Alex Katehakis - Center for Healthy Sex - IITAP Supervision 2011

“I love you, I hate you”: Transference and
Counter-transference Issues in Supervision

Presented by
Alexandra Katehakis, MFT, CSAT-S, CST-S
February 17, 2011

www.thecenterforhealthysex.com

What is supervision?

“Clinical supervision is a
disciplined, tutorial
process wherein principles
are transformed into
practical skills, with four
overlapping foci:
administrative, evaluative,
clinical and supportive.”

David J. Powell, 2004


Know your Candidate(s)

“A productive Supervisor/Candidate
working relationship is grounded in a clear
understanding of the goals of supervision
and clearly worked out supervision plan.
Such a plan presupposes an accurate
assessment of the Candidate’s knowledge
and skills – the level of professional
development the Candidate has attained.”

“Clinical Supervision in Alcohol & Drug Abuse Counseling,”
David J. Powell


Know your Candidate(s)

Know your ethics & get consultation!

Make sure you are clear about the law
and ethics binding you and that the
candidate is adhering to the law and
ethics of the board that governs their
license in the state they are in.

Seek your own consultation!


Supervision involves…

• Four realms of inquiry:

• Affective/Emotional/bodily
• Cognitive/Behavioral
• Insight
• Systemic

www.TheCenterForHealthySex.com

Supervision involves…

• Four systemic processes:

• Patient
• Self As Therapist
• Treatment Process
• Consultation Process


Sample Questions for Consultation Evaluation and
Intervention
Affective/Emotional

Patient: How/Does this patient express emotions? If so,
What is the patient feeling in their body? Where do they feel
it?

Self as Therapist: How do you feel as you talk about this
patient? What are you noticing in your body?

Treatment Process: How does the patient feel towards you?

Consultation Process: How do my reactions effect you?


Intervention
Cognitive/Behavioral

Patient: What does the patient say and what are they
thinking?

Self as Therapist: What interventions did you make with this
patient?

Treatment Process: What did the patient do to prompt your
choices or reaction?

Consultation Process: Can you describe what just happened
between us?

Intervention

Insight:

Patient: What themes are apparent that help you understand
this patient?

Self as Therapist: Does your reaction to this patient seem
familiar to you? Are these bodily-based reactions?

Treatment Process: What approach is best for this patient?

Consultation Process: How is our relationship similar to others
in your life?

Questions for Sample Consultation Evaluation and
Intervention
Systemic:

Patient: What rules does this patient operate from?

Self as Therapist: What rules are you operating from when
working with this patient? Do these rules assist or limit you?

Treatment Process: What rules guide the therapy relationship
you have with this patient?

Consultation Process: What rules guide the work we do here?
Adapted from Piercy, F & Sprenkle, D. (1988). Family therapy theory-building questions. Journal of Marital & Family Therapy,
14, 307-309


Psychobabble…


Counter-transference
• Freud 1910 – perceived
it as emanating from
therapist’s unresolved
unconscious issues and
conflicts deeming it
potentially harmful to
the therapeutic process.
(Vulcan, 2009)


Counter-transference
• Complex and mostly unconscious, making
it difficult to measure and
operationalize(Fauth, 2006)

• CT is often thought of as thoughts,
feelings, images, fantasies, and dreams.
(Stone 2006)


The Moderate Approach to CT
• Five domains can offer a framework for to
review work with clients to “looking for
evidence of counter-
transference…supervisors and counselor
educators may find the model similarly
helpful in teaching trainees how to identify
counter-transference and use the self as a
therapeutic instrument. Hayes, et al (1998)


Moderate Approach for Managing CT
Hayes, et al., 1998
• Origins: areas of unsolved conflict within
the therapist
• Triggers: are the tangible counseling
experiences that touch upon or elicit
therapists’ unresolved issues.
• Manifestations: When CT origins are
triggered, therapists experience cognitive,
affective, and behavioral reactions.


The Moderate Approach for Managing CT

• CT effects are the subsequent results of
CT manifestations on the therapy process
and outcome.
• CT Management refers to therapists’
strategies for coping with their CT

• Rosenberger & Hayes, 2002


Counter-transference Issues in Sex Addiction
Consultation

Minimization:

 Upon initial assessment, sex addicts often minimize their thoughts
and behaviors.

 Watch for supervisees believing and/or siding with the minimization
and challenge this as you would the patient. This can have the
supervisee missing crucial acting out behaviors leaving them with a
weak treatment plan.

