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Journal of Genetic Counseling, Vol. 9, No. 5, 2000
The Interface Between Countertransference and Projective Identification in a Case Presented to Peer Supervision Marisa Ladoulis Likhite1,2
This case report, presented to a supervision group, is a prenatal genetic counseling case that caused me a great deal of emotional discomfort as the events unfolded. The discomfort originated during my first meeting with the couple for routine preamniocentesis counseling and continued through later encounters. This case illustrates the process of working through countertransference and projective identification issues that may arise in genetic counseling. KEY WORDS: case report; group supervision; genetic counseling.
INTRODUCTION I presented this case to the supervision group two to three months after my work with the couple ended. It was chosen for two reasons. First, it was a seemingly straightforward routine prenatal genetic counseling case that turned into a much more challenging series of encounters. Second, as the events unfolded, I felt a nagging emotional discomfort, which affected my ability to provide support. My goal was to better understand why I found it so difficult to work with this family. CASE REPORT Sally, a thirty-six-year-old woman, and her thirty-nine-year-old husband, John, were referred for genetic counseling during Sally’s third pregnancy due to her age and her family history of mental retardation (MR). During the second 1 Perinatal
Diagnostic Unit, Massachusetts General Hospital, Boston, Massachusetts. should be directed to Marisa L. Likhite, Perinatal Diagnostic Unit—Blake 1053, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114; e-mail: mlikhite@ partners.org.
2 Correspondence
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pregnancy, they had genetic counseling and an amniocentesis at another center. The procedure went without complications, the results were normal, and Sally went on to deliver a healthy daughter. They decided to have amniocentesis in her third pregnancy also, and Sally chose to have genetic counseling on the same day as her procedure. Sally seemed hesitant to enter the room and initially made little eye contact, which surprised me since I had the preconceived notion that, as a counselor with a private clinical practice, she would have confidence and good social skills. I wondered about possible reasons for her apparent coolness and speculated that perhaps she felt our meeting was unnecessary since they had had genetic counseling during their second pregnancy. She may have been nervous about having the amniocentesis or concerned about the possibility of abnormal test results. I reviewed the purpose of our meeting and let them know that I planned to obtain a family history, review the amniocentesis procedure, review what tests would be performed, and try to answer any questions they might have. I also let them know that I was familiar with the events of their previous pregnancy. Sally and John were reportedly in good health and they had two healthy daughters aged six and two. There were no relatives with developmental delays in their immediate families. However, Sally reported having three first cousins with developmental delays; one was ‘slow’ and the other two ‘mentally retarded.’ These cousins were the children of two maternal aunts. To her knowledge, these individuals had no specific diagnosis and she was unfamiliar with fragile X syndrome. Sally had many other maternal first cousins and there were no other individuals with learning disabilities or developmental delays. Sally and John both were of Northern European ancestry. Sally actively participated when I took the couple’s family history. She provided details about her relatives with developmental delays and made sure I recorded the correct relationships. She wondered why all three had delays and questioned what this might mean. Unlike when she had first arrived, she made good eye contact, gave clear information, and looked to me for a possible explanation. After completing the family history, I identified two factors for which they should consider having testing: her age-associated risk of having a child with a chromosome abnormality and her family history of unexplained developmental delays. Therefore, in addition to routine amniocentesis, fragile X carrier testing was a consideration. The clinical details and genetics of fragile X syndrome were discussed. If found to be a carrier, Sally would be at increased risk for having a child with developmental delays, and studies of the fetus could be performed. Sally seemed overwhelmed by this new option and reported that she was not sure whether she wanted to have the additional test. Her demeanor appeared to change and she physically pulled away, looked down, and seemed frightened. She became very indecisive and appeared pressured into making a decision, even though I did not need an immediate answer. She positioned her hand in front of her
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face and stated “I don’t know what to do” and repeated more than once “This is very scary.” She did not appear to be looking to me for help with the decision. Her husband stated that he felt she should be tested and he encouraged her, pointing out that it was something they would want to know. What surprised me the most was that Sally suddenly seemed helpless and indecisive. In response to her attitude and behavior, I found myself responding emotionally and behaviorally. I felt uncomfortable, more than I usually feel in this type of situation. For some reason, her indecision caused me to feel very annoyed. I also felt guilty about causing her so much distress. Sally and John were told that they could let me know their decision after the amniocentesis or even go home to discuss it and call with a decision in a couple of days. Perhaps she could get further information from her aunts about whether or not there had been any testing of her cousins. Sally eventually decided to have her blood drawn for fragile X carrier testing and then went on to have an uncomplicated amniocentesis. Test results showed that Sally was a carrier of a fragile X premutation, based on 93 CGG repeats (Nolin et al., 1996). This put her at risk of having a child with a full