Instructor Responses to Week 4 Homework

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    Patricia Burke
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    Supervision and Ethics

    Instructor Response to Homework 4

    Hello everyone,

    Once again, I appreciate your thoughtful responses to the homework questions for class 4. I also appreciate your willingness to reflect on your own reactions and responses to particular clients that you have worked with. I think this kind of open sharing normalizes for us all the idea and the lived experience that clients affect us just as we affect them and that our emotional and visceral reactions to client expressions can actually be a useful barometer for what might be happening for the client and a signal for us to take time to be self-reflective. Below are some of my thoughts and responses to your stories.

    1) Without using any identifying information, briefly describe a few client characteristics.

    I was struck by the diversity of client presentations you all described. Your stories affirm the research and clinical literature that suggests that the more complex the clinical presentation of the person seeking help, the more complex and intense the emotional responses of the clinician. The clients who are most likely to engender strong reactions for you are clients who “are sexually violent and in denial, have dementia, suicidal ideation, depression, Oppositional Defiant Disorder, anxiety, have a history of trauma, are feeling hopeless, is a family member of someone with a substance use disorder, aren’t ready or willing to make personal changes but expect others to change.”

    Some of the most common issues to address in clinical supervision with regard to client characteristics include:

    1) The more severe and/or crisis oriented the clinical presentation of the client the greater the possibility of strong clinician responses.

    2) The more diffuse, porous, or unskillful the client’s relationship boundaries, the greater the possibility of strong clinician responses.

    3) Active substance misuse effects people’s judgment, insight, behavior and relational boundaries, not to mention increasing the risk of impulsive behavior including self-harm and harm to others. When clients are actively misusing substances this makes the client/clinician relationship more tenuous as a safety net and container within which therapeutic relationship issues can be addressed.

    2) Without disclosing personal information you are not comfortable sharing, briefly describe your countertransference reactions to this particular client.

    Below is a sampling of the variety and diversity of the emotional and visceral reactions you described:

    * I began dreading client appointments and began losing sleep the night before sessions

    * I feel frustration over the client avoiding in therapy sessions, the constant derailing to avoid addressing her emotional pain.

    * The passive suicidal ideations scare me and that is at a baseline; the fear comes from questioning whether the client is under reporting.

    * My body was very tense and I was very still, leaning forward and listening intently for the whole session. I felt slightly nauseous, even after the session.

    * 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.

    * When she described her physical response when she hears her husband put ice in a glass, because she knows he is going to start drinking hard alcohol, I started to feel my heart race. I want to help her get out of her situation, and I jump to solving her problem and wanting to tell her what to do.

    * Honestly, I dreaded these sessions. I felt incompetent as I could not establish a rapport with this client.

    * I dreaded every session with her, hoped she’d cancel, felt bored, watched the clock every 5 minutes.

    Thank you for your honest responses. As I read your reactions to your clients I found myself saying to myself, “Oh yeah, I got that one.” Or, “I am relieved I am not the only one.”  I am reminded of our collective humanity and how common it is for clients to evoke strong feelings in us and vice versa. Your expressions help normalize this experience for all of us. These experiences are neither good nor bad, they are simply signals to pay attention to in your work with clients and with the people you supervise.

    3) Briefly describe how your reactions facilitate or inhibit your empathy for the client.

    Again, thank you for being so candid with your reactions and how they facilitate or inhibit empathy. I think what is important to remember is that our strong reactions to clients are normal and that there will be times when those feelings will enhance or inhibit empathy. It is also important to note that it is possible to under-empathize and over-empathize with clients and empathy can turn into other emotions. As Chelsea noted, “My reactions inhibited empathy for him and caused me to struggle with unconditional positive regard.” Beth remarked, “It took me some time to recognize that she is what was called a ‘help-rejecting complainer’. . . 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. Dsinskie noted, “Oh, inhibited my empathy for sure. At some point, I don’t think I wanted to try anymore and might have demonstrated my frustration during session subconsciously.”

