Countertransference in the initial care of victims of sexual and urban violence: a qualitative-quantitative research

Abstracts

OBJETIVO: Avaliar a contratransferência dos terapeutas durante o atendimento inicial de pacientes mulheres vítimas de violência sexual e urbana, investigando a influência do gênero do terapeuta e da natureza e momento do trauma. MÉTODO: A amostra foi composta por 36 relatos redigidos por médicos residentes de psiquiatria do Hospital de Clínicas de Porto Alegre, oriundos do atendimento de 36 pacientes. Este estudo utilizou métodos qualitativos e quantitativos para a análise dos seus dados. Os relatos foram classificados em seis grupos, conforme o gênero do terapeuta e a natureza do trauma. Foi realizada a análise de conteúdo dos relatos. Associou-se uma análise estatística dos dados. RESULTADOS: Houve predomínio de sentimentos de aproximação nos terapeutas de ambos os sexos no atendimento de vítimas de violência sexual. Entre terapeutas mulheres, a natureza do trauma (sexual ou urbano) não influenciou os padrões contratransferenciais (p = 0,7). Entre os terapeutas homens, ao contrário, a natureza do trauma influenciou de forma significativa (p = 0,044) o padrão contratransferencial, havendo um número elevado de sentimentos de distanciamento nos relatos de atendimentos de vítimas de violência urbana. CONCLUSÕES: Houve um predomínio de sentimentos de aproximação dos terapeutas de ambos os sexos no atendimento inicial de pacientes vítimas de violência sexual. Foi observado um predomínio de sentimentos de distanciamento nos terapeutas homens que atenderam vítimas de violência urbana. Mais estudos são necessários para uma melhor compreensão das relações terapêuticas nos atendimentos de vítimas de trauma psíquico.

Contratransferência; violência sexual; violência urbana; trauma psíquico; psicoterapia

ORIGINAL ARTICLE

Countertransference in the initial care of victims of sexual and urban violence: a qualitative-quantitative research

Mariana Eizirik^I; Guilherme Polanczyk^II;Sidnei Schestatsky^III; Maria Amélia Jaeger^IV; Lúcia Helena Freitas Ceitlin^V

^IPsychiatrist. MSc. student in Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.

^IIPsychiatrist. MSc. in Psychiatry, UFRGS

^IIIAssociate professor, Department of Psychiatry and Legal Medicine, UFRGS. Coordinator, Núcleo de Estudos e Tratamento do Trauma Psíquico (NET-TRAUMA), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil

^IVPsychologist. MSc. in Psychology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

^VAssociate professor, Department of Psychiatry and Legal Medicine, UFRGS. Coordinator, NET-TRAUMA, HCPA, Brazil

^{Correspondence}

ABSTRACT

OBJECTIVE: To assess therapists' countertransference during initial care of female victims of sexual and urban violence with the aim of investigating influence of therapist's gender, type and moment of trauma.

METHODS: The sample comprised 36 reports written by psychiatry residents at Hospital de Clínicas de Porto Alegre based on the care provided to 36 patients. This study used qualitative and quantitative methods of data analysis. Reports were classified into six groups according to therapist's gender and type of trauma. A content analysis and a statistical analysis of the data were performed.

RESULTS: Therapists of both genders presented a prevalence of feelings of closeness when providing care to victims of sexual violence. Among female therapists, type of trauma (sexual or urban) did not have an influence on countertransference patterns (p = 0,7). On the other hand, among male therapists, type of trauma had a significant influence (p = 0,044) on countertransference, with a high rate of feelings of distance in reports of care provided to victims of urban violence.

CONCLUSIONS: Therapists of both genders presented a prevalence of feelings of closeness when providing initial care to patients victims of sexual violence. Male therapists who provided care to victims of urban violence presented a prevalence of feelings of distance. Further studies are needed for a better understanding of therapeutic relationships in the care of victims of psychic trauma.

Keywords: Countertransference, sexual violence, urban violence, psychic trauma, psychotherapy.

