by Anna Velychko
“Treatment relationship is a human relationship,” says Carolyn Saari in her article Created Relationship: Transference, Countertransference, and the Therapeutic Culture (1986). Therefore, while considering a patient-therapist relationship, we have to look at it as a dual relationship, parties of which consistently and dynamically influence each other. While the patient may experience certain issues and difficulties that made him/her reach out for professional help and support, it is paramount to understand that the person on the other side – therapist – as any other human being has his/her personality, needs, and expectations. Resultantly, therapist’s maturation of the character and perception of the world directly influence the therapeutic relationship with the client. So to define what it means to work with “difficult” client, two aspects need to be taken into account: 1. Patient’s needs and desires; 2. Therapist’s reactions and need to feel effective (Noonan, 1998), as well as his/her theoretical knowledge. Eda Goldstein in her essay What is Clinical Social Work? Looking Back to Move Ahead talks about MSW graduates lacking the clinical knowledge and skills necessary for direct practice. This statement may suggest that new professionals in the field of social work have to be mindful of their own emotional needs and expectations when it comes to working in private practices.
“Difficult” client is defined as someone who is having difficulty establish transference and lack a capacity for self-reflection (Noonan, 1998). Transference occurs when a patient redirects his/her conflicted feelings and/or unresolved aspects of his/her past onto a therapist or caregiver. Christopher Faiver in his book The Counselor Intern’s Handbook writes, “transference refers to the client’s unconscious tendency to experience feelings, attitudes, longings, and fears toward the counselor that were originally felt for other important people in the client’s life.” Going by Faiver’s definition, the feelings that a client experiences during transference do not necessarily have to be negative. Contrary to transference, countertransference occurs when a therapist redirects his/her own conflicted feelings onto a patient that symbolizes a figure from his/her past. Therapists must come to recognize their range of distorted and non-distorted perceptions so that they can recognize when they should examine themselves of countertransference responses. To provide the best possible service, mental health workers must acknowledge the possibility of experiencing countertransference and combat it once they had acknowledged it.
To build healthy relationships with others, relationships that are mostly the foundation of every revelation the human race has been a part of requires one to have an awareness of emotions, sensations, feelings, and behaviors; so that we can better understand not just ourselves, but each other. To understand others, we needed to become more psychologically minded and motivated as people, with intentions to learn and a willingness to accept. In doing this, we too will learn about ourselves. However, not everyone has or can develop a capacity for self-reflection due to traumatic experience or personality predispositions like psychosis, borderline, narcissistic and schizophrenic conditions (Goldstein, 1995).
As I am embarking on a journey of a social work intern at Federation of Organizations I have to be very much aware of my patients and my own needs and reactions, majority of the population I will be serving are people with severe mental illnesses such as schizophrenia, bipolar and borderline disorders, which are known to have severe impairments in internalized object relations and quality of interpersonal relationship (Goldstein, 1995). I can use my knowledge from my college readings and try applying it into my relationship with clients. For example, the case study about Peter was beneficial for me in gaining more insight into potential triggers I may experience while working with “difficult” clients. The author, Maryellen Noonan, shares her story that changes from being triggered and indifferent to her client, Peter, to become more introspective and understanding to where Peter was coming from (1998). I find it fascinating to be witnessing Maryellen’s subjective perspective on what she thought would be useful for Peter’s recovery, whereas, in reality, it was the opposite. Once she allowed herself to modify her expectations and become less critical of Peter, he, in turn, was able to tap into his deep internal conflict and be able to pay more attention to his own needs and feelings.
Putting aside my humble theoretical knowledge in this regard, I had experienced countertransference with one client last year. I worked at the psychiatric unit at Elmhurst Hospital with a teenage girl from India – the victim of sexual abuse who had reoccurring suicidal ideations. I perceived her as a being “difficult” client, as she would not want to engage in any form of conversation and most of the time she was shut down (being non-verbal). The time I spent with her seemed to be useless in regards to my assessment of the therapeutic effectiveness. Once I brought the book by Radhanath Swami called Journey Within for us to read, and she was disengaged and seemingly depressed. I remember me feeling useless, hopeless, and frustrated. That night I dreamt about being raped by one of my closest protective figures. That dream shook me to the extent that I could not function throughout the day. My boss backs them who is a psychologist explained to me that I connected with this girl on “metaphysical” level – I relived the horror of her everyday reality.
Now, I understand that I experienced countertransference, similarly to what Carolyn Saari described in her article (1986). This very experience taught me not only how I can convert my anxiety into a more mature form of thought, but also how naïve I was thinking that I know where my client is coming from. Indeed, Saari (1986) emphasizes that both the client and the therapist have different perceptions of reality. And since there is no guarantee of precision in the therapist’s viewpoint, the therapist’s role should focus on creating a supportive therapeutic relationship in which the client can form a contemplative attitude toward his/her environment. Once we can listen and understand our clients’ stories with all their beauteous imperfections; only then we can create relevant links of interaction with people around us maintaining a healthy peaceful mindset.
Faiver, C., Eisengart, S., & Colonna, R. (2004). The Counselor Intern’s Handbook, California: Brooks/Cole.
Goldstein, E. G. (1995). Ego psychology and social work practice. New York: Free Press.
Goldstein, E. G. (1996). What is clinical social work? looking back to move ahead. Clinical Social Work Journal, 24(1), 89-104.
Noonan, M. (1998). Understanding the “difficult” patient from a dual person perspective.
Saari, C. (1986). The created relationship: Transference, countertransference and the therapeutic culture. Clinical Social Work Journal, 14(1), 39-51.