The National Counselor Examination (NCE) is a 200-item multiple-choice examination designed to assess knowledge, skills and abilities determined to be important for providing effective counseling services. The NCE is a requirement for counselor licensure in many states. It is also one of two examination options for the National Certified Counselor (NCC) certification. It may also be accepted by military health systems to become a recognized provider.
Alcohol and drug counselors, along with other mental health professionals, face a number of challenges and special issues when working with people who have suffered abuse or neglect as children. Like most people, counselors become upset or angry when they hear about children getting hurt or being abused. Some counselors are recovering from substance abuse disorders and were themselves abused or neglected as children, and they may find themselves in a professional situation where they have to confront their own abuse experience and its impact on their lives. As a consequence, counselors who were abused or who had substance-abusing parents may experience feelings that interfere with their efforts to work effectively with adult survivors. For example, counselors may find it difficult to relate to clients effectively and to reach a balance of providing enough--but not too much--support and distance.
Survivors of abuse may pose many relational challenges to the counselor. These clients are often mistrustful at the same time that they need a trustworthy relationship, and a "push-pull" dynamic may result. Counselors may find themselves overly fascinated by and invested in a client's abuse history (sometimes to the exclusion of other life and therapy issues), or they may want to avoid discussion of the abuse for personal reasons. Counselors must be mindful of these possible reactions and develop appropriate strategies to ensure effective care of the client. Because child abuse and neglect reflect the ultimate violation of trust, it is critical that counselors maintain a professional relationship with appropriate boundaries and limitations in place. The counselor must be trustworthy and provide a safe relational context that--in contrast to the client's past experience--presents a unique opportunity for healing.
This chapter reviews some of the challenges posed by transference and countertransference issues with this treatment population and discusses possible secondary traumatization in counselors. The Consensus Panel recommends that counselors establish and maintain clear boundaries from the outset, as well as establishing a "treatment frame." Some of the topics discussed below are basic to good counseling and clinical practice, but it is helpful to review them in the context of treating clients with histories of child abuse or neglect.
The counselor-client relationship is a crucial component of all therapy. Its importance is highlighted in work with abuse survivors because of the nature of the injury caused by the abuse--it was often caused by someone in close relationship to the client, on whom she was dependent, and from whom she should have received care and protection. The counseling relationship is therefore instrumental in providing the client with the necessary support to address and work through issues related to abuse (including substance abuse) while modeling a healthy, nonexploitive relationship.
Transference generally refers to feelings and issues from the past that clients transfer or project onto the counselor in the current relationship. When clients interact with other persons, they are likely to respond in ways that repeat old patterns from their past. Clients bring the everyday responses and distortions of life into the relationship with the counselor, who, as a professional, can recognize these problems that are interfering with clients' daily functioning (Kahn, 1991). These transference reactions have specific implications for survivors of childhood abuse, who may perceive the counselor as threatening or abandoning in the same way as the perpetrator of the abuse. Conversely, clients may idealize the counselor, seeing him as the warm and loving parent they always wanted.
Clients' feelings about themselves might also affect the relationship. Many survivors have enormous shame and low self-esteem and feel responsible and guilt-ridden about the abuse. This may lead to attempts to distract the counselor from abuse-related issues so that they are not discussed or examined, or to respond to the counselor in ways that replicate the past (e.g., as caretaker, as self-sufficient and not expecting or deserving supportive attention). The counselor must be aware of and prepared for possible responses of this sort and must work to bring them to clients, attention for discussion. The counselor must also avoid replicating relational patterns from the past even if clients expect them and act in ways to encourage them. For example, the counselor should not allow clients to be overly caretaking toward him, nor should he be so overinvolved with clients that objectivity is lost. These issues are discussed in more detail below in the section "Establishing the Treatment Frame and Special Issues."
