Tag: Body-Centred Countertransference

What is Vicarious Traumatisation?

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Introduction

Vicarious trauma (VT) was a term coined by McCann and Pearlman that is used to describe how working with traumatised clients and the effect it has on trauma therapists.

Previously, the phenomenon was referred to as secondary traumatic stress coined by Dr. Charles Figley. The theory behind VT is that the therapist has a profound world change and is permanently altered by the interaction of empathetic bonding with a client. This change is thought to have three conditional requirements: empathic engagement and exposure to graphic and traumatising material, the therapist being exposed to human cruelty, and re-enactment of trauma within the therapy process. This change can produce changes in a therapist’s sense of spirituality, worldview, and self-identity.

VT is still a subject of debate by theorists, with some saying it is based on the concept of countertransference (refer to transference), burnout, and compassion fatigue. McCann and Pearlman argue, however, that there is probably a relationship between these constructs, but VT is unique and distinct.

As time has progressed, the term VT has expanded to more than just indirect trauma experienced by trauma therapists and has come to include many more populations, although the phenomenon is still evolving.

Signs and Symptoms

The symptoms of vicarious trauma align with the symptoms of primary, actual trauma. When helping professionals attempt to connect with their clients/victims emotionally, the symptoms of VT can create emotional disturbance such as feelings of sadness, grief, irritability and mood swings. The signs and symptoms of VT parallel those of direct trauma, although they tend to be less intense. Workers who have personal trauma histories may be more vulnerable to VT, although the research findings on this point are mixed.

Common signs and symptoms include, but are not limited to:

  • Social withdrawal;
  • Mood swings;
  • Aggression;
  • Greater sensitivity to violence;
  • Somatic symptoms;
  • Sleep difficulties;
  • Intrusive imagery;
  • Cynicism;
  • Sexual difficulties;
  • Difficulty managing boundaries with clients; and
  • Core beliefs and resulting difficulty in relationships reflecting problems with security, trust, esteem, intimacy, and control.

Contributing Factors

VT, conceptually based in constructivist self-development theory, arises from an interaction between individuals and their situations. This means that the individual helper’s personal history (including prior traumatic experiences), coping strategies, and support network, among other things, all interact with his or her situation (including work setting, the nature of the work s/he does, the specific clientele served, etc.), to give rise to individual expressions of vicarious trauma. This in turn implies the individual nature of responses or adaptations to VT as well as individual ways of coping with and transforming it. Some have postulated that this traumatisation occurs when one’s view of the world or a feeling of safety is shattered by hearing about the experiences of their clients. This exposure to trauma, however indirectly, can cause an interruption to the daily functioning of the clinician reducing their effectiveness.

Anything that interferes with the helper’s ability to fulfil their responsibility to assist traumatised clients can contribute to vicarious trauma. Many human service workers report that administrative and bureaucratic factors that impediment to their effectiveness influence work satisfaction. Negative aspects of the organisation as a whole, such as reorganisation, downsizing in the name of change management and a lack of resources in the name of lean management, contribute to burned-out workers.

Vicarious trauma has also been attributed to the stigmatisation of mental health care among service providers. Stigma leads to an inability to engage in self care and eventually the service provider may reach burnout, and become more likely to experience VT. The research has also begun to show that vicarious trauma is more prominent in those with a prior history of trauma and adversity. Research indicates that a mental health provider’s defence style might pose as a risk factor for VT. Mental health providers with self-sacrificing defence styles have been found to experience increased VT.

Research has demonstrated that females are more likely to develop secondary traumatic stress than males and counsellors not in private practice are more likely to develop secondary traumatic stress. Those with stronger counsellor professional identity (CPI) experience less secondary traumatic stress as well.

Specifically, in emergency medical service (EMS) personnel, previous veteran status increased likelihood of experiencing VT.

