Section 5 Special topics in fertility counseling

Chapter
The view from the fertility

17 counselor’s chair
Janet Jaffe

self-disclosure and awareness of countertransference

A deep understanding of one’s own pain makes it
feelings – is addressed. Additionally, as we are exposed
possible to convert weakness into strength and to offer
to a great deal of grief and loss by our clients’ stories,
one’s own experience as a source of healing to those
who are often lost in the darkness of their own we may experience vicarious trauma and/or compas-
misunderstood sufferings [1, p. 87]. sion fatigue. Thus the need for therapist self-care also
is discussed.
Along with theoretical constructs and ethical con-
Fertility clients come to us in crisis: they have been siderations, clinical vignettes illustrate these concepts.
traumatized and have experienced multiple losses – These examples, however, are not meant to provide a
perhaps of a child, a pregnancy, or yet another failed recipe for the right or wrong way to approach clients:
cycle, perhaps how they feel about themselves, their each client and each therapeutic relationship needs to
intimate relationships with family and friends, and of be assessed for its own unique set of circumstances. As
their hopes and dreams for the future. Whether they such, this chapter hopefully will make you, the fertility
are seeking ongoing psychotherapy or a consultation, counselor, more acutely aware of the ramifications of
their reproductive story – their conscious, but often the relationship between you and your clients.
unconscious, ideas about becoming parents – clearly
has not gone as they had hoped [2]. What is often not
addressed is that you, as a mental health professional Anna: a case of self-disclosure
and a human being, also have a reproductive story. The A woman, Anna, calls to set up an initial appointment.
nature and course of your own personal story, whether She found you through your website which describes
you have children or not, are in the midst of a crisis your work with infertility and pregnancy loss clients.
now or have long resolved it, has an impact on the clin- When you ask her what is going on, she breaks down
ical work you do. You even may have been motivated and reveals that she has just experienced her sec-
to enter this field because of your personal story. Call- ond IVF failure: another chemical pregnancy. With-
ing upon your inner psychological narrative can have a out knowing anything else about her, her relationships
powerful effect on your therapeutic relationships; this or history, your genuine response, “I am so sorry to
chapter discusses how to use your own history to avoid hear that,” reveals much about you and your capacity
pitfalls and foster healing in your patients. to empathize, and can set the tone for the therapeutic
The purpose of this chapter is to explore the com- relationship.
plexities of our relationships with our clients: the When she comes in for her first session with you,
impact their fertility struggles have on us, and how Anna asks if you have any children. A seemingly
our life’s challenges and crises can affect them. Being innocuous question, one that is asked all the time in
aware of our own conflicts and wounds allows us to use social situations, undoubtedly is loaded for Anna. Thus
them constructively in the service of our clients. How how you answer Anna’s question, or if you do, is not to
we use these emotions to enhance the psychother- be taken lightly. What does it mean to her if you have
apy of fertility clients – by the controversial use of children or if you don’t? How is your answer going to

Fertility Counseling: Clinical Guide and Case Studies, ed. Sharon N. Covington. Published by Cambridge University Press.

C Cambridge University Press 2015.

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 239
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Section 5: Special topics in fertility counseling

