Transference and Counter-Transference Issues in Supervision

Alexandra Katehakis, MFT, CSAT-S, CST-S, Founder and Clinical Director of Center for Healthy Sex presents a slideshow for the International Institute of Trauma and Addiction Professionals (IITAP) on getting the most out of supervision and addressing counter-transference.

Presentation Transcript

1. “I love you, I hate you”: Transference and Counter-transference Issues in Supervision Presented by Alexandra Katehakis, MFT, CSAT-S, CST-S February 17, 2011
2. What is supervision?
   • “Clinical supervision is a disciplined, tutorial process wherein principles are transformed into practical skills, with four overlapping foci: administrative, evaluative, clinical, and supportive.” -David J. Powell, 2004
3. Know your Candidate(s)
   • A productive Supervisor/Candidateworking relationship is grounded in a clear understanding of the goals of supervision and clearly worked out supervision plan.
   • Such a plan presupposes an accurate assessment of the Candidate’s knowledge and skills – the level of professional development the Candidate has attained.
   • “Clinical Supervision in Alcohol & Drug Abuse Counseling,” David J. Powell
4. Know your Candidate(s)
   • Know your ethics & get consultation!
   • Make sure you are clear about the law and ethics binding you and that the candidate is adhering to the law and ethics of the board that governs their license in the state they are in.
   • Seek your own consultation!
5. Supervision involves…
   • Four realms of inquiry:
   • Affective/Emotional/bodily
   • Cognitive/Behavioral
   • Insight
   • Systemic
6. Supervision involves…
   • Four systemic processes:
   • Patient
   • Self As Therapist
   • Treatment Process
   • Consultation Process
7. Sample Questions for Consultation Evaluation and Intervention
   • Affective/Emotional
   • Patient: How/Does this patient express emotions? If so, what is the patient feeling in their body? Where do they feel it?
   • Self as Therapist: How do you feel as you talk about this patient? What are you noticing in your body?
   • Treatment Process: How does the patient feel towards you?
   • Consultation Process: How do my reactions effect you?
8. Sample Questions for Consultation Evaluation and Intervention
   • Cognitive/Behavioral
   • Patient: What does the patient say and what are they thinking?
   • Self as Therapist: What interventions did you make with this patient?
   • Treatment Process: What did the patient do to prompt your choices or reaction?
   • Consultation Process: Can you describe what just happened between us?
9. Sample Questions for Consultation Evaluation and Intervention
   • Insight
   • Patient: What themes are apparent that help you understand this patient?
   • Self as Therapist: Does your reaction to this patient seem familiar to you? Are these bodily-based reactions?
   • Treatment Process: What approach is best for this patient?
   • Consultation Process: How is our relationship similar to othersin your life?
10. Questions for Sample Consultation Evaluation and Intervention
    • Systemic
    • Patient: What rules does this patient operate from?
    • Self as Therapist: What rules are you operating from when working with this patient? Do these rules assist or limit you?
    • Treatment Process: What rules guide the therapy relationship you have with this patient?
    • Consultation Process: What rules guide the work we do here?
    • Adapted from Piercy, F & Sprenkle, D. (1988). Family therapy theory-building questions. Journal of Marital & Family Therapy, 14, 307-309
11. Counter-transference
    • Freud 1910 – perceived it as emanating from therapist’s unresolved unconscious issues and conflicts deeming it potentially harmful to the therapeutic process. (Vulcan, 2009)
12. Counter-transference
    • Complex and mostly unconscious, making it difficult to measure and operationalize (Fauth, 2006)
    • CT is often thought of as thoughts, feelings, images, fantasies, and dreams. (Stone 2006)
13. The Moderate Approach to CT
    • Five domains can offer a framework for to review work with clients to “looking for evidence of counter-transference.
    • supervisors and counselor educators may find the model similarly helpful in teaching trainees how to identify counter-transference and use the self as a therapeutic instrument.
    • Hayes, et al (1998)
14. Moderate Approach for Managing CT
    • Origins: areas of unsolved conflict within the therapist.
    • Triggers: are the tangible counseling experiences that touch upon or elicit therapists’ unresolved issues.
    • Manifestations: When CT origins are triggered, therapists experience cognitive, affective, and behavioral reactions.
    • Hayes, et al., 1998
15. The Moderate Approach for Managing CT
    • CT effects are the subsequent results of CT manifestations on the therapy process and outcome.
    • CT Management refers to therapists’ strategies for coping with their CT
    • Rosenberger & Hayes, 2002
16. Counter-transference Issues in Sex Addiction Consultation
    • Minimization:
    • Upon initial assessment, sex addicts often minimize their thoughts and behaviors.
