The psychotherapist in context
(Or: Countertransference – How the therapist’s personal life, roles and social context influence therapy)
The vast majority of the literature on psychotherapy deals with therapeutic techniques and theories – the “what” and “how” of a process that is, ostensibly, aimed at ameliorating suffering and/or adjusting the thoughts or behaviours of persons who are in need of (or are deemed by others to be in need of) such ministrations.
Much consideration is also given in that literature to one part of the “who” in that process, namely the “patient” (or “client”, which is the identification I will use in this paper), although the scope of those discussions is usually limited to that aspect of the client which constitutes his maladjustment or suffering.
The other part of the “who” is the therapist (and I will use the term “therapist” to stand for a number of mental health professionals, such as psychotherapists, psychiatrists, psychoanalysts, social workers, and counsellors). But just as the client is usually seen only in his role of carrier of maladjustments and sufferings, the therapist is usually seen only in her role of the one who “has” (i.e., owns) the skills and knowledge to deal with those problems.
Other aspects of the therapist – her personality, life experience and beliefs, to name but a few – are usually disregarded or touched on only in the briefest manner. However, as in any relationship, these aspects come to bear quite heavily on the social interchange we call therapy. The lack of attention to these aspects can be illustrated with a few examples from widely used text books on counselling and psychotherapy: Brammer (1985) dedicates 19 out of 163 pages to “Characteristics of helpers”, Egan (1975) spends 2.5 out of 239 pages on “Portrait of a helper”, and in his 390-page text book, Corey (1986) has a 33-page chapter on “The counsellor as a person and as a professional”. Some writers do not touch on the subject at all, notably behaviourists (e.g., Brown, 1977).
This paper attempts to sketch some elements of the influence the person of the therapist has on the therapeutic process. An example of this influence would be a therapist steering a musically inclined client towards attending law school because the therapist harbours great admiration for lawyers but not for musicians. This example also shows that the therapist does not only bring her own personal issues into the therapeutic process, but also her social environment, which, to varying degrees, she shares with the client. In this case, the preference of lawyers over musicians might also occur in the social environment common to client and therapist – and we must also note that because the therapist most likely has a higher social status in this environment than does the client, her values might weigh heavier than the client’s.
In the title of this paper, I speak not only of the “personal” (i.e. private) aspects of the therapist but also of her roles (in our example, she might have taken on the role of an adviser). Roles can be seen as expressions of accommodating the personal (i.e., “private”) aspects of the therapist, of her interactions with the client, and of social conditions and demands.
Thus, one aim of my discussion is to pay attention to the particularity of the person of the therapist and not only to the universality of skills and theories which can be learned by all; and to pay attention to the subjectivity of the therapist and perhaps to lessen the emphasis of the objectivity she is often admonished to preserve, sometimes at all costs. Another aim is to attempt to make explicit the interplay between social environments and therapists’ personal needs and attitudes.
The influence of the therapist’s personality and history on the therapeutic process is recognized in psychoanalysis and is subsumed under the notions of countertransference and counterresistance. However, although psychoanalytic theory recognizes the existence and importance of countertransference, it is not a topic writers of the psychoanalytic persuasion are eager to discuss (Robertiello & Schoenewolf, 1987, p.7) The term countertransference is first mentioned by Freud in 1910 (qtd. in Robertiello & Schoenewolf, p.7). Johansen (1993) explains that in the controversies over countertransference, there are two main categories of definitions. One sees it strictly as conscious and unconscious responses to the client, the other includes all personal responses to the client, including those that arise out of the therapist’s past (p.87).
Many writers insist that countertransference consists of “emotional” and “irrational” responses that interfere with therapist objectivity (e.g. Corey, p.33). Racker (1968), an oft-cited writer on the matter, speaks of countertransference as “psychopathological processes” in the analyst (p.2), indeed a form of neurosis, which influences the therapist’s perception and/or interpretation of the unconscious processes of client and therapist in the therapeutic context.
