Professional Issues in Clinical Psychology

Developing a Professional Identity through Training and Beyond

Will Curvis

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781351056243
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Professional Issues in Clinical Psychology: Developing a Professional Identity through Training and Beyond offers insights from a range of trainee, recently qualified and experienced clinical psychologists as they reflect on the process of developing their professional identity through consideration of dilemmas and issues they experienced through clinical psychology training.

Reflecting the breadth of the profession and the range of services in which clinical psychologists work, the chapters highlight the different types of roles that clinical psychologists are expected to undertake throughout training and post-qualification. The book provides practical clinical recommendations that can be applied in work settings in line with contemporary research, policy and guidance, as well as personal reflections from the authors on how managing professional issues has shaped their practice as a developing clinical psychologist.

Developing a professional identity as a clinical psychologist is vital in learning to navigate these challenges. The process by which a professional identity develops is an individual journey. However, Professional Issues in Clinical Psychology offers aspiring, trainee or qualified clinical psychologists - and other healthcare professionals - with a contemporary resource around professional issues which might be encountered within clinical psychology practice.

Part I

Challenges in learning to deliver psychological therapy through clinical psychology training

Chapter 1

Managing and using countertransference emotions within therapy

Roisin Turner

Summary points

• Countertransference can be seen as a way to assist the therapist understand his/her relationship with the client, and despite the value of using countertransference as a therapeutic tool, therapists can feel challenged and stressed by these emotions.
• There are a number of ways in which countertransference emotions can be explored and understood, for example, through supervision, personal therapy and professional support.
• Using psychological theories such as attachment theory and psychological formulation can aid understanding of a client’s difficulties and our own responses.

To understand the process of countertransference, it is important to first consider transference and the therapeutic relationship. Essentially, transference refers to the client’s attitudes and feelings, often towards an early attachment figure, which is displaced onto the therapist (Freud, 1912). Countertransference refers to the thoughts, emotions and fantasies experienced by the therapist which have been triggered by the client, but are to do with or arise from the therapist’s experiences and reactions (Jacobs, 1999). Countertransference is an unconscious process which the therapist only becomes aware of through careful introspection (Heimann, 1950). When a therapist is making efforts to build a therapeutic alliance, both transference and countertransference responses are likely to occur.

Psychotherapy is itself a human interaction (Norcross & Wampold, 2011), and both transference and countertransference are essential aspects of any relationship (Brenner, 1982). Freud’s early work highlighted his beliefs that countertransference within therapy should be recognised, managed and overcome (Freud, 1959). Countertransference in modern psychotherapy is viewed positively and is seen as a way to assist the therapist in understanding his/her relationship with the client, for example, through interpersonal patterns (McDougall, 1978). Countertransference offers a direct source of information about clients, revealing what may be happening within the therapeutic relationship, and therefore what happens in the client’s life external to the therapeutic setting (Heimann, 1960). It acts as a guide to learning more about the client’s state of mind (Eagle, 2010; Frawley O’Dea & Sarnat, 2001) and provides access to the unconscious feelings and behaviours of the client (Wilson, 2013).

Despite the value of using countertransference as a therapeutic tool, clinicians often feel challenged and stressed by these emotions (Rothschild, 2006; Sherman & Thelen, 1998). Therapists can experience strong reactions (Farber & Heifetz, 1982), which can be emotionally draining (Guy, 1987), increase vulnerability to burnout and decrease clinical competence (Briere, 1992). The client’s transference of negative feelings onto his/her therapist can be challenging and can elicit countertransference experiences such as a sense of inadequacy (Freudenberger & Kurtz, 1990).

Within clinical psychology training, alongside attending university and conducting research, trainee clinical psychologists attend clinical placements to further aid understanding and enhance their clinical practice. During my placements I was encouraged to become more aware of my emotions and responses to clients during sessions and to reflect on these. This can particularly be relevant within clinical psychology training; trainees can lack confidence and be more vulnerable to feelings of uncertainty with the various pressures and new experiences that come with training. These feelings, termed as professional self-doubt (Nissen-Lie et al., 2017), may continue to be present once qualified. However it is argued that this can enhance therapists’ work, because they are conscious of their own limitations and more likely to resolve barriers to therapeutic progress (Macdonald & Mellor-Clark, 2014). Other countertransference reactions may include guilt related to unresolved personal issues, unhelpful projections onto clients, boredom and impatience (Palmer, 1980). Many countertransference responses are appropriate and necessary, and may be used as tools in the therapeutic relationship. However, dealing with them can nonetheless be challenging and stressful.

