Countertransference 101
Over at Maggie's Farm, Dr. Bliss feels badly for a Baylor psychiatric resident who has a dilemma; she is attracted to her patient. Oddly enough, she is told by her supervisor that she is the only resident the supervisor has seen with this problem:
The therapist/patient attraction is psych 101. It's generally covered in supervision on counter-transference issues the first year of doing therapy, at least it was in my experience getting a PhD in psychology. Too bad this psychiatric resident wasn't prepared in advance--it would have helped her to deal with the situation without the guilt and anguish. Perhaps that is the difference between psychiatric training in preparing for the MD and psychological training for the PhD--the human component might be emphasized more for the PhD, both for the therapist and the patient.
“I think you need to take this one to Dr Gabbard. I have never seen a resident with this problem before.” “Never!?” I thought, “I’m the only one!?” I worried incessantly about what was wrong with me to feel so incapacitated, unable to feel in control of the therapy in this particular case. I kept thinking in circular fashion, “I should not have this problem. I must stop it. I can’t stop it. I should not have this problem”—and on and on.
The therapist/patient attraction is psych 101. It's generally covered in supervision on counter-transference issues the first year of doing therapy, at least it was in my experience getting a PhD in psychology. Too bad this psychiatric resident wasn't prepared in advance--it would have helped her to deal with the situation without the guilt and anguish. Perhaps that is the difference between psychiatric training in preparing for the MD and psychological training for the PhD--the human component might be emphasized more for the PhD, both for the therapist and the patient.
Labels: psychiatry, psychology, therapy
posted by Helen at 6:24 AM
29 Comments:
I am not a psychologist/psychiatrist, so here is my question, borne of total ignorance.
Shouldn't a person entering this profession, know better than to get involved with a patient? Seems like it would be a common sense knowledge.
Danny,
It is common knowledge--and therapists know not to do it, typically. However, being attracted to certain patients sometimes happens and the idea is for the supervisor to assist the trainee in understanding that the feelings are normal and how to cope with it without acting on it. If the therapist does not address the feelings, they can become overwhelming or cause anxiety and guilt as the Baylor resident mentioned, and can in turn, interfere with the therapy. The main goal is to help the patient progress and it is hard to do so, if the therapist does not acknowledge their own feelings, thoughts etc. in supervision. Certainly, in some cases, if the therapist cannot overcome their feelings, they should transfer the patient to another provider.
It would seem that "The Impossibility of Sex" by Suzie Orbach would be relevant.
It is also bad if, knowing the attractions are possible, the therapist manipulates the situation to exploit the patient.
This can be for sex, or for keeping the patient in repeat business.
I know this may be a bit off topic but after reading the original article why is this man in therapy? He found letters between his wife and another man? The therapist should have recommended a good divorce lawyer!
No previous case of an erotic counter transference? Dude was not well trained enough to ask about it.
I recall a patient I worked with for a brief time. She was an underwear model. Yep, she was smoking. She presented with a history of sexual abuse and relationship problems. She had a same age boyfriend she loved and a couple of sugar daddies that she needed. We exchanged cards after the first visit and I started doing some paperwork after she left the office.
But I could not get her off my mind. It was like I could smell her, as if she was sitting on my lap! And she had left the office 20 minutes ago. Sadly, I knew what had to be done. I had to call my supervisor and find a transfer for her. I mean, usually you can work through these feelings, but I was hallucinating her smell, so I just needed to find her someone else to work with.
My supervisor was out, so I decided to call the young lady myself and tell her that she was being transfered to see another therapist who had more experience working with her issues. But I could not find her phone number in my notes, then I remembered. She had given me her card!
I took it out of my shirt pocket and smelled the perfuse it had liberally been dosed with! I wasn't hallucinating her smell, I was smelling her business card! I wasn't nuts, she was just used to leaving men quivering with desire in her wake and knew how to do it!
I still called my supervisor, we had a good laugh. And the patient got much better.
But since I had training about erotic counter transference, I knew what to do. Or at least I thought I did. 8)
Trey
Sexual attraction is something that cannot be turned on and off at will. At least with men, we will always notice an attractive woman and our behavior will change in response to that attraction. In most situations this attraction can be contained through various boundaries.
For example, if you are a businessman with an attractive young secretary, it is probably not wise to travel and have dinner alone with her if you wish to maintain a professional relationship. Despite his best intentions, his natural impulses, unless checked, will lead to an affair.
