Your Worst Counter-transference

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Good afternoon. This is my first post. I'm a psych grad, in my second year, started doing clinical work. I know, you might think it's late, but this is a pretty research oriented program I'm in. Anyhow, I'm glad I found this forum. For a number of reasons, I'm more comfortable talking about some of my experiences, with other grad students who are not necessarily in my program. So this forum seems like the right place.

Anyhow, what is your worst counter-transference? Mine so far has been to abusers whose abuse is not severe enough to warrant legal involvement yet significant enough that make me want to stop it. We have talked about how certain patients can be tough on certain therapists. So I'm aware of my own reaction. We talked about it in my small clinical class too, but I like to go into more details here, again, if this is allowed. Thank you, and have a good day.

Ridiculously attractive clients around my age range (working in a college counseling center provided some of these experiences) are the ones that I have the hardest time with. Usually I get nervous that they will sense it and it will be awkward.

Worst in terms of potentially affecting my ability to help them? Clients who remind me of myself. Attractive clients are a challenge as well. More so than violent offenders and the like.

Thank you for your contributions guys.

Yes, I mean in the sense the countertransference that interferes the most with you performing your job. So yes, if there's a surprisingly beautiful and flirtatious girl in the room and you're a red-blood young heterosexual man like myself, and if you're not deeply and madly in love with a pretty girl who is too good for you and just a dream come true, then I can understand how difficult that session with a pretty girl can be for you.

In any case, back to my own countertransference. It so happens that people who are abusive have often been abused themselves (not always the case of course), and you can see before your eyes how easily they are doing what has been done to them (at times worse than has been done to them) to another helpless person--usually a child who doesn't know better and couldn't do anything anyways if she knew better. The invalidation, the verbal abuse, all that, is too much. So if after seven or eight sessions, you can't control your rage during the session and you sort of raise your voice and say to the person something like "But he's just a child! Do you not know how damaging your behavior is? What kind of a mother are you?" then you know you've lost it. You know you've done horrible damage to the relationship. You apologize but it's too late. Because then the person goes into the victim mode and you know you're lost the rapport that you worked so hard to build.

p.s. the name I've chosen is a distorted reference to an episode of Frasier where he's trying to come up with a little catchy opening for his show: "If you can feel, I can heal."

Originally Posted by Iwillheal

p.s. the name I've chosen is a distorted reference to an episode of Frasier where he's trying to come up with a little catchy opening for his show: "If you can feel, I can heal."

I'm watching Frasier right now. Love that show!

...

Thank you Vasa, very helpful response. Speaking of the workshop about dealing with sexual predators and violent offenders with compassion, I think those experiences ought to be up there amongst therapists' most distressing counter-transferences. That the person at the workshop could deal with such people, with care and compassion, is commendable.

Talking specifically about active issues of counter-transference during training are best addressed with your supervisor(s), and not on an internet forum. There are process groups for professionals out in practice, though they are far more private than a public message board. There is always a risk of revealing too much identifying information on here, particularly when there is a need to talk about it.

Originally Posted by Therapist4Chnge

Talking specifically about active issues of counter-transference during training are best addressed with your supervisor(s), and not on an internet forum. There are process groups for professionals out in practice, though they are far more private than a public message board. There is always a risk of revealing too much identifying information on here, particularly when there is a need to talk about it.

I echo T4C on this issue. This is not the proper forum discussing clinical issues. This thread should be shut down ASAP.

Originally Posted by Therapist4Chnge

Talking specifically about active issues of counter-transference during training are best addressed with your supervisor(s), and not on an internet forum. There are process groups for professionals out in practice, though they are far more private than a public message board. There is always a risk of revealing too much identifying information on here, particularly when there is a need to talk about it.

I appreciate what you're suggesting but I did ask in my first post if such discussions would be permitted here. As far as confidentiality, I don't think there is a problem. Nobody knows what college I attend, I am not using a patient's name or age or any obvious identifying information. There are tens of thousands of people with history of abuse and seeing a therapist, so chances of someone knowing who I am seeing is probably one in ten thousand or something like that. Still, I respect your concerns as a moderator and do as you please. I do discuss active counter-transference with my supervisor but he is not always available, and in addition, given circumstances that I can't describe here, it is not as easy to discuss these matters with classmates in the clinical program, and I do want to share this to the extent that I feel I'm not alone in this and there are others who have difficulties dealing with certain patient populations, that's all. I would appreciate being given contact information for process groups that you mention, if you think that would be more appropriate. Thank you and have a good day.

