2. 1. To treat our clients, we all need to, at some
extent, develop a relationship with them.
2. Sometimes, this can be quite challenging.
3. What we call transference/countertransference
partially accounts for that.
3.
4. • “The essential impact of schizophrenia on carers is the
apparent meaninglessness of the person’s behaviour
(…). That incomprehensibility is shared by the patient;
without his proper sense of identity, his experiences
are incomprehensible for him too.”
(Hinshelwood, 2013)
7. Countertransference concept
• First introduced by
Sigmund Freud in 1910.
• Noted that the patient’s
influence on the
analyst’s feelings can
interfere with
treatment
9. Empirical Research
A. Testing correlation
between specific patient
health issues (i.e.
personality disorders,
trauma) and staff
emotional response
(Book et al, 1978; Colli, Tanzilli,
Dimaggio et al, 2013; Sansone &
Sansone, 2013)
B. Developing and testing
countertransference
inventories
(Fuertes et al, 2015; Friedman &
Gelson, 2010; Kachele et al , 2015)
C. Testing
training/education/
supervision on
countertransference
(Cartwright et al. 2015; Ponton &
Saurheber, 2014)
13. a natural psychological process
Takes place in everyday relationships
Ordinary relationship: use the term “projection”
Staff-client relationship: use the word
“countertransference”
23. What may happen, then, in clinical
practice?
Distort the perception that we have of our clients
24. Countertransference becomes an issue
for clinical practice
“While clients might exert ‘pulls’ on the
therapist, it is the ‘hook’ in the therapist that
leads to his or her countertransference
response. ”
(Gelso & Hayes, 2007, p. 82).
25. 1. intense emotional
reaction.
2. distorted perception of
the client
3. staff needs are
prioritized
4. therapeutic
role relinquished
IMPACT ON TREATMENT OUTCOME
(Cartwright et al. 2015; Epstein & Feiner, 1979; Fuertes et al,
2015; Friedman & Gelson, 2010; Kachele et al , 2015)
Countertransference becomes an issue
for clinical practice
26. Scenario 1 of countertransference
Feeling overwhelmed and exhausted by a
patient who seemed rigid and “stuck,” I was
reminded of my mother not listening to any
other point of view. Feeling overwhelmed by the
feelings of helplessness to make change.
(Cartwright, C. et al., 2015).
27. Scenario 2 of non-countertransference
Felt amused when a depressed client told a joke.
It was funny, I laughed and it was good to see
his smile.
(Cartwright, C. et al., 2015).
28. Scenario 3 of countertransference
Client has a history of his emotional needs being
attended to by his parents and, subsequently, by
his wife. From the beginning of our time
together, I had a sense of needing to help him
and to attend to his needs.
(Cartwright, C. et al., 2015).
31. Why should I do that?
Underpinning principles:
1. “Your vision will become clear only when you can look into your
own heart. Who looks outside, dreams; who looks inside,
awakes.”
2. “Knowing your own darkness is the best method for dealing with
the darknesses of other people.”
3. “Everything that irritates us about others can lead us to an
understanding of ourselves.”
4. “Whatever is rejected from the self, appears in the world as an
event.”
Carl Gustav Jung
32. THE ROUND TABLE IMAGE:
connecting with your different selves
The plural nature of our
personality requires
regular dialogue between
EGO and the different
SELVES.
34. Exercise 1 – Mapping my shadow
Facilitate exploration of selves and
their qualities
Become aware of selves and their
qualities
Clarify selves needs and intentions
Promote space to manage these selves
and their qualities
35. BE MINDFUL OF MY INTERACTION
PATTERNS WITH CLIENTS
• Transactional Analysis: contributions to
awareness of interaction patterns in clinical
practice.
(Berne, 1961)
36. Interaction patterns in clinical practice
• The Transactional Analysis offers a graphic opportunity to reflect on possible
patterns of interaction driven by countertransference and transference.
• It proposes to analyse interaction considering three basic possible positions in an
adult relationship
(Berne, 1961)
ADULT
position
PARENT
position
CHILD
position
37. Interaction patterns in clinical practice
CHILD
• Respond to the here and now driven by the past.
• Echo of our earlier version of the self / how we responded in the past.
(unware of that).
PARENT
• Respond to the here and now driven by the past.