Singer (1965) contends that countertransference can be grouped into roughly three categories: irrational kindness, irrational hostility, and anxiety reactions (p.303). Robertiello & Schoenewolf, in “101 common therapeutic blunders”, a delightful – and sometimes frightening – book of teaching tales, give examples of the following categories: erotic (e.g., “The therapist who feared his sexual feelings”), sadomasochistic (e.g., “The therapist who had to be The Boss”), and narcissistic (e.g., “The vain therapist and the slob”).
Robertiello & Schoenewolf also discuss counterresistance, a phenomenon that other writers often subsume under countertransference. While countertransference can be understood as a type of projection in which, for example, the therapist treats the client as if he were her father, counterresistance can be seen as therapist behaviours which influence the therapeutic process through such “blockings” as (hostile) silence, attempting to change the subject, or otherwise preventing unwanted ideas or feelings from rising to the fore.
Counterresistance can result from a therapist’s colluding with the patient’s resistance to explore or work through unpleasant issues but can also originate exclusively from the therapist (Robertiello & Schoenewolf, p.5). Robertiello & Schoenewolf’s tales of counterresistance have titles like “The therapist who denied his own obesity” and “The religious therapist and the atheist”. These titles speak for themselves as illustrations of some of the types of countertransference and counterresistance that can be found.
Generally, however, countertransference connotes therapist irrationality and unwanted lack of objectivity, even though many writers stress that countertransference can be used productively (e.g., Singer, p.298; Beskind et al, 1993, p.16). Partly because of this connotation, I will avoid the use of the term “countertransference”, preferring in my discussion terms like “the influence of the personal”, “social influence”, etc.
If the influence of the personal is not a favourite topic for many writers, social influence is even less so. It appears that when issues of social influence arise, they are frequently decontextualized or dealt with by tokenism (Cushman, 1995, p.283). For example, a therapist’s values might indeed be recognized as intruding in the therapeutic process – but implicitly they are her values. The question of how these values relate to prevailing ethics, politics, or other social contexts, and how that influences the therapeutic process is rarely asked.
What follows are four short vignettes of roles therapists might take on as a result of these (usually unexamined) personal and social influences. These vignettes I have compiled from a rather arbitrarily assembled body of literature, where some instances of the influence of the personal were either discussed by various writers or which I have observed in therapists (including myself during four years of counselling and group facilitation).
All vignettes have eight components: The name of the role; a few brief examples of the therapist’s interventions typical for that role; some personal reasons why the therapist might choose these interventions; the type of client these interventions might be useful for; the dangers inherent in the role; theories that endorse or condemn such interventions; and, finally, the types of environments these roles and interventions might fit into. Following each vignette will be a brief discussion of some of the elements of the role and interventions discussed.
A caveat: because of their brevity, the vignettes are almost caricatures – it goes without saying that the “real-life” therapist will feel and behave in a much more complex way, that she does not always take on that role, and that more likely than not, she will play more than one role with a particular client, even within a particular session. Also, my discussion is informed mostly by North American psychotherapy; some of the points I make, especially about social context, may not entirely apply to therapists outside this geographical area.
The Good Parent
What she does: Is supportive of client at all costs; often colludes with client against uncovering neuroses; does not confront
Why she does it: Has a need to “kiss and make it better”, perhaps because her parents did not do that for her; shies away from looking at her own neuroses; is afraid of confrontation
Useful for: Clients who are unable to trust other therapists
Dangers: May turn against client if “rejected”; her “shadow” is unchecked
Model: The Ideal Mother
Theories: Explicitly scorned by Singer (psychoanalysis) (p.119), Kopp (Jungian) (1974, p.155), Corey (eclectic) (p. 371, p.376); conceivably more likely to happen among Rogerians and some feminist therapists
Environmental fit: Where preservation of status quo is important; some church-affiliated institutions; some women’s centers
While the above-mentioned theories explicitly scorn this type, the Good Parent is a very common trap for therapists of any stripe – after all, the desire to help, to ease suffering, is the stated goal of the majority of those entering the helping professions (e.g. Corey, p.368; Guggenbuehl-Craig, 1979, p.10). Also, the warmth and caring which are typical of the Good Parent are seen by many as indispensable qualities in therapists (e.g. Brammer, p.34). It is a very short step from the desire help and feelings of warmth and caring to becoming overly solicitous and somewhat possessive, especially when driven by the needs described above.
