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Countertransference in psychotherapy: Definitional issues

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Chapter
1
Countertransference in
Psychotherapy:
Definitional Issues
he first strong emotion I recall feeling in the room with
T
my traumatized clients was terror. I was 22 and facing
55-year-old Mr.
B,
who had recently been banned from his
profession due to misconduct.
I
felt
17.
The other
two
trauma
clients I recall from that first year were a 6-year-old boy (who
was recovering from an accident that broke his legs and left
both parents with paraplegia) and a 32-year-old battered
woman. I could not have articulated it at the time, but
I
felt
a
duty not only to them, but also to the magnitude of their
pain, and
I
was very afraid that
I
would fail them. I needed
the expertise of my supervisors desperately, and in response
to my nervous questions, they freely offered it.
Gently but firmly, and with ample citations to support their
positions, my early supervisors suggested that I must not let
my clients know my feelings, positive or negative, about
working with them. Knowledge of a therapist’s feelings is
”burdensome,” one noted. And because most clients are ca-
pable of some intuitive knowledge of their therapists’ emo-
tional reactions, it was important to internally monitor and
short-circuit these feelings. I had informed Mr.
B
of my ner-
vousness, which several of my supervisors believed to be a
major and perhaps irreversible error.
Obediently,
I
began nodding sagely at my first clients, hop-
ing to think of a brilliant and transformative interpretation
or a sophisticated cognitive-behavioral analysis to offer. It
3
http://dx.doi.org/10.1037/10380-001
Countertransference and the Treatment of Trauma, by C. J. Dalenberg
Copyright © 2000 American Psychological Association. All rights reserved.
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4
COUNTERTRANSFERENCE AND TRAUMA
was during this period that my supervisors introduced my
colleagues and me to the term ”countertransference.”
The label countertransference was selectively applied to
some of our strong positive and negative feelings about our
clients, and it appeared to provide the theoretical underpin-
nings for the advice that
I
had been given. Depending on the
supervisor,
counfertransference
meant either the therapist’s
conflict-based emotional reactions to the client or all emotional
reactions and related behaviors by the therapist.
This
contro-
versy in definitions
is
discussed below. However, it was
in-
teresting that, independent of their theoretical orientation, ex-
perienced clinicians felt the need to discuss
this
concept.
As
a group, my colleagues and
I
were intrigued by the new
topic of countertransference but were not entirely grateful.
Typically,
if
countertransference reactions were to be a major
focus of discussion, the general supervision session would be
more threatening than usual. Not only would we be told that
we were making the wrong interventions in the wrong
places, we also would learn that the thoughts and feelings
that accompanied our actions were probably linked to our
own neuroses. We were told that we were not controlling,
containing, suppressing, or even sufficiently monitoring our
countertransference; instead we were ”acting it out.” Defects
in our characters and hidden desires to punish or to be pun-
ished were typically presented as the source of our mistakes
by the analytic supervisors; the cognitive-behavioral profes-
sors concentrated more on our more consciously felt wish to
rescue and to be admired and on our lack of attention to
clients’ spoken needs.
In
general, countertransference was
presented as the enemy of neutrality-a crack or bubble in
the mirror we were to hold before our clients to reflect their
own behaviors, conflicts, desires, and deficits.
My analytic supervisors were presenting the mainstream
view of countertransference at the time, best illustrated by
one of Sigmund Freud’s most commonly quoted statements
on the subject:
We
have become aware
of
the ”counter-transference,”
which
arises
in
[the therapist]
as
a
result
of
the
patient’s
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COUNTERTRANSFERENCE: DEFINITIONAL ISSUES
5
influence on his unconscious feelings,
and
we are almost
inclined to insist that he shall recognize
this
counter-
transference in himself and overcome it
(S.
Freud,
19101
1957,
pp.
144-145).
Countertransference must be ”overcome,” it is argued-mas-
tered, controlled, or eliminated-because it can interfere with
the neutral and objective operations of the psychotherapist.
And certainly
this
describes one plausible outcome.
Coun-
tertransference can be a source of enormous problems. At the
time of
his
writing, Freud was deeply entangled
in
a number
of
countertransference-based
debacles-often they were erotic
relationships between his colleagues and protegbs and their
current or former patients. Breuer, Freud’s coauthor in
Studies
on
Hysteria
(1895/1955), fled in panic from the sexual trans-
ference of the first patient of psychoanalysis, Bertha Pappen-
heim (Anna
0);
others engaged in sexual affairs that were
embarrassing to the young science.