Mod note: While it's okay to discuss *general* clinical and countertransference issues on this forum (e.g., "I have a difficult time working with sex offenders/clients I find attractive/people with severe medical issues/clients with BPD/etc") but you should NOT issues about *specific* clients (e.g., "I have this 20 year old client with MDD who I have a lot of countertranference because..."). If you have any questions about what is allowed or not allowed, please PM the mod staff or use the "report post" button,

Thanks!

Okay, without mentioning any identifying info about your clients, I would appreciate if others shared their own most distressing counter-transferences. Is it just to attractive clients, those who are abused but are abusing others (my case), Cluster B, addiction, psychosis, medical illness complicating the treatment....? And how do you deal with it--other than being aware of it when it happens, discussing it with supervisor, and seeing a therapist yourself? Rely on religion, philosophy, or literature to put it in context? Discuss it with other students/therapists?

Originally Posted by Iwillheal

Good afternoon. This is my first post. I'm a psych grad, in my second year, started doing clinical work. I know, you might think it's late, but this is a pretty research oriented program I'm in. Anyhow, I'm glad I found this forum. For a number of reasons, I'm more comfortable talking about some of my experiences, with other grad students who are not necessarily in my program. So this forum seems like the right place.

Anyhow, what is your worst counter-transference? Mine so far has been to abusers whose abuse is not severe enough to warrant legal involvement yet significant enough that make me want to stop it. We have talked about how certain patients can be tough on certain therapists. So I'm aware of my own reaction. We talked about it in my small clinical class too, but I like to go into more details here, again, if this is allowed. Thank you, and have a good day.

I'm glad to see that this is being discussed here - it's an important topic and as long as no identifying information is given, then I think it is very appropriate to discuss it openly and candidly.

My worst problems with counter transference have occurred with animal abusers (I simply *cannot* work with them), and with people with BPD. Of course, nobody really wants to treat people with BPD, so one sometimes is more or less stuck with them, although they usually can't maintain treatment for very long.

However:

Note that they can be extremely dangerous if they feel abandoned or mistreated in any way. I usually tell them that I feel that their issues are so complex that they need someone who is better than I am at sorting these things out - and I give them at least three names of people who apparently do not mind attempting to treat them.

It's very important to discuss counter transference issues with your supervisor, and, in many cases, with peer(s). It's also important to know when to refer patients to other practitioners, and it is NOT an admission of failure to do so, but rather a sign of clinical maturity.

Originally Posted by SHFWILF

It's also important to know when to refer patients to other practitioners, and it is NOT an admission of failure to do so, but rather a sign of clinical maturity.

This is a GREAT point.

This allows for an opportunity to discuss issues of counter-transference with your supervisor in a more meaningful way than just doing "hypothetical" situations. My first patient made it very difficult for me to view him as anything but an animal because because he would purposefully/constantly talk about how he enjoyed torturing small animals, abusing young children, stalking providers, etc. After discussing my reaction to his actions with my supervisor I realized that it was how he controlled people and ultimately avoided any significant treatment. It is easy to see now, but as a novice it was daunting.

My biggest struggle is with clients who won't do ANYTHING outside of session. I've seen it most often in those with borderline traits (i.e. the "you have to fix me" folks who are looking for a savior) though it isn't limited to them. I'm not talking about folks who just aren't somewhat lax in their completion of thought logs, but folks who will not even attempt anything, will not use any of the skills they are given, will continue to make the same mistakes over and over again against all reason and regardless of their in-session insight into it.

Even when I was little, I was always a fairly autonomous person. I dislike relying on others. Heck, I grew up in a fairly traditional family and learned to cook/clean/saw mainly because I didn't want to be completely reliant on someone else for basic household duties the way my parents are for many things. To just sit back and say "Help me" without doing anything to help myself is simply foreign to me. My second ever client was a multi-morbid individual with BPD, and while I had limited insight at the time, I was an absolute basket-case. I would be literally sick to my stomach on days I had to see her. I still find such clients frustrating, but have gotten far better and containing my reactions to it outside of sessions/supervision/clinical time.

