Countertransference and transference

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With any relationship, the boundaries between people can sometimes become blurred. An interaction that has been identified in social work practice as a potential for blurring boundaries is called countertransference. This dynamic occurs when a social worker unconsciously relates to the client’s situation. Perhaps the client reminds the social worker of themselves at a point in their lives or of a close friend. This perspective may result in intense feelings, a narrowing of professional boundaries, and ultimately a weakened client-social worker relationship.

Similarly, these same intense feelings can occur in the client if the client aligns the social worker with an influential person in their life, such as seeing the social worker as a mother figure. This phenomenon is known as transference. Reflect on countertransference and transference and how you might minimize its effects in a social work scenario.

  • Define the concepts of countertransference and transference as they relate to working with a client.
  • Identify a population or a social issue to which you may personally relate.
  • Reflect on and describe how countertransference could negatively impact your relationship with a client who may relate to the population or social issue you identified.  
  • Reflect on and describe how the client may engage in transference with you for similar reasons. Identify two strategies you would use to address countertransference and/or transference in this scenario.

Psychoanalytic Social Work, 18:136–148, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 1522-8878 print / 1522-9033 online
DOI: 10.1080/15228878.2011.611788

Working Through Countertransference Blocks
in Cultural-Competence Training

Ben-Gurion University, Beer-Sheva, Israel

The encounter with clients from diverse cultural backgrounds may
stir in the practitioners intense counter-transferencial reactions,
which if unexplored may obstruct the helping relationships and in-
terventions. This article presents and demonstrates a cultural com-
petence training where such countertransference can be worked
through. The training applies a combination of narrative analysis
that emphasizes the active participation of the listener in the sense-
making process and of the exploration of group processes from a
psychoanalytically oriented point of view. Presented are four vi-
gnettes that demonstrate different types of countertransference and
of the group process.

KEYWORDS immigration, cultural competence, countertransfer-
ence, training


It is commonly agreed that three basic elements are necessary for effective
cross-cultural practice in the helping professions: cultural awareness, culture-
specific knowledge, and culture-attuned skills (Lu, Lum, & Chen, 2001; Sue,
2001; Lee & Greene, 2003). Cultural awareness typically implies the aware-
ness of the impact of culture on the lives of clients, but also self-awareness
of practitioners as to their own cultural background, and culturally molded
attitudes, beliefs, and biases (NASW, 2001). Expanding practitioners’ self-
awareness is, therefore, one of the aims of cultural-competence training. To
achieve this aim, experiential learning has become an important compo-
nent in training (Weaver, 1998; McCreary & Walker, 2001; Lijtmaer, 2004).
A multitude of experiential techniques is applied in training, among them
structured exercises and role play (Arbour, Bain, & Rubio, 2004), narrative

Address correspondence to Julia Mirsky, Social Work Department, Ben-Gurion University,
PO Box 653, Beer-Sheva, 84105, Israel. E-mail: [email protected]


Countertransference Blocks in Cultural-Competence Training 137

analysis (Kerl, 2002), cultural immersion (Lough, 2009), multimedia and Web-
based learning (Korhonen, 2004), etc.

Viewing self-awareness as a prerequisite for developing cultural aware-
ness as well as internalizing cultural knowledge and skills, this article sug-
gests that conscious as well as unconscious barriers to self-awareness need
to be overcome in training programs for cultural competence. The en-
counter with clients from a different culture, whose experiences as immi-
grants, refugees, or members of a social minority are unfamiliar to Western
practitioners, may stir in the latter a myriad of intense, often unconscious,
emotions. The term cultural countertransference, borrowed from the clin-
ical context, was put forward to denote such emotional reactions. It was
suggested that cultural countertransference is expressed in a matrix of in-
tersecting cognitive and affect-laden beliefs and experiences that may exist
within the practitioner at varying levels of consciousness. Within this matrix
lies the practitioner’s cultural life value system; theoretical beliefs and prac-
tice orientation; subjective biases about ethnic groups; and subjective biases
about his or her own ethnicity. These countertransference attitudes are often
disavowed by the practitioner but they may exert a debilitating influence on
the encounter and interventions (Perez-Foster, 1998).