 It can also have them doubting whether the patient is really a sex
addict.


Consultation

Disgust:

 Disgust can arise when assessing pedophiles or any other paraphelia that is
disturbing or uncomfortable for the therapist to talk about.

 Supervisees can report feeling “creeped out,” uncomfortable or judgmental. It is
recommended that these feelings be processed in detail so that an assessment can be
made as to whether the therapist should continue to treat the patient.

 If the therapist cannot work through their upset, they should be advised to take their
deeper issues to their own personal therapy.

 A sex addiction therapist should be ABLE to work with paraphelias, but has the right
to CHOOSE not to.


Consultation

Anger: “I don’t like him” and/or “I want to kill him!”

 Passive/aggressive and narcissistic personalities are often difficult to like.

 The supervisee has to be vigilant about their counter-transference.

 Unchecked anger can lead to punitive interventions which can have the
effect of shaming the patient. The therapist needs to talk openly about the
triggers that block them from being empathic.

 Supervisees should have a good understanding of narcissistic defenses and
examine why they are recoiling or judging in the face of these defenses.


Consultation

Argumentative/power struggle:

 This is a no win situation. Trying to convince, cajole, demand, etc. recovery
leads to power struggles. If a patient is terribly resistant, doesn’t comply with
treatment recommendations, or is a “general pain,” the therapist should step
back and reevaluate why the patient is in recovery.

 The therapist also needs to look at whether their treatment agenda is ahead of
the patient’s or if they have fallen out of therapeutic alliance with the patient.

If the situation becomes intractable, both parties should seriously consider if
treatment is right at this time. Should the therapist decide to end treatment, they
should review their thoughts and reflections on the case with the supervisor first.


Consultation

Patient admits to sexualizing the therapist:

 It is not uncommon for sex addicts to sexualize their therapist. It usually comes out
at some point in treatment either directly or indirectly. If it is not stated directly, but
the supervisee has an inkling that it is occurring, they should talk about it with their
consultant.

 If it happens in early recovery, it is usually coming from an addictive/manipulative
place in the addict. When the addict makes this known early on in treatment, it can
be an inappropriate way to try and connect or a way to devalue the therapist due to
discomfort or anxiety.

 Therapists should be advised to “file” the information for processing when they feel
the patient has made significant progress in their recovery.


Consultation

Therapist is seduced by patient:

 The patient can have the therapist feeling he is “such a nice guy,” “my
favorite patient” or “really trying hard.” If this happens early on the
treatment, it is imperative to remember that our patients have “dark sides.”
They are expert at looking good, rationalizing, minimizing, and justifying their
behaviors.

If that same supervisee reports task work isn’t being completed, denial
hasn’t been broken through (I.e. patient hasn’t owned up to the damage he
has wrought), or the patient seems to be going through the motions, then
they have to be confronted. This type of confrontation can bring up many
issues for the therapist which may be why the seduction was happening to
begin with.


Consultation

Idealization as seduction:

 If the therapist starts feeling or believing that “they’re the best therapist ever” they
should be aware of idealization by the patient and talk about it.

 This is especially true if the patient has had many therapists or has been through a
lot of treatment centers.

 If the supervisee feels special or like they are the only therapist who will be able to
help this patient, they’re in a trap. Believing this will have the therapist losing traction
in the treatment process and give the addict ground for running treatment.

 When this happens, the patient starts to decide whether and how many meetings to
attend, what homework they will and won’t do, etc.


Consultation

Therapist is sexually attracted to patient:

 If the therapist finds their patient attractive they can find themselves struggling to
stay on task, and/or it can have them engaging in covert seduction with the patient.

The therapist finds themselves feeling sleepy during sessions

 If they are not aware that they find the patient attractive, but find themselves doing
things they wouldn’t normally do, then this too has to be examined.

 Being attracted to the patient can have the therapist not holding boundaries with
homework assignments or having blind spots in their recovery.

 Either of these are ultimately harmful to the therapy and both parties. It is essential
to talk about these attractions and if necessary, should be taken to personal therapy.