mutation. Shortly before receiving her fragile X test results, I had received her amniocentesis results revealing the fetus to be a chromosomally normal male. I reviewed the test results with Sally’s obstetrician who in turn phoned Sally. Sally called me almost immediately. She seemed to have a very clear understanding of the fragile X results and was appropriately concerned. She quickly decided that she wanted the fetus to be tested, and I let her know that cells were being prepared to send for further testing. Initially our conversation about the test results flowed easily. Sally is an intelligent woman and quickly grasped the concept of being a carrier of a fragile X premutation and its attendant risks. She wanted prenatal testing and wondered how long the results would take. It was estimated that the results would be available in two weeks. Sally expressed concern and reported negative feelings about herself at the knowledge that she was a carrier. She seemed very open and willing to discuss her feelings. The conversation turned to our first office visit. Sally reported that she felt I had pushed her to have testing. This surprised me. My recollection was that she had been indecisive and that her husband had talked her into it. I began to feel uncomfortable and reminded her that her husband had encouraged her to be tested. She stated with certainty that “You wanted me to have testing,” and I ended that part of the discussion because there were more important issues to deal with. An appointment was set up for Sally and John to meet with the medical geneticist to review the fragile X blood test results and discuss the implications of further testing. I was unavailable to attend that meeting but I saw them in the hallway as they were leaving. We spoke and I asked how they were doing. Sally made little eye contact with me and seemed put off by my concern. John thanked me for having offered them testing and seemed relieved that they were aware of the risk and were having additional tests.
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Sally and I spoke several times by phone while they waited for their results. Throughout the process I felt uncomfortable with our interactions. Sally would at one moment open up to me emotionally by discussing her fears, guilt, and concerns and then quickly retreat and seem to push me away. She would call for further information, which I supplied verbally and by mailing written materials. The prenatal studies indicated that their fetus had a fragile X full mutation with greater than 900 repeats. The medical geneticist and I met with them to discuss these results. We could not make any predictions on exactly what degree of MR the child would have or if the child would also have autism as some boys with fragile X do. Sally discussed her feelings about children and adults with MR. She had worked with individuals with MR in the past and had had many positive experiences with them. She also talked about her cousins with MR who were now adults. Sally was very conflicted about whether or not to continue the pregnancy. It was my impression that John wanted to terminate the pregnancy, but would support continuation if Sally wanted to do so. He let Sally verbalize her conflicting feelings and seemed very attentive and caring. I noticed that at one point he tried to comfort her and she verbally pushed him away. I was surprised by the suddenness of her reaction and thought that John had not done anything to provoke the reaction he had received. The couple chose to go home to discuss the information further. Ultimately they decided to terminate the pregnancy. Once they had made the decision to terminate the pregnancy, I phoned Sally to let her know I was thinking of them and wanted to see how she was doing. She reacted to my question by stating bitterly “What do you want me to say?” Her tone was angry and annoyed as if I was trying to force something from her. Perhaps her grief was showing itself through expressions of anger. I offered to give her the name and number of another woman, who had also terminated a pregnancy because of a genetic indication, if she felt it would help to talk to someone who had been through a similar experience. She immediately said “No” and we ended the call. On the day of their pregnancy termination, I thought many times about visiting the couple, but never did. I was concerned about how Sally might react to me, and I did not want to end up feeling like an intruder walking away feeling helpless and guilty. I was very conflicted about not going to see Sally that day. I was avoiding showing and offering support due to my own discomfort because too often I had felt frustrated by my encounters with her. CASE PREPARATION FOR GROUP SUPERVISION This case was presented to the supervision group approximately two to three months after the above events occurred. I was unsettled with my negative feelings after my initial encounter with Sally and believed that I could not provide support for Sally emotionally. My feelings of annoyance and guilt originated during our first meeting and seemed to intensify with subsequent encounters. My goal
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was to find out the basis for it. Intellectually, I felt that I had provided accurate risk assessment, offered appropriate tests, coordinated appropriate follow up appointments, and handled my interactions with the couple professionally. It was a relief to be working with a team of providers who may have been able to provide her the emotional support that I felt I was incapable of at the time. This team included her obstetrician and a perinatal social worker. In preparation for presentation to the group, I reviewed some psychosocial literature provided by the group leader, which gave me some insights and helped me generate hypotheses about our counseling session. I came across a chapter on countertransference (Hamilton, 1992) and what struck me initially was the following: The therapist will be affected by a patient the way other people are. His emotional impressions provide a sample of feelings the patient tends to bring out in those around him. If the therapist is not too intrusive, this sampling will derive more from what the patient brings to therapy than from what the therapist brings to it (p. 235).
