The subject of countertransference, or the sum total of our conscious and unconscious emotional responses to our clients, has fascinated me since I first learned about it in graduate school. Our instructors repeatedly emphasized the importance of self-care, but their focus was more on burnout and compassion fatigue than active engagement with our countertransference.
Most clinicians have some way that they unwind after a day of intense sessions. Perhaps they get some exercise, read a book, binge watch their favorite show, or spend time with loved ones. All these activities feel good, help us to rest and stay connected to our sense of peace or calm, and keep us stable enough to continue to do the hard work of being a therapist. For many practitioners, this will be enough to sustain them for many years in the field.
But how do we therapists continually manage our own emotional responses to the myriad of clients and stories we hear day in and day out? Should we have better systems in place specifically for the management of countertransference? “Traditional self-care activities, which are usually focused on relaxing, reducing stress, and increasing our joy, may be inadequate in and of themselves for managing countertransference”.
That we would have emotional responses at all to our clients is natural. Human beings are social and relational animals, and when we work in such proximity to one another, dealing with such intensely personal subject matter, countertransference is inevitable. These responses in clinicians can be constructive when they are recognized and contextualized, but they can become obstacles to good treatment when they are ignored, devalued, or isolated in our psyches. Countertransference has valuable lessons to teach us if we pay attention. The question is… are we?
Unrecognized Countertransference
Unrecognized countertransference may not be just a barrier to doing great clinical work; perhaps it is the barrier. I should ask myself: Who am I attending to? When I do or say anything in session, For whose benefit is it? I have found that when I can quickly answer, “For the client,” I am generally on the right track. If that answer comes more slowly or with more hesitation, it usually cues me to look inward at my own feelings and motivations.
We have all had clients who trigger an emotional response in us. If I am working with someone who is intimidating to me, I may be more hesitant to challenge that person or hold professional boundaries when appropriate. If I am working with someone who is experiencing something similar to what I have gone through, I may suggest that they do what I did, or do the thing that I failed to do. This is one of the most classic examples of countertransference, wherein I attempt to resolve conflicts in myself via my work with the client. In another example, when I am more interested in a particular aspect of the client’s story, I will probably focus on it more, and when I am less interested, that experience will receive less focus. In all these instances, the direction I take is informed by my own feelings rather than the client’s needs.
To use a real example from my own practice, some months back I found myself feeling impatient with one client in particular and was frustrated that he was not applying the skills and concepts we were practicing in session. I had a very difficult time getting him to engage with nearly anything I thought was indicated. He would almost exclusively recount stories in which he was the hero. In his narratives, he always did the right thing, made the hard choice, and overcame the villains. I was aware of my impatience and frustration, but at the time I still attributed my feelings to his lack of engagement and insecurity. In other words, with all my education, training and experience, I was inwardly blaming the client for my emotional state. “I began to dread sessions with him” and engaged in avoidant behaviors while working with him. I fell into a pattern of offering tepid, half-hearted validation instead of addressing his avoidance and hesitation. My approach served more to make the sessions bearable to me by reducing my frustration, and less to help him reduce his chronic PTSD symptoms. He didn’t seem to be making progress, so what did that say about me? Sound familiar?
Is Self-Care Enough?
At around this time, I attended a workshop on trauma treatment. I asked the facilitator how he stayed calm and well-adjusted while doing so much trauma work. He responded that positive self-care was critical to this process; he did not elaborate further. He clearly knew something, because he has been doing trauma treatment for decades. He was a wonderful clinician and trainer and I suspect that at that moment, he just did not want to get sidetracked on that issue. But I found the response for my own training and understanding to be inadequate. You might be surprised to hear how many times I have received this response from the numerous professionals I have asked. As clinicians, I think we need to have a collective strategy for countertransference, and one that has an active dialogue around it.
There are many skilled clinicians who specialize in working with countertransference issues; the problem for me is that they are not getting much notice or airtime in the profession. When I have spoken about this issue with colleagues, I have encountered a wide range of responses. Usually, what I find is that they have a basic familiarity with the concept of countertransference but no actual working tools for recognizing, addressing, and resolving it. We teach our clients that we are emotional beings, and that we are experiencing some level of affective response throughout the day. Is it possible that countertransference is taking place with our clients all or much of the time, whether we notice it or not? The critical aspect of this is how and when we begin to notice that it is occurring.
In Ernest Hemingway’s novel The Sun Also Rises, the character Mike Campbell is asked, “How did you go bankrupt?"
“Two ways,” he replies. “Gradually, and then suddenly.”
So, “it is in that way countertransference starts to impair our clinical work: gradually, and then suddenly”. Like any problem, it is always best to catch it early, when it is a small and manageable issue.
