COUNTERTRANSFERENCE AND
THERAPIST SELF-CARE
Diane A. McKay, Psy.D., P.A.
1845 Morrill Street
Sarasota, FL. 34236
(941) 365-7240
The Irony Of It All?
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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 care.
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?
Resistance?
 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
vacation
 fantasies about being taken care of.
Therapist Distress
 Therapist distress describes conscious discomfort of
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suffering
Distress “per se does not necessarily imply
impairment” (O’Connor, 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 career
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 point
 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 patient’s trauma can develop
 emotional distancing or insensitivity
 loss of trust in others
 increased alcohol use
 and/or ultimately burnout.
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Burnout
 Terminal Phase of Therapist Distress
 Freudenberger (1984) defined the term as “a
depletion or exhaustion of a person’s 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.
PURPOSE FOR PRESENTATION
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It is not my intent to be able to teach today’s
attendees how to care for themselves, personally
and professionally, especially in less than one hour.
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.
OBJECTIVES
 Stimulate and enable therapists, of all ages and
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stages, to develop and institute a conscious, ongoing
practice of personal and professional self-care
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 selfcare and thus to contribute to the evolving therapist
self-care literature
Support ongoing education and research pertinent to
therapist self-care.
SELF-CARE AS A CONCEPT
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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 selfnourishment.
Self-care is a responsible practice – for all human
beings – and in disputably for those employed in the
service and care of others, like psychology.
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 success.
 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 we’re honest or pressed, feel very
human indeed.
Paradox Of Providing Therapy?
(cont’d)
 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.
WHY TODAY?
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Isn’t 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
therapist.
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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 gratification”.
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 (cont’d)
 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 (cont’d)
 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 X’s
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
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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
strategies.
*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
professionally.
 Exploring the benefits, opportunities, goal,
challenges, risks, conflicts, crises, as well as the
sequences and patterns of change, experienced.
 Reflecting on the individual differences and the
multidirectionality of change with age.
 Self Psychology/Object Relations
 The relationship with the self is core to self-care.
 The structure and cohesion, along with development
of the self, are important.
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Theories Useful To The Process Of
Self-care (cont’d)
 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.
 Winnicott’s “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.
SELF-AWARENESS
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“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
SELF-AWARENESS (cont’d)
 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.
SELF-AWARENESS (cont’d)
 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/Countertransference
 Reality Testing and Doubt
 Intensity of the countertransference: The BLAME
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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 patient’s 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
 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 reality.
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Compounded by inability to trust one’s own
perceptions of reality.
Disbelief can alienate the therapist and patient.
Unbelievable Accounts of Trauma: The press to
disbelieve.
Empathic Doubt – patient wants to be proven wrong?
Transference-Based Reactions VS. Reality Based
Reactions
The Blame and Shame Game
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Intensity of the countertransference
The stronger the intensity of the patient’s
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 patient’s and therapist’s 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.
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Malfeasance/Incompentency
Accusations
Virtually every text on treatment of trauma
highlights this area
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The patient attacks or accuses for self-protection,
provoking defensive responses in the therapist.
Leaving the therapist with 2 dilemmas:
 manage their own countertransference anger
and counterhostility
 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 selfendangerment in the traumatized patient.
Malfeasance/Incompentency
Accusations (cont’d)
 “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
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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
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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
patient?
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
SELF-REGULATION
 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 equilibrium.
 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.
SELF-REGULATION (cont’d)
 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 self-integration
 A fine line may exist between stimulation that is
nourishing and enriching AND stimulation that is
overwhelming and stultifying.
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SELF-REGULATION (continued)
 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.
FIRST, DO NO HARM
*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 patient’s need to know and not therapist’s 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 patient’s ability to
hear?
 Is type of content or countertransference disclosure
appropriate, responsive to patient’s needs, and
unlikely to overwhelm patient?
4 Reasons to Disclose Anger/Hatred
 Epstein (1977)
 Winnicott – demonstrates credibility and
genuineness
 Source of information regarding patient’s
effect on other people
 Diminish patient’s guilt and paranoia by
making the apparent the ACTUAL impact of
his/her own behavior
 Diminish the patient’s envy and establish
therapist’s humanity (patient does not need to
be alone in his/her susceptibility to hostility)
Dangers Of Disclosure
 Leaking of therapist affect without therapist
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disclosure of true state
Unpredictable Emotions in an Attachment Figure
Hypervigilance Discovery of Therapist Emotions
Successful Therapist Suppression of Affective
Display
Countertransference Suppression for the Therapist’s
Psychic Health
Advantages Of Disclosure
 Reinforcing patient’s reality testing functions and
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modeling the universality of Transference
Establishment of Therapist’s Honesty and
Genuineness
Establishment and Cementing of therapist’s
involvement with the patient
Providing a source of information about the patient
Breaking an impasse or mending a
countertransference-based enactment
Increased tolerance of the affect of others
BALANCE
 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. It’s an ongoing process to learn, find,
practice, maintain, and regain our balance.
BALANCE (cont’d)
 A high level function involving modulation and
oscillation
 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 one’s self.
CONCLUSION
 We know that self-care is a healthy, self-respecting,
mature process.
 Appropriate self-consideration is a manifestation of a
healthy respect for one’s self and one’s 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, selfabsorption, or self-indulgence.
CONCLUSION
 Self-preoccupation is, in fact, more likely to occur as
a result of inadequate self-care over time.
 Given the fine line between the therapist’s 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 friends.
THE END
Thank you!