Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Countertransference. Show all posts
Showing posts with label Countertransference. Show all posts

Saturday, February 11, 2023

Countertransference awareness and treatment outcome

Abargil, M., & Tishby, O. (2022). 
Journal of counseling psychology,
69(5), 667–677.
https://doi.org/10.1037/cou0000620

Abstract

Countertransference (CT) is considered a central component in the therapy process. Research has shown that CT management does not reduce the number of CT manifestations in therapy, but it leads to better therapy outcomes. In this study, we examined therapists' awareness of their CT using a structured interview. Our hypotheses were (a) treatments in which therapists were more aware of their CT would have a better outcome and (b) different definitions of CT would be related to different therapy outcomes. Twenty-nine patients were treated by 19 therapists in 16 sessions of short-term psychodynamic therapy. We used the core conflictual relationship theme to measure CT, a special interview was developed to study CT awareness. Results show that awareness of CT defined as the relationship with the patient moderated 10 outcome measures and awareness of CT defined as the relationship with the patient that repeats therapist conflicts with significant others moderated three outcome measures We present examples from dyads in this study and discuss how awareness can help the therapist talk to and handle patient challenges.

From the Discussion section

Increased therapist awareness of CT facilitate improvement in patient symptoms, emotion regulation and affiliation in relationships. Since awareness is an integral part of CT management, these findings are consistent with Hayes’ results from 2018 regarding the importance of CT management and its contribution to treatment outcome. Moreover, therapist’s self-awareness was found to be important in treating minorities (Baker, 1999). This study expands the ecological validity of therapist awareness and shows that the therapists’ awareness of their own wishes in therapy, as well as his perception of himself and the patient, is relevant to the general population as well. Thus, therapists of all theoretical orientations are encouraged to attend to their personal conflicts and to monitor their reactions to patients as a routine part of effective clinical practice. Moreover, therapist awareness has been found in the past to lead to less therapist self-confidence, but to better treatment outcomes (Williams, 2008). Our clinical examples illustrate these findings (the therapist who had high awareness showed much more self- doubt) and the results of multilevel regression analysis demonstrate better improvement for patients whose therapists were highly aware. Interestingly, the IIP control dimension was not found to be related to the therapist’s awareness of CT. It may be that since this dimension relates to the patient’s control need, the awareness of transference is more important. Another possibility is that the patient’s experience of the therapist as “knowing” may actually increase his control needs. Moreover, regarding patient main TC, we only found a trend and not a significant interaction. One reason may be the sample size. Another explanation is that patients do not necessarily link the changes in their lives to the relationship with the therapist and the insights associated with it. Thus, although awareness of CT helps to improve other outcome measures, it is not related to the way patients feel about the reason they sought out treatment.

A recent study of CT found that negative types of CT were correlated with more ruptures and less repair in the alliance. For positive CT the picture is more complex; Positive patterns predicted resolution when the therapists repeated positive patterns with par- ents but predicted ruptures when they tried to “repair” negative patterns with the parents (Tishby & Wiseman, 2020). The authors suggest that awareness of CT will help the therapist pay more attention to ruptures during treatment so they can address it and initiate resolutions processes. Our findings support the authors’ suggestion. The clinical example demonstrates that when the therapist was aware of negative CT and was able to talk about it in the awareness interview, he was also able to address the difficult feelings that arose during a session with the patient. Moreover, the treatment outcomes in these treatments were better which characterizes treatments with proper repair processes.

Sunday, October 11, 2020

Psychotherapy With Suicidal Patients Part 2: An Alliance Based Intervention for Suicide

E. M. Plakun
Psychiatric Practice
January 2019 - Volume 25: Issue 1, 41-45

Abstract

This column, which is the second in a 2-part series on the challenge of treating patients struggling with suicide, reviews one psychodynamic approach to working with suicidal patients that is consistent with the elements shared across evidence-based approaches to treating suicidal patients that were the focus of the first column in this series. Alliance Based Intervention for Suicide is an approach to treating suicidal patients developed at the Austen Riggs Center that is not manualized or a stand-alone treatment, but rather it is a way of establishing and maintaining an alliance with suicidal patients that engages the issue of suicide and allows the rest of psychodynamic therapy to unfold.