I began to wonder about the feelings I had experienced and what I could learn from the encounter about my client and myself. Could there have been an unconscious countertransference event? The original definition of countertransference posits that a counselor’s emotional response to a patient is somehow triggered by an unconscious conflict within the counselor herself and is something to “work through” and eliminate. This view has evolved over time; for example, Hamilton (1992) views countertransference more broadly. In this broader definition, a counselor’s feelings may also arise from a client’s “characteristic relationship style,” i.e., “Patients can behave in such a way as to elicit unwanted affects in the people around them, including clinicians” (p. 237). This broader definition includes the possibility that countertransference could be helpful in understanding the client. A client may behave or interact with the counselor in a way that creates feelings in the counselor that surprise her, and she may not know where these feelings are coming from. If she can recognize and define these feelings in herself, and question how her clients are bringing them out in her, she may gain better insight into her client’s conflicts and communication styles, as well as her own. There is a subtype of countertransference known as projective identification. Reading further into the chapter on countertransference and examples of projective identification (Hamilton, 1992), I came across a section on the victim–victimizer roles. The section begins: “Victims have a special place in our society. They elicit strong feelings in the people around them” (p. 244). Further, victims may unknowingly take on the role of the victimizer or, alternatively, may project the role of the victimizer onto others. Reflecting upon this reading and these quotes, I began to think about my first encounter with Sally. Offering Sally fragile X testing seemed to cause her to withdraw, regress, become indecisive, and talk about how scary it was. It was as if she was afraid and somehow I was causing her a great deal of pain. She looked, sounded, and acted like a victim. I had feelings of confusion, annoyance,
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and guilt, much like a victimizer might. In reviewing her history obtained from her obstetrician, I was reminded that Sally had been the victim of a vicious assault as a teenager and the victim of domestic abuse by an ex-partner. According to Hamilton (1992), victims may feel vulnerable by opening up to their counselors and through projective identification may project the victimizer role onto their counselors. Sally had allowed me to ask questions and she gave detailed information about her family. Once the information she elicited so openly was used to suggest she might have additional risks based on her family history, she withdrew physically and emotionally. My suggestion to her that she consider having fragile X testing, which implied that she could be a carrier, seemed to cause her a great deal of anxiety as was evident by her response. Perhaps Sally took on the role of the victim and projected the role of the victimizer onto me. She withdrew from me physically, shielded her face with her hand, reported how scary it was, and became almost childlike. Perhaps I allowed myself unconsciously to take on the role of the victimizer, the one who was causing her fear and pain, and as a result I experienced intense feelings of guilt. My past experience with offering additional tests when clients did not expect them, such as fragile X testing, showed me that it can be very confusing to a couple and may cause a great deal of anxiety. There may be some urgency for a decision to be made if an amniocentesis is scheduled for that same day. As a prenatal genetic counselor for many years, I have offered numerous tests to clients, causing anxiety and indecision for many. Something was different this time. I felt annoyed and guilty after our interaction and for some reason I resented Sally because of those feelings. It was not until months later, while preparing this case and spending some time thinking about our initial encounter, that I thought perhaps the role of the victimizer had been projected onto me and, unknowingly, I took on the role and felt responsible for the distress she was exhibiting. Through projective identification I may have experienced myself as the victimizer, which led to feelings of annoyance and guilt. I believe the intensity of these feelings stemmed from some of my own personal issues, i.e., countertransference. Sometimes feelings of annoyance represent mild feelings of anger for me. Perhaps I was annoyed at myself for taking on the role of the victimizer, and/or, I was annoyed with Sally for projecting this role onto me. I am uncomfortable with even mild feelings of anger and tend to feel guilty about them. It is also possible that my inability to provide emotional support to Sally was related to my feelings of annoyance and guilt. As Hamilton (1992) writes, counselors who experience strong negative feelings when working with their clients may be unable to help them: Many therapists, as helpers, feel they must care about their patients and not find them annoying, much less, infuriating. They often believe they must be able to help everyone and maintain objectivity. When patients elicit strong negative feelings in them, therapists may become immobilized with guilt, which interferes with their setting appropriate limits. They become inactive; nothing they do can help (p. 246).