Freud’s disciple, Sandor Ferenczi, became involved with
analysand Gizella Palos and then with her daughter Elma.
Eventually, Ferenczi convinced Freud to step into the middle
of this scenario to see whether Elma’s love for Ferenczi
would stand up to the analysis. Carl Jung also consulted
Freud regarding his sexual involvement with his adolescent
patient Sabina Speilrein (Carotenuto, 1982). Freud refused to
see Speilrein, but consoled Jung that ”such experiences,
though painful, are necessary and hard to avoid” (cited in
McGuire, 1974,
p.
230). Speilrein eventually became a psy-
choanalyst, herself writing to Freud about Jung’s role
in
her
life as ”a faithless lover and a cad” (cited in Baur, 1997, p.
39).
We can well imagine Freud’s fears for psychoanalysis, as
he continued to hear accusations against Jones, Fromm-
Reichman (who had married her patient Erich Fromm), Otto
Rank, and Fritz Perls. It
is
not surprising, in this historical
context, that Freud considered countertransference itself to
be dangerous. Freud counseled Jung that the latter had not
yet achieved ”the necessary objectivity in [his] practice,” not-
ing that Jung still became involved emotionally with his pa-
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6
COUNTERTRANSFERENCE
AND
TRAUMA
tients.
”I
believe an article on ‘countertransference’ is sorely
needed,” he wrote in 1911. ”Of course we could not publish
it, we should have to circulate copies among ourselves’’
(cited in McGuire, 1974, p. 476). Early cognitive or behavioral
texts were similarly silent on the subject.
Modern texts on treatment in general and trauma treat-
ment in particular now more commonly suggest at least some
more positive roles for countertransference (see Chapter
2).
Most frequently they note that countertransference can be a
critical source of information, although the sharing of this
information with the patient is still controversial. The impor-
tance of boundaries
in
practice remains and becomes increas-
ingly clear,
and
the examination of countertransference itself
has taken a much more respected place within the field.
There are now few arenas within
this
domain that are treated
in the secretive manner that Freud advocated. Yet, counter-
transference continues to be a source of much shame and
discomfort among therapists (cf. Davies
&
Frawley, 1994;
Pearlman
&
Saakvitne, 1995; Pope
&
Tabachnick, 1993). Un-
fortunately, even the definition of the concept is unclear.
Definitions
of
Countertransference
A
case example from my more recent clinical past can be
used to illustrate the problems of defining countertransfer-
ence:
When
I
walked to the waiting room to meet Mr.
C
and
stood holding the door, he came abruptly to his feet and
strode past me, bumping my shoulder as he went
by.
I
directed him to my office, which he entered before me.
Standing in the center of the room with his arms crossed,
he said that he had been to six [expletive deleted] psy-
chologists before me, all of whom had falsely accused
him of threatening them with violence. Although he had
an arrest record and admitted to previous violence, he
continued, these accusations by previous psychologists
were lies. He suspected that they stemmed from a con-
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COUNTERTRANSFERENCE: DEFINITIONAL ISSUES
7
spiracy between the psychologists and his ex-wife, all of
whom were trying to keep him from his sons. His wife
was accusing him of sexual molestation of his children,
which also was
a
lie. He had filed suit against her already
for defamation and planned to sue the psychotherapists.
His meeting with me was
a
court-ordered evaluation.
In our initial 90-minute meeting, he spoke angrily
about his abuse-ridden childhood, drug history, previous
assaults on others, and corruption
in
the mental health
profession. He spoke in
a
loud and angry voice, sprin-
kling his monologues with obscenities, threats of litiga-
tion, and reminders that he was a very violent man who
had been wronged by psychologists before. The results
of his Minnesota Multiphasic Personality Inventory
(MMPI) had been forwarded, and it showed elevations
on the Psychopathic Deviancy, Paranoia, and
Mania
scales. He frightened me.
Was my fear countertransference? It depends, naturally, on
the choice of definitions. The broadest or most inclusive def-
initions are called ”totalistic” views. Here my fear obviously
qualifies: Countertransference is defined as “the entirety of
the analyst’s emotional reactions to the patient within the
treatment situation” (Bouchard, Normandin,
&
Seguin, 1995,
p.
719). Another example of a totalist definition
is
Christo-
pher Bollas’s (1983) statement that countertransference is ”a
continuous internal response to the presence of an analy-
sand”
(p.
1).
My own definition of trauma countertransfer-
ence, detailed below, is
in
the totalist camp.
