Countertransference and Related Experiences of Psychologists

Serving Suicidal Patients: Implications for Training and Supervision

Perry A. Staltaro

DISSERTATION.COM

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Countertransference and Related Experiences of Psychologists Serving Suicidal Patients: Implications for Training and Supervision

Copyright © 2001 Perry A. Staltaro All rights reserved. No part of this book may be reproduced or transmitted in any form or by any

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Dissertation.com

Boca Raton, Florida USA • 2010

ISBN-10: 1-59942-300-6

ISBN-13: 978-1-59942-300-5

iii

DEDICATION

For my loving wife, Shirley, my parents, Pat and Maria,

my sister Rose, my brother John, and my dear companions Bon,

Bianca, Anna and Nene.

“This is a narrative of very heavy duty proportions...”

Dr. Teeth, “The Muppet Movie”

iv

ACKNOWLEDGMENTS

This dissertation was an enormous undertaking and it

would not have been possible to do this without the

substantial support of my wife, Shirley Staltaro Psy.D, and

my parents, Pat and Maria Staltaro. I cannot accurately

emphasize how they directly, unsparingly and

uncompromisingly contributed. They provided me with every

conceivable support. Mom, Dad, and Shirley--please accept

my most heart-felt gratitude and appreciation.

In addition, I would like to acknowledge the

substantial contributions of my dissertation chairman and

professor, Thomas W. Shaffer, Ph.D. His work in suicidology

is renowned in our community as is his integrity and

dedication to our field. Dr. Shaffer inspired this project

and followed its growth through countless and massive

drafts, and his efforts deserve recognition.

Also, I express my appreciation to over three hundred

and sixty psychologists across the nation who took the time

to openly disclose their reactions, experiences, thoughts

and wisdom regarding their work with suicidal clients.

I also extend my warmest gratitude to the exceptional

individuals who contributed to my growth as a person and a

professional: Errol Leifer PhD, Susan Orovitz PhD,

v

Kathy Sullivan PhD, Marie Tomeo PhD, Paul Gardecki, Keith

Lyons, and the many others who offered the wisdom and

courage to glance further than I ever thought possible. To

approach the appropriate expression of thanks due to them

would necessitate increasing the volume of this dissertation

beyond the capacity of our humble library. Allow me to

spare the backs of our librarians and suffice to say, Thank

You.

Finally, let it be said that those who take on the

challenge of working with those whose lives hang in the

balance of intrapsychic ambivalence deserve the utmost

recognition for the burden they undertake. Societal and

professional expectations have been laid down that place the

responsibility of life and death into their hands,

regardless of their capacity to determine either outcome.

These men and women risk personal and professional outcast

through an arbitrary and misinformed judicial process that

hastily casts blame with neither rhyme nor reason. Out of

contradiction, misshaped roles, and whimsically constructed

ideals has emerged a series of phenomena that rest not so

subtly on their shoulders. To you, my colleagues, I say

continue to fight your good fight and “rage, rage, against

the dying of the light.”

vi

ABSTRACT OF THE DISSERTATION

Countertransference and Related Experiences of Psychologists

Serving Suicidal Patients: Implications

for Training and Supervision

by

Perry Anthony Staltaro

California School of Professional Psychology, Fresno Campus

Thomas W. Shaffer, PhD

Dissertation Committee Chairperson

1999

This study examined countertransference and other

experiences of therapists serving suicidal patients. A

survey was constructed to assess for aversion, narcissistic

injury and similar iatrogenic constructs. Participants

offered both Likert scale responses and spontaneous

unstructured comments. Likert data were analyzed

quantitatively. Content and phenomenological analyses were

applied to the comments. The findings suggest that a

substantial number of therapists treating suicidal patients

experience negative countertransferences. The implications

for training, treatment and supervision are discussed.

vii

TABLE OF CONTENTS

Page DEDICATION . . . . . . . . . . . . . . . . . . . . . iii ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . iv

ABSTRACT OF THE DISSERTATION . . . . . . . . . . . . vi

LIST OF TABLES . . . . . . . . . . . . . . . . . . . xvii

Chapter

1. INTRODUCTION. . . . . . . . . . . . . . . . 1

2. LITERATURE REVIEW . . . . . . . . . . . . . 5 Introduction. . . . . . . . . . . . . 5

The Risks of Treating a Suicidal Patient . . . . . . . . . . . . . . . 8

The Effect of a Patient’s Suicide on

the Therapist . . . . . . . . . . . . 15

Patient Communication of Suicidal Intent. . . . . . . . . . . . . . . . 19

Projective Identification . . . . . . 24

Introjective Identification . . . . . 30

Projective Identification

and Diagnosis . . . . . . . . . . . . 32

Projective Identification and Implications for Treatment, Training and Supervision . . . . . . . . . . . 36