In preparation for writing this chapter, I spent some time reflecting on my work with clients, both as a trainee and qualified clinical psychologist. I noticed that for some clients I would remember the positive interactions we had, whereas with others there was a sense of frustration and agitation. I also noticed that I have experienced emotions such as sadness and strong compassion for some clients, particularly when thinking about my work with clients who have restricted choice and power, for example, children and older clients with a diagnosis of dementia. Reflecting on my experiences with clients I worked with during training and post-qualification, this chapter will highlight aspects of our work that I found challenging and discuss the approaches I used to manage countertransference responses.

Use of supervision

During my clinical psychology training placement within an adult community mental health team (CMHT), I noticed that when working with particular clients I would become frustrated when they did not complete out-of-session work. I did not experience this response with all clients, but it was particularly noticeable when working with one man who presented with low mood. I was surprised by the strength of this emotional reaction and felt uncomfortable that I should feel negatively towards someone I was trying to help. We were using a cognitive-analytic therapy (CAT) approach (Ryle & Kerr, 2005), and the relational nature of this framework meant it was particularly important for me to disentangle my own emotional responses from what was happening for the client.

In clinical supervision, which is mandatory for both trainee and qualified clinical psychologists, I discussed my emotional responses using CAT as a framework to help guide my thinking. We identified that perhaps I expect too much from clients; when they feel hopeless and struggle with motivation and consequently struggle to meet my expectations, I can become frustrated. This makes me feel ‘stuck’, which then becomes a vicious cycle for both the client and myself. We reflected that their feelings of hopelessness may be being transferred onto myself, and I in turn felt despairing and stuck in my work as a result. At the time I did not share these thoughts with my client as I was concerned that he would find this too challenging and critical. However I did at times feel as if I was being drawn into a ‘rescuer’ role; on reflection, discussing the ‘here and now’ pulls that I was experiencing may have helped us to explore the past and current relationship patterns that increased his feelings of hopelessness.

Within supervision I have drawn upon Vygotsky’s (1978) zone of proximal development to help me consider my work with clients. The theory proposes that an individual can make changes and learn for him/herself if provided with the right tools and concepts. At the start of therapy, not every client has the emotional resources or resilience for change at that time (Skovholt, 2001). In supervision, I also learned the importance of stepping back, not being drawn into client’s feelings and reflecting on times when this may be happening. I became able to acknowledge that I have passion and drive, and want to instil this in others. However, I also realized that I need to carefully consider how best to motivate others, particularly when they are not emotionally ready for this.

Through these experiences, I became more aware of the high expectations I place on others and myself, both clinically and personally. Now, when working with clients who have difficulties completing out-of-session work, I try to explore their reasons and be curious about how they can overcome any barriers to this. I also consider with them whether they have conflicting motivations about change; for example, do they fear failure which may then reinforce feelings of hopelessness? Will success in therapy then mean that they will need to take responsibility for how their life proceeds, causing them to feel frightened? When thinking about engaging people in out-of-session tasks, I have learned that it is useful to focus on building the therapeutic relationship first. I then suggest a small (and realistic) out-of-session task to try, aiming to build on gradual successes without feeling the need to rush people.

Personal therapy

I experienced some personal therapy during clinical psychology training. During this, I explored whether I became more frustrated with clients who shared similar insecurities or patterns to myself, for example, being overly self-critical. My personal therapist used a CAT approach and this helped me to reflect upon my past relationships and experiences. We explored how I can become stuck in patterns of thinking or behaving that have originated from childhood experiences and relationships.

There are many benefits to personal therapy for therapists, and I valued having this opportunity during training. Rake (2009) found in her qualitative study that therapists identified both personal and professional benefits to engaging in their own therapy. Timms (2010) identified that clinical psychology trainees reported increased self-awareness, understanding and confidence through personal therapy experience. Being self-aware can be challenging and unpleasant as it involves becoming conscious of internal tensions and conflicts, and revealing these may threaten our view of self. However, personal therapy allowed me to consider more deeply the emotional aspects of therapeutic work, alongside exploring these on a more intellectual level in supervision.