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PRESENTATION TO SUPERVISION GROUP I was looking forward to receiving the group’s feedback on my hypothesis, therefore I asked the members to review the chapter on countertransference prior to our meeting. I presented my case from start to finish, followed by my hypothesis. We discussed my ideas as well as some alternative explanations. A second hypothesis suggested by the group was that this represented the common response of ‘shoot the messenger.’ I was the one who told Sally that her family history of MR might influence her risks for having a child with MR and subsequently we needed to discuss the abnormal blood and amniocentesis test results. A third possibility was that Sally felt shame with respect to her family history of MR and perhaps also on a more personal level with respect to events that had happened in her own life such as the assault and the abuse. In general, there seemed to be support for my hypothesis of a victim–victimizer countertransference, as delineated in Hamilton (1992). We then discussed my discomfort during subsequent interactions with Sally and my conflicting feelings about wanting to be involved but also wanting to avoid her. The counselors helped reinforce my belief that I did not push Sally to be tested. Although there was a chance that Sally was a fragile X carrier, most women we test who have a family history of MR turn out not to carry the fragile X premutation. Although she was at risk, without a positive diagnosis in the family she was not at considerably high risk of being a carrier. Discussing this issue with the group and hearing of others experiences helped me feel confident that I did not force or push Sally to be tested. Sally reacted to her husband in a manner similar to the way she reacted to me. I witnessed an interaction between Sally and her husband in which he attempted to comfort her with words and she verbally and physically pushed him away. It was as if he was about to harm her and she needed to fight him off. This event gave the group and me the sense that this may be the way she reacts to others, even those who are close to her, when events seem out of control or are very painful. I did not meet with the couple on the day of their pregnancy termination. I avoided it because of my own discomfort and the sense that I would be an intruder. I struggled with this at the time. I felt that I was avoiding seeing them for my own reasons and could not provide support to them. Discussing my feelings with the group helped me to understand the patient more clearly and to trust my feelings. I probably would have been viewed as the intruder, the unwelcome victimizer. Because of my own discomfort, I did not want to see her, but the group helped me to recognize that my decision not to see her was probably also best for Sally. POST-GROUP PRESENTATION ENCOUNTER The supervision process led to some resolution for me. By chance, I met Sally and John briefly in the waiting room a couple of months after I presented
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to the supervision group. I was surprised at how relaxed I felt talking to Sally and how I could focus on her and her husband. I also recognized some ways that she communicated verbally and nonverbally, which had previously made me feel uncomfortable, but no longer bothered me. The feelings of annoyance and guilt were gone.
SUMMARY Countertransference and projective identification are difficult responses to recognize, but considering them here, even months later, will help me to be aware of them in the future. Preparing and presenting this case to the supervision group helped me to realize where my feelings of confusion, annoyance, and guilt may have originated and how they could have affected my ability to provide support. If I had presented this case to the group sooner I may have had ideas for intervention that would have opened up communication and increased my ability to empathize with the patient. In general, there can be turning points in a counseling session when feelings arise in the counselor that may challenge her ability to understand and empathize with her client. At these junctions there may be the greatest need to increase one’s empathy. Through group or individual supervision, a counselor has the opportunity to explore these circumstances and discuss effective counseling interventions. For me, the group supervision process was validated when I met the couple by chance at a later date and realized that the nagging uncomfortable feelings, which had evolved during our previous encounters, had been resolved.
ACKNOWLEDGMENTS The author wishes to thank Annette Kennedy and June Peters whose instrumental comments and suggestions aided in the development of the final version of this paper.
REFERENCES Hamilton NG (1992) Self and Others: Object Relations Theory in Practice. New Jersey: Jason Aronson Inc. Nolin SL, Lewis FA, III, Ye LL, Houck GE, Jr., Glicksman AE, Limprasert P, Li SY, Zhong N, Ashley AE, Feingold E, Sherman SL, Brown WT (1996) Familial transmission of the FMR1 CGG repeat. Am J Hum Genet 59:1252–1261.