The Good Parent is also a societal ideal – it is a mother-ideal: all-giving and all-forgiving, nurturing, supporting. Therefore, while therapeutic theories generally slight the Good Parent, there is not much opposition against her from other parts of society. But if the Good Parent is like the Jungian Great Mother archetype, it also incorporates its dangers: for example, the solicitousness can become suffocating (perhaps when well-meaning advice is not taken). The Good Parent may also have a tendency never to refuse to take on a client, no matter how difficult – only to end up “getting rid of patients unwittingly … by unacknowledgedly evil ploys aimed ostensibly at helping the patient” (Kopp, p.155). Indeed, Singer calls the “urge to appear angelic … one of the most dangerous compulsions” (p.119).
The Irreproachable Professional
What she does: Is very mindful to adhere to theoretical, ethical and other guidelines given by leaders in the field, associations, etc.; does not share or shares only minimally with the client personal matters and countertransference issues; models and teaches objectivity and rationality
Why she does it: Has a need for the security, status and power that comes with being a professional (because of own insecurities, anxieties, etc.); believes, consciously or unconsciously, that vested authority is needed to effect change in the client; believes she has acquired and now owns knowledge about human attitudes and behaviour
Useful for: Clients who change only or believe they can change only under pressure from or with the help of authority
Dangers: Difficult or impossible to establish a true connection with client; inattentive or pays only lip service to her fallibility
Model: The Priest; The Just Father
Theories: Prescribed by classical psychoanalysis (Singer, p.126); implicit in rational-emotive theory (Corey, p.216); condemned by Rogers (Pietrofesa et al., 1971, p.132); chided by approaches influenced by Eastern Religion (e.g. Dass, 1985, p.21)
Environmental fit: Psychiatry; prisons; some social work milieux (e.g. Brandon, 1976)
When some of the more negative aspects of this role are blotted out (or presented in a more favourable light), it seems to me that The Irreproachable Professional is the official picture of the therapist presented to the public. The Irreproachable Professional behaves in a politically correct manner, is above sexual, aggressive or otherwise “inappropriate” feelings (or worse, acts) towards clients, is trained to approach everything objectively and rationally, and, above all, is an “expert” on things psychological.
The terms “inappropriate” and “appropriate” are important instruments of The Irreproachable Professional; like erstwhile the priest, The Irreproachable Professional often uses them to designate who goes to heaven (i.e. remains in the fold of “normal” society, moves up the status latter, etc.) or to hell (i.e. is sent to mental hospitals, has their children taken away, etc.). Just like The Good Parent, The Irreproachable Professional often upholds the status quo, since that is the sociopolitical context in which professional associations, the academic teaching framework and other background structures are found which are necessary for any occupation officially labelled “profession”.
The symbiosis between The Irreproachable Professional and established power explains is another reason why I have used as model the figure of the priest. Guggenbuehl-Craig (p.129) points out the loneliness inherent in having too high of an investment in being The Irreproachable Professional. When clients attempt to reach beyond the professional mask, the therapist reacts defensively and interprets these attempts as problematic issues residing within the client.
The Irreproachable Professional cannot bear to be called into question. Robertiello & Schoenewolf see essentially the same problem; however, unlike Guggenbuehl-Craig, who thinks that open, honest friendships and intimate and familial relationships constitute such a therapist’s saving grace (p.135, p.149), Robertiello & Schoenewolf maintain that continuous supervision is the answer: “Doing therapy without extensive or deep analysis [i.e., supervision] is comparable to doing surgery with a dull spoon.” (p.290) This advice is true also for The Good Parent. Perhaps here we have two opposite yet complementary roles: The Irreproachable Professional would then be the strict, just, aloof father, and The Good Parent the gentle mother, an interminable fountain of unconditional love.