Countertransference Experiences . . . 40

The Rescuer Role of the Therapist . . 45

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Chapter Page

Manipulation and Blackmail . . . . . 56

Countertransference Reactions . . . . 58

Malignant Alienation . . . . . . . . 68

Therapist Anxiety and the Patient . . 69

Countertransference Hate . . . . . . 73

Avoidance, Aversion and Reaction Formation . . . . . . . . . . . . . . 84

Projection of Countertransference

Hatred. . . . . . . . . . . . . . . . 96

Patient Ambivalence Toward Therapy. . 97

Countertransference Management. . . . 99

The Suicidal Therapist. . . . . . . . 103

Treatment Techniques Using Countertransference . . . . . . . . . 108

Therapist Training. . . . . . . . . . 113

Therapist Self-Care . . . . . . . . . 114

In-Patient Staff Countertransference. 117

Stress/Burnout. . . . . . . . . . . . 121

Case Management . . . . . . . . . . . 122

Cultural Differences in Suicide

Attitudes . . . . . . . . . . . . . . 126

Survey Design . . . . . . . . . . . . 127

The Research Purpose. . . . . . . . . 129

Summary . . . . . . . . . . . . . . . 131

ix

Chapter Page

3. METHOD. . . . . . . . . . . . . . . . . . 132

Participants and Procedures . . . . . 132

Protection of Human Participants. . . 133

Instrument. . . . . . . . . . . . . . 134

Hypotheses. . . . . . . . . . . . . . 135

Data Analysis . . . . . . . . . . . . 137

4. RESULTS . . . . . . . . . . . . . . . . . 141

Preliminary Listing of Statistics . . 142

Demographics. . . . . . . . . . . . . 143

Writer’s Caveat of Interpretation . . 146

Format of Presentation of Results . . 147

Descriptive Analysis of Each Construct and Respective Items. . . . 152

Aversion. . . . . . . . . . . . . . . 152

Item 4: “I experienced disappointment when the client arrived for their appointment.” . . . 152 Item 5: “Sometimes I wished the client would go to another therapist, move, or just go away.” . . . . . . . 156

Item 6: “I often found myself anticipating the end of the session.” . . . . . . . . . . . . . . 158 Item 8: “I felt a sense of compassion toward the client.” . . . 159

x

Chapter Page Item 12: “I would work with this/these client/s similar clients in the future.” . . . . . . . 161 Item 13: “During sessions, I found myself glancing toward the clock, daydreaming, or feeling bored.” . . . 163 Item 19: “During sessions I had difficulty keeping my attention on the client.”. . . . . . . . . . . . . . . 165 Item 22: “There were times when I regretted having accepted the client into therapy with me.”. . . . . . . . 166 Item 23: “During sessions, I felt a sense of closeness toward the client.”. . . . . . . . . . . . . . . 167 Item 26: “I would like to work with this or similar clients again in the future.”. . . . . . . . . . . . . 169 Item 28: “I often yawned, felt sleepy or tired during sessions with the client.”. . . . . . . . . . . . . 170 Item 29: “I experienced apathy toward the client.” . . . . . . . . . 172 Item 30: “I considered terminating and referring the client to another therapist.” . . . . . . . . . . . . . 173 Introjective Identification Scale . . 175 Item 9: “During treatment of the client, I experienced feelings of sadness.” . . . . . . . . . . . . . . 175 Item 10: “While treating the client I often felt a sense of hopelessness.”. . . . . . . . . . . . 177

xi

Chapter Page Item 11: “During sessions, I experienced unusual somatic symptoms.”. . . . . . . . . . . . . . 180 Item 17: “I experienced suicidal thoughts.”. . . . . . . . . . . . . . 181 Item 20: “During sessions, there were often times when I felt annoyed.” . . . . . . . . . . . . . . 182

Malice Scale. . . . . . . . . . . . . 184

Item 7: “I was bitter or resentful Toward the client.” . . . . . . . . . 184

Item 25: “I often felt angry with the client.”. . . . . . . . . . . . . 187 Item 31: “I have never had an angry fantasy about the client” . . . . . . 189

Narcissistic Injury Scale . . . . . . 190

Item 2: “I often felt overwhelmed while treating the client”. . . . . . 190 Item 3: “I felt particularly anxious before, during or after sessions with the client.”. . . . . . . . . . . . . 193 Item 14: “Treating the client, I experienced feelings of professional failure.”. . . . . . . . . . . . . . 195 Item 15: “I am bothered when a client does not like me.” . . . . . . 197 Item 16: “I experienced thoughts or feelings of inadequacy while treating the client.” . . . . . . . . . . . . 199