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Journal of Genetic Counseling, Vol. 9, No. 5, 2000
The Interface Between Countertransference and Projective Identification in a Case Presented to Peer Supervision Marisa Ladoulis Likhite1,2
This case report, presented to a supervision group, is a prenatal genetic counseling case that caused me a great deal of emotional discomfort as the events unfolded. The discomfort originated during my first meeting with the couple for routine preamniocentesis counseling and continued through later encounters. This case illustrates the process of working through countertransference and projective identification issues that may arise in genetic counseling. KEY WORDS: case report; group supervision; genetic counseling.
INTRODUCTION I presented this case to the supervision group two to three months after my work with the couple ended. It was chosen for two reasons. First, it was a seemingly straightforward routine prenatal genetic counseling case that turned into a much more challenging series of encounters. Second, as the events unfolded, I felt a nagging emotional discomfort, which affected my ability to provide support. My goal was to better understand why I found it so difficult to work with this family. CASE REPORT Sally, a thirty-six-year-old woman, and her thirty-nine-year-old husband, John, were referred for genetic counseling during Sally’s third pregnancy due to her age and her family history of mental retardation (MR). During the second 1 Perinatal
Diagnostic Unit, Massachusetts General Hospital, Boston, Massachusetts. should be directed to Marisa L. Likhite, Perinatal Diagnostic Unit—Blake 1053, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114; e-mail: mlikhite@ partners.org.
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pregnancy, they had genetic counseling and an amniocentesis at another center. The procedure went without complications, the results were normal, and Sally went on to deliver a healthy daughter. They decided to have amniocentesis in her third pregnancy also, and Sally chose to have genetic counseling on the same day as her procedure. Sally seemed hesitant to enter the room and initially made little eye contact, which surprised me since I had the preconceived notion that, as a counselor with a private clinical practice, she would have confidence and good social skills. I wondered about possible reasons for her apparent coolness and speculated that perhaps she felt our meeting was unnecessary since they had had genetic counseling during their second pregnancy. She may have been nervous about having the amniocentesis or concerned about the possibility of abnormal test results. I reviewed the purpose of our meeting and let them know that I planned to obtain a family history, review the amniocentesis procedure, review what tests would be performed, and try to answer any questions they might have. I also let them know that I was familiar with the events of their previous pregnancy. Sally and John were reportedly in good health and they had two healthy daughters aged six and two. There were no relatives with developmental delays in their immediate families. However, Sally reported having three first cousins with developmental delays; one was ‘slow’ and the other two ‘mentally retarded.’ These cousins were the children of two maternal aunts. To her knowledge, these individuals had no specific diagnosis and she was unfamiliar with fragile X syndrome. Sally had many other maternal first cousins and there were no other individuals with learning disabilities or developmental delays. Sally and John both were of Northern European ancestry. Sally actively participated when I took the couple’s family history. She provided details about her relatives with developmental delays and made sure I recorded the correct relationships. She wondered why all three had delays and questioned what this might mean. Unlike when she had first arrived, she made good eye contact, gave clear information, and looked to me for a possible explanation. After completing the family history, I identified two factors for which they should consider having testing: her age-associated risk of having a child with a chromosome abnormality and her family history of unexplained developmental delays. Therefore, in addition to routine amniocentesis, fragile X carrier testing was a consideration. The clinical details and genetics of fragile X syndrome were discussed. If found to be a carrier, Sally would be at increased risk for having a child with developmental delays, and studies of the fetus could be performed. Sally seemed overwhelmed by this new option and reported that she was not sure whether she wanted to have the additional test. Her demeanor appeared to change and she physically pulled away, looked down, and seemed frightened. She became very indecisive and appeared pressured into making a decision, even though I did not need an immediate answer. She positioned her hand in front of her
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face and stated “I don’t know what to do” and repeated more than once “This is very scary.” She did not appear to be looking to me for help with the decision. Her husband stated that he felt she should be tested and he encouraged her, pointing out that it was something they would want to know. What surprised me the most was that Sally suddenly seemed helpless and indecisive. In response to her attitude and behavior, I found myself responding emotionally and behaviorally. I felt uncomfortable, more than I usually feel in this type of situation. For some reason, her indecision caused me to feel very annoyed. I also felt guilty about causing her so much distress. Sally and John were told that they could let me know their decision after the amniocentesis or even go home to discuss it and call with a decision in a couple of days. Perhaps she could get further information from her aunts about whether or not there had been any testing of her cousins. Sally eventually decided to have her blood drawn for fragile X carrier testing and then went on to have an uncomplicated amniocentesis. Test results showed that Sally was a carrier of a fragile X premutation, based on 93 CGG repeats (Nolin et al., 1996). This put her at risk of having a child with a full mutation. Shortly