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From the Conclusion

There is no magic in ABIS (Alliance Based Intervention for Suicide), and it will not work in all cases, but these principles are effective in making suicide an interpersonal issue with meaning in the relationship. This allows direct engagement of the issue of suicide in the therapeutic relationship and direct discussion of the central question of whether the patient can and will commit to the work. ABIS supports the therapist in efforts to assess whether the therapist has the will and the wherewithal to meet the patient’s anger and hate, as manifested by suicide, as fully as the therapist is prepared to meet the patient’s love and attachment. Neither side of the transference alone is adequate in work with suicidal patients.

There are no randomized trials of ABIS, but it is a way of working that has evolved at Austen Riggs over the course of a hundred years. In a study of previously suicidal patients at Riggs, at an average of 7 years after admission, 75% were free of suicidal behavior as an issue in their lives.6 These patients were considered “recovered” rather than “in remission,” using the same slope-intercept mathematical modeling as in cancer research. These findings offer encouraging support for the value of ABIS as an intervention to add to psychodynamic psychotherapy as a way to establish and maintain a viable therapeutic alliance with suicidal patients.

The article is here.

Monday, October 15, 2018

ICP Ethics Code

Institute of Contemporary Psychoanalysis

Psychoanalysts strive to reduce suffering and promote self-understanding, while respecting human dignity. Above all, we take care to do no harm. Working in the uncertain realm of unconscious emotions and feelings, our exclusive focus must be on safeguarding and benefitting our patients as we try to help them understand their unconscious mental life. Our mandate requires us to err on the side of ethical caution. As clinicians who help people understand the meaning of their dreams and unconscious longings, we are aware of our power and sway. We acknowledge a special obligation to protect people from unintended harm resulting from our own human foibles.

In recognition of our professional mandate and our authority—and the private, subjective and influential nature of our work—we commit to upholding the highest ethical standards. These standards take the guesswork out of how best to create a safe container for psychoanalysis. These ethical principles inspire tolerant and respectful behaviors, which in turn facilitate the health and safety of our candidates, members and, most especially, our patients. Ultimately, ethical behavior protects us from ourselves, while preserving the integrity of our institute and profession.

Professional misconduct is not permitted, including, but not limited to dishonesty, discrimination and boundary violations. Members are asked to keep firmly in mind our core values of personal integrity, tolerance and respect for others. These values are critical to fulfilling our mission as practitioners and educators of psychoanalytic therapy. Prejudice is never tolerated whether on the basis of age, disability, ethnicity, gender, gender identity, race, religion, sexual orientation or social class. Institute decisions (candidate advancement, professional opportunities, etc.) are to be made exclusively on the basis of merit or seniority. Boundary violations, including, but not limited to sexual misconduct, undue influence, exploitation, harassment and the illegal breaking of confidentiality, are not permitted. Members are encouraged to seek consultation readily when grappling with any ethical or clinical concerns. Participatory democracy is a primary value of ICP. All members and candidates have the responsibility for knowing these guidelines, adhering to them and helping other members comply with them.

The ethics code is here.

Friday, January 13, 2017

Disgust as embodied loss aversion

Simone Schnall
European Review Of Social Psychology Vol. 28 , Iss. 1, 2017

ABSTRACT

A quickly expanding literature has examined the link between physical disgust and morality. This article critically integrates the existing evidence and draws the following conclusions: First, there is considerable evidence that experimentally induced disgust and cleanliness influence moral judgment, but moderating variables and attributional processes need to be considered. Second, moral considerations have substantial effects on behavioural concomitants of disgust, such as facial expressions, economic games and food consumption. Third, while disgust involves a conservation concern, it can manifest itself in both liberal and conservative political attitudes. Overall, disgust can be considered to form part of a behavioural loss aversion system aimed at protecting valuable resources, including the integrity of one’s body. Recommendations are offered to investigate the role of disgust more rigorously in order to fully capture its role in moral life.

Friday, December 23, 2016

Hiding true emotions: micro-expressions in eyes retrospectively concealed by mouth movements

Miho Iwasaki & Yasuki Noguchi
Scientific Reports 6, Article number: 22049 (2016)
doi:10.1038/srep22049

Abstract

When we encounter someone we dislike, we may momentarily display a reflexive disgust expression, only to follow-up with a forced smile and greeting. Our daily lives are replete with a mixture of true and fake expressions. Nevertheless, are these fake expressions really effective at hiding our true emotions? Here we show that brief emotional changes in the eyes (micro-expressions, thought to reflect true emotions) can be successfully concealed by follow-up mouth movements (e.g. a smile). In the same manner as backward masking, mouth movements of a face inhibited conscious detection of all types of micro-expressions in that face, even when viewers paid full attention to the eye region. This masking works only in a backward direction, however, because no disrupting effect was observed when the mouth change preceded the eye change. These results provide scientific evidence for everyday behaviours like smiling to dissemble, and further clarify a major reason for the difficulty we face in discriminating genuine from fake emotional expressions.