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Chapter Page Item 18: “I felt like the client was trying to punish me.” . . . . . . . . 201 Item 21: “I believe the client used the threat of suicide as a means to manipulate me.” . . . . . . . . . . . 202 Item 27: “The client was manipulative toward me.”. . . . . . . 205 Item 32: “I worried my license might be revoked if the patient committed suicide.” . . . . . . . . . . . . . . 206 Item 34: “During sessions, I often felt apologetic.” . . . . . . . . . . 208 Item 35: “While treating this client, I experienced myself as a highly capable and competent therapist.” . . . . . . . . . . . . . 209 Suppression Scale . . . . . . . . . . 210 Item 33: “It is likely that I may have a future client commit suicide.” 211 Reaction Formation Scale. . . . . . . 212 Item 24: “I would often extend the session time with the client.” . . . 212 General Comments. . . . . . . . . . . 214

5. DISCUSSION. . . . . . . . . . . . . . . . 229

Demographics Discussion . . . . . . . 231 Item 4: “I experienced disappointment when the client arrived for their appointment.” . . . 236

xiii

Chapter Page Item 5: “Sometimes I wished the client would go to another therapist, move, or just go away.” . . . . . . . 237 Item 30: “I considered terminating and referring the client to another therapist.” . . . . . . . . . . . . . 238 Item 6: “I often found myself Anticipating the end of the session.” 239 Item 8: “I felt a sense of compassion toward the client.”. . . . 240 Item 12: “I would work with this/these client/s or similar clients in the future.” . . . . . . . 242 Item 26: “I would like to work with this or similar clients again in the future.”. . . . . . . . . . . . . . . 243 Item 13: “During sessions, I found myself glancing toward the clock, daydreaming, or feeling bored.” . . . 244 Item 28: “I often yawned, felt sleepy or tired during sessions with the client.” . . . . . . . . . . . . 245 Item 19: “During sessions I had difficulty keeping my attention on the client.” . . . . . . . . . . . . 246 Item 22: “There were times when I regretted having accepted the client into therapy with me.”. . . . . . . . 247 Item 23: “During sessions, I felt a sense of closeness toward the client.”. . . . . . . . . . . . . . . 248

xiv

Chapter Page Item 29: “I experienced apathy toward the client.” . . . . . . . . . 248

Introjective Identification Scale . . 250 Item 9: “During treatment of the client, I experienced feelings of sadness.” . . . . . . . . . . . . . . 251 Item 10: “While treating the client I often felt a sense of hopelessness.” . . . . . . . . . . . 254 Item 11: “During sessions, I experienced unusual somatic symptoms.” . . . . . . . . . . . . . 255 Item 17: “I experienced suicidal thoughts.” . . . . . . . . . . . . . 257 Item 20: “During sessions, there were often times when I felt annoyed.” . . . . . . . . . . . . . . 260

Malice Scale. . . . . . . . . . . . . 261 Item 7: “I was bitter or resentful toward the client.” . . . . . . . . . 263 Item 25: “I often felt angry with the client.” . . . . . . . . . . . . 265 Item 31: “I have never had an angry fantasy about the client.” . . . . . 266

Narcissistic Injury Scale . . . . . . 267

Item 2: “I often felt overwhelmed while treating the client.” . . . . . 268 Item 3: “I felt particularly anxious before, during or after sessions with the client.” . . . . . . . . . . . . 270

xv

Chapter Page Item 14: “Treating the client, I experienced feelings of professional failure.” . . . . . . . . . . . . . . 271 Item 15: “I am bothered when a client does not like me.” . . . . . . 272 Item 16: “I experienced thoughts or feelings of inadequacy while treating the client.”. . . . . . . . . . . . . 275 Item 35: “While treating this client, I experienced myself as a highly capable and competent therapist.”. . . . . . . . . . . . . 277 Item 34: “During sessions, I often felt apologetic.”. . . . . . . . . . 278 Item 18: “I felt like the client was trying to punish me.”. . . . . . 279 Item 21: “I believe the client used the threat of suicide as a means to manipulate me.” . . . . . . . . . . 281 Item 27: “The client was manipulative toward me.” . . . . . . 283 Item 32: “I worried my license might be revoked if the patient committed suicide.” . . . . . . . . 285 Suppression . . . . . . . . . . . . 286 Item 33: “It is likely that I may have a future client commit suicide.”. . . . . . . . . . . . . . 286 Reaction Formation . . . . . . . . . 288 Item 24: “I would often extend the session time with the client.” . 288

