Week 4 Homework Assignment (Ethical Issues in Clinical Supervision)

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  • #4530
    Patricia Burke
    Keymaster

    Take a moment to reflect on your own countertransference reactions to a client you have worked with or are currently seeing. Remember, these responses are a normal part of any helping relationship. Reflect on some of your own emotional, cognitive, and physical reactions that were or are specific to your work with that person.

    Now take a meta-position by imagining that you are your own clinical supervisor. Please answer the following questions with regard to how you, as a clinical supervisor, would guide you, as a clinician, through an exploration of your own countertransference responses to this particular client. These questions are based, in part, on Pearlman and Saakvitne’s strategy for exploring countertransference. The purpose of this exercise is to help you heighten your self-awareness with regard to countertransference and to give you an opportunity to practice a respectful, non-judgmental method of exploring countertransference with the clinicians you supervise.


    Homework Questions

    Please do not use any identifying information about the client and only share specific personal information that you feel comfortable sharing.

    Question 1

    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.

    Question 2

    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.”

    Question 3

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

    Question 4

    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).

    Question 5

    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?

    Question 6

    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?

    Question 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)?


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    #16640
    CHELSEA SPEAR
    Participant

    Question 1

    This client has been accused of being domestically and sexually violent but vehemently denies it. This client is also very persuasive and prides himself on being assertive

    Question 2

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

    Question 3

    My reactions inhibited empathy for him and caused me to struggle with unconditional positive regard

    Question 4

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

    Question 5

    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. So I think the plan would be to get increased supervision, increased self care, my own therapy if needed, and transfer the client if this wasn’t successful

    Question 6

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

    Question 7

    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

    #16715
    Esther Cyr
    Participant

    1. Without using any identifying information, briefly describe a few client characteristics.
    History of depression, anxiety, multiple deceased family members within family of origin, liver disease, dementia, hopelessness, suicidal ideation.
    2. Without disclosing personal information you are not comfortable share, briefly describe your countertransference reactions to this particular client.
    I feel frustration over the client avoiding in therapy sessions, the constant derailing to avoid addressing her emotional pain. Client only attends 1 session a month, if scheduled more frequently she says it is too much and will cancel. The passive suicidal ideations scare me and that is at a baseline; the fear comes from questioning whether the client is under reporting. I see borderline characteristics and a sense she could go beyond the ideation to who the family the emotional pain she is experiencing. I dread appointments with this client as I know ahead it will take half the session to get to a point of working on an issue, then time runs out to cover what needs to be covered and I may not see this person for another month.
    3. Briefly describe how your reactions facilitate or inhibit your empathy for the client.
    My fear facilitates careful review of the reported suicidal ideation without a plan. The multiple loss of family of origin members is part of the hopelessness and I can empathize that she misses them and has no one outside of therapy who listens after years of mourning. 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.
    4. Briefly describe the extent to which your countertransference reaction my be intensified by your own history.
    I have experienced significant loss in my life. The client’s emotional pain reminds me of my own at various times of my life. Looking back I did not want to resolve my losses, but express them. My empathy and ability t stay present with this client and allow her process to be what the client needs and now what I would want for her. My history tells me it is o.k. to process and grieve in one’s own way and at one’s own pace.
    5. Devise a strategy for the countertransference issue.
    a. My understanding of the response has allowed me to see her need and support her growth in therapy based upon how she responds. I ask the client at the end of each session if therapy made a difference as was it helpful or not. The response she gives becomes my guide on proceeding with treatment.
    b. 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.
    c. Part of the disclosure was helpful, however, not all of the countertransference would be helpful and could possibly harmful. what is important is to address with client countertransference that would increase understanding in and build on the therapeutic relationship.
    6. 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?
    If I experience problems with sleep, irritability, intense fear, noticing difficulty with working with client on the treatment plan, feeling stuck, physical symptoms such as sore muscles, headache, tightness in chest, starting to lose hope for the client’s treatment outcome.
    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 (or other client with similar presentations)?
    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.

