countertransference and related experiences of ... · kathy sullivan phd, marie tomeo phd, paul...
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Countertransference and Related Experiences of Psychologists
Serving Suicidal Patients: Implications for Training and Supervision
Perry A. Staltaro
DISSERTATION.COM
Boca Raton
Countertransference and Related Experiences of Psychologists Serving Suicidal Patients: Implications for Training and Supervision
Copyright © 2001 Perry A. Staltaro All rights reserved. No part of this book may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the publisher.
Dissertation.com
Boca Raton, Florida USA • 2010
ISBN-10: 1-59942-300-6
ISBN-13: 978-1-59942-300-5
iii
DEDICATION
For my loving wife, Shirley, my parents, Pat and Maria,
my sister Rose, my brother John, and my dear companions Bon,
Bianca, Anna and Nene.
“This is a narrative of very heavy duty proportions...”
Dr. Teeth, “The Muppet Movie”
iv
ACKNOWLEDGMENTS
This dissertation was an enormous undertaking and it
would not have been possible to do this without the
substantial support of my wife, Shirley Staltaro Psy.D, and
my parents, Pat and Maria Staltaro. I cannot accurately
emphasize how they directly, unsparingly and
uncompromisingly contributed. They provided me with every
conceivable support. Mom, Dad, and Shirley--please accept
my most heart-felt gratitude and appreciation.
In addition, I would like to acknowledge the
substantial contributions of my dissertation chairman and
professor, Thomas W. Shaffer, Ph.D. His work in suicidology
is renowned in our community as is his integrity and
dedication to our field. Dr. Shaffer inspired this project
and followed its growth through countless and massive
drafts, and his efforts deserve recognition.
Also, I express my appreciation to over three hundred
and sixty psychologists across the nation who took the time
to openly disclose their reactions, experiences, thoughts
and wisdom regarding their work with suicidal clients.
I also extend my warmest gratitude to the exceptional
individuals who contributed to my growth as a person and a
professional: Errol Leifer PhD, Susan Orovitz PhD,
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Kathy Sullivan PhD, Marie Tomeo PhD, Paul Gardecki, Keith
Lyons, and the many others who offered the wisdom and
courage to glance further than I ever thought possible. To
approach the appropriate expression of thanks due to them
would necessitate increasing the volume of this dissertation
beyond the capacity of our humble library. Allow me to
spare the backs of our librarians and suffice to say, Thank
You.
Finally, let it be said that those who take on the
challenge of working with those whose lives hang in the
balance of intrapsychic ambivalence deserve the utmost
recognition for the burden they undertake. Societal and
professional expectations have been laid down that place the
responsibility of life and death into their hands,
regardless of their capacity to determine either outcome.
These men and women risk personal and professional outcast
through an arbitrary and misinformed judicial process that
hastily casts blame with neither rhyme nor reason. Out of
contradiction, misshaped roles, and whimsically constructed
ideals has emerged a series of phenomena that rest not so
subtly on their shoulders. To you, my colleagues, I say
continue to fight your good fight and “rage, rage, against
the dying of the light.”
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ABSTRACT OF THE DISSERTATION
Countertransference and Related Experiences of Psychologists
Serving Suicidal Patients: Implications
for Training and Supervision
by
Perry Anthony Staltaro
California School of Professional Psychology, Fresno Campus
Thomas W. Shaffer, PhD
Dissertation Committee Chairperson
1999
This study examined countertransference and other
experiences of therapists serving suicidal patients. A
survey was constructed to assess for aversion, narcissistic
injury and similar iatrogenic constructs. Participants
offered both Likert scale responses and spontaneous
unstructured comments. Likert data were analyzed
quantitatively. Content and phenomenological analyses were
applied to the comments. The findings suggest that a
substantial number of therapists treating suicidal patients
experience negative countertransferences. The implications
for training, treatment and supervision are discussed.