Sexualization by Therapist
• Sexualization may defend against feelings
of love which may be more difficult for
therapists to acknowledge. (Gabbard,
1994)
• Oedipal desire is romantic and idealised,
whereas post-Oedipal desire tolerates
imperfections, and can experiece
disappointment without the death of desire.
(Gerrad, 2004)

Deepening intimacy…
• Is crucial for successful work and occurs
as a result of the interpersonal space
between therapist and patient
• Termination requires a letting go of the
patient and a kind of mourning so that the
patient can go have his own healthy, adult
sexual life. (Searles, 1959)


Erotic Counter-transference most likely to
occur with patients who:
• Have passive-obsessional and narcissistic
character disorders
• Suffer from borderline and chronically psychotic
conditions
• Those whose general character defenses and
areas of specific conflict are similar to the
therapist. The entangled transference-
countertransference relationsip leads to the
therapist withdrawing into sleepiness (Stone,
2006) www.TheCenterForHealthySex.com

Consultation

Intellectual seduction:

 Since many of the addicts we see are extremely intelligent, accomplished
professionals, therapists can be seduced into thinking that the person has really
“gotten it” and that they are on track quickly. CEO’s, doctors, lawyers, and so forth
are excellent at going to the top of the class.

 Intellect is no measure of sexual sobriety. The supervisee should be reminded to
look closely at the behavior and thinking of the patient first and foremost.
Supervisees can be triggered into their own issues of feeling less than when in the
presence of highly successful and/or powerful people.

The supervisee should know their triggers around intelligence, success and
money.

Consultation

Humor as seduction:

 We all know humor can be a defense against deeper, more painful
feelings.

 If a supervisee reports having a jolly good time with their patient and talks
about what a “funny guy” he is, pay attention to how the humor is being
used to keep the treatment off track.

This kind of humor can be a relief to the therapist if they are feeling
anxiety about the work.


Flirting…
• Flirting need not be seen as a purely
seductive act.
• If it occurs in the symbolic, meaning
change has actually occurred, it can be a
type of play and an acknowledgement of
attraction under safe conditions. (Davies
1998, Gerrard, 2004)


Consultation

Rescuing or caretaking to the patient:

 Therapists by nature are care-givers, but if they are inclined to care-take and have these issues
in their backgrounds, they can easily fall prey to this dynamic.

 Rescuing/caretaking can occur when someone is mandated to treatment and the therapist
wants to advocate for the patient, or while the patient is preparing for disclosure.

 Although it is, in part, the therapist’s job to advocate, be on the lookout for personal
involvement in the outcome like wanting to “soften the blow” for the patient.

 If the supervisee seems heavily invested in rescuing the addict from his consequences, and
doesn’t see the consequences as a part of the addict’s unmanageability, this can be problematic.

 Facing consequences are an essential part of the recovery process and it is not the therapist’s
job to thwart those, but to assist the recovering person in their grieving process.


Consultation

Siding with the patient:

 This is similar to the above but is more blatant and often occurs in relation to the patient’s
spouse.

 Addict’s can villanize their partners and play the victim. If the supervisor hears the
supervisee siding with the addict by validating all the hard work he is doing in recovery and
agreeing that his spouse must be “crazy,” “not working a program,” and “unfair,” then this is
a red flag.

 It is crucial that the therapist be aware of partner issues and the natural evolution of
recovery for a couple.

 Rather then taking sides with the addict, the therapist should confront the addict about his
unmanageability and what his part has been in his partner’s upset.


Consultation

Impatience:

 Therapists can get frustrated when their patient’s don’t move as quickly in
their recovery as they would like them to.

 Remembering to slow down and pace appropriately is a clinical skill. Each
person has different cognitive and emotional skills and many sex addicts have a
low emotional IQ.

 Knowing when to put pressure on the patient to take responsibility for task
work and feel their feelings, while at the same time having empathy for them is
required to effectively execute treatment.


Consultation

Flight into health:

 Be wary of the “model prisoner.” This is a more advanced version of looking
good. This is what they call a “Big Book Thumper” in AA. If the patient has
become religious about 12-step and their recovery, it becomes more challenging to
confront their denial and point out how they are using the program to hide out.

 Conversely, the patient can be very compliant leaving the therapist feeling like
their patient is a “piece of cake” and that the treatment is “smooth sailing.”

 Challenge the supervisee to see the fear and seduction in this and how it does
not serve the patient to collude with how well they’re doing. Look for the
inconsistencies and holes in the person’s recovery. Challenge the flight into
health.


