Countertransference and Children With Severe Irritability

In psychotherapeutic treatments, counter-reactions are inevitably evoked within the clinician. As with any other person, the clinician’s experience of the patient is colored by residues from the clinician’s own past (countertransference). The clinician needs to discern, as much as possible, the degree to which their reactions to the patient are derived from their own past and how much is provoked by the patient. Of course, it is always a mixture.

The impact on the clinician

Irritable children (those who are sensitive to the most minor of stimuli) have an uncanny ability to become aware of their effects on their clinicians. In order to protect themselves from their own painful emotions, such as powerlessness, shame, and distress, they are able to evoke negative feedback from the clinician and attack them. The provocations of and the attacks on the clinician are often a repetition of children’s behaviors that occur with others or those that have occurred in the past. The sooner the clinician becomes aware of their countertransference, the more effectively the clinician can respond therapeutically rather than perpetuate a non-therapeutic cycle with the patient.

A significant mental health problem

Irritability and externalizing behaviors are some of the most significant mental health problems, if not the most significant, from which children and their families suffer. Parents, teachers, caretakers, and other professionals are often at a loss with these children and, thus, seek mental health care. The adults believe that the child who is very disruptive needs intervention even though the child believes that it is the adult’s problem, which would easily be solved if the environment changed. In fact, the most prevalent clinical approach to these children is working with parents (parenting management training or PMT) and, often, because of the difficulties these children pose for themselves, their, peers, caretakers and teachers, a significant number are treated with antipsychotic medications.

Why are severely irritable children difficult to treat psychologically?

Despite the pervasiveness of the symptoms and the long-term problematic prognosis for a significant number of these children, the lack of effective psychological treatments prompts several considerations and a central question that needs empirical exploration:

Are children with externalizing behaviors inherently so much more difficult to treat with psychological methods than children with internalizing problems? Or does the difficulty with psychological treatment ensue as a result of the inevitable problematic interactions between the child who externalizes and the clinician lacking the proper therapeutic tools to help the child with externalizing behaviors and, thus, being overwhelmed by their countertransference so they cannot help the child?

The importance of addressing how a child deals with their feelings

Because of the importance of appreciating the power of countertransference, my book, The Manual of Regulation-Focused Psychotherapy for Children (RFP-C), begins with an example of a countertransference enactment where a 7-year-old child abruptly left treatment because the therapist was unable to manage their countertransference. The therapist did not appreciate that a clinician’s job is not to communicate, even implicitly, to a child to “shape up” and “act right.” The clinician’s task is to first, develop a relationship with the child in order to help the child with the emotions that trigger the disruptive maladaptive behavior.

In the next post, we will discuss the centrality of emotion regulation.