NU672 Unit 4 Countertransference, Foster Care Youth Example

Fifteen Minutes, a Landlord and a Question I Did Not Ask: A Countertransference Reflection on Rescuing a 23-Year-Old Who Aged Out of Foster Care

[Student Name]

Purdue University Global

NU672: PMHNP Psychotherapy for Individuals, Groups, and Families Clinical

Unit 4 Countertransference Reflection

[Instructor Name]

[Date]

The client is composite; details are bracketed.

What Happened

Ms. [K.] is [23] and aged out of foster care at [18] after [seven] placements. She works at a coffee shop, rents a room in a shared house and was referred for depression and self-harm; she disclosed cutting her thigh [two] weeks before the session. In session six she arrived upset because her landlord had told her she might have to leave at the end of the month. She talked about the landlord, her roommates and a previous eviction.

I made three choices in that session that I would not normally make. I let the session run [15] minutes over, although my next client was waiting. I offered to call her landlord to "explain her situation." And I did not ask about the cutting, although my plan for the session, written the night before, listed it as the first item after check-in.

My Feelings

I felt a strong wish to protect her. I noticed it as tenderness when she described moving between placements with her belongings in trash bags, and as anger at the landlord. By the end of the session I felt responsible for whether she would have somewhere to live. After she left I felt uneasy, and when my supervisor asked about the self-harm check I felt embarrassed that I had skipped it.

Tracing Each Choice to the Feeling

The overrun came from not wanting to be another adult who ended things on schedule when she was upset. The offer to call the landlord came from wanting to act on her behalf, the way an advocate or a parent might. The dropped question came from not wanting to add to her distress on a day that already felt like too much.

All three choices came from the same place: a wish to spare her the experience of adults who let her down, which in practice meant I stopped acting as her therapist.

Countertransference, in the broad sense used in current research, is the therapist's reaction to the client shaped by the therapist's own history and vulnerabilities. A series of meta-analyses found that countertransference reactions were modestly associated with poorer outcomes, but that successful management of countertransference was strongly associated with better outcomes (Hayes et al., 2011). The feeling was not the problem. Acting on it without noticing was.

What the Feeling Got Right

The protective feeling was not simply mine to discard. It noticed something true about her: she has had many adults leave or fail her, and she may be testing whether I will too. That is clinically useful information, and it may help explain the pull I felt. My supervisor suggested that the pull might be something others feel with her as well, which could be part of how she ends up in relationships where people either rescue or reject her.

Where It Took Me Off Course

Two of my choices crossed boundaries. Gutheil and Gabbard distinguish boundary crossings, which may be harmless or even helpful in context, from boundary violations, which harm the client, and they note that time, role and services are among the areas where crossings occur (Gutheil & Gabbard, 1993). Running over once is a crossing; it may not harm her, but it tells her that my time bends when she is distressed, which may shape future sessions. Offering to call her landlord changes my role from therapist to advocate. It could harm her by implying that she cannot handle it herself, and it would involve me in a dispute outside therapy.

The dropped question is the most serious. She has recent self-harm, and her distress that day was a reason to ask, not to avoid asking. I had assumed that asking would upset her further. The evidence does not support that fear: when Dazzi and colleagues gathered the studies on this question in adults and adolescents, none showed that asking about suicidal thoughts raised them, and the authors suggested that talking about it may reduce distress (Dazzi et al., 2014). My protective feeling led me to withhold the very question that would have protected her.

What I Will Do

1. At the start of session seven I will ask about self-harm since our last meeting, and I will explain that I should have asked last week.

2. I will not call the landlord. I will ask whether she would like help planning the conversation herself, and I will offer a referral to the clinic's housing advocate, whose role that is.

3. I will end sessions on time and, if she is distressed near the end, name it and plan the next steps rather than extending.

4. I will keep noting the protective pull in my reaction log and bring it to supervision when it appears, since it seems likely to return with her.

5. I will talk with my supervisor about how to use the feeling therapeutically, for example by noticing when she seems to invite rescue and exploring that with her.

References

Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. https://doi.org/10.1017/S0033291714001299

Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150(2), 188-196. https://doi.org/10.1176/ajp.150.2.188

Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy, 48(1), 88-97. https://doi.org/10.1037/a0022182