make her feel? How much is too much to tell, and is question, or if personal information about the ther-
saying nothing too little? What is the potential impact apist is inadvertently exposed, the therapist must be
on the therapy? prepared. In the moment when a clinician’s private life
Anna’s question pushes the conventional boundary is revealed, whether intentionally or not, s/he may not
of therapist privacy and anonymity [3]. She has delved have time to ponder all the pros and cons of the most
into territory that may be loaded with profound feel- therapeutic response, and may feel a loss of composure
ings for you. What if you have had your own series and professional control. Thus, thinking about these
of losses, perhaps similar or completely different from matters ahead of time can help when clinical decisions
hers? What if your reproductive issues are in the past need to be made quickly [8–10].
and have been resolved? On the other hand, what if you
are in the midst of trying to have a child yourself? What
if you or your partner is pregnant? With new clients, do What is self-disclosure?
you address this on the phone? With ongoing patients, Broadly speaking, everything a counselor does or does
do you wait until they notice? How do you answer if not say is a self-disclosure [11]. Disclosures can be
having children was easy for you? These are essential deliberate or accidental, verbal or non-verbal, avoid-
questions to consider because not only does Anna have able or unavoidable. From the way one dresses to one’s
a reproductive story, so do you. The question is: Do you office décor, one’s physical attributes, ethnicity, gen-
answer her question, and if so, how? der and age – these are self-revealing unavoidable,
Therapist self-disclosure is a provocative topic: non-verbal disclosures [9,12]. One’s body language – a
some practitioners believe that revealing personal smile, a look of concern, a change of position – are also
information will contaminate the therapeutic treat- non-verbal disclosures revealing instinctual expres-
ment, while others strongly support it [4]. Although sions of the therapist’s feelings. If the counselor has a
a highly controversial and rarely used clinical strat- home office or resides in a small community, his/her
egy (only about 3.5% of all therapeutic interventions) personal life becomes more transparent as inevitable
[5], a review of empirical research indicates that more boundaries may cross. Unexpectedly running into a
than 90% of therapists have used self-disclosure in client in a grocery store with one’s kids in the shop-
their work [6]. This section explores therapist disclo- ping cart is an unavoidable, unintentional, and perhaps
sure and addresses if, how, why, and when you answer very awkward disclosure. Additionally, with informa-
a question such as Anna’s. Included in this discussion tion readily available on the Internet and Facebook,
are: it is common today for clients to search for reviews
r A definition of self-disclosure. or other information about the therapist. A click of a
r The different types of therapist disclosure. mouse can reveal intentional postings (articles, web-
r The risks/benefits of therapist disclosure for the sites), but also may make known information that was
client. posted by others – without the therapist’s knowledge.
r Theoretical viewpoints. Anonymity has become virtually impossible with per-
r The ethics of self-disclosure. sonal information readily available, and may include a
r The implications of answering direct, or home phone number and/or home address, informa-
not-so-direct inquiries (i.e., how did you get into tion about family members or other people the ther-
the field of reproductive psychology?). apist knows, reviews, photos, lawsuits, political affili-
r The timing of disclosures. ations and donations [13]. The access to information
r The impact of your reproductive story on the can feel like a boundary violation with the client poten-
client and the therapy: case example. tially knowing more about the counselor at the onset
of treatment than the counselor is aware of. Depend-
These issues are important, regardless of theoreti- ing on the client’s issues and diagnosis, this kind of
cal orientation, as the dynamic between the client information about the therapist can affect the course
and the counselor accounts for so much in the ther- of treatment.
apeutic process. Indeed the strength of the thera- When therapists think about self-disclosure, they
peutic relationship has been found to be the best usually refer to deliberate, verbal disclosure of per-
predictor of both positive and negative clinical out- sonal information, perhaps prompted by a client’s
comes [7]. Additionally, when a client asks a direct question, sometimes by the clinical material they are

240
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Chapter 17: The view from the fertility counselor’s chair