vii
TABLE OF CONTENTS
Page DEDICATION . . . . . . . . . . . . . . . . . . . . . iii ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . iv
ABSTRACT OF THE DISSERTATION . . . . . . . . . . . . vi
LIST OF TABLES . . . . . . . . . . . . . . . . . . . xvii
Chapter
1. INTRODUCTION. . . . . . . . . . . . . . . . 1
2. LITERATURE REVIEW . . . . . . . . . . . . . 5 Introduction. . . . . . . . . . . . . 5
The Risks of Treating a Suicidal Patient . . . . . . . . . . . . . . . 8
The Effect of a Patient’s Suicide on
the Therapist . . . . . . . . . . . . 15
Patient Communication of Suicidal Intent. . . . . . . . . . . . . . . . 19
Projective Identification . . . . . . 24
Introjective Identification . . . . . 30
Projective Identification
and Diagnosis . . . . . . . . . . . . 32
Projective Identification and Implications for Treatment, Training and Supervision . . . . . . . . . . . 36
Countertransference Experiences . . . 40
The Rescuer Role of the Therapist . . 45
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Chapter Page
Manipulation and Blackmail . . . . . 56
Countertransference Reactions . . . . 58
Malignant Alienation . . . . . . . . 68
Therapist Anxiety and the Patient . . 69
Countertransference Hate . . . . . . 73
Avoidance, Aversion and Reaction Formation . . . . . . . . . . . . . . 84
Projection of Countertransference
Hatred. . . . . . . . . . . . . . . . 96
Patient Ambivalence Toward Therapy. . 97
Countertransference Management. . . . 99
The Suicidal Therapist. . . . . . . . 103
Treatment Techniques Using Countertransference . . . . . . . . . 108
Therapist Training. . . . . . . . . . 113
Therapist Self-Care . . . . . . . . . 114
In-Patient Staff Countertransference. 117
Stress/Burnout. . . . . . . . . . . . 121
Case Management . . . . . . . . . . . 122
Cultural Differences in Suicide
Attitudes . . . . . . . . . . . . . . 126
Survey Design . . . . . . . . . . . . 127
The Research Purpose. . . . . . . . . 129
Summary . . . . . . . . . . . . . . . 131
ix
Chapter Page
3. METHOD. . . . . . . . . . . . . . . . . . 132
Participants and Procedures . . . . . 132
Protection of Human Participants. . . 133
Instrument. . . . . . . . . . . . . . 134
Hypotheses. . . . . . . . . . . . . . 135
Data Analysis . . . . . . . . . . . . 137
4. RESULTS . . . . . . . . . . . . . . . . . 141
Preliminary Listing of Statistics . . 142
Demographics. . . . . . . . . . . . . 143
Writer’s Caveat of Interpretation . . 146
Format of Presentation of Results . . 147
Descriptive Analysis of Each Construct and Respective Items. . . . 152
Aversion. . . . . . . . . . . . . . . 152
Item 4: “I experienced disappointment when the client arrived for their appointment.” . . . 152 Item 5: “Sometimes I wished the client would go to another therapist, move, or just go away.” . . . . . . . 156
Item 6: “I often found myself anticipating the end of the session.” . . . . . . . . . . . . . . 158 Item 8: “I felt a sense of compassion toward the client.” . . . 159
x
Chapter Page Item 12: “I would work with this/these client/s similar clients in the future.” . . . . . . . 161 Item 13: “During sessions, I found myself glancing toward the clock, daydreaming, or feeling bored.” . . . 163 Item 19: “During sessions I had difficulty keeping my attention on the client.”. . . . . . . . . . . . . . . 165 Item 22: “There were times when I regretted having accepted the client into therapy with me.”. . . . . . . . 166 Item 23: “During sessions, I felt a sense of closeness toward the client.”. . . . . . . . . . . . . . . 167 Item 26: “I would like to work with this or similar clients again in the future.”. . . . . . . . . . . . . 169 Item 28: “I often yawned, felt sleepy or tired during sessions with the client.”. . . . . . . . . . . . . 170 Item 29: “I experienced apathy toward the client.” . . . . . . . . . 172 Item 30: “I considered terminating and referring the client to another therapist.” . . . . . . . . . . . . . 173 Introjective Identification Scale . . 175 Item 9: “During treatment of the client, I experienced feelings of sadness.” . . . . . . . . . . . . . . 175 Item 10: “While treating the client I often felt a sense of hopelessness.”. . . . . . . . . . . . 177
xi
Chapter Page Item 11: “During sessions, I experienced unusual somatic symptoms.”. . . . . . . . . . . . . . 180 Item 17: “I experienced suicidal thoughts.”. . . . . . . . . . . . . . 181 Item 20: “During sessions, there were often times when I felt annoyed.” . . . . . . . . . . . . . . 182
Malice Scale. . . . . . . . . . . . . 184
Item 7: “I was bitter or resentful Toward the client.” . . . . . . . . . 184
Item 25: “I often felt angry with the client.”. . . . . . . . . . . . . 187 Item 31: “I have never had an angry fantasy about the client” . . . . . . 189
