Treatment Guidelines? Effect on Therapists? Willin

gnessTreatment Guideline's Effect
Abstract
Working with trauma survivors leads to intense countertransference reactions. These are counterproductive to the efficacious treatment environment of survivor empowerment. A theoretical orientation using medical analogies can further frustrate the survivor and clinician with the implicit assumptions of the clinician having a "cure" and the survivor having symptoms that should be treated and alleviated. Both of these assumptions lead to decreased survivor empowerment and a strain on the theraputic alliance with pressures for a quick cure and an assumption that generalized guidelines can be applied to specific relationships. The clinician may respond with a sense of being "deskilled" and rely more than usual upon outside sources including "expert" consultation and written guidelines based upon diagnosis. Unfortunately, experts have their own bias, based upon their own unresolved countertransferences and methodological orientation. These biases can then be passed on to the primary clinician. This study will attempt to determine how strongly this bias might affect the primary clinician by looking at willingness to use coercion on a "paper patient" with strongly differing treatment guidelines as the independent variable.

Treatment Guideline's Effect
Research Literature Review of
Treatment Guideline's Effect on Therapists' Willingness to Use Coercion with Trauma Clients
Impetus for conducting this study. As I have done volunteer peer-support service work over the Internet, I have noticed more and more therapy clients describing problems in the theraputic alliance. Many therapists have decided what goals they have for the client, and refuse to work with any clients that don't agree with the goals. Others seem to be fearful of a client's possibility of acting out, and act with pre-emptive haste to control, causing severe disruptions in the development of a trusting relationship. These techniques are in direct contradiction to what is generally recognized in the literature as efficacious treatment for trauma clients. When negative treatment outcomes occur, countertransference is usually the culprit. However, there seemed to be a specific trend that indicated there was some education somewhere that encouraged disempowerment. I was finding that a large number of therapists were setting integration goals for their DID clients, regardless of their client's feelings about those goals. They were also taking over the personality system management in their offices by only allowing one personality to talk--the personality they chose to call the "host". They put further constraints on these clients by only allowing them to talk about present day management issues, and refused to delve into feelings, especially about past abuse. They had inflexible boundaries regarding between session contacts; several said they were not available at all, and emergencies had to be 911 calls only. Because it was showing up across the country, I started looking for possible education sources that might be recommending these treatments. I found some treatment guidelines that ISSD put together in 1997 that could very well be the source of these trends. In my research, I also came across some other treatment guidelines that were very client empowering. As I read the guidelines, it also became clear to me that the tension between medical-model and client-centered theraputic care was re-surfacing here. In this paper, I intend to outline the generally accepted model for trauma survivors. I will then describe how medical models have maintained their hold, and the tension that causes for therapists. I will look at some of the counter-transference tendencies that have been described in the literature, arriving at feasible conclusions for therapist's being willing to use coercion, despite it's anti-theraputic effects. My research will then focus on two treatment guidelines, one that is client-centered, and one that is based on the medical model, to see if there is a significant difference in therapist's willingness to resort to coercion with a paper patient, and nebulous indications of harm.

Description of Efficacious Treatment for Trauma Survivors
Empowerment. In Trauma and Recovery, (1992), Judith Herman states, "the core experiences of psychological trauma are disempowerment and disconnection from others. Recovery, therefore, is based upon the empowerment of the survivor and the creation of new connections." Healing takes place in relationship, and that relationship focuses on the survivor as the source of her own healing. "Others may offer advice, support, assistance, affection, and care, but not cure. No intervention that takes power away from the survivor can possibly foster her recovery, no matter how much it appears to be in her immediate best interest" (italics added, p. 133).
This statement receives further validation in a report by Carbonell (1999), in which she compared four treatment approaches in traumatology. The approaches that were compared were Traumatic Incident Reduction, Visual-Kinesthetic Disassociation, Eye Movement Desensitization and Reprocessing, and Thought Field Therapy. In her discussion, she states that although these techniques vary greatly in their outward appearance, they all require the client choose the level of exposure to stressful materials. It is the client who controls and directs the process, not the therapist.
Ochberg (1993) has three principles in his outline of PTSD treatment. The first principle is normalization where the survivor's responses are demystified and expected. This restores the survivor's sense of power, with a well-mapped out plan that others have followed, to restore a sense of hope. The second principle is the collaborative and empowering principle. Survivors of violent crime, who have felt dehumanized and powerless, can only heal in a collegial environment, which they experience as empowering. The third principle is the individuality principle. Every human has a stress response that is as unique as a fingerprint. "Therapist and client walk the path (of posttraumatic adjustment) together, aware of a general direction, of predictable pitfalls, but ready to discover new truths at every turn." The overarching principle of client empowerment is present in all three of these guidelines.

Ed Schmookler, (1996), states:
Perhaps the simplest and best rule in healing is to trust the other person's process. Nature heals, not you, and the person will bring things up in their own way and own time, as they are ready. It is therefore often best to sit in comfortable silence, once initial greetings have taken place and you have let the other person know that they can talk about whatever they want, and wait for them to decide what they want to talk about.
This shows a practical way to incorporate the principle of empowerment in the theraputic setting.