Originally Posted by Ollie123

My biggest struggle is with clients who won't do ANYTHING outside of session.

My second ever client was a multi-morbid individual with BPD, and while I had limited insight at the time...

These are two types of cases EVERY graduate student should be REQUIRED to treat at some point during their training. Clinicans actively avoid seeing these types of cases, but I think it helps build your clinical skills far more effectively than seeing 100+ mild to moderately depressed pts. Some may even learn to love the challenge. Back when I had to do traditional therapy I would cherry-pick these cases. Cherry-picking cases was generally frowned upon by the out-pt clinic, but the team made an exception because no one wanted a caseload of Axis-II and "problem" cases.

Originally Posted by Ollie123

Even when I was little, I was always a fairly autonomous person. I dislike relying on others. Heck, I grew up in a fairly traditional family and learned to cook/clean/saw mainly because I didn't want to be completely reliant on someone else for basic household duties the way my parents are for many things. To just sit back and say "Help me" without doing anything to help myself is simply foreign to me.

I hope you realize that you are so well-adjusted because of your fantastic upbringing?! And further that people with so-called "borderline" personalities are not so lucky? I do think this is a problem that young students can get into, particularly those with stellar academic stats, because they are raised in such optimal environments and attribute their accomplishments to their own internal locus of control (their "special snowflakeness," if you will). I'm not attributing this to you, specifically, but really the young smart ones have a very steep learning curve when it comes to dealing with people who have had brutal upbringings.

Originally Posted by Psychadelic2012

I hope you realize that you are so well-adjusted because of your fantastic upbringing?! And further that people with so-called "borderline" personalities are not so lucky? I do think this is a problem that young students can get into, particularly those with stellar academic stats, because they are raised in such optimal environments and attribute their accomplishments to their own internal locus of control (their "special snowflakeness," if you will). I'm not attributing this to you, specifically, but really the young smart ones have a very steep learning curve when it comes to dealing with people who have had brutal upbringings.

And this is a big reason, at least in my opinion and from what I've heard, why many clinicians are averse to treating patients BPD (not saying it's the only reason, mind you).

Originally Posted by AcronymAllergy

And this is a big reason, at least in my opinion and from what I've heard, of why many clinicians are averse to treating patients BPD (not saying it's the only reason, mind you).

I think the reason is that they are more challenging, require more effort, and to do it well you need to have extensive training in DBT and/or similar approaches that often 'feel' counter to what you want to do.

There is, of course, the other end of the spectrum where clinicians have an overabundance of compassion/empathy/effort extended to these clients. They really, really, really want to help and believe they can be THE person to finally break through to the person with a diagnosis of BPD. That leads to poor boundaries and frustration.

Originally Posted by Psychadelic2012

I hope you realize that you are so well-adjusted because of your fantastic upbringing?! And further that people with so-called "borderline" personalities are not so lucky? I do think this is a problem that young students can get into, particularly those with stellar academic stats, because they are raised in such optimal environments and attribute their accomplishments to their own internal locus of control (their "special snowflakeness," if you will). I'm not attributing this to you, specifically, but really the young smart ones have a very steep learning curve when it comes to dealing with people who have had brutal upbringings.

My situation unquestionably plays a role (which is why I brought it up). I wasn't intending to attribute blame...simply that despite my best efforts I really struggle to relate to these people, struggle to empathize, etc.. The issue is that recognizing it does not do much to ease my frustration, and I'm constantly fighting to not place undue pressure on myself to "save" them.

Though I will note I find it equally fascinating your assumptions about our relevant upbringings. The most common place I have encountered this has actually been my higher SES clients, who had far more "advantages" than I did growing up - at least from an objective standpoint (of course, its always a complicated picture): more money, more resources, parents who were far more involved in their lives than mine were, etc.. That is also a big part of what has made it difficult for me to work with them. Their experiences were certainly different, but "brutal" is not the word I would use to describe them. I'm somewhat better when they are clients who really did have a rough time of it, since it is easier to see where their feelings of helplessness might come from, and their reluctance to put in work outside session when their environment may BE the primary source of distress gives me far more to relate to and work with.

