In this regard, Atwood and Stolorow (1984) described two common situations: 1) conjunctive countertransference, where the patient's experience resonates with and is assimilated by the internal experience of the therapist, which enhances empathy and facilitates the therapeutic process and 2) disjunctive countertransference, whereby the therapist alters the meaning of the patient's experience in accordance with their own history, which can result in the patient feeling misunderstood. To correct disjunctive countertransference, the therapist can create new points of reference and reset themselves into an empathic mode of understanding the patient's subjective experience.
Empathic strain may often lead to premature termination of therapy, neglect and retraumatization of the patient. A permeable boundary -- a flexible balance between empathy and limit setting -- will encourage the development of healthy boundaries for the injured person. McCann and Colletti (1994) referred to the alternation between an empathic position of the therapist and the phenomenon of being understood by the patient as an "empathic dance," which facilitates understanding and propels the effectiveness of the therapeutic process.Countertransference
The regressive effect of trauma often gives rise to a transference that associates the therapist with victimhood, shame and demanding assumptions. Therapists may respond with complementary reactions. Two major patterns have been described: 1) avoidant countertransference, in which the therapist distances themselves from the traumatic stories and the patient and 2) overidentification countertransference, in which faulty boundaries may lead to the therapist feeling overwhelmed, exhausted and ineffective (Wilson and Lindy, 1994).
A multitude of factors can influence the particular type of countertransference invoked: the nature of stressors, the trauma stories, the therapist's personal beliefs and perceptions, the patient's demographics or personality characteristics, and institutional factors such as attitudes toward trauma patients and adequacy of resources. With special trauma patients (e.g., victims of genocide or war), countertransference factors may originate in the greater societal context, i.e., prevalent attitudes toward certain events or trends in psychotherapy. In the case of man-made traumatic events, the therapist has to confront the evil side of mankind, which has been referred to in the literature as existential shame (Danieli, 1994). Under such circumstances, the countertransference often becomes directed toward the trauma per se.
A good knowledge base of the historical context of traumatic events is tantamount. Danieli (1981b) described an early reaction to survivors of the Holocaust, where psychotherapists, families and society adopted a suppressive attitude, referred to as a "conspiracy of silence." The failure of therapists, families and society to share part of the patient's pain has been referred to as a second injury to victims (Symonds, 1980).
The therapist's adverse reactions to trauma patients has been described under different constructs: burn-out (Freudenberger and Robbins, 1979), which includes symptoms of depression, cynicism, boredom, loss of compassion and discouragement; secondary victimization (Figley, 1983), where therapists and others who are close to the victim develop symptoms similar to that of the victim, including PTSD; or countertransference (Danieli, 1981a; Lindy, 1988).
Drawing on constructivist self-development theory, McCann and Pearlman (1990a) described a profound change in some therapists who work with traumatized individuals. Here the therapist's beliefs, expectations and assumptions about the world are changed by repeated exposures to the patient's traumatic events. Such therapists may become distrustful, suspicious, cynical and often adopt thoughts and images about their own personal vulnerability. At times, images similar to those reported by their patients may be triggered by relatively benign stimuli outside work (McCann and Pearlman, 1990b). Therapists affected by vicarious traumatization may develop diminished esteem for other people or the human race in general, which results in feelings of bitterness and pessimism. In time, vicarious traumatization deeply affects the therapist's personal life and the ability to maintain a therapeutic stance.
Intervention must be preventive, by a modified type of case conference in which countertransference can be processed (McCann and Pearlman, 1990b). Personal consultation, psychotherapy, support groups and professional organizations may all maintain the functionality of the trauma community, especially when centered around a local tertiary teaching hospital.Conclusions