Even when there is a significant possibility of suicide, Herman maintains that this principle of client empowerment can still be maintained.
In exceptional circumstances, where the survivor has totally abdicated responsibility for her own self-care or threatens immediate harm to herself or others, rapid intervention is required with or without her consent. But even then, there is no need for unilateral action; the survivor should still be consulted about her wishes and offered as much choice as is compatible with the preservation of safety" (Italics added, p. 134).
George Weinberg, in The Heart of Psychotherapy, points out that actively interfering with the client's life is a psychotheraputic "betrayal", and the therapist has risked the entire theraputic relationship in order to keep the client alive. This is further complicated by the fact that, no matter how closely monitored he is, a person can kill themselves or others anyway, if that is what they really want to do. So, the biggest advantage the therapist has in effecting long-term change can be lost in an instant, with safety still not guaranteed (pp. 260-261).
Theraputic Alliance/Relational Healing: There is abundant documentation for the beneficial effect of the theraputic relationship in bringing about positive change in clients. Erskine (1989) has done a review of psychotherapy literature where he found the single most consistent concept is that of relationship. He cites Peris, Rogers, Fairbairn, Sunivan, Winnicott, Guntrip, Berne, Kohut,, the Stone Center, Buber, Bowlby, and Stem who all have emphasized that an individual's meaning and validation have their source in relationship. He further states "that it is the therapist's capacity to be involved in a theraputic relationship, such as creating a working alliance or taking responsibility for repairing ruptures in the theraputic process that is the defining variable in clients' growth and change; not a theoretical or technique orientation."
Van der Kolk, (1995) also confirms this stance when he discusses the importance of the theraputic alliance in the reworking and mastery of traumatic material. He asserts that it is the secure attachment to a trusted therapist in a safe environment that allows the client to flexibly remember the trauma and correct the faulty traumatic beliefs. He believes that the behavioral studies (systematic desensitization, implosive therapy, and flooding) are probably more the result of the therapist's "personal investment in the well-being of their patients" than the actual technique used.
Fisher, et al (1998) states "the theraputic or healing relationship is consistently mentioned by all scholars as a vital element that is present across all psychotherapies and healing in all cultures." The strength of the relationship was a strong predictor of positive outcome. The qualities that are needed in this bond include warmth, genuineness, empathy, and affirmation.
Chance and Glickauf-Hughes (1995) provide some differentiation between a positive theraputic alliance and a positive transference in the theraputic relationship. The theraputic alliance is reality-based and includes appropriate negative feelings for times that are less than ideal. The client is able to express these feelings and the therapist is able to hear them without a defensive stance. Positive transference, on the other hand, does not allow for negative feelings. It may be a reaction-formation to underlying hostility or appropriate hostility gets displaced onto another person. Positive transference impedes the true theraputic alliance and should be analyzed.
Length of Treatment. The third component necessary for chronically abused trauma survivors is time. Researchers agree that, because of the severity of the disruption of trust, and the sheer number of difficulties involved, the length of a course of treatment is measured in years. In recent years, as time limited service constraints have become more and more common, this element of time has become increasingly difficult to obtain:
A treatment and ethical dilemma of major proportions is being created by service limitations imposed by managed care; it is not to strong to say that the longer-term and more intensive treatment requirements of many adult survivors and the limitations imposed by many insurance plans are on a collision course. Clinicians may also need to take on the role of advocates in order to argue for appropriate treatment that meet ethical considerations. (Courtois, 1997)
In summary, although there are a number of specific treatment techniques, most researchers indicate the necessity for empowerment, a strong theraputic alliance, and, for the more complex cases, a lengthy period of time in the theraputic relationship to ameliorate the damaging effects of trauma.

Problematic Aspects in Maintaining an Efficacious Treatment Environment
Understanding the need for client empowerment and a trusting theraputic alliance does not seem to be enough in the real-world problems that trauma clients and their therapists encounter. There are numerous problematic aspects to this relationship. Some of the problems that have been noted in the literature include the strain between medical model therapy guidelines and humanistic client-centered principles, and the particular strain of the effect trauma has on transference-countertransference complications in therapy, with a special need to pay attention to boundary guidelines. Also, the positive and negative effects of a therapist's prior experience with similarly labeled clients will be explored.

Discussion of the Strain Between Symptom Management of the Medical Model
and the Relational Priority of the Humanistic, Client-Centered Model of Therapy
The scientific method with empirical results is the cornerstone to medical-model thinking. It is reductionistic, with an emphasis on the biophysical aspects of body function. It is a powerful tool. Because of it, we now have a powerful arsenal of medications and treatments that contribute both to the quality and the length of human life. When applied to the mind, this model has been effective too, because the brain is a biophysical organ, subject to the same forces and laws of nature as any other organ in the body. Today's pharmacopoeia for treating mental illness is impressive in its advancements over 20 years ago. Also, the interactive effect of other bodily functions on the function of the brain is a significant contribution of the medical model. Neppe's book Cry the Beloved Mind: A Voyage of Hope is an excellent example of the helpfulness of the medical model in treating mental distress with chemical intervention. I use this general term of chemical intervention rather than the more specific term of medication, because there is a great deal of emphasis on things we ingest such as food, smoking, etc., and the chemical interactions those every items have on mental functioning, as well as the actions and interactions of the psychotropic drugs.