Originally Posted by Ollie123

Though I will note I find it equally fascinating your assumptions about our relevant upbringings. The most common place I have encountered this has actually been my higher SES clients, who had far more "advantages" than I did growing up at least from an objective standpoint (of course, its always a complicated picture), parents who were far more involved in their lives than mine were, etc.. That is also a big part of what has made it difficult for me to work with them. Their experiences were certainly different, but "brutal" is certainly not the word I would use to describe them.

Point taken, although I wasn't intending to assign blame or assume. Optimal upbringings are certainly not equivalent to higher SES, although they could be...doesn't mean that means everything, though. The premise behind DBT, for example, in the conceptualization of borderline personality is the absense of validation, right? That can happen to anyone, regardless of status, although it's even harder to imagine when everything looks so good from the outside .

Oh absolutely not - I was just picking out the word "Brutal" since when we think borderline, many immediately leap to "Chaotic family, abuse, etc."...which is certainly a correlate, but BPD traits are in no way a guarantee that one came from that sort of environment. Of course, this is also why I made the point that it isn't limited to BPD - I've seen it run of the mill cases as well, and even for minor adjustment issues.

Basically - when I feel I'm working wayyyyyyy harder than the client is to try and help them, that's really the only situation I've encountered where I seem to have a strong reaction. Clients telling me about their violent crimes...meh. A bit of a reaction sure, but nothing I can't deal with. Its when we're 10 sessions in, talking about the same thing we talked about in session one, and not a thing we discuss is actually getting implemented that I start to really struggle.

My distressing counter-transference to parents abusing children (yet not sufficient abuse to be able to report them) has a central theme and that's about feeling helpless. It's about feeling helpless to help a helpless child. The few people who have trouble dealing with people who abuse animals may be feeling something similar, as both animals and children may not have the ability to protect themselves against certain kinds of abuse. Other posters have brought up BPD. What is it about that, that makes it very difficult to deal with? I mean what feelings, what central theme is there? I have yet to deal with a patient with that condition but based on what I've heard from others in my class, it brings up lots of conflicting emotions in the person, which is perhaps what the person with BPD is feeling herself.

Oh, and as far as BPD, and of course now, c-PTSD which tries to cover similar grounds, I think--based on my limited understanding/experience--that this is about a "fragile self" subjected to "traumatic experiences" over time, especially in earlier years. I think both are requirred. Because not everyone subjected to trauma develops BPD. They may develop PTSD. Or various phobias. The self must have been somewhat fragile to begin with.

Originally Posted by Iwillheal

Oh, and as far as BPD, and of course now, c-PTSD which tries to cover similar grounds, I think--based on my limited understanding/experience--that this is about a "fragile self" subjected to "traumatic experiences" over time, especially in earlier years. I think both are requirred. Because not everyone subjected to trauma develops BPD. They may develop PTSD. Or various phobias. The self must have been somewhat fragile to begin with.

I think there's a lot we don't know, especially since this idea of complex PTSD is relatively new and not totally accepted now. I think the idea is that a trauma is not a trauma is not a trauma. Complex traumatic symptoms, theoretically, occur based on highly conflicted feelings after an interpersonal trauma that is often long-term. I know what you're getting at with the "fragile self" thing, but it sounds too much like "weak" to me to be acceptable--as in, it's not just the inherently fragile that suffer after a life experience. As in, it's not something we're born with. Many factors at play here.

Thank you for your reply. I think certain events are traumas nearly universally while many others do depend on person and the context to a great extent, and so I agree with you there. As far as your comment on my use of "fragile self", I was not quite clear what you meant. When I say someone's "self" is fragile or, say, weak, I am not expressing any "negative" opinion. Some "selves" have more resources and are more resilient, and some are not. It's all relative. So a self that was fragile or weak, may have become even weaker as a result of very earlier experiences or because of the biological makeup or whatever. But that it is weak presently, is fact, in my opinion. There is no single trauma, beyond which that self is strong. There are too many weak points. A person with borderline personality is not psychotic but is more likely to experience psychosis than your "average" neurotic person. A person with PTSD, on the other hand, most likely experiences psychosis mainly in situations that somehow resemble the original trauma.