While the term “vicarious trauma” has been used interchangeably with “compassion fatigue”, “secondary traumatic stress disorder,” “burnout,” “countertransference,” and “work-related stress,” there are important differences. These include the following:

  • Unlike compassion fatigue, VT is a theory-based construct. This means that observable symptoms can serve as the starting for a process of discovering contributing factors and related signs, symptoms, and adaptations. VT also specifies psychological domains that can be affected, rather than specific symptoms that may arise. This specificity may more accurately guide preventive measures and interventions, and allow for the accurate development of interventions for multiple domains (such as changes in the balance between psychotherapy and other work-related tasks and changes in self-care practices).
  • Countertransference is the psychotherapist’s response to a particular client. VT refers to responses across clients, across time.
  • Unlike burnout, countertransference, and work-related stress, VT is specific to trauma workers. This means that the helper will experience trauma-specific difficulties, such as intrusive imagery, that are not part of burnout or countertransference. The burnout and VT constructs overlap, specifically regarding emotional exhaustion. A worker may experience both VT and burnout, and each has its own remedies. VT and countertransference may also co-occur, intensifying each other.
  • Unlike VT, countertransference can be a very useful tool for psychotherapists, providing them with important information about their clients.
  • Work-related stress is a generic term without a theoretical basis, specific signs and symptoms or contributing factors, or remedies. Burnout and VT can co-exist. Countertransference responses may potentiate VT.
  • Vicarious post-traumatic growth, unlike VT, is not a theory-based construct but rather is based on self-reported signs.
  • Body-centred countertransference.

Mechanism

The posited mechanism for VT is empathy. Different forms of empathy may result in different effects on helpers. Batson and colleagues have conducted research that might inform trauma helpers about ways to manage empathic connection constructively. If helpers identify with their trauma survivor clients and immerse themselves in thinking about what it would be like if these events happened to them, they are likely to experience personal distress, feeling upset, worried, distressed. On the other hand, if helpers instead imagine what the client experienced, they may be more likely to feel compassion and moved to help.

Measurement

Over the years, VT has been measured in a wide variety of ways. VT is a multifaceted construct requiring a multifaceted assessment. More specifically, the aspects of VT that would need to be measured for a complete assessment include self capacities, ego resources, frame of reference (identity, world view, and spirituality), psychological needs, and trauma symptoms. Measuring of some of these elements of VT exist, including the following:

  • Psychological needs, using the Trauma and Attachment Belief Scale.
  • Self capacities, using the Inner Experience Questionnaire and/or the Inventory of Altered Self-Capacities.
  • Trauma symptoms, using the PTSD Checklist, Impact of Events Scale, Impact of Events Scale-Revised, children’s revised Impact of Events Scale (Arabic Version), Trauma Symptom Inventory, Detailed Assessment of Posttraumatic Stress, and/or the World Assumptions Scale.
  • Secondary Traumatic Stress Scale is a 17 item, 5-point Likert scale that distinguishes between PTSD measures by framing the questions as stressors from exposure to clients.
  • The Professional Quality of Life (ProQol) version 5. This assessment has 30 questions on a 5-point Likert scale and measures compassion fatigue and secondary trauma.

Addressing

VT is not the responsibility of clients or systems, although institutions that provide trauma-related services bear a responsibility to create policies and work settings that facilitate staff (and therefore client) well-being. Each trauma worker is responsible for self-care, working reflectively, and engaging in regular, frequent, trauma-informed professional confidential consultation.

There are many ways of addressing VT. All involve awareness, balance, and connection. One set of approaches can be grouped together as coping strategies. These include, for example, self-care, rest, escape, and play. A second set of approaches can be grouped as transforming strategies. Transforming strategies aim to help workers create community and find meaning through the work. Within each category, strategies may be applied in one’s personal life and professional life. Organisations that provide trauma services can also play a role in mitigating VT.

Research shows that many simple things increase happiness and this aids to lessen the impact of VT. People who are more socially connected tend to be happier. People who consciously practice gratitude are also shown happier. Creative endeavours that are completely detached with work also increase happiness. Self-care practices like yoga, qigong, and sitting meditation are found to be helpful for those who practice. The Harvard Business Review in a case study regarding to traumatisation stated that it is essential to create an organisational culture in which it is cool to be a social worker or a counsellor, where these professionals are empowered to influence the workplace issues, the strategy of human services in both corporate and care services. Additionally, research indicates clinicians who are exposed to VT are in need of targeted interventions that will boost their resilience. Findings have show interventions such as respite, increasing self efficacy, and having appropriate professional support buffer against the effects of vicarious trauma.

Individuals Found to Experience Vicarious Trauma

Children

Children have been found to experience VT from the traumas experienced by their caregivers and peers. In children the following factors have been found to predict vicarious trauma symptoms:

  • Socioeconomic status.
  • Gender (girls more than boys).
  • Race.
  • Witnessing the trauma directly.
  • Caregiver warmth and hostility.