The problem with therapy is that the discussion may lead into topics that are typically private and emotional. It is difficult for a man and a woman to discuss such matters and remain professional if there is an underlying sexual attraction.
A hypothetical example - the girl that cuts my hair is young and attractive. But as we discuss things such as the weather and the news topics of the day, the relationship never has a chance to become improper. However, if we were to discuss our intimate and sexual feelings, the chance of the relationship going beyond the professional would be greatly enhanced.
As much therapy (not all) is based on intense feelings, I would argue that it might be wise to limit the situations in which the therapist and the client are of the opposite sex.
It sounds to me as if Dr. Raymer handled the situation about as well as one could expect, especially as she is early in her career. I agree with Maggie that her supervisor was not helpful, though I saw her response more as lacking insight, than being cold.
I have read numerous books on therapy, and known many therapists, and have to say that both show a lot of blindness about human emotions. Specifically, patients' feelings for therapists are categerized as transference, and therapists' feelings for patients are categorized as counter-transference. In both cases, the assumption is that the person with the feelings is transferring to the the other person some feelings that originate in another relationship.
While I don't doubt that both transference and counter-transference happen, labeling all feelings that patients and therapists have about each other as a kind of transference is ridiculous. Patients and therapists are perfectly capable of having authentic feelings about each other, i.e. feelings that make sense, given who they are. Someone who thinks, "My therapist is a jerk," or "My patient is a really appealing person," may well be responding to the other as he or she is, not as a stand-in for another person.
I think the blindness towards authentic feelings in therapeutic relationships serves as a defense mechanism for therapists. Life is easier for them, if they can label all feelings in that relationship as transference. For therapists to acknowledge that they strongly like or dislike their patients, or vice versa, because of who they both are, is frightening. It removes the appearance of control that labels provide, and strips away the protective veneer of authority. Yet the failure to recognize the true origin of feelings brings its own danger, as patients may become alienated by what they perceive as the therapists' dishonesty or lack of insight.
It is better, surely, to understand which feelings involve transference, and which do not. I don't know if Dr. Raymer's feelings arose from counter-transference, or simply from the truth that her patient was the kind of man she finds attractive, but I have to believe that knowing the truth better enables her to make the right decisions.
"I still called my supervisor, we had a good laugh. And the patient got much better."
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Another excellent case study in the land of la-la psychologists, where pretty much everyone gets better. And even if they don't, the psychologists think very deep, insightful thoughts, much more deep and insightful than "normals", which is just good in and of itself.
The fact that reality is different, as described to me by several couples who have gone to marriage counseling (ALL got divorced) and a few who went to psychologists for other reasons, doesn't really matter.
The fact that depressive patients got better with the same average length of time by simply talking to friends vis-a-vis "psychological treatment" doesn't really matter.
The fact that objective studies of things like the Rorschach Test have shown that it doesn't have results any greater than chance doesn't matter.
Keep thinking your deep thoughts.
Snake oil and investment help from Madhoff - that's where it's at.
I fear a placebo (if well executed and very convincing) would be more effective than some of the crap psychologists come up with.
Now excuse me, I have to go to Scream Therapy.
Here's what I'm curious about:
I worked with a guy for years before I coincidentally found out that he had a doctorate in physics. His job was to apply quantum effects to new real world devices (an example of an older quantum device would be a tunnel diode). Extremely smart guy.
On the other hand, dopes like Dr. Phil (and as I understand it, he has some Psy.D degree that borders on a mail-order type thing, along with a suspension of his license that he ran from in Texas). But he's DOCTOR Phil.
Gee, I'm a DOCTOR too, but I personally wouldn't dream of shoving it in people's faces, especially if it's a crappy doctorate (like psychology, multidisciplinary studies or the like).
It only fools stupid people.
While I don't like it when people shove their doctorate in my face(it's an obvious sign of insecurity if they keep doing it), I have no problem with people with psychology doctorates. From my experience, you want someone who has a psychology background to interpret your various tests, not any bozo can do it correctly(just imagine having the worst HR person in your entire company interpret your psych tests).
As far as Transference issues, I agree in some of these relationships between the therapist and patient, there are legit sexual feelings based on appearance and such(unless all therapists get their brains replaced with computers when they graduate).
MB- I wouldnt write off a PhD from a good US University as casually as you seem to do. PhD degrees from Univs like Michigan, and the Ivys put their Clinical Psych grad students through some very rigorous academic and practical training. This is not the kind of degree that Dr Phil has.