The Solution Must Be Social
Experienced clinicians can teach and model that self-care is not the miracle cure that will resolve countertransference. Taking a bath or watching Netflix will not resolve countertransference, because these activities do not address some of the underlying mechanisms through which it takes place. Stress and fatigue are important factors, but they are not always the principal engines that drive our experience of countertransference. It arises from a very complex set of interpersonal and neurobiological factors. As such, simply relaxing more often or more effectively is not always an appropriate solution by itself. A close friend and colleague of mine once said to me that “social problems require social solutions.” Much of my self-care is not sufficiently social in nature; being in such a social job, my reset button often involves solitary pursuits like playing music, writing, and woodworking — all things that I do by myself. Perhaps a social phenomenon like countertransference can only be resolved in a social situation. We need other people to help us get through it.
Given the appropriate limitations of confidentiality in our profession, this leaves the earnest clinician with a few viable options. Much has been written about the benefits of social relationships, personal therapy, supervision, and consultation, and I agree with many of these points. All of these provide a social experience to solve a social problem. There are, however, some limitations to regular socializing, supervision, and therapy for resolving countertransference.
Social Relationships
Our social relationships with friends and family should provide us with outlets to find support, reduce our stress, and feel a sense of community. Sometimes our friends and family are not as equipped to hold the enormity of what we might have to share. Therapists tend to develop a fairly thick skin for hearing about truly awful human experiences. It is not that we are numb to them, it is probably more the case that experience in the profession has allowed us to develop the proper cognitive and emotional mechanisms to deal with them on a daily basis — just as the trauma surgeon is not probably too distressed by what she sees on a regular day, but her neighbor might not be able to handle the details of what her job requires her to see and experience. This leaves us with the option to share some feelings, perhaps, but not the intimate aspects of our experience with our friends and families.
Supervision
A supervisory relationship offers support, is social in nature, and is often accepted as the place for clinicians to deal with countertransference. Numerous therapists receive effective support and leadership from very capable and experienced supervisors. For everyone to work through countertransference in this way presumes every therapist’s having access to a very competent supervisor. For my colleagues who place their trust in statistics, an analysis of any bell curve should suggest that supervisor competency follows the same statistical rules as nearly anything else in the natural world. There will be exceptional supervisors who can hold and handle anything, and there will be supervisors who are not equipped for the challenge of addressing therapist countertransference effectively. In many situations, the supervisee often does not feel free to authentically share an experience of countertransference, and for good reason: it could easily be perceived as a limitation, and therefore hinder advancement opportunities. It can result in very real consequences.
Imagine a supervisee reporting experiencing a romantic attraction to the client. The supervisee finds her or himself trying to impress the client, or to be seen as funny. He or she notices that being liked has suddenly become a distraction and wants to work through this. In clinical work, scenarios like these happen from time to time. In the best-case scenario, the supervisor would help the supervisee address this countertransference, work through it, and hopefully resolve it. It is possible that they would agree that referring the client out to another therapist is necessary; it is also possible that they would not come to this conclusion, if the supervisee can effectively work through their emotional responses to the client. But what if the supervisor is incredibly stressed out because his agency is currently being sued for malpractice? What if the supervisor is dealing with the same issue with one of her clients? What if her name is on the building? A supervisor, by definition, is in a position of power which is greater relative to that of the supervisee. It is not hard to imagine scenarios where a supervisee could be negatively affected by sincerely trying to seek out help in resolving countertransference, which is an ethical thing to do.
There is a time in most clinicians’ development where supervision often sounds like, “Have you tried this intervention? Have you tried that technique?” As clinicians progress in their skill development, if and when they get stuck, supervisors can assume that they have tried their usual go-to stock of interventions and tools. While training therapists in new techniques and interventions has a large role to play, they may also search for emotional barriers in their supervisees to carrying out good clinical work. The Discrimination Model of supervision in particular allows that sometimes, the supervisor will act as your counselor in the process. As stated above, many experienced and skilled supervisors can expertly help their supervisees navigate countertransference issues. The problem is that supervisees will not know who can and cannot do this until they have truly put ourselves out there. “Revealing our struggles with countertransference can be a deeply vulnerable experience”. It must be held in a safe and supportive environment. While supervision is enormously helpful, it has limitations for addressing countertransference. I write this as a supervisor myself, and someone who has had some truly phenomenal supervisors.
Personal Therapy
Doing our own personal therapy will certainly help us recognize our patterns of relating and certain triggers that may set us off. It is invaluable for our overall health and well-being. It seems fair to say that anything I do in my own personal therapy is about me, and therefore when I bring things from that personal therapy into my working sessions with clients, I will at least sometimes be dealing with my own issues. This is not black and white; some countertransference is diagnostic in the sense that I may infer that if I feel a certain way around the client, then others likely feel the same. From there, I can make educated guesses about the client’s social world and ways of relating. I may gather additional psychosocial information based on this. And then there is the kind of countertransference that has little or nothing to do with the client but is based on my own history and experiences. In short, just because I am frustrated in session with a client does not mean that everyone gets frustrated when interacting with this person. It is critical that we are able to separate these two ideas.