What she does: Stresses the shared humanness of therapist and client, for example by freely disclosing own history, values, etc.; may deny the inherent power differential between therapist and client; takes a somewhat atheoretical, anti-technique approach
Why she does it: Wants client to be her friend (has a strong need to be liked); committed to a belief in equality; has a need to rebel against present or past authority figures or symbols
Useful for: Clients unresponsive to authoritarian approaches; clients for whom empowerment is a priority issue
Dangers: Blurring/overstepping of healthy boundaries between therapist and client; clients who need structure may feel lost
Model: The Friend
Theories: Extolled by approaches influenced by Eastern Religion (e.g. Dass, Brandon) and numerous feminist approaches (Simi & Mahalik, 1997); encouraged by Rogers (Pietrofesa et al., p.127); antithetical to behaviourism (Corey, p.179), classical psychoanalysis and some other strongly theory and/or technique oriented approaches
Environmental fit: Support groups; community based counselling (Corey, p.113)
If we imagine The Irreproachable Professional as sitting in her lonely ivory tower, we can picture The Companion meeting with her client-buddy over a cup of coffee at a neighbourhood cafe. At this point I wish to remind the reader that my descriptions are deliberately colourful, in order to highlight certain features; of course I wish by no means to imply, for example, that Rogerians can routinely be found chitchatting with their clients at Starbuck’s.
However, the picture just painted illustrates how intuitively easy it can be to simply like The Companion and to feel less attracted to The Irreproachable Professional. But the question is: what is gained by liking a therapist, by seeing her as a friend, and are there drawbacks? If, for example, therapist and client are attracted to each other on the basis of their common dislike for authority, might it be difficult for them to look at issues beyond or outside of the antiauthoritarian framework, and might that be detrimental to the client?
More “classical” boundary issues, such as overly flexible hours, avoidable interaction outside the therapeutical context, frequent telephone contacts, etc. can confuse both client and therapist. On the other hand, consciously sharing with another person the experience of humanness may be the most powerful healing any therapist may hope to offer. Kopp (p.42) relates this:
When [the patient] comes down in the rubble of his life, he will find me there with him as a committed though world-weary companion. And as he undertakes the frightening pilgrimage of a life open to the perils of the dark forces from which he would usually hide, I will go with him, hoping that we may draw courage from one another.
Here Kopp highlights something very important: that therapy is – can be -beneficial to both players, in a way that goes far beyond the obvious complementarity of their roles. When this reciprocity takes place, it is not only the therapist who gains but also the client who often, too, has a desire to give and to teach.
The therapist who knows how and when to gracefully accept such gifts has overcome what Brandon (p.45) calls “the greed of giving”. However, it may indeed take an experienced, “world-weary companion” to know how to accomplish that. Therapists whose convictions regarding equality truly run deeply, such as Ram Dass, whose spiritual orientation generally leads him away from believing in separateness of persons, may also be useful companions. However, most therapists, especially when university-trained, have some very deeply engrained if unconscious convictions regarding separateness of persons as well as their own authority and superior knowledge. They may better serve their clients by openly acknowledging and working with the power differential rather than stubbornly paint it over by insisting on perfectly egalitarian ideals.
What she does: Relies heavily on techniques; disregards or deemphasizes the role of feelings and the client-therapist relationship; is directive and solution-oriented
Why she does it: Conceptualizes humans from within a mechanistic framework; may be uncomfortable regarding emotional matters; may be attracted to solution-oriented approaches because she is unable to tolerate ambiguities; may enjoy the power afforded by the use of techniques
Useful for: Persons for whom insight or relationship oriented approaches do not work, e.g. some persons with Asperger’s Syndrome; persons who do not wish to go beyond symptom removal
Dangers: May only cure the symptom, not the underlying problem
Model: The Engineer
Theories: An important aspect of the following approaches: behaviour therapy (Corey, p.179); some cognitive-behaviourist approaches (e.g. Meichenbaum, 1977, qtd. in Corey, p.230); some (definitely not all!) of the brief approaches used in managed care. Criticized by Rogerians, existentialists, and psychoanalysts.