presenting. Seven different types of therapist disclo- Table 17.1 Benefits and risks of therapist self-disclosure.
sures have been proposed:
Benefits of Therapist Risks of Therapist Disclosure
r Facts: sharing your professional experience and Disclosure
credentials. Model behavior & expression Focus on therapist rather than
r Feelings: validating the client’s feelings by of feelings client
comparing your own feelings in a similar Offer alternate ways of Burden client with
situation. thinking information
r Insight: revealing perceptions of your own life in a Reduce shame; increase trust Violate boundaries
comparable situation. Decrease sense of feeling Contaminate transference
r Strategy: advising the client in ways you have alone
handled like circumstances. Enhance therapeutic alliance Overshadow client’s needs
r Reassurance/support: normalizing the patient’s Normalize & validate Create role reversal
experience by acknowledging your own Decrease power differential May create desire to take care
experience. of therapist
r Challenge: divulging information about your own Allow view of therapist as May not promote a
similar life trials. human/imperfect therapeutic goal
r Immediacy: providing feedback to the client as to Expand client’s self-awareness
how their behavior with others is occurring in the Increase client’s
therapy with you [14]. self-disclosure
Demystify therapeutic
Whether intentional or unwitting, disclosures affect process
the therapeutic alliance. They may create “a real Repair therapeutic
moment of human sharing of vulnerability and help- ruptures/misunderstandings
lessness that has the potential to bring the patient to Promote insight
a new level of feeling and enrich the treatment” [10,
p. 15]. On the other hand, a therapist disclosure can detriment to therapy because it shifts the focus away
have the opposite effect, interfering with transference from the patient and onto the therapist; by introducing
feelings and/or burdening the patient with concern “real” elements of the clinician, the client’s fantasies
about the counselor. (See Table 17.1 for the benefits and transference may be disrupted and contaminated.
and risks of therapist disclosure.) Decisions about dis- Much has changed since Freud’s early work. Some
closure are influenced by one’s theoretical perspective; of the more recent psychoanalytic/psychodynamic
the patient’s diagnosis; the strength of the therapeu- thinking views therapy as a two-person model, with
tic alliance; whether it is at the beginning, middle or both patient and therapist contributing to the relation-
end of treatment; and, ultimately, by ethical concerns ship, and recognizes that strict neutrality is not only
of what is in the best interest of the client. Addition- impossible, but also may be harmful to the therapeu-
ally the therapist’s personal history of loss and trauma tic experience [17,18]. A therapist who comes across
plays a factor in these choices. as distant and withholding may in fact do damage to a
patient whose self-esteem is already battered and who
To disclose or not: theoretical is feeling depressed and isolated, as many infertility
patients feel. In a treatment outcome study at a uni-
orientation versity counseling center, it was found that an increase
When Freud first discussed self-disclosure, he sug- in therapist disclosure lowered clients’ symptoms [19].
gested that the therapist should be “like a mirror,” Thus infrequent and judicial use of self-disclosure may
reflecting back only what the patient reveals [15, p. 18]. actually facilitate healing: the therapist can serve as a
Traditional psychoanalytic therapists were trained to role model, reassure clients that they are not alone, and
be neutral and not to self-disclose. The theory purports help normalize their struggle [14].
that the key to successful treatment is the working Other theoretical approaches consider self-
through of transference: the feelings that clients have disclosure to be an essential component of therapy.
from earlier significant relationships that are displaced Fundamentally different from the psychoanalytic per-
onto the therapist [16]. Self-disclosure is seen as a spective, humanists advocate therapist self-disclosure

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 241
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Section 5: Special topics in fertility counseling

