civilian
  control group.
• 1997 study Childhood Sexual Abuse correlated to
  homicidal ideation, arrest, and violence against
  others (similar for physical abuse and neglect
  victims). This effect has also been noted in very
  young abused children.

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Therapist Self-Care

• Therapist Self-Care is a comprehensive and broad
  subject that benefits from a Broad-Based
  Theoretical Orientation which considers character
  development, symptom reduction, and coping
  strategies.
• Responsible self-care is a complex, lifelong,
  trial and error process.

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Theories Useful To The Process Of Self-care

• Lifespan Development
• Considering our own Developmental Stages and the
  changes across the lifespan, personally and
  professionally.
• Exploring the benefits, opportunities, goal,
  challenges, risks, conflicts, crises, as well as
  the sequences and patterns of change,
  experienced.
• Reflecting on the individual differences and the
  multidirectionality of change with age.
• Self Psychology/Object Relations
• The relationship with the self is core to
  self-care.
• The structure and cohesion, along with
  development of the self, are important.

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Theories Useful To The Process Of Self-care
(contd)

• Object Relations helps us to focus on the within
  and between self relations.
• It provides a means of thinking about our
  relationships with the self and others.
• It holds that interpersonal connectedness is
  essential for emotional health and reminds us
  that therapists, as well as patients, are
  affected by the experience of the relationship.
• Winnicotts true self and good enough
  functioning and also valuable to this discussion.

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3 Key Components of Self-Care

• Self-Awareness (uncovering)
• Self-Regulation (coping)
• Balance (centering)
• Despite the myriad of theoretical definitions of
  countertransference, all have one similarity
  It is the therapist who experiences it, first.

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SELF-AWARENESS

• Awareness is a prelude to regulating our way of
  life, modifying behavior as needed.
• It involves benign self-observation of our own
  physical and psychological experience to the
  degree possible without distortion or avoidance.
  
• Only if we are aware of our needs and limitations
  can we consciously weigh our options in tending
  to those concerns, whether external or internal
  and whether related to personality, life state,
  or circumstance.
• SELF-AWARENESS includes Countertransference

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SELF-AWARENESS (contd)

• Without it, we risk acting out repressed (and
  thereby unprocessed and unmanaged) emotions and
  needs, in indirect, irresponsible, and
  potentially harmful ways that are costly to our
  self, personally and professionally, and to our
  patients, family, and others.
• If unaware of our self needs and self dynamics,
  we may unconsciously and unintentionally neglect
  our patients or exploit them to meet our own
  needs for intimacy, esteem, or dominance.

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SELF-AWARENESS (contd)

• Being self-aware is not always easy or pleasant.
  
• It involves becoming conscious of our internal
  conflicts and the tensions that exist between our
  different kinds and levels of needs.
• Sometimes the content of our impulses and
  feelings may seem very raw, primitive, and
  threatening to our view of our self.

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Themes of Traumatic Transference/Countertransferen
ce

• Reality Testing and Doubt
• Intensity of the countertransference The BLAME
  and SHAME game.
• Malfeasance/Incompentency Accusations
• Ambivalence about Attachment
• Resolution and Termination
• Anger and Manipulation are found throughout
  each theme, as well as in and of itself.

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Reality Testing

• Trauma by definition attacks the coherence,
  reality-testing, and worldview of the victim.
• As the therapist attempts to fight the
  dissociation and to inhabit at least partially,
  the patients inner world he/she also feels the
  threat to self-coherence.
• (Anxiety is a frequently reported response to
  groups whose reality-testing is under stress.)

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Doubt

• Doubt Do you believe me? Feeling validated.
• Desires to be a victim? Is it really that common?
• What did and did not happen? The search for
  reality.
• Compounded by inability to trust ones own
  perceptions of reality.
• Disbelief can alienate the therapist and patient.
  
• Unbelievable Accounts of Trauma The press to
  disbelieve.
• Empathic Doubt patient wants to be proven
  wrong?
• Transference-Based Reactions VS. Reality Based
  Reactions

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The Blame and Shame Game

• Intensity of the countertransference
• The stronger the intensity of the patients
  transference, the more likely the
  countertransference may overwhelm the therapist
• This type of transference often feels coercive to
  the therapist and they may inadvertently, or
  unfairly, blame the patient. When it is less a
  conscious manipulation than an outgrowth of the
  meeting of intense unmet need with the human
  capacity for empathy.

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The Blame and Shame Game

• The patients and therapists desires to maintain
  a safe and benevolent world lead them to
  wrestle, simultaneously, with blame, shame, and
  responsibility in the relationship.
• Therapy in and of itself
• creates shame for the patient because it
  encourages disclosure of unpleasant truths
• places the therapist in the role of prosecutor
  and character assassin for someone who came to
  them for help.

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Malfeasance/Incompentency Accusations

• Virtually every text on treatment of trauma
  highlights this area
• The patient attacks or accuses for
  self-protection, provoking defensive responses in
  the therapist. Leaving the therapist with 2
  dilemmas
• manage their own countertransference anger and
  counterhostility
• retain a hold on his/her own true self in the
  face of continued relational information that he
  is evil, dangerous, or a potential danger.
• Such attacks often hit home to a therapist who is
  frightened and frustrated by the propensity for
  self-endangerment in the traumatized patient.

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Malfeasance/Incompentency Accusations (contd)

• Repetition Compulsion continuing to care for
  a patient constantly at risk of physical and
  psychic destruction is taxing and places the
  therapist at risk for compassion fatigue and
  emotional exhaustion. This encourages therapist
  acting out to protect themselves.

