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Yet, in reality, it is this self-care, personal and professional, that ultimately is the most important not just for us, ... Paradox Of Providing Therapy? – PowerPoint PPT presentation

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  • Diane A. McKay, Psy.D., P.A.
  • 1845 Morrill Street
  • Sarasota, FL. 34236
  • (941) 365-7240

The Irony Of It All?
  • As therapists, we use our education, training,
    and skills to help our patients to live more
    rewarding and healthy lifestyles, independently.
  • Ironically, many of us are reluctant to offer
    ourselves the same kind of understanding and
  • Yet, in reality, it is this self-care, personal
    and professional, that ultimately is the most
    important not just for us, but for our patients.
  • It is possible that we are one of the few, if not
    the only profession, that does not purchase or
    utilize its own product?

  • Why is it so hard to attend to our own needs for
    nurturance, balance, and renewal?
  • External stressors
  • Perfectionism
  • Narcissism or a Narcissistically gratifying ideal
  • Another should to resist
  • Fear of criticism, judgment, or penalty.

Not Me!!!
  • Many factors influence the effects of stressors
    on individual therapists. Our personal history,
    developmental state, and personality as well as
    the potency of the individual or cumulative
    stressors, affect our susceptibility to stress.
  • An accumulation of stressors together in some
    critical mass (Kottler Hazler, 1997, p. 194)
    can conceivably happen to any psychotherapist in
    the course of a personal and professional
    lifetime and can knock even the physically and
    mentally healthiest of therapists off balance.

Emotional Overload/Depletion
  • We witness and vicariously experience a
    cumulative barrage of raw emotion.
  • Emotional overload or depletion is not disabling.
  • Can include many symptoms such as
  • disrupted sleep
  • depleted physical and mental energy
  • emotional withdrawal from family
  • less interest in socializing with friends
  • fantasies about mental health days or paid
  • fantasies about being taken care of.

Therapist Distress
  • Therapist distress describes conscious discomfort
    of suffering
  • Distress per se does not necessarily imply
    impairment (OConnor, 2001)
  • It might be seen or used as a warning signal
  • Has the potential to affect the quality of
    patient care
  • Many personal and professional sources
  • Over 60 of therapists reported having been
    seriously depressed at some point during their
  • Others experience marital/relationship
    difficulties, inadequate self-esteem, anxiety,
    and career concerns (Pope Tabachnick, 1994)

Work Related Distress
  • (National Survey by Pope Tabachnick, 1993)
  • Eighty percent reported feelings of fear, anger,
    and sexual arousal at various times in their work
  • Ninety-seven percent feared that a client would
    commit suicide
  • Almost 90 had felt anger at a client at some
  • Over half admitted to having been so concerned
    about a patient that their eating, sleeping, or
    concentration was affected.
  • Like their patients with a corresponding
    diagnosis, therapists exposed to a patients
    trauma can develop
  • emotional distancing or insensitivity
  • loss of trust in others
  • increased alcohol use
  • and/or ultimately burnout.

  • Terminal Phase of Therapist Distress
  • Freudenberger (1984) defined the term as a
    depletion or exhaustion of a persons mental and
    physical resources attributed to his/her
    prolonged, yet unsuccessful striving toward
    unrealistic expectations, internally or
    externally derived.
  • Symptoms include fatigue, frustration,
    disengagement, stress, depletion, helplessness,
    hopelessness, emotional drain, emotional
    exhaustion, and cynicism.

  • It is not my intent to be able to teach todays
    attendees how to care for themselves, personally
    and professionally, especially in less than one
  • It is also not my intent to provide an in-depth
    review of countertransference.
  • It is my HOPE that today by revisiting the
    concept of SELF-CARE, we create a renewed,
    positive, focus on its necessity throughout the
    lifespans of our careers and our personal lives.
  • Today, we readdress the elusive and conflictual
    issue of SELF-CARE, from a psychological
    perspective, regardless of our age, level of
    experience, orientation, and histories.

  • Stimulate and enable therapists, of all ages and
    stages, to develop and institute a conscious,
    ongoing practice of personal and professional
  • Advocate for the need and value of normalizing
    therapist self-care
  • Foster communication among therapists on the
    subject of self-care to help them confront the
    loneliness and isolation of working in the field
  • Organize and share information, resources, and
    various perspectives on the process of therapist
    self-care and thus to contribute to the evolving
    therapist self-care literature
  • Support ongoing education and research pertinent
    to therapist self-care.

  • Self-care is being widely discussed these days as
    a healthy and valuable process. The myriad of
    books available on the general market address the
    benefits of self-care, self-nurturance, and
  • Self-care is a responsible practice for all
    human beings and in disputably for those
    employed in the service and care of others, like
  • Self-care is a lifespan issue, personally and
    professionally, whatever your theoretical or
    clinical worldview.