Practitioners who have experienced immigration, even those who be-
long to a similar cultural group as their clients, are not necessarily free
from unconscious counter-transferencial blocks. In addition to the dynam-
ics described above, these practitioners may be dealing with unconscious
conflicts over their own immigrant identities or immigration experiences,
and unresolved personal issues may hamper their empathy toward clients
(Comas-Diaz & Jacobsen, 1991; Chamorro, 2003; Yedidia, 2005).

This article presents a training model for cultural competence that at-
tempts to address conscious as well as unconscious blocks stemming from
practitioners’ counter-transference. The conceptual assumptions of the model
are presented and followed by number of vignettes that illustrate how the
model is implemented.


Aims and Rationale

The long-term goals of the training are (1) to help practitioners develop
empathy toward clients from various cultural backgrounds, (2) enrich their
knowledge about clients’ culture, and (3) help them implement culture-
attuned interventions. The training emphasizes the open-ended nature of
this process and encourages ongoing cultural knowledge seeking and skills
developing. An intermediate aim, central to the training model, is to help
trainees develop the awareness of their own subjectivity and of their cultural
attitudes and biases. Modeling is offered for a continuous reflection and

138 J. Mirsky

self-exploration as an inseparable part of multicultural practice in the helping
professions. The training combines two techniques—narrative analysis and
the exploration of group processes—each based on a conceptual rationale.

Narratives have been increasingly recognized in mental health and re-
lated disciplines as an important source of insight into the complexity of
human experience (Lieblich, 1998; McAdams, Josselson, & Lieblich, 2001).
Narrative techniques are especially suited for the exploration of the experi-
ences of immigrants, refugees, and members of minority populations. They
are flexible and narrator oriented and therefore can contain unique cultural
as well as personal materials (Holland & Kilpatrick, 1993; Peterson & Van
Meir, 1996; Lijtmaer, 2004).

The analysis of narratives is based on the notion that sense making is an
interactive human activity (Glanz, 2003). Therefore, it investigates the mean-
ing (not the cause) of experience, and this meaning is shaped in a collabo-
rative creative relationship between the narrator and the listener. The use of
narrative analysis in training and teaching is recent and follows a postmodern
view of learning—that is, that truth is constructed through the interaction of
participants. When trainees are active participants in the sense-making pro-
cess, learning may result in greater self-awareness, which then becomes the
ground for empathy (Kerl, 2002). This approach is in line with the concept
of intersubjectivity, the intersection of two (or more) subjectives, which has
become a key concept in contemporary psychoanalysis (Schulte, 2000).

The conceptualization of the class setting as a group is based on a
psychodynamic view of group processes. Two fundamental notions typify
this approach: one is that a “group mind” exists (McLeod & Kettner-Polley,
2004), and the other is that unconscious processes may shape behavior in
groups and the group mind (VanGunten & Martin, 2001). When identified,
verbalized, and made conscious, these processes may be conducive to the
work of the group.

Following these basic notions, it is assumed that the class-group be-
comes a “resonant box” for immigrants’ narratives. The conscious and es-
pecially unconscious reactions of the participants come together with the
narrative to create a “group sound” of the narrative (Mirsky, 2008). The
group resonant box can be conceptualized in Winnicott’s terms as a tran-
sitional space: the overlapping space between two (or more) individuals,
neither subjects nor objects but some of both; an imaginary space, in which
the child projects both real and fantasy elements into his play in an effort
to master and comprehend the world (Winnicott, 1953). Through the use
of verbal language (which in adulthood replaces the language of play), the
students, in an effort to comprehend the narrator’s experience, project into
the “group space” elements that derive from the narrative (“objective”) as
well as elements of their own inner world (“subjective”).

It was demonstrated in a previous publication how when properly iden-
tified, verbalized, and interpreted the group sound may become an important

Countertransference Blocks in Cultural-Competence Training 139

source of insight into the narrator’s experience (Mirsky, 2008). The present
article shows how group processes may become an invaluable source of
insight into the trainees’ unconscious emotional reactions, attitudes, and

Setting and Techniques

This model is put into practice in a course that I have been teaching for the
past 10 years to Social Work graduate students at the Department of Social
Work at Ben-Gurion University of the Negev, Israel. It is an elective course
and consists of 48 to 50 academic hours offered over one or two semesters
with weekly sessions (double sessions, in the case of a semester-long course).
Annually, between 24 and 26 students participate in the course.