Discussion of the Survey Overall . . 290

xvi

Page REFERENCES . . . . . . . . . . . . . . . . . . . 314

APPENDICES . . . . . . . . . . . . . . . . . . . 327

A. Table of Constructs . . . . . . . . . . 328

B. Research Instruments . . . . . . . . . . 337

C. Quantitative Analysis. . . . . . . . . . 345

D. Content Analysis . . . . . . . . . . . . 405

E. Phenomenological Analysis. . . . . . . . 459

Epoche. . . . . . . . . . . . . . . 460

General Comments. . . . . . . . . . 462

F. Writer’s Final Comments. . . . . . . . . 640

xvii

LIST OF TABLES

Table Page 1. Aversion Construct Survey Items . . . . . . 153 2. Introjective Identification Scale . . . . . 176 3. Malice Scale. . . . . . . . . . . . . . . . 185 4. Narcissistic Injury Scale . . . . . . . . . 191 5. Aversion Scale. . . . . . . . . . . . . . . 234 6. Introjective Identification Scale . . . . . 252 7. Malice Scale. . . . . . . . . . . . . . . . 262 8. Narcissistic Injury Scale . . . . . . . . . 269 9. Table of Constructs . . . . . . . . . . . . 329 10. Demographics . . . . . . . . . . . . . . . 346 11. Year First Doctoral License Was Received. . 347 12. Total Years of Having Practiced Psychotherapy . . . . . . . . . . . . . . . 348 13. Primary Employment Setting . . . . . . . . 349 14. Orientation and Specialization . . . . . . 350 15. APA Membership . . . . . . . . . . . . . . 351 16. Current Caseload . . . . . . . . . . . . . 352 17. f Distribution of Likert Responses to Scale Items . . . . . . . . . 353 18. P Distribution of Likert Responses to Scale Items . . . . . . . . . 357 19. Survey Item Analysis. . . . . . . . . . . . 361 20. Skewness and Kurtosis . . . . . . . . . . . 363

xviii

Table Page 21. Correlations of Scales to Demographics and Scale Items . . . . . . . . . . . . . . 365 22. Inter-Item Correlations Sorted by Strength of Correlation . . . . . . . . . . 368 23. Demographics Correlations . . . . . . . . . 378 24. Inter-Item Correlations, Complete Listing . 379 25. Complete Listing of Inter-Item rs . . . . . 393 26. Content Analysis: Elaborations to Survey Items . . . . . . . . . . . . . . . . . . . 406 27. Content Analysis: Elaborations Assigned to Primary and Secondary Content . . . . . . . 437 28. Transformation of General Comments to Meaning Units . . . . . . . . . . . . . . . 463 29. Transformation of Meaning Units to Themes . 485 30. Transformation of Survey Item Comments to

Meaning Units . . . . . . . . . . . . . . . 502 31. Transformation of Meaning Units into Themes 581 32. Results of Likert Responses to Survey Items . . . . . . . . . . . . . . . . . . . 634

xix

“During those months I didn’t really hate you. I just hated

everything you stood for--insight, care and hope.” --”Sarah”

(Gorney, 1979, p. 322).

1

Chapter 1

INTRODUCTION

This study seeks to explore the personal reactions and

experiences of therapists who work with moderately to highly

suicidal patients. The cognitive, affective, and behavioral

reactions of therapists will be examined as aspects of the

countertransference with special attention to projective

identification.

A working definition of countertransference has been

offered by Slackter (1987). After an extensive review of

the widely ranging uses of the term, he writes that

Countertransference concerns those personalized emotional responses each analyst makes to a broad range of individual patients in a wide variety of situations during various phases of treatment. While in themselves neither inherently positive nor negative, these responses can promote or hinder the therapeutic process, and it is from this effect that they derive their value, and ultimately their meaningfulness.

Such meaningfulness can hardly be overstated in terms of

treatment efficacy, especially in regards to the treatment

of the highly suicidal patient. These internal, personal,

and affect-laden experiences have the capacity to propel or

destroy the therapeutic alliance (Slackter, 1987).

2

Therapists, given their training, and the very nature

of true human empathy cannot avoid entanglement with the

powerful and moving world of patients whose lives are in the

balance (Maltsberger, 1994). At times the therapist’s

cognitive, affective, and behavioral experience will elicit

an iatrogenic reaction toward clients that may exacerbate

suicidality (Maltsberger, 1994).

