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Article by Anna Keyter
Online Therapist Analysing InTreatment Week 4 | Sophie & Paul:
This article is a critical analysis of a therapy session based on an assessment of the HBO episode: In Treatment. (Disc Four) with Sophie and Paul. The purpose of the session was for Paul to write a report on Sophie’s suicidality. However, the assessment turned into therapy. Sophie presents self-harming behaviour, risky sexual activity and substance use.
Sophie was raped and exhibits the typical acting out behaviour of teenage rape victims. Signs of adolescent rape include conduct such as extreme agitation, anger outbursts, depression, sleep and school problems (NSOPW, n.d.). She also engages in alcohol misuse, promiscuity, eating disorder and running away from home and possibly comorbid depression (DSM5, 2013). Contextual variables, including transference-countertransference, will be discussed first, followed by the strategies Paul used to develop the therapeutic relationship. Ruptures will be addressed firstly by looking at ethical challenges that arose followed by ruptures due to cues Paul missed during the session. Each section describes behaviours/events and recommendations on the ruptures that occurred during the session.
The contextual variables will be discussed in terms of countertransference and transference experienced by Paul (therapist) and Sophie (client). From a psychodynamic perspective, countertransference can be defined as the therapist’s subconscious emotional reaction to the experiences of the client. Transference is when the client subconsciously redirects feelings for one person to the therapist. Gelso (2014) refers to a tripartite model of psychodynamic intervention, “asserting that all therapeutic relationships, to varying degrees, consist of a real relationship, a working alliance, and a transference-countertransference configuration”.
Paul | Countertransference
Paul, a middle-aged man with children, is providing therapy to Sophie, a teenage girl who was raped. Sophie’s experiences affect Paul. Countertransference is not necessarily bad and could serve as an internal barometer to assess personal reactions to social interaction when the psychologist is aware of it (Gelso, 2014). During my observation of the session, Paul seemed to assume an almost fatherly role in his interaction with Sophie which could be due to a subconscious need to act as a parent to her. Schaeffer (2007) expresses the importance for therapists to identify transference and countertransference as soon as possible for the therapist to be in control of it and not be controlled by it.
Hence, countertransference could be useful if Paul examines his reasons for the way he behaves. Even though Paul is a psychodynamic therapist, I am uncertain if he is aware of his emotions of countertransference. Paul should pursue personal therapy to distinguish reasons for the countertransference that was evoked by Sophie throughout the session. In particular, Paul reacted strongly when Sophie’s commented on the gymnast that told her sex with her was like having sex with someone who had been sexually abused. Paul responded by saying “Prick”. At one stage Paul also tried to comfort Sophie by putting his arm around her and stroking her shoulder and hugging her (which could have ethical implications).
Sophie | Transference
Sophie is a teenage girl who was referred to Paul after a bicycle accident that was possibly a suicide attempt. She has a strained relationship with her mother and only mentioned her father once. She is a hopeful Olympic level gymnast. However, she had been sexually abused by her coach Sy. Initially, the relationship with Sy’s family seemed close; she spent time at their house, babysitting their daughter Dena.
Sophie was on Sy’s bicycle the night of the accident, and it should have been Paul’s intention to assess possible suicidal behaviour. The helping relationship should be the interaction between the therapist’s intentions and the client’s reactions (Hill, 2014). According to Gelso (2014), the therapeutic relationship is the core of successful psychotherapy, and the two critical elements of the therapeutic relationship are transference and the real relationship. As a psychodynamic therapist, Paul should encourage this transference intentionally to assist Sophie to get insight into her distress through the therapeutic relationship. Transference is the way the client experiences and perceives the therapist. However, the client is shaped by her psychological structures, including past experiences and involves the displacement and carrying the feelings, attitudes, and behaviours to the therapist deriving from earlier significant relationships (Gelso, 2014).
Sophie displayed sexualised behaviour when she entered the therapy room. Paul did not successfully use transference to develop the conversation around transference behaviour. Instead, he played into it by taking her hand and bowing. During the session, Sophie seemed to “transfer” feelings from people in her life to her therapist Paul by the way she interacted with him. It is interesting to note that Sophie tried to commit suicide using Sy’s bike and taking an overdose of Paul’s medication in his office. Is Sophie trying to say something by using something belonging to Sy and Paul to commit suicide?
Therapeutic Strategies and Skills
Paul is a Psychodynamic therapist however, his methods seem more in line with the Rogerian model. Paul’s strategies include empathic reflections, probing for insights and listening. A positive of the session was that Sophie could speak openly and freely about her problems. Paul was listening to Sophie and displayed nonverbal cues such as nodding and using gestures. He prompted for more information by asking open-ended questions and restated comments. Paul also used alternatives, commenting that Sophie tried to get her mother’s attention by running away from her.