More like what Helen has.
"As much therapy (not all) is based on intense feelings, I would argue that it might be wise to limit the situations in which the therapist and the client are of the opposite sex."
I think 90% of malpractice against psychologists happens when the shrink can't keep his hands to himself.
Trey
"From my experience, you want someone who has a psychology background to interpret your various tests, not any bozo can do it correctly(just imagine having the worst HR person in your entire company interpret your psych tests)."
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I guess it depends on what psych test.
There admittedly isn't a whole lot of information on objective studies of certain tests. Psychologists don't like it. So please don't nail me with the "it's not peer reviewed" crap or the "I didn't personally like the methodology in the peer-reviewed study" crap. Just take a look:
Evocative Images: The Thematic Apperception Test and the Art of Projection, by Lon Gieser and Morris I. Stein (publishers). American Psychological Association, 1999.
Projective Measures of Personality and Psycho-Pathology: How Well Do They Work? By Scott O. Lilienfeld in: Skeptical Inquirerer, Vol. 23, No. 5, p. 32: September/October 1999.
The Scientific Status of Projective Techniques. By Scott O. Lilienfeld, James M. Wood and Howard N. Garb.
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I'm tired of typing those in, but I'll type more later.
Customary psychological tests like Rorschach ACCORDING TO EVERY OBJECTIVE STUDY are not much better than chance.
Now I agree that some experimental psychology tests, for instance giving random questions like "Do you like cooked carrots or raw carrots" and then statistically evaluating the results along the lines of various pathologies or abilities, are useful, these can be developed by ANYONE once you get the idea and they can then be graded on a computer basis.
IN FACT, psychologists will fuck it up, because they don't get the idea of letting the statistical results be what they are - they have to superimpose their theories.
In short, I'm just not impressed. Sorry.
Combine that with this: The stupidest people on any campus are majoring in elementary education (clearly No. 1 on the retard scale), education in general, women's studies, psychology, social work and (later on) "multidisciplinary studies".
It doesn't get better at the Master's or doctorate level. Just longer time to diddle around in school without having to work.
And if anyone's interested: I was there myself in academia. I later woke up as to what is real and what is just arrogant pretension.
I'm starting to hate arrogant pretension, and that's all a lot of psychology DOCTORS have. That's all.
Love,
Important DOCTOR MB
LOL
I guess I'm a doctor too (JD - at least it says "Doctor" on the diploma), so I get to also be important and boss people around who haven't written a long paper on PMS or something.
Sometimes you get psychological trends that truly harm people.
There was a trend in the 1980s towards "recovered memories", if anyone remembers that.
Even proponents of psychology have to admit that there are some practitioners who are either truly evil or massively stupid. And yes, more than some other fields. I would probably trust a used-car salesman before I would trust a recovered memories specialist.
Sorry, I didn't mean to cut down used-car salesmen by placing them in the same category. LOL
Gee guys...did someone pour fox urine in your Wheaties?
^5 br5.
Trey
Look closely at the interchange-- “I think you need to take this one to Dr Gabbard. I have never seen a resident with this problem before.” “Never!?” I thought, “I’m the only one!?”
I understand the reaction of the resident. But with my more mature (or saturnine?) perspective, I'd say the notable operative phrase is "I have never seen..."
Oh, it was there, probably; but the person / mentor quoted never saw it. [rueful headshake]
The female psychologist should not worry one iota: as can be seen from the more recent article on the two teens in Philly, if she has heterosexual sex, she will not be blamed or punished; she may go unnamed.
I'm not a therapist, nor have I taken a claas in psychology, but I've tried to educate myself on this fascinating subject.
I'm not a fan of the "transference" explanation here. If one person has feelings for and about another, they must take ownership of them. If this doctor chooses to act out of her feelings, it will be her responsibility and consequence.
She did the right thing by going to her supervisor, however she wasn't honest. I am going to assume that one of her responses to her feelings led her to be less than true. It seems to me that the supervisor ought to ask enough probing questions to at least delve into the situation to partially understand it. Once some understanding has occured it is then very easy to tell the young doctor that the sessions are over and a new, in this case, male therapist will be assigned.
You are going to assume she was "led to be less than true" (what a curious circumlocution...)?
I don't see any evidence of untruth. I applaud your superior midreading skills. :)
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