CASE STUDY 1

Case Study: Type I Countertransference Reaction

Mr. A is a psychotherapist who has worked at a community mental health clinic for the past 10 years serving adults with a wide range of presenting problems. He has been treating Patient M for the past six months. Patient M is a highly educated, married woman, 35 years of age, from a country in Latin America and has been in the United States for the past two years. She was referred to the mental health clinic by her primary care doctor because of her severe and frequent panic attacks, nightmares, seeing and hearing dead people talking to her, and severe depression. Over the course of the first several months of treatment, Patient M has shared bits and pieces of her story with Mr. A. He has learned that the patient was working as a teacher in her community and was active in one of the opposition political groups in her country. She fled her country after soldiers killed opposition party supporters and their families in her town one night, including her husband and child. She was at a distant neighbor's house when the massacre took place, tending to a sick friend, and she believes that is why the soldiers did not find her. She tells Mr. A that she is too afraid to return to her country and is seeking asylum in the United States.

Mr. A finds himself flooded with many painful emotions in and after sessions with Patient M. He often feels horrified and has desires for revenge as she discusses her memories of finding her dead husband and child when she returned home that night. He feels terrified by the thought that Patient M may be deported to her native country where her life may be in danger. Mr. A has not experienced much trauma in his own life and definitely does not identify with Patient M's experiences.

Mr. A finds it extremely difficult to tolerate the intensity of his feelings when working with this patient. In order to avoid the pain associated with these feelings, he unconsciously develops empathic withdrawal toward Patient M. Mr. A's countertransference reactions alternate between intellectualizing, blank-screen façade, and misconception of the dynamics with his client. For example, Mr. A has unconsciously distanced himself from Patient M and often blankly stares at her when she brings up anything related to her traumas. Mr. A's reactions have led him to neglect to thoroughly assess the patient's traumatic experiences and the origins of her current symptoms. This, in turn, has led him to inaccurately assume and interpret Patient M's experiences of seeing and hearing of dead people talking to her as psychotic symptoms rather than as possibly part of her post-traumatic stress reaction. Patient M has not experienced any significant relief of symptoms.

Reflection Questions

CASE STUDY 2

Case Study: Type II Countertransference Reaction

Ms. B is a relatively new therapist who works at a center that serves women who predominantly have experienced domestic violence and abuse as children. She is only one year out of graduate school and has not had extensive specialized training about trauma or the impact of trauma work on herself. She has begun to feel extremely overwhelmed in her work with Patient P, a young Cambodian woman, 19 years of age.

Patient P was referred to Ms. B's center by the Federal Bureau of Investigation (FBI) a month ago after they rescued her from a sexual human trafficking ring in a sting operation. The FBI has arranged for the patient to stay at a secure shelter, and they have certified her as a trafficking victim in exchange for her cooperation in prosecuting her traffickers. She should be eligible to be granted a T-visa, which would entitle her to legal status in the United States as well as work authorization because of her cooperation with the federal authorities. Patient P will be required to testify in court against her traffickers, something that frightens her considerably, particularly because they threatened to harm her and her family back in Cambodia if she ever reported them to the authorities. She worries that her traffickers may see her when she leaves the shelter to go to the store or to the center.

In the past month, Patient P has shared with Ms. B about the extensive emotional and physical abuse she experienced as a child—abuse that left her with a broken arm and two broken ribs. She was eventually sent by her parents to live with a distant aunt in the capital Phnom Penh. When Patient P was 16 years of age, her aunt lost her job and became financially destitute. The aunt told Patient P that she had found a well-paying job for her with a family, but when she showed up for her first day of work she quickly learned that her aunt had sold her into a life as a sex worker. Patient P initially refused to cooperate, and her traffickers beat her daily and drugged her in order to force her to submit to engaging in prostitution. They kept her locked up and, after several months, trafficked her to the United States, where she continued to be forced to engage in sex work, servicing up to 8 or 10 men per day, seven days per week. She developed gonorrhea and herpes and became pregnant. She had an abortion, and her traffickers forced her to return to sex work after only two days of rest.

Ms. B develops intense stomach pains and headaches during and following sessions with Patient P. She finds herself full of uncertainty about how to proceed with treatment and overwhelmed by intense anxiety and horror, as well as graphic images of the patient's repeated abuse. She is plagued by self-doubt and insecurities about her ability as a therapist to help Patient P heal from the traumas she has experienced and prepare psychologically to testify against her traffickers. Ms. B feels exhausted every day and at times feels despair; her countertransference reactions are illustrative of empathic disequilibrium.