There is a problem, however, with using the medical model alone when interacting with another human being. The reductionistic thinking results in negation of some very important factors in a person's healing. A person's attitude, drive, spiritual beliefs, and many other factors that are hard to describe, much less test, using rigorous scientific methods, are tremendously important in health and wellness. The recognition of this aspect to human healing is gaining strength now, even in the traditional medical community with writers like Christiane Northrup. Dr. Northrup is a traditionally educated ob-gyn who has seen the limitations and abuses of traditional medicine in her field and has incorporated many of the wholistic Eastern healing principles into her practice. She has attempted a synergistic approach, taking the strengths of both traditions, in order to create the most effective healing environment for her clients. Chip Brown, a veteran newspaper journalist (a Washington Post staff writer during the Watergate era), also explores the tension between Western-style scientific medicine and the hugely popular alternative medicine Eastern-style "energy" movement. As he uses his "reporter's eye", he finds it harder and harder to remain objective as he encounters phenomena that don't fit into his rational, research-oriented mindset. He discovers that he has to make a paradigm shift, as disconcerting and disorienting as the shifts physicists had to make as they moved away from Newtonian physics and into relativity and quantum mechanics. The inherent limitations to Western, scientific thinking became evident to this writer, as he allowed his mind to see more and question more of his basic beliefs.
This tension of humanistic versus medical-model thinking is especially manifest in the field of psychology. Even in the basic education, there is a split with Ph.D. psychologists trained along philosophical lines and MD psychiatrists trained in medical school. Once they are in practice, the lines of divergence grow stronger, with tremendous variability in schools of thought and practice.
The inherent limitations of medical model practice with its discarding of information that doesn't fit into its paradigm has been described well by Richard Erskine (1998) when he argues that the standardized protocols of empirically validated treatments are, of necessity, based on a symptom-focused medical model or a research-based behavioral model. He says,
We need a sense of caution and skepticism when the appropriate' treatment is touted or the empirically validated' become the standard. When psychotherapy is governed by statistically validating techniques or driven by diagnosis-based manuals, the focus on the client's uniqueness is lost and the healing power in the relationship between client and therapist is overlooked. If we are to be truly responsive to our clients, psychotherapy cannot be practiced with uniformity. Psychotherapy requires an interpersonal relationship of inquiry, attunement and involvement.
John Fosett (1992) describes the problem with the client-centered approach, which is that good treatment cannot be verified. It depends on subjective "satisfied customers". The core qualities of good counseling can't be verified or monitored with the ease or preciseness of psychotropic drugs, for instance. But, when counselors and society are left to subjective impressions, they are also open to the criticisms of collusion and anecdotalism.
While the medical model is helpful in treating the biological components to the stress trauma survivor's experience , and can give general guidelines for efficacious treatment approaches for various client populations, it has significant drawbacks. It cannot address the significant healing that occurs in the one-on-one relationship. It also predisposes the therapist and the client toward some error-filled thinking. The medical model assumes that the therapist is the healer, the client is a patient needing to be cured and the impetus of action is primarily on the therapist's shoulders. As discussed above, the emphasis on trauma therapy needs to be exactly the opposite, where the client understands he or she holds the key to healing and the therapist is a valued guide, providing direction and cautions along the way. The inherent tension with these opposing mindsets is the source of much of the conflict and debate in the trauma-treatment literature.

Description of Countertransference Problems Encountered in the Treatment of Trauma Survivors
"Trauma is Contagious," asserts Judith Herman. What she means by this statement is that simply the act of witnessing the story of disaster or catastrophe is emotionally overwhelming to the hearer. This phenomenon is known as "traumatic countertransference" or "vicarious victimization". Since engagement in trauma work poses a threat to the therapist's own psychological health, it is crucial that the therapist have a support system as well. Some of the countertransference reactions she notes are:
A: Empathic helplessness evidenced by a competent clinician suddenly feeling "deskilled" in the face of a traumatized patient. As a defense to this feeling of helplessness, the therapist is tempted to take on the role of rescuer. But in doing so, the patient is disempowered. If carried to extremes, the temptation to play "god" results in severe boundary violations including sexual intimacy.

B: Empathetic rage that can preempt the patient's own anger, or at the other extreme, becoming too deferential toward the patient's anger.

C: Empathetic grief, described as being "infected with hopelessness". If this countertransference is not dealt with, the therapist cannot carry out her promise to bear witness, and will withdraw instead.

D: There are other countertransferences besides emotional identification with the patient. The therapist is likely to find that identification with the perpetrator has also occurred. This is a horrifying revelation as it challenges their identity as a caring person. Behaviors that show identification with the offender include skepticism of the story, rationalizing or minimizing the abuse, revulsion or disgust at the patient's behavior and extreme judgmental, censorious beliefs about proper "victim behavior". There may be moments of frank hate and desire to terminate with the patient. There may also be voyeuristic, sexual attraction.