Introduction

The concept of countertransference, introduced by Freud¹ and developed by other authors,^2-4 is essential in current psychoanalytical theory and technique, which consider the feelings awakened by the patient in the therapist as powerful tools to understand the patient's communication and internal world. Based on the growing recognition of the importance of the therapist's mind and of the therapeutic field established between the pair, new theories and empirical research studies have been developed.^5-7 Currently, focus on countertransference is highlighted in medical teaching, considering it as a major instrument in the development of an adequate doctor/patient relationship - including cases of basically pharmacological treatment.

Gabbard⁸ stresses that nowadays there is a consensus in considering the usefulness of countertransference to understand the patient, being a "joint creation" of the therapeutic pair. In addition, characteristics of the therapist's real person have been widely discussed, such as gender, training stage and age group, which could be associated with constant countertransference patterns and that could have a direct implication in choice of therapists according to characteristics of clinical and patient's situation.^9-11

Empirical studies on countertransference are not commonly found in the literature yet, although their importance is clear in a recent article by Betan et al.¹² Through a factor analysis of a scale to assess countertransference processes, eight classes of different reactions were found, independent of the therapist's theoretical orientation, associated with different types of axis II disorders. Despite the singularity of each therapeutic pair, significant correlations have been demonstrated between specific countertransference feelings and symptoms of personality disorders. This suggests that countertransference responses may occur in coherent and predictable patterns, strengthening their use in diagnostic understanding and in patients' understanding and treatment. The authors stress the possibility and relevance of screening countertransference patterns aroused by patients with different psychiatric diagnoses or in those who share certain experiences, such as history of sexual violence.¹²

Studying the feelings aroused by patients victims of sexual violence is important, since besides being intense, such feelings are often barriers against treatment success.¹³ There is a growing number of studies on violence and therapeutic approach provided to its victims, among which there are still few regarding countertransference.

Therapists can be the first to identify, through themselves, patients' anger, fear, shame and insecurity, since they are not initially conscious of their affective experiences. Such feelings are often intolerable and contradictory, usually reproduced and vividly re-experienced during the treatment by the therapeutic pair, and can threaten both and create impasses if they are not properly recognized and elaborated.¹⁴ Trauma victims are super-represented in situations of impasse or therapeutic failure, having lower success rates compared with people with no history of trauma.¹⁵ It is known that the probability of occurring impasse throughout a psychotherapeutic treatment is related to "conditions of unconscious order that rule the therapeutic pair",¹⁶ including here the non-understanding of transference/countertransference processes involved.¹⁵

The moment in the patient's life in which a situation of sexual violence occurred is associated with the development of specific forms of psychopathology, especially mood and personality disorders, which could also be related to specific countertransference responses.^17-21

Violence is the second main cause of overall mortality in Brazil, which is the fourth country with the highest prevalence rate of homicides in the world. The mortality rate due to external causes is 14.58%; rate of felonious homicides per 100,000 inhabitants is 22, thefts is 511 and rape is 16.²² Prevalence studies show rates of sexual abuse throughout life ranging between 15-25% in the female population.²³ This alarming situation creates a great demand for health services in Brazil, especially for mental health professionals, who are faced with the direct victims of these situations and with their relatives, stressing the need of performing studies to better understand this theme. The possibility of understanding the emotional responses aroused during such contacts may help therapists recognize and manage their countertransference feelings. Thus, there would be fewer chances of such countertransference feelings becoming larger obstacles to the development and maintenance of a proper therapeutic relationship.

Considering that providing care to victims of violence, especially sexual violence, is a challenge to mental health professionals - clinical psychiatrists, psychotherapists or psychoanalysts - and that the number of people exposed to these situations has been dramatically increasing, this study aimed at evaluating countertransference responses aroused in therapists during initial care of patients victims of psychic trauma. The influence of therapist's gender, type and moment of trauma in such reactions was investigated. Taking into account the complexity of the phenomenon under investigation (countertransference), we chose to combine qualitative and quantitative analysis methods, in the sense of increasing reliability of findings.

Methods

Sample

The sample comprised 36 reports written by second-year psychiatry residents at Hospital de Clínicas de Porto Alegre (HCPA), regarding 36 female patients receiving care at Núcleo de Estudos e Tratamento do Trauma Psíquico [Center for Studies and Treatment of Psychic Trauma - NET-TRAUMA] at HCPA, for 9 consecutive months, between 2005 and 2006. That outpatient clinic provides care to patients victims of psychic trauma referred by primary, secondary and tertiary care services in the municipality. After the first appointment with the patient, therapists were required to freely and anonymously register what they had felt when providing care.