    #16718

    Question 1. Client characteristics
    Previous mental health major with anxiety/ relationship issues and childhood parental loss. A few months into treatment, client’s sibling died in an accident.

    Question 2. Countertransference reactions from this therapist
    I had extremely high empathy when the client. 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.
    She was usually self-directed in control of the session; however, this session she wanted direction on how to create a self-care plan for the next 24 hours as she went to see family. When we created this plan together, during a small section; I did a self-disclosure in increasing her awareness of an additional self-care coping skill specific to the situation.

    Question 3. Facilitative or harmful?
    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.

    Question 4 – my experience
    My countertransference was intensified because of my own similar experience. As an adult, my parent was killed suddenly in a car accident. Both my siblings chose to use some different self-care coping skills to quickly move through the burial process and subsequently had extremely long, intensive repercussions of this act. Through many discussions and reading more about this type of loss afterward, I became aware that this skill can be helpful for closure.
    Other countertransference which was lesser was her similar field of study and that we had both had a parent die, although very different situations.

    Question 5: Strategy
    My strategy at the time was to respond to my client’s request for assistance at a time when she was not cognitively strong. My strategy after that time was to briefly process the disclosure in a following session to make sure A) no harm was done to the client B) to address any clarity issues regarding the disclosure and C) to be transparent about the rareness of this type of disclosure and why I chose to offer it to the client.
    I do think my understanding of this type of out of control loss added to my understanding of the client’s position.
    I think the way disclosure of the countertransference response would be harmful to the therapeutic relationship would be if we did not process the disclosure, if we did not set it apart as a different, rare action on the therapists’ part. I am also aware that I was working with a client who was thinking about being in the mental health field. Being transparent about my process in this disclosure may also be important in her own journey of becoming a helper.

    Question 6: Self-care for the therapist
    When I do or want to do a different intervention in session, I know that I need to process my feelings and choices with my supervisor. If a single session does not release my need to talk about this disclosure, I would go to a therapist to begin processing this issue. 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.

    Question 7: Supervisor addresses the issue
    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.

    I would also check in with the supervised about how they are doing with self-care in a later session.

    #16728
    bethandrews.hope
    Participant

    Question 1
    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.
    Question 2
    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.
    Question 3
    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.
    Question 4
    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.
    Question 5
    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.
    Question 6
    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.
    Question 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)?
    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.

    #16729
    melissa cormier
    Participant

    Question 1
    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.

    This client is a married mother of three young children. Her husband is in the military and is an alcoholic. Her sister passed away at a young age due to alcoholism and her father is a recovering alcoholic. She struggles with anxiety and struggles with balancing parenting and working.

    Question 2
    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.”

    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.

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

    My empathy grows for her, however, I notice I become more maternalistic and what to “help her out of her situation.”
    I have increased empathy for her because she is a mom and working and I am a working mom as well.

    Question 4
    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).

    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 have to remind myself that everyone journey is different and is different than mine. My job as a therapist is to be neutral and help my clients find the answers/skills they are looking for without judgment.

    Question 5
    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? It increases my empathy towards the client. We have shared experiences in being mothers and working full time while raising children with a distant partner who is using substances. I can feel her challenges because I have walked in her shoes.

    Would disclosure of the countertransference response be helpful to the client or the therapeutic relationship? How?
    I would not disclose in this situation because of the risk of having the client wanting me to tell her what to do. I would share that I am a mother and working full time, however I would not share how similar our stories are. I would worry that the amount of information would harm the aspects of our clinical relationship that need to be neutral to help her come to her own conclusions without judgment or by me leading her to a conclusion.

    Would disclosure of the countertransference response be harmful to the client or the therapeutic relationship? How? I think it could potentially harm the relationship. The risk of the client wanting me to “tell them what do to” is great with the stories as similar as they are.