The course combines two interweaving elements; one is the presentation
and discussion of scientific articles on psychological aspects of migration
and the other is the analysis of immigrants’ narratives. The readings include
state-of-the-art theoretical and research publications on individual and family
processes in migration, stress, coping strategies, and psychopathology as
well as clinical papers on interventions with clients from diverse cultural
backgrounds and on countertransference with these clients.

The narratives are collected by students through in-depth, unstructured
interviews with people who had experienced migration or cultural transition.
With Israel being an immigrant society with more than one-third of its pop-
ulation foreign born, students have no difficulty finding interviewees in their
immediate environment. Typically they interview their friends, neighbors,
coworkers, and, sometimes, relatives. Interviews are tape-recorded and tran-
scribed. Each student submits a paper based on the analysis of the interview
material and the relevant literature.

Students may choose to present their interviews in class and typically
10 to 12 students opt to do so. The interviewer presents the narrative from
transcripts and almost verbatim for 40 to 45 minutes. Then the class is in-
vited to comment and share their emotional reactions and thoughts that the
narrative evoked. I facilitate the discussion. My comments may have to do
with cultural information or relate to contents or processes that come up in
class and integrate them with relevant literature.


The vignettes below demonstrate how the training model works. The descrip-
tions are based on notes I take after each meeting. The names of students
and interviewees are concealed in order to protect their privacy.

140 J. Mirsky

A Parallel Group Sound

The first vignette demonstrates how a group experiences unconscious de-
fensive processes parallel to the ones that the narrator experiences and how
the working through of such process may bring about change. The title is
borrowed from Racker’s concept of “parallel counter-transference” in an in-
dividual setting, which is widened here to the helping practice in general.
This term denotes an unconscious communication process that occurs in
psychotherapy whereby via the countertransference the therapist can expe-
rience emotions or fantasies that the patient fails to contain and allow into his
or her consciousness (Racker, 1982). When unconscious to the practitioner,
such processes may obstruct the helping interaction. Their identification may
turn them into a source of insight about the client and render the helping
relationships more profound and containing.

Irena, whose narrative was presented in class, immigrated to Israel from
Poland in 1959 when she was in her twenties. About 70 at the time
of the interview, she tells her immigration story in an entertaining and
humoristic way. The class is amused and there is a lot of laughter. Irena
also speaks very positively of her homeland:

Irena: . . . Poland is my homeland. . . . Under the communists . . .

whoever wanted to study ballet or piano could do so, it was all
open and free, it didn’t cost anything. University, too—everything,
everything, everything . . .. Jews hadn’t had a bad life in Poland. . . .

In the discussion that follows students initially respond to the way the
story is told:

Student A: Irena is a very talented storyteller. This is the most inter-
esting and by far the funniest story we have heard.

Then they to try to make sense of this style:
Student B: I think this is an indication of inner strength. She is
optimistic, never despairs, and takes all the things that happen to her
with humor.
Student C : Maybe it is because she was very young. Everything is an
adventure to her.
Student D: And she came with her husband and her brother, who
were apparently very supportive of her.

Some relate to the fact that Irena did not genuinely choose to emigrate
from her homeland:

Student E: She is neither bitter nor angry although she encountered
difficulties in Israel and did not really want to leave Poland.

As more students relate to Irena’s strengths and coping abilities, and to
how she loved her homeland, the phrase “Jews hadn’t had a bad life in
Poland” disturbs me more and more. I calculate that Irena, being born
between 1935 and 1937, must have lived in Poland during World War II
and is in fact a Holocaust child-survivor. There is not one word about this
in her narrative. I am surprised how long it took me to become aware of

Countertransference Blocks in Cultural-Competence Training 141

the omission, and that none of the students noticed it either. Only three
weeks previously a Holocaust survivor’s narrative was presented in class
and we addressed the issue at length. I verbalize my insight:

JM: None of us noticed that Irena omits from her narrative the Holo-
caust, which, living in Poland, she must have gone through.

The students now become aware of other painful experiences against
which Irena activates unconscious defense mechanisms:

Student F : Now that I think of it, the incident with the ship almost
sinking is not funny at all. The way she told it we all laughed, but in
fact she was in mortal danger.

Student D: Also when she finds out that the house where she is
supposed to live does not have running water. I would have been in
shock and furious for being cheated, and she tells it as a funny story.

I summarize the discussion and generalize what we have learned.