Inclusion criteria were: 1) female gender; 2) victims of sexual violence up to 12 years old (childhood) or over the past 3 months (current); or 3) victims of robberies or those who had a relative killed due to urban violence (other traumas). Exclusion criteria were: 1) inability to adequately report the fact; and 2) presence of intensive symptoms that justified indication of psychiatric hospitalization.

Our sample was restricted to the female population because few men seek for treatment at NET-TRAUMA.

Content analysis

Reports were classified into six groups according to therapist's gender and type of trauma (sexual violence in childhood, current sexual violence and other traumas) by one of the authors. At that time, all references made to the moment and type of trauma, as well as to the therapist's gender were excluded from the reports, without compromising their content. Later, three other authors performed a blinded content analysis of the reports, without knowing their classification.

Content analysis²⁴ is a research methodology used to describe and interpret the content of documents and texts, helping reinterpret messages and reach an understanding of their meanings at a level that goes beyond a common reading.²⁵ It is comprised of five stages: 1) preparation of information (in which the material to be used for research is selected and the coding process is started); 2) unitarization (when units of analysis are defined); 3) categorization or classification of units into previously defined categories by the authors (when the data are grouped considering the common part existing between them, in a process of reduction and synthesis); 4) description; and 5) interpretation (stage in which results are discussed, deepening the understanding of the material obtained).

Content analysis was started by reading the material, followed by a division into units of analysis, defined as representative words within a sentence, such as, for example: "initially, the patient aroused in me marked hopelessness and much pity, much discomfort too," in which the words "hopelessness," pity" and "discomfort" were taken as units of analysis in that sentence. It was possible to establish two categories of interest based on reported feelings, grouping units of analysis into feelings of closeness or distance. Units that were not characterized by such feelings were not considered.

Processes of unitarization and categorization were performed individually by two authors and, later, as a whole through consensus. In case of lack of consensus, decision was made by a senior author, after discussing the material.

Statistical analysis

Patients' demographic characteristics, stratified by nature of trauma, were compared using ANOVA for continuous variables (age) and Fisher's exact test for categorical variables (ethnic group, marital status, schooling level). Fisher's exact test was used to compare categories of feelings between gender and type of trauma, followed by a test of multiple comparisons, using the software WINPEPI, Module Compare2, version 1.45. p value 0.05was considered statistically significant.

Ethical issues

Patients and therapists were not identified at any moment of the study. All participants signed a consent term. The study was approved by the Research Ethics Committee of HCPA.

Results

Throughout the study, 36 patients met the inclusion criteria. Of these, 13 were victims of sexual violence in childhood; 15 of current sexual violence; and eight of other traumas. All reports of countertransference feelings described after the first appointments of all patients were included in this study. Table 1 shows patients' demographic characteristics; there were no statistically significant differences between groups. The total number of units of analysis of these reports was 141; 98 corresponded to feelings of closeness and 43 to feelings of distance.

Clique here to enlarge

Influence of type of psychic trauma on countertransference pattern of male and female therapists was individually investigated. Among female therapists, type of trauma did not have an influence on countertransference patterns (p = 0.7) (Table 2). The following vignettes taken from care provided to patients with the three different types of trauma, performed by female therapists, illustrate the reports. "I felt apprehension for realizing that it might happen to anyone, I desired that this had not occurred with the patient;" "I felt confused in the beginning of the session and later a feeling of dealing with a much too large problem, of impotence and, at the same time, satisfaction for knowing I would be able to help a little in the middle of so much confusion;" "I felt anxious, I pitied the patient and was angry at the person responsible for the trauma;" "I felt the patient behaved as a child, I wanted to look after her and, at the same time, make her have the same functioning as she had before the trauma. She also aroused curiosity and interest in me;" "Initially she aroused marked hopelessness and much pity, and much discomfort too. During the session, I felt sad and willing to help, but with a great feeling of immobility."