The article is here.

Editor's note: This research may apply to transference and countertransference reactions in psychotherapy.

Thursday, November 5, 2015

The Funny Thing About Adversity

By David DeSteno
The New York Times
Originally published October 16, 2015

Here are several excerpts:

In both studies, the results were the same. Those who had faced increasingly severe adversities in life — loss of a loved one at an early age, threats of violence or the consequences of a natural disaster — were more likely to empathize with others in distress, and, as a result, feel more compassion for them. And of utmost importance, the more compassion they felt, the more money they donated (in the first study) or the more time they devoted to helping the other complete his work (in the second).

Now, if experiencing any type of hardship can make a person more compassionate, you might assume that the pinnacle of compassion would be reached when someone has experienced the exact trial or misfortune that another person is facing. Interestingly, this turns out to be dead wrong.

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As a result of this glitch, reflecting on your own past experience with a specific misfortune will very likely cause you to under appreciate just how trying that exact challenge can be for someone else (or was, in fact, for you at the time). You overcame it, you think; so should he. The result? You lack compassion.

The entire article is here.

Wednesday, August 26, 2015

Dreading My Patient

By Simon Yisreal Feuerman
The New York Times - Opinionator
Originally published August 25, 2015

I didn’t want him to show up.

He was a bright, handsome and winning patient. His first three sessions had been perfectly ordinary. And yet a few minutes before his fourth session, I found myself ardently wishing for him not to come.

This feeling was puzzling. It had overtaken me suddenly.

My patient was in his late 20s and had decided to enter therapy, as he explained in his first session, because he did not have enough confidence. He talked about not being able to think for himself and make his own decisions, not being able to hold his own at work or find his way when he was around women. He found that he stammered a lot and said the “wrong” things.

The entire article is here.

Saturday, June 13, 2015

Biological Biases Can Be Detrimental to Effective Treatment

By John Gavazzi
Originally published in The Pennsylvania Psychologist

During workshops on ethical decision-making, I typically take time to highlight cognitive and emotional factors that adversely affect clinical judgment and impede high quality psychotherapy.  In terms of cognitive heuristics that hamper effective treatment, the list includes the Fundamental Attribution Error, Trait Negativity Bias, the Availability Heuristic, and the Dunning-Krueger Effect.  Emotionally, a psychologist’s fear, anxiety, or disgust (also known as countertransference) can obstruct competent clinical judgment.  A PowerPoint presentation providing more details on these topics is on my SlideShare account found here.

Research from cognitive science and moral psychology demonstrates many of these heuristics and emotional reactions are automatic, intuitive, and unconscious.  The cognitive heuristics and emotional responses are shortcuts intended to evaluate and respond to environmental demands quickly and efficiently, which is not always conducive for optimal clinical judgment and ethical decision-making.  For better or worse, these cognitive and affective strategies are part of what makes us human.  It is incumbent upon psychologists to be aware of these limitations and work hard to remediate them in our professional roles.

Recent research by Lebowitz and Ahn (2014) provides insight into another cognitive bias that leads to potentially detrimental emotional responses.  Their research illustrates how a clinician’s perception as to the causes of mental health problems can undesirably influence his or her perceptions of patients.  The authors chose to investigate clinicians’ perceptions of patients when using a biological model of mental disorders.  The biological model supports the belief that genetics play an important role in the creation of mental distress; that central nervous system dysfunction is the most important component of the mental health disorder; and, because of these biological origins, a patient’s thoughts and behaviors are largely outside of the patient’s control.

The entire article is here.

Friday, June 13, 2014

Teaching doctors when to stop treatment

By Diane E. Meier
The Washington Post
Originally published May 19, 2014

Here is an excerpt:

For years I had tried to understand why so many of my colleagues persisted in ordering tests, procedures and treatments that seemed to provide no benefit to patients and even risked harming them. I didn’t buy the popular and cynical explanation: Physicians do this for the money. It fails to acknowledge the care and commitment that these same physicians demonstrate toward their patients. Besides, my patient’s oncologist would make no money from the neurosurgery required for the intrathecal chemotherapy procedure.