    What is essential is to be aware of your reactions and be willing to engage in this kind of exploration in order to determine how to evaluate your reactions and their potential to promote positive outcomes or when they might be roadblocks in the clinical work. For example Esther mentioned, “The dread of the appointment results in mentally preparing for the pace, content, outcome of the session and reality that client is in the maintenance phase and my wanting the client to achieve more may not be reasonable or even the clients expectation.” As Beth mentioned, “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.” Good observation and strategy for enhancing your empathetic awareness Beth.

    As we become more skillful at recognizing these emotional reactions they can help us deepen our insight into and compassion for our clients and also help us recognize when we need to seek help to process our feelings.

    Recognizing our emotional reactions can also help us become more aware of how important self-care is in maintaining our capacity for empathetic understanding. Reframing our emotional reactions as signals about how the client might be feeling brings us back to the basis of the empathetic response, even if the emotional reaction is “negative” or intense.

    Our emotional reactions are never all bad nor all good and they can both facilitate and inhibit our work with clients. As Gretchen commented, “I believed my reaction to the client was facilitative. In the next session, we briefly processed the creation of her self-care plan including my disclosure – and she said that it was extremely helpful because she had needed direction and would not have considered that skill on her own.” Melissa remarked, “I have increased empathy for her because she is a mom and working and I am a working mom as well.” We can help ourselves and the people we supervise explore both aspects of clinician reactions to client behavior and expressions. As a clinical supervisor, your ability to understand and be empathetic with the people you supervise can be greatly enhanced by your exploration of your own emotional reactions to clients.

    4) Briefly describe the extent to which your countertransference reaction may be intensified by your own history.

    Some of the personal history experiences you described that intensified your reactions to your clients included:

    * As an adult, my parent was killed suddenly in a car accident.

    * I have experienced significant loss in my life. The client’s emotional pain reminds me of my own at various times of my life.

    * It was definitely greatly impacted by my own history of being abused.

    * 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.

    * My ex-husband struggled with alcohol. I am mindful of this when working with female clients who are in relationships where their partners are using substances.

    * I’m not sure how my own history would have intensified this reaction. Maybe because sometimes I have doubts of my own skills . . . I have always had difficulty getting in deep and often keep things on the surface so as not to offend anyone or “be wrong”. I’m a natural “fixer” or people pleaser which I think contributes to the issue.

    * This always intrigued me as we had some family cultural similarities of cultural background and I personally have experienced depression but didn’t think to her extent.

    While it may or may not be necessary to explore personal history deeply with regard to a clinician’s countertransference reactions to a particular client, it is important to recognize (as you have all done) that our own stories of trauma, addiction, family of origin issues, physical, emotional, and developmental issues come with us into our current relationships. Our client’s stories and our stories interact with each other in unique and often potent ways that need to be understood and addressed when that interaction interferes with the clinical work. As a clinical supervisor you can offer a well-placed question or two to the people you supervise to help them bring this understanding to the foreground of awareness.

    5) Devise a strategy for addressing the countertransference issue.

    The most important strategies for addressing countertransference issues include:

    • being aware of your own emotional reactions to the client and using that awareness to enhance empathy and connect more deeply with the client.
    • exploring those reactions in your clinical supervision
    • exploring your reactions in your personal therapy when the reactions are related to personal history that would not be appropriate to address in clinical supervision.

    As Sindee wrote: I tried to look at my response in order to quiet the countertransference and stay more connected with her pain. I tried using more motivational interviewing, both the skills and spirit of MI. Occasionally I used disclosure of frustration and not sure how to help as it seemed she wanted it but didn’t, to try to better understand and move into her pain.

    Most of you felt that in your work with a particular client, at a particular moment in the therapeutic relationship, that you would not disclose your countertransference reaction to the client; that this would not have been helpful to the client, and that it might harm the therapeutic relationship. As Chelsea commented, “I do not think disclosing the countertransference issue directly would be beneficial for the client. However, I think getting more support for processing my own reaction would help me to be more empathic and regain my unconditional positive regard for the client” Melissa remarked, “I would not disclose in this situation because of the risk of having the client wanting me to tell her what to do.”

