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Without using any identifying information, briefly describe a few client characteristics, e.g. this person has a history of childhood sexual trauma, multiple substance abuse issues, and depression with hopelessness.
16 year old female, homeschooled. Diagnosed with Major Depressive Disorder, severe, recurrent and Generalized Anxiety. She reports emotional abuse at home, and frequently talks about feeling hopeless, that her life will never change, that she can not foresee a future in which she can have happiness. I have contact with both parents periodically, with client’s permission. Parents are extremely averse to therapy, but tolerate me because their daughter feels it is helping her. She has recently been hospitalized (and discharged) for suicidal ideation. She has no substance use issues. I have seen her fairly consistently since she was 12 and first struggled with symptoms of depression.
Without disclosing personal information you are not comfortable sharing, briefly describe your countertransference reactions to this particular client, e.g. “I feel sick to my stomach when I know I have an appointment with this client. I feel intense guilt about the fact that the client continues to drink and hopeless about her getting better.”
I get very tired and struggle to not yawn when I am with her. I anticipate our sessions with fear that this will happen and that I will find myself watching the clock, wishing for the session to be over. I get a bit disgusted with myself that I have this anticipatory reaction.
Briefly describe how your reactions facilitate or inhibit your empathy for the client.
This was not a reaction I initially had to this client. It took me some time to recognize that she is what was called a “help-rejecting complainer” in grad school. I spent a long time in relationship development with her, and during this time, used a great deal of motivational interviewing. I wasn’t trying to fix problems, but help her find her own motivations for starting to make change. Change did happen, and she discharged for about a year. She started up again, at about age 14. It has been since then that I have noticed my countertransference. This reaction has inhibited my ability to be empathetic toward her. I have a conversation with myself before she comes into session about how much I know she is hurting. She seems to continue to want to connect with me but not work to make any change for herself. I believe my countertransference is that I feel frustrated and helpless. I try to understand that this is probably exactly what she is feeling as well, and I try to connect with her on that level.
Briefly describe the extent to which your countertransference reaction may be intensified by your own history (e.g. your own or family’s trauma, depression, substance abuse, etc).
I do not know where this comes from. I do not relate to her in any specific ways that I can identify (and I have talked about this in consultation). She does not remind me, in any obvious way, of significant relationships in my past. As I think about it, I believe she may remind me of people I grew up with who had potential to be more successful than they believed they could be, so they rejected the idea and never really tried. I would feel frustrated with them in similar ways.
Devise a strategy for addressing the countertransference issue.
Some questions to explore:
• How does your understanding of your response to the client help you hear, see, understand the client more clearly?
• Would disclosure of the countertransference response be helpful to the client or the therapeutic relationship? How?
• Would disclosure of the countertransference response be harmful to the client or the therapeutic relationship? How?
I have addressed this with her, without specifically naming it. My strategy was to “notice” with her that she tends to balk at anything that moves towards change talk. Actually, the first time we had that conversation is when she finally admitted to some suicidal thoughts. It was a very helpful conversation that did allow us to move forward in some ways for a short time. I did, of course, notice that during those conversations, I was not yawning or clock watching. I know that was because I knew we were making something good and therapeutic happen for her. Lately, I have noticed myself having to “prepare” for sessions with her in the same ways I used to, so I realize we are probably avoiding something very difficult that needs to be brought out into the open.
How would you know that your countertransference response needs to be addressed with your own counselor/psychotherapist? What might be some signs to look for?
Maybe it would be helpful to explore more deeply why I am having these reactions. I have not done that. If I felt that I was not able to understand my reaction, or that I was letting my reactions become more obvious or less well-managed, I would definitely need to explore this in my own work. Another sign that it would be time to address this myself would be if I took it home with me and it affected me outside of work With this particular client, since I have had the experience before that using my countertransference to usefully inform an intervention, I obviously need to use some similar tactics again.
As your own clinical supervisor, how would you suggest to yourself, as a clinician, that you might need to seek counseling/psychotherapy to address your own personal history as it relates to your work with this client (and other clients with a similar presentation)?
As a supervisor, if I noticed clinical skills and ability to maintain a professional and therapeutic boundary with clients was being compromised, I would hopefully recognize what might be happening for the clinician. I would schedule supervision and start by asking the clinician how she feels her work is going. I would use MI to get her reflecting on her work, and start to explore any concerns/feelings/questions coming up for her. I would ask her to wonder about why she may be reacting in certain ways, and hopefully help her get in touch with any countertransference that might be happening. Because I always emphasize that self-awareness is a large part of being an effective therapist, I do not believe any supervisee would be surprised or offended if I suggested that this was an issue that might need to be raised in their own therapy.