Narcissistic Injury Scale . . . . . . 190
Item 2: “I often felt overwhelmed while treating the client”. . . . . . 190 Item 3: “I felt particularly anxious before, during or after sessions with the client.”. . . . . . . . . . . . . 193 Item 14: “Treating the client, I experienced feelings of professional failure.”. . . . . . . . . . . . . . 195 Item 15: “I am bothered when a client does not like me.” . . . . . . 197 Item 16: “I experienced thoughts or feelings of inadequacy while treating the client.” . . . . . . . . . . . . 199
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Chapter Page Item 18: “I felt like the client was trying to punish me.” . . . . . . . . 201 Item 21: “I believe the client used the threat of suicide as a means to manipulate me.” . . . . . . . . . . . 202 Item 27: “The client was manipulative toward me.”. . . . . . . 205 Item 32: “I worried my license might be revoked if the patient committed suicide.” . . . . . . . . . . . . . . 206 Item 34: “During sessions, I often felt apologetic.” . . . . . . . . . . 208 Item 35: “While treating this client, I experienced myself as a highly capable and competent therapist.” . . . . . . . . . . . . . 209 Suppression Scale . . . . . . . . . . 210 Item 33: “It is likely that I may have a future client commit suicide.” 211 Reaction Formation Scale. . . . . . . 212 Item 24: “I would often extend the session time with the client.” . . . 212 General Comments. . . . . . . . . . . 214
5. DISCUSSION. . . . . . . . . . . . . . . . 229
Demographics Discussion . . . . . . . 231 Item 4: “I experienced disappointment when the client arrived for their appointment.” . . . 236
xiii
Chapter Page Item 5: “Sometimes I wished the client would go to another therapist, move, or just go away.” . . . . . . . 237 Item 30: “I considered terminating and referring the client to another therapist.” . . . . . . . . . . . . . 238 Item 6: “I often found myself Anticipating the end of the session.” 239 Item 8: “I felt a sense of compassion toward the client.”. . . . 240 Item 12: “I would work with this/these client/s or similar clients in the future.” . . . . . . . 242 Item 26: “I would like to work with this or similar clients again in the future.”. . . . . . . . . . . . . . . 243 Item 13: “During sessions, I found myself glancing toward the clock, daydreaming, or feeling bored.” . . . 244 Item 28: “I often yawned, felt sleepy or tired during sessions with the client.” . . . . . . . . . . . . 245 Item 19: “During sessions I had difficulty keeping my attention on the client.” . . . . . . . . . . . . 246 Item 22: “There were times when I regretted having accepted the client into therapy with me.”. . . . . . . . 247 Item 23: “During sessions, I felt a sense of closeness toward the client.”. . . . . . . . . . . . . . . 248
xiv
Chapter Page Item 29: “I experienced apathy toward the client.” . . . . . . . . . 248
Introjective Identification Scale . . 250 Item 9: “During treatment of the client, I experienced feelings of sadness.” . . . . . . . . . . . . . . 251 Item 10: “While treating the client I often felt a sense of hopelessness.” . . . . . . . . . . . 254 Item 11: “During sessions, I experienced unusual somatic symptoms.” . . . . . . . . . . . . . 255 Item 17: “I experienced suicidal thoughts.” . . . . . . . . . . . . . 257 Item 20: “During sessions, there were often times when I felt annoyed.” . . . . . . . . . . . . . . 260
Malice Scale. . . . . . . . . . . . . 261 Item 7: “I was bitter or resentful toward the client.” . . . . . . . . . 263 Item 25: “I often felt angry with the client.” . . . . . . . . . . . . 265 Item 31: “I have never had an angry fantasy about the client.” . . . . . 266
Narcissistic Injury Scale . . . . . . 267
Item 2: “I often felt overwhelmed while treating the client.” . . . . . 268 Item 3: “I felt particularly anxious before, during or after sessions with the client.” . . . . . . . . . . . . 270
xv
Chapter Page Item 14: “Treating the client, I experienced feelings of professional failure.” . . . . . . . . . . . . . . 271 Item 15: “I am bothered when a client does not like me.” . . . . . . 272 Item 16: “I experienced thoughts or feelings of inadequacy while treating the client.”. . . . . . . . . . . . . 275 Item 35: “While treating this client, I experienced myself as a highly capable and competent therapist.”. . . . . . . . . . . . . 277 Item 34: “During sessions, I often felt apologetic.”. . . . . . . . . . 278 Item 18: “I felt like the client was trying to punish me.”. . . . . . 279 Item 21: “I believe the client used the threat of suicide as a means to manipulate me.” . . . . . . . . . . 281 Item 27: “The client was manipulative toward me.” . . . . . . 283 Item 32: “I worried my license might be revoked if the patient committed suicide.” . . . . . . . . 285 Suppression . . . . . . . . . . . . 286 Item 33: “It is likely that I may have a future client commit suicide.”. . . . . . . . . . . . . . 286 Reaction Formation . . . . . . . . . 288 Item 24: “I would often extend the session time with the client.” . 288