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Ambivalence about Attachment

• Confusing and disheartening to the therapist, who
  is unaccustomed to the experience of attachment
  as dangerous and yet necessary for survival.
  It is the equivalent of an addiction and an
  allergy to closeness.
• Leads to repeated boundary negotiations, as the
  therapist manages requests for intimacy at one
  moment and accusations of intrusion in the next.

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Resolution and Termination

• What does it mean to resolve trauma?
• How do you really know when treatment is over?
• Is the answer in understanding the treatment
  alliance and what it is and what purposes it is
  meant to serve?
• Unrealistic expectations?
• Resistance to saying Good-Bye, is it just the
  patient?

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Anger Perceived Manipulation

• Anger, Rage, and Hostility is reported as a major
  problem in working with trauma patients.
  (Finkelhor et al. 1993)
• The clearest countertransference pattern noted in
  the literature that is linked to patient anger
  and hostility is counterhostility.
• Therapist anger, hatred, and hostile response to
  patients form one of the 2 emotional reactions
  most commonly discussed in the literature
• The other is love and sexual feelings

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SELF-REGULATION

• Used in both behavioral and dynamic psychology,
  refers to the conscious and less conscious
  management of our physical and emotional
  impulses, drives, and anxieties.
• Regulatory processes, such as relaxation,
  exercise, and diversion, help us maintain and
  restore our physiological and psychological
  equilibrium.
• Our sense of well-being and esteem is closely
  related to the level of mastery of our
  self-regulation and impulse control skills.
  Difficulties in self-regulation often cause
  frustration of shame.

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SELF-REGULATION (contd)

• To regulate mood and affect
• we must learn how to both proactively and
  constructively manage dysphoric affect (such as
  anxiety and depression)
• AND
• adaptively defuse or metabolize intense,
  charged emotional experience to lessen the risk
  of becoming emotionally flooded and overwhelmed
• Adaptive modulation between different self or ego
  states is vital to the service of
  self-integration
• A fine line may exist between stimulation that is
  nourishing and enriching AND stimulation that is
  overwhelming and stultifying.

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SELF-REGULATION (continued)

• Our goal is to learn what we need to do to keep
  our self selves on course to develop our own
  internal gyroscope.
• Our ability to self-regulate increases when we
  are self-aware of our feelings, needs, and limits
  and when we practice managing dysphoria and
  intense emotions.

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FIRST, DO NO HARM

• The Provision of Safety
• Providing
• a safe, therapeutic environment
• is
• a necessity in therapy.

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TO disclose or NOT to Disclose?

• Is the reason for disclosure appropriate?
  Relevant to the patients need to know and not
  therapists need for discharge affect, protect
  own ego, advance his own needs?
• Are the method and timing of disclosure
  appropriate? Is the manner of disclosure
  perceived as information rather than an assault,
  mindful of patients ability to hear?
• Is type of content or countertransference
  disclosure appropriate, responsive to patients
  needs, and unlikely to overwhelm patient?

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4 Reasons to Disclose Anger/Hatred

• Epstein (1977)
• Winnicott demonstrates credibility and
  genuineness
• Source of information regarding patients effect
  on other people
• Diminish patients guilt and paranoia by making
  the apparent the ACTUAL impact of his/her own
  behavior
• Diminish the patients envy and establish
  therapists humanity (patient does not need to be
  alone in his/her susceptibility to hostility)

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Dangers Of Disclosure

• Leaking of therapist affect without therapist
  disclosure of true state
• Unpredictable Emotions in an Attachment Figure
• Hypervigilance Discovery of Therapist Emotions
• Successful Therapist Suppression of Affective
  Display
• Countertransference Suppression for the
  Therapists Psychic Health

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Advantages Of Disclosure

• Reinforcing patients reality testing functions
  and modeling the universality of Transference
• Establishment of Therapists Honesty and
  Genuineness
• Establishment and Cementing of therapists
  involvement with the patient
• Providing a source of information about the
  patient
• Breaking an impasse or mending a
  countertransference-based enactment
• Increased tolerance of the affect of others

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BALANCE

• A positive connection and relationship with our
  self, others, and the universe which serves as an
  antidote to the anxieties of the human condition.
  
• Balance is essential in enabling us to tend our
  core needs and concerns, including those of the
  body, mind and spirit of the self in relation to
  others and in our personal and professional
  lives. Balancing can involve many factors, such
  as time, energy, and money.
• The goal of balance is commonsensical, frequently
  cited advice. Its an ongoing process to learn,
  find, practice, maintain, and regain our balance.

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BALANCE (contd)

• A high level function involving modulation and
  oscillation
• A search for the center on the continuum between
  the extremes
• Deals with trade offs, costs and benefits, pros
  and cons
• The reward for achieving it is HIGH a sense of
  mastery, esteem, and self-trust in a capacity to
  care for ones self.

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CONCLUSION

• We know that self-care is a healthy,
  self-respecting, mature process.
• Appropriate self-consideration is a manifestation
  of a healthy respect for ones self and ones
  clients. It is, in turn, in the service of a
  robust, autonomous self.
• We need to replenish if we are to share with
  others. We require both physical and
  psychological nourishment and rest to restore our
  well-being and to give what we want to give to
  our patients, as well as to the significant
  others in our lives.
• Self-care thus is different from selfishness,
  self-absorption, or self-indulgence.

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CONCLUSION

• Self-preoccupation is, in fact, more likely to
  occur as a result of inadequate self-care over
  time.
• Given the fine line between the therapists
  personal and professional self, self-denial or
  self-abnegation is neglectful not only of real
  self needs, but ultimately of patient care.
• The reality is that therapists, as professionals
  and as human beings, have the right, and deserve,
  to share with ourselves the same time, care, and
  tenderness we extend to clients, family, and
  friends.

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THE END

• Thank you!