Among male therapists, type of trauma had a significant influence (p = 0.044) on countertransference pattern. There was a high rate of feelings of distance in reports of care provided to victims of robbery or with deceased relatives (55%). When compared to other groups (current sexual violence and sexual violence in childhood), such frequency had a statistically significant difference in relation to frequency of feelings of distance in cares provided to victims of sexual violence in childhood (55 vs. 14.3%; p = 0.025), with no significant difference compared to the group of victims of sexual violence over the past 3 months (55 vs. 25%; p = 0.18) (Table 3).

Next are some vignettes of cares provided by male therapists to victims of robbery or to those who had family members murdered: "I felt impotent in the beginning of the session, which was gradually increasing, and the end of the session was a relief to me, as if I could return to live without knowing that such tragic events may happen to any of us. I felt a prevalence of impotence, with hopelessness and a great despair;" "I felt immobility and feeling of shock from the details of the trauma, sometimes feeling afraid and worried about the vulnerability of people to tragedies;" "From the start, the patient caused me a certain lack of sympathy, a certain distance, perhaps difficulty in identifying with the situation and tending to devalue the patient's suffering."

Based on what can be observed from the statements above, the impact of those cares triggered in male therapists feelings of impotence, hopelessness and fear of being involved in a situation beyond their management ability, which possibly aroused deeper anxieties, of a confusional or persecutory nature. These might have led to attitudes of distance and strangeness toward the patients, avoiding the danger of closer identifications.

The influence of therapist's gender on countertransference feelings was analyzed, stratified by type of trauma. We observed that male and female therapists did not present a significantly different pattern of countertransference response when providing care for victims of sexual violence in childhood (p = 0.30) or over the past 3 months (p = 0.99) and victims of robbery or patients who had a family member murdered (p = 0.14) (Table 4)

Clique here to enlarge

Discussion

This study used a qualitative method - content analysis - to evaluate countertransference responses by undergraduate therapists in the initial care of female patients victims of sexual and urban violence. Results show a prevalence of feelings of closeness when compared with feelings of distance in the therapists' reports. Care of victims of urban violence aroused, in male therapists, a higher number of feelings of distance than care provided to victims of sexual violence in childhood (55 vs. 14.3%; p = 0.04).

Exposure to sexual violence in childhood is associated with the development of psychopathology in adult age,^17-19,26,27 which according to empirical findings, would arouse specific countertransference responses. Betan¹² found significant associations between different classes of countertransference and specific symptoms of personality disorders, like Brody²¹ and Mclntyre,²⁰ who demonstrated an equally significant relationship between patient's diagnosis and countertransference pattern. Opposed to these findings, Holmqvist²⁸ did not find associations between organization of the patient's personality and types of feelings in the therapist, contributing to the discussion of this theme, which is still controversial.

The results of the present study showed a prevalence of countertransference responses of closeness, such as interest, empathy, sadness, both in patients victims of sexual violence in childhood and over the past 3 months. This finding can be related to the occurrence of specific psychopathology after sexual violence in adult women with no history of sexual violence in childhood, as shown by Faravelli.²⁹ Such association would exclude specificity of moment of trauma in the development of symptoms and disorders, and consequently in the production of characteristic reactions in therapists.

The study of patients victims of non-sexual trauma was due to the hypothesis that there would be a characteristic psychopathology in patients victims of sexual violence, as shown by Faravelli,²⁹ with consequent differences in countertransference feelings. Our findings revealed a prevalence of feelings of closeness in relation to all groups of patients, regardless of type of trauma and therapist's gender, except for patients victims of non-sexual trauma receiving care by male therapists.

There is a reduced number of studies on countertransference when providing care to patients victims of non-sexual trauma,^30,31 besides a lack of data relating this theme to the therapist's gender. One hypothesis to be evaluated is that prevalence of feelings of distance experienced by male therapists when providing care to victims of urban, non-sexual violence is related to a feeling of vulnerability, considering the highest prevalence of violent crimes against men in Brazil, which would not occur in terms of sexual violence.

Influence of therapist's gender in the development of a relationship with the patient and in the treatment has been investigated with growing interest. A common idea among many psychoanalytical authors is that it is not "actual" therapist's gender that will have a more relevant influence on treatment process, but their technical abilities, professional experience, personality traits and self-knowledge.^10,32,33 Relationship between countertransference and therapist's gender is a main theme in those issues, considering its importance in psychoanalytic and psychotherapeutic practice. Empirical studies in patients with specific diagnoses show divergent results. Zlotnick³⁴ and Mclntyre²⁰ did not find differences in countertransference feelings due to therapist's gender in the care of patients with major depressive disorder and borderline personality disorder. Latts,³⁵ in a study in patients victims of sexual violence, observed a significantly higher prevalence of avoidance responses in male therapists, compared with female therapists.

