COUNTERTRANSFERENCE AND PLAY THERAPY HISTORY AND BEST PRACTICES

COUNTERTRANSFERENCE AND PLAY THERAPY: HISTORY AND BEST PRACTICES By Amanda Gurock, LICSW, PLADC

AGENDA OF WEBINAR v History of Countertransference v Define Countertransference and Cultural Countertransference (Problems of Cultural Countertransference) v Discuss Types of Countertransference v Manifestation of Countertransference v Discuss Facts about Countertransference v Countertransference and Children v Use of Countertransference and Bad Outcomes v Ethical Applications: Case Example v Steps of Handling Countertransference

HISTORY OF COUNTERTRANSFERENCE v This term was coined by Freud in 1910: he viewed it as a personal problem of the analyst (NEGATIVE) v Jung: cautioned against countertransference because the ‘cases of counter-transference when the analyst really cannot let go of the patient. . . both fall into the same dark hole of unconsciousness’ leading to a “chaotic situation. ” (NEGATIVE) v Middle years: Countertransference is no longer viewed as a interference but rather is considered a source of vital confirmation. Paula Heimann stated 'analyst's countertransference is not only part and parcel of the analytic relationship, but it is the patient's creation, it is part of the patient's personality’. (POSITIVE)

HISTORY OF COUNTERTRANSFERENCE v Late 20 th Century viewed Countertransference being focused on the importance of having a distinction between "personal countertransference" (which has to do with therapist) and "diagnostic response" – that indicates something about the patient. . . “diagnostic countertransference. ” A new belief had come into being that 'countertransference can be of such enormous clinical usefulness. . You have to distinguish between what your reactions to the patient are telling you about his psychology and what they are merely expressing about your own’ in order to distinguish between what your reactions to the patient are telling you about his psychology and what they are merely expressing about your own. (Fordham)- (POSITIVE)

HISTORY OF COUNTERTRANSFERENCE v The 21 st Century has led to transference and countertransference being dependent on one another. Both are used to help the client and to make everyone aware of their feelings. It means that it is “jointly created” between the treater and the patient. (POSITIVE) v Body-centered countertransference involves a psychotherapist's experiencing the physical state of the patient in a clinical context. It can incorporate therapist's gut feelings, as well as changes to breathing, to heart rate and to tension in muscles. (POSITIVE)

DEFINITION OF COUNTRANSFERENCE v. Countertransference: The projecting of a counsellor’s experiences, values and repressed emotions that are awakened by identification with the client’s experiences, feelings and situation that affect the dynamics of a counselling relationship. v. SIMPLE Definition: Complex feelings of therapist towards their client

CULTURAL COUNTERTRANSFERENCE v. Definition: “culture-related distortions of the client or rigid interpersonal behaviors rooted in [the therapist’s] direct or vicarious experiences with members of the client’s [racial/ethnic or sexual minority] group” *** Usually includes attitudes towards age, gender, and ethnicity.

EXAMPLE OF CULTERAL COUNTERTRANSFERANCE v When a Jewish therapist is treating an Arab Israeli. v Potential Problems v Exert a powerful influence on the course of treatment v They are usually perceived by the client v Usually denied/ unknown by therapist

TYPES OF COUNTERTRANSFERENCE v John Rowan (1983) “The Reality Game” v Defensive Countertransference v Aim Attachment Countertransference v Transferential Countertransference v Reactive Countertransference v Induced Countertransference v Identification Countertransference v Displaced Countertransference

DEFENSIVE COUNTERTRANSFERENCE v Definition: is the most general type, and occurs when the client triggers off therapist’s unresolved struggles with areas such as dependency, sexuality or aggression. v Flescher (1973) says: “The therapist’s unconscious readiness to accept or refuse specific material is an important suggestive factor in stimulating the patient to surrender or withhold such material. ”

AIM ATTACHMENT COUNTERTRANSFERENCE v Aim Attachment Countertransference: is about therapist’s motives. Unconscious need for success, power, omnipotence or money can distort therapeutic relationship; so can desperate searches for love, recognition and admiration. EXAMPLES: Other things of this kind which can enter in are savior and rescuer fantasies; voyeuristic impulses; the need to feel superior by working with sick or inadequate people; and attempts to alleviate guilt feelings by helping others.

TRANSFERENTIAL COUNTERTRANSFERANCE v Transferential Countertransference: happens when therapist responds as though the client is a parental figure or a sibling figure. EXAMPLE: if the client is silent and with-holding, therapist may have feelings stirred up of parents and not being able to get through to them.

