In his paper ‘Managing distress over time in psychotherapy: guiding the client in and through intense emotional work,’ Peter Muntigl (2020) explores how difficult it can be to respond well to clients’ disclosures of distress in therapy, but he focuses on the distress as experienced by the client, rather than what reactions this might provoke in the therapist. It assumes that the therapist is perfectly able to listen openly and evenly to the client’s distress, without having any subjective responses to it that might interfere with the therapeutic process. This is imagining the ‘ideal’ therapist; unfortunately, most therapists practicing today are far from this ideal – they are human, after all. Of course it goes without saying that it’s the psychological well-being of the client that takes priority in the therapeutic encounter, but I don’t think that goal will be reached if we ignore the challenges that face the therapist. If we don’t prepare ourselves for these challenges, we will be poor therapists! A study by Da Silva & Carvalho (2016) found that intense emotions experienced by medical clinicians while in the presence of their patients impacted the physical-patient relationship, so this is surely the case with mental health professionals (but I can’t seem to find the research outside of psychoanalytic case studies?).
The two difficulties identified by Muntigl are 1) The difficulty that therapists may have in responding to the client’s past or present feelings in an appropriately congruent manner – the therapist’s responses may not necessarily fit with client’s understandings of their distress. And 2) The therapist having to manage distress as it is occurs on potentially two levels: as it is reported (when the client tells of a distressing experience that happened in the past), and as it is expressed in the present (e.g. the client crying whilst telling of this past experience) – this 2nd difficulty being, should the therapist attend to the presently felt distress, or explore what the past feelings of distress meant?
But I think more needs to be said about the first challenge that Muntigl identifies. He describes the difficulty that confronts the therapist as being, how to respond accurately to the client’s distress? How to find a way to validate their distress without seeming to confirm the helplessness that the distress might also signify for the client? “Therapists may sometimes need to individualize their response to best suit their client and to know when empathy is called for and when it is not” (pg. 2). And he writes of a related issue being: “The difficulty for therapists … to offer clients enough security through which they may risk more directly confronting their upsetting experience” (3). But while he describes the conversational tight-rope the therapist must tread in avoiding provoking the client’s displeasure or disagreement, we never hear about the countertransference responses that may or may not be occurring in the therapist. What internal conflicts might the therapist be dealing with as they listen to their patients distress? We must not pretend that these don’t exist, even in the best therapists who have been through years of intensive psychotherapy themselves.
I would be interested to read about how clinicians remain open to listening to reports and expressions of distress. We all know it’s hard to listen to someone telling us about a difficult experience – it provokes all kinds of reactions in us, both empathetic ones and those that are less so. I’m guessing, or hoping at least, that most therapists go into the profession because they want to support a patient’s healing process. So that initial motivation should be there, but that doesn’t necessarily make it easier to do so…
Has anyone read any good research on this subject? Nancy McWilliams, in her book Psychoanalytic Diagnosis, writes of the various countertransference feelings that frequently arise in response to different presenting problems (e.g. clients with narcissism provoking feelings of boredom or frustration in their therapists), but I would love to read further on how exactly therapists overcome these countertransference reactions…
I’m guessing that alongside having had your own intensive psychotherapy, another answer to this question might be having regular supervision – a place where you yourself can go to ‘off-load’. But I think other, micro things must be going on in the therapists’ minds to regulate these difficult countertransference reactions, and I would love to know more about them!
Da Silva, J. V., & Carvalho, I. (2016). Physicians experiencing intense emotions while seeing their patients: what happens?. The Permanente Journal, 20(3).
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press.
Muntigl, P. (2020). Managing distress over time in psychotherapy: guiding the client in and through intense emotional work. Frontiers in psychology, 10, 3052.