• Behave as if we were one of our parents (unware of that).
ADULT
• Responds to the here and now driven by a realistic perception of the
present.
• It is the neo-self and deliberately
• ie. Appropriately acting like Parent like (being protective, nurturing,
controlling, critical and punishing) or Child like (being spontaneous,
creative).
45. Exercise 2 – Mapping interaction
Recognize interaction patterns with
the client
Become aware of the impact of these
patterns on clinical practice
Promote space and distance to
manage interaction patterns
Opportunity to learn new interaction
patterns to promote client’s recovery
46. Wrapping up…
• Countertransference is...
• A strong emotional reaction,
• A compelling need to act in a certain way,
• A distorted perception of the client,
• A distorted perception of myself,
• An inability to see the diversity of the client and
to identify the different levels of his
needs/potentials/strengths/difficulties.
47.
48. REFERENCE
• Betan, E; Heim, AK; Conklin, CZ; Western, D. (2005). Countertransference Phenomena and Personality Pathology in
Clinical Practice: An Empirical Investigation. American Journal of Psychiatry, 162, 890–898.
• Berne, E. (1961). Transactional analysis in psychotherapy. New York, NY: Evergreen.
• Book, H; Sadavoy, J; Silver, D. (1978). Staff countertransference to borderline patients on an inpatient unit.
American Journal of Psychotherapy, v 32(4), 521-532.
• Cartwright, C; Rhodes, P; King, R; Shires, A (2015). A Pilot Study of a Method for Teaching Clinical Psychology
Trainees to Conceptualise and Manage Countertransference. Australian Psychologist 50, 148–156
• Colli, A; Tanzilli, A; Dimaggio, G; Lingiardi, V. (2014). Patient Personality and Therapist Response: An Empirical
Investigation. American Journal of Psychiatry, v. 171, 102-108.
• Friedman, SM & Gelso, CJ (2000). The development of the inventory of countertransference. Journal of Clinical
Psychology, vol. 56 (9), 1221-1335.
• Fuertes, JN; Gelso, CJ; Owen, JJ; Cheng, D. (2015). Using the countertransference inventory behaviour as an
observer-rated measure. Psychoanalytic Psychotherapy, vol. 29 (1), 38–56.
• Gelso, C., & Hayes, J. (2007). Countertransference and the therapist’s inner experience: Perils and possibilities.
Mahwah, NJ: Lawrence Erlbaum.
49. REFERENCE
• Jung, C G (1963). The Psychology of the Transference, USA: Princeton University Press.
• Hinshelwood, R D (2013). Suffering the impact: psychosis and the professional caregiver. In:
Gumley, A; Gilham, A; Taylor, K and Schwannauer, M (2013) Psychosis and emotion: the role of
emotions in understanding psychosis, therapy and recovery. London/New York: Routledge. p. 84-
97.
• Kachele, H.; Erhardt, I. Seybert, C. & Buchoolz, M. B. (2015). Countertransference as object of
empirical research? International Forum of Psychoanalysis, v. 24, 2, 96-108.
• Mayers, A. M. (1996). The manifestation and management of staff countertransference on a
pediatric AIDS team. Bulletin Of The Menninger Clinic, 60(2), 206-218.
• Ponton, R F & Sauerheber, J D (2014). Supervisee Countertransference: A Holistic Supervision
Approach. Counselor Education & Supervision, v. 53, 254-266.
• Samuels, A., (1989). The Plural Psyche: Personality, Morality & The Father. London: Routledge.
• Sansone, RA & Sansone, LA (2013). Responses of Mental Health Clinicians to Patients with
Borderline Personality Disorder. Innov Clin Neurosci. 2013;10(5–6), 39–43
Editor's Notes
Today, we are going to talk about “countertransference” which is an important topic in mental health practice.
The meeting of two personalities such as the staff personality and the client’s ones creates a reaction by which both are transformed, the client and the staff. Every relationship with a client precipitates a staff reaction. Most of the times this is fine, but, sometimes, this can be quite problematic and “toxic” for both, the client and staff, because this may create problems for both and in the relationship. And countertransference partially accounts for that.
This “chemical reaction” is a metaphor that certainly applies to a staff-client relationship and this is even more important if we consider that we are here basically working with psychotic clients and, most of the them diagnosed with schizophrenia.