REACTIVE COUNTERTRANSFERENCE v Reactive countertransference: arises when therapist responds to the client’s transference distortions as if they were real. v EXAMPLE: I had a client who used to accuse me from time to time of having lured him into therapy when he didn’t know what he was doing. If I had replied to him by defending myself or explaining what had really happened, this could only have come from reactive countertransference. Instead, I invited him to work on his feelings about that, with good results.

INDUCED COUNTERTRANSFERANCE v Induced Countertransference: is where therapist takes up a role suggested by the client’s transferential behavior. v EXAMPLE: a dependent client may send out strong take-care-of-me signals, which therapist may respond to by giving advice, answering questions, giving reassurance and so forth – in other words, acting like a parent. This is feeding the neurosis, not changing it.

IDENTIFICATION COUNTERTRANSFERANCE v Identification Countertransference: is where therapist over-identifies with the client, entering into a covert alliance with the client’s neurotic aims. You can become aware of this whenever you find yourself blaming others for the client’s difficulties. Loeser and Bry (1953) say that this is the most common form of countertransference. It can also take a negative form, where therapist avoids areas which are reminiscent of therapist’s own problems. v EXAMPLE: you are working with a mother, who lost her children to CPS, and you being to blame the system for her not having her children back in the home, instead of working with her on the reason that lead to the removal.

DISPLACED COUNTERTRANSFERANCE v Displaced Countertransference: occurs when therapist displaces feelings from his or her own personal life on to a client, or when feelings towards one client are displaced and acted out on another. Also therapist may displace feelings towards a client on to people in his or her personal life, such as family or friends. v EXAMPLE: This is the source of that common experience of therapists that ‘all my clients seem to have the same problems at the moment. ’

MANIFESTATIONS OF COUNTERTRANSFERENCE v Manifestation of Countertransference: • Subjective: The therapist’s reactions to the client originate from therapist’s own unresolved conflicts and anxieties which may be harmful to therapeutic process if undetected (Spotnitz). **The therapist reacts to their client as they are a person from their past that they have unresolved feelings/ issues from: I. E. they mother they wanted unconditional love from. • Objective: The therapist’s reactions to the client are evoked primarily by the client’s maladaptive behaviors which can be beneficial to therapeutic process (Ligiéro & Gelso, 2002) **The therapist is responding to the behaviors and personality of the patient. It gives insight and diagnostic information to therapist, as to how other’s feel when with the client: I. E. How the client struggles to make conversation.

COUNTERTRANSFERENCE v Showing of Countertransference towards our Clients: • Positive Indulgence: The therapist is over-supporting the client, trying to befriend the client, and/or engaging in too much self disclosure. Attempts to be “nice” may damage relationship by serving therapist’s needs while avoiding the client’s conflicts. This can be DETRIMENTAL to our clients. • Negative Indulgence: The therapist’s behaviors are negative, excessively critical, punitive, and/or rejecting of the client. The therapist defends against THEIR OWN uncomfortable feelings by acting out in ways that minimize THEIR OWN personal discomfort (Friedman & Gelso, 2000).

EXAMPLE OF COUNTERTRANSFERENCE v SITUATION: The therapist may meet with a person who has extreme difficulty making conversation. The therapist begins to feel bored during the sessions and notices that they are struggling in the during the sessions. v POSITIVE USE/ OUTCOME: • A therapist who realizes this can then point to the countertransference to help that person better understand the effect a difficulty making conversation can have on others. • A therapist who has experienced the same issues as a person being treated may also be able to empathize with that person more deeply, whetherapist decides to share those personal stories or not.

EXAMPLE OF COUNTERTRANSFERENCE v SITUATION: The therapist may meet with a person who has extreme difficulty making conversation. The therapist may begin, unwittingly, to lead the conversation and provide additional prompts to the person in treatment to encourage discussion. v NEGATIVE USE/ OUTCOME: • A therapist begins to take a punitive tone with the client when they do not respond to questions and may begin to be dismissive at the little conversation that is made. • A therapist may begin to stop encouraging the client to have a part in the conversation and may dominate the conversation.

COUNTERTRANSFERENCE WHEN WORKING WITH CHILDREN v. Reactions when working with children: • one is a “better parent” than the child’s actual parent • not tolerating aggression in the sessions • Child needs a “better protector” from the world • feeling that the parents are overly critical or indulgent

EXAMPLE OF COUNTERTRANSFERENCE v Working with a client that is your daughter’s age and the client become argumentative and is not listening to you. v COUNTERTRANSFERENCE: A person in treatment triggers a therapist’s issues with therapist’s own child. The person being treated, for example, might be defiant with therapist and may transfer defiance felt toward a parent onto therapist. If therapist reacts to the individual as one would react to one’s own child, by becoming increasingly controlling, for example, without recognizing the countertransference, this could negatively impact therapeutic relationship and perpetuate unhealthy patterns in the life of the person in treatment.