Originally Posted by Iwillheal

My distressing counter-transference to parents abusing children (yet not sufficient abuse to be able to report them) has a central theme and that's about feeling helpless. It's about feeling helpless to help a helpless child. The few people who have trouble dealing with people who abuse animals may be feeling something similar, as both animals and children may not have the ability to protect themselves against certain kinds of abuse. Other posters have brought up BPD. What is it about that, that makes it very difficult to deal with? I mean what feelings, what central theme is there? I have yet to deal with a patient with that condition but based on what I've heard from others in my class, it brings up lots of conflicting emotions in the person, which is perhaps what the person with BPD is feeling herself.

I work with people who have BPD (unlike Ollie, I like it ) and there are a lot of reasons. There is a lot of drama, first off, and you have a lot more reason to be concerned about legal matters like suicidality. Second, these patients often try to cross boundaries and it's easy for the clinician to let them. Third (and this is what I dislike the most) is that because of the splitting tendency, patients tend to love you one day and hate you the next. Early on, my favorite clients are always the ones with BPD, but then they end up being far more difficult than you think they'll be. This is due to splitting, but also because of the "apparent competence" that Linehan talks about which refers to patients with BPD seeming far more capable of coping and adaptive than they actually are--and that can throw you for a loop. Fourth, a lot of clinicians feel that people with BPD tend to be manipulative. I don't really see them that way and neither does Linehan, but it can sure feel like it at times.

What's really funny is that I only know one psychologist who will supervise me on these cases because the rest are like "Axis II, oh God no!"

Originally Posted by Iwillheal

As far as your comment on my use of "fragile self", I was not quite clear what you meant. When I say someone's "self" is fragile or, say, weak, I am not expressing any "negative" opinion. Some "selves" have more resources and are more resilient, and some are not. It's all relative. So a self that was fragile or weak, may have become even weaker as a result of very earlier experiences or because of the biological makeup or whatever. But that it is weak presently, is fact, in my opinion. There is no single trauma, beyond which that self is strong. There are too many weak points. A person with borderline personality is not psychotic but is more likely to experience psychosis than your "average" neurotic person. A person with PTSD, on the other hand, most likely experiences psychosis mainly in situations that somehow resemble the original trauma.

I just mean that you (and the field in general) need to be clear with the language. "Fragile" needs to be operationally defined. Fragile or weak, how? What are you referring to--SES, validation, anxiety, some biological or neuorological deficit, etc.? As professionals, we need to do this and not just talk in wide sweeping language that can't be measured.

I'm not familiar with the statement you made about people with BPD or PTSD experiencing psychosis. Again, are you literally talking about psychosis? If so, what exactly--delusions, hallucinations? Of what kind? Or, are you talking about flashbacks or dissocation (which are not psychosis)? I really hope you're not confusing PTSD symptoms with psychotic hallucinations or paranoid delusions.

Originally Posted by cara susanna

What's really funny is that I only know one psychologist who will supervise me on these cases because the rest are like "Axis II, oh God no!"

I've had the same experience. We've had clients who would have been refused b/c no one else would accept them because they were diagnosed with BPD or had borderline traits. And then we had difficulty finding supervision for the cases.

Originally Posted by Psychadelic2012

I just mean that you (and the field in general) need to be clear with the language. "Fragile" needs to be operationally defined. Fragile or weak, how? What are you referring to--SES, validation, anxiety, some biological or neuorological deficit, etc.? As professionals, we need to do this and not just talk in wide sweeping language that can't be measured.

I agree with this. If one considers a person "fragile/weak" due to limited resources, then one needs to be specific about this due to reasons x, y, or z that we actually know about with information we've gathered from that person's history; not make assumptions based solely upon the person's diagnosis or because well it's know that some people are weaker and some people stronger.

I'm not familiar with the statement you made about people with BPD or PTSD experiencing psychosis. Again, are you literally talking about psychosis? If so, what exactly--delusions, hallucinations? Of what kind? Or, are you talking about flashbacks or dissocation (which are not psychosis)? I really hope you're not confusing PTSD symptoms with psychotic hallucinations or paranoid delusions.

I also was a bit confused about this, and I've worked with both BPD/PTSD clients and worked on PTSD research for years. I'd love to hear the elaboration re: psychosis?

Psychadelic, thank you, yes, it's clear to me now. I was using the term "fragile" and "weak" in a vague manner. I do that sometimes, and thank you for bringing it to my attention. I was speaking mostly in terms of anxiety and sense of identity (ego). But of course the operational definition would need to be more specific.