E: Finally, she describes countertransferences exclusive to the unharmed bystander with the term "witness guilt". This is the guilt of not having had to endure the suffering the patient had to endure. It shows up as anhedonia in the therapist's life. In the therapy relationship, she may try to alleviate this guilt by assuming too much responsibility for the patient's life, and again, causing disempowerment in the long run. Guilt may also be experienced as the therapist watches the pain unfold in therapy, and this can lead to an aversion to exploring the trauma, even when the patient is ready for it (pp. 140-146).
Mary Conners (1997) described her own experience with a severely traumatized client, and found her to be "the most difficult, draining, and worrisome patient I have ever treated". The most significant problem for her was to determine the optimum level of responsiveness, faced with the challenges of poor self-care. The final treatment outcome was a success for the client, but for the therapist, the result was that she never wanted to treat another patient who was so deeply impaired and dependent. "The demands of this therapy, particularly outside of treatment hours, were simply too great for me to be willing to go through such a process again." As she described the course of treatment, several of the features Herman mentioned are evident. She felt deskilled and sought to take care of that by "a great deal of reading", conferences and expert consultation. As the suicidal impulses continued over a lengthy period of time, Mary showed a pattern of retreating, blaming and finally, renegotiating with termination as a consequence if the client could not meet her conditions. Mary's anxiety was self-described as oppressive and it was interfering with her own sleep. After the re-negotiation, the client's attitude and behavior showed a marked change for the better, with a reported sense of well being and happiness. I think this case history is instructive in showing the power of the traumatic counter-transference and how easy it is to become caught up in the "victim-rescuer-offender" triangle in the intensity of the theraputic relationship. Mary also described the difficulties she had in maintaining appropriate boundaries with regard to touch. But, the revulsion she felt when she thought of touching her client was related more to identifying with the offender than simply holding the boundary only for the client's sake and well being. Mary described her reaction as being primarily parental. She saw her client as a child, with severe developmental deficits. She saw the unmet needs for attachment and self-regulation, and sought to provide directly for those needs. In that process, she lost sight of the strength of the theraputic relationship, and developed many countertransferences that contributed to further regression by the client and Mary's own spiraling feelings of being victimized and hatred toward her client. She used the threat of abandonment as the means for obtaining the needed distance to re-group and re-stabilize her client. This study shows how easily countertransference can unravel the treatment ideals of client empowerment within a collegial theraputic alliance.
Courtois (1997), in her guidelines for treating adult survivors of incest, mentions the stretching or blurring of boundaries to be particularly challenging with this population. She emphasized the need for specialized training and consultation for these clients (reminiscent of Herman's observation of deskilled feelings). She also suggested that many therapists are not able to work with this population "by temperament or choice, others by their own person history of abuse or by other life stresses that make it hard for them to have the emotional resources necessary for the demands of the work. These therapists have an obligation to self-assess and refer patients as needed." Countertransferential issues she described included inappropriate anger, sexual expression or behavior, and physical or psychological boundary violations. She stressed that informed consent with clear boundaries need to be stated clearly at the beginning of treatment, with any special techniques that might be used and the possible risks and benefits associated with them. She emphasized that object relations and interpersonal attachments needed serious consideration throughout the course of treatment. She warned that tranferences would be intense and to use these tranferences as important clues to the past, rather than to react and replay the original abuse. She believes countertransference reactions that are caught and managed sensitively can add to, rather than detract from the beneficial theraputic alliance. She organized the countertransference reactions into three categories: Attraction, avoidance and attack.

A.Attraction types of countertransference include overidentification, overprotection and
fascination. They occur with patient neediness, and with therapist exposure to their abuse history and pain. Rescue attempts such as reparenting, or indulging to "make up for the incest" are common mistakes at this level. Boundary violations follow, and therapist anger at feeling victimized ensues. (Mary's case study is a good example of this progression.)
B.Avoidance countertransferences are described as disbelieving, denying, dismissing, or discouraging disclosure of abuse-related material. This occurs with some theoretical orientations or with the therapist's personal aversion to hearing the material. They may resort to the same numbing responses used by their patients or they may maintain such an overly rigid professional stance that they are basically unavailable and unempathetic.

C.Attraction occurs when the therapist is aroused by the abuse description. This voyeurism repeats the original abuse by the same mechanism of sexual objectification. Sexual exploitation in the therapy relationship shows that incest survivors are the most at risk population for therapist exploitation.
Karyn Jones (1998) also delineated similar counselor responses in the categories of rage, avoidance, over-involvement/over-identification, guilt, overwhelmed, shock and horror, and sexual arousal. She noted that counselors who work with child sexual abuse trauma clients are particularly vulnerable to assuming the role of rescuer to the client. She indicated that these clients induce feelings of fright, overprotectiveness, guilt, and excessive responsibility in the counselor. These feelings can lead to boundary violations. She suggested personal counseling, a balanced lifestyle, attending to spirituality, supervision, and continuing education as ways to modify these reactions.
Wilson and Lindy (1994) identified countertransference reactions along two poles. Type I includes avoidance, counterphobia, distancing, and detachment while Type II involves overidentification, overidealization, enmeshment, and excessive advocacy processes. The authors categorize four modes of empathetic strain as the underlying dynamic to these reactions and point out several factors that contribute to the breakdown of empathy. The strains are not only the result of the therapists' reactive styles, but also manifest at different times during the treatment and are very dynamic processes. They found that most disruptions of the theraputic stance occurred as a result of the client's lack of progress or engaging in acting out behaviors.
Thus, it appears that most countertransference problems are linked to either an expectation of a certain rate of progress (medical-model thinking) or anxiety about client's behavior that the therapist cannot control. This sets up the dilemma of feeling responsible, but simultaneously helpless. This anxiety must be worked out within the counselor's own process, but it is often acted out upon the client with threats and various levels of coercion to ease the therapist's feelings of loss of control and sense of professional failure or both. Mary Connor's article is a case in point.
Setting Boundaries. Boundary violations correspond to the countertransference extremes. Therapists with high anxiety tend to set up overly rigid boundaries and use punishing consequences including threats and coercion to control the trauma survivor's behavior. Therapists with problems of overidentification tend to cross professional boundaries and have problems in distinguishing appropriate role limitations. Both extremes are damaging to the survivor and result in re-traumatization.