as a means to foster change. By being authentic and (Avoiding Harm) and 3.08 (Exploitative Relation-
real, counselors help minimize the power differential ships) raise the issue of the potential power differen-
in the therapeutic relationship, thus aiding their tial in the therapist–client relationship. If a boundary
clients’ openness and willingness to share their own is broken with a therapist disclosure, is it for the thera-
struggles. The genuine dialogue between therapist and pist’s need, or is it in service of the client? Clearly, tak-
client is used to address problems that may arise in ing advantage of a patient is an ethical breach. A coun-
the therapist–client relationship. Similarly, feminist selor who unburdens him/herself with no clear benefit
theories espouse the use of self-disclosure in fostering to the client is in violation of the professional ethical
an egalitarian relationship. Appropriate disclosures guidelines.
are seen as a way to transmit feminist values, and are Equally important to consider is therapist non-
used to validate and normalize struggles, decrease disclosure. It has been suggested that a refusal to dis-
feelings of shame and promote empowerment of close, especially when asked a specific question by a
the client. Therapist self-disclosure in the Lesbian client, is a kind of disclosure in and of itself [8]. In
Gay Bisexual Transgender (LBGT) community has an empirical study with current therapy clients, non-
been used to create a safe space to process feelings disclosures were twice as likely to be experienced as
of marginality [20]. Cognitive-behavioral therapists unhelpful [24]. Non-disclosures can be read as rejec-
(CBT) use self-disclosure to challenge clients’ dis- tions, felt as withholding and increase a sense of alien-
tortions about themselves or others by providing ation and inferiority [13,14]. As many reproductive
feedback and modeling more effective behavior [14]. clients already have low self-esteem from the trauma
Dialectical behavior therapists (DBT) also judiciously of infertility treatments and/or pregnancy loss, a coun-
use disclosure to support the emotional experience of selor who comes across as cold or aloof would not be
the client. As many of the client’s issues are interper- in the client’s best interest. Non-disclosures have the
sonal in nature, it can be validating, for example, to potential to compromise the therapeutic relationship,
hear that a therapist also would react in a similar way, but too much disclosure also can be perceived as a
given the situation the client described [21]. burden to the client. Too much information about the
counselor’s life circumstances or emotional state can
make the client feel as if they are in a role-reversal,
Disclosure and ethical considerations having to take care of the counselor. This can feel
Regardless of theoretical orientation, it is important overwhelming, frightening, unsafe and intimidating –
to understand the consequences of disclosing or not. creating a non-therapeutic climate for the client. The
Under what circumstances should a counselor disclose questions then arise: If, when, and how much? And
when working with reproductive patients? What types should infertility and pregnancy loss clients be treated
of disclosures are necessary? What is it that the client differently than the general therapeutic population?
needs? How will a particular disclosure affect the client
and the therapy? Will it be helpful or harmful? Back to Anna’s question: Do you
The most salient question to consider is: Is this dis-
closure in the client’s best interest? The motive for dis- have children?
closure should be to promote a therapeutic goal and All of us, clinicians and clients alike, experience ill-
be in the service of the patient [12]. Professional orga- ness, death and loss throughout life. As mental health
nizations for psychologists, social workers and coun- professionals, we are in the unique position of deal-
selors in the United States as well as in other countries ing with our own distressing life situations while help-
provide guidelines for addressing the issue of thera- ing our clients through theirs. The intersection of these
pist disclosure. For example, the American Psycho- events can create feelings of emotional chaos in the
logical Association (APA) Ethical Principle A states, patient and a loss of feeling safe and cared for [10].
“Psychologists strive to benefit those with whom they Likewise, shared experiences with clients can generate
work and take care to do no harm” [22, p. 3]. uncertainty in therapists, and throw them off their nor-
Regardless of training, mental health professionals mal professional footing and objectivity [14]. In other
should strive to practice beneficence (do what is help- words, when the counselor is personally challenged by
ful for the patient) and nonmaleficence (avoid doing life events, there may be a disruption in the connec-
harm) [8,9,23]. Similarly, APA Ethical Standards 3.04 tion/relationship with clients. Thus, where you are in

242
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Chapter 17: The view from the fertility counselor’s chair