As far as my reference to psychosis, I'm a bit surprised you're not familiar with that. I have not confused PTSD with BPD. I was under the impression that it's common knowledge that a person with BPD is more prone to psychotic breaks from reality than a neurotic person. In other words, given that a person with BPD has a more fragile sense of identity--or maybe I should say a more fragmented sense of identity--then compared to your "normal" or neurotic person, it is more likely that during an intense therapy session they may experience a psychotic break. That is why certain forms of therapy such as psychoanalytic psychotherapy may not be the best idea for a person with BPD.

What do I mean by "psychotic break"? Lets say...the delusion that the therapist is in love with this person and wants to marry them. Or hates them. A belief that despite therapist's reassurance, does not go away; it stays with them for a long while. The patient is very certain of this belief. It's not a possibility, it's the truth, in his mind. Etc

p.s. I realize I'm moving away from the main topic of the thread, so I'll try to get back on track...

Originally Posted by cara susanna

....because of the "apparent competence" that Linehan talks about which refers to patients with BPD seeming far more capable of coping and adaptive than they actually are--and that can throw you for a loop.

Yes, I've heard about that from my supervisor. I have yet to see a BPD patient but this aspect of it has intrigued me the most. How could someone who has all these problems, the anxieties, the relationship difficulties, the rage and emotional instability, how could such a person come off being more adaptive and competent than they really are. I mean shouldn't it be just the opposite?

People with BPD are prone to paranoid ideation under extreme stress. I've witnessed it.

Iwillheal: Linehan thinks it's because people with BPD tend to do okay when the environment isn't that stressful. It's when things become stressful that they tend to fall apart.

Paranoid ideation, yes. I'm fine with and seen this. And I've known that there are individuals with BPD who experience delusions, hallucinations, etc., but I'm not sure iwillheal was saying this was characteristic of the disorder itself or more of a sometimes associated symptomology found with it?

Originally Posted by cara susanna

I work with people who have BPD (unlike Ollie, I like it ) and there are a lot of reasons. There is a lot of drama, first off, and you have a lot more reason to be concerned about legal matters like suicidality. Second, these patients often try to cross boundaries and it's easy for the clinician to let them. Third (and this is what I dislike the most) is that because of the splitting tendency, patients tend to love you one day and hate you the next. Early on, my favorite clients are always the ones with BPD, but then they end up being far more difficult than you think they'll be. This is due to splitting, but also because of the "apparent competence" that Linehan talks about which refers to patients with BPD seeming far more capable of coping and adaptive than they actually are--and that can throw you for a loop. Fourth, a lot of clinicians feel that people with BPD tend to be manipulative. I don't really see them that way and neither does Linehan, but it can sure feel like it at times.

What's really funny is that I only know one psychologist who will supervise me on these cases because the rest are like "Axis II, oh God no!"

We do research on BPD as well. I haven't noticed the manipulativeness either, but they do tend to be drastic in avoiding abandonment (e.g. threatening their lives, engaging in self-harm/cutting if they feel a relationships ending or whatnot). But the chronic feelings of "emptiness", the impulsiveness criteria, and the anger criteria are usually spot on. Also highly comorbid with depression and I always have trouble figuring out if they have always felt depressed or whether there are distinct periods when they feel better.

Anyways, I also had the experience of having a very attractive person around my age come in for a day of testing, which involved a 3 hour interview by myself.

Originally Posted by deadmau5

We do research on BPD as well. I haven't noticed the manipulativeness either, but they do tend to be drastic in avoiding abandonment (e.g. threatening their lives, engaging in self-harm/cutting if they feel a relationships ending or whatnot). But the chronic feelings of "emptiness", the impulsiveness criteria, and the anger criteria are usually spot on. Also highly comorbid with depression and I always have trouble figuring out if they have always felt depressed or whether there are distinct periods when they feel better.

Anyways, I also had the experience of having a very attractive person around my age come in for a day of testing, which involved a 3 hour interview by myself.

LOL, I've had a very attractive BPD patient around my age for therapy when I was an intern. That case dominated my use of supervision during the year, that's for sure. My boundaries are now rock solid.

Being able to set and maintain solid boundaries is a great skill to acquire early on in training because you may not see great examples once you get out 'in the real world.' Most psychologists I know seem to have pretty good boundaries, but this isn't the case for all providers.