Discussion of the Survey Overall . . 290
xvi
Page REFERENCES . . . . . . . . . . . . . . . . . . . 314
APPENDICES . . . . . . . . . . . . . . . . . . . 327
A. Table of Constructs . . . . . . . . . . 328
B. Research Instruments . . . . . . . . . . 337
C. Quantitative Analysis. . . . . . . . . . 345
D. Content Analysis . . . . . . . . . . . . 405
E. Phenomenological Analysis. . . . . . . . 459
Epoche. . . . . . . . . . . . . . . 460
General Comments. . . . . . . . . . 462
F. Writer’s Final Comments. . . . . . . . . 640
xvii
LIST OF TABLES
Table Page 1. Aversion Construct Survey Items . . . . . . 153 2. Introjective Identification Scale . . . . . 176 3. Malice Scale. . . . . . . . . . . . . . . . 185 4. Narcissistic Injury Scale . . . . . . . . . 191 5. Aversion Scale. . . . . . . . . . . . . . . 234 6. Introjective Identification Scale . . . . . 252 7. Malice Scale. . . . . . . . . . . . . . . . 262 8. Narcissistic Injury Scale . . . . . . . . . 269 9. Table of Constructs . . . . . . . . . . . . 329 10. Demographics . . . . . . . . . . . . . . . 346 11. Year First Doctoral License Was Received. . 347 12. Total Years of Having Practiced Psychotherapy . . . . . . . . . . . . . . . 348 13. Primary Employment Setting . . . . . . . . 349 14. Orientation and Specialization . . . . . . 350 15. APA Membership . . . . . . . . . . . . . . 351 16. Current Caseload . . . . . . . . . . . . . 352 17. f Distribution of Likert Responses to Scale Items . . . . . . . . . 353 18. P Distribution of Likert Responses to Scale Items . . . . . . . . . 357 19. Survey Item Analysis. . . . . . . . . . . . 361 20. Skewness and Kurtosis . . . . . . . . . . . 363
xviii
Table Page 21. Correlations of Scales to Demographics and Scale Items . . . . . . . . . . . . . . 365 22. Inter-Item Correlations Sorted by Strength of Correlation . . . . . . . . . . 368 23. Demographics Correlations . . . . . . . . . 378 24. Inter-Item Correlations, Complete Listing . 379 25. Complete Listing of Inter-Item rs . . . . . 393 26. Content Analysis: Elaborations to Survey Items . . . . . . . . . . . . . . . . . . . 406 27. Content Analysis: Elaborations Assigned to Primary and Secondary Content . . . . . . . 437 28. Transformation of General Comments to Meaning Units . . . . . . . . . . . . . . . 463 29. Transformation of Meaning Units to Themes . 485 30. Transformation of Survey Item Comments to
Meaning Units . . . . . . . . . . . . . . . 502 31. Transformation of Meaning Units into Themes 581 32. Results of Likert Responses to Survey Items . . . . . . . . . . . . . . . . . . . 634
xix
“During those months I didn’t really hate you. I just hated
everything you stood for--insight, care and hope.” --”Sarah”
(Gorney, 1979, p. 322).
1
Chapter 1
INTRODUCTION
This study seeks to explore the personal reactions and
experiences of therapists who work with moderately to highly
suicidal patients. The cognitive, affective, and behavioral
reactions of therapists will be examined as aspects of the
countertransference with special attention to projective
identification.
A working definition of countertransference has been
offered by Slackter (1987). After an extensive review of
the widely ranging uses of the term, he writes that
Countertransference concerns those personalized emotional responses each analyst makes to a broad range of individual patients in a wide variety of situations during various phases of treatment. While in themselves neither inherently positive nor negative, these responses can promote or hinder the therapeutic process, and it is from this effect that they derive their value, and ultimately their meaningfulness.
Such meaningfulness can hardly be overstated in terms of
treatment efficacy, especially in regards to the treatment
of the highly suicidal patient. These internal, personal,
and affect-laden experiences have the capacity to propel or
destroy the therapeutic alliance (Slackter, 1987).
2
Therapists, given their training, and the very nature
of true human empathy cannot avoid entanglement with the
powerful and moving world of patients whose lives are in the
balance (Maltsberger, 1994). At times the therapist’s
cognitive, affective, and behavioral experience will elicit
an iatrogenic reaction toward clients that may exacerbate
suicidality (Maltsberger, 1994).