    • Watch for supervisees believing and/or siding with the minimization and challenge this as you would the patient. This can have the supervisee missing crucial acting out behaviors leaving them with a weak treatment plan.
    • It can also have them doubting whether the patient is really a sex addict.
17. Counter-transference Issues in Sex Addiction Consultation
    • Disgust:
    • Disgust can arise when assessing pedophiles or any other paraphelia that is disturbing or uncomfortable for the therapist to talk about.
    • Supervisees can report feeling “creeped out,” uncomfortable, or judgmental. It is recommended that these feelings be processed in detail so that an assessment can be made as to whether the therapist should continue to treat the patient.
    • If the therapist cannot work through their upset, they should be advised to take their deeper issues to their own personal therapy.
    • A sex addiction therapist should be ABLE to work with paraphelias, but has the right to CHOOSE not to.
18. Counter-transference Issues in Sex Addiction Consultation
    • Anger: “I don’t like him” and/or “I want to kill him!”
    • Passive/aggressive and narcissistic personalities are often difficult to like.
    • The supervisee has to be vigilant about their counter-transference.
    • Unchecked anger can lead to punitive interventions which can have the effect of shaming the patient. The therapist needs to talk openly about the triggers that block them from being empathic.
    • Supervisees should have a good understanding of narcissistic defenses and examine why they are recoiling or judging in the face of these defenses.
19. Counter-transference Issues in Sex Addiction Consultation
    • Argumentative/power struggle:
    • This is a no-win situation. Trying to convince, cajole, demand, etc. recovery leads to power struggles. If a patient is terribly resistant, doesn’t comply with treatment recommendations, or is a “general pain,” the therapist should step back and reevaluate why the patient is in recovery.
    • The therapist also needs to look at whether their treatment agenda is ahead of the patient’s or if they have fallen out of therapeutic alliance with the patient.
    • If the situation becomes intractable, both parties should seriously consider if treatment is right at this time. Should the therapist decide to end treatment, they should review their thoughts and reflections on the case with the supervisor first.
20. Counter-transference Issues in Sex Addiction Consultation
    • Patient admits to sexualizing the therapist:
    • It is not uncommon for sex addicts to sexualize their therapist. It usually comes out at some point in treatment either directly or indirectly. If it is not stated directly, but the supervisee has an inkling that it is occurring, they should talk about it with their consultant.
    • If it happens in early recovery, it is usually coming from an addictive/manipulative place in the addict. When the addict makes this known early on in treatment, it can be an inappropriate way to try and connect or a way to devalue the therapist due to discomfort or anxiety.
    • Therapists should be advised to “file” the information for processing when they feel the patient has made significant progress in their recovery.
21. Counter-transference Issues in Sex Addiction Consultation
    • Therapist is seduced by patient:
    • The patient can have the therapist feeling he is “such a nice guy”, “my favorite patient”, or “really trying hard.” If this happens early on the treatment, it is imperative to remember that our patients have “dark sides.” They are expert at looking good, rationalizing, minimizing, and justifying their behaviors.
    • If that same supervisee reports task work isn’t being completed, denial hasn’t been broken through (i.e. patient hasn’t owned up to the damage he has wrought), or the patient seems to be going through the motions, then they have to be confronted. This type of confrontation can bring up many issues for the therapist which may be why the seduction was happening to begin with.
22. Counter-transference Issues in Sex Addiction Consultation
    • Idealization as seduction:
    • If the therapist starts feeling or believing that “they’re the best therapist ever” they should be aware of idealization by the patient and talk about it.
    • This is especially true if the patient has had many therapists or has been through alot of treatment centers.
    • If the supervisee feels special or like they are the only therapist who will be able to help this patient, they’re in a trap. Believing this will have the therapist losing traction in the treatment process and give the addict ground for running treatment.
    • When this happens, the patient starts to decide whether and how many meetings to attend, what homework they will and won’t do, etc.
23. Therapist is Sexually Attracted to Patient
    • If the therapist finds their patient attractive they can find themselves struggling to stay on task, and/or it can have them engaging in covert seduction with the patient.
    • The therapist finds themselves feeling sleepy during sessions.
    • If they are not aware that they find the patient attractive, but find themselves doing things they wouldn’t normally do, then this too has to be examined.
    • Being attracted to the patient can have the therapist not holding boundaries with homework assignments or having blind spots in their recovery.
    • Either of these are ultimately harmful to the therapy and both parties. It is essential to talk about these attractions and if necessary, should be taken to personal therapy.