    While it might not be helpful to disclose your personal history to a client, it can sometimes be helpful to share some of your feelings in the moment-to-moment experience of the session. An example of a situation in which a clinician might share his or her feelings of frustration with a client might be one in which a clinician might observe how the session feels disorganized and that disorganization can sometimes elicit feelings of frustration for people. Then it might be useful to ask the client if she feels frustrated by the lack of focus and ask the client if she has any ideas about how the clinician and client can work together to get back on track with the treatment goals. As Beth noted about working with a client who elicitied feelings of frustration for her, “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.” What I am suggesting is that the “frustration” can be commented on, in a non-judgmental way, as a barometer of what might be happening for the client. This is a way that commenting on countertransference (without going into personal details) might be therapeutic and helpful. Esther mentioned another disclosure that had a positive impact on the work, “I have disclosed to the client questioning whether therapy was helping and whether this was the right approach. The outcome was helpful and she contributed on what is helpful for her in therapy sessions.

    This way of dealing with your emotional reactions in a session is called transparency and it is not self-disclosure, because you are not disclosing personal details about your life, but offering the client feedback about your moment-to-moment experience with him/her in a non-judgmental way. The focus is always on the client and the client in the context of the therapeutic relationship. So the decision to disclose your own countertransference reactions to a client is based on the context, the nature of your relationship with the client, and a thoughtful assessment of whether or not the disclosure would be helpful to the client. This idea is based on the ethical principle of “do no harm.”

    6) How would you know that your countertransference response needs to be addressed with your own counselor/psychotherapist?

    Below are some of the signs you suggested that might indicate that emotional reactions to clients should be addressed in counseling/psychotherapy:

    * For lack of a clinical term, if the feelings continue to “stick” with me, I know I need take care of myself outside of my profession.

    *  I would be transparent about discussing the process of self-care for the therapist. Therapy is just one option for self-care when a clinician is dealing with a trigger from session.

    * I would know I needed my own therapist if my countertransference reactions were impairing my life- affecting sleep, interpersonal relationships, etc.

    * 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.

    * I would also pay attention to if I am thinking about the case at home or after work hours. Or if I am noticing more emotional dysregulation when I interact with my ex-husband.

    * Anger towards the client, dreading the session or loathing the client, sense of relief if client no shows or cancels, putting off rescheduling.

    * perhaps because of some of the weird connections I felt that frustrated me, it would have been enlightening [to seek therapy].

    * if I felt I was giving up and just sitting there, so to speak, and not engaged, then I would recommend therapy of the therapist. If it was also bleeding over into my work with other clients, or subsequent sessions during the day, or holding boundaries or taking it home, that would be another reason to recommend therapy.

    Sometimes I say during that processing, “Hey, I go to a therapist when I need to….. helps me be a better clinician.” It conveys being genuine, normalizing the self-care process and helping the therapist learn their own self-care options.

    I think you have pointed out some important clues that clinicians needs to be aware of in relation to what reactions to clients can be addressed in clinical supervision and what reactions might need to be addressed in the clinician’s own psychotherapy. If the emotional reactions cannot be effectively addressed in supervision or they a re-occurring and interfering with personal or professional functioning, then consultation with a counselor or therapist is warranted.

    7) 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)?