Explanations for suicide include that it can serve as

an act of violent retaliation, a desperate plea for help, or

a final resolution to hopelessness (Beck, Kovacs, &

Weissman, 1975; Maltsberger, 1994). Each involves a fantasy

of interpersonal interaction highly charged with elements of

intimacy, rage, and abandonment. The patient who threatens

suicide sets the context for an involved, and intense,

patient-therapist interpersonal reaction. Naturally,

therapists are inclined to assume a defensive stance once

they have considered the possible consequences should the

patient commit suicide while under their care.

As Olin (1976) remarked, the therapist is in a delicate

balance of confirming the suicidal patient’s responsibility

without being rejecting or rescuing toward him or her. The

therapist’s capacity to maintain this balance is influenced

in part by the manner in which the therapist manages

countertransference (Maltsberger, 1994; Olin, 1976).

3

Of particular interest in this study is a specific type

of countertransference, which is the therapist’s use of

introjective identification in response to a patient’s use

of projective identification. Projective identification is

a process by which the patient projects an aspect of the

self or its objects (Scharff, 1992). More simply, patients

project an aspect of themselves upon the therapist and via

unconscious processes manipulate the therapist to act in

concordance with the projection. Through projective

identification, the suicidal patient induces the clinician

to play the roles of rescuer, abandoner, and even sadist

(Flarsheim, 1975; Gorkin, 1987; Jensen & Petty, 1958;

Maltsberger, 1994). Introjective identification is the

process by which the therapist identifies with the projected

part of the patient and subsequently introjects it (Scharff,

1992).

How the therapist manages the patient’s projected

material often has direct and significant implications for

efficacy of the treatment (Ogden, 1979; Scharff, 1992). For

example, in one study, which is later reviewed, 6% of cases

in which a patient committed suicide involved clear and

substantial therapeutic errors that stemmed from therapist

behaviors related to negative countertransferences

(Modestin, 1987). The implications are that if the treating

4

therapists had been more closely attuned to their own

countertransference they would not have made such serious

treatment errors (Modestin, 1987).

It is the aspiration of this dissertation to illustrate

the common countertransference experiences therapists report

when working with suicidal patients. At present, the

literature lacks collected self-disclosures and what exists

is theory based on case studies, individual self-reports,

and anecdotal evidence.

This study collects anonymous therapist self-

disclosures regarding the cognitive, affective, and

behavioral experiences they had while working with suicidal

patients. Additionally, this study explores how the

personal reactions and experiences therapists report compare

with the existing literature. Such research may aid in

continued theory development and offer practical information

to therapists and supervisors on understanding the

commonalties of the countertransferences toward suicidal

patients.

5

Chapter 2

LITERATURE REVIEW

Introduction

This literature review will offer an in-depth

exploration of the countertransference experiences of

therapists treating suicidal patients. Foremost to be

considered is the conscious risk the therapist assumes in

entering the treatment arrangement. Inherent to accepting

the suicidal patient into therapy are several personal,

professional, and legal risks. Following this will be a

discussion of the concepts of projective and introjective

identification in relation to the treatment of the suicidal

patient. Implications for therapist training, case

management, and supervision are discussed.

The specific countertransference experiences that

therapists have reported when treating suicidal patients are

examined. These include rescuing-behaviors, hate, aversion,

avoidance, and multiple other reactions. The therapist’s

specific countertransference and the associated patient

intra-psychic and behavioral patterns are then explored.

The effect of introjective identification upon the therapist

is studied, particularly in regard to the concept that

performing psychoanalysis is suicidogenic. The therapist’s

6

use of countertransference is explored in terms of potential

for diagnosis and various therapeutic techniques. Case

management issues including in-patient staff management,

consultation, therapist self-care, burnout stress, and the

legal implications of negative therapist behaviors based

upon unexamined or unresolved countertransference matters

are also discussed.

It has been written that “death is the ongoing enemy of

the physician,” and though the physician may postpone death,

he may never stop it altogether (Schwartz, Flinn, & Slawson,

1979). From the outset lies a particular challenge when the

agents of death are suicidal impulses within the patient.

Making the matter worse, the unconscious, which stirs such

impulses, may be oblivious to the threat of suicidality.

This perspective was taken by Freud when he wrote that “Our

unconscious . . . does not believe in its own death; it

behaves as if it were immortal . . . there is nothing

instinctual in us which responds to a belief in death”

(Freud, 1961c, p. 288).

Before exploring the literature regarding the treatment

of the suicidal patient, a brief exploration of the

definition and degrees of suicidality will be offered. In

1897, Emile Durkheim defined suicide as “all cases of death

resulting directly or indirectly from a positive or negative