Professional support

Through my clinical placements on training and my post-qualification work, I have found that sharing my experiences of countertransference with peers, colleagues, mentors and supervisors has been invaluable. The British Psychological Society (BPS, 2009) advise in their code of ethics and conduct that clinical psychologists should “seek consultation and supervision when indicated, particularly as circumstances begin to challenge their scientific or professional expertise” (p. 16), and should monitor their personal wellbeing, identifying when they may be negatively impacted by their work. I am aware that I have a tendency to be task-focused and aim to get on with things. Although this can be helpful at times, on other occasions I benefit from sharing my challenges.

I have learned that communicating my struggles does not mean others perceive me as being inadequate, as has been my fear. Within my final year of training I participated in a psychodynamic-based peer group, and found this invaluable to provide continued personal development to explore the countertransference emotions I experienced. It gave me space to increase my awareness of and reflect on my own emotions within clinical practice and hear how others can experience similar feelings.

Theories to aid understanding

Developing psychological formulations has helped me identify the challenges clients have faced and how these have impacted on their past and current relationships. It also allows me to understand how a client responds to and regulates his/her own emotions, and puts his/her responses into context. Using an attachment framework (e.g., Hewitt, 2008) can provide explanations for seemingly unpredictable emotions and this has helped me gain confidence when faced with strong emotions from a client. For example, when working with clients who as children did not have their needs not met by caregivers, they may increase attachment behaviours in an attempt to get their needs met, or they may withdraw (Bowlby, 1969). Gaining an understanding of a client’s early attachments can aid greater awareness of current behaviours and how we can help them. Individuals with avoidant attachment styles may struggle to verbalise feelings and interact with others, and offering intervention that encourages this may benefit them. These concepts offer a useful starting point for making sense of transference and countertransference responses.

I have also reflected on other methods I can use to become more aware of my countertransference responses. Ryle and Lipshitz (1974) endorsed the use of repertory grids to help identify and understand countertransference amongst work with clients. The therapist lists his/her clients and personality constructs are developed from considering behaviour, formulation, client’s transferences during sessions and the therapist’s countertransference responses. The ways in which the grid information can be used provides a new lens with which to view relational patterns. This approach can be used over time with a particular client to highlight changes within the relationship, or enable a therapist to reflect upon patterns that may occur between clients.

Self-care and social support

The National Institute of Clinical Excellence guidelines (NICE, 2009) highlight the importance of clinician wellbeing, for both the individual staff member and to ensure the delivery of high-quality care. It is therefore imperative to recognise and address the early signs of compassion fatigue or burnout. Compassion fatigue may occur when the issues clients bring begin to exhaust the therapist’s ability to work effectively (Figley, 2002), and burnout is emotional exhaustion due to prolonged, yet unsuccessful striving toward unrealistic expectations which can be internally or externally derived (Maslach, Schaufeli, & Leiter, 2001). These are considerations that I continue to be aware of now that I am qualified, as this is when I am more likely to be involved in longer-term complex clinical work.

Alongside making good use of clinical supervision, I use indirect means of countertransference management such as physical exercise, rest and relaxation and engaging in enjoyable activities within personal relationships with family and friends. It is critical to use self-care before a crisis occurs, as this is usually when it is needed most but often overlooked (Pope & Vasquez, 2005). The importance of self-care is highlighted by research (Brady, Guy, & Norcross, 1995; Jennings & Skovholt, 1999; Mahoney, 1997; Norcross, 2000). This might include consideration of diet, exercise and self-reflection through different mediums including writing (Pennebaker, 1997).

Conclusion

Countertransference responses can offer valuable insights into the working...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of figures
• Note on contributors
• Preface
• Foreword: Professional issues in clinical psychology training
• Part I Challenges in learning to deliver psychological therapy through clinical psychology training
• Part II Understanding the broader role of clinical psychology: professional issues across areas of practice
• Part III Developing a professional identity as a clinical psychologist: integrating the personal and professional
• Glossary of terms
• Index