1. COUNTERTRANSFERENCE AND THERAPIST SELF-CARE
Diane A. McKay, Psy.D., P.A.
1845 Morrill Street
Sarasota, FL
(941)

2. 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?

3. 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.

4. 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.

5. 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.

6. Therapist Distress
Therapist distress describes conscious discomfort of suffering
Distress “per se does not necessarily imply impairment” (O’Connor, 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)

7. 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 patient’s trauma can develop
emotional distancing or insensitivity
loss of trust in others
increased alcohol use
and/or ultimately burnout.

8. Burnout Terminal Phase of Therapist Distress
Freudenberger (1984) defined the term as “a depletion or exhaustion of a person’s 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.

9. PURPOSE FOR PRESENTATION
It is not my intent to be able to teach today’s 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.

10. 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.

11. 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.

12. 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 we’re honest or pressed, feel very human indeed.

13. Paradox Of Providing Therapy? (cont’d)
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.

14. WHY TODAY?
Isn’t 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.

15. 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”.

16. 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.

17. Trauma Patient Data (cont’d)
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”.

18. Trauma Patient Data (cont’d)
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.

19. 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 X’s 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.

20. 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.*

21. 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.

22. Theories Useful To The Process Of Self-care (cont’d)
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.
Winnicott’s “true self” and “good enough” functioning and also valuable to this discussion.

23. 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.

24. 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

25. SELF-AWARENESS (cont’d)
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.

26. SELF-AWARENESS (cont’d)
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.

27. Themes of Traumatic Transference/Countertransference
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.**

28. 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 patient’s 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.)

29. 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 one’s 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

30. The Blame and Shame Game
Intensity of the countertransference
The stronger the intensity of the patient’s 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.

31. The Blame and Shame Game
The patient’s and therapist’s 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.

32. 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.

33. Malfeasance/Incompentency Accusations (cont’d)
“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.

34. 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.

35. 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?

36. 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

37. 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.

38. SELF-REGULATION (cont’d)
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.

39. 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.

40. *The Provision of Safety* Providing
FIRST, DO NO HARM
*The Provision of Safety*
Providing
a safe, therapeutic environment is
a necessity in therapy. *

41. TO disclose or NOT to Disclose?
Is the reason for disclosure appropriate? Relevant to the patient’s need to know and not therapist’s 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 patient’s ability to hear?
Is type of content or countertransference disclosure appropriate, responsive to patient’s needs, and unlikely to overwhelm patient?

42. 4 Reasons to Disclose Anger/Hatred
Epstein (1977)
Winnicott – demonstrates credibility and genuineness
Source of information regarding patient’s effect on other people
Diminish patient’s guilt and paranoia by making the apparent the ACTUAL impact of his/her own behavior
Diminish the patient’s envy and establish therapist’s humanity (patient does not need to be alone in his/her susceptibility to hostility)

43. 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 Therapist’s Psychic Health

44. Advantages Of Disclosure
Reinforcing patient’s reality testing functions and modeling the universality of Transference
Establishment of Therapist’s Honesty and Genuineness
Establishment and Cementing of therapist’s 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

45. 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. It’s an ongoing process to learn, find, practice, maintain, and regain our balance.

46. BALANCE (cont’d)
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 one’s self.

47. CONCLUSION
We know that self-care is a healthy, self-respecting, mature process.
Appropriate self-consideration is a manifestation of a healthy respect for one’s self and one’s 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.

48. 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 therapist’s 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.

49. THE END
Thank you!