Countertransference refers to the range of reactions and responses that the counselor has toward clients (including the clients' transference reactions) based on the counselor's own background and personal issues. Although countertransference occurs in all therapy and can be a useful tool, an unhealthy countertransference occurs when the counselor projects onto clients her own unresolved feelings or issues that may be stirred up in the course of working with the client. If the counselor's own boundaries are not firm, she is more likely to have difficulty remaining objective and may respond to a client's transference reaction with countertransference. This is not the same thing as the counselor's subjective feelings toward the client, which may be positive (if the client is a friendly and attractive person) or negative (if the client has an unpleasant appearance and temperament). For example, if clients act seductively, the counselor may feel uncomfortable or threatened. Counselors must pay close attention to their own feelings to protect their clients and to learn more about them. At the same time, the counselor should keep in mind that the feelings clients evoke in a counselor are likely to be feelings that clients are evoking in their daily interactions with others.
Countertransference occurs when the counselor loses her objectivity and becomes overwhelmed, angry, or bereft when hearing a client's story. In such a situation, the counselor may push a client to deal with childhood abuse or neglect issues before the client is ready--out of the counselor's own emotional needs. For the same reason, a counselor might discourage the client from talking about abuse issues, saying it is not the right time. However, it is very important to let the client determine when and at what pace to work on the issues, especially when dealing with child abuse and neglect. Effective treatment will be severely diminished if the counselor is unaware of her countertransference feelings toward a client. In these cases, the counselor should be closely supervised, or the client may need to be referred to another counselor.
Counselors must also be cautious not to see signs of childhood abuse in every symptom. Because of the high incidence of childhood abuse and neglect among clients in substance abuse treatment and many counselors' earnest desire to help, there is a danger of overinterpreting nonspecific sequelae. Not everyone in treatment has been abused, and counselors should be aware of the possibility of clients recovering nonexistent repressed memories, especially from clients who are eager to please their counselor. (See also the section below, "Avoiding the 'Rescuer' Role.")
It is important for counselors to have a general awareness of these transference and countertransference issues and to be as knowledgeable as possible about their own areas of emotional vulnerability and unresolved emotional issues. This is especially important for counselors who are themselves survivors of childhood abuse or neglect.
Many counselors find the level of violence and cruelty they are exposed to in working with adult survivors of abuse upsetting and incomprehensible. The counselor who is repeatedly confronted by disclosures of victimization and exploitation, especially between parent and child, may experience symptoms of trauma, such as disturbing dreams, free-floating anxiety, or increased difficulties in personal relationships. He may also experience anger or helplessness, which are detrimental to both the counselor and the client. Or, after a day of dealing with intense material in client sessions, a counselor may seem unaffected until strong emotions emerge--seemingly out of nowhere. The stress and "burnout" that may result from working with such clients can even produce symptoms similar to those of posttraumatic stress disorder (PTSD) (e.g. anhedonia, restricted range of affect, diminished interest, irritability, difficulty concentrating, and insomnia). Counselors can have these reactions even if they have no personal history of childhood abuse.
Counselors experiencing these symptoms may lose perspective and become either over- or underinvested in a client (Briere, 1989; Pearlman and Saakvitne, 1995). Counselors who are underinvested may become numb to feelings that would otherwise cause anxiety, anger, or depression. A counselor may unintentionally, even unconsciously, dismiss, negate, or minimize a client's history of abuse. This reaction represents an attempt to avoid and distance oneself from the uncomfortable issues raised by the abuse. He may respond to the client coldly and clinically. Those counselors who overinvest, on the other hand, become extremely involved with their clients, going beyond the appropriate boundaries of the relationship. They may respond by becoming parental and doing problematic things such as lending their clients money, trying to solve their problems for them, or seeing them too frequently. They may also fail to confront clients when they behave inappropriately or destructively. When working with a client who was abused as a child, an overinvested counselor may have rescue fantasies or feel inappropriate anger directed at former therapists, child protective services (CPS) workers, and parents or caretakers. In extreme cases, the relationship can cease to be beneficial as it becomes overly personal, with the attendant loss of objectivity that is necessary in a professional relationship (Briere, 1989). 041b061a72