Countertransference issues

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In its broadest sense countertransference refers to all the feelings arising in the counsellor as a result of working with a particular individual. Our humanity and compassion allow us to be emotionally connected with others and to share their joys and pains. The positive side of being affected is that it enables us to help; our humanity enables us to reach out to one another and emotionally share by our empathic and compassionate responsiveness. However, in the world of medical genetics there is a negative side to being affected. Counsellors are exposed to the experiences of their patients who may be shocked, overwhelmed with anxiety or fear, grieving or struggling with relationship difficulties and many other emotional challenges. The genetic counsellor is therefore exposed to an emotionally highly-charged environment which can be personally upsetting, challenging or even draining and stressful.

The exchange of information and the professional conversation around genetic counselling is a human encounter in the service of the patient but, the counsellor is also there as a real person. The experienced and secure counsellor will have little difficulty acknowledging personal reactions but, sometimes, the less experienced or insecure can regard their personal emotional reactions as a lack of professionalism which needs to be hidden or denied. All counsellors are at risk of being disturbed at some point or another and they may experience physical sensations or feelings. Headaches, tiredness, or being depleted or stressed are common physical complaints; depression, anxiety or feeling unexpectedly angry, common emotional reactions. These feelings and sensations are unpleasant but can be understood, alleviated or even prevented by a deeper understanding of the delicate, interactional processes by which individuals affect one another. This involves addressing counter-transference issues. In contemporary psychoanalysis, the historical idea of the analyst as a blank screen has been dismissed and all modes of therapy and counselling prefer to create the inter-subjective shared space. In the same way, modern medicine has changed and recognises that, when doctors or nurses hide behind desks or white coats taking refuge in defensiveness, it can result in coldness towards patients and the professionals themselves can close down and become depressed. The professional position of defensively distancing emotions is no longer considered constructive in psychotherapy or medicine. The difficult tasks of medicine have to be done which means defences are adopted as a necessary personal protection. However, the professionals might find it helpful to understand more about themselves, what goes on between people and how to process and use the experience for their own good and that of the patient.

An analysis of the concept of countertransference not only helps the counsellor with their personal feelings, but also furnishes the counsellor with additional information about the patient which can be an effective therapeutic tool. The counsellor becomes like a human barometer, recording impressions, feelings and attitudes. The skill is in learning to develop the self as an instrument and then knowing how to use it.

The term countertransference comes from psychoanalysis where originally it was considered a hindrance and a resistance on the part of the analyst, whose own neurotic conflicts were seen as being awakened in response to the patient (Freud, 1937). Over time, the understanding has changed and the definition widened. Based on Heimann's (1950) description, it is now regarded as one of the most important tools for understanding the patient's unconscious. The term encompasses all those feelings aroused or evoked by the patient, whether arising from the counsellor's personal life, the patient's emotional condition, the way the patient handles upset or the dynamics set up in the professional relationship. In simple terms the counsellor will be debating internally, 'Is this something to do with me and my past?' or 'Is this feeling telling me something about the pain of this patient?' or 'Is this connected to the relationship pattern set up by this patient?' 'Is this feeling something the patient is denying?' These questions will be explored further and then applied to genetic counselling.

The counsellor understands the patient's subjective experience by the process of empathy internally saying, 'I am feeling the feelings of the patient but it is not my world, it belongs to the patient'. However, sometimes the connection between the counsellor and patient goes beyond empathy and then becomes a particular form of countertransference known as projective identification, a term derived from the theory of Melanie Klein (1952). To explain it, Gordon (1965) uses metaphorical language and differentiates between three mental mechanisms: identification, projection and projective identification. Identification is likened to ingestion, where the two people think they are similar; projection is thought of as the psychic equivalent of excretion, where one denies feelings and projects them into the other; and projective identification is described as fusion, where ownership of behaviours and feelings is confused. Another useful explanation is given by Tarnopolsky (1995) who considers three countertransference positions which are based on the quality and intensity of projective identification. They are described as empathy, complementarity and enactment. In empathy, the counsellor resonates with the patient and develops an intuitive understanding of the patient and their situation; in complementarity, the counsellor experiences something the patient disowns; in enactment, the counsellor performs what the patient disowns. The internal dialogue of the counsellor might therefore include, 'I am feeling something of the patient's pain by being in tune' or 'I am feeling rather angry and the only way I can make sense of the feeling is that the patient is denying it' or further, 'I'm behaving uncharacteristically, I wonder if the patient is disowning feelings, pushing strong feeling into me which are forcing me to act uncharacteristically'. These experiences furnish the counsellor with an additional understanding of the patient by the development of an internal dialogue which cultivates self-awareness and asks the question: 'What is it like to be with this person?' or 'What am I feeling, thinking or registering physically'. The counsellor can learn to translate these ideas of countertransference and apply or adapt them with the help of regular supervision.

The following breakdown simplifies and adapts countertransference ideas to genetic counselling. Countertransference can be considered under these headings:

(a) Feelings belonging to the counsellor, with the re-experiencing of a previous personal experience which has been triggered by the patient.

(b) Feelings belonging to the patient but experienced by the counsellor, ranging from empathy to projective identification.

(c) Feelings arising in response to the attachment style of communication of the patient.

(d) The angry attack on the counsellor.

(e) The counsellor's distress at witnessing inadequate care in the family.

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