A psychologist whom I greatly admire once told me that he works through countertransference in his own personal therapy. While I do not begrudge him that preference and have done so myself, there is potential for us to muddy the personal and professional waters there. I may end up setting goals in my own personal therapy, such as being more assertive or holding better boundaries, and I may then bring those ideas into the professional session with my clients. These are fine things to work on and have obvious application in therapy. But there will be times when those pursuits have absolutely nothing to do with my clients. I will refer to earlier questions I asked in this article: Who am I attending to? For whose benefit is this? In my previous example about the client who only wanted to tell stories that bolstered his sense of personal power, suppose my well-meaning therapist encourages me to name this behavior and challenge it, even if gently. Perhaps I will return and in the next session challenge the client on his avoidance. In response, he stops showing up to sessions with me. On one hand, I overcame my own hesitance and mustered the courage to challenge him. On the other hand, a traumatized client who was in therapy is now not in therapy. Have I, in a stroke of clinical genius, revealed the client’s lack of readiness for treatment? Is it possible that if I were simply more patient, this client would come around in time, even absent any challenge or confrontation from me?
Consultation
Consultation, in my opinion, holds more promise than supervision or personal therapy for addressing countertransference, for several reasons. These groups can be set up so there are not marked power differentials. Given the reduction in power dynamics in a consultation group, it follows that each attendee incurs less risk by sharing authentically. In addition, the group’s diversity of experience, perspectives and opinions can offer any therapist increased response flexibility for countertransference when compared with the judgement of almost any lone supervisor or therapist. A consultation group of peers can be more objective, explorative, and therefore helpful, given that they also do not incur any personal risk based on what they hear. I should note the exception, of course, is when unethical or negligent behaviors are revealed in a consultation group. Then the members of that group will need to decide if they should report that behavior to their state licensing board, just as a supervisor or therapist might.
Returning to the example discussed earlier, simply experiencing a romantic attraction to a client is not in and of itself unethical. Whereas a lone supervisor with a large personal stake in the clinician’s performance may have a disproportionate reaction to that, a consultation group made up of peers is less likely to have the same response. They are more likely to consider the times they may have experienced this and what might have been helpful to them at the time. “The consultation group format also provides a social solution to the social problem”.
As part of this exploration, some colleagues of mine formed a consultation group that was focused on countertransference. I have found it enormously helpful to share my own internal conflicts in the profession with a group of trusted professionals. They help to normalize and contextualize my experience, while showing me where my blind spots are and where there is room for growth and development. Because these clinicians are not signing my paychecks, I feel a certain freedom to share openly. And in doing so, I have found that countertransference really can be addressed, processed, and resolved.
Regarding the client I was working with, the consultation group helped me to recognize that my impatience had more to do with my own desire to be competent and achieve some specific result. I needed to solve the client’s problem to end my frustration and thereby feel effective. How much more cliché could I get? My peers helped me to see that this client has lacked safety most of his life. As a result, he has crafted an internal narrative where he occupies a position of power and influence. I can reduce my frustration outside of session and work to increase my sense of competence on my own time. I now have more confidence that I can thread the needle by being patient and allowing him to establish safety and comfort with me, while also moving in the direction of gently prompting him to engage more with working to reduce his symptoms. My personal feelings are not all tied up in this client’s progress now. I was lucky to have a community of knowledgeable and supportive clinicians with whom I could consult. These friends and colleagues were able to create a helpful container in which I could safely discuss this issue and ultimately resolve it.
Flexibility is Key
Examining our own countertransference regularly and often is an important part of being an effective clinician.
I wholeheartedly believe that self-care is a critical aspect in maintaining one’s own wellness and longevity in the profession. We all encourage our clients to reduce their stress and to engage in hobbies and activities that bring them peace or joy, and we should absolutely walk the talk. When we are calm, healthy, and centered, we can do our very best work. As countertransference is a social and relational issue, the more solitary pursuits involved in self-care may not be of much help in recognizing and resolving it. This was true in my case.
“Friends and family can be an outlet for support, although we may feel limited in what we can share” by their lack of familiarity with the profession’s norms and difficulties. Capable and experienced supervisors can provide a wonderful space for working on countertransference. But there is usually a power differential, and with natural variability in supervisor’s competence, these factors can become limits. For those of us who examine countertransference in our personal therapy sessions, I hope we can recognize our patterns and responses, and apply those lessons to our work somewhat dispassionately. Otherwise we run the risk of inadvertently playing out our own therapeutic goals with our clients and will continue to experience unresolved countertransference. Consultation would seem to offer positive support in addressing countertransference, both in the variety of opinions that can be expressed and the potential for reducing or removing power differentials among the participants. I would recommend doing all the above. The important thing is that we keep looking at our countertransference and keep paying attention to what it is telling us.