    It essential that a supervisor address this issue with the same mindful/non-judgmental awareness, and acceptance of the clinician as a human being with the same vulnerabilities we all share, while not accepting the behavior that is interfering with the clinician’s ability to function effectively at work. Normalizing countertransference reactions and offering non-judgmental observations about how the clinician’s emotional reactions might be interfering with the therapeutic process with certain clients can be an important part of the professional growth experience. As Chelsea wrote: “I would do so by coming at the conversation from a place of empathy and gently point our discrepancy between the clinician’s desire to have unconditional positive regard and inability to do so due to current struggles.” Offering a number of options including an EAP referral or suggestions for private therapy can also be helpful. Dsinskie commented, “I would be direct yet supportive in my approach. I might say something like “ Dalene, based on our previous discussion I am aware that you feel less than competent with this client. You have stated that you are struggling with connecting with her and that you feel frustrated with her and yourself. Im wondering if perhaps connecting with a therapist to talk about your feelings of self-doubt and your fears of offending people would be helpful to move you to a place where you could gain some self-confidence and assertiveness skills. I think it would be helpful for your work with this client and in general.”

    Another possibility is to frame the conversation in terms of the importance of clinician self-care and that seeing a counselor or therapist is a viable self-care strategy. For example, Gretchen commented, “I would be transparent about discussing the process of self-care for the therapist. Therapy is just one option for self-care when a clinician is dealing with a trigger from session. . . Sometimes I say during that procesing “Hey, I go to a therapist when I need to….. helps me be a better clinician.” It conveys being genuine, normalizing the self-care process and helping the therapist learn their own self-care options.”

    Esther offered this comment: “I would say to self, I have dealt with this countertransference in supervision. I am feeling more fear than is natural to have within a therapeutic relationship, when client feels hopeless I am starting to have feelings of helpless in helping the client, however, this may be linked to feeling helpless in areas of my life. The therapeutic relationship is starting to be impacted with my response it is time to seek counseling to address some of these responses and increase my self awareness of what is causing these and gain insight into strengths, limitations, and areas that need healing.”

    Some questions that might be useful as a supervisor to help you open up a conversation with a clinician about the impact of their countertransference and seeking additional help: “Do you think these feelings are affecting the quality of care the client is receiving? Do you think your awareness of these challenges can create more empathetic and healing conversations without disclosing that you feel similarly?  Are these feeling becoming more present as you work with this client? Would it be helpful to explore them with a counselor yourself? I wonder if the client has any awareness you feel this way?”

    I personally believe that engagement in psychotherapy/counseling is an essential part of clinician self-care and personal and professional development. I have been in psychotherapy for most of my adult life. I have experienced it as an invaluable support in helping me sort out when my emotional reactions to clients are arising, in part from my personal history, and how to explore those negative effects so they don’t interfere with my ability to be present and empathetic with my clients.

    When I experienced strong emotional reactions to a client who was a survivor of childhood trauma, suicidal and actively engaged in destructive drinking, I processed my reactions with my therapist. I lost my grandmother to alcoholism when I was a child. She literally drank herself to death. I came to realize in my therapy that the client was activating my feelings of over-responsibility for my grandmother’s “suicide by drinking” in that I believed, as a child, that if I could just have been a better kid she would have loved me enough to stay on this earth. Once I recognized the connection between my sense of over-responsibility for my grandmother and my rescue fantasies for my client, I was able to take reasonable steps to shift my level of engagement with my client. While I also discussed this client situation in my peer supervision group, I needed the more personal exploration I did in therapy to uncover the historical context of my strong emotional reactions to my client.

    One last comment about the use of the words “transference” and “countertransference” in this lesson. This language can have the effect of heightening the power differential in the therapeutic relationship and that post-modern thinking about the therapeutic relationship (such as systems theory and Narrative therapy practices) emphasize more mutuality in the relationship. While I use this language because it is commonly understood in the counseling field, I also want to acknowledge that language is powerful and that we explore alternative ways of languaging this experience of the ways that people engaged in a helping relationship impact each other emotionally, cognitively, physically and spiritually.

    Thank you all, again for your willingness to be so open about your personal reactions, responses and lived experience in your responses to the homework. I hope that you are able to bring this process of encouraging such self-reflection back to your work with colleagues and the people you supervise.

    In our next and final lesson we will be exploring the multiple roles of supervisors and ways we can help the people we supervisor understand and prevent boundary violations that may turn into ethical dilemmas.

    ~Patricia

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