before receiving her fragile X test results, I had received her amniocentesis results revealing the fetus to be a chromosomally normal male. I reviewed the test results with Sally’s obstetrician who in turn phoned Sally. Sally called me almost immediately. She seemed to have a very clear understanding of the fragile X results and was appropriately concerned. She quickly decided that she wanted the fetus to be tested, and I let her know that cells were being prepared to send for further testing. Initially our conversation about the test results flowed easily. Sally is an intelligent woman and quickly grasped the concept of being a carrier of a fragile X premutation and its attendant risks. She wanted prenatal testing and wondered how long the results would take. It was estimated that the results would be available in two weeks. Sally expressed concern and reported negative feelings about herself at the knowledge that she was a carrier. She seemed very open and willing to discuss her feelings. The conversation turned to our first office visit. Sally reported that she felt I had pushed her to have testing. This surprised me. My recollection was that she had been indecisive and that her husband had talked her into it. I began to feel uncomfortable and reminded her that her husband had encouraged her to be tested. She stated with certainty that “You wanted me to have testing,” and I ended that part of the discussion because there were more important issues to deal with. An appointment was set up for Sally and John to meet with the medical geneticist to review the fragile X blood test results and discuss the implications of further testing. I was unavailable to attend that meeting but I saw them in the hallway as they were leaving. We spoke and I asked how they were doing. Sally made little eye contact with me and seemed put off by my concern. John thanked me for having offered them testing and seemed relieved that they were aware of the risk and were having additional tests.
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Sally and I spoke several times by phone while they waited for their results. Throughout the process I felt uncomfortable with our interactions. Sally would at one moment open up to me emotionally by discussing her fears, guilt, and concerns and then quickly retreat and seem to push me away. She would call for further information, which I supplied verbally and by mailing written materials. The prenatal studies indicated that their fetus had a fragile X full mutation with greater than 900 repeats. The medical geneticist and I met with them to discuss these results. We could not make any predictions on exactly what degree of MR the child would have or if the child would also have autism as some boys with fragile X do. Sally discussed her feelings about children and adults with MR. She had worked with individuals with MR in the past and had had many positive experiences with them. She also talked about her cousins with MR who were now adults. Sally was very conflicted about whether or not to continue the pregnancy. It was my impression that John wanted to terminate the pregnancy, but would support continuation if Sally wanted to do so. He let Sally verbalize her conflicting feelings and seemed very attentive and caring. I noticed that at one point he tried to comfort her and she verbally pushed him away. I was surprised by the suddenness of her reaction and thought that John had not done anything to provoke the reaction he had received. The couple chose to go home to discuss the information further. Ultimately they decided to terminate the pregnancy. Once they had made the decision to terminate the pregnancy, I phoned Sally to let her know I was thinking of them and wanted to see how she was doing. She reacted to my question by stating bitterly “What do you want me to say?” Her tone was angry and annoyed as if I was trying to force something from her. Perhaps her grief was showing itself through expressions of anger. I offered to give her the name and number of another woman, who had also terminated a pregnancy because of a genetic indication, if she felt it would help to talk to someone who had been through a similar experience. She immediately said “No” and we ended the call. On the day of their pregnancy termination, I thought many times about visiting the couple, but never did. I was concerned about how Sally might react to me, and I did not want to end up feeling like an intruder walking away feeling helpless and guilty. I was very conflicted about not going to see Sally that day. I was avoiding showing and offering support due to my own discomfort because too often I had felt frustrated by my encounters with her. CASE PREPARATION FOR GROUP SUPERVISION This case was presented to the supervision group approximately two to three months after the above events occurred. I was unsettled with my negative feelings after my initial encounter with Sally and believed that I could not provide support for Sally emotionally. My feelings of annoyance and guilt originated during our first meeting and seemed to intensify with subsequent encounters. My goal
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was to find out the basis for it. Intellectually, I felt that I had provided accurate risk assessment, offered appropriate tests, coordinated appropriate follow up appointments, and handled my interactions with the couple professionally. It was a relief to be working with a team of providers who may have been able to provide her the emotional support that I felt I was incapable of at the time. This team included her obstetrician and a perinatal social worker. In preparation for presentation to the group, I reviewed some psychosocial literature provided by the group leader, which gave me some insights and helped me generate hypotheses about our counseling session. I came across a chapter on countertransference (Hamilton, 1992) and what struck me initially was the following: The therapist will be affected by a patient the way other people are. His emotional impressions provide a sample of feelings the patient tends to bring out in those around him. If the therapist is not too intrusive, this sampling will derive more from what the patient brings to therapy than from what the therapist brings to it (p. 235).