Foster Parents

Foster parents have been found to experience VT related to the trauma of those they care for. Several studies have found that foster parents experience vicarious trauma, burnout, and compassion fatigue and report that emotional disengagement (a common symptom of VT) is a coping strategy.

Counsellors and Other Mental Health Providers

Counsellors and other mental health professional have been found to experience vicarious trauma when working with veterans and others that have experienced trauma. Some of the factors that predict vicarious trauma severity include:

  • Professional trauma.
  • Level of peer supervision.
  • Social support availability.
  • Emotional coping strategies.
  • Long hours and high caseloads.
  • Population served by the clinician.
  • Defensc mechanisms of the therapist.

American Muslims

After the terrorist attack on the World Trade Centre in the United States, many Muslims were relegated with terrorists and attacks of violence were perpetrated against them. This caused many individuals in this community to experience VT and added to a feeling of worry and being unsafe. Those feeling a stronger sense of religious identity were more likely to experience VT.

What is Body-Centred Countertransference?

Published on by Andrew Marshall2 Comments

Introduction

Body-centred countertransference involves a psychotherapist‘s experiencing the physical state of the patient in a clinical context.

Also known as somatic countertransference, it can incorporate the therapist’s gut feelings, as well as changes to breathing, to heart rate and to tension in muscles.

Refer to Countertransference.

Various Approaches

Dance therapy has understandably given much weight to the concept of somatic countertransference. Jungian James Hillman also emphasised the importance of the therapist using the body as a sounding-board in the clinical context.

Post-Reichian therapies like bioenergetic analysis have also stressed the role of the body-centred countertransference.

There is some evidence that narcissistic patients and those suffering from borderline personality disorder create more intense embodied countertransferences in their therapists, their personalities favouring such non-verbal communication by impact over more verbalised, less somatic interactions.

Orbach

Susie Orbach has written emotively of what she described as “wildcat sensations in my own body…a wildcat countertransference” in the context of body countertransference. She details her role responsiveness to one patient who evoked in her what she called “an unfamiliar body experience…this purring, reliable and solid body” to counterbalance the fragmented body image of the patient herself.

The Irish Experience

In Female Trauma Therapists

Irish psychologists at NUI Galway and University College Dublin have recently begun to measure body-centred countertransference in female trauma therapists using their recently developed ‘Egan and Carr Body-Centred Countertransference Scale’ (2005), a sixteen symptom measure.

Their research was influenced by developments in the psychotherapy world which was beginning to see a therapist’s role in a therapeutic dyad as reflexive; that a therapist uses their bodies and ‘self’ as a tuning fork to understand their client’s internal experience and to use this attunement as another way of being empathic with a client’s internal world. Pearlman and Saakvitne’s seminal book on vicarious traumatisation and the effect of trauma work on therapists has also been an important directional model for all researchers studying the physical effects of trauma work on a therapist.

High levels of body-centred countertransference have since been found in both Irish female trauma therapists and clinical psychologists.[16] This phenomenon is also known as ‘somatic countertransference’ or ’embodied countertransference’ and it links to how mirror neurons might lead to ‘unconscious automatic somatic countertransference’ as a result of postural mirroring by the therapist. Hamilton et al (2020) revisited BCT in a larger sample of 175 therapists (122 females) and that the a similar pattern of body-centred countertransference was reported as in the previous two studies. The most common being:

  • Muscle Tension: 81%;
  • Tearfulness: 78%;
  • Sleepiness: 72%;
  • Yawning: 69%;
  • Throat constriction: 46%;
  • Headache: 43%;
  • Stomach disturbance: 43%;
  • Unexpectedly shifting in body: 29%;
  • Sexual arousal: 29%;
  • Raised voice: 28%;
  • Aches in joints: 26%;
  • Nausea: 24%;
  • Dizziness: 20%; and
  • Genital pain: 7.5%.

The authors reported how previous researchers did not find BCT because surveys have previously failed to ask specifically about it, and have focused on emotional and cognitive and relational CT. The authors finally called for larger longitudinal studies and also larger sample sizes to allow a comparison of gender and orientation effects as well as whether higher levels affect levels of burnout and therapeutic engagement and treatment outcomes 26. Hamilton, L., Hannigan, B., Egan, J., Trimble, T., Donaghey, C., & Osborn, K. (2020). An exploration of body-centred countertransference in Irish Therapists. Clinical Psychology Today, 4(2), 26-38.

