Physical Pain Stops my Pain - Treating Teen Self Mutilation

Countertransference phenomena in the therapist are as meaningful and potent in therapy as transference phenomena in the child. The physical setting in which the therapist sees a child should be comfortable for both the child and therapist. If control of sound and noise is inadequate, conversations of others are overheard and privacy is lacking for child and therapist. Both will be uncomfortable. A therapist might think that the child "does not mind," or might disregard the child's need for privacy since the therapist is the adult in control. If the therapist has many objects that he treasures in his office, he can be concerned about the child's movements. If the therapist is too concerned about being liked, he might provide many toys, candy and cookies, frequently give "presents," and permit or ask the child to address him by his first name to demonstrate that they are friends and equals. This serves to confuse the child since they are not equal, though at different times from the child's point of view they may or may not be friendly to each other.

Over-identification with the child will lead the therapist to be excessively giving and permissive. When the therapist has difficulty with aggressive impulses, he will allow the child to become aggressive and vicariously enjoy the child's behavior as some parents do. Or, again, the therapist will inhibit an expression of aggression because he is uncomfortable when it happens. In attempting to hide his discomfort, he might say that he is not angry, or imply that his anger will lead to a dangerous situation. He may even resort to making the session as bland as possible as a means of diverting or minimizing the child's anger.

When a child senses that a therapist has particular needs, he may do the following: concentrate on them to please the therapist, play games or make models which the therapist likes, or bring in frequent evidence of "good" performance and behavior, if the therapist asks too often about the child's progress at home, at school, or with peers. A child will be aware of the therapist's needs if they become manifest as countertransference. The therapist's ego interests will be evident to the child, but these are not countertransference phenomena and need not intrude in the therapy hours. However, when the child makes observations and comments, he should be answered unambiguously.

The therapist's countertransference behavior may manifest itself in various ways toward the child's parents. A therapist who imagines all parents are "bad" might be very critical, aloof, or exceedingly friendly toward the parents. If he overindentifies with the child, wishes to rescue him, and sees the child's environment as harsher than it is, he will be excessively critical of the parents and undermine their positive attributes. His approach to them could become overly moral and judgmental. The need to rescue can lead the therapist to recommend placement of the child out of the home when it is not indicated. If he feels as a child in relationship to the parents, he may need to please them excessively and in so doing avoid critical areas of discussion. His need for the parents' approval makes this kind of behavior necessary. He might attempt to cajole, seduce, or coerce the child into "good" behavior to get the parents' approval; he might be too accommodating when it comes to changing appointments, canceling appointments, and in other ways seeking the parents' approval. A therapist who needs to please the parents will allow them to believe they are not involved in the child's difficulty, even in situations where they are, and permit them to be the sole reporters of the child's behavior, or be the recipients of advice on management from the therapist.

The therapist who has unresolved conflicts over aggressive or sadistic impulses and controls them by reaction formation will be too permissive with a child in therapy. He will avoid discussing and limiting behavior when it is necessary. When he needs affirmation of his competence to bolster his self-esteem and avoid narcissistic injury, he will often strive for rapid symptomatic "cures," and in so doing can gain his own approval as well as the approval of others. The therapist who cannot feel comfortable with ambiguity, or adopt a formulation which has some unexplained facets, will strive for closure and not be receptive to alternative explanations when they patently are more suitable. If the therapist believes he must always be available, does not take vacations, spends little time with his family, or is too "dedicated," he may be acting out of his fears of abandonment or the role of the idealized "good" parent. He might not enjoy pleasure because of superego prohibitions. Though the therapist engages in various maneuvers as part of the therapeutic process, he is very much a "real" person. The healthy part of the child cannot fail to observe this person and it serves a useful purpose.
- Committee on Child Psychiatry, The Process of Child Therapy, Brunner/Mazel Publishers: New York, 1982.

Self-Injurious Behavior: Characteristics and Innovative Treatment Strategies

- Dykes, Michelle, Specian, Victoria, Nelson, Meredith, Gray, Neil Self-Injurious Behavior: Characteristics and Innovative Treatment Strategies.

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Personal Reflection Exercise #9
The preceding section contained information about countertransference with children. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 23
The therapist who has unresolved conflicts over aggressive or sadistic impulses and controls them by reaction formation will be to what? Record the letter of the correct answer the Answer Booklet.