your own reproductive journey and how that intersects Some possible scenarios for the mental health
with your client’s will affect the therapy. professional:
As Anna’s new counselor, her question provides
you with an array of opportunities and dilemmas. A. Yes, you do have children and you struggled to
Because you know that Anna may be particularly sen- have them (this includes biological, third party, or
sitive to your answer, it is essential to give it some adopted child(ren), and this is in the past.
thought and be mindful of what it means to her. Some B. Yes, you do have children, and you did not
issues to consider in your response to Anna’s question: struggle with infertility or pregnancy loss.
r Therapeutic Alliance: Research has shown that C. Yes, you have a child or children, and are still in
the family building phase, actively trying to
the effectiveness of therapist disclosure is highly
conceive.
dependent on the strength of the therapeutic
D. You (or your partner) are currently pregnant.
alliance [24,25]. This is bi-directional: not only is
E. No, at this point you do not have children, and
it important for the patient to trust the counselor,
know you want them someday.
but for therapists to reveal personally sensitive
material they, too, must trust the patient F. No, you do not have children and are in the midst
deeply [3]. of trying.
r Client Traits: There may be traits in the client that G. No, you are child free, not by choice.
would make disclosure harmful to them. For H. No, you are child free by choice.
instance, those with poor boundaries or reality
testing, those who might try to take care of the Let’s say, for example, that you have recently found out
therapist, or clients who are self-absorbed may that you are pregnant with your first child. Because
actually be harmed by a counselor disclosure [9]. the changes of pregnancy are gradual, you can decide,
r Stage of Treatment: Early in treatment, therapist case by case, when it is appropriate to discuss it with
disclosures (your office decor, how you dress, etc.) your clients. You may decide it is important to let cer-
are inevitable. In the middle phase of treatment, tain clients know as soon as possible, while with other
disclosures are likely to be used when clients, you may decide to wait. Processing clients’
therapeutically necessary [23], whereas emotional reactions to the pregnancy can be challeng-
disclosures at the end of treatment serve a ing depending on their background, history and the
different function. During termination with a strength of the therapeutic alliance. What are some of
client, it can be empowering to demystify the the issues that may arise in therapy when the coun-
therapeutic process, discuss what was effective in selor becomes pregnant? Clients may feel abandoned,
treatment and what was not, and see the as the fantasy of the therapist’s care shifts from them
counselor as a genuine human being [14,16]. to a baby. They may feel angry and jealous, especially
r Your Reproductive Story: Are you in the midst of if they are trying to conceive as well, but may feel too
a reproductive crisis yourself or is this something inhibited to express their negative feelings. Issues of
that has been worked through? Disclosure has mistrust may surface and patients may leave treatment
been found to be much more risky if the prematurely. Therapists, on the other hand, may feel
therapist’s issues have not been resolved [14]. more vulnerable because of their pregnancy, and may
not want to invite patients’ hostile feelings about them
As this is your first meeting with Anna, and you or the pregnancy [10].
are just getting to know each other, it may not be In Anna’s case, because you know she is struggling
possible to explore her fantasies about you at this to have a child, you may decide to let her know about
juncture of the treatment. You may not yet have a your pregnancy when she asks if you have children.
sense of her needs, her personality traits, or her his- To wait may create feelings of tension and anxiety for
tory. You may not want to expose private information you; likewise, she may trust you less if she knows you
with concerns of how she will receive it, nor do you were not forthcoming. Saying something like, “I imag-
want to be dismissive. A question like Anna’s, about ine this will be difficult to hear: I have recently learned
whether you have children or not, can elicit a variety that I am pregnant. It has not been an easy journey for
of reactions in you depending on your own personal me either. I realize this may be hard for you to toler-
story. ate, and I would understand if you would like to see

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 243
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Section 5: Special topics in fertility counseling