Loughran (2002) found that 38 therapists out of 40 who had responded to a questionnaire (which was distributed to a sample of 124 therapists) on a therapist’s use of body as a medium for transference and countertransference communication reported that they had experienced bodily sensations (nausea or churning stomach, sleepiness, shakiness, heart palpitations, sexual excitement, etc.) while in session with patients.

Frequency of Symptom Occurrence

A list of the frequency of occurrence of body-centred countertransference symptoms reported by trauma therapists (Sample A: 35 Female Irish Trauma therapists[20]) and Irish clinical psychologists (Sample B: 87 Irish Clinical Psychologists[21]) in the previous six months ‘when in-session with a client’ is given below in order of frequency:

  • Sleepiness (A; 92%, B; 76%).
  • Muscle Tension (A; 83%, B; 79%).
  • Yawning (A; 65%, B; 77%).
  • Unexpected shift in body (A; 77%, B; 57%).
  • Tearfulness (A; 71%, B; 61%).
  • Headache (A; 54%, B; 53%).
  • Stomach Disturbance (A; 41%, B; 46%).
  • Throat Constriction (A; 34%, B; 36%).
  • Raised Voice (A; 29%, B; 33%).
  • Dizziness (A; 26%, B; 19%).
  • Loss of voice (A; 32%, B; 18%).
  • Aches in joints (A; 37%, B; 18%).
  • Nausea (A; 23%, B; 18%).
  • Numbness (A; 29%, B; 15%).
  • Sexual Arousal (A; 26%, B; 11%).
  • Genital pain (A; 6%, B; 2%).

Somatisation

A small but significant relationship was found between female trauma therapists’ level of body-centred countertransference and number of sick leave days taken, suggesting a possible relationship between uncensored body-centred countertransference and somatization. This relationship was not however found in clinical psychologists who were working mainly with a non-trauma population. Therapists have noted the connection between a tendency for some clients to express emotional discomfort by focusing on bodily symptoms rather than being able to put their emotional distress into words. It is thought that such processes are more common in people who have experienced childhood abuse and trauma.

Recent research which measured female genital arousal in response to rape cues found that women when listening to rape, consent or violence developed genital arousal more frequently than men. It also might explain the relatively frequent reported experience of sexual arousal amongst Irish female trauma therapists. Further validation of body-centred countertransference in psychologists and therapists is on-going in both NUI Galway and Trinity College Dublin.

Cautions

Therapists have been warned against assuming too automatically that their body-feelings always involve somatic resonance to the client, as opposed to being produced from their own feelings/experiences – the same problem appearing with countertransference generally.

What is Countertransference?

Published on by Andrew Marshall9 Comments

Introduction

Countertransference is defined as redirection of a psychotherapist‘s feelings toward a client – or, more generally, as a therapist’s emotional entanglement with a client.

Refer to Transference and Body-Centred Countertransference.

Early Formulations

The phenomenon of countertransference (German: Gegenübertragung) was first defined publicly by Sigmund Freud in 1910 (The Future Prospects of Psycho-Analytic Therapy) as being “a result of the patient’s influence on [the physician’s] unconscious feelings”; although Freud had been aware of it privately for some time, writing to Carl Jung for example in 1909 of the need “to dominate ‘counter-transference’, which is after all a permanent problem for us”. Freud stated that since an analyst is a human himself he can easily let his emotions into the client. Because Freud saw the countertransference as a purely personal problem for the analyst, he rarely referred to it publicly, and did so almost invariably in terms of a “warning against any countertransference lying in wait” for the analyst, who “must recognize this countertransference in himself and master it”. However, analysis of Freud’s letters shows that he was intrigued by countertransference and did not see it as purely a problem.

The potential danger of the analyst’s countertransference – “In such cases, the patient represents for the analyst an object of the past on to whom past feelings and wishes are projected” – became widely accepted in psychodynamic circles, both within and without the psychoanalytic mainstream. Thus, for example, Jung warned against “cases of counter-transference when the analyst really cannot let go of the patient…both fall into the same dark hole of unconsciousness”. Similarly Eric Berne stressed that “Countertransference means that not only does the analyst play a role in the patient’s script, but she plays a part in his…the result is the ‘chaotic situation’ which analysts speak of”. Lacan acknowledged of the analyst’s “countertransference…if he is re-animated the game will proceed without anyone knowing who is leading”.