More ”particularist” views carve out specific classes of the
psychotherapist’s emotional response to define as “counter-
transference” (M. Cohen, 1952; Gitelson, 1952; Grotstein,
1995). The focus could be on whether the psychotherapist’s
response is a hindrance to the treatment
(if
so,
it is counter-
transference) or a help. Alternatively, the question could be
whether a response is ”objective” or the result of preexisting
biases and conflicts of the therapist (objective responses not
being countertransferential), or whether the response is re-
lated directly to the client’s transference or is independent of
it (countertransference being defined as counter to the client’s
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8
COUNTERTRANSFERENCE AND TRAUMA
transference). Briere (1989), for instance, defined counter-
transference in the treatment of victims of sexually abuse as
”biased therapist behaviors that are based on earlier life ex-
periences or learning”
(p.
73). Cohen (1952), another partic-
ularist, wrote, ”when, in the patient-analyst relationship,
anxiety is aroused in the analyst with the effect that com-
munication between the
two
is interfered with by some al-
teration in the analyst’s behavior, verbal or otherwise, then
countertransference is present”
(p.
235).
The ”classical” view, most in keeping with the original def-
inition as it has been understood by Freud’s many critics and
followers, is that ”countertransference is equated with the
[therapist’s] transference, or with other conflict-laden reac-
tions to the patient” (Gorkin, 1987,
p.
3),
and that it is distinct
from the ”real” relationship.
A
modern example is Grotstein’s
(1995) particularist definition of countertransference as the
therapist’s ”own unforced reemergence
of
his or her own in-
fantile transference neurosis/psychosis that constitutes sub-
jective feelings toward the patient”
(p.
491). Some (e.g., Bird,
1972) have argued that “countertransference” and ”transfer-
ence” are not meaningfully different concepts. Countertrans-
ference is merely the therapist’s transference to the client.
The problem with most of these dichotomies is that almost
all reactions of the therapist contain both objective and sub-
jective features, both reactions that are dependent on the
patient and reactions independent of him or her, both real-
istic reactions and fantastic-magical-conflict-ridden beliefs,
wishes, and emotions. My fear of Mr. C made me uncom-
fortable, and interfered with my ability to give him the deep-
est level of my attentive concentration. On the other hand,
Mr. C’s hostile engagement pattern was in part unconscious,
and
his
discovery and understanding of the way in which he
invoked fear in me, through my disclosure of the counter-
transference, appeared to be valuable to him. My own and
Mr.
C’s
awareness of my fear was both helpful to the later
treatment (in that he learned something of his effect on oth-
ers) and a hindrance to it (because it was distracting to me).
Similarly, having spoken to a few of Mr. C’s previous psy-
chotherapists,
I
found universal agreement on the subject that
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COUNTERTRANSFERENCE: DEFINITIONAL ISSUES
9
Mr.
C
was a frightening man, particularly for those who be-
came more closely involved with him. I therefore could claim
evidence that my reaction was objective. Yet I was reared in
a sheltered family enclave in a violent
and
riot-torn area,
where one family rule for dividing the bad guys from the
good guys was their use or nonuse of profanity. My parents’
daughter disapproved strongly of Mr.
C
and was frightened
by
his
sexually explicit and primitively violent speech. My
fear thus was both objective, in Winnocott’s
(1949)
sense of
being a reality-based reaction to the patient’s material and
presentation, and subjective, because of my classification of
Mr.
C
based on my own prejudicial (at least in part) reactions
to his use of language.
To
make the matter more complicated,
as I came to know him, Mr.
C
admitted that his language
was in part a conscious intimidation tactic.
If we were to use the transference-countertransference
models in the literature, we might also say that this is an
example of
an
aggressor-victim pattern (Davies
&
Frawley,
1994).
Mr.
C
identified with his violent parents, playing the
aggressor, and I countertransferentially played his prior role,
that of victim. Thus he let me know his feelings through a
repetition within the relationship.
In
this formulation, I re-
acted directly to the transference with my own countertrans-
ference. But, as the author of this narrative, I have free rein
to claim that the first irrational emotional reaction came from
Mr.
C,
not from me. After all, Mr.
C
was a labeled perpetrator
with a history of harassing therapists before he walked into
my office. Then again,
I
knew that before he came to me.
Perhaps mine was the opening invitation to play aggressor
to my victim. Perhaps my transference led to his counter-
reaction. If we reserve the label countertransference for re-
actions that are ”counter,” or reactions to the client’s trans-
ference, it thus is extremely difficult to classify a given
response.