Somatic Counter-transference
• SCT can be thought of as
“the therapists
awareness of their own
body, of sensations,
images, impulses,
feelings, and fantasies
that offer a link to the
client’s process and the
intersubjective field.
(Orbach & Carroll 2006)


• “the non-verbal behavior of both patient
and analyst is an aspect of the analytic
situation that receives comparatively little
attention either in supervision or in the
teachings of technique…it is uncommon
for supervisors to regularly inquire about,
or for students to regularly report on, the
nonverbal behavior of their patients.”
(Jacobs, 1994)

• Bodily-based, embodied knowing,
embodied cognition
• SCT commonly includes sleepiness, erotic
and sexual arousal, trembling (Field, 1998)
as well as aches, pains, rumblings,
coughing, nausea, and suffocation (Stone,
2006), tension, emptiness, and numbness.
• Non-verbal, primary process


• The therapist has to be aware of their own
bodily-based reactions or be “rooted in a
continuous awareness of their own
somatic reality in the first place.” (Soth,
2002)
• The “therapist body experience [may
provide] invaluable information relating to
the intersubjective space between
therapist and client.” (Shaw, 2004)

Therapeutic Enactment
• Sometimes the therapists past gets recreated in
symmetry with the patient
• It can also happen as a result of counter-
transference dominance, disrupting the
treatment, and potentially traumatizing the
patient
• Enactment is an “inevitable mutual event”
• Mutual unplanned behavior, a sense of
puzzlement, and a sense of being emotionally
out of control by both parties.
Maroda, 1998

• Most definitions
agree that there are
two essential
elements: the
stimulation of strong,
unconscious affect
and some resulting
behaviors. Maroda
1998


Therapeutic Enactment…
• …differs from strong transference,
counter-transference because it is
“unconsciously motivated by the mutual
stimulation of strong affect, with both
persons usually stating that they felt out of
control, or at least felt something come
over them that was mysterious and
powerful.” Maroda 1998


Neuropsychoanalytic model of patient-therapist
enactments

• “Heightened affective moments in which
overwhelming and thereby dissociated
trauma is experienced by both members of
the therapeutic dyad.
• This highlights not only the resistances
and defenses of the patient, but how these
align with the resistances and defenses of
the therapist.” Schore, 2011


Therapeutic Enactment…
 Patient’s transference will distort reality and
imagine that the therapist feels toward her in the
present what some other family member had felt
toward her in the past.
 They can also stimulate in the therapist the exact
emotions they had experienced with someone else in the
past
 Constructive expressions of these emotions and the
mutual working through of the subsequent emotions and
behaviors are crucial.


Feelings not within our control…
• Murderous rage
• Sexual attraction
• Anger
• Overwhelming grief and a desire to
physically hold or touch the patient
• Envy
• Deadness and not caring


• TE can take the form behaviorally as a heated argument,
spontaneous hug, physical gesture, sadomasochistic
exchange, shortening or lengthening of session, failure
to collect fees, unexpected dissolution into tears, or a
withdrawal into silence. Maroda 1998
• This is a a right amygdala to right amygdala, and right
insula to right insula communication, and pairs with
dissociation.
• It is a survival strategy.
• BOTH parties have to control and limit their behaviors so
the therapy can progress.


• The drama of the enactment ultimately belongs to the
patient. It is his/her chance to relive the past from an
affective standpoint, with a new opportunity for
awareness and integration.
• When the patient stimulates something real and primitive
in the therapist that is split off, then they can relieve the
drama in a real way together.

• Maroda, 1998


Transparency
• While the affect-laden enactment is inevitable,
the therapists behavior should not be. (rage,
erotic counter-transference, etc.)
• Therapist should remain reasonably in control.
• Admit what you are feeling and take
responsibility for it
• Avoid extensive processing of your behavior
• Keep explanations brief and return the focus to
the impact on the patient


Transparency in action
• Don’t blame the patient, accept what you
feel which will give your greater control
over your behavior.
• Feelings should be related at the patient’s
direction and behest so they are in control
of the emotional action between them.
• The interpersonal has to be addressed
• Maroda, 1998


• T.E. is a dynamic,
naturally occurring
manifestation of the
transference and
counter-transference
merging into a living
entity, making the
past alive in the
present.” Maroda,
1998

• The goal should be that more of the
patient’s past is re-created than the
therapists, and that the patient have every
opportunity to safely work through the
events within the boundary of the
therapeutic relationship.
• Therapists should expect enactments and
be reasonably in control of how they
behaves. Maroda, 1998

Coming 2010! HCI Publications

• Igniting Hot, Healthy,
Sex After Recovery
From Sex Addiction


Center for Healthy Sex
Los Angeles


Alex Katehakis - Center for Healthy Sex - IITAP Supervision 2011

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