It seemed that giving more treatment was the only way the oncologist knew to express his care and commitment. To him, stopping treatment was akin to abandoning his patient. And yet the only sense in which she felt abandoned was in her oncologist’s unwillingness to talk with her about what would happen when treatment stopped working.

The entire story is here.

Tuesday, June 10, 2014

When Doctors Treat Patients Like Themselves

By Abigail Zuger
The New York Times
Originally posted May 19, 2014

Here is an excerpt:

Professional training may not remove the interpersonal chemistry that binds us to some and estranges us from others, but it can neutralize these forces somewhat, enough to enable civilized and productive dialogue among all comers. Yet until the day when we deal only in cells, organs and genes and not their human containers, we will, for better or worse, always see ourselves in some patients, our friends and relatives in others, and our patients will likewise instinctively experience doctor as mother or father, buddy or virtual stranger.

Are the ties that bind us for better, medically, or are they for worse? Is health care more effective when patient and doctor are the same — the same sex, class, race, tax bracket, sore feet and cholesterol level? Or does essential objectivity require some differences? When your doctor looks at you and sees a mirrored reflection, is that good for you, or bad?

The entire article is here.

Thursday, May 15, 2014

Erotic Feelings Toward the Therapist: A Relational Perspective

By Jenny H. Lotterman
Journal of Clinical Psychology
Volume 70, Issue 2, pages 135–146, February 2014

Abstract

This article focuses on the relational treatment of a male patient presenting with sexual and erotic feelings toward the therapist. The use of relational psychotherapy allowed us to collaborate in viewing our therapeutic relationship as a microcosm of other relationships throughout the patient's life. In this way, the patient came to understand his fears of being close to women, his discomfort with his sexuality, and how these feelings impacted his ongoing romantic and sexual experiences. Use of the therapist's reactions to the patient, including conscious and unconscious feelings and behaviors, aided in the conceptualization of this case. Working under a relational model was especially helpful when ruptures occurred, allowing the patient and therapist to address these moments and move toward repair. The patient was successful in making use of his sexual feelings to understand his feelings and behaviors across contexts.

The entire article is here.

Editor's Note: Psychologists do not talk enough about erotic transference and countertransference in psychotherapy.  These emotions happen more frequently than psychologists are willing to admit.

Wednesday, February 5, 2014

A Review of the Research on Romantic and Sexual Feelings, Thoughts, and Behaviors in Psychotherapy

The “Vicissitudes of Love” Between Therapist and Patient: A Review of the Research on Romantic and Sexual Feelings, Thoughts, and Behaviors in Psychotherapy

Janet L. Sonne and Diana Jochai
Journal of Clinical Psychology
Volume 70, Issue 2, pages 182–195, February 2014

Abstract

Beginning with Freud's observations in the early 1900s, therapists’ and patients’ experiences of romantic and sexual reactions to each other during the course of therapy has been a topic that has generated alternating waves of avoidance and intense discussion in the professional literature. Research in the area flourished in the 1980s and 1990s but then nearly disappeared with very little integration. We offer a review of the research to date. Although we focus primarily on quantitative studies, we also reference some qualitative studies when the data help illuminate other findings. Our review is structured to answer 10 key questions in an effort to integrate the findings in a meaningful way for clinicians and researchers. In our conclusion, we note implications raised by the review for clinicians to consider in their practice and we highlight some directions for future research.

The entire article is here.

Sunday, December 1, 2013

Morality, Disgust, and Countertransference in Psychotherapy

John D. Gavazzi, Psy.D., ABPP
Samuel Knapp, Ed.D., ABPP
            
At the most basic level, successful outcomes in psychotherapy require a strong therapeutic alliance between psychologist and patient. A strong therapeutic bond can be cultivated in many different ways including, but not limited to, similarities between psychologist and patient (such as age, socioeconomic status, gender, etc.), psychologist empathy and acceptance, and patient confidence in the psychologist’s skills. A similarity in moral beliefs likely enhances the working relationship and correlates with positive outcomes in psychotherapy.

            
Just as shared values and moral similarities can strengthen the therapeutic relationship, negative moral judgments about a patient’s behaviors and beliefs (both past and current) can erode or rupture the helping relationship. In clinical terms, moral judgments can lead to negative countertransference. When a psychologist experiences a negative, morally-driven emotion related to the patient, this dynamic may adversely affect the quality of the therapeutic relationship. Within the therapeutic discourse, there are many topics related to the patient’s values, personal responsibility, and moral behaviors. Moral judgments and beliefs, like countertransference, are complex, intuitive, automatic, and emotional. In this article, we will focus on one theory of moral origins to understand how these complicated, instinctive, and gut-level reactions may promote negative countertransference.

Sunday, July 28, 2013

Peter Attia: What if we're wrong about diabetes?

As a young ER doctor, Peter Attia felt contempt for a patient with diabetes. She was overweight, he thought, and thus responsible for the fact that she needed a foot amputation. But years later, Attia received an unpleasant medical surprise that led him to wonder: is our understanding of diabetes right? Could the precursors to diabetes cause obesity, and not the other way around? A look at how assumptions may be leading us to wage the wrong medical war.




Monday, June 24, 2013

In Bed with our Clients: Should Psychotherapists Play Matchmaker or is this Plain Old Erotic Transference?

By Keely Kolmes, PsyD.
http://drkkolmes.com

Last January, there was an opinion piece in the New York Times, written by Richard Friedman on whether therapists should play Cupid for clients, basically performing as a matchmaker, setting them up on dates. The article focused primarily on the fantasies that some clinicians have about wanting to do this and the potential issues that could come up regarding transference. It did not speak directly to erotic transference, but I think this is a key component of such a question.

Following the article, HuffPost Live did a segment on which I was one of four guests interviewed about our points of view on the issue. As expected, the show included diverse opinions and even had the one clinician, Terah Harrison, who has expanded her practice to include matching services.

Another clinician, Dr. Lazarus, argued passionately that we are "uniquely well positioned" to make such matchmaking recommendations to our clients. Jeff Sumber agreed it was unethical but he admitted to having such strong fantasies about fixing up his clients that he'd deliberately scheduled people in hopes they might meet. (I imagine his clients are now wondering as they arrive for therapy if the person leaving is someone he has chosen for them?)

Guess which role I played on this segment? Yes, I was the conservative fuddy-duddy talking ethics, dual relationships, and risk management.

The entire story is here.


Friday, February 1, 2013

Should Therapists Play Cupid?

By Richard A. Friedman
The New York Times Sunday Review
Originally published January 19, 2013

IF you are in psychotherapy, there’s a good chance your therapist knows more about your inner thoughts and secret desires than anyone else.

So, if you’re looking for a mate, wouldn’t your therapist be a more reliable matchmaker than eHarmony and Match.com and other sites that rely on impersonal algorithms?

The idea that therapists might play Cupid with patients tantalizes patients and therapists. An anecdotal survey of my psychiatrist colleagues suggests that the matchmaking impulse is very common.

A senior colleague, for example, tells me he was treating a young man who was struggling to find a partner. My colleague said he knew someone who was perfect for his patient and wanted to set them up on a date, but didn’t because he was afraid — there were too many ways even the most well-intentioned therapist fix-up could go wrong.

Why? Psychotherapy, especially insight-oriented therapy, is designed to conjure intense feelings — on the part of the patient and therapist. Much of what patients feel toward their therapists, the so-called transference, are unconscious feelings that are redirected from important early figures in their lives — parents, family members and teachers. Your therapist mirrors this phenomenon with his own countertransference.

One of psychotherapy’s aims is to use the patient-therapist relationship to better understand the patient’s relationships with others and to remedy problems in the little lab that is the therapeutic connection.

The entire story is here.

Saturday, August 18, 2012

Psychologist Christopher M. Allen surrenders license under investigation for sex with client

PsychCrimes Database
Originally published on August 11, 2012

On May 2, 2012, psychologist Christopher M. Allen surrendered his license to the Oregon Board of Psychologist Examiners while under investigation. According to the Board’s stipulated order, Allen provided psychotherapist to a female client (Client A) who was referred to Allen by her boyfriend (Client B). During therapy with Client A, Allen made inappropriate self-disclosures to her and displayed poor judgment by continuing to see Client A during a time when he reported feeling strong attraction toward her.

The entire story is here.

Thursday, February 2, 2012

Supervising the Countertransference Reactions of Case Managers

Supervising the Counter Transference of Case Managers

This chapter is found in the public domain.