In my literature review, I was amazed at the justifications used for punishing behaviors. In an in-patient setting, behaviors such as bed making and cleaning were required, and if those activities did not occur, the patient was barred from eating lunch. One patient refused to do these activities and was not admitted to lunch "for weeks on end". Even after losing a lawsuit filed by the patient's family, this writer still maintains the ethics of that decision, stating "setting limits must take into account legal standards that might at times be in conflict with purely clinical considerations".
Stuart Twemlow (1997), in his study on boundary violations, has determined that exploitations are the result of power inequities within the therapy relationship. Dominance-submission themes are particularly likely to occur in the transference-countertransference interaction with a trauma client. He states, "the more aggression dominates the relationship, the more pathological are the forms of exploitation." He found this to be true at both the rigid and the overly-merged ends of the boundary continuum. He specifically mentioned "traditional, rigidly applied boundaries" as being "fear-based artificial constructs that stand in the way of true healing". He believes that boundaries must be tailored to the individual situation, but they should follow these general guidelines: 1) It is a fiduciary relationship, which means that in any boundary violation, the responsibility lies totally in the hands of the therapist. Therefore, all activity in the theraputic relationship should be for the benefit of the patient only. "Helping relationships are a dialectical balance between altruism and egoism, and the therapists must always move the equation toward the altruistic side." The second axiom addressed what the therapist should expect from the patient. He clearly states "the only absolute expectation that a therapist can have from the relationship with a patient is that of a reasonable fee or salary."
Chadda and Slonim (1998) agreed that the therapist's role is a fiduciary relationship, but they had considerably more expectations of the patient. In the time boundary, both were expected to maintain a regular time and duration. Phone calls between session are a part of that boundary. Place and space boundaries determined the location of treatment. The business boundary was defined by the regular payments of money. Proper clothing is a social boundary. The language boundary includes word choice as well as tone. Self-disclosure boundaries are about the extent and purpose of the information transmitted by either party. Finally, the physical contact boundary is determined by acceptable professional standards. These authors believed the patient was equally obligated to maintain these boundaries as his or her therapist. They cite Connors article as an example of a patient's boundary violations victimizing a therapist. I find this thinking difficult to understand. There is a clear power differential in the theraputic relationship, akin to the parent-child relationship. The patient or child behavior isn't held to the same standards that of the parent or therapist. If it were, there would be no reason to need a parent or a therapist .in the first place.
Therapist Anxiety and Boundaries.In order to set appropriate boundaries, a therapist needs to remember that anxiety about a client's possible acting out and actual acting out are two different things. If boundaries are set with a high fear level, anticipating any possible acting out, the client has an onerous burden of being in the position of guilty until proven innocent. The theraputic goals of client empowerment and a healing theraputic alliance are lost under the therapist's need to control client behavior and the client being asked to prove, over and over, their trustworthiness. Walter Menninger (1990) did a survey to find what triggers the most anxiety in practicing therapists. He found that anxiety associated with a patient's suicide was the number one anxiety, with two-thirds of the respondents identifying this as a problem. The specific situations ran the gamut from a therapist's hunch that a patient might be suicidal to having to call authorities after a successful attempt. The second response was the more generic category of violence, of one type or another. To cope with anxiety, therapists set firm boundaries, consulted with colleagues, as well as doing their own self-care or using avoidance defenses. More than half used extraordinary actions including restraints, hospitalization, notifying police or security, termination, or filing charges. In my support work with survivor's, I have seen all of these items reported. Unfortunately, many therapists will do this based on their own anxiety, without the client demonstrating actual acting out behavior. Needless to say, this creates tremendous problems with trust in the theraputic relationship, including any future relationships with new therapists. Clients who have been encouraged to tell the truth, no matter how frightening, now find that there are forbidden areas that must not be discussed. They also learn to caretake their therapist and often replay the same secret-keeping, caretaking relationship they had in the original abuse.
Since it is the therapists' fear level that is the primary contributor toward their impulse to use coercion, it is worthwhile to review the factors that contribute to these fears.
Countertransference. The primary factor is the therapist's countertransference reaction as previously discussed.