Therapeutic Alliance Ruptures
Safran and Muran (2000) define therapeutic alliance ruptures as impasses or ruptures in the therapeutic alliance. Three roads can lead to an impasse – therapist and client developing a hopeless narrative about presenting difficulties; therapeutic strategy halts; leaving the interaction trapped in a negative pattern. To overcome the impasse, the therapist should become solution-focused and get help during the consultation on developing a new strategy (Safran & Muran, 2000).
Many ruptures occurred during the session as indicated below:
Safran (1993) views ruptures in the therapeutic relationship as the breakdown of the collaboration between therapist and client as indicated below.
Contracting | Privacy and Confidentiality
Problem. Psychologists should be respectful to clients by including them in the decision-making process. Paul called Sophie’s mother behind her back. He did not obtain full and active participation from Sophie on decisions that affected her. Sophie mentioned her mother took her shopping on the weekend because Paul told the mother she was going to “off” herself. Sophie asked Paul why he called her mother. Later on, Sophie expressed anger in an outburst again, telling him how upset she was that he called her mother and told her she was going to kill herself. Paul brushed it off.
Recommendation. During the initial assessment, Paul should have discussed informed consent and the implications thereof. Before involving Sophie’s mother on her suicidal thoughts, Paul should have explained to Sophie that psychologists promote their client’s right to privacy, however, when there is a threat of harm to self and others they are compelled by law to report it. The relationship could repair if the client actively participates in the change process (Horvath, 2009).
Challenges in future sessions. Sophie may become reluctant to share critical information, and risk assessment could become difficult.
Issue. Paul seemed oblivious to the harm caused to Sophie as a result of the ruptures in their relationship. He did not clarify what Sophie could expect from the therapeutic encounter. On a number of occasions, Paul pushed Sophie to go on with her story, even when she was not ready to continue. Paul did not handle the situation competently; he was more interested in what happened next than how the event affected Sophie emotionally.
Recommendation. The therapist’s ideas should not be imposed on the client in therapy (Safran & Muran, 2000). Problems should be addressed within the therapeutic alliance so that the client can reflect on problems. Paul needs to discuss this case in supervision to get guidance on how to deal with the situation.
Issue. When Sophie showed Paul a backflip, she started to walk on the back of the couch; Paul did not know how to deal with the situation. He asked her to stop, but instead of addressing his concerns about her safety, after a perfect landing he said, “That was incredible.”
Recommendation. Paul should discuss potentially harmful behaviours honestly and openly with Sophie and establish boundaries within their relationship. In this way, Sophie could model boundary behaviours from Paul.
Issue. During the session, Sophie also disclosed that Sy had a sexual relationship with her, which Paul seemed to miss.
Recommendation. Paul should have addressed the seriousness of the situation with Sophie and worked towards a plan on how to report the case to the police.
Challenges in future sessions. Paul seems to have difficulty understanding serious issues and how to address it in a lawful way as well as safety practices in his office.
Integrity in Relationships
Issue. Paul was not honest with Sophie. When Sophie confronted Paul about his phone call to her mother, he said: “That’s not what I said.” Later on, Paul admitted to Sophie that he told her mother saying “because I was worried about you.”
Recommendation. A therapist with integrity would have an honest approach. Not dealing with Sophie’s question could hamper trust going forward. Sophie could also view this as an empathic failure and end the relationship. However, the relationship could still repair if they work through the trust issues.
Issue. Sophie does not have clear boundaries; she mentioned: “screwing half the Olympic gymnastics team.” She stayed up all night after a party and then walked to her session for her appointment with Paul. He does not seem to pick up on her cues about her excessive drinking and a boy that she felt was ‘eye candy’. Her lack of boundaries are further apparent when she lies on his couch, and it seemed like she was falling asleep.
Paul’s behaviour did not help. A boundary infringement from Paul was when he sat in front of Sophie, his face only inches away from hers and encouraged her to talk. He then got up and sat very close to Sophie. As a therapist, he should be aware of the boundary breakdown experienced by raped teenagers. He moved next to her and stroked her shoulder, which is highly inappropriate behaviour for a therapist.
Recommendation. Paul should understand the underlying issues of boundaries, perhaps attend a course on how to work with teenage survivors of rape. Paul could have used cognitive processing therapy. CPT treatment includes education, exposure and cognitive techniques. Survivors identify sections of the trauma that they battle to process and then work through stuck points (Galovski, Schuster Wachen, Chard, Manson & Resick, 2015).
Challenges in future sessions. Paul did not address the issue of personal boundaries with Sophie. If Paul does not address or respect boundaries, Sophie could remain vulnerable and victimised.
Responsibility to Society
Paul needs to engage in regular supervision to monitor, assess, and report on his ethical practices to safeguard his clients. An honest exploration of his countertransference would resolve the generational issues he possibly experienced. Furthermore, if Paul does not report Sy to the police, Paul would be doing a disservice to society as a whole, especially vulnerable groups.
Feelings of Dissociation.
Sophie tells Paul about a risky sexual encounter; a gymnast took her to his room, as usual, she felt nothing. On another occasion she said, “everything around me was falling apart, disintegrating, turning to ash right in front of me, … But as soon as I started to fall asleep the pasture would turn to rot, it’s terrible.” Sophie further commented on her eating disorder and how she experienced floating on clouds disassociating from her body when she would not eat when she was younger. She felt that same feeling of when she was on the beam, and enjoyed the sense of disassociation; she pushed until it felt like she didn’t have a body at all.
Effect on Relationship. Paul missed the consistent theme of disassociation.
Recommendation. From a behavioural perspective, survivors of rape can be assisted using CBT (Jaycox, Zoellner & Fao, 2002). Paul can help Sophie to get a new understanding of her thinking patterns that can lead to behavioural change and an understanding of underlying assumptions by directly addressing disassociation. According to the DSM5, disassociation is common in people who experienced PTSD.
Feelings of being objectified
Sophie felt that her mother hated that she was a gymnast. Her mother said:“Your boobs won’t grow, you will hate your body, be deformed”. Her mother also decided on the shoes. “She picked out those Barbie doll shoes” | “Sophie wore those Barbie doll shoes that you bought her…”
Effect on Relationship. Sophie felt objectified by her mother. Paul did not recognise Sophie’s feelings, and he did not explore the Barbie doll comments.
Recommendation. Paul should explore Sophie’s feelings on the shoes and her position as a gymnast. He did not ask her what Barbie doll meant to her. Paul is aware of Sophie’s eating disorder and body image issues. I would recommend DBT strategies which include mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness to help Sophie deal with these issues (Cooper & Parsons, 2010).
The desire to run away
Sophie expressed a desire to run away from her mother to the gymnasium. However, she is unable to get away from her mother.
Effects on Relationship. It is clear that Sophie is not happy at home. Instead of addressing her feelings to run away, Paul tells her the Wizard of Oz story. “…They remind me of, of Dorothy’s shoes. Dorothy discovered that she could go home anytime she wants with or without her shoes.” This was upsetting for Sophie, and she asked him “Why are you infantasizing me?”
Recommendation. Paul did not explore the reasons Sophie wanted to run to the gymnasium. He also did not ask her what she would find there. Exploration (Rogerian approach) could have worked in this instance.
Suicidal thoughts and attempts
Sophie came to therapy to get assessed for suicidal behaviour. The situation that brought her to therapy was when she was on Sy’s bike, and she admitted to Paul that she tried to kill herself. At the end of the session, Sophie went to Paul’s bathroom to vomit, reflected in the mirror, opened the medicine cabinet and removed a bottle of pills and consumed them. Once out of the bathroom, she said she’s going home. Paul told Sophie that they had more time, but she started slurring and fell to the ground.
Effects on the relationship. Sophie attempted suicide using Paul’s medication. This could be due to the culmination of therapeutic ruptures.
Recommendation. Paul did not do a proper risk assessment knowing that Sophie was suicidal. He did not ask her about suicidal plans or how often she had thoughts of killing herself. He should have worked with her on a safety plan. Knowing that he had a suicidal client, he should have removed the medication from his public bathroom.
Therapeutic collaboration stopped when Sophie attempted suicide. Paul did not explore the ruptures that happened during therapy. He did not seem to notice that the therapeutic interaction was blocked. Sophie was unable to cope, and Paul seemed distracted. Behaviours associated with the rupture include Paul’s inability to pick up on Sophie’s cues and the distress she expressed as a result of him speaking to her mother behind her back. When Paul did not know how to respond to issues, he brushed it off or changed the topic. Cozolino (2004) highlights the importance of the psychologist’s intentions to explore the client’s experiences in the moment, which Paul seemed unable to do.
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Galovski, T.E., Wachen J.S., Chard K.M., Monson C.M., Resick P.A. (2015). Cognitive Processing Therapy. In: Schnyder U., Cloitre M. (eds) Evidence Based Treatments for Trauma-Related Psychological Disorders. Springer, Cham
Jaycox, L.H., Zoellner. L., Foa, E.B. (2002). Cognitive-behavior therapy for PTSD in rape survivors. J Clin Psychol, 58 (8), 891-906.
Schaeffer, J. A. (2007). Transference and countertransference in non-analytic therapy: Double-edged swords. New York: UniversityPress of America.