Paradox Of Providing Therapy?
  • We are rewarded for our choice of profession in
    so many ways, from intellectual, emotional, and
    spiritual challenges to opportunities for
    personal growth, social status, and material
  • Nonetheless, our work is also intensely
    demanding, depressing, frustrating, terrifying,
    and even isolating at times.
  • The very pains and joys of human existence that
    our patients experience, we experience.
  • Most of us, when were honest or pressed, feel
    very human indeed.

Paradox Of Providing Therapy? (contd)
  • Masterful at helping others learn about and
    practice self-care, many of us struggle with
    conflicts and deterrents to our own self-care.
  • Each of us brings our own personal and
    professional history to the practice of
    self-care. This history can both help and
    complicate the process.

  • Isnt this seminar about the Assessment and
    Treatment of Sexual Offenders?
  • The simple answer is No one likes a sexual
    offender or the associated concepts.
  • There is universal agreement that this arena of
    behavior is the ultimate of taboos. That leads us
    to believe that working with this population is
    likely to be more challenging, creating a
    stronger need for self-care.
  • Regardless of the view of countertransference you
    subscribe to, therapy by its nature involves the
  • As the instrument of therapy, the therapist
    requires its own maintenance/self-care.

Traumatic Transference
  • The therapeutic relationship as a system includes
    the patient/therapeutic entity (couple, family,
    group) and the therapist. Therefore, one might
    conclude that in order for the therapist to have
    a countertransference, it must be triggered by
    some sort of stimuli, mainly the transference.
  • Herman (1992) defined Traumatic Transference as
    life or death quality unparalleled in ordinary
    therapy experience.
  • 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/her own narcissistic

Trauma Patient Data
  • Survivors of trauma figure prominently in
    virtually every well-known therapeutic dilemma or
    disaster associated with strong
    countertransference reactions.
  • They are over represented among those who
    self-mutilate or commit suicide (sometimes the
    reasons given suggest the event was related to
    countertransference errors).
  • Trauma survivors (especially those diagnosed with
    BPD or having been sexually abused as children)
    show higher tendencies
  • to terminate therapy early,
  • fail to attach to the therapist,
  • or to act aggressively in therapy.
  • Their success rates are also lower, even with
    well-proven treatments, leaving the therapists
    often frustrated and/or confused.

Trauma Patient Data (contd)
  • Trauma Survivors are also highly overrepresented
    among patients who become involved in erotic
    attachments with their therapists either ending
    in enactment or termination.
  • Trauma Patients reports include more likely to
  • be disappointed or even betrayed by therapists
  • experience episodes of therapy that they rate as
    making things worse.

Trauma Patient Data (contd)
  • The litany of difficult situations this suggests
    that by mere virtue of the symptoms that tend to
    occur with trauma history, the clinician will
    face more than the usual number and severity of
    opportunities to sort through difficult
    transference countertransference interactions.
  • There is reason to believe that the traumatic
    transference often differs in form and character
    from the transference of other patients.
  • Mismanagement of these transferences can place
    the therapist and patient in psychic and/or
    physical danger.

National Vietnam Readjustment Study
  • 40 of combat veterans engaged in violent acts 3
    or more times in previous year
  • One or more violent act per month was 5 Xs
    higher in the combat sample than in civilian
    control group.
  • 1997 study Childhood Sexual Abuse correlated to
    homicidal ideation, arrest, and violence against
    others (similar for physical abuse and neglect
    victims). This effect has also been noted in very
    young abused children.

Therapist Self-Care
  • Therapist Self-Care is a comprehensive and broad
    subject that benefits from a Broad-Based
    Theoretical Orientation which considers character
    development, symptom reduction, and coping
  • Responsible self-care is a complex, lifelong,
    trial and error process.

Theories Useful To The Process Of Self-care
  • Lifespan Development
  • Considering our own Developmental Stages and the
    changes across the lifespan, personally and
  • Exploring the benefits, opportunities, goal,
    challenges, risks, conflicts, crises, as well as
    the sequences and patterns of change,
  • Reflecting on the individual differences and the
    multidirectionality of change with age.
  • Self Psychology/Object Relations
  • The relationship with the self is core to
  • The structure and cohesion, along with
    development of the self, are important.

Theories Useful To The Process Of Self-care
  • Object Relations helps us to focus on the within
    and between self relations.
  • It provides a means of thinking about our
    relationships with the self and others.
  • It holds that interpersonal connectedness is
    essential for emotional health and reminds us
    that therapists, as well as patients, are
    affected by the experience of the relationship.
  • Winnicotts true self and good enough
    functioning and also valuable to this discussion.

