To Minimize Countertransference, Clinicians Must Maintain Control in Relationship

Experiencing countertransference in therapy is essentially unavoidable and can often lead to boundary violations in the patient-clinician relationship, a behavioral health consultant and educator told a breakout session audience at NCAD East. It becomes the clinician's job to maintain control over the relationship with patients, who will seek to manipulate the interaction early in treatment, Thomas Baier explained.

Baier stated frankly that many of the techniques behavioral health clinicians learn in counseling are manipulative, such as reading a client's body language without that client knowing he/she is being analyzed. He advised, “If you're not good at manipulating other people, get good, because you'll be a better counselor.”

In his own work supervising addiction and mental health professionals, Baier has focused on a simple question when he has observed a clinician pushing boundaries with a patient: “What was your clinical rationale for that intervention?” He added, “We're not operating off the seat of our pants,” and there should be a theoretical basis behind all clinical actions.

One of Baier's own rules of thumb, for instance, has been not to initiate physical contact with patients (no hugs, and not even a handshake unless the patient extends the hand first). For clinicians uncomfortable with the implications of that for patients, their agency's policy can give them an out: “We don't do that here—my boss says so,” he said.

Baier teaches ethics at Drexel University and has served on numerous ethics boards for behavioral health professionals. He said that good clinical supervision can be critical in helping clinicians address issues around countertransference, but he expressed skepticism that many counselors receive high-quality supervision.

Clinical supervision should not be confused with administrative supervision that focuses mainly on making sure counselors keep up with their paperwork, Baier said. What he called “note Mommies” don't make good supervisors, he said. In his own career, he invested in supervision from outside his agency because he wasn't receiving it there, he explained.

Treatment for pregnant addicts

Another Aug. 17 breakout session at NCAD East focused on what the research says about optimal treatment strategies for pregnant women with opioid use disorders.

The session led by Mariana Izraelson, PsyD, program director of outpatient services at Ashley Addiction Treatment, also addressed findings on the effects of prenatal substance exposure, generally concluding that the most broadly harmful effects result from exposure to alcohol.

Izraelson discussed issues around medication treatment choice for pregnant women with an opioid use disorder. She said babies exposed to buprenorphine during pregnancy tend to experience milder withdrawal symptoms than babies exposed to methadone, but added that pregnant women on buprenorphine are more likely to discontinue treatment than pregnant women on methadone. The treatment that therefore appears to keep women abstinent most effectively is methadone, she said.