Fall 2014
Supervision in Care Management: Managing Quality

Using the Concepts of Transference and Counter-transference in Care Management Supervision

About the Author

Vince Brim is a licensed clinical psychologist and certified care manager, specializing in clinically complex cases. He incorporates wrap-around services for clients unable to live independently, selecting and managing clinical teams to meet clients’ special needs. Vince currently serves as the Clinical Director at Eldercare Services in Walnut Creek, CA.

Vince Brim, PsyD, CMC

Care manager supervisors can utilize the concepts of transference and counter-transference as a tool in helping care managers handle the many challenging situations they experience in working with clients and families. The concepts of transference and counter-transference were initially developed in clinical psychology to explain the phenomenon that happens between patient and therapist when the patient “transfers” feelings and a pattern of relating onto the therapist, and the therapist uses his/her understanding of his/her own feelings in response. To be clear, I am not talking about using this concept between supervisor and supervisee because this relationship is not that of a patient-therapist.

Transference as a tool in psychotherapy is defined as the feelings and wishes often rooted in unconscious childhood experiences redirected toward a new person.  For example, a patient might relate to a therapist as if the therapist was his mother. Therefore, any old feelings such as love, hate, resentment, etc., the patient continues to harbor for his mother will be transferred to the therapeutic relationship.  He will relate to the therapist accordingly, patterning his interactions and responses to the therapist as he has done with his mother. This dynamic typically occurs unconsciously. While a therapist might do little to nothing to create such feelings in the patient, the patient will still relate to the therapist in ways similar to how he related to his mother. It is the job of the therapist to identify these feelings in the patient through the therapist’s use of counter-transference. By identifying unresolved feelings in the patient, the therapist can help him become more aware of some of the unresolved feelings harbored that may be getting in the way of healthier and more productive relationships. The therapist helps the patient become more aware of how he relates to others in destructive ways, and models new and healthier interpersonal engagement.

The phenomenon of transference is not limited to the realm of psychotherapy. We all engage in transference without recognizing it, since it happens so unconsciously.  However, outside of therapy, we do not have the benefit of having the recipient of our transference help to enlighten us. Transference left unchecked can wreak havoc interpersonally, and restrict the development of healthy and positive relationships.  For example, your boss reminds you of your critical father, so you cower accordingly and feel some pressure to please him and fear you never will. Meanwhile, your co-worker has a more positive transference to him and is reminded of her encouraging and supportive grandfather. She is fond of your boss and thrives in their relationship, while you are feeling insecure and resentful. In this example, if you feel insecure and bitter when relating to your boss, he will likely respond in kind through his own counter-transference and the two of you will unwittingly recreate that old relationship you had with your critical father.

How does counter-transference fit into all of this?  In the context of psychotherapy, counter-transference is the phenomenon that occurs between patient and therapist when the therapist experiences feelings generated as a result of the way the patient is relating to him/her. Psychotherapists are trained to recognize their own counter-transference and to use it profitably in the therapeutic setting.  An example might be when a therapist finds herself being pulled to act like her client’s mother. She would likely notice the tug to keep the sessions easy and positive, if her own relationship with her mother was better when she behaved that way. Discussing unpleasant feelings with her client might bring up discomfort that she wouldn’t normally experience with other clients.  If this counter-transference went unnoticed on the part of the therapist, the temptation to avoid difficult feelings in the session would continue, colluding with the client’s pressure to do so.

To use counter-transference constructively, the therapist would be very aware of her own feelings and use them to inform her client of the client’s feelings, experience, and needs. Counter-transference in a clinical setting can be quite significant and, when not kept in check, can tempt a therapist to act inappropriately.  A skilled clinician will be aware of such pitfalls and make use of the important information provided by her own counter-transference.  Of course, entire books have been written on the topic of counter-transference, so I am using only a more rudimentary explanation here for the purposes of this brief article.