Diagnostic labeling. Another factor is the diagnosis of the client. Diagnosis-related anxieties show one of the fallacies of using the medical model in a counseling practice. As a client is given labels, the subsequent health care professionals have expectations that may or may not be accurate, based on the label the client carries. I know of one client whose label got put in her HMO record. Based on that label alone, with no other identifying psychological tests, she was threatened with permanent in-patient hospitalization, state removal of custody of her children and loss of employment. She was fully functional, a single mother with no history of ever abusing any of the children, and a master's level social worker with impeccable credentials. Clearly, this MD's anxiety and action was terribly wrongful, causing tremendous stress that never should have happened to this woman. She was able, in the long run, to prove her trustworthiness, but this is something that no trauma survivor should have to go through, with the system that is supposed to be there to help and advocate for them.
In my research, I found that labels created the same difficulties in widely varying fields, from special education, and educational testing, to gerontology, to feminist psychology. All stated that labels tended to put the problem on the individual, creating a prejudicial bias, while ignoring the larger factors of relationships and society.

In the field of special education, Denti and Katz (1995) state: "Unfortunately, in our view, the diagnostic model makes all problems appear to be individualistic: Problems are always the individual's problems. Thus, the student with a disability is viewed as an atomistic unit, to be studied and treated apart from his or her social relations. In our view, the diagnostic model allows little room to examine a student's interpersonal or group relationships, for these relationships are not seen as essential to what the individual needs to become a socially productive group member or "citizen". The diagnostic model places a diminished emphasis on students as social beings."
Zappardino (1995) says this regarding educational testing: " Nowadays, diagnostic labels often follow individuals forever once the labels are applied, in many cases creating self-fulfilling prophecies. Today's terms may be kinder than the "technical" terms used earlier in this century to describe different IQ levels--moron, idiot, and imbecile--but the results are the same."
Enns says that labels tend to bias therapists, causing them to view their clients as more disturbed than they really are. They also "reflect the inappropriate application of social power, ignore environmental influences on symptom formation, represent a major instrument of oppression, and reduce one's respect for clients." She further states,
Diagnostic labels encourage therapists to focus exclusively on intrapsychic problems and symptoms, the removal of which may ignore the communicative function of symptoms, encourage adjustment to status quo norms, and reinforce stereotypes. If symptoms are removed without attention to context, the person is deprived of the indirect influence and symbolic communication associated with the problem and thus, may be less powerful after therapy than before treatment. As a result, feminist efforts have focused less on diagnosing and controlling symptoms and more on exploring the role of strong emotions, such as anger and depressed feelings. Clients are encouraged to use these intense emotions to create satisfactory solutions for themselves.
Perkins and Tice (1994), in their gerontological studies note, "
Current practice is heavily invested in diagnosing or labeling. The value of labels as a method to integrate people in the mental health system and to guide practitioners in their choice of intervention is not minimized by a strengths perspective of practice. Rather, as supported by the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), the assignment of a label is recognized as a process of categorization to assist in financial coverage and reimbursement. However, the strengths perspective does confront a problem orientation of practice where the person is actually perceived as the problem or pathology named. This use of diagnostic labels implies that something is wrong with the person and therefore is demeaning.
They go on to state, "The basic tenet of most client/therapist relationships is honoring and respecting the client for whom he/she is. To unravel the complexities of human nature, the client's strengths must be recognized and respected."
Thus, while the practice of diagnostic labeling is desirable in creating easily understood categories for the purpose of third-party reimbursement or in discussing the treatment of certain populations having traits that can be generalized across a large number of clients, it also creates significant problems of bias that interfere with optimal treatment.

Prior negative experience with similar clients. Some related possible sources for therapist anxiety are prior negative experiences with clients who share some characteristics with their present clients. If these previous clients acted out in anxiety-provoking ways, the therapist is more likely to burden the new client with negative expectations. This can be from their own personal experience or from others such as Mary Connors, who has used her single experience with her client as the basis for consulting with other health care professionals. These implicit assumptions might also be transmitted through published guidelines for care.

This study will focus specifically on whether client-centered empowering guidelines or symptom-based medical-model guidelines will make a difference in a therapist's willingness to use extraordinary measures, as outlined in Menninger's article. It will test the null hypothesis that there is no difference between groups of therapists who have different treatment guidelines pertaining to the same "paper patient" with regard to their willingness to employ threats, hospitalization, and physical or chemical restraints when confronted with a nebulous indication of danger.

I have collected a few narratives here to illustrate both the problems mentioned and good, supportive therapy.

"(My first therapist)didn't work with me the way I started to feel I needed in therapy. I had asked her about talking to certain alters and her theory was that all the alters listen anyway and besides not all alters like therapists, so I think that was the problem. I believe she was afraid that an alter might come forward that either didn't like her or who gave her a hard time. But, because of her reaction, I don't think my insiders trusted her even if they felt they needed to come out"
"(My psychiatrist)...helped the system organize and cooperate so that I could gradually move into mainstream society. However, the system restructuring was done behind my back, so as the host, I wasn't even ware I had MPD. It didn't matter since I was functioning like a normal person, and my alters had their nightlife while I slept'.