Environmental fit: Third-party (e.g. insurance company) driven practices and situations where in-depth attention to many individuals is not possible (e.g. schools, inner-city mental health clinics, etc.) (Fein, 1992)
One of the dangers faced by this therapist is, in a way, the danger of technology. Instead of using, say, negative reinforcement as a tool when and where such a technique appears to be genuinely promising, the therapist may tend to have it handy as a solution searching for a problem. What should be a tool becomes an end in itself; technology then overwhelms both client and therapist. Just as in a technologically oriented world, The Adjuster can also fall prey to an obsession with efficiency and efficacy. When the standard by which these are measured is also heavily influenced by the therapist (when, for example, a therapist does not aim for a client’s stated goal of pain relief but for a reduction in “pain behaviours”), it is not surprising that The Adjuster is often seen as quite successful.
Like everyone else, The Adjuster can become quite enamoured – and blinded by – such successes. The Adjuster sees the ideal human as a perfectly running machine. Sometimes parts of this machine can break down, malfunction, etc., and it is her task to fix it, or to “impart proper behaviour to sometimes recalcitrant individuals” (Fein, p.172). Undoubtedly, this gives The Adjuster a feeling of control – perhaps she experiences herself as having become part of the environment that, according to behaviourism, controls individuals’ behaviour? This would satisfy not only the lust for power over other people which lurks in all of us but would also alleviate feelings of anxiety and helplessness she might experience vis-a-vis the chaotic, complicated environment that controls her.
Returning to the use of tools, it is curious that The Adjuster, concerned as she is with techniques, does not place any importance on the one instrument closest to her, namely her own person. It would be wrong to say that she does not use it at all – in my opinion, it is impossible to leave aside one’s predilections, history, needs, etc. – but she may well use this instrument in an unexamined and unsystematic fashion.
In this, she is the complete opposite of psychoanalysts and client-centered therapists. The former are not allowed to do therapy until they are well ahead in their own analysis. Person-centered therapists, too, are exhorted to examine themselves, preferably through therapy, support groups, or the like (Johns, 1996). These latter views notwithstanding, considering the limited public resources for therapy, The Adjuster might be just the right person to hand out therapeutic band-aids, which may be all that is needed in some cases, and which, in many cases, is better than no therapy at all.
Before I go on to some concluding thoughts, I wish to stress again that while the above vignettes may at times appear like caricatures, indeed like strawmen which I then gleefully tear down, it is very important to keep in mind that these roles are not nearly the whole story of how a given therapist might behave with her clients. My attempt is to take a look at some traps therapists might fall into, not, as it were, to trap therapists in vulnerable moments and expose them to ridicule. Neither is it my intention to stereotype certain approaches – I do not believe, for instance, that all behaviourists lead unexamined lives, or that feminist therapists cannot see beyond antiauthoritarian biases, and with the exception of what seems to me like misues in managed care, I often find brief therapy to be a fascinating, powerful way to improve peopleï€½s lives.
I will build my conclusion around the question of how the examination of roles and traps as described above might help me with my own counselling endeavours in the future. After criticizing others for not paying attention to their own personal history and social surroundings, it seems only fair for me to take a critical look at my own practice. Let us take a look at some of the topics that came up frequently in the above discussion. Incidentally, the frequency of these topics are a reflection not only of the literature reviewed and my observation of other therapists, but also of my own attentional biases and interests.
As can be seen, one theme that came up repeatedly was anxiety – around ambiguity and authority, as well as generally the relational aspect of therapy and two topics related to it: confrontation and the expression of emotions. Even the most aloof therapist cannot help but be on the receiving end of a constant onslaught of intimate details of another: emotions, thoughts, stories, etc. She is constantly “in relationship” in a way which is contrary to that which almost everyone else generally does. Except in special situations, we avoid discussing details of our lives, we avoid excessive eye contact, we strive to maintain superficiality by smoothing our interactions with deeply engrained social protocol, etc. It takes a very robust personality to constantly act in a manner that goes contrary to what most have been socialized for – no wonder that this sometimes (or often?) evokes anxiety, perhaps mostly in those areas where we feel especially weak.