I do not find objectionable, and in fact I applaud, the at-
tempts by other theorists to differentiate the objective from
the nonobjective and the neurotic from the healthy within the
therapist’s reactions.
I
also agree that the disentanglement of
the causal threads (who pulled what reaction out of whom)
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COUNTERTRANSFERENCE AND TRAUMA
is
a worthy endeavor in a therapeutic hour. What
I
challenge
is
the assumption-even for theory’s sake-that there are
pure cases of these types: purely objective emotional reac-
tions to the client, for instance, entirely free from the influ-
ence
of
the therapist’s prior history, conflicts, and biases.
I
disagree that it
is
typically useful to say that one emotional
reaction
is
”objective” and another is ”countertransference.”
Even
in
the largely objective case, such a dichotomy can blind
the therapist to the client’s claim that he or she too has a
piece of the truth.
It
is
important to acknowledge that the totalistic view of
countertransference
I
advocate-including all of the thera-
pist’s feelings and emotion-related behavior toward the client
-has been subjected to criticism from the time that Heimann
(1950)
introduced it. ”Such a sweeping definition of counter-
transference,” wrote Gorkin
(1987,
p.
13)’
”[has] obvious
problems, for unless one is prepared to categorize all of the
patient’s feelings and fantasies toward the therapist as trans-
ference, it would seem to make little linguistic sense to sub-
sume all of the therapist’s reactions under the rubric of coun-
tertransference.” True enough, but
I
would take a different
lesson from the statement than Gorkin wished to imply. Spe-
cifically,
I
would argue that, with the exception of purely
physiological or biologically based reactions of one individ-
ual to the presence of another, all human interactions are
based on interactions that come before and the conflicts
and
rewards that are associated with these relationships. This
is
a basic principle of learning. However, given our varied hu-
man experiences, some of the transferences we bring into the
therapeutic hour-those to a given personality presentation
or to a specific situation-will be consensual (shared
by
many or most in our culture) whereas others will be (rela-
tively) unique.
I
believe that, when most therapists speak of countertrans-
ference that is “objective” (cf. Winnicott,
1949)
or part of the
”real relationship” and not countertransference at all, they
typically mean that the feeling would be expected to occur
in most people confronted by the same stimulus. Winnicott’s
discussion, for example, centered on the internal ac-
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knowledgment and possible disclosure of countertransfer-
ence hate, most specifically when it is ”objective and justified
hate’’ (p.
72),
that is, a consensually agreed-on occasion for
hate. Of course, a consensual occasion for hostility also can
serve a purpose for a therapist or client with a uniquely de-
termined or conflict-based ax to grind. However, in making
the crucial decisions of whether the countertransference re-
sponse in question is a good source of information for the
patient about his or her own extratherapy relationships and
therefore appropriate for disclosure, it is the consensual-
unique rather than the
conflictual-nonconflictual
dimension
that is likely to be of most use. If most individuals will react
to the client (consensually) with fear, this will no doubt be
an interpersonal problem independent of why this
is
so.
If a
countertransference reaction is consensual rather than unique
to the psychotherapist, it is thus more likely to constitute
valuable information for the client.
Thus, it is my goal in this book to discuss the common
(consensual) countertransference responses to traumatized
patients.
I
hope to make them more recognizable, easier to
integrate into a treatment process, and less personally dis-
ruptive to the therapist. Furthermore, as a practical aid to the
clinician, I hope to provide a somewhat more sophisticated
lexicon for disclosure of countertransference when necessary.
I also hope to speak in a language that is equally applicable
to the psychodynamic, humanistic, and cognitive therapist-
a goal more easily met when countertransference is divorced
from its connection to infantile conflict.
I will consider as part of my definition of
traumatic
COUM-
tertrunsference
the following types of responses:
0
o
0
the characteristic attachment that the therapist feels and
displays toward the traumatized patient
the characteristic emotional reaction
in
the therapist to
common trauma transference dynamics
the actions taken by the therapist in trauma treatment
that have emotional significance to the client and
to
the
therapist in defining their relationship
the unique and conflict-based responses
of
the therapist
to trauma material.
0
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COUNTERTRANSFERENCE AND TRAUMA
Countertransference
and
Trauma
Although the literature on countertransference
is
broad, the
writings that are specific to the trauma therapist are much
more limited. Of great value have been
Treating the Adult
Sur-
vivor
of
Childhood Sexual Abuse:
A
Psychoanalytic Perspective,
(M.