This worked well for many years, however, it got to the point where those parts containing the most severe abuse and pathological behaviors started sneaking out and doing minor things"
"(Another therapist's) way to deal with it was to do the cognitive bit and tell me I couldn't fracture off all those parts of myself because it wasn't logical or age-appropriate, and if I just understood that it was all an error and that getting abuse from the past confused with patterns in the present is faulty thinking and if I just said that was then and this is now and everything is ok and there are no other people in my head and I have all the skills I could ever need to deal with anything' and really made an effort to do it, I'd be 100% fine. I wondered why I kept on feeling so lousy."
"It was hard for me to accept that I HAD DID when I was diagnosed, even though I already had been introduced to three of the others by an imaginary friend who's grown up with me. Then to be told it was all a thinking error and if I just denied it and "refused to do the behavior patterns" it would all go away, and not be allowed to talk about the past cos it was supposed to be irrelevant, was terribly confusing. I mean, did this T think DID existed or not, and did he think I had it or not? Cos if he though it was a figment of my imagination, why did he spend nearly 3 months trying to convince me I had it? I felt very anxious about it, I didn't even seem to be capable of being all tangled up "right". I get tight muscles when I'm under stress and headaches too, and my memory goes down into a black hole cos the inside others "borrow" it. I like to be able to know what people want me to do, and I just couldn't figure it out."
"Another T I tried refused to talk to anyone but the host."
"guy was seeing us for free, I think he wanted to write a paper on us or something. Refused, however, to talk to anyone inside, even when one of us came right out (the first time this alter had ever revealed himself to anyone but the SO!) & said "please help us with this". Never gave his reason, think he just thought we were full of sh*t. this was MAJORLY upsetting for this alter, to be blown off like that& now flat-out refuses to speak to anyone but maybe two people, neither of whom are the T."
In another communication this same person states: "the alter I'm talking about still refuses to speak directly to any psych. professional, which is kind of awkward since he is one of the main "adults" who deals with stuff like work, bills, etc., & that little conversation sent him into a spiral where he kept trying to prove or disprove his own existence to himself"
"one thing she did that totally set the rest of us off was when she started telling us that we couldn't switch in her office anymore. She had this thinking that switching was just our way of not taking responsibility and/or getting out of dealing with things we didn't want to deal with. Our thinking was if we switched, obviously the person who came out had more information and was related to the subject at hand. Opposite thinking."
"My current therapy is far and away the best I have had. My therapist is a Jungian analyst, with experience in DID but not a specialty in it. What makes the therapy so good is that he trusts my process and absolutely lets me set the direction and pace. He never tries to tell me what is right for me, but lets me figure it out for myself. This is not only empowering but lets me follow a crooked path that actually gets me there faster. For example, for a long time I didn't want to integrate, and he accepted that. Then I reached a point where integration began to happen and I felt it gave me strength I needed and decided I did want to be integrated, and he accepted that..My worst therapy was a therapist who didn't want me to go into unconscious/subconscious material but just wanted to talk about managing my present life. I was ready to
do deeper work and he was trying to stop it, without saying so directly. Very frustrating."
"Good story's: 1st t treated us for a long time for PTSD, she suspected DID, but let us choose the pace. Our pace at that time was thanks but no thanks- don't want to even look at that, so we didn't. She eventually helped us to come to terms with it. Those were rough years, thanks to her, we survived."
"phone calls, to touch base, in between visits has really helped us. We think of them as "monkey bars". You can swing just so far sometimes!
e-mailif T has it or permits it. Ours does. He answers when he can, not always right away which can be hard, but her always responds. The responses, which some of us read over and over again, can be a simple one line. LikeI know this is hard, but you don't have to do it alone" kind of thing". This same person wrote this upon the return of their therapist from vacation:
"We were very fortunate that T called this afternoon to say he was home, safe
and sound.

That nothing had changed, and that we would pick up where we left off.

He goes above and beyond sometimes.

we feel a bit stronger; and a bit closer to things that we've been trying to
squash since he left."
Another wrote:
"Our therapist called tonight, too! Jenny and I each had about 15
mins. with her. She is going to have water balloons for Jenny to throw at the
outside wall tomorrow for her anger! Jenny is much calmer tonight, thank goodness."
"(my previous therapist's) availability was only during appointment time. If I had a crisis, it was 911 which I would never have done. New T has email and I can call him 24 hours a day. Most of my crisis times have come late evening and he has always returned my call within 20 minutes (pager #) and talked me through whatever. A little cane out to him our second time together and it was pretty awesome. This totally petrified little came out to him and was completely consoled by him. Huge difference."
"I had one T who was very good until my anger started to surface. At this time she said that she does not work on anger except to draw or write. No yelling or throwing allowed. She seemed to be scared of anger."
"how bout a pushy pollyanna of a YWCA therp who does virtually nothing but say "look at the bright side and live in the here and now"?
"as for being scared by us, I think it was that she was more scared by our family, parents especially, then she was by us. We were technically minors when we started seeing her and she met our biological parents. They pretty much had her terrified and that affected how she worked with us. She tried hard but we needed more. She never saw the signs that we gave her to let her know that we were still being hurt at the time, I don't think she really knew what to look for. Either way it has had ill effects"
"My opinion about dealing with "old anger" issues in therapy is that there is no clear-cut best method, so use the anger technique you feel most comfortable with. However, current anger does have to be recognized also. Most clients will need to be taught assertive, functional confrontation techniques. I was fortunate in having a therapist who recognized this as a primary need, and encouraged me to practice these confrontations with hernot in role playing, but in noticing the things that she did that were less than helpful in my own process, and then confronting her with them. She was tremendously non-defensive, listening and thanking me for sharing my reality with her. Often she would agree with me, but even when she didn't, she would always support me in having my own views and not try to change them. If I could point to any one area in therapy that was most beneficial for me, it would be this one."
--Personal communications collected from around the country in response to the question: "What has or hasn't worked in your personal therapy process?" (1999)
Reference List:
The International Society for the Study of Dissociation, (1997). Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults. Available: http://www.issd.org.isdguide.htm
Herman, J. L., (1992). Trauma and Recovery. New York: HarperCollins.