I began to wonder about the feelings I had experienced and what I could learn from the encounter about my client and myself. Could there have been an unconscious countertransference event? The original definition of countertransference posits that a counselor’s emotional response to a patient is somehow triggered by an unconscious conflict within the counselor herself and is something to “work through” and eliminate. This view has evolved over time; for example, Hamilton (1992) views countertransference more broadly. In this broader definition, a counselor’s feelings may also arise from a client’s “characteristic relationship style,” i.e., “Patients can behave in such a way as to elicit unwanted affects in the people around them, including clinicians” (p. 237). This broader definition includes the possibility that countertransference could be helpful in understanding the client. A client may behave or interact with the counselor in a way that creates feelings in the counselor that surprise her, and she may not know where these feelings are coming from. If she can recognize and define these feelings in herself, and question how her clients are bringing them out in her, she may gain better insight into her client’s conflicts and communication styles, as well as her own. There is a subtype of countertransference known as projective identification. Reading further into the chapter on countertransference and examples of projective identification (Hamilton, 1992), I came across a section on the victim–victimizer roles. The section begins: “Victims have a special place in our society. They elicit strong feelings in the people around them” (p. 244). Further, victims may unknowingly take on the role of the victimizer or, alternatively, may project the role of the victimizer onto others. Reflecting upon this reading and these quotes, I began to think about my first encounter with Sally. Offering Sally fragile X testing seemed to cause her to withdraw, regress, become indecisive, and talk about how scary it was. It was as if she was afraid and somehow I was causing her a great deal of pain. She looked, sounded, and acted like a victim. I had feelings of confusion, annoyance,
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and guilt, much like a victimizer might. In reviewing her history obtained from her obstetrician, I was reminded that Sally had been the victim of a vicious assault as a teenager and the victim of domestic abuse by an ex-partner. According to Hamilton (1992), victims may feel vulnerable by opening up to their counselors and through projective identification may project the victimizer role onto their counselors. Sally had allowed me to ask questions and she gave detailed information about her family. Once the information she elicited so openly was used to suggest she might have additional risks based on her family history, she withdrew physically and emotionally. My suggestion to her that she consider having fragile X testing, which implied that she could be a carrier, seemed to cause her a great deal of anxiety as was evident by her response. Perhaps Sally took on the role of the victim and projected the role of the victimizer onto me. She withdrew from me physically, shielded her face with her hand, reported how scary it was, and became almost childlike. Perhaps I allowed myself unconsciously to take on the role of the victimizer, the one who was causing her fear and pain, and as a result I experienced intense feelings of guilt. My past experience with offering additional tests when clients did not expect them, such as fragile X testing, showed me that it can be very confusing to a couple and may cause a great deal of anxiety. There may be some urgency for a decision to be made if an amniocentesis is scheduled for that same day. As a prenatal genetic counselor for many years, I have offered numerous tests to clients, causing anxiety and indecision for many. Something was different this time. I felt annoyed and guilty after our interaction and for some reason I resented Sally because of those feelings. It was not until months later, while preparing this case and spending some time thinking about our initial encounter, that I thought perhaps the role of the victimizer had been projected onto me and, unknowingly, I took on the role and felt responsible for the distress she was exhibiting. Through projective identification I may have experienced myself as the victimizer, which led to feelings of annoyance and guilt. I believe the intensity of these feelings stemmed from some of my own personal issues, i.e., countertransference. Sometimes feelings of annoyance represent mild feelings of anger for me. Perhaps I was annoyed at myself for taking on the role of the victimizer, and/or, I was annoyed with Sally for projecting this role onto me. I am uncomfortable with even mild feelings of anger and tend to feel guilty about them. It is also possible that my inability to provide emotional support to Sally was related to my feelings of annoyance and guilt. As Hamilton (1992) writes, counselors who experience strong negative feelings when working with their clients may be unable to help them: Many therapists, as helpers, feel they must care about their patients and not find them annoying, much less, infuriating. They often believe they must be able to help everyone and maintain objectivity. When patients elicit strong negative feelings in them, therapists may become immobilized with guilt, which interferes with their setting appropriate limits. They become inactive; nothing they do can help (p. 246).