    Question 6
    How would you know that your countertransference response needs to be addressed with your own counselor/psychotherapist? I would look for my own avoidance during sessions. Am I holding back or not asking specific questions. Or the opposite, am I noticing myself leading her to certain conclusions. Is my language changing to be more directive vs more curious and open? What might be some signs to look for? 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.

    Question 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)?

    If boundaries seem compromised, or if there appears to be greater emotional distress during supervision related to specific cases. If the clinician appears “stuck” with a specific case that has triggering elements to it. Or if the clinicians’ self-care routines appear to not be working. If a clinician is discussing feeling burned out or traumatized, then I would also explore the need for counseling.

    #16730
    dsinskie
    Participant

    Question 1
    Client 17 – year old female with history of ODD/IED/ and perhaps on the spectrum.
    Question 2
    Honestly, I dreaded these sessions. I felt incompetent as I could not establish a rapport with this client. She would be nice when she wanted me to do something (write a letter for her service animal) however if I declined her something, she would say “im done” and leave the office. I was forever hopeful she would be a no show/cancel.
    Question 3
    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. I sought out supervision at least twice to try to work through this and gain some insight and direction.
    Question 4
    I’m not sure how my own history would have intensified this reaction. Maybe because sometimes I have doubts of my own skills and feel I need so much more “training” and skill development as I’m coming back into private practice. 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.
    Question 5
    I would start preparing more for meetings with the client in advance. I also would back up and focus on meeting the client where she was versus having my own agenda. Developing trust and rapport would need to be primary before digging into any work. If I was feeling frustrated and discouraged, I can only imagine what she must have been feeling. I would continue to seek supervision as well.
    With this particular client, I don’t feel disclosure would be helpful. I am not certain she would understand and might only take away the negative aspects of the issue versus the clarity gained.
    Question 6
    Anger towards the client, dreading the session or loathing the client, sense of relief if client no shows or cancels, putting off rescheduling.
    Question 7
    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.

    #16731
    Sindee Gozansky
    Participant

    Question 1
    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.
    Client was a mom, highly intelligent, in unhappy marriage, pregnant with second baby, both professionals from parents who were doctors. She was depressed, in conflict with mother-in-law, friends, cried most of the entire sessions, didn’t seem to want to make any changes personally, only expected others around her to change.
    Question 2
    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 dreaded every session with her, hoped she’d cancel, felt bored, watched the clock every 5 minutes.
    Question 3
    Briefly describe how your reactions facilitate or inhibit your empathy for the client.
    It was hard for me to have empathy when she seemed to want help but rejected every intervention. I tried to not show my frustration or boredom, and even at times tried to use that as a way to connect more deeply with her. I tried to remember her pain and desperation and stay with that to support her.
    Question 4
    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).
    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. I also have a physician father as she and raised with high expectations, so I think that played a role. It was odd that we shared the same birthdate (not year) and I felt so disconnected from her. I also shared a cultural name with her sister (which I did not reveal). There were these oddities that just added to my frustration that I should feel more connected to her and be able to help her more. Also, I didn’t feel that I shared her tendency to push others away and be in conflict with them, and so that was confusing, plus I experienced her doing that with me.
    Question 5
    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 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. I also didn’t disclose often because I felt it mostly would not be helpful and would recreate her cycle of conflict with others, and didn’t sense that she was emotionally resourced enough to address this process therapeutically. I also used the strategy of exploring issues like career around which she could engage in a different way sometimes with more engagement.
    Question 6
    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?
    If I was not able to remain somewhat empathic or if my reactions got in the way of doing therapy and not being able to hold her in positive regard, then I would seek more supervision. I’m not sure that I needed therapy per se to work with her. I did not seek therapy, however perhaps because of some of the weird connections I felt that frustrated me, it would have been enlightening.
    Question 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)?
    If my countertransference reactions as a therapist were getting in the way of therapy, of continuing to serve the client well with the highest level of empathy and support and use of skills—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. Also, if I found myself engaging in poorer self-care or unable to do so, that would be a big indicator for need of therapy.

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