_____________________________________ Setting Ethical Limits: For Caring and Competent Professionals
client’s experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client’s past [46]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client’s own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [47]. Therapists’ emotional reactions to their patients (countertransference) impact both the treatment process and the outcome of psychotherapy. REFLECTION It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one’s thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [48]: • A questioning attitude towards one’s own feelings and motives • The recognition that we all have blind spots • An understanding that staff are affected by clients • An understanding that clients are affected by staff behavior • A recognition that clients often have strong feelings toward staff Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [50]. Freud believed transference to be universal, with the possibility of occurring in the counselor as well as the client. He described this “countertransference” as “the unconscious counter reaction to the client’s transference, indicative of the therapist’s own unresolved intrapsychic conflicts” [51]. Freud felt that countertransference could interfere with successful treatment [45]. Since the 1950s, the view of countertransference has evolved. It is no longer believed to be an impediment to treatment. Instead, it is viewed as providing important information that the professional can use in helping the client [45]. Empathy allows the counselor to experience and thus know what the client is experiencing. Countertransference emerges when the client’s transference reactions touch the counselor in an unresolved area, resulting in conflictual and irrational internal reactions [52]. Good indicators of countertransference are feelings of irritability, anger, or sadness that seem to arise from nowhere. Countertransference frequently originates in counselors’ unresolved conflicts related to family issues,
needs, and values; therapy-specific areas (e.g., termination, performance issues); and cultural issues [53]. When feelings have intensity or when they persist, this is an indicator for future work and healing. The counselor’s work is to bear the client’s transferences and interpret them. When the counselor refuses the transference, there is often a mutual projective identification going on, in which both counselor and client project part of themselves onto the other. Refusal may also mean that one of the counselor’s own blind spots has been engaged. As Shapiro explains, “a rough edge of our character has been ‘hooked’ by a bit of what the patient is struggling with, and we act out a bit of countertransference evoked in us by the transference” [54]. In a group therapy setting, family dynamic re-enactments can emerge as transferences. Managing these complex dynamics can raise the counselor’s anxiety and mobilize his or her defenses, compromising a usually thoughtful stance. When counselors experience intense reactions in trauma groups that pull them out of the present moment, they should investigate whether they are responding to traumatic content, personal unresolved issues, or individual or collective transference [55]. Counselors who find themselves ruminating about a previous session’s content, a client’s welfare, or their own issues should talk with a trusted, objective colleague. Countertransference issues for the mental health professional should be resolved apart from the therapeutic environment to avoid burdening and potentially harming clients [51]. One study of countertransference found that therapists’ self-reported disengaged feelings over a treatment period adversely impacted the effect of transference work for all patients, but especially for patients with a history of poor, nonmutual, complicated relationships [48]. SELF-AWARENESS Problems arise when the professional lacks awareness or refuses to devote the necessary time to process the personal emotions and thoughts that arise within the therapeutic relationship. Feelings of anger, grief, jealousy, shame, injustice, trauma, and even attraction can, when they touch a wound from the past, trigger reactions within even experienced professionals. Clients’ experiences can replicate the professional’s past relationships and trigger emotions that have not been worked on or addressed. If this occurs, the professional can, without disrupting the client’s session, make a mental note of the feelings. This allows the professional to attend to the present moment. After the client’s session has ended, the professional can arrange to talk to a colleague or supervisor for processing. If the countertransference continues, it may be necessary for the professional to seek counseling. Self-awareness helps the professional to reflect back to the client’s true emotions. It also is an important component of training, development, and effectiveness [56]. Mental health professionals need to possess certain values, qualities, and sensitivities, and should be open-minded and have an awareness of their comfort levels, values, biases, and prejudices [57].
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