24. Sexualization by Therapist
    • Sexualization may defend against feelings of love which may be more difficult for therapists to acknowledge. (Gabbard, 1994)
    • Oedipal desire is romantic and idealised, whereas post-Oedipal desire tolerates imperfections, and can experiece disappointment without the death of desire. (Gerrad, 2004)
25. Deepening intimacy
    • Is crucial for successful work and occurs as a result of the interpersonal space between therapist and patient.
    • Termination requires a letting go of the patient and a kind of mourning so that the patient can go have his own healthy, adult sexual life. (Searles, 1959)
26. Erotic Counter-transference most likely to occur with patients who:
    • Have passive-obsessional and narcissistic character disorders.
    • Suffer from borderline and chronically psychotic conditions.
    • Those whose general character defenses and areas of specific conflict are similar to the therapist. The entangled transference- countertransference relationsip leads to the therapist withdrawing into sleepiness. (Stone, 2006)
27. Counter-transference Issues in Sex Addiction Consultation
    • Intellectual Seduction:
    • Since many of the addicts we see are extremely intelligent, accomplished professionals, therapists can be seduced into thinking that the person has really “gotten it” and that they are on track quickly. CEO’s, doctors, lawyers, and so forth are excellent at going to the top of the class.
    • Intellect is no measure of sexual sobriety. The supervisee should be reminded to look closely at the behavior and thinking of the patient first and foremost. Supervisees can be triggered into their own issues of feeling less than when in the presence of highly successful and/or powerful people.
    • The supervisee should know their triggers around intelligence, success, and money.
28. Counter-transference Issues in Sex Addiction Consultation
    • Humor as Seduction
    • We all know humor can be a defense against deeper, more painful feelings.
    • If a supervisee reports having a jolly good time with their patient and talks about what a “funny guy” he is, pay attention to how the humor is being used to keep the treatment off track.
    • This kind of humor can be a relief to the therapist if they are feeling anxiety about the work.
29. Flirting
    • Flirting need not be seen as a purely seductive act.
    • If it occurs in the symbolic, meaning change has actually occurred, it can be a type of play and an acknowledgement of attraction under safe conditions. (Davies 1998, Gerrard, 2004)
30. Counter-transference Issues in Sex Addiction Consultation
    • Rescuing or caretaking to the patient:
    • Therapists by nature are care-givers, but if they are inclined to care-take and have these issues in their backgrounds, they can easily fall prey to this dynamic.
    • Rescuing/caretaking can occur when someone is mandated to treatment and the therapist wants to advocate for the patient, or while the patient is preparing for disclosure.
    • Although it is, in part, the therapist’s job to advocate, be on the lookout for personal involvement in the outcome like wanting to “soften the blow” for the patient.
    • If the supervisee seems heavily invested in rescuing the addict from his consequences, and doesn’t see the consequences as a part of the addict’s unmanageability, this can be problematic.
    • Facing consequences are an essential part of the recovery process and it is not the therapist’s job to thwart those, but to assist the recovering person in their grieving process.
31. Counter-transference Issues in Sex Addiction Consultation
    • Siding with the patient:
    • This is similar to the above but is more blatant and often occurs in relation to the patient’s spouse.
    • Addict’s can villanize their partners and play the victim. If the supervisor hears the supervisee siding with the addict by validating all the hard work he is doing in recovery and agreeing that his spouse must be “crazy”, “not working a program”, and “unfair”, then this is a red flag.
    • It is crucial that the therapist be aware of partner issues and the natural evolution of recovery for a couple.
    • Rather then taking sides with the addict, the therapist should confront the addict about his unmanageability and what his part has been in his partner’s upset.
32. Counter-transference Issues in Sex Addiction Consultation
    • Impatience:
    • Therapists can get frustrated when their patient’s don’t move as quickly in their recovery as they would like them to.
    • Remembering to slow down and pace appropriately is a clinical skill. Each person has different cognitive and emotional skills and many sex addicts have a low emotional IQ.
    • Knowing when to put pressure on the patient to take responsibility for task work and feel their feelings, while at the same time having empathy for them is required to effectively execute treatment.
33. Counter-transference Issues in Sex Addiction Consultation
    • Flight into health:
    • Be wary of the “model prisoner.” This is a more advanced version of looking good. This is what they call a “Big Book Thumper” in AA. If the patient has become religious about 12-step and their recovery, it becomes more challenging to confront their denial and point out how they are using the program to hide out.
    • Conversely, the patient can be very compliant leaving the therapist feeling like their patient is a “piece of cake” and that the treatment is “smooth sailing.”
    • Challenge the supervisee to see the fear and seduction in this and how it does not serve the patient to collude with how well they’re doing. Look for the inconsistencies and holes in the person’s recovery. Challenge the flight into health.