another therapist, but perhaps we can work through is the process of understanding one’s own wounds and
your feelings about this together.” It may feel like a recovering from them that facilitates healing in others
relief for Anna to be able to process her emotions with [32]. If the counselor’s wounds are not mended, pro-
you. If she can work through her anger, envy, resent- cessed and understood enough, his or her own heal-
ment and grief with you, it is possible that she will ing may interfere with his or her work with clients
cope better with the pregnancies of friends or family [33]. Indeed, therapist disclosure has been found to be
members. much riskier if the therapist is in the midst of unre-
A risky and challenging situation is if the fertility solved problems [14]. If the wound is fresh, therapist
counselor and the client are both trying to conceive objectivity may be lost; the focus may shift from the
at the same time. Should the therapist become preg- patient’s needs to the therapist’s. The challenge is to use
nant, self-disclosure will eventually become a neces- our wounds in the service of the client.
sity and, as above, a sensitive and honest discussion
is called for. If the situation is reversed, that is, if the The wounded healer: personal stories
client should become pregnant, the counselor may feel
jealous, angry and competitive. It may be difficult to of therapists’ crises
celebrate the client’s hard-won battle and hard to main- There are times when counselors are able to prepare,
tain therapeutic neutrality. If the client is aware that strategize and discuss personal life changes (as in a
the therapist is “trying” to conceive, she may feel guilty pregnancy). However, when a therapist has a mis-
about her own success and may feel the need to take carriage, stillbirth or other perinatal demise, there is
care of the therapist. The client should be reassured no time to prepare herself or her clients, and it may
that the therapist has her own support and, indeed, it not be possible to keep the loss private. A sudden
is recommended that the therapist seek consultation. absence from clinical work can evoke a multitude of
feelings in clients, from anxiety and concern about
the counselor’s well-being, to antagonistic and aggres-
The wounded healer sive feelings. Some patients may express relief regard-
Many of us become involved in the mental health pro- ing a pregnancy loss (i.e., the therapist will not aban-
fessions because of our own history of pain or loss [26]. don them or be in competition with them), while
Studies have found a link between a therapist’s history others may struggle with guilt over destructive fan-
of trauma, his/her desire to specialize in trauma care, tasies [34]. Clients also may worry that their reproduc-
and the effects on the clinical work [27]. For example, tive story may overwhelm their counselor; they may
in the area of substance abuse and eating disorders, it is feel the need to minimize their own grief and loss in
not uncommon, and often preferred, for the clinician order to protect and take care of the therapist. Several
to have “been there” [28,29]. Specific to reproductive mental health professionals have courageously written
medicine, a survey of nurses and mental health pro- about their own reproductive traumas, and how these
fessionals revealed that more than half had a history of struggles affected their clinical work. Through the per-
infertility, and almost three-quarters of those surveyed sonal accounts of these clinicians, we learn how they
began working in the field after their diagnosis [30]. In managed the impact their loss had on their clients.
a small sample of psychologists working in reproduc- Dana Comstock was teaching at a university as well
tive medicine, it was found that about 42% specialized as doing clinical work when, about halfway through
in the field because of their own infertility [31]. Thus it her pregnancy, her daughter was stillborn. Her medical
is not uncommon, but not necessary, to choose to work emergency, followed by a three-month absence from
with reproductive clients because of our personal life work, made it necessary to disclose to her students
events. and clients. When she did return to work, feeling raw
A “wounded healer” is a formidable image suggest- and vulnerable, she was able to discuss her loss with
ing that the healer’s wounds carry curative power. Hav- clients as it affected them. “[T]hose explorations felt
ing a similar “wound” as the client may increase greater really different in the context of my now being a ‘touch-
empathy and understanding of what they are expe- able’ therapist, versus being perceived as ‘untouchable’
riencing. It is important to emphasize, however, that prior to my loss” [35, p. 262]. As a wounded healer,
simply being wounded does not make one an expert. It she was able to shift to a deeper level with her clients.

244
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Chapter 17: The view from the fertility counselor’s chair

