Avoiding Countertransference and Codependency

When Working with Other Healthcare Professionals

Stephanie Trumm, BA, RN, CARN

Objectives 1. To gain a greater understanding of the various

aspects of countertransference and to identify their impact on a therapeutic relationship

2. To gain a greater understanding of how to manage countertranference when it does manifest, and how to prevent countertransference from sabotaging a therapeutic relationship

3. To gain insight into codependency and to learn ways to identify and to also prevent codependency from sabotaging a therapeutic relationship

What Does Countertransference Mean To You?

Definition Dilemma No consensus of definition Term frequently used to denigrate nurses regarding their

reactions to patients (Ens, 1998) Countertransference originated out of Freud’s

psychodynamic theory in 1910 (Freud, 1959) Term used in reference to the unresolved conflicts within the clinician-later viewed as a weakness in the psychoanalyst in response to the patient’s transference (Stem, 1924)

Function of the Hippocampus The “Memory Bank”- records every event and mental

process in tandem with the emotion experienced

Family of Origin Issues

Transference- “A set of expectations, beliefs, and emotional responses

that a patient brings to the clinician-patient relationship; these do not come from the development of new feelings but rather the return to old feelings patients had toward someone in their family of origin”. (Pearson, 2001, p. 8)

Feelings lie in the unconscious-

often reflect experiences that the patient had with early authority figures- can result in a distorted perception of the clinician (either very good or very bad)

Countertransference

Refers to sometimes disruptive feelings that the clinician brings to the clinician-patient relationship, again unconscious in origin, that are formed by the clinician’s early developmental experience

Definition Realm Dilemma Countertransference can either be positive or negative

Negative countertransference-often presents in punitive actions or attitudes toward the participant, which results in detriment to the interpersonal relationship and to the team’s clinical functioning (Sebree & Popkess-Vawter, 1991)

Positive Countertransference-can have equally detrimental effects-often manifests in oversolicitous care and Participant overinvolvement (Holden, 1990)

One More Dilemma-Empathy The Exception;

Empathy is a part of countertransference that is therapeutic-a feeling elicited from the patient’s feelings or circumstances

Term coined by Racker (1957) and defined as identification concordance with the patient

Is usually in conscious realm-countertransference usually isn’t

Has temporal “here-and-now” dimensions

Requires freedom from judgment

Surrogate Terms to Assist Understanding- Rodger’s Concept of Countertransference Mutual Withdrawal (Tudor, 1952)

aka “benign neglect” (Stamm, 1985) and “countertransference traps” (Climo, 1983)

“Countertransference Acting Out” (Bellis, 1988)

“Overprotectiveness”

“Overinvolvement”- “Omnipotent Rescuer”

“Sympathy”

Related Concepts-Not Usually Countertransference

“Identification”-similarities

“Reaction”- nearly universal conscious behavioral responses

“Therapeutic Reciprocity”

Attributes of Countertransference 1. Occurs in context of some relationship that has

therapeutic intent and is interactive

2.The past enters the her-and-now aspects of the relationship (Schroder, 1985)

3.Resides in the psychopathology of the patient, but the strength of the response is mitigated by the manner in which the clinician’s past needs and conflicts influence his or her reactions (Venn & Derdeyn, 1988)

4.Originates in the unconscious, but seeps into awareness (Savage,1961)

Countertransference Happens

5. It is a given in therapeutic interactions, and as such, is essentially neutral, potentially good or bad, valuable or harmful (Little, 1960)

Therefore, Pay Attention to the intense feelings and reactions that occur within you!