Davies
&
Frawley, 1994),
Trauma
and
the Therapist: Coun-
tertransference and Vicarious Traumatization in Psychotherapy
with Incest Survivors
(Pearlman
&
Saakvitne, 1995), and
Coun-
tertransference
in
the Treatment of
PTSD
(Wilson
&
Lindy, 1994).
These texts are helpful, although they focus largely on vic-
tims of sexual abuse or incest and not (with the partial
exception of Wilson and Lindy) on the broader issues of
trauma.
But why
should
one focus on trauma victims in a book on
countertransference? The most obvious answer
is
that trauma
victims figure prominently in virtually every well-known
therapeutic dilemma or disaster associated with strong coun-
tertransference reactions. They appear to be overrepresented
among those who self-mutilate or commit suicide (Briere
&
Runtz, 1988; Himber,
1994)-at
times for reasons that are
later tied to countertransference errors (Modestin, 1987).
Trauma victims, particularly those who have received a
borderline-personality diagnosis or who were abused as chil-
dren, also show heightened tendencies to terminate therapy
early, to fail to attach to the therapist, or to act aggressively
in therapy (Briere, 1989; Gabbard
&
Wilkinson, 1994). Simi-
larly, their success rates in well-proven treatments for other
mental illnesses are lower than
is
found for clients who have
no history
of
trauma, leading to frustration and confusion in
the treating professional (Baider, Peretz,
&
De-Nour, 1997).
Trauma victims also are clearly overrepresented among cli-
ents who become involved in erotic attachments with their
therapists that end poorly-either in termination or in en-
actment (Bates
&
Brodsky, 1989; Collins, 1989). Mismanage-
ment of these transferences can put client
and
therapist alike
in psychic or physical danger (see chapters
6,
7, and
8).
The litany of difficult situations above suggests that the
trauma victim, by virtue of other symptoms that tend to oc-
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cur along with trauma history, will present the clinician with
more than the usual number of opportunities to sort through
difficult transference-countertransference interactions. There
is reason to believe that the traumatic transference often dif-
fers in form and character from the transference of other cli-
ents. This in itself is an important finding to explore (and
could well be related to the undesirable psychotherapy out-
comes cited above).
It
is not surprising that, given the complexities we are be-
ginning to touch on, traumatized patients report that their
therapists often disappoint or even betray them. One-quarter
of interview participants (patients with histories of child
abuse)
in
the Dale, Allen,
&
Measor
(1996)
study had expe-
rienced episodes of therapy that they rated as “making things
worse.”
In
the Trauma Countertransference Study described
on page
19
and in Appendix,
48
of
84
respondents stated that
they had experienced a ”serious betrayal” in psychotherapy
from one or more therapists. These ”betrayals” were frequent
both in successful and in unsuccessful therapies (as defined
in this case by client report). It was illuminating to me to
hear these descriptions of therapist failures, as well as the
descriptions of the therapists’ efforts, again with varying suc-
cess, to repair the breaches.
I
am deeply grateful to these
individuals for their generous contribution to my education.
Finally, as is discussed more deeply in chapter
3,
there is
good clinical and experimental evidence to suggest that ther-
apists often have countertransferential reactions to the
fact
of
trauma that are distinct from their feelings about the trau-
matized patient. The therapist’s pre-existing thoughts and be-
liefs about the trauma itself may affect the course of therapy
greatly.
Organization
of
the
Text
To
provide information that is valuable to the trauma thera-
pist, this text is organized along the lines of relational diffi-
culties common to traumatized populations and their inti-
mate others (including their therapists). The text begins with
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COUNTERTRANSFERENCE AND TRAUMA
a general argument in favor of countertransference disclosure
as a useful tool within trauma therapy (chapter
2).
Chapter
3
focuses on countertransference as a facilitator and
hin-
drance to client disclosures of trauma memories and there-
fore to their evaluations of those memories. In subsequent
chapters, major themes within the literature on traumatic
transference are tied to the parallel literature on traumatic
countertransference, as defined earlier.
The themes in traumatic transference include the follow-
ing:
By
definition, and given its unassimilable nature,
trauma attacks the coherence, reality-testing, and
worldview of the victim. As the therapist attempts to
fight the dissociation and to ”inhabit partially the pa-
tient’s inner world” (Briere, 1992,
p.
85),
he or she too
feels the threat to self-coherence. Anxiety is a frequent
reported response to other groups (e.g., psychotics)
whose reality-testing wavers under stress (e.g., Brody
&
Farber, 1996). The client’s struggle
to
determine what is
true and to live with uncertainty is examined in chapter
4, as
is
the countertransference response to the client’s
unconscious and conscious press for belief
or
disbelief.