JM: What we may be experiencing is an unconscious collusion with
Irena’s denial of her traumas. Denial is often an adaptive mecha-
nism vis-à-vis a trauma, and Irena appears, indeed, to be an adjusted
individual. But, in our practice we encounter clients who have ad-
justment difficulties. When we are in an unconscious collusion with
their denial, our ability to help them may become restricted. There-
fore, it is part of our responsibility to constantly explore our own
unconscious resistances.

For further working through, I refer the students to a paper on counter-
transference with immigrant clients.

A Group Mirror to an Individual Member

The next vignette also demonstrates an unconscious resistance to painful
experiences of immigration, but on an individual level. The group mir-
rors to one of its member’s emotions, which she unconsciously defends
against. Thus the group-work initiates a learning process, which may lead to
greater self-awareness, provided the trainee continues working through the

Dina chose to interview her 60-year-old aunt, who as a child immigrated
to Israel from Morocco. Typically, I discourage students from interviewing
close relatives and warn them that the interview may complicate their
relationships. However, Dina convinced me that the interview was very
important to her and that she was aware of the pitfalls and able to
deal with them. When the narrative is presented in class, it is obvious
to everybody that the aunt has been traumatized by her immigration
and especially by the fact that her parents, stressed by the challenges
of adjustment, were not adequately available and attuned to her. The
narrator describes various traumatic events and the group analysis very

142 J. Mirsky

quickly reveals almost overt and not entirely unconscious bitterness and
grudge the interviewee bears since then.
Dina disagrees with this interpretation and during the group discussion
occasionally protests: “this is an exaggeration” or “you don’t know her,
she is not like that,” etc. I tell her that she does not have to agree
with what is being said (recalling another reason for not encouraging
interviews with close relatives—the constraints this puts on the group
work). When the class ends, Dina tells me that we “totally misunderstood
the narrative,” that her aunt is “a central figure in the family and a very
competent woman.” I repeat that what we interpreted is not the objective
truth and that in her final paper she is free to offer a different view on
the narrative.
Six months later Dina submits an excellent paper, where she is able
to be in touch with her aunt’s vulnerabilities, integrate them with other
aspects of the aunt’s personality, and embed the understanding of her
experiences in relevant literature. Here is what Dina writes about the
process she went through:

Dina: My aunt’s story forced me to deal with painful parts of my
family’s past of which I was not aware. Following the interview,
my initial reaction was that my aunt tends to exaggerate and over-
dramatize. The consensus in class as to her being traumatized by
immigration, helped me to connect to her differently, listen to her
more bravely, not to underestimate the intensity of her experiences
and be less judgmental and defensive. . . . My mother is angry with
her for being preoccupied with the past, for not letting go of it. . . .

After the interview I talked to my mother trying to get her to see her
sister’s perspective. . . . I suggested to my mother that she reads my
paper, but she never got to it, under various excuses. It is not easy
for my mother too, to cope with the past and she, unlike her sister,
chooses simply not to deal with it. . . .

It was interesting and painful to write the paper remembering that
my mother immigrated to Israel when she was the age of my baby
daughter. I realize how lucky I and my daughter are, that I can lend
myself fully to being a mother and allow my daughter to be what she
needs to be—my daughter.

An Individual as a Mirror to the Group

While the previous vignette highlights the potential contribution of the group
to an individual member, the next one is an example of how an individual
may contribute to a group. Naturally these processes are not mutually exclu-
sive and can complement each other.

Olga, about 30 at the time of the interview, immigrated to Israel from
the former Soviet Union when she was 12. Her narrative centers on her
adolescence, which was typified by endless fights with her parents. They