A client diagnosed with schizophrenia normally trigger high stress levels on staff, mainly because of the “intense emotional experience” of the client that threatens “the stability of carers” . On top of that, the stress stems from the “apparent meaninglessness of the client’s behaviour”. The client, without a proper sense of identity, do not understand his own experiences too.
Under such a potential distressing relationship, staff may experience intense emotional reactions that are only partially related to the client’s presentation. “Different staff may react differently to the same distressing client”. Therefore, staff reaction is related to the client’s presentation, but includes the singular reaction of staff to this distressing situation. This singular reaction is countertransference.
However, based on my experience and the Jungian Psychodynamic perspective, I will approach this theme today with you. However, I will not get into deep analysis of the topic as this is educational session is an introduction and supposed to be something helpful to your clinical practice rather than a theoretical discussion of this.
The topic transference and countertransference can be developed in different ways from a Psychological perspective. I made my choices and this presentation is certainly incomplete, because a lot of information and possible angles to address this were desconsidered.
Based on my clinical experience and on the Jungian Psychodynamic perspective, I will approach this theme today with you.
Have you ever heard of Freud?
Freud was a neurologist who developed a discipline Psychoanalysis in Viena (Europe) in XX century. He was the inventor of the modern talking therapies for the mentally ill. Other psychoanalytic authors develop the concept from the one introduced by Freud
1. Research on countertransference reactions of staff treating clients with personality disorders
2. Developing inventories to identify staff countertransference reaction response
3. Developing strategies to support trainee’s learning of the countertransference concept.
Example of the “A” type of research presented in the other slide.
Researches identified countertransference patterns on staff when treating clients with personality disorders. This is important, because the countertransference can be used as a source of information to understand and even diagnose the client. However, this is an avenue about this topic that we will not be dealing with today. Probably next time.
FOR EXAMPLE:
Antisocial personality disorder: “criticized/mistreated countertransference”: which means that staff felt strongly unappreciated, dismissed or devalued by the patient.
Borderline personality disorder: “overwhelmed /disorganized countertransference”: which means that staff felt a desire to avoid or flee the patient and strong negative feelings including dread, repulsion and resentment.
Avoidant personality disorder: “protective/parental countertransference”: which means that staff had a wish to protect and nurture the patient in a “parental way”, but the problem is that this was above and beyond normal positive feelings toward the patient.
Sorry, but I will have to add an second concept to our discussion: the concept of personality.
This is necessary to understand why countertransference is a part of our life and interaction, including the one we have with our clients.
What do you see here?
We have two pictures here of the sky.
First picture: The first one is a picture of a twilight where we can see stars, some clouds, the sun rising, etc. It is a complex picture. Unfortunately, we can’t see everything because of the fact that the sky is partially dark and there are also some clouds in the sky.
Second picture: The second one is a picture of a sunny day without clouds, we can see only the sun but there are no visible stars or clouds preventing us to see the sun. It is a simple picture without a lot to see.
We are going to consider these as two possible models of human personality. I mean, we are going to consider this as two possible ways of representing our personality through a picture.
At a first glance, based on what you can see on each picture, which one would you choose to represent human personality? Why?
From a Jungian perspective of personality, we would choose the first one because…
Our personality has different structures, components that are represented by the different stars in the sky instead of just one that could be represented by the sun in the sky in the second picture.
Our personality has different levels of visibility as shown in the first picture: some parts can be easily seen whilst others are not seen because it is still too dark, for example we can sense that the sun is coming because we can see the sun rays, but we cannot see the sun yet.
In a nutshell, our personality is not a crystal clear one as a clear, blue sky in which there is nothing preventing us from seeing what there is there to be seen. Our personality has different structures: some are visible while others we cannot see properly because of the visibility conditions (ie.: presence of clouds, darker parts)
As a starry sky in the twilight picture that I’ve just shown you, our personality has a group of different structures that we may call DIFFERENT SELVES. The stars in the picture of the sky are the different selves in our personality. We are all made up of MULTIPLE SELVES. Many individual selves, each with its own way of perceiving the world, each with its own personal history, physical characteristics, emotional and physical reactions, and opinions on how we should run our lives.