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PRESENTATION TO SUPERVISION GROUP I was looking forward to receiving the group’s feedback on my hypothesis, therefore I asked the members to review the chapter on countertransference prior to our meeting. I presented my case from start to finish, followed by my hypothesis. We discussed my ideas as well as some alternative explanations. A second hypothesis suggested by the group was that this represented the common response of ‘shoot the messenger.’ I was the one who told Sally that her family history of MR might influence her risks for having a child with MR and subsequently we needed to discuss the abnormal blood and amniocentesis test results. A third possibility was that Sally felt shame with respect to her family history of MR and perhaps also on a more personal level with respect to events that had happened in her own life such as the assault and the abuse. In general, there seemed to be support for my hypothesis of a victim–victimizer countertransference, as delineated in Hamilton (1992). We then discussed my discomfort during subsequent interactions with Sally and my conflicting feelings about wanting to be involved but also wanting to avoid her. The counselors helped reinforce my belief that I did not push Sally to be tested. Although there was a chance that Sally was a fragile X carrier, most women we test who have a family history of MR turn out not to carry the fragile X premutation. Although she was at risk, without a positive diagnosis in the family she was not at considerably high risk of being a carrier. Discussing this issue with the group and hearing of others experiences helped me feel confident that I did not force or push Sally to be tested. Sally reacted to her husband in a manner similar to the way she reacted to me. I witnessed an interaction between Sally and her husband in which he attempted to comfort her with words and she verbally and physically pushed him away. It was as if he was about to harm her and she needed to fight him off. This event gave the group and me the sense that this may be the way she reacts to others, even those who are close to her, when events seem out of control or are very painful. I did not meet with the couple on the day of their pregnancy termination. I avoided it because of my own discomfort and the sense that I would be an intruder. I struggled with this at the time. I felt that I was avoiding seeing them for my own reasons and could not provide support to them. Discussing my feelings with the group helped me to understand the patient more clearly and to trust my feelings. I probably would have been viewed as the intruder, the unwelcome victimizer. Because of my own discomfort, I did not want to see her, but the group helped me to recognize that my decision not to see her was probably also best for Sally. POST-GROUP PRESENTATION ENCOUNTER The supervision process led to some resolution for me. By chance, I met Sally and John briefly in the waiting room a couple of months after I presented
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to the supervision group. I was surprised at how relaxed I felt talking to Sally and how I could focus on her and her husband. I also recognized some ways that she communicated verbally and nonverbally, which had previously made me feel uncomfortable, but no longer bothered me. The feelings of annoyance and guilt were gone.
SUMMARY Countertransference and projective identification are difficult responses to recognize, but considering them here, even months later, will help me to be aware of them in the future. Preparing and presenting this case to the supervision group helped me to realize where my feelings of confusion, annoyance, and guilt may have originated and how they could have affected my ability to provide support. If I had presented this case to the group sooner I may have had ideas for intervention that would have opened up communication and increased my ability to empathize with the patient. In general, there can be turning points in a counseling session when feelings arise in the counselor that may challenge her ability to understand and empathize with her client. At these junctions there may be the greatest need to increase one’s empathy. Through group or individual supervision, a counselor has the opportunity to explore these circumstances and discuss effective counseling interventions. For me, the group supervision process was validated when I met the couple by chance at a later date and realized that the nagging uncomfortable feelings, which had evolved during our previous encounters, had been resolved.
ACKNOWLEDGMENTS The author wishes to thank Annette Kennedy and June Peters whose instrumental comments and suggestions aided in the development of the final version of this paper.
REFERENCES Hamilton NG (1992) Self and Others: Object Relations Theory in Practice. New Jersey: Jason Aronson Inc. Nolin SL, Lewis FA, III, Ye LL, Houck GE, Jr., Glicksman AE, Limprasert P, Li SY, Zhong N, Ashley AE, Feingold E, Sherman SL, Brown WT (1996) Familial transmission of the FMR1 CGG repeat. Am J Hum Genet 59:1252–1261.