Countertransference Blocks in Cultural-Competence Training 143

fought over everything: what clothes she was to wear, what friends she
was to spend her time with, curfew, homework, etc. The parents were
working very hard to establish the family in the new country and were
faithful to the more conservative cultural norms of their homeland. Olga,
in touch with native peers and wanting to become like them, rebelled.
At the time of the interview Olga’s relationship with her parents was
The group discussion of Olga’s narrative very quickly drifts to a dispute
over the acculturation stance of immigrant parents. Some of the students
think that Olga’s parents were wrong to try to impose on her norms
that were irrelevant in the new society. Some argue that it was the re-
sponsibility of the educational system to help immigrant parents become
more flexible and accept local norms. In contrast, other students hold
that immigrant parents, stressed as it is by the tasks of adjustment in a
new country, should not be pressured to change but rather supported
to provide the sort of parenting they can best provide—that based on
values and norms they internalized in their home culture.
Judging by the emotional intensity of the dispute, I realize that the
group is having trouble integrating the conflicting aspects of parent-
ing in migration. My attempt at integration with reference to research
and clinical material—which suggests a more complex approach than
either/or—does not bring the dispute to closure. When one of the stu-
dents, herself an immigrant from the former Soviet Union, tells the class
that she sent her three-year-old son, born in Israel, to a Russian-speaking
kindergarten, the dispute becomes even more heated. Most of the native-
born students think this could harm the child’s integration into the soci-
ety. However, upon hearing about the advantages of Russian-speaking
kindergartens—lower fees, longer hours, smaller groups, English and
French as well as physics and chess classes—a number of students be-
come rather tempted to send their children there.
At this point, Dunia joins the discussion. She is an Arab-Christian woman
who was born and raised in a small village with an exclusively Arab
population. In order to pursue her graduate studies she moved with her
husband and son to a Jewish city:

Dunia: We decided to take advantage of the possibilities that the
city offers and send our four-year-old son to a Jewish kindergarten.
He is getting an excellent education and is developing wonderfully.
But, there are complications. One day he asked me to light Shabbat
candles, like they did in the kindergarten. It was difficult to explain
to him why we don’t light Shabbat candles. Then, there are problems
with our parents every time we go visiting to our home village. His
Arabic is not very good, so they have communication problems. But,
moreover, he is behaving like a Jewish child and they expect of a
child a more restrained behavior. So they constantly tell him “don’t
do this” and “don’t do that” and he does not like going there. They
also criticize us for the way we are bringing him up. It is very difficult.
The sad fact is that we go visiting less and less often.

144 J. Mirsky

This intervention brings the dispute to an end and opens a discussion of
the complexities of cultural transitions for parents as well as children. In
addition, it becomes possible now to explore the reasons for the dispute.
The difficulty students have not “to take sides” seems to have to do
with the fact that all group participants, except Dunia, are either children
of immigrants, or immigrant parents themselves. It is noteworthy how
only Dunia, more “neutral” vis-à-vis migration, could offer an integrated
position that allowed the group to overcome the impasse and advance.
My verbalization of this understanding makes sense to the group. I use
this opportunity to suggest the idea of peer supervision as an important
tool in practice with immigrants.

A Complementary Group Sound

Borrowing again from Racker the term complementary countertransference
(Racker, 1982), the next vignette shows how partly unconscious reactions
evoked by covert messages in the narrative may paralyze the group. While in
parallel countertransference the practitioner’s experiences parallel those of
the client, in this sort of unconscious communication, the practitioner’s ex-
periences complement those of the client. The exploration of such reactions
and their verbalization is modeled.

Rita, in her late twenties at the time of the interview, centers on the very
bad welcome she received from local peers when she immigrated to Israel
at the age of nine. She was ridiculed and rejected by her classmates. They
called her “stinky” and bullied her. Her teachers, unaware and, in her
view, uninterested in her, did nothing to help. Back in her homeland,
Rita also had some problems with peers, and her parents came to Israel
in the hope to better her situation. They did not expect this would be the
welcome she’d receive. She told them little of her experiences at school
so as not to worry them and they did not feel there was anything they
could do. At the age of 30, Rita is still very bitter and angry with Israeli
society. She is socially isolated and ill adjusted.
After Rita’s narrative is presented in class, the atmosphere becomes very

Student A: I feel like crying.
Student B: I cannot believe it. I listen and cannot believe it.
JM: Rita tells us the “dirty” details. As if saying: “This is the true story,
not what you want to believe.”
Student C : This is indeed a genuine immigration story, with all the
resentment and anger. Not like the ones we heard so far. I could not
treat her—too close to home, too painful.
Student D: I thought how when I was a child we had immigrant kids
in class and we were nasty to them.