We can say that we have three main different SELVES in our personality:
And starting from the surface/external SELF to the deep SELF we can say that these three selves are the following ones:
The PERSONA– Persona is a Latin word for the word mask in English. The Persona level corresponds to the dominant self in our personality and this includes all the qualities that society, the family, the culture expect us to develop to live with others for example to be responsible, disciplined, helpful, productive.
2. The SHADOW– This is the disowned self – for some social, cultural and family context reasons some qualities of our personality are disowned, either through repression or deliberate supression, and kept away from our sight. This is away from our sight, but is still there, do not disappear. Some qualities tend to be kept out of sight such as laziness, childishness, selfishness, etc and this constitutes our Shadow. These qualities are kept under our Shadow self. This can be made of positive or negative qualities.
3. The POTENTIAL – Is the self that we have with the potential qualities to be developed over our different stages in life. These are the qualities that our social/cultural – our life experiences – did not triggered so far. For example, a dependant man can develop his other side of action and autonomy. These qualities are under the Potential self to be developed.
18
19
We all have an operating aware part of our personality that can observe and reflect on the fact that we are not a single psychological entity and make decisions. It is called EGO in Psychology. It is a Latin word that means I in English. Our ego is our manager and has to make contact with the different selves of our personality.
The vast majority of culture, society, family and peers tend to foster the PERSONA and to neglect/ignore/criticize the SHADOW and the POTENTIAL selves, but mainly the shadow one. This happens probably because we tend to like comfort and to avoid anxiety by following the rules, repeating what is expected from us/learnt in the past and avoiding risks.
Therefore, our ego tends to value PERSONA (which is our social Self) and to repress the SHADOW, keeping this disowned, out of our sight.
The same thing happens to our potential SELF, most of the times, our ego ignores the potential self, which means that we don’t believe/want that we can be different.
To learn more about read the following: PERSONA: “The Picture of Dorian Gray”, from Oscar Wilde / SHADOW: ”Dr Jeckyll and Mr Hyde”, Robert Louis Stevenson
We normally do not learn at home, at school, with our peers how to acknowledge, be aware of and cope with our plural personality. Our ego tends to identify him/herself with one of the selves and forget, overlook, repress the other ones.
The majority of us tend to like comfort and to avoid anxiety by following the rules, repeating what is expected from us/learnt in the past and avoiding risks. Therefore, our ego tends to value the qualities that belong to our PERSONA self, our social self, and to repress the qualities under our SHADOW one, keeping these disowned, out of our sight. Most of the times, our ego ignores the potential SELF, which means that we don’t believe/want that we can be different.
CONSEQUENTLY,
Tend to become rigid and narrow-minded - (we believe that we are only our PERSONA selves)
Tend to ignore our POTENTIAL selves.
Tend to repress the self that does not agree with our PERSONA ones
Instead of acknowledging the disowned qualities that are kept out of sight by us, namely the qualities under our Shadow self, staff may project this onto clients. In other words this is the content of the countertransference. So the qualities that you deliberately or unconsciously keep away from your awareness are transferred to the client.
For example, you may see your antisocial qualities, your selfishness in others, because you project this onto others instead of acknowledging these as part of you, which means being aware of these qualities and accepting these.
For example, these qualities kept under our Shadow self are projected onto others, clients and other staff. This can be made of positive or negative qualities. For example, woman in the XIX century were not allowed to develop their industriousness, because of the cultural and social strict boundaries to women, and this was kept under many years under the Shadow, but now can be experienced by women. For example, a man that was brought in a family that taught him that “feeling proud about what you do” is wrong, as you need to be “humble”. He may experience self-worth problems as he is not allowed to experience pride in what he does. He probably may project his worthiness onto others and, therefore, always think that others are more important them him.
Another example is that woman in the XIX century were not allowed to develop their industriousness, because of the cultural and social strict boundaries to women, and this was kept under many years under the Shadow, but now can be experienced by women.
THE disowned qualities under our SHADOW SELF constitutes an important part of the the content of our contertransference. The SHADOW is projected onto our clients and this constitutes the countertransference.
This is a barrier to see our clients as they are, with their bad and good qualities, their limits and their potentials.
The Shadow self is the hook for the countertransference response.
The position of the professional, if it is a doctor, a nurse, an OT, etc in the institutional hierarchy counts and modulates the transference from our clients to us and, hence, the countertransference. So apart from our personal history (personality), there are institutional, cultural, social variables that modulate our transference and countertransference.