Additionally, she noted that details of her personal life Lessons learned: my own story
did not need to be discussed in depth. In a case that
shared some similarities to her own loss, and with the My own reproductive trauma consisted of four mis-
hope that sharing would validate the pain her client carriages and five years of fertility interventions and
was experiencing, Comstock simply stated that she, procedures. This was before IVF was readily available,
too, had lost a baby. No details were discussed, but using a donor was not even on the horizon, and it
that self-disclosure let the client know that her ther- seemed as if our reality was that we would not have
apist “got it.” children. I was in graduate school when I had my third
When analyst Barbara Gerson was put on bed rest miscarriage. None of my fellow students/colleagues
because of problems following an amniocentesis, she knew my secret; the shame I felt was overwhelming as
continued to see some of her patients at home, thus if I were defective (a theme I since have heard repeat-
unavoidably disclosing a great deal about her personal edly from clients). I can remember a lecture in one of
life. Sadly, she had to terminate the pregnancy, and this my classes about grief and loss – it was all very theoret-
“real” experience brought core issues to the foreground ical to me until the professor said, “Even miscarriages
for her patients. Her own grief brought up feelings need to be grieved.” My heart began to race, I glanced
of loss for some clients; others became overwhelmed around to see if anyone was staring at me (of course
with fear and anger as boundaries loosened. A gen- not!), I felt sick to my stomach, and couldn’t wait to
uine person replaced the fantasy of the omnipotent bolt from the room. That’s how humiliated I felt. It was
therapist; a shift occurred in the authenticity of the also at that point that I realized I could probably help
therapist/patient relationship. Because she was in the others through this kind of trauma, but I had to get
midst of acute grief, her therapeutic “armor” was through it first myself.
weaker and it was, at times, difficult to tolerate her My son was born a year later. His birth was one of
patient’s negative reactions. Her personal crisis, how- those miraculous events – after all the interventions, it
ever, elicited some of the most intense work for her just happened. It was only after he was about 4 years
patients as they confronted, together, difficult and old that I felt ready to take on my first reproductive
deep-seated issues [18]. clients. I realized that as much as I wanted to help
What happens if the therapist and client face others through their reproductive traumas, it would
experiences that are psychologically similar? Jo Ellen have been too painful had I not resolved my own grief
Patterson discussed her active pursuit of fertility treat- [14,33]. And so, when the question arose – “do you
ments while working with a couple that had a disabled have kids?” – I found myself facing an interesting inter-
child. “We were similar ages and all struggling with nal dilemma. Like so many clinical psychologists, I had
a major developmental milestone – the transition to been trained that disclosure is taboo. I did my best to
parenthood – that had gone awry” [36, p. 24]. Patter- understand the reasons why the question was being
son chose not to disclose any information about her posed and to focus on what my answer might mean to
personal life, but was able to use her own experience that particular client. Sometimes I would explore the
of grief and loss to empathize with the couple. Other fantasies before I responded, at other times I would
counselors found that disclosing traumatic life events respond directly and then get deeper into the client’s
to their clients enhanced the therapeutic alliance; it feelings about my personal admission. I let them know
allowed patients to have a genuine give and take with that I was willing to answer their questions, but that
their therapist, and deepened the sense of collabo- we had to talk about it. It was important for our work
ration [37]. The important point is that each coun- together to know how my answers made them feel. To
selor/client dyad needs to be assessed for its unique be clear, I did not go into details about my reproduc-
dynamics. What is right for one patient may not be tive journey; I simply said that I had been able to have a
right for others. The amount of disclosure, if any at all, child. For the most part, clients felt comforted by this;
will depend on the strength of the therapeutic relation- it seemed to give them hope. Additionally I tried to
ship, the trust that has been established, whether or not reassure patients that their life crisis could have any
the client has asked a direct question, the psychologi- number of resolutions, with or without children; being
cal needs of the client, and on the therapist’s clinical open to new endings to their reproductive story was
judgment regarding the client’s needs [3,36,38]. key to working through the grief.

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 245
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Section 5: Special topics in fertility counseling