Ibid.

Carbonell, J. L., (1999). A systematic clinical demonstration of promising PTSD treatment approaches. TRAUMATOLOGYe, 5:1. Available: http://www.fsu.edu/trauma/promising.html
Ochberg, F. M., (1993). Gift form Within. In J. P. Wilson & B. Raphael (Eds.), International Handbook of Traumatic Stress Syndromes. New York: Plenum Press.

Schmookler, E. L., (1996). Trauma Treatment Manual. Available: http://users.lamminds.com/eds/manual.html
Herman, J. L.,(1992). Trauma and Recovery.

Weinberg, G., (1984). The Heart of Psychotherapy: A journey into the Mind and Office of the Therapist at Work. New York: St. Martin's Press.
Erskine, R. G., (1989). A relationship therapy: developmental perspectives, in B.R. LORIA (Ed.) Developmental theories and the clinical process: Conference proceedings of the Easter Regional Transactional Analysis Conference. Madison: Omnipress, pp. 123-135.

Erskine, R. G., (1998). Psychotherapy in the USA: A Manual of Standardized techniques or a Theraputic Relationship? International Journal of Psyxhotherapy, 3, 231-235.

Van der Kolk,, van der Hart, & Burbridge, (1995) Approaches to the Treatment of PTSD. Originally appeared as a chapter in Stress and Trauma, eds: Stephen Hobfoll, & Martin de Vries Available: http://www.trauma-pages.com
Fisher, A. R., Jome, L. M., et. al., (1998). Reconceptualizing Multicultural Counseling : Universal Healing Conditions in a Culturally Specific Context. Counseling Psychologist, 26, 525-589.

Chance, S. E., Glickauf-Hughes, C. (1995). Understanding and differentiating client's positive feelings in psychotherapy. American Journal of Pyschotherapy, 49, 514-526.

See Herman (1992) p. 156, 160; Courtois (1997), ISSD guidelines (p. 5). All discuss complex post-traumatic treatment in length of several years.

Courtois, C. A., (1997). Healing the incest wound: A treatment update with attention to recovered-memory issues. American Journal of Psychotherapy, 51 464-497.

Neppe, V. M., (1999). Cry the beloved Mind: A voyage of hope. Seattle: Brainquest Press.

Northrup, C., (1994). Women's bodies, women's wisdom: Creating physical and emotional health and healing. New York: Bantam Press.

Brown, C., (1998). Afterwards, You're a Genius: Faith, Medicine and the Metaphysics of Healing. New York: Riverhead Books.

Erskine, R. G., (1998).

Fosett, J., (1992). Ethical issues in counselling and pastoral care. British Journal of Guidance & Counselling 20. 39-43.

See Selye, H. (1978, revised ed.) The Stress of Life. New York: McGraw-Hill.for the seminal work on biological effects of stress and van der Kolk, B. A.,(1997), The psychobiology of post-traumatic stress disorder. Journal of Clinical Psychiatry, 58, suppl 9, 16-24., for his work at the biochemical level of the interactions between trauma and biology.

Herman, J. L., (1992)
Conners, M. E., (1997). Need and Responsiveness in the treatment of a severely traumatized patient: A relational perspective. American Journal of Psychotherapy, 51, 86-102.

Courtois, C. A., (1997)
Jones, K. D., (1998). Coping with reactions to clients traumatized by child sexual abuse. Journal of mental health counseling, 20. 232-244.

Wilson, J. P., & Lindy, J. D.,(1994). Empathetic strain and countertransference. Countertransference in the treatment of PTSD J. P. Wilson & J. D. Lindy (eds). New York: Guilford Press.

Connors, M. E., (1997).

Pam, A., (1994). Limit setting: Theory, techniques, and risks. American Journal of Psychotherapy, 48 432-441.

Twemow, S. W., (1997) Exploitation of patients: Themes in the psychopathology of their therapists. American Journal of Psychotherapy, 51, 357-376.

Chadda, T., Slonim, R., (1998). Boundary transgressions in the psychotheraputic framework: Who is the injured party? American Journal of Psychotherapy, 52, 489-501.

Menninger, W. W., (1990). Anxiety in the psychotherapist. Bulletin of the Menninger clinic, 54, 232-245.
Personal communication, A.M. (1998).

Denti, L. G., Katz, M. S., (1995). Escaping the cave to dream new dreams: A normative vision for learning disabilities, Journal of Learning Disabilities, 28 413-423.

Zappardino, P. H., (1995). FairTest: Charting a course for testing reform. Clearing House, 68, 248-253.

Enns, C. Z., (1993). Twenty years of feminist counseling and therapy: From naming biases to implementing multifaceted practice. Counseling Psychologist, 21, 3-88.

Perkins, K., Tice, C., (1994). Suicide and older adults: The strengths perspective in practice. Journal of Applied Gerontology, 13, 438-455.

Connors, M. E., (1997).

Menninger, W. W., (1990).