Experiences in Clinical Decision-Making and Countertransference of Expert
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Supplement to Dissertation The Role of Reactivity: Experiences in Clinical Decision-Making and Countertransference of Expert Trauma Counselors Rebekah Lancelin Oregon State University December 2019 2 SUPPLEMENT TO DISSERTATION TABLE OF CONTENTS Round One Interview Transcripts……………………………………………………………........3 Round Two Interview Transcripts………………………………………………..………..…….96 Round Three Interview Transcripts………………………………….………………...……….192 3 Round One Interview Transcripts P#= participant P1 Round One Researcher: We'll just start and I'll just ask some follow-up questions. If you could describe to me your process when making clinical decisions with trauma survivors. This is your thoughts and feelings that lead to any decisions you have either during the session or after the session, when meeting with a trauma survivor. Just real generally, your process. P1: I mean it's somebody that I'm not real familiar with, is my initial impression. My major focus would be ego strength and stability, safety. I think that I would want to make sure that my client's external resources, as well as his or her internal resources are well enough intact to proceed with what can be some pretty [inaudible] work. I'm just sort of thinking extemporaneously. Researcher: Exactly. P1: That's I guess, pretty standard, too. Researcher: Say more about ego strengths, and safety that you mentioned. P1: If somebody is unskilled in self soothing, and relaxation and grounding skills, then I would be concerned about moving ahead recklessly into exposure work or doing a lot of recall work. I think that even after I've established that there is a safety structure in our sessions, and that we have solid informed consent and agreements, and that a person is able to take care of their own emotional needs in the core of the session, and between sessions, I would still want to kind of tread into the issues of trauma, again depending on the situation. If it's a single incident trauma in adulthood, that's one thing. If we're talking about complex PTSD, I would tread a little bit lighter, and just get headliners, without encouraging a lot of detail that may not be helpful, in initial stages of treatment. I don't know if this is the sort of thing you're interested in hearing? Researcher: No, this is exactly ... This is good. P1: I'd want to know what the person's living situation is, if they're living in relationships that are supportive of their work or if it's a destabilizing type relationship. If there are, I think I would want to do a lot more social skills training, and that sort of thing before going into formal trauma work. I'd want to know if this person has some supportive relationships at all, even if it's not in their home life, that they can rely on if they should find themselves in need to sort of reach out to somebody. 4 I'd want to know also that they understand the formal emergency procedures, of calling emergency screeners and emergency workers, and make sure they know how to reach out in that way. How to know when they need a higher level of care. Researcher: You're teaching them about when they can identify these things within themselves. P1: Certainly, and also how to understand the system, and what's available to them, which I think has to go hand in hand. If somebody knows that the need a higher level of care, but don't know how to get it, it doesn't help much. Sort of doing some education around that ability to understand their own needs, but also to understand their resources, and how to act on them. Researcher: Great, so once safety and stabilization are established, how do you decide to proceed? P1: I think that a lot of the assessment probably would happen without my request. Sometimes people will come in, and they're kind of anxious to get into the meat of things. Sometimes, they're very avoidant of it. Some of that information certainly would be able to utilize to determine how exactly I want to proceed in treatment. There are folks for example, I wouldn't necessarily consider a great EMDR candidate for example, for one reason or another. Sometimes people, I'm trying to think of a good example, as to why that would be. Some people are close to psychotic, so it's difficult to predict how things might go if I open a lot of doors, processing can be jarring using that particular modality, and others as well. It's sort of a jump in with both feet kind of work. If somebody ... I guess that kind of goes back to safety, you're just sort of assessing their ego strength, and how their symptoms might suggest stability. I want to kind of keep my eye on that. I think that if everything's a go, and somebody really seems ready to look directly at some old events that are sticking in their craw, I would want to talk more specifically about what those are. Again, I probably have some of that information, just from doing a family history, and also from people spontaneously wanting to talk about it. I would want to have a direct, structured conversation about what are the highlighted things that they would like to put behind them, that they haven't been able to. A lot of times, people have either a vague sense of that, or they have a very clear sense of that, depending on how complex the trauma background. If they are unable to really say what they want to work on specifically, we'd probably be looking at, we'd probably go to looking at triggers, to see how the thing manifests right now in their lives, and what are 5 the moments that it comes up at issue, then to do a float back from there, to see when they remember the first time feeling that way. Take it from that sort of a ... Is that called reverse engineering? I'm not sure what that's called. Start from the present, then go back. I think that's sort of the next thing. To sort of lay out the road map for what specifics we are going to be trying to desensitize and to process. Researcher: So that the client knows what they're in store for? P1: Perhaps, it's hard to know for anybody, how it's going to unfold, but so they know the specific traumatic events that they're interested in working on. Researcher: How do you ... You mentioned avoidance, which of course is significant in trauma work, I think. How do you manage their, or even assess their avoidance, in doing their work? P1: I think probably the first thing I do is, it depends on what form it takes. If it's therapy distancing behaviors, like calling in sick or making excuses, or talking about the weather rather than [crosstalk]. It's just something to put on the table, to sort of explore with them, and say "gee, you know, it's occurred to me that maybe there might be something like a defensive sort of thing, what do you think?" Ask them to look in quite a little bit. Hopefully, they're [inaudible] skills are intact well enough to kind of say well "gee, I guess that's what it feels like to me, or what's inside of me when I 'm wanting to run out the door." Whatever the case may be, you know? It's almost the same thing, as if they were to get angry at me, you know? Just say "well, you know, OK, just as long as you're angry, we're not talking about it, and so I just kind of noticed that, what do you think?" I would just put the thing in the table and see how they respond to that. Researcher: You're leading [crosstalk]. Hopefully what? P1: Hopefully open the discussion. Researcher: You are leading right into countertransference, which is the perfect segue. P1: You're welcome. Researcher: Perfect, say just a little bit more about that moment when you're picking up on ... I mean countertransference, of course, there's many different definitions of countertransference, even within the counseling field. There's all sorts of different definitions, and maybe you could just start with sharing how, your understanding of countertransference. P1: When I have a reaction to my client, a strong reaction of one sort or another, I have to wonder, assuming I'm mindful enough to recognize as a moment. Even 6 if I'm not, in between sessions it occurs to me that this is what's going on for me, I would want to fold that into my work in one way, shape, or form. I always have to ask myself the question - is this what other people in my client's life feel like? Does this have to do with social skills, or does that have to do with therapeutic resistance? If there's something defensive happening, I want to be able to bring that into session, in some way, shape, or form. Researcher: Initially, you're sort of asking yourself these questions, if you're picking up on something? P1: Yeah, exactly. Researcher: When you're picking up on something, is it ... You know, what form does that take? Is it a feeling, thoughts, tell me a little bit about that. P1: It's reactivity, I think. For example, when somebody starts making noises about wanting to harm somebody.