Ego is in charge of doing that – lets say the reflective and executive part of our personality
A plural psyche, personality demands the round table meeting, which means contacting your different selves, acknowledging these, giving space to them INSTEAD of repressing, supressing and projecting. THE INTERNAL DIALOGUE. Our internal plurality should be acknowledged to avoid the traps.
OUR TASK in life – and mandatory to be aware of and cope with countertransference - is to relate to and engage with our different SELVES, the persona, the shadow and the potential. This means that we do not have only the qualities that society wants from us
Myself at work: a self-reflection exercise. Mapping our disowned qualities requires indirect sources of information, because we are dealing with the unknown. It is present in our reactions, countertransference, but we are not aware of this.
GOALS:
Exploration of SHADOW not changing this.
Identification of the aspects of your shadow.
Promoting awareness, distance and space to manage you shadow selves instead of acting on these.
Engaging with Shadow instead of keeping these disowned and projected onto others.
Apart from the MULTIPLE SELVES PERSPECTIVE that we have just discussed, we can use another interesting concept from Psychology, namely “interactions patterns”. This is about the Transactional Analysis stream of thought in Psychology. This has been used by some researches, supervisors to develop clinicians’ ability to identify and better cope with countertransference and transference. This was created by the psychiatrist Eric BERNE.
Transactional Analysis tells us about interpersonal interaction patterns.
Based on TA, we may consider three basic positions in interactions: adult, parent and child.
The adult position – when you act like an adult.
Ex: A man feeling angry with a person who deliberately is blocking his view of a film, then assertively asks
him to move, and if he refuses asks the steward to deal with the matter.
The parent position – when you act like you parent would act.
Ex: A man, who was told by his mum that he was silly to feel fear when she was late to pick him up at school, does the same with his kids.
And the child position – when you act like.
Ex: A man becomes fearful when his wife is late home from work and after ten
minutes is feeling scared, just like he did when he was a child of four and his mother failed to arrive on time to pick him
up from school.
So, through the analysis of the interaction patterns it is simple to understand and analyse transference/countertransference
relationships in the here and now.
If a client responds to a therapist from either a Child position or from a Parent one then you know that the
client is inviting a transferrential relationship with the therapist.
If the therapist is coming from Parent or Child position, then, this is therapist countertransference.
YOU NEED A GOOD THERAPEUTIC RATIONALE to deliberately hold a parent or a child position and to give your client a child or adult position when interacting with him. For therapeutic purposes if we do so we are holding an adult position that connects with the here and now present time and situation and, deliberately, chooses to act holding these positions for therapeutic purposes, for the sake of the client and not to attend to our personal needs.
Hopelessness and helplessness is a telltale sign for holding a child position, because if you connect with the present, there is always in the here and now, in the present time, alternatives
Whenever we have a therapeutic rationale for holding a parent position and seeing the client from a child position, we are still able to see that the client holds more than the child position or that he/she can be sometimes in a parent or adult position. We need to have flexibility in our perception to acknowledge the different potentials and positions that our client can have.
If we become fixed and have a stereotyped perspective of our client that do not change, ie always holding a parent position and treating the client like a child even when the present situation requires a different interaction approach this means that there are driven by the past. Hence, we, staff, will most likely be driven by an emotional reaction, namely a COUNTERTRANSFERENCE . Whenever staff start seeing himself or the client just/mostly from one position, child or parent, it is time to stop and reflect.
Different situations may require different interactions with clients to act therapeutically with patients. The interaction can be therapeutic if we become aware of this and meet our clients needs, based on a therapeutic rationale for doing this.
Identify the position you are holding. Is this congruent with your therapeutic role? Are you interacting with your client based on a therapeutic rationale? If not, you can try to change your position in the present time or next time:
During the present time: breath, give you some time, let the client have a say while you recompose yourself. And ask yourself what is the situation asking from me to be therapeutic to my client.
Connect to the present time, the adult position, which means to connect with the here and know
GOALS:
Facilitation: exploration not changing the selves
The facilitator helps each self to clarify its views and to give as much information as possible
Promote Awareness, distance and space to manage you shadow selves instead of acting on these.
Engage with Shadow selves – own these instead of keeping these disowned