COUNTERTRANSFERENCE v. Not all psychotherapy has good and happy endings, which may be due to relational impasses, pathology in family, fragile ego function prone to psychosis, and countertransference issues to certain patients. v. Countertransference, when properly identified, will only constitute a small part of the feelings that exist between therapist and client

USE OF COUNTERTRANSFERENCE v The utility of countertransference depends on the ability of therapist to Discriminate accurately between feelings towards a client that are activated by client projections, and feelings better understood as having their origins elsewhere v Countertransference can be helpful when used as an evidentiary basis or a formulation and if Reflection on it helps decide where to go in treatment v Regardless of therapy framework, emotional responses of client and therapist to each other can inform the work of therapy, and enhance the impact of therapeutic communication

BAD OUTCOMES OF COUNTERTRANSFERENCE v Privileging countertransference over more transparent client communications risks ruptures in therapeutic relationship v When countertransference is stimulated, therapists often fail to maintain an appropriate therapeutic distance v Inappropriate levels of disclosure that compounds transference v Not working with the countertransference v Not acknowledging the countertransference v Unable to discuss case reflectively in supervision v Reinforcing Client’s and own relationship patterns v Difficulty ending therapy

COUNTERTRANSFERENCE CASE: ETHICAL APPLICATION v An attorney representing a clinical social worker's former client. The attorney explained that her client, a mother who was involved in a protracted, contentious child custody battle with her ex-husband, was "enraged" by the social worker's alleged conduct arising out of a dispute between the social worker and the client. v According to the attorney, during the course of their clinical relationship, the client became increasingly concerned that her social worker, Mr. A. , was critical of the client's parenting style. The client, the attorney reported, was especially concerned because her ex-husband’s attorney had subpoenaed Mr. A. in an effort to discredit and impeach the mother as part of the custody dispute. v The former client’s attorney then explained that the mother had asked Mr. A. for a copy of his clinical notes so she could review their contents and explore their legal implications pertaining to the custody dispute. The mother reportedly challenged the content and wording of several of Mr. A. ’s entries in the clinical record. Mr. A. told the client he was offended by her request to review his records and her criticism of several of his clinical notes. Toward the end of one angerfilled telephone conversation, Mr. A. told the client that he could no longer be an effective therapist for her and abruptly hung up the telephone. The former client subsequently sued Mr. A. and filed an ethics complaint against him, alleging that the social worker mishandled his management of the client's request to review the clinical record and the termination of their professional relationship. During a formal deposition, Mr. A. admitted that he “lost it” due to the intense anger he felt toward his client and, as a result, stopped recording clinical notes, abruptly terminated his clinical relationship with the client, and failed to refer the client to another clinician. All these admissions constituted evidence that Mr. A. violated prevailing ethical standards in the profession.

COUNTERTRANSFERENCE CASE: ETHICAL APPLICATION OUTCOME v The former client subsequently sued Mr. A. and filed an ethics complaint against him, alleging that the social worker mishandled his management of the client's request to review the clinical record and the termination of their professional relationship. During a formal deposition, Mr. A. admitted that he “lost it” due to the intense anger he felt toward his client and, as a result, stopped recording clinical notes, abruptly terminated his clinical relationship with the client, and failed to refer the client to another clinician. All these admissions constituted evidence that Mr. A. violated prevailing ethical standards in the profession.

ETHICAL APPLICATIONS OF COUNTERTRANSFERENCE v Risk Management: • Therapists know its normal to have feelings about our clients • Therapists should be able to monitor the countertransference so it does not impact therapy • invaluable "use of self" skills for managing clinical risks, and they can be extended to social workers' management of ethical risks • We follow the social standards

BOUNDARIES AND DUAL RELATIONSHIPS v. Mr. A. cooperated with his estranged client’s ex-spouse and his attorney with regard to the custody dispute. The ex-spouse’s attorney sought information from Mr. A. in an effort to discredit the mother, Mr. A. ’s client. In the client’s ethics complaint, she alleged that Mr. A. failed to maintain clear boundaries. v***Clients needs are the primary concern***

CONFLICTS OF INTEREST v Social workers who become angry with a client must be careful not to respond impulsively and vindictively because doing so can easily generate a conflict of interest v Mr. A. ’s relationship with his client became more negative over time; eventually, Mr. A. collaborated with his client’s ex-spouse and his attorney, thus creating a conflict of interest. v NASW code, “Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client”

CONFIDENTIALITY AND INFORMED CONSENT v Practitioners let their anger get the best of them, and they share confidential and privileged information without authorization v In response to a subpoena issued by the attorney representing the exspouse of Mr. A. ’s client, Mr. A. disclosed confidential information, without the client’s consent, during a formal deposition. This violated NASW Code of Ethics standards.

