Whether you are a therapist for an eating disorder program or a therapist who sees a single patient with anorexia nervosa, it is important to recognize and be knowledgeable about the complexities and power of countertransference in the treatment of eating disorders. Treatment often evokes a wide range of emotional responses. It will challenge even the most seasoned therapist.
It has been said that humans are so prone to destruction that it speaks to the deepest social need to provide a setting where two people can sit together and eventually, given the opportunity, out of chaos and misery a healing process will take place. This therapeutic twosome creates a structure for decreasing the destructive consequences of fear and aggression and for enhancing the capacity for affection and love.
Transference is the unconscious tendency of our clients to shift their emotional interest toward new persons or objects in the hopes of re-experiencing old persons or objects, often with the subconscious hope of succeeding where formerly they feel they have failed. For example, a 23 year old bulimic female arrives for therapy under the influence of marijuana. She is vaguely aware that she wishes the therapist to be irritated with her, angry enough to set limits on her behavior and control her. This is soon revealed to be a repetition of her adolescent behavior, which was designed to get a response from a remote and distracted mother. Rather than the client’s remembering, she presents the memory by transference. Transference may be adaptive to the extent that it reflects the urge to master the past and provides repeated opportunity to do so.
In the strictest sense, countertransference is the therapist’s counterpart to the transference of the client. It is not simply the multitude of varied reactions we have to stories and behaviors presented by our clients. It is the unconscious tendency of the therapist to shift his or her emotional interest from persons and experiences of the past onto the client. It may be damaging to the therapeutic process when there is resistance to conscious awareness, and therefore an acting-out on the part of the therapist. For example, a therapist who has unresolved adolescent rebellion issues may have difficulty in setting limits for the multi-impulsive eating disordered client.
Both transference and countertransference imply an overriding, coloring influence of the past on the perception of present reality. It is through ongoing supervision that the therapist can become aware of his or her own countertransference, identify ways to be a participant and not just the observer, and engage in the therapeutic relationship in a way that is mindful of the present experience.
As therapists, we do not consciously offer ourselves up for the various roles our clients need us to play. However, we find ourselves taking them, and then if we are fortunate, understanding them. Of great value to the comprehension of transference/countertransference is the realization that understanding our clients and their struggles is often times experiential, and not merely intellectual.
At EDC Denver, newly graduated clinicians call to inquire about employment opportunities with passionate intention to work solely in the field of eating disorders. We ask why? Often, their reply is “my cousin or my roommate” suffers from this illness and I want to make a difference. Experienced clinicians also express a desire to counter societal pressures for thinness and to empower women in the face of this ravaging disease. Despite statistics indicating that eating disorders have the highest mortality rate of any mental illness and are reported to be the hardest to treat, therapists are compelled to engage in the recovery process with the individual in need of eating disorder treatment. Effective treatment brings rewards but it may also take several years, involve numerous setbacks, and include periods of resistance and difficult physical and emotional struggles.
A common form of countertransference for the therapist is a state of frustration, impotency, and impatience responding to an anorexic’s passivity, intense resistance, and need for control in response to the change agent and encouragement to let go of the eating disorder. With most presenting problems, therapists are in a position to help identify and rectify the source of the conflict. In the case of the eating disordered patient, the therapist may quickly feel placed in an adversarial position. It can be quite uncomfortable to shift from being viewed as the emphatic and supportive caregiver to the identified enemy who will somehow steal their best friend, the eating disorder, from them.
Since transference and countertransference are natural aspects of the therapeutic relationship, it bodes well for the therapist to be prepared for the countertransferential responses and take good care of themselves as individuals and professionals.
Trish O’Donnell, MA, ATR-BC, LPC