Countertransference Blocks in Cultural-Competence Training 145

Student A: I took in two immigrant children to host in my house. I
was in touch with their parents who were both physicians and were
too busy to take care of them. When I moved to a different city, the
older boy did not want to speak to me.
JM: Rita’s story makes us feel guilty. Some of us feel guilty for what
we did as children. Those of us who are older feel guilty we did not
do enough as parental figures.
Student E: I was 16 when I came and encountered similar reactions.
How a child of 9 deals with this!
Student A: The child really believed she stank!
Student E: She did not integrate into the society, does not feel at
home. My fantasy is to save her.
Student F : Would she have been better off, had she not migrated?
Student G: Were she to remain in her homeland, maybe this would
have not happened to her?

I understand that the guilt the class is feeling paralyzes the students and
pushes them away from Rita’s reality into attempts to undo the harm in
fantasy. My initial refection of the guilt sufficed to open the discussion
for students who were immigrants themselves and identify with Rita. But,
it did not suffice to alleviate the guilt and allow a more integrated view
of Rita. Therefore I intervene:

JM: We take all the guilt upon ourselves. There was nothing “dra-
matic” in Rita’s life: no Holocaust, no illness, no abandoning parents.
She comes from a normative family. We feel that we did it to her. We
are to blame. The feeling is so hard to contain, that we flee to fantasy
and then we cannot help much. By failing to contain these feelings,
we confirm our clients’ own experience that what they went through
is indeed unbearable and cannot be worked through. And we are
busy coping with our own inner world instead of being available to
our clients. When we can tolerate some guilt, we may be able to help
our clients work through their painful experiences and move on with
their lives. We may also be able to change attitudes in the receiving

The group is now able to resume work: the discussion moves to profes-
sional issues such as identifying immigrant adolescents in risk, helping
immigrant children integrate with their local peers, etc.


This article shows how cultural-competence training can address practition-
ers’ emotional reactions, which may interfere with the provision of appro-
priate service to clients from diverse cultural backgrounds. The encounter
with the “other” may awaken in the practitioner aspects of the inner world
that have been disclaimed in order to protect the self: weakness, vulnerabil-
ity, or feelings of “otherness” (Lijtmaer, 2001). The psychic pain of clients,

146 J. Mirsky

which they experience in the encounter with the majority culture, may evoke
intense identification, guilt, or aggression in the practitioner. Unconscious re-
sistances against the awareness of such experiences may block empathy and
sabotage interventions. When such reactions are uncovered and made con-
scious, as was demonstrated above, the way is opened for empathy and
further learning. The term cross-cultural empathy (Dyche & Zayas, 2001), or
cultural empathy (Ridley & Udipi, 2002), developed in the psychotherapeu-
tic context helps conceptualize the process further. Cultural empathy focuses
first and foremost on the practitioner’s receptivity, emotional resonance with
the other, the ability to see and experience the world through another’s eyes.
The second component of cross-cultural empathy, which complements re-
ceptivity, is knowledge, the intellectual understanding of the other’s feeling
in order to grasp that person’s experience. And finally, collaborative skills
make it possible to translate the emotional resonance and intellectual under-
standing into helpful culturally attuned interventions (Dyche & Zayas, 2001;
Ridley & Udipi, 2002).

This article demonstrates how it is possible in group training to iden-
tify, explore, and resolve failures in receptivity. This work appears to have
opened the way for the acquisition of knowledge and skills. A qualitative
evaluation study was performed over three years, two months after the
completion of each training course. The analysis of personal accounts by
51 trainees (76% of all trainees) revealed that they acquired insight into
the centrality of immigration in the lives of immigrants, the psychological
processes typical to migration, and the unique nature of immigrants’ ex-
periences. The trainees also reported that in their practice they became
more attentive to their clients’ experience of migration as well as more
empathetic and respectful toward their clients’ cultural diversity (Mirsky,
in press).

Although the short-term subjective evaluation provides encouraging re-
sults, it needs to be complemented by a long-term follow-up with additional
independent measures. It is important to emphasize that a one-time training
does not suffice to make a culturally competent practitioner. Dina’s case
demonstrates how the group work was an incentive, but it was thanks to
her personal choice that Dina embarked upon the journey of self-reflection
and self-exploration. Working through the emotional reactions that arise in
cross-cultural encounters and developing cultural knowledge and skills is a
constant challenge in culturally competent practice.