I personally find it often difficult to be confrontational, to violate the social norm of not hurting others’ feelings. Only recently, my anxiety regarding confronting an overly self-reliant client may have resulted in a regrettable delay in her getting more sorely needed social support. Looking back on the corresponding role of the “Good Parent”, I might even have to ask myself whether unconsciously, I wanted to be the only one who “understood” and “loved” that client. [A note of humility almost seven years after first writing this article: I still battle this very problem of wanting to be “the one!”]
This brings us to the next topic: inadequate self examination and/or supervision. The Good Parent may deny her shadow, the devouring mother-goddess, The Irreproachable Professional may not want to be reminded of her fallibility, The Companion may confuse her client with her unexamined need to be a “buddy” to everyone, and The Adjuster may, in her unchecked zeal to find a quick fix for every problem, show her unwillingness (or even inability) to probe for deeper meanings in both her own and her clients’ lives.
As Robertiello pointed out, supervision is definitely a way to deal with these problems. However, Guggenbuehl-Craig (p.130-134) cautions that therapists, within the limited scope of supervision, may pay selective attention to their “safer” problems; as well, with their supervisors, they may conspire to reach implicit consensus about what is to be discussed and what not, possibly leaving out the most difficult and harmful problems. For many, including myself, there may also be logistic problems with supervision, such as time, money, and finding the right supervisor. Ironically, those who face the most challenges in the area may precisely be those who need it most, for example, therapists just starting out in private practise, or those practising in small communities. [Another note from seven years later: While I have found supervision very useful, I find it even more valuable to combine it with frequent conversations with supportive but honest friends and colleagues – without violating confidentiality, of course.]
The question of the therapist’s power, control, authority and ownership of knowledge is extremely important. Fritz Perls (1969, p.78) speaks of his ambiguity regarding this topic:
“I’ve lately gotten such a reputation as a therapist that I can’t possibly live up to it. It was about three years ago when I finally could accept what people always told me, that I was a genius. This lasted only three months, and I discovered that I didn’t have it in me to be a genius anymore.”
Most clients want or need the therapist to be someone they can lean onto, and in that context it is important for the therapist to be a confident expert and authority (Brammer, p.28). Problems arise when this almost naturally required authority is exaggerated. The reasons for this exaggeration can be manifold. It is probably impossible to disentangle them from each other; I will simply list a few.
Clients’ need for therapists’ authority may be met more than half way by therapists’ desire for for that authority. This desire can stem from feelings of insecurity on the part of the therapist, from her genuine belief in the necessity for authority, from her sheer greed for power and control (which psychoanalysts may trace back to narcissism or masochism), or from society’s endorsement of therapist power.
In turn, this endorsement may be rooted in the mystique that academia and professional organisations have created, in a general societal need to have “leaders”, and in the early roots of applied psychology out of which psychotherapy partly grew and which was a means of social control. It is probably safe to say that most therapists feel uncomfortable about the issue of power; however, not everyone is as frank about this discomfort as Perls.
A study aptly named “What troubles the trouble shooters” (Kaplan Daniel, 1974) shows that some therapists appear to partly deal with this discomfort by disparaging colleagues – they call each other “arrogant, unfriendly, uncommunicative” and decry each others’ “need for security.” (p. 205) It is hard to believe that such difficult and obviously unresolved issues would not intrude into the therapeutic process. In my personal practice, I have often found myself seduced by my tendency to be somewhat of a “know-it-all”; conversely, I have sometimes also fallen into the trap of The Companion where I have not exercised authority when clearly it would have been helpful for a client.
It is obvious to me that the foregoing discussion can only briefly touch the tip of the iceberg of the many personal and social influences the therapist brings into the therapeutic process. However, this paper can perhaps serve as a point of departure for further thoughts both on my part and on the part of the reader.
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