A study carried out in our country evaluated mental status and countertransference responses of male and female psychotherapists after reading real clinical vignettes, one related to a case of rape, and another about a case of mourning. More negative countertransference reactions were identified after reading about the rape; female therapists were more reflexive, and male therapists expressed more negative reactions in both cases.³⁶

The results of the present study pointed to a similarity in countertransference responses between therapist's gender in the care of patients victims of sexual violence. Latts³⁵ found that female therapists were more able to use empathy than male therapists when providing care to these patients, even in contact with a situation that could expose them more intensely to a feeling of vulnerability. However, such finding was not replicated in our sample.

It is important to consider that the report made by the therapist occurred after their first contact with the patient and their history, usually in a moment of great emotional burden for the pair. It is also relevant to stress the fact that all therapists were in the beginning of their professional formation, with fewer tools to deal with a potentially difficult countertransference situation. Even with such characteristics, which could lead to prevalence of distance or immobility responses, there was a higher number of reports of feelings such as curiosity, desire to help, pity and interest in therapists of both genders. One may assume that both male and female therapists can use empathy to moderate the anxiety aroused in countertransference when providing care to women victims of sexual violence.

It is necessary to understand the results taking into account the study limitations. It is a clinical sample, with a reduced number of patients, receiving care by undergraduate therapists, in a program dedicated to provide treatment for patients victims of violence. Such characteristics restrict result generalization.

With regard to stage of therapist's professional formation, there is evidence that it is associated with how countertransference reactions are dealt with.²⁰ In our study, all therapists were at the same level of professional formation, which makes this variable stable in all groups. As to number of patients included, although small, it is necessary to consider that there are important barriers against patients victims of sexual violence seeking treatment, which makes the study of this clinical situation difficult.

Since it is a situation of undeniable emotional impact, it is also worth stressing that use of psychoanalytic theoretical instruments is particularly relevant in this study. Not only for being used in a research project, but also for the possibility of aroused countertransference feelings being discussed in supervision and used as a compass to guide subsequent therapeutic management.

We used a qualitative methodology, content analysis, so that reports of countertransference feelings - subjective - could be better understood. Objective instruments, although relevant, are not sufficient to capture the complexity of countertransference experiences, which end up by being reduced.

This study aims at exposing and discussing its findings, raising research questions, without the objective of confirming obtained results, neither extrapolating them to other populations. Proper and deep understanding of countertransference feelings when providing care to victims of violence could bring significant benefits to the therapist's formation, focusing on the presence of basic psychoanalytic concepts, as well as to patient treatment and prognosis. Considering the lack of studies on this theme in the Brazilian population, we suggest further investigations to be performed, using qualitative and/or quantitative methods, to enhance knowledge in this area full of complex phenomena.

Conclusions

Results showed that therapists of both genders presented a prevalence of feelings of closeness when providing initial care to women victims of sexual violence. Based on these findings, we consider that male therapists, as well as female therapists, are able to empathize and tune themselves affectively with their patients during that moment of treatment. There were no differences in countertransference reactions in relation to patients victims of sexual violence in different developmental stages.

A prevalence of responses of distance was identified in male therapists providing care to patients victims of non-sexual trauma, related to urban violence. We believe that this finding can be due to a feeling of vulnerability aroused in therapists, because of an increasing prevalence of urban violence in the male population. The present study provided several research questions that can contribute to further investigations.

References

Received June 9, 2007.

Accepted July 18, 2007.

This study was carried out at Department of Psychiatry and Forensic Medicine, UFRGS, and at NET-TRAUMA, HCPA, Brazil.

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Correspondence:

Mariana Eizirik

Rua Dona Laura, 228/707

CEP 90430-010, Porto Alegre, RS, Brazil

Tel.: [phone]

Publication Dates

• Publication in this collection
  13 Dec 2007
• Date of issue
  Aug 2007

History

• Received
  09 June 2007
• Accepted
  18 July 2007