Consequences that can follow negative countertransference Often manifests in attitudes and behaviors:

Misuse of confrontation

Continual arguing with a participant

Labeling the participant as “manipulative”, “always lying”

Providing an inappropriate interpretation of a participant’s behavior

Experiencing an unreasonable dislike for or resentment and anger toward a participant

Making derisive comments about the participant to others

R-E-S-P-E-C-T

Labels Belong on Cans, Not on People

Scheike’s Model of STEDFAST Self-Aware Mindfulness Development Model (2004) Self-Awareness and Mindfulness- my first line of defense

Take time to learn and to study myself

Learn my personal mission

Active awareness involves nonjudgmental acceptance of myself, my investment in this present moment, and my ability to experience life in a fresh way

helps me to monitor my professional boundaries

Results in an increased capacity, using a balanced approach

S-T-E-D S-Self-Assess

Check in with yourself before you start your shift

T-Therapeutic Role

Are you ready/willing to take on your role at work today?

E-Empathy

Are you willing to “put yourself in your participant’s shoes”?

D-Detached Reflection

Are you willing to own and to deal with intense/ disproportionate feelings elicited within you?

F-A-S-T F-Facilitated debriefing Are you willing to reach out and process with a trusted colleague or

non-administrative supervisor? A-Alert Empathy Can you balance an alert, attentive, empathetic relationship with

you participant and keep vigilant to your need to honor own self-boundary?

S-Self-Aware Mindfulness Have I learned anything new? Able to more quickly accept myself

and identify/manage intense feelings? T-Therapeutic Use of Self Able to identify how you bring your “mindful self” to the

relationship with your participant and be able to facilitate some of the participant’s needs?

The Codependency Dilemma What does “Codependency” mean to you?

Definition Dilemma “A psychological condition manifested through a

dysfunctional pattern of relating to others, characterized by extreme focus outside of self, a lack of open expression of feelings, and attempts to derive a sense of purpose through relationships”. (Fischer, Spann, & Crawford, 1991, p. 87)

A dysfunctional pattern of living, which emerges from repeated exposure to stressful conditions, resulting in an overreaction to external cues and an underreaction to internal cues (Friel & Friel, 1987)

A spectrum-disorder rather than a diagnosed disease

Aspects of Codependency Difficulty with emotional individuation boundaries (Uhle,

1994)

Thought to originate when a loss or alienation of one’s authentic self occurs through a wounding experience in early childhood (Whitfield, 1997) or in the early attachment period; emotional neglect present

Often low sense of personal worth, painful relationships with others, internalized shame, exaggerated sense of responsibility for others, rescue orientation, intense need for approval, and sustained difficulty with identifying and expressing one’s own feelings

Cermak’s Model (1991) Most critical feature is the ongoing investment of self-

esteem in the ability to influence or control feelings and behavior, directed toward both oneself and others, in the midst of negative circumstances

May be primary, embedded deeply into a person’s character structure, or secondary, which is often more transient, in response to a present relationship with an individual who has a SUD, mental illness, or other dysfunctional family relationship patterns

Difference Between Caring and Codependent Caretaking Caring involves empowering participants to be

responsible for themselves, as clinicians take responsibility for themselves, in order to be understanding. involved, supportive, and proficient (Herrick, 1992)

Caretaking involves being “absorbed in another’s problems at the expense of taking care of oneself” (Herrick, p. 12)and as neglecting oneself “due to the exaggerated sense of commitment to helping others” (Farnsworth & Thomas, 1993, p. 180)

Avoiding Codependency with Participants-Suggestions Identify and manage your own codependent issues-

trauma distorts

Suggestions Self-Awareness and Mindfulness

S-T-E-D-F-A-S-T Pay attention to degree of self-disclosure and your role

Key in on boundary awareness-especially if the participant is in crisis or has just relapsed

Talk about healthy boundary maintenance on your team or with a trusted colleague- no caring case manager is immune from codependency issues

Practice self-care-hold yourself accountable to a trusted friend

Seek help if needed-You are worth it!

Suggestions If your program is 12-step oriented, listen, validate,

then gently refer your participants exhibiting their own codependent issues/ anxieties to steps 1 and 3, as well as to their sponsors and/or therapist to continue to process feelings

Debrief with a trusted colleague or supervisor if a traumatic event has occurred to or with your participant

Final Thoughts

You Are Worth Succeeding Also!

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