Explanations for suicide include that it can serve as
an act of violent retaliation, a desperate plea for help, or
a final resolution to hopelessness (Beck, Kovacs, &
Weissman, 1975; Maltsberger, 1994). Each involves a fantasy
of interpersonal interaction highly charged with elements of
intimacy, rage, and abandonment. The patient who threatens
suicide sets the context for an involved, and intense,
patient-therapist interpersonal reaction. Naturally,
therapists are inclined to assume a defensive stance once
they have considered the possible consequences should the
patient commit suicide while under their care.
As Olin (1976) remarked, the therapist is in a delicate
balance of confirming the suicidal patient’s responsibility
without being rejecting or rescuing toward him or her. The
therapist’s capacity to maintain this balance is influenced
in part by the manner in which the therapist manages
countertransference (Maltsberger, 1994; Olin, 1976).
3
Of particular interest in this study is a specific type
of countertransference, which is the therapist’s use of
introjective identification in response to a patient’s use
of projective identification. Projective identification is
a process by which the patient projects an aspect of the
self or its objects (Scharff, 1992). More simply, patients
project an aspect of themselves upon the therapist and via
unconscious processes manipulate the therapist to act in
concordance with the projection. Through projective
identification, the suicidal patient induces the clinician
to play the roles of rescuer, abandoner, and even sadist
(Flarsheim, 1975; Gorkin, 1987; Jensen & Petty, 1958;
Maltsberger, 1994). Introjective identification is the
process by which the therapist identifies with the projected
part of the patient and subsequently introjects it (Scharff,
1992).
How the therapist manages the patient’s projected
material often has direct and significant implications for
efficacy of the treatment (Ogden, 1979; Scharff, 1992). For
example, in one study, which is later reviewed, 6% of cases
in which a patient committed suicide involved clear and
substantial therapeutic errors that stemmed from therapist
behaviors related to negative countertransferences
(Modestin, 1987). The implications are that if the treating
4
therapists had been more closely attuned to their own
countertransference they would not have made such serious
treatment errors (Modestin, 1987).
It is the aspiration of this dissertation to illustrate
the common countertransference experiences therapists report
when working with suicidal patients. At present, the
literature lacks collected self-disclosures and what exists
is theory based on case studies, individual self-reports,
and anecdotal evidence.
This study collects anonymous therapist self-
disclosures regarding the cognitive, affective, and
behavioral experiences they had while working with suicidal
patients. Additionally, this study explores how the
personal reactions and experiences therapists report compare
with the existing literature. Such research may aid in
continued theory development and offer practical information
to therapists and supervisors on understanding the
commonalties of the countertransferences toward suicidal
patients.
5
Chapter 2
LITERATURE REVIEW
Introduction
This literature review will offer an in-depth
exploration of the countertransference experiences of
therapists treating suicidal patients. Foremost to be
considered is the conscious risk the therapist assumes in
entering the treatment arrangement. Inherent to accepting
the suicidal patient into therapy are several personal,
professional, and legal risks. Following this will be a
discussion of the concepts of projective and introjective
identification in relation to the treatment of the suicidal
patient. Implications for therapist training, case
management, and supervision are discussed.
The specific countertransference experiences that
therapists have reported when treating suicidal patients are
examined. These include rescuing-behaviors, hate, aversion,
avoidance, and multiple other reactions. The therapist’s
specific countertransference and the associated patient
intra-psychic and behavioral patterns are then explored.
The effect of introjective identification upon the therapist
is studied, particularly in regard to the concept that
performing psychoanalysis is suicidogenic. The therapist’s
6
use of countertransference is explored in terms of potential
for diagnosis and various therapeutic techniques. Case
management issues including in-patient staff management,
consultation, therapist self-care, burnout stress, and the
legal implications of negative therapist behaviors based
upon unexamined or unresolved countertransference matters
are also discussed.
It has been written that “death is the ongoing enemy of
the physician,” and though the physician may postpone death,
he may never stop it altogether (Schwartz, Flinn, & Slawson,
1979). From the outset lies a particular challenge when the
agents of death are suicidal impulses within the patient.
Making the matter worse, the unconscious, which stirs such
impulses, may be oblivious to the threat of suicidality.
This perspective was taken by Freud when he wrote that “Our
unconscious . . . does not believe in its own death; it
behaves as if it were immortal . . . there is nothing
instinctual in us which responds to a belief in death”
(Freud, 1961c, p. 288).
Before exploring the literature regarding the treatment
of the suicidal patient, a brief exploration of the
definition and degrees of suicidality will be offered. In
1897, Emile Durkheim defined suicide as “all cases of death
resulting directly or indirectly from a positive or negative