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Journal of Social Work in End-of-Life & Palliative Care

ISSN: 1552-4256 (Print) 1552-4264 (Online) Journal homepage:

Counter Transference in the Face of
Compassionate Care

Kimberly E. Giamportone

To cite this article: Kimberly E. Giamportone (2015) Counter Transference in the Face of
Compassionate Care, Journal of Social Work in End-of-Life & Palliative Care, 11:3-4, 220-223, DOI:

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Counter Transference in the Face
of Compassionate Care

St. Luke’s University Health Network, Palliative Care, Bethlehem, Pennsylvania, USA

As the social worker on the palliative team, maintaining professional
boundaries goes beyond being mindful of ethical practice; it is an essential
component to psychological well-being. Being cognizant of countertransfer-
ence potential and assisting staff who are not trained in the strengths model
of care is part of my everyday role. However, even those of us mindful of
boundaries and limitations can be tested and challenged.

I first met C.A. on a cold winter afternoon. He was alone in his hospital
room on the adult oncology floor of the hospital. The room was dark and his
head was hidden under the covers. C.A. was 17 years old; his birthday was
one day away when he would officially become an adult. His emotional
age was closer to that of a 12 year old. The mother of two teenage boys, I
recognized the potential trigger and tried not to imagine my own children
in his place. I took a moment to recall the social work boundary lectures I
had ever delivered or received before proceeding with the introductions.

There was little in the medical chart regarding his background and
family contacts; the information listed was incomplete or needed correcting.
C.A.’s mother was documented as the primary contact; unfortunately, she
had died 2 years prior from breast cancer. The case management team shared
that the patient’s biological father had attempted to visit on admission but
was intoxicated and escorted out. No other visitors were noted. C.A. was a
scared boy, diagnosed with Acute Myelogenous Leukemia (AML), currently
in a blast crisis, with no one to advocate or comfort him. My motherly self
wanted to scoop him up and protect him; my professional self of course said,
‘‘This is not your child; this is his journey.’’ I took solace in the fact that I was
well within my purview as the palliative care social worker to advocate for
his needs and well-being.

The next day, C.A.’s room had a few birthday balloons and stuffed bears
from the nursing staff. He was quick to state that he asked his family not to

Address correspondence to Kimberly E. Giamportone, MSW, LSW, St. Luke’s University
Health Network, Palliative Care, 801 Ostrum Street, Bethlehem, PA 18015, USA. E-mail:
[email protected]

Journal of Social Work in End-of-Life & Palliative Care, 11:220–223, 2015

Copyright # Taylor & Francis Group, LLC

ISSN: 1552-4256 print=1552-4264 online

DOI: 10.1080/15524256.2015.1107804


come because he was concerned about germs. C.A. explained that he has
lived with his aunt, a family friend, since his mother’s death. He had two
half-siblings, an older deceased brother, and a younger brother, aged 5,
living with his grandmother. He had school friends that he would text, but
they did not have transportation to visit. As he explained his history to me,
C.A. took pride in his racial mixture; his mother was African American,
his father was Hispanic, and his maternal grandmother was Caucasian.
Unfortunately, finding a bone marrow match with these unique genetic
features would prove to be unachievable.

I knew the palliative care physicians would address the physical
symptoms; his pain was real as was his lack of ability to regulate his anxiety
and fear. I was privileged that C.A. learned to trust me as an advocate.

Pt was listening to music on his headphones, but did agree to sit and talk
with MSW. Pt expressed frustration that nobody listens to him. He feels
that staff ‘‘talk at him’’ and not ‘‘with him.’’ Pt noted that he is made to
feel like a child; states he does not want to share concerns or ask ques-
tions of the physicians because they just ignore his concerns anyway. Pt
was asked if he would share his concerns with MSW and he agreed . . . . Pt
asked MSW several times if she really intended to help him. MSW agreed
to help pt find answers to his medical questions. MSW returned with the
palliative care physician having arranged for a conversation together. Pt
shared that he felt palliative care attending understood his concerns and
thanked the team for listening to him. (MSW personal notes)

Complicating the management of his physical needs, was the issue of
behavioral outbursts. Although he exhibited age appropriate behaviors, staff
quickly became irritated and wanted him to act like the patients who were
older. Nurses were frustrated that C.A. would manipulate the I.V. machine
regulating the flow of fluids, especially when he was lonely. He discovered
which alarms needed to sound in order to make the nurses run into his room.
I thought this was quite clever; the nursing staff was not amused. Eventually,
the floor manager provided C.A. with a VCR, not standard in most rooms, so
that he could watch movies in an effort to self-pacify.