I have been fascinated about the assumptions my In one of our sessions, after she had gotten another
clients have made about me over the years: some dose of, “Why don’t you just adopt?” from a close rela-
thought that I had gone through IVF, others concluded tive, it occurred to me that she assumed I felt the same
that I had adopted, others said, “Oh you are one and way. Her distorted belief that I thought negatively of
done!” as if that was by choice. Interestingly, their her because she did not want to adopt was: (1) not at
conjectures often ran parallel to their own decisions, all what I was feeling, and (2) keeping her from choos-
almost as if they were projecting their choices onto me ing her own path. My intuition propelled me to take a
(if I did it, it must be okay). While I was (and am) risk. I said, “You know, adoption isn’t for everyone. It
willing to answer the “do you have kids question” I try wasn’t for me.” This disclosure turned out to be a turn-
to maintain my neutrality; I do not want to influence ing point in her therapy. Her relief was palpable: Here
clients one way or another, nor do I want to presume to was someone whom she respected (clearly I was not a
know how they feel. While this is a good rule of thumb, “bad” person in her mind), giving her permission not
it is also valuable to be a realistic sounding board as to adopt. Although it felt risky to share something that
clients rethink their story. The following case, a woman I had struggled with as well, I believe it was my ability
who I call Kathy, illustrates a valuable lesson learned: to truly feel her anxiety that allowed me to call upon
the use of self-disclosure to assist in working toward my own.
treatment goals [23]. Soon after that, Kathy began talking about the pos-
itives of a child-free life. She was able to be more
Kathy: taking a risk with disclosure forthright with her husband, began taking writing
classes (something she had always wanted to do),
Kathy began once-a-week individual psychotherapy started a small business, and put more energy into
to cope with infertility and its impact on her her nieces and nephews. The result of loosening my
relationship, and to sort through decisions about her boundaries gave her the authority to let go of societal
life. Her lifelong dream had been to become a pressures and turn the page to a new chapter in her life.
mother; infertility caused her self-esteem to
plummet. This came out in multiple ways: she had
difficulty making decisions, would acquiesce to the
What is countertransference? It’s not
needs of others, and even felt insecure calling people just Freudian any more
on the phone. It was often difficult for her to get Akin to therapist self-disclosure is the concept of
started in our sessions; she felt awkward and clumsy
countertransference. Our personal history, intrapsy-
talking about herself. Her transference feelings
chic struggles and interpersonal relationships make us
toward me were positive. I was aware of her
deference to me and was concerned that she was in who we are. Even the most neutral clinician brings his
constant need of my approval. or her personality and life experiences into the therapy
arena, which when used correctly can have a positive
impact on the patient.
She had been getting a great deal of pressure from When Freud first described countertransference –
friends and family to seek out alternate ways to have therapists’ unconscious, defensive response to their
children. Part of our work together was to process the clients – it was not thought of as something benefi-
plusses and minuses of third party reproduction, as cial to the therapy, but rather something to be avoided
well as adoption. Over the course of several months, [39]. As psychological theory has evolved, however,
we explored her wavering feelings, especially regard- so has the understanding of countertransference. It
ing adoption. Part of me was secretly hoping she would has now been defined as the “internal and overt reac-
embrace it; I wanted to see her fulfill her dreams, and I tions to clients that are rooted in therapists’ unresolved
was feeling as stuck as she was. I did not, however, want intrapsychic conflicts” [25, p. 173]. It is not merely
her to make any decision in order to please me, and so I the definition that has broadened, but countertrans-
was acutely aware of not offering an opinion and main- ference is seen now as a valuable self-reflective tool
taining my neutrality. She vacillated back and forth; that therapists can use to gain insight into the ther-
she clearly was tormented by social pressure, with the apy. While many believe that countertransference is
belief that if she truly were a “good” person she would strictly a Freudian concept, others view it as a univer-
open herself up to adoption. sal phenomenon, regardless of theoretical orientation.

246
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Chapter 17: The view from the fertility counselor’s chair

As noted by Hayes, Yeh and Eisenberg, humanistic, The following case illustrates how countertrans-
existential, feminist and cognitive-behavioral theorists ference initially interfered with the therapy; it then
all have emphasized the importance of the therapist’s describes how awareness of these feelings was used to
personal history and mental health on the quality of gain a better understanding of the client and help her
therapy [40]. through her grief and loss.
How does countertransference apply to the fertil-
ity counselor? If a client’s struggle with infertility or Melissa: Countertransference
pregnancy loss triggers unresolved personal conflicts
in the therapist, it may adversely affect interactions in action
with the client. Research suggests that therapists may
When Melissa, 41 years old, began weekly
become anxious, have distorted perceptions of clients
psychotherapy with me, she was distraught over
and exhibit avoidance behavior when unresolved
secondary infertility. She had struggled with primary
issues have been aggravated [41]. If a client is coping infertility as well, and through IUI had a daughter,
with reproductive issues that provoke a reaction in the age 4. All her attention, however, was on the son she
counselor, it is important for the counselor to examine hoped to have one day. She spent endless hours on
his/her personal issues. Not only can this intro- internet forums obsessed with increasing her
spection lead to greater understanding of one’s own chances of having a boy; she went so far as
wounds, but also it can help to better understand the stockpiling little boy outfits and toys that she found
patient. on sale. As Melissa had been trying for a second child
An interesting study on countertransference in for a couple of years to no avail, she met with her
bereavement therapy found that the more the therapist reproductive endocrinologist; her goal was to do IVF
and test for gender selection. Unfortunately, her IVF
missed a deceased loved one, the less empathy clients
cycle failed, