Question Two: Self-disclosure and Countertransference
Freud originally thought that the ideal therapist needed to be a blank slate; that they needed to remain neutral and not project any of their own thought and experiences onto their clients (Henretty & Levitt, 2010). However, this is no longer widely believed to be true; social workers who are more client-centered believe that through therapy-relevant self-disclosure and by “modeling openness, strength, vulnerability, and the sharing of intense feelings,” clients will be able to learn from this behavior and become more trusting and empathetic (Kottler, 2003 & Knox, Peterson, & Hill, 1997 as cited in Henretty & Levitt, 2010). However, a majority of the training still warns against self-disclosure and so choosing to do so, even when appropriate, can create an internal struggle within the therapist (Knox & Hill, 2003). Self-disclosure generally consists of statements that reveal personal information about the therapist and are usually verbal (Hill & Knox, 2002 and cited in Knox & Hill, 2003). Broken further down, self-disclosure consists of at least seven subtypes; disclosures of facts, feelings, insights, strategies, reassurances and support, and immediacy (Knox & Hill, 2003).
Self-disclosure has been an incredibly useful tool in working with children. I have found that the children I work with are very curious and have become more comfortable working with me when I disclose some age and situation appropriate information about myself. I am careful of when I do this and make sure that I am doing so to help further my clients’ treatments and not just to make myself feel better. One of my clients, Jason, is an eleven year old, African American, male who lives in the Bronx. When I first began working with Jason, he did not trust me because I was the third therapist he was seeing in a very short amount of time. He was also still working on accepting that his father had left the family and was not coming home. I had trouble engaging him in the room and he did not want to talk to me or answer any of my questions. At one point, he mentioned to me that he did not want to tell me anything about himself because he knew nothing about me other than my name and I was just going to leave soon anyway. I felt that this was a very valid feeling and thought to have so I came up with a game where we had to throw a ball to one another and the person who was catching had to answer a question about ourselves such as our favorite color or animal, thus disclosing facts about myself to him (Knox ; Hill, 2003). Through this game, I was able to promote a sense of realness that helped Jason to become more open and trusting of me (Knox ; Hill, 2003). After this day, we had no problem with engagement and we were able to move along with his treatment smoothly. I have also tried to use disclosure of insight and strategy (Knox ; Hill, 2003) with Jason to help him to figure out coping strategies he can use that best suit him. He often asks me what I have done in the past when I have felt distracted, I try to answer as openly, and honestly, as I can, I think it is important to promote this in the work. I think a client, especially a child, will shut down and be distrustful if they think you do not trust them with information about yourself (as long as it is not too personal).
A risk with opening yourself through self-disclosure and becoming somewhat vulnerable in the room (even on a surface level) is countertransference, although this phenomenon can occur with any client relationship. Countertransference occurs when the therapist unconsciously begins fitting their relationship with a particular client into the psychodynamic structure of a previous relationship and then reacts to that transference (Mattinson, 1975 as cited in Agass, 2002). This is natural and something that occurs unconsciously, however to be an effective clinician, one must be aware of their countertransference and be able to use it to help the client heal. Part of countertransference is projective identification which is when the client insights in the clinician the same emotions and state of mind that they are trying to dispel within themselves (Agass, 2002). Feelings such as anxiety, frustration, insignificance, or uselessness, amongst others may be provoked within the clinician and can cause that client to “get to them” making it difficult to work with them (Agass, 2002).
I have one client that I find particularly difficult to work with. Jamie is a nine year old, African American, female who grew up in the Bronx and more recently moved to Harlem. Jamie has dealt with complex trauma stemming from her father being emotionally abusive towards the family and from her brother being shot and stabbed when they were living in the Bronx. As a result, she reacts aggressively when she feels she is being “personally attacked” (whether it be a teacher reprimanding her, a peer annoying her, someone not doing what she wants them too, etc.). There are times when she will act out in session by throwing toys, running out of the room, locking herself in the bathroom, or kicking and hitting the walls. This can be infuriating and makes it very difficult to make forward steps in her treatment; it also has sometimes made me feel like I am being personally attacked by her. The most recent incident of this is when Jamie called 911 on me when I told her I could not add her on social media because I am her therapist. I was shocked and hurt by this and had to keep reminding myself that Jamie’s reaction had nothing to do with me. However, when I approached the subject with Jamie, I made sure to express to her how she made me feel when she called 911. Carpy (1989) argues that allowing a client to see that they have had an actual effect on the clinician and that the clinician now has to deal with these feelings without acting out can be very helpful to the client in helping them be able to work and struggle through their own emotional responses (as cited in Agass, 2002). I wanted to be able to help Jamie understand that she is allowed to feel frustrated and hurt, but that she has to be able to work through this without acting out and hurting other people and by appropriately expressing how she feels.
Question Three: Termination
Delgado and Strawn (2012) define termination as the time when either the adolescent or their parents end the relationship with the therapist as a result of the adolescent resuming a developmentally healthy course of growth and functionality. They believe that this occurs through a decrease in the symptomology that caused the adolescent to originally seek out treatment and through the integration of the skills achieved through therapy into day-to-day life. However, termination is very complex; adolescents may have different feelings related to termination (excitement, ambivalence, etc.), the length, weaning process, and degree of planning of the termination process will be unique to each client’s needs, and the concerns of their parent’s must be considered when deciding if termination is appropriate because their parents may have supplementary information regarding their child’s symptomology that the clinician is not aware of (Delgado ; Strawn, 2012). Forced termination occurs when the therapist leaves; this can happen during the engagement phase of treatment, in the middle, or closer to the end of treatment. In deciding whether the client should be transferred to a new clinician, the patient’s accomplishments, where in treatment this forced termination occurs, and the wants and needs of the patient should be considered (Delgado & Strawn, 2012).
During a forced termination, it is very helpful to be able to help with the transfer of the patient to their new clinician by introducing them to each other a few sessions before the last session to allow the client to express and work through their feelings regarding having to work with someone new (Delgado & Strawn, 2012). However, this is not possible at my placement because there are too many clients waiting to see clinicians and not enough clinicians to see them all. The waitlist is too long. I have had to tell all of my clients that I am leaving and I am unsure of when they will be transferred to a new clinician. This is frustrating and difficult because not only can I not tell my clients who they will be working with, I cannot tell them how long they will have to wait before then can resume treatment.
Furthermore, the agency has no role in the termination process of clients other than blindly assigning them to new clinicians when they become available and forcing clinicians to terminate clients that are unable to meet the attendance policy regardless of why they are unable to. In order to make termination a better experience for all clients, the agency needs to take responsibility for them. The agency needs to work harder at placing clients with new clinicians when their old ones leave and be better at placing clients that have been bounced from clinician to clinician with more stable, long-term therapists instead of continuing to place them with new interns. For the client that I most recently began termination with, the most important part of the process for him was me telling him that we would be terminating in a few more sessions. This is because his last clinician, another intern, left without telling any of her clients she was leaving and, as a result, he internalized her leaving as being his fault for a long time. He even thanked me for letting him know we were ending so he could both mentally prepare for it and know that my leaving had nothing to do with him.
Siebold (1991) talks about her own experiences with forced termination and applies theories and techniques to these experiences. She applies anticipatory grief theory onto forced termination and postulates that there is no right way to mourn and that the way the client processes this loss is influenced by the environment that they are in. This theory can help in understanding different reactions that patients may have to the news of forced termination (Siebold, 1991). This theory helped me understand why some of my clients accepted the news of my leaving right away with little to no emotion, some thanked me for telling them, and some reacted negatively. Sieblold (1991) waited a week to tell her patients she was leaving out of fear that their therapeutic processes would be disturbed, she tried to stagger the announcements and put off telling some because they always began sessions in crisis mode. I put off telling this same client about my leaving for longer than I felt I should have because of this same reasoning. Every time he came into my office, he was anxious and seemed to be in crisis. I finally had to interrupt him during one session to give him the news like Siebold (1991) did with some of her clients. This forced termination is also a break in the bond between the client and the clinician and can be considered a serious narcissistic injury; the clinician is supposed to be there to support the client, not leave them (Siebold, 1991). Additionally, therapy should be a corrective emotional experience for those who experienced poor termination with a previous clinician (Siebold, 1991). I think that by just telling my last client three weeks before our last session that I was leaving acted as a corrective emotional experience because he told me he felt I respected him and cared enough about him to let him know I was leaving unlike his last clinician, especially since one of the problems he is working through in treatment is feeling like no one respects him and communicates with him.
Mirabito (2006) took a different approach and explored the perceptions of clinician’s about unplanned terminations of economically disadvantaged, inner city adolescents from outpatient mental health treatment. She also looked at how these clinicians use termination to inform their work and how and why these adolescents terminate the way they do. The study took place at an adolescent center that provides medical, mental health, and school based services to Black and Latino adolescents dealing with a wide range of mental health and social problems and used interviewing to gather information from nine of the social workers on staff (Mirabito, 2006). The results showed that for most cases, termination was unplanned, unannounced, and initiated by the adolescents; furthermore, adolescents typically did not make their intentions for termination known to the clinician and often avoided creating a deliberate and jointly agreed-upon termination plan to mark the ending of their mental health treatment (Mirabito, 2006). Planned terminations seemed to only occur as a process at the end of short-term treatment or when situational factors of both clinicians and clients created an end for treatment, but even these terminations were brief (Mirabito, 2006). From the perspective of the clinicians, there were mixed ideas about what these unplanned terminations meant. Some viewed them as failures and reacted with anger and frustration, others viewed them as being the outcome of successful treatment and thought adolescents only leave treatment once their needs have been met, and others viewed these unplanned terminations as normal and developmentally appropriate (Mirabito, 2006). Mirabito (2006) also found evidence to suggest that, overall, engagement and termination are both influenced by client factors such as environment, family, and development, clinician factors such as a lack of time for case analysis and management, burnout, and minimal time spent planning termination, and clinic factors such as high volumes of cases per clinicians and overall, lack of structure, and inhospitable clinic environments. All of these factors affect how adolescents view treatment and respond to it (Mirabito, 2006).
I was worried that this same client of mine would stop coming to treatment after I had told him we were coming close to termination because even though he was thankful that I told him I was leaving, I tend to side with the social workers who think unannounced termination by adolescent is developmentally appropriate and I knew that I would have stopped coming to treatment if I had been in the same situation at his age. He also missed our second to last termination session which is when I began to feel worried and sad about potentially not being able to say goodbye which is also an example of my own countertransference because he is one of my favorite clients. However, he followed through and came to our last session, which, as Mirabito found, was very short. The session itself was the same amount of time as all of our other sessions, but my client did not want to spend a lot of time talking about his thoughts and feelings related to me leaving and so we briefly spoke about it at the beginning of our session before moving on to other issues in his life that he felt were more pressing to discuss.
Termination for me has been complicated. I was struggling with being ready to be done with school and field and with not wanting to have to join the “real world” yet, but also excited about the new opportunities that will present themselves to me as I begin a new chapter in my life. The notion of having to study for my license, find a job, terminate with my clients, and finish finals had me feeling very stressed. My biggest concern and the thought that caused me the most strain was how my client’s would handle my leaving and whether it would interfere with their therapeutic processes, just as this was Siebold’s (1991) concern when she was leaving her clients. There were times when I wanted to just walk away and not celebrate the end of school, to just drop what I was doing without really terminating similar to how the adolescents in Mirabito’s (2006) study would stop coming to treatment without making their intentions known to their clinicians and without creating an actual plan for their termination. At times, it felt easier and less stressful to do so. However, after having already terminated with my clients, I found out that I don’t have to terminate with my agency. I am going to be working there over the summer doing part time work while I study for my license, which has made the process of graduating feel more comfortable and has made me feel less anxious and nervous. However, I am still concerned about how my clients will handle seeing me in the building still and am considering calling their families to let them know I will still be at the agency so that it does not come as a surprise or feel like a betrayal.
Question Four: A Population I Find Difficult to Work With
The client population that I find the most difficult to work with is adult clients who do not speak any English. I worked with young children (preschool and kindergarten age) who only spoke Hebrew and Arabic while I was living abroad and found it easier and more effective working with them than the adults I have worked with who cannot speak English which is why I made the specification. I cannot speak any languages other than English and the limited Arabic and Hebrew I learned and, for myself, I find it nearly impossible to get the work I think needs to get done when I cannot personally communicate with my clients without the use of a translation service or interpreter. I personally believe that engagement is key to creating a positive therapeutic alliance, which is so important for the work, but that this is tempered by not being able to communicate directly with the client. Last semester I was working at Southern Brooklyn Family Services, which is a program through the Jewish Board making home visits and doing prevention and therapeutic work with domestic violence survivors. However, most of my clients only spoke Russian and Spanish, which meant I had to bring my phone or an interpreter with me every time I made a visit or nothing could get done. The first few visits were the hardest because I could not be sure the interpreters were translating what both the clients and I were saying to each other. I kept thinking about how much of what we were divulging was being lost in translation and I could tell that we were all feeling very uncomfortable and so this created some issues in the work.
Boundary issues occur when possible conflicts of interests are created due to there being dual or multiple relationships generated between client and social worker or colleague and social worker (Reamer, 2003). These boundary issues are not necessarily exploitive; they can be much more benign or subtle such as becoming friends with clients, accepting gifts, and giving a client your phone number (Reamer, 2003). The boundary issues that occurred in my work with these clients focused more closely on trying to learn how to navigate the cultural differences between them and me. Often I would come into their homes and they would offer me food and drinks as if I was there as a friend, I was never sure if I was supposed to accept so as not to offend them or if I should decline. They would also speak with me as if we were friends and catching up, asking me about how school was going and what I had been up to the week before. I did not know where the line fell between being culturally sensitive and maintaining ethical boundaries or what the ethnic norms were for these families (Reamer, 2003). I did not know how open and receptive I should have been to this friend-like aspect of the relationship. Another boundary issue that would often present itself was the relationship between my clients and the interpreters that would come with me to the sessions. Far too often, the interpreters would begin asking their own questions to my clients and I found myself having very little control in stopping this. They would speak back and forth in their own languages and have conversations that I would not be a part of regardless of me asking them to stop. This was very frustrating for me and not something I wanted to continue to be a part of or deal with.
This language barrier also had an effect on the way I listened and internalized my client’s experiences. Domestic violence work is very difficult because of the trauma associated with surviving it. Some clinicians even develop symptoms similar to post-traumatic stress disorder (PTSD) from being exposed to hearing the traumatic experiences of their clients repeatedly (Knight, 2013). This can include becoming preoccupied with thoughts about one’s clients, re-experiencing client’s trauma through dreams and intrusive thoughts, becoming hyper-vigilant, and developing hyper-arousal (Knight, 2013). This phenomenon is known as secondary traumatic stress (Knight, 2013). I did not develop any of these symptoms; I found that secondary traumatic stress did not affect me because I was hearing my client’s stories through a third party and at times the people interpreting seemed emotionless. I once asked about this and was told that they were not supposed to exhibit emotions when interpreting. I found that this also made it difficult to connect with clients; while I did feel empathy for them, I did not show it as much as I may have otherwise because I sometimes would stop paying attention when the clients were talking because I could not understand them and I knew the interpreters would begin translating soon after. This was a terrible habit that I was trying to stop and caused me to sometimes miss the emotions that the clients were exhibiting. My countertransference towards these clients also became problematic at times because I would walk into their homes and automatically feel frustrated that I could not communicate with them, especially when the interpreters were late. I also knew that my sessions with these clients would be twice as long as other sessions since someone needed to translate everything said by both my clients and I and that I often felt bored during them. These feelings made me automatically dread going to their homes, which was very unfair to these clients. This experience taught me that this is not a population I feel comfortable working with and that it is unfair to both me and these clients to do so.