DOCUMENTATION AND TERMINATION v When Mr. A. decided to stop recording notes because his client challenged the accuracy of several entries in the clinical record, Mr. A. violated the NASW code mandate that “social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future” v Social workers who conclude they can no longer have a constructive therapeutic relationship with a client, for whatever reasons, have an ethical duty to terminate services properly and offer the client appropriate referrals. Mr. A. ’s abrupt termination of his client constituted what lawyers call client abandonment.

STEPS TO HANDLING COUNTERTRANSFERENCE v Step One: Become Aware v Is this feeling characteristic, i. e. , does the resident have it much of the time? If so, it may say a lot about the resident, but probably nothing about his or her patient. v Is the feeling triggered by something unrelated to the patient? Feelings caused by hunger, one's personal life, bureaucracy in the medical center, and so forth are not useful data for helping the patient. v Is the feeling related to the patient in an obvious way? Feeling put off by a patient who is screaming obscenities and viciously destroying the office is countertransference of a sort, but not very illuminating.

STEPS TO HANDLING COUNTERTRANSFERENCE v Step One: Become Aware v Is the feeling uncharacteristic of therapist, a reaction to one particular patient, and yet the exact trigger is not immediately obvious? These are the most helpful feelings to notice in oneself, as they often shed light on subtle yet important dynamics in the patient. ” v By using this systematic characterization of a feeling, a beginning therapist can not only begin to identify their own pitfalls as a practitioner, but also, and more importantly, “[countertransference] examination sharpens therapist’s sensitivities and contributes to improved therapeutic outcomes. ” 2

STEPS TO HANDLING COUNTERTRANSFERENCE Step 2: Be Self Aware v Unreasonable dislike for the client v Inability to empathize with the client v An over reaction to a client’s hostility v Discomfort with Client, dread sessions v Difficulty paying attention to the client v Mind wonders or Bored in sessions

STEPS TO HANDLING COUNTERTRANSFERENCE Step 3: KNOW YOURSELF v Beginning appointments late or running over time v Getting involved in arguments with the client v Defensive or vulnerable to client’s criticism v Repeated misunderstanding of therapist by the client v Provoking Affect in the Client

STEPS TO HANDLING COUNTERTRANSFERENCE Step 3: KNOW YOURSELF v. Over concern about the confidential nature of his work with the client v. Sympathy with the client regarding his treatment by others v. Feeling of doing something “active” for the client v. Appearance of therapist/ client in each other’s dreams

STEPS TO HANDLING COUNTERTRANSFERENCE v. Step Four: Seek Out Consultation with a Supervisor v GOAL: figure out where the feelings are coming from… v. Supervisor should support therapist v. Should provide a safe place for therapist to discuss thoughts and feelings v. Give another perspective to working with difficult clients and cases

TOOLS TO HELP IN SUPERVISION v #1 Countertransference Index, developed by Hayes, Riker & Ingram, (1997) Measures supervisor’s rating of the extent a therapist’s behavior in a counseling session reflect some areas of unresolved conflict. Allows supervisor to help trainees assess learning process, determine the nature & source of reaction, and examine the full range of their reaction to the clients’ issues. v #2 Countertransference Factors Inventory ~ (CFI) Measures Therapist: Self-insight: awareness of personal feelings, Self-integration: intact, healthy character structure and ability to differentiate self from other. Anxiety management: possess the internal skill to control and understand Empathy: put one's self in the other's shoes Conceptualizing ability: grasp the client's dynamics (Gelso & Hayes, 2001) v #3 The Inventory of Countertransference Behaviors (Friedman & Gelso, 2000) completed by supervisors who rate therapist behavior during session on Likert scale Three scores are obtained: positive & negative countertransference behaviors and a total score Negative countertransference behaviors were negatively related to the quality of therapist– client working alliance Positive countertransference was not related to supervisor ratings of working alliance. Negatively related to the bond component of the working alliance (Ligiéro & Gelso, 2002)

SUMMARY OF WEBINAR v History of Countertransference v Define Countertransference and Cultural Countertransference (Problems of Cultural Countertransference) v Discuss Types of Countertransference v Manifestation of Countertransference v Discuss Facts about Countertransference v Countertransference and Children v Use of Countertransference and Bad Outcomes v Ethical Applications: Case Example v Steps of Handling Countertransference