The intensity of the traumatic transference, and thus, in
many cases, of the traumatic countertransference, can
overwhelm both participants. Herman (1992) referred to
traumatic transference as possessing a “life or death
quality [that is] unparalleled in ordinary therapeutic ex-
perience” (p. 136).
I
certainly agree. Further, the inten-
sity of the transference often feels coercive to the ther-
apist. He or she might blame the client (unfairly) for
this felt coercion, when it is less a conscious manipu-
lation than an outgrowth
of
the meeting of intense un-
met need with the human capacity for empathy.
The client’s and therapist’s desires to maintain a safe
and benevolent world lead them to wrestle jointly with
blame, shame, and responsibility in the relationship (cf.
Dalenberg
&
Jacobs, 1994). Therapy itself can be a
source of shame for the client, because it encourages
disclosure
of
unpleasant truths, and for the therapist,
who can feel as if he or she is placed in the role of
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prosecutor or character assassin for someone who came
for help and compassion (Josephs, 1995). Such issues are
discussed in chapter
5.
The likelihood that a client will accuse his or her ther-
apist of malfeasance is highlighted in virtually every
text on treatment of trauma. Spiegel and Spiegel (1978)
defined traumatic transference as occurring when “the
patient unconsciously expects that the therapist, despite
overt helpfulness and concern, will covertly exploit the
patient for his or her own narcissistic gratification” (p.
72).
For self-protection, the client often attacks or ac-
cuses, provoking understandably defensive responses
in the clinician. Thus, the therapist is confronted with
two
emotionally difficult dilemmas. First, the therapist
must manage his or her own countertransference anger
and counterhostility. Second, the therapist must some-
how retain a hold on his or her own true self
in
the face
of continued relational information that he or she is evil,
dangerous, or a potential abuser.
The accusations of malfeasance and incompetence at
times strike home to a therapist who is frightened
and
frustrated by the propensity for self-endangerment in
the traumatized client. The phenomenon of ”repetition
compulsion,” although
I
believe it to be misunderstood
in the scholarly literature on trauma, still represents a
pattern that is familiar and upsetting to any trauma
therapist. Continuing to care for an individual who is
constantly at risk of physical or psychic destruction
is enormously taxing and places the therapist at risk
for “compassion fatigue” and emotional exhaustion
(Stamm, 1995). Exhaustion and psychic disequilibrium
encourage acting out countertransference to protect the
self against these changes. These themes are addressed
in chapters
6
and
7.
Client ambivalence about attachment can be extremely
confusing and disheartening to the therapist, who is un-
accustomed to client experience
of
attachment as dan-
gerous and yet necessary for survival
(cf.
Waites, 1993).
This
quality, which often looks as though it were a com-
bination of an addiction and an allergy to closeness,
leads to rapid fluctuation in transference dynamics. The
therapist might find himself or herself in repeated
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COUNTERTRANSFERENCE AND TRAUMA
boundary negotiations, feeling besieged by requests for
intimacy one moment and accused of intrusion the next.
The issue of boundaries and the additional specific issue
of sexual transference and countertransference are dis-
cussed in chapter
8.
Chapter
9
addresses the resolution of trauma and issues
regarding termination in trauma therapy. What does it
mean, in the long run, to ”learn to live with” trauma
and tragedy?
Data Sources for the Present Discussion
of
Countertransf erence
Case
Studies
The data, theory, and clinical examples
I
offer in the chapters
that follow integrate a number of very distinct sources, some
of which have been underutilized.
As
is true for most texts
I
have read and admired,
I
use the accounts of my clients and
case studies provided by my colleagues. Verbatim dialogue
is
offered when it is available.
I
suspect that many readers
will see much complexity in the therapist and client ex-
changes.
Other case examples are taken from the hundreds of in-
dividual stories of physical, emotional, and sexual trauma
offered by research participants at the Trauma Research
In-
stitute (TRI) in La Jolla,
CA.
The similarities in the clients’
accounts (in their understanding,
in
their affective reactions
and transference, in the transference-countertransference
patterns) are explored here. The patterns are evidence for the
possibility of building a scientific framework for predicting
the consequences of trauma and the manifestations of those
consequences
in
psychotherapy.
As
a scientist,
I
welcome the discovery of similarities, hop-
ing
that they will line up neatly into theorems and ”laws”
that simplify our lives. The task of the therapist would be
less arduous
if
there were some regularity to the problematic
transference patterns, and the resultant countertransference
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patterns, that traumatized patients bring to therapy. If, in the
broadest sense, it could be discovered that the meaning as-
signed to trauma and the emotional responses to it are not
infinite, then a more fruitful and focused discussion of re-
sponses and patterns would be likely to emerge over time.
But then there are differences-error variance, the enemy
of statistical significance and hardworking researchers. Yet
differences
between
individuals highlight the potential of dif-
ferences that can take place
within
individuals. They give
emotional ammunition (perhaps faith) to the therapist in his
or her fight against the common client belief in the inevita-
bility
of
his or her own brand of pain. ”But anyone with my
background would feel
suicidal/worthless/violent,”
we hear
clients say. ”I cannot erase my past,
so
I cannot change my
emotional present.” But this version of the adage ”as the twig
is bent,
so
grows the tree” is as false for people as it is for
trees. Once the splint is removed, the twig bends and grows
toward the
sun.
Interpretations and conclusions drawn from
traumatic transference thus can change when the cognitive
and emotional environment changes. I hope that the client
and therapist accounts here will present the therapist with
more variability, and thus more flexibility, in response to
common trauma dynamics.
I
also should mention that
I
have deeply considered the
issues related to confidentiality in this text. With few excep-
tions, my own clients have seen the transcripts and sum-
maries used here. Many times, they commented in the text
on their histories or their views of our interactions. For client
protection, little demographic information is offered about
clients or TRI study participants other than the nature of the
trauma and the gender, age, and race of the client.
A
demo-
graphic summary is given in Table
1.1.
The clinical sample
consisted of
22
clients whom
I
have treated, and the research
sample (from the Trauma Countertransference Study)
in-
cluded
84
participants in an in-depth survey study of client
assessment of therapist countertransference during trauma
treatment. Table
1.1
also suggests my interest in providing a
range of patient traumas and related countertransference di-
lemmas for thoughtful examination.
In
the text, my clients
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COUNTERTRANSFERENCE AND TRAUMA
Table
1.1
Demographic Description
and
Source of Trauma: Clinical
and
TRI Countertransference Study Samples
Research Sample
Trauma
Race/Gender/Trauma Clinical Sample Countertransference Study
Black
White
Hispanic
Male
Female
Abuse
Rape- Assault
Traumatic loss
War
Other
3
15
4
10
12
10
3
5
2
2
9
62
13
22
62
41
13
16
7
7
are identified by letters (e.g., Client
M);
research study par-
ticipants have been given fictitious names.
Empirical Literature
Abstraction of general principles on the basis of clinical case
histories from a limited sample
of
psychologists is subject to
well-known
(if
frequently ignored) sources of error. If ever
the “ideal observer” were postulated to exist, certainly there
now
is
adequate evidence that he or she does not. Instead,
the picture has emerged of the personal historian (clinicians
included) as motivated by social
desirability-inappropri-
ately confident and often misled. The specific research arena
of countertransference is further complicated by the fact that
theory would suggest that the person telling the tale (often
the therapist) might be the individual least competent to do
so.
That
is,
because countertransference is by definition often
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unconscious, it is difficult to justify the assumption that the
dynamics will be well explained by the clinician who gen-
erated the experience.
In response to this challenge, at
TRI
we have attempted to
develop research paradigms and strategies that would sup-
plement the knowledge gained from clinician reports. These
include studies of the clinician and studies that use clients as
the historians of therapy progress. In clinician studies, we
often try to present the therapist with situations to which
they might react naturally in their therapist role, rather than
asking them what they might or might not do
in
a given
situation. For example, we might present the clinician with
realistic tapes
of
clients speaking to them, stopping the tape
at various points and asking for an immediate response.
In
client studies, we have conducted in-depth analysis of the
client’s view of the therapist, with particular attention to the
client’s view of hindrances and obstacles produced by ther-
apist countertransference. Additional samples provide ex-
amples of client disclosure style within differing trauma
types. A brief list of our research paradigms is given here.
Trauma Countertransference Study. Eighty-four clients,
who were participants in a larger questionnaire study,
were surveyed about experiences in therapy. Each person
had sought therapy for perceived trauma-related symp-
toms. Interviews focused on client perceptions of thera-
pists’ countertransference reactions to the clients’ trauma
as a help or hindrance to therapy. Further description of
the methods of this study is given
in
the Appendix, in-
cluding a list of interview questions. Results are dis-
cussed throughout this text.
Child Disclosure Study. More than
3000
tapes were
available for random selection from the vast library of
the Center for Child Protection in
San
Diego, California.
In
these tapes, children are questioned by expert foren-
sic interviewers regarding their memories and feelings
about recent experiences of sexual or physical abuse. This
research sample is a source
of
examples of interviewer
countertransference responses to traumatic material. Ma-
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COUNTERTRANSFERENCE AND TRAUMA
jor results of this project are discussed in chapter
3
and
4.
Sexual Countertransf erence Study.
Experienced and in-
experienced therapists listened to professional actors ex-
press sexual feelings toward therapists and responded to
the “clients” on tape. The therapists’ responses were then
rated by a client sample along perceived countertrans-
ference dimensions.
A
follow-up sample of clients who
had resolved or who had not resolved sexual transfer-
ence or countertransference issues was collected through
the Internet. Results and excerpts are discussed in chap-
ter
8.
Holocaust Remembrance Study.
Survivors of the Holo-
caust participated in one of
two
interviews, one focusing
on societal and interpersonal reactions they had experi-
enced in telling their stories, the other centered on
decision-making in communicating the story to their
children. Thirty participants have completed one of these
2-
to 4-hour interviews. Excerpts from these interviews
are included in chapter
3
and chapter
9.
Standards-of-Care Study.
A
series of surveys of profes-
sionals in the San Diego area assessed complex ethical
and treatment standards regarding clinical and boundary
issues and dilemmas. Topics covered included touch,
self-disclosure, and use of informed consent. Participants
were interviewed for
1-2
hours. The findings of the Stan-
dard of Care interview on touch are presented in chapter
8.
Participant-as-Teacher Study.
This experimental para-
digm was used to investigate the predictors
of
punitive
behavior toward children, particularly in those with
abuse history. Participants believe they are rewarding or
punishing a child in a nearby room (actually a tape)
through a computer as the child learns to spell.
As
the
”child” becomes increasingly provocative, the effect of
participant anger, shame, dissociation, and abuse history
on subsequent angry and punitive behavior by an au-
thority figure is measured. Results are discussed in chap-
ter
6.
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The empirical literature as it now exists is a mass of con-
flicting, largely atheoretical studies with differing and often
poorly articulated definitions of trauma and the damage it
breeds. Yet patterns emerge in careful examination of these
hundreds of books and articles. The distributions of findings
form an image, much as the clients’ stories create an image,
of reality. It
is
hoped that these pictures, taken from many
angles, might combine to create a hologram that is more ac-
curate, more comprehensive, and more helpful than the in-
formation provided using a single method. This book is writ-
ten to educate researcher and clinician to one another’s
discoveries and to encourage each to gain a bit more respect
for the difficulties inherent in the achievement of the other’s
professional goals.
In
moving back and forth between the
examinations of the empirical and theoretical literature on
signs and patterns in countertransference, theoretical under-
standing of these reactions, and case examples of successful
and unsuccessful resolution,
I
am mindful of Latts and Gel-
son’s
(1995)
empirical demonstration that both theory and
countertransference awareness are necessary to develop skills
for the management of countertransference.
A
Final
Word
on
Words
To
conclude
this
section, it is important to comment on the
use
of
the words ”victim” and ”survivor” throughout this
book. The ”Survivor Psalm,” written and used by trauma
victims at the Dimondale Clinic in Chicago, ends with the
words ”I was a victim;
I
am a survivor.”
Word choice is a matter of controversy in therapeutic cir-
cles. ”Victim” implies lack of control, helplessness, and lack
of power; “survivor” calls to mind strength, courage, and
invulnerability. The issues raised by those who challenge the
use of ”victim” are fair, but
I
argue that the usage is appro-
priate. It is crucial to ”empower” victims
of
trauma, allowing
them to recognize their infinite options. But this excellent
point-too long in coming to the trauma literature-should
not overshadow the reality of exploitation and harm.
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22
COUNTERTRANSFERENCE
AND
TRAUMA
I
remember
an
abusive father who also was uncomfortable
with the word and the concept of ”victim.” Disdainfully, he
spoke to
his
weeping son, whom he had humiliated
in
front
of family and therapist: ”You’ll survive,” he said. ”We all
survive.” The father meant, and later said, that he believed
his own abusive actions were justified and should not gen-
erate distress in his son or censure from his community. But
his son
was
his victim, and ”victim” and “survivor” are not
incompatible terms. Both capture a part of the picture, and
I
use
both of these important and accurate words.
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