How does this all apply to the field of care management, and how can supervisors in care management benefit from understanding transference and counter-transference?   Transference and counter-transference occur in daily living and color our interpersonal relationships, often without our awareness.  Awareness on our part as care managers will improve effectiveness of our work considerably. By understanding the needs and feelings of our clients and their families more accurately, we can develop more successful interventions and more effectively serve them. Clients and their families often display transferences to their care managers.  For example, care managers have all worked with people who will respond negatively to our best intentions, leaving us puzzled as to why. When this occurs, transference may be at play.  And a good response may be to utilize our counter-transference in planning and executing our responses.

Without having to learn all the complexities of counter-transference, as care managers, we can simply learn to understand our own feelings in response to our clients. Utilizing our counter-transference at this basic level is enough for profitable use in our field.  For example, your client with advanced dementia is easily agitated and can become threatening to the degree that he frightens others in his presence. You are exposed to his aggression and feel fearful. Without considering your own counter-transference, you might conclude that his problem is aggressive behavior, and conventional interventions might include medication to control agitation. However, you are now in touch with your own counter-transference and use it to inform you more about your client’s experience.

If you can notice that you feel fearful in the face of your client’s outbursts, you can conclude that your client’s experience is likely fear which is causing anxiety. Many of us will become aggressive when we feel threatened or frightened, so this human response isn’t foreign. You can relate to your client at a level that transcends dementia. Responding to the emotional experience of who we are working with will always help us to understand, connect, and be effective. So, in this case, you might redirect your efforts at developing an intervention to address his fear, and not necessarily his aggression.

Now let’s apply the same concept to the above client’s family member who calls you to complain about your inadequate service as a care manager. Your client’s son goes on and on about how you are incompetent, how you don’t know his father well, how you can’t understand him, and how your absence from his father’s life would be inconsequential. Your reaction without considering your counter-transference might be to respond defensively and to explain and justify all you have done, asserting how much experience you have in these matters. However, if you were to tap into your counter-transference, you would notice that your client’s son made you feel shame, incompetent, and as if all your efforts didn’t really matter.  How might you respond differently to your client’s son’s attacks? By empathizing with his feelings of shame, incompetence, and sense of insignificance related to his failed attempts to help his demented father, you would probably reply in a manner that would be in the service of him, instead of defending yourself.

As a supervisor, you can help your supervisee make use of his/her counter-transference to work more effectively with his/her clients as has been illustrated. Remember that attempting to analyze the transference and counter-transference between your supervisee and yourself would be inappropriate, as your role is not to psychoanalyze your supervisee. Your role is to help your supervisee serve clients optimally. Helping him/her to identify what he/she is or was feeling in response to the client can be very helpful in supervision, and a powerful learning experience.

Intellectual comprehension of these concepts can be more easily achieved than their application.  Even those well-versed in the practice of utilizing counter-transference often cannot identify it as events occur, but instead can be coached to refrain from responding until there is an opportunity to understand their counter-transference.  In supervision, encourage the practice of slowing down and raising awareness of the supervisee’s own emotional responses to clients. Supervisees can learn to develop skill at using counter-transference to form responses and interventions only after understanding how their own feelings might be affected in their work with a particular client or family.

Therefore, having frequent discussions about counter-transference in supervision is helpful in developing this skill. Ask supervisees to identify the way they felt/feel in response clients, and not what they thought/think. For some, this is foreign territory as we are often trained to “think,” hence the importance of aiding supervisees to become aware of their own emotional responses. Hopefully by understanding the most basic fundamentals of transference and counter-transference, we can all become better care managers, supervisors, and benefit in our own interpersonal relationships as an added bonus.

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One thought on “Using the Concepts of Transference and Counter-transference in Care Management Supervision”

  1. Paula Atwood says:

    I would love to be able to share a copy of this wonderful article you have written with the participants of my workshop on Transference and CounterTransference I do for Benjamin Institute on Aging, the first workshop to be given June 17, 2015.
    Thank you,
    Paula Atwood, MSSA, LISW-S, EMBA, LICDC-CS

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