One week later, I was notified that C.A. had been placed on a 1-to-1
watch due to a suicide attempt. My heart sank as I rushed to his room.
C.A. looked at me sheepishly and explained that the event was being ‘‘blown
out of proportion.’’ C.A. discovered that if he pushes on his carotid artery
long enough, it makes him ‘‘pass out.’’ He used this technique in the past
when trying to fall asleep during difficult times. We were able to talk about
the emotions behind his behaviors, and I was struck at the raw vulnerability
this child was sharing with me. C.A. asked me to stay with him for the day. I
explained the difficulty of C.A.’s request as I needed to visit other patients. It
was a simple request that I could not grant; I felt like a horrible ogre saying

Reflections 221

no to him. I was cognizant of the countertransference and kept pushing away
the image of my own sons, wondering how I would act if they were in his
place. I was angry and judgmental toward his family for not being there to
comfort him through this scary life event.

My attempts to advocate with the primary team for C.A. to be transferred
to a children’s hospital more capable of meeting his physical and emotional
needs was met with physician ego, judgment, and dismissive remarks. I was
infuriated and keenly aware of my limitations within the scope of my role.
C.A. again shared some of his concerns with me.

Pt was concerned that MSW might be a therapist. Pt said he does not like
therapists because they label people . . . . MSW reassured pt that her role
was to assist pt with communicating his needs and to help advocate for
those needs. Pt expressed that he was scared about the discharge plan-
ning and fears that he will be alone to deal with his illness if he has
another event related to the AML. Pt is fearful of teasing and status among
his school friends if his hair falls out from the chemo treatments. He is
concerned that the nurses avoid him because he is difficult to deal with
sometimes. MSW provided emotional counseling around behavioral
issues. Pt stated he will try to behave so the nurses will visit more fre-
quently. (MSW personal notes)

One month after his admission date, C.A. was deemed medically stable
for discharge. Emotionally, however, he had become used to the support of
the team. C.A. reverted to tantrum behaviors (i.e., throwing books and VHS
tapes, yelling at the staff), and eventually curled into a ball sobbing under the
covers. His aunt was no longer willing to house him based on her belief that
once he became 18 she would no longer receive monetary compensation for
him. C.A. talked to me about the physical and sexual abuse he suffered under
his father’s care and returning to that home was not an option; his grand-
mother had enough on her plate caring for his younger sibling and could
not take him in either. C.A. screamed,

What is the point of undergoing all this treatment, if I don’t have anyone
to care for me when I leave? It’s a death sentence, and I may as well jump
off the bridge when you people kick me out of the hospital.

He was right; tears filled my eyes as we sat together in contemplating next
steps. The hospital administration was tired of dealing with his behaviors.
His oncology team, still refusing to transfer him to a children’s hospital, stated
he needed to learn how to cope on his own. We discussed available options
with the assistance of the case management social worker on the floor.
Without a home, the hospital would have to connect him with a shelter for
the night. We decided to reach out to his aunt one more time. His aunt

222 K. E. Giamportone

was willing to take C.A. back into her home, and added that she was just
trying to scare him into behaving.

C.A. left the hospital that day, but returned four additional times during
the year. Eventually, he was admitted to a university hospital in the city due
to an eye infection and for assessment of bone marrow transplant candidacy.
C.A. spent 3 months there; his only comment about the experience was that
he was glad to be out.

Nearly one year to the date of our first meeting, C.A. was back in our
hospital. Here he was at 18, dying afraid and alone. He asked me to gently
rub his back, as my children often do, while he fell asleep. I had felt like a
complete failure.

The next morning I learned that he was moved to the MICU; he was
intubated and restrained. As I neared his room, I was greeted by cousins,
his step-mother, and two clergy members from his church. I wanted to
scream, ‘‘Where have you been?! What gives you the right to show up,
NOW, and direct who is allowed to be in the room holding this child’s hand?’’
It hurt to be reminded by their presence that I was not the one to companion
him any further on this journey. He was not my child to comfort; his family
had assumed their rightful place, albeit late, as C.A. has always wanted.

In the end, I was never able to facilitate the care that I would have
wanted for him. However, C.A. did finally get his wish — his family,
friends, and clergy surrounding his bedside with expressions of love for
him as he took his final breath.

Reflections 223

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