|Year : 2014 | Volume
| Issue : 2 | Page : 131-133
Therapy for therapists
Chief Resident, Department Of Psychiatry, Aga Khan University Hospital, Karachi, Pakistan
|Date of Web Publication||4-Jul-2017|
Chief Resident, Department Of Psychiatry, Aga Khan University Hospital, Karachi
Source of Support: None, Conflict of Interest: None
Counter transference (CT) is a common phenomenon, which is encountered by many therapists during therapy sessions. This paper discusses possible underlying intra-psychic conflicts present in therapist, which need to be dealt before commencing therapy of patients. As problematic relationships present in therapist life can influence or worsen course of therapy because of inadequate responses that therapist can exhibit due to counter transference (CT). CT can be dealt by enabling therapists to recognize this process and to maintain patients' priorities over their own needs. This can be emphasized in teaching or residency programs of training through therapy of a resident during training period. Constant and closed supervisions are required to note subtle behavioral processes going on in therapeutic alliance to prevent boundary violations, transference and issues like resistance.
Keywords: Childhood conflicts, Counter transference, Patient, Psychodynamic, Therapist
|How to cite this article:|
Jawaid H. Therapy for therapists. Acta Med Int 2014;1:131-3
| Therapy for Therapist|| |
Psychotherapy plays a vital role in modifying the course of illness and progression of many acute psychiatric illnesses. Usually crisis intervention is followed by series of specific therapies, either in form of counseling, on basis of individual, expressive and insight-oriented therapy or dealing with interpersonal issues (interpersonal therapy), personality issues (dialectical behavioral therapy) or to maintain family cohesion in form of family therapy, marital conflicts in form of couple or marital therapy.
Therapist plays vital role in establishing alliance, support and is able to serve as a medium for a patient to discharge emotions. In many studies various processes have been identified as crucial in hindering expression. These processes include emotional inhibition and linguisticproblems.Conversion of emotional pain into verbal form offers mentalization of trauma and leads one towards problem solving approach.
| Psychodynamic Viewpoints|| |
“Talking things through” reflects open conversation which is not an indicator of narcissism but a productive exercise for managing difficult situations and understanding problems. Therapist mediates, processes, modifies information (given by patient) to correct cognitive distortions, emotional instability and replace negative beliefs and schemes with appropriate alternatives. In some mental disorders where bodies are mostly used as mean of ventilation and expression of emotions are better treated with “talking cure”, for example psycho-somatic disorders, conversion and eating disorders.
For all this work to be done therapist should process and evaluate his own level of satisfaction with life, work and experiences. In absence of this comfort, one survives throughout life with the demand of gratification, which tends to be filled by others in later life. In presence of unresolved conflicts, therapist can indulge in rescue fantasies and can go through intense preoccupation in sessions with patients having childhood trauma; reflecting their own self in patient's place and thus can detach from reality of patient's dynamics. High level of anxiety among therapists predicts higher chances of counter transference than less anxious therapists. Cohen defined therapist anxiety in settings where there is an involvement of situational factors or unresolved problems that is present in the therapist and communication of patient's anxieties to therapist. Thus, Self assessment is crucial before embarking upon therapy for any illness. Its significance can be outlined by incidents of boundary violations.
In psychiatry, patients are most gullible in hands of physician; because of their depressed state, impaired judgment, and call for dependence with an approach to obtain support from therapist. Patient's vulnerability for dependence and idealization somehow provoke the underlying instinct of self affirmation within therapist; and thus alliance can be modulated with respect to personal desire rather than established rules of psycho-therapeutic interventions.
Therapy is a process of change in which therapist internal state of cohesion is quite crucial. Usually malformed intra-psychic structures (formed in earlier phases of life) join together to build up self integrity; and dissolution of these structures are necessary for evolution of healthier self. But unfortunately, this dissolution predisposes one to loss self integrity which can be frightening and either consciously or unconsciously “Therapy of Therapist” remains quite difficult experience to be established.
Not only the childhood experiences, interpersonal account and personal coping of patient count in, but therapist also holds vital ground for contribution.
Childhood experiences of both Therapist and Patient are equally important; thus advice for resolution of therapist internal chaos comes first then patient, because contribution of traumatic past into current clinical picture of patient can malign the healing process. It is not uncommon that traumatic childhood experiences present in therapists’ life makes them more vulnerable for CT. They may take patients as a tool to vent out their frustration or prolong sessions to receive self gratification or enact rescuer fantasy in one way or another to repair injured self esteem.
Heinz kohut as psychoanalyst is well known for his theory of self psychology. He notes:
“There could be unhealthy expressions of the grandiose self that could develop when individuals failed to integrate grandiose ideas of themselves with realistic views of their failures and shortcomings. He felt that this was caused by a traumatic interruption of the healthy narcissistic development through parental “rejection and overindulgence” and that if the grandiose self had not evolved into a realistic sense of self worth “then the adult ego will tend to vacillate between an irrational overestimation of the self and feelings of inferiority and will react with narcissistic mortification to the thwarting of its ambitions”
| Case Vignette|| |
“Salma, 34 years old girl came to psychiatrist with presenting complaints of fear from sexual pain. Her marriage has not been consummated for 1 year (from time of marriage). Her husband has tried a lot for intimacy, but due to fear she withdraws herself by end of foreplay. This has been quite frustrating for him. Now her husband is tired of her. He wants to have second marriage. This is causing loss of self esteem and feeling of inadequacy within her. After proper history taking, examination and counseling, in 3rd session therapist advised patient to go for divorce, seeing husband's attitude of anger towards patient. This may serve as a reminder for therapist regarding her father's threats towards her mother, which has been a constant fear in her childhood.”
Many psychologists emphasized the crucial role of early mother – child attachment. It is significant for toddlers when he wants to explore world while at the same time feels in need to see mother constantly; where her eyes’ glow “refuel” him for “practicing” this separateness.
As Mahler writes:
“… The child in the rapprochement sub-phase (roughly from eighteen to twenty-four or thirty months) can be thought of as going through a double emotional crisis. The first is between the need for the mother as part of oneself and perception of the fact of separateness, with reality on the side of the latter, which ordinarily wins out. The second is between the child's wish to cling, on the one hand, and for autonomy on the other—a crisis in which reality testing does not figure as prominently and which can linger as an intra-psychic conflict.
Need of self-gratification in any therapy hinders its progressive nature; rather fixates it at oneplace.
The diagrammatic representation of therapeutic relationship progression of healing process [Figure 1] and in picture B, process is around point of fixation, where patient is idealizing therapist and therapist getting self affirmation in return. Both of them fulfilling each other needs but therapeutic process is static.
|Figure 1: The diagrammatic representation of therapeutic relationship progression of healing process|
Click here to view
It is as important for therapist to clarify his patients regarding these issues as much as he needs operative and preventive measures himself to understand this phenomenon.
Therapist unfulfilled needs could result in narcissism and grandiose sense of self that relies on patients for affirmation. Early recognition and supervision of these processes can prevent therapeutic process from violations or subjective judgments.
| Conclusion|| |
Unresolved conflicts of therapists may deteriorate therapeutic alliance, patient's relationships and may violate boundaries due to counter-transference. Rescue fantasies are part of therapists’ frustrations which they contain and introduce in therapy. These measures negatively affect patient's cognitive style, coping strategies and symptoms.
| Acknowledgment|| |
Dr. Riffat Muazzam Zaman, Professor, Department of Psychiatry, Aga Khan, University Hospital, Karachi, Pakistan
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