A Therapist's Conundrum

Originally Published: 2/24/11:
As some of my more devout readers may know, I am a Marriage and Family Therapist Trainee (soon to be Intern with any luck from the Board of Behavioral Sciences once they get past their anal retentive stage). I began my journey to becoming a therapist back in 2003, but it didn't become apparent until 2007 that this was not going to be an easy profession for me, a perfectionist who seems to equate success with self-worth and a hard-nosed bitch who deep down inside cares more than she ever wishes to admit.

Working as a counselor with severely emotionally disturbed foster kids and juvenile delinquents for two years was never an easy job. At one job it was guaranteed you would be cursed out and met with attitude every single day; at another, bruises, cuts, concussions, and trips to the emergency room after various assaults from the kids were not in short supply. But, in spite of the frustrations, the abuse, and the resulting PTSD, the day I had to make the decision to leave these kids was one of the most difficult days of my life. The guilt of what I believed to be was giving up on these kids was overwhelming. Flashing back to my first day on the job at one facility, after being cussed out by one client, another came up and asked "Miss, are you going to quit?" Being cussed out was not a novelty and I wasn't phased, but I could see the genuine concern in her eyes. "No, of course not, I'm not quitting," I'd assured her. "Good," she said, "because staff here always quit, people always give up on us." The following three weeks after giving my resignation were murky with depression and self-condemnation. And as stories of my former clients continuing to fall and fail trickled back to me through the grape vine, I couldn't help but take a chunk of the responsibility for not being there to set them straight again. Their failure was my failure.

Now, as a therapist, I find myself in the same position, struggling with the question of removing myself from a case because various extraneous factors are impeding the progress of treatment. Coping with the resulting counter-transference is like standing on the shoreline battling the ocean, one wave conquered but another to come and then the promise of endless swells after that. I have been pummeled with question by confidence-eroding question: If I leave, am I giving up on my patient? If I can't help him, am I failing as a therapist? If I can't handle my counter-transference, have I failed as a professional? Walking into my supervisor's office last week and admitting that I am incapable of continuing on as things are was virtually degrading. Given that this was a known difficult case to begin with, with this confession came an admission of someone else's misplaced faith in me by putting me on it, and in spite of the chorus of supportive dictum, I carried the burden of failure on my shoulders.

Stepping outside the fog of my own clouded perception, I am well aware of the reality of the situation. Reality: there are factors beyond my control that have not only halted progress but have fostered a heart-breaking regression in this case. Reality: my patients are largely responsible for their own success, I am responsible for my conduct as a therapist. Reality: if, after three months of attempting to manage counter-transference, being successful with one issue before failing when being blind-sided by another, and if that counter-transference affects my therapeutic relationship with my patient, then as a professional, I am required ethically to remove myself from the case. Reality: the fact that I am angered and frustrated by the results of this case is a testament to my care for this patient and my desire to see him succeed. And with this final reality comes more implications.

Yesterday's psychology fervently warned about becoming too close to patients, caring too much, feeling too much, but I often wondered how effective one could be in dealing with the emotions of others when they cut themselves off. As a youngster in therapy, one recollection I have was sitting on the couch, recalling something painful and bursting into tears. My psychiatrist sat there opposite from me stone-faced, watching me cry like it was the most absurd thing I could have done. No movement was made to embrace me or lay a comforting hand on my shoulder, no soothing comment made to set me at ease, to reassure me. The ethical and legal issues that frighten therapists into cold professional conduct stayed her hand, leaving a broken nine year old to shatter, and I never felt more alone and ashamed of myself. I never wanted to be that, I could never manage a shot of Novocaine to the heart, to be dead from the chest up, and it seems to be the number one complaint I hear from friends and family who have sought treatment and ended up leaving, refusing to return to try someone new. The problem comes when that connection becomes too powerful (counter-transference), and the path the case follows becomes a personal issue (personal failure). The only medium I can manage to find is a balance between caring, recognizing when I care too much, and calling it off when I can't resolve the matter. Is this right? I'm not sure, but it's the only way I can, with a clear conscience, secure for myself the continuing passion to work in this field.

So, in knowing the reality of the situation, but feeling the opposite, the discrepancy lies in trying to align the thoughts with the feelings into a happy medium. But getting my head and my heart on the same page is easier said than done. It's a work in progress and this blog is acting partially as an example for other aspiring therapists to learn from my struggles, and partially as my own attempt to process this issue. I've not left the case yet, my supervisor has allowed for the rearrangement of treatment methodology to facilitate more success and lessen my frustration, and some colleagues on the same case are being incredibly supportive. I'm monitoring my counter-transference in the wake of these alterations, and hoping for some positive results. In the possibility that I have to walk away, I can only hope I can successfully navigate away from the destructive self-blame and carry on the lessons learned to the next patient. As my former supervisor once said "Don't take too much credit for your patient's success, and don't take too much blame for their failures".