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This article describes issues of countertransference in disaster psychiatry and makes use of specific examples from therapists working in the aftermath of the terrorist attacks of September 11, 2001.
Ethical dilemmas in end-of-life care, such as the request for assisted suicide, must be understood in the context of the relationship that exists between patients and the clinicians treating them. This context includes the way health professionals respond to the tasks in caring for a dying patient. This article reviews the literature exploring the factors the influence clinical decision making at the end of life. The interplay of ethics, countertransference and transference are explained in detail.
The final scenes of the failed marriage are replayed in the consulting room not only in the painful content of the verbal interactions but in the transference reactions of client and countertransference responses of clinician--material rooted in the current crisis as well as the developmental histories of the protagonists. The theoretical underpinnings of this broadened conception of transference/countertransference are discussed and its role in assessment and treatment is highlighted.
The relevance and validity of ethnocultural factors in transference and countertransference reactions are proposed. Some of those prevalent in dyadic psychotherapy are described, focusing on intra-ethnic and inter-ethnic dyads. Case vignettes are presented to illustrate the ways in which ethnocultural factors serve as catalysts for such major therapeutic issues as trust, ambivalence, anger, and acceptance of disparate parts of the self.
Group therapy is an essential component of the treatment of sexually abused children. Since the painful effects associated with the abuse are often dissociated or acted out, the group leaders learn of the affective experience of the abuse through the process of projective identification. The leaders must be aware of this process, set limits on the abusive acting out in the group, and help moderate, label, and empathize with the affect. It is through this difficult process that the children have a chance to reintegrate and work through their abuse experiences so they no longer feel compelled to act them out through repetitive abusive relationships. Specific leadership, countertransference, and projective identification issues in group therapy with sexually abused boys are discussed.
Subjective countertransference can sharply limit any group leader's effectiveness. However, a therapist can use the group itself to identify such a bias and to remove it as an influence. A five-step method for doing this is presented. These steps begin with introspection but hinge upon the analyst's turning to the group for the vital information that, in the end, clarifies the analyst's own perceptions and helps him or her free the group from the harmful effects of any bias.
This paper reviews and critiques the literature on countertransference (CT) in group psychotherapy. The literature review is organized within a framework that calls attention to the origins, triggers, manifestations, and effects of CT in groups, as well as CT management factors. An overriding critique is that the present literature lacks a research foundation of any kind. An argument is made for beginning research in this domain, and guidelines for doing so are presented.
Most of the literature on countertransference reactions with criminals has emphasized negative emotions such as hatred, rage, and fear. This article discusses reactions that have been relatively neglected, such as fascination and envy. Fantasies of leading a life of excitement are frequently evoked. Recognizing these fantasies and emotions and accepting them as attractive can increase our understanding of the offender and his life. The lure of criminality, despite its severe consequences, become more understandable. Accepting these emotions can bring a challenge to life, and a reevaluation of one's morals and values. A balance between the reality of "normal" life and fantasy is ultimately accepted.
In brief sex therapy rapid disappearance of symptoms may appear to signal success. However, superficial indications of success may be utilized by the sex therapist as an opportunity to escape from a therapeutic situation which evokes uncomfortable feelings. The need to terminate treatment abruptly may be conscious or unconscious. This presentation discusses a few of the multiple factors which may lead the therapist to initiate premature termination or to collude with the patient's problems rather than the patients' to alert clinicians to the adverse effects of countertransference.
Marital therapy for infidelity may bring up intense countertransference feelings in the therapist. Biases and identifications with one or the other spouse, moralism, and feelings of anger, helplessness, and hopelessness often surface while working with clients dealing with extramarital affairs. When the reactions are conscious they are less likely to interfere in the couple therapy, but when unconscious the work may be negatively affected. This article discusses some pitfalls in marital therapy with infidelity.
The study reported here revealed a very high incidence of unrecognized feelings toward the patient ("countertransference") and potentially harmful associated behaviors in a group of medical students at the midpoint of their training. Fifteen students were studied individually by the author during a clinical interview each student conducted with a patient. Typically, unrecognized feelings were fear of harming the patient, fear of loss of control, performance anxiety, and fears unique to the individual student (such as fear of cancer in self). One or more of these feelings were present in 14 of the students. Interview behaviors that were potentially deleterious were present in 13 students; avoidance and/or overcontrol of the psychosocial aspects of the interview accounted for 11 of these instances, while two students exhibited behaviors unique to the student. Although these students all had demonstrated adequate interviewing skills previously, the unrecognized feelings were, in each of the 13 instances, related to impaired interview performance. These data suggest the need for interviewing instructors to teach medical students about the concept of counter-transference in addition to interviewing techniques.