34. Somatic Counter-transference
    • SCT can be thought of as “the therapists awareness of their own body, of sensations, images, impulses, feelings, and fantasies that offer a link to the client’s process and the intersubjective field. (Orbach & Carroll 2006)
35. Somatic Counter-transference
    • “The non-verbal behavior of both patient and analyst is an aspect of the analytic situation that receives comparatively little attention either in supervision or in the teachings of technique…it is uncommon for supervisors to regularly inquire about, or for students to regularly report on, the nonverbal behavior of their patients.” (Jacobs, 1994)
36. Somatic Counter-transference
    • Bodily-based, embodied knowing, embodied cognition.
    • SCT commonly includes sleepiness, erotic and sexual arousal, trembling (Field, 1998) as well as aches, pains, rumblings, coughing, nausea, and suffocation (Stone, 2006), tension, emptiness, and numbness.
    • Non-verbal, primary process.
37. Somatic Counter-transference
    • The therapist has to be aware of their own bodily-based reactions or be “rooted in a continuous awareness of their own somatic reality in the first place.” (Soth, 2002)
    • The “therapist body experience [may provide] invaluable information relating to the intersubjective space between therapist and client.” (Shaw, 2004)
38. Therapeutic Enactment
    • Sometimes the therapists past gets recreated in symmetry with the patient.
    • It can also happen as a result of counter-transference dominance, disrupting the treatment, and potentially traumatizing the patient.
    • Enactment is an “inevitable mutual event”.
    • Mutual unplanned behavior, a sense of puzzlement, and a sense of being emotionally out of control by both parties.
    • Maroda, 1998
39. Therapeutic Enactment
    • Most definitions agree that there are two essential elements: the stimulation of strong, unconscious affect and some resulting behaviors. Maroda 1998
40. Therapeutic Enactment
    • Differs from strong transference, counter-transference because it is “unconsciously motivated by the mutual stimulation of strong affect, with both persons usually stating that they felt out of control, or at least felt something come over them that was mysterious and powerful.” Maroda 1998
41. Neuropsychoanalytic model of patient-therapist enactments
    • Heightened affective moments in which overwhelming and thereby dissociated trauma is experienced by both members of the therapeutic dyad.
    • This highlights not only the resistances and defenses of the patient, but how these align with the resistances and defenses of the therapist.
    • Schore, 2011
42. Therapeutic Enactment
    • Patient’s transference will distort reality and imagine that the therapist feels toward her in the present what some other family member had felt toward her in the past.
    • They can also stimulate in the therapist the exact emotions they had experienced with someone else in the past.
    • Constructive expressions of these emotions and the mutual working through of the subsequent emotions and behaviors are crucial.
43. Feelings not within our control
    • Murderous rage
    • Sexual attraction
    • Anger
    • Overwhelming grief and a desire to physically hold or touch the patient
    • Envy
    • Deadness and not caring
44. Therapeutic Enactment
    • TE can take the form behaviorally as a heated argument, spontaneous hug, physical gesture, sadomasochistic exchange, shortening or lengthening of session, failure to collect fees, unexpected dissolution into tears, or a withdrawal into silence. (Maroda 1998)
    • This is a a right amygdala to right amygdala, and right insula to right insula communication, and pairs with dissociation.
    • It is a survival strategy.
    • BOTH parties have to control and limit their behaviors so the therapy can progress.
45. Therapeutic Enactment
    • The drama of the enactment ultimately belongs to the patient. It is his/her chance to relive the past from an affective standpoint, with a new opportunity for awareness and integration.
    • When the patient stimulates something real and primitive in the therapist that is split off, then they can relieve the drama in a real way together.
    • Maroda, 1998
46. Transparency
    • While the affect-laden enactment is inevitable, the therapists behavior should not be. (rage, erotic counter-transference, etc.)
    • Therapist should remain reasonably in control.
    • Admit what you are feeling and take responsibility for it.
    • Avoid extensive processing of your behavior.
    • Keep explanations brief and return the focus to the impact on the patient.
47. Transparency in action
    • Don’t blame the patient, accept what you feel which will give your greater control over your behavior.
    • Feelings should be related at the patient’s direction and behest so they are in control of the emotional action between them.
    • The interpersonal has to be addressed
    • Maroda, 1998
48. Therapeutic Enactment
    • T.E. is a dynamic, naturally occurring manifestation of the transference and counter-transference merging into a living entity, making the past alive in the present. (Maroda, 1998)
49. Therapeutic Enactment
    • The goal should be that more of the patient’s past is re-created than the therapists, and that the patient have every opportunity to safely work through the events within the boundary of the therapeutic relationship.
    • Therapists should expect enactments and be reasonably in control of how they behaves.
    • Maroda, 1998