Reflection Questions

While not all countertransference reactions are problematic, each of the discussed reactions would likely have a less than optimal impact on the therapeutic relationship and course of treatment of the survivor. It is an ethical duty, above all, for health and mental health professionals not to do harm to their clients and patients. Therefore, it is essential that clinicians strive to become aware of, understand, and develop the skills to address or make therapeutic use of the information provided by their countertransference reactions. Attending effectively and appropriately to one's countertransference reactions will also enhance one's professionalism and the quality of one's work.

CASE STUDY 3

Case Study: Anticipating and Preventing Burnout

Before Ms. C decided to apply for admission to a Master's in Social Work (MSW) graduate program, she reflected on whether this was a good choice for her or not. She had heard stories about social workers who burned out. Professionals, once passionate about their work with runaway teens or domestic violence victims, had become disillusioned and exhausted and had lost their passion and energy for their work. This gave Ms. C pause and made her worried. She was nervous about entering a profession that seemed to pose a high risk for burning out, but she was raised in a family where she was encouraged to pursue a career that she was passionate about and was surrounded by examples of family who remained energized and fulfilled in their work after many years. Ms. C was told that she had many options open. She had not had any significant contact with social workers up until then, and she was not sure if this would be a career she loved. She did know, however, that many jobs were definitely a poor match for her abilities and interests.

Ultimately, Ms. C decided to give social work a try and applied to graduate school. Before she applied to a MSW program, however, she developed a plan and commitment to herself that served her well over more than two decades in the field. Her plan was to check in with herself often about how she was feeling and functioning in relation to work and life in general. Ms. C vowed that if she ever found that she was starting to burn out, she would make a change by switching the population she worked with or changing her role and duties; she could leave clinical work altogether and do policy- or community-based advocacy, or she could combine clinical work with research and policy work. Ms. C was relieved to know that the options within the profession of social work were many. Just knowing that she had options and the power and ability to be in control of her choices and work life made a huge difference. Over the years, she made several changes in her work setting, role(s), and the populations served. Ms. C is pleased to report that she has successfully avoided burning out.

Reflection Questions

It is possible to recover from burnout, and compassion fatigue in general. Not all of the symptoms are extreme or long-term in nature. Burnout and compassion fatigue exist on a continuum of severity. It can be helpful when one becomes aware that they have developed a sign or symptom of burnout or compassion fatigue, as this could serve as a signal of the need to do something about it. Without such awareness, it is less likely for professionals to make positive changes in their lives to promote well-being. Ideally, however, professionals will develop plans to prevent becoming burnt out or developing compassion fatigue in the first place.

CASE STUDY 4

Case Study: An Early Warning Sign

Ms. C's first job after graduating with her MSW degree was as a psychiatric social worker and trainer of paraprofessional refugee counselors in a first asylum camp for Vietnamese boat people on an isolated island in the Philippines. When she arrived, she found that she had the most mental health training of anyone on the island. The Filipino non-profit she worked for had psychiatrists on call for consultation by phone and would fly a psychiatrist in for several days every two months to assess and prescribe medications. There were very few telephones on the island, and Ms. C had to borrow another agency's phone to make a call. Often, the connection was poor, and it was hard to communicate with the psychiatrist. Ms. C had a caseload of more than 100 clients who had fled Vietnam by boat and had experienced multiple traumas. Many of the clients were suffering from severe mental health problems, and some faced ongoing violence. Ms. C found herself working with multiple cases of trauma with both the perpetrator(s) and victim(s) at the same time. She only had access to peer supervision, with only sporadic access to a more senior, experienced supervisor when they visited the island.

Within several months, Ms. C's sleep became routinely disrupted. She began to have frequent nightmares. When she examined her nightmares, she realized that they were not her own—they were those of her clients, especially those who had experienced atrocities on the high seas during their escapes from Vietnam. The nightmares were filled with images of Ms. C hanging on to driftwood, watching helplessly as her loved ones lost strength and drowned in front of her. She also saw images of herself being attacked by pirates at sea, shot, and left for dead in a pile of dead bodies, and pretending to be dead until the pirates left. She had a recurrent nightmare of watching her brother murdered by others on the boat and seeing them eat his corpse in order to stay alive.

Instead of becoming alarmed at this development, however, her anticipatory work prior to starting the MSW program (vowing to check in regularly with how she was feeling and functioning) proved protective and reassuring. Her approach was to view these nightmares as fortuitous, because it gave her the opportunity to develop and implement a prevention plan and recognize the importance of taking care of herself and creating balance in her life very early in her career. More than two decades later, she is still working with trauma survivors. Her role has evolved and expanded and the population she works with is different (survivors of state-sponsored torture from all over the world—no longer restricted solely to Southeast Asian refugees). She also reports that she no longer has the nightmares of her clients.

Reflection Questions