AIM: This paper discusses the emotional, cognitive and behavioural effects of self-injury on nurses as helpers, and shows the usefulness of a cycle that can affect care provision for this group of people. BACKGROUND: People self-injure for many different reasons, such as feeling angry, sad, guilty or frightened, and these emotions are often linked to feeling helpless, powerless or out of control. Self-injury has often been reported as a coping strategy to gain control. Psychoanalytic and cognitive behavioural concepts have been used to understand why people self-injure and also inform intervention strategies. Unfortunately, negative emotional responses in professionals may interfere with the effectiveness of any therapeutic relationship. DISCUSSION: Negative emotional responses from nurses can affect the way they think about and behave towards clients who self-injure. During clinical supervision or education, nurses' thoughts can be challenged to become less negative, so that their resulting behaviour can also become less punitive. Non-punitive or more positive behaviour can in turn challenge some of the negative self-beliefs of clients. CONCLUSIONS: Knowledge about countertransference when working with people who self-injure may reduce nurses' negative thoughts and behaviours, which may result in improved client care.
Uneasy feelings toward death and the dying are probably more universally shared than any others. The nature of countertransference toward the dying and the extent of its denial, which could constitute a hindrance to therapy, is explored. A questionnaire survey of professionals and a nonprofessional control group revealed no significant differences between the two groups. The need for additional training in this area for professionals is indicated.
In the treatment of patients with factitious disorder it is important to realize that at various levels of their experience these patients are more intimate with death than with life. This requires a particular awareness of resistance mechanisms to countertransference as well as of the importance of clinical procedures, in particular with regard to superego analysis. A requirement for establishing a psychotherapeutic alliance with patients suffering from factitious disorder is a high degree of 'therapeutic eros', hope and trust in one's own capabilities. The emphasis on a 'biophile attitude' does, however, involve the danger that the destructive potential, fantasies of death or killing, but above all feelings of guilt and shame are euphemistically interpreted and played down. A supportive superego analysis is viewed by the patient as playing down her or his 'terror of conscience' and a sense of being left alone. The therapist can be of greater help to the patient by focusing on his or her need and by escorting him or her. This requires that the therapist accept the feelings of relentlessness and hopelessness experienced by the patients in her- or himself. By relinquishing the denial of death-directed tendencies, the therapist is able to establish normality, reality and structure, and is thus in a position to exert a stabilizing effect, initially on her- or himself, but frequently also on the patient, for whom new horizons open.
The rational and irrational aspects of fear in the countertransference will be discussed. Arguments are presented for the potent force of fear in personality development and psychotherapy hitherto underemphasized in the literature. Manifestations of unacknowledged fear in clinical settings are identified and discussed. Recommendations are made for dealing with rational and irrational fears. These include supervision and interpretation in the case of irrational fear and effective security in the case of rational fear.
Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.
Countertransference among hospital staff was investigated as part of ongoing research on difficult-to-treat psychiatric hospital patients. Staff's ratings of their emotional reactions to 127 patients on long-term units were analyzed by factor analysis, and the resulting factors were correlated by discipline with patient problem behaviors. Among the conclusions were that different forms of psychopathology elicit characteristic patterns of emotional reaction from staff; that some dimensions of psychopathology, particularly suicidal-depressed behavior and violence-agitation, elicit different emotional reactions among different disciplines, thus laying the groundwork for division among staff; and that the more difficult the process of hospital treatment, the more likely staff will experience a variety of emotions.
Over the past decade the management of aggression on psychiatric units has generally focused on pharmacologic and physical interventions rather than on psychodynamic concerns. The author reviews the dynamics of violence and discusses how clinical staff's fantasies, countertransferences, and psychological defenses may interact to trigger patient aggression. Interventions that address these issues with staff include developing a cohesive treatment team in which clinical staff can express their feelings without the need to explore the psychodynamic underpinnings, having clinical leaders maintain a strong presence on the unit to serve as role models, and providing regular inservice training.