In this sense, the term includes unconscious reactions to a patient that are determined by the psychoanalyst’s own life history and unconscious content; it was later expanded to include unconscious hostile and/or erotic feelings toward a patient that interfere with objectivity and limit the therapist’s effectiveness. For example, a therapist might have a strong desire for a client to get good grades in university because the client reminds her of her children at that stage in life, and the anxieties that the therapist experienced during that time. Even in its most benign form, such an attitude could lead at best to “a ‘countertransference cure’…achieved through compliance and a ‘false self’ suppression of the patient’s more difficult feelings”.

Another example would be a therapist who did not receive enough attention from her father perceiving her client as being too distant and resenting him for it. In essence, this describes the transference of the treater to the patient, which is referred to as the “narrow perspective”.

Middle Years

As the 20th century progressed, however, other, more positive views of countertransference began to emerge, approaching a definition of countertransference as the entire body of feelings that the therapist has toward the patient. Jung explored the importance of the therapist’s reaction to the patient through the image of the wounded physician: “it is his own hurt that gives the measure of his power to heal”. Heinrich Racker emphasised the threat that “the repression of countertransference…is prolonged in the mythology of the analytic situation”. Paula Heimann highlighted how the “analyst’s countertransference is not only part and parcel of the analytic relationship, but it is the patient’s creation, it is part of the patient’s personality”. As a result, “counter-transference was thus reversed from being an interference to becoming a potential source of vital confirmation”. The change of fortune “was highly controversial. Melanie Klein disapproved on the grounds that poorly analysed psycho-analysts could excuse their own emotional difficulties” thereby; but among her younger followers “the trend within the Kleinian group was to take seriously the new view of counter-transference” – Hanna Segal warning in typically pragmatic fashion however that “Countertransference can be the best of servants but is the most awful of masters”.

Late Twentieth-Century Paradigm

By the last third of the century, a growing consensus appeared on the importance of “a distinction between ‘personal countertransference’ (which has to do with the therapist) and ‘diagnostic response’ – that indicates something about the patient…diagnostic countertransference”. A new belief had come into being that “countertransference can be of such enormous clinical usefulness….You have to distinguish between what your reactions to the patient are telling you about his psychology and what they are merely expressing about your own”. A distinction between “neurotic countertransference” (or “illusory countertransference”) and “countertransference proper” had come (despite a wide range of terminological variation) to transcend individual schools. The main exception is that for “most psychoanalysts who follow Lacan’s teaching…counter-transference is not simply one form of resistance, it is the ultimate resistance of the analyst”.

The contemporary understanding of countertransference is thus generally to regard countertransference as a “jointly created” phenomenon between the treater and the patient. The patient pressures the treater through transference into playing a role congruent with the patient’s internal world. However, the specific dimensions of that role are coloured by treater’s own personality. Countertransference can be a therapeutic tool when examined by the treater to sort out who is doing what, and the meaning behind those interpersonal roles (The differentiation of the object’s interpersonal world between self and other). Nothing in the new understanding alters of course the need for continuing awareness of the dangers in the narrow perspective – of “serious risks of unresolved countertransference difficulties being acted out within what is meant to be a therapeutic relationship”; but “from that point on, transference and counter-transference were looked upon as an inseparable couple…’total situation'”.

Twenty-First-Century Developments

Further developments in the current century might be said to be the increased recognition that “Most countertransference reactions are a blend of the two aspects”, personal and diagnostic, which require careful disentanglement in their interaction; and the possibility that nowadays psychodynamic counsellors use countertransference much more than transference – “another interesting shift in perspective over the years”. One explanation of the latter point might be that because “in object relations therapy…the relationship is so central, ‘countertransference’ reactions are considered key in helping the therapist to understand the transference”, something appearing in “the post-Kleinian perspective…[as] Indivisible transferencecountertransference”.

Body-Centred Countertransference

Psychologists at NUI Galway and University College Dublin have recently begun to measure body-centred countertransference in female trauma therapists using their recently developed “Egan and Carr Body Centred Countertransference Scale”, a sixteen symptom measure. High levels of body-centred countertransference have since been found in both Irish female trauma therapists and clinical psychologists. This phenomenon is also known as “somatic countertransference” or “embodied countertransference” and links to mirror neurons and automatic somatic empathy for others due to the actions of these neurons have been hypothesised.