3 Key Components of Self-Care
  • Self-Awareness (uncovering)
  • Self-Regulation (coping)
  • Balance (centering)
  • Despite the myriad of theoretical definitions of
    countertransference, all have one similarity
    It is the therapist who experiences it, first.

  • Awareness is a prelude to regulating our way of
    life, modifying behavior as needed.
  • It involves benign self-observation of our own
    physical and psychological experience to the
    degree possible without distortion or avoidance.
  • Only if we are aware of our needs and limitations
    can we consciously weigh our options in tending
    to those concerns, whether external or internal
    and whether related to personality, life state,
    or circumstance.
  • SELF-AWARENESS includes Countertransference

  • Without it, we risk acting out repressed (and
    thereby unprocessed and unmanaged) emotions and
    needs, in indirect, irresponsible, and
    potentially harmful ways that are costly to our
    self, personally and professionally, and to our
    patients, family, and others.
  • If unaware of our self needs and self dynamics,
    we may unconsciously and unintentionally neglect
    our patients or exploit them to meet our own
    needs for intimacy, esteem, or dominance.

  • Being self-aware is not always easy or pleasant.
  • It involves becoming conscious of our internal
    conflicts and the tensions that exist between our
    different kinds and levels of needs.
  • Sometimes the content of our impulses and
    feelings may seem very raw, primitive, and
    threatening to our view of our self.

Themes of Traumatic Transference/Countertransferen
  • Reality Testing and Doubt
  • Intensity of the countertransference The BLAME
    and SHAME game.
  • Malfeasance/Incompentency Accusations
  • Ambivalence about Attachment
  • Resolution and Termination
  • Anger and Manipulation are found throughout
    each theme, as well as in and of itself.

Reality Testing
  • Trauma by definition attacks the coherence,
    reality-testing, and worldview of the victim.
  • As the therapist attempts to fight the
    dissociation and to inhabit at least partially,
    the patients inner world he/she also feels the
    threat to self-coherence.
  • (Anxiety is a frequently reported response to
    groups whose reality-testing is under stress.)

  • Doubt Do you believe me? Feeling validated.
  • Desires to be a victim? Is it really that common?
  • What did and did not happen? The search for
  • Compounded by inability to trust ones own
    perceptions of reality.
  • Disbelief can alienate the therapist and patient.
  • Unbelievable Accounts of Trauma The press to
  • Empathic Doubt patient wants to be proven
  • Transference-Based Reactions VS. Reality Based

The Blame and Shame Game
  • Intensity of the countertransference
  • The stronger the intensity of the patients
    transference, the more likely the
    countertransference may overwhelm the therapist
  • This type of transference often feels coercive to
    the therapist and they may inadvertently, or
    unfairly, blame the patient. When it is less a
    conscious manipulation than an outgrowth of the
    meeting of intense unmet need with the human
    capacity for empathy.

The Blame and Shame Game
  • The patients and therapists desires to maintain
    a safe and benevolent world lead them to
    wrestle, simultaneously, with blame, shame, and
    responsibility in the relationship.
  • Therapy in and of itself
  • creates shame for the patient because it
    encourages disclosure of unpleasant truths
  • places the therapist in the role of prosecutor
    and character assassin for someone who came to
    them for help.

Malfeasance/Incompentency Accusations
  • Virtually every text on treatment of trauma
    highlights this area
  • The patient attacks or accuses for
    self-protection, provoking defensive responses in
    the therapist. Leaving the therapist with 2
  • manage their own countertransference anger and
  • retain a hold on his/her own true self in the
    face of continued relational information that he
    is evil, dangerous, or a potential danger.
  • Such attacks often hit home to a therapist who is
    frightened and frustrated by the propensity for
    self-endangerment in the traumatized patient.

Malfeasance/Incompentency Accusations (contd)
  • Repetition Compulsion continuing to care for
    a patient constantly at risk of physical and
    psychic destruction is taxing and places the
    therapist at risk for compassion fatigue and
    emotional exhaustion. This encourages therapist
    acting out to protect themselves.

Ambivalence about Attachment
  • Confusing and disheartening to the therapist, who
    is unaccustomed to the experience of attachment
    as dangerous and yet necessary for survival.
    It is the equivalent of an addiction and an
    allergy to closeness.
  • Leads to repeated boundary negotiations, as the
    therapist manages requests for intimacy at one
    moment and accusations of intrusion in the next.

Resolution and Termination
  • What does it mean to resolve trauma?
  • How do you really know when treatment is over?
  • Is the answer in understanding the treatment
    alliance and what it is and what purposes it is
    meant to serve?
  • Unrealistic expectations?
  • Resistance to saying Good-Bye, is it just the

Anger Perceived Manipulation
  • Anger, Rage, and Hostility is reported as a major
    problem in working with trauma patients.
    (Finkelhor et al. 1993)
  • The clearest countertransference pattern noted in
    the literature that is linked to patient anger
    and hostility is counterhostility.
  • Therapist anger, hatred, and hostile response to
    patients form one of the 2 emotional reactions
    most commonly discussed in the literature
  • The other is love and sexual feelings

  • Used in both behavioral and dynamic psychology,
    refers to the conscious and less conscious
    management of our physical and emotional
    impulses, drives, and anxieties.
  • Regulatory processes, such as relaxation,
    exercise, and diversion, help us maintain and
    restore our physiological and psychological
  • Our sense of well-being and esteem is closely
    related to the level of mastery of our
    self-regulation and impulse control skills.
    Difficulties in self-regulation often cause
    frustration of shame.

  • To regulate mood and affect
  • we must learn how to both proactively and
    constructively manage dysphoric affect (such as
    anxiety and depression)
  • AND
  • adaptively defuse or metabolize intense,
    charged emotional experience to lessen the risk
    of becoming emotionally flooded and overwhelmed
  • Adaptive modulation between different self or ego
    states is vital to the service of
  • A fine line may exist between stimulation that is
    nourishing and enriching AND stimulation that is
    overwhelming and stultifying.

  • Our goal is to learn what we need to do to keep
    our self selves on course to develop our own
    internal gyroscope.
  • Our ability to self-regulate increases when we
    are self-aware of our feelings, needs, and limits
    and when we practice managing dysphoria and
    intense emotions.

  • The Provision of Safety
  • Providing
  • a safe, therapeutic environment
  • is
  • a necessity in therapy.

TO disclose or NOT to Disclose?
  • Is the reason for disclosure appropriate?
    Relevant to the patients need to know and not
    therapists need for discharge affect, protect
    own ego, advance his own needs?
  • Are the method and timing of disclosure
    appropriate? Is the manner of disclosure
    perceived as information rather than an assault,
    mindful of patients ability to hear?
  • Is type of content or countertransference
    disclosure appropriate, responsive to patients
    needs, and unlikely to overwhelm patient?

4 Reasons to Disclose Anger/Hatred
  • Epstein (1977)
  • Winnicott demonstrates credibility and
  • Source of information regarding patients effect
    on other people
  • Diminish patients guilt and paranoia by making
    the apparent the ACTUAL impact of his/her own
  • Diminish the patients envy and establish
    therapists humanity (patient does not need to be
    alone in his/her susceptibility to hostility)

Dangers Of Disclosure
  • Leaking of therapist affect without therapist
    disclosure of true state
  • Unpredictable Emotions in an Attachment Figure
  • Hypervigilance Discovery of Therapist Emotions
  • Successful Therapist Suppression of Affective
  • Countertransference Suppression for the
    Therapists Psychic Health

Advantages Of Disclosure
  • Reinforcing patients reality testing functions
    and modeling the universality of Transference
  • Establishment of Therapists Honesty and
  • Establishment and Cementing of therapists
    involvement with the patient
  • Providing a source of information about the
  • Breaking an impasse or mending a
    countertransference-based enactment
  • Increased tolerance of the affect of others

  • A positive connection and relationship with our
    self, others, and the universe which serves as an
    antidote to the anxieties of the human condition.
  • Balance is essential in enabling us to tend our
    core needs and concerns, including those of the
    body, mind and spirit of the self in relation to
    others and in our personal and professional
    lives. Balancing can involve many factors, such
    as time, energy, and money.
  • The goal of balance is commonsensical, frequently
    cited advice. Its an ongoing process to learn,
    find, practice, maintain, and regain our balance.

BALANCE (contd)
  • A high level function involving modulation and
  • A search for the center on the continuum between
    the extremes
  • Deals with trade offs, costs and benefits, pros
    and cons
  • The reward for achieving it is HIGH a sense of
    mastery, esteem, and self-trust in a capacity to
    care for ones self.

  • We know that self-care is a healthy,
    self-respecting, mature process.
  • Appropriate self-consideration is a manifestation
    of a healthy respect for ones self and ones
    clients. It is, in turn, in the service of a
    robust, autonomous self.
  • We need to replenish if we are to share with
    others. We require both physical and
    psychological nourishment and rest to restore our
    well-being and to give what we want to give to
    our patients, as well as to the significant
    others in our lives.
  • Self-care thus is different from selfishness,
    self-absorption, or self-indulgence.

  • Self-preoccupation is, in fact, more likely to
    occur as a result of inadequate self-care over
  • Given the fine line between the therapists
    personal and professional self, self-denial or
    self-abnegation is neglectful not only of real
    self needs, but ultimately of patient care.
  • The reality is that therapists, as professionals
    and as human beings, have the right, and deserve,
    to share with ourselves the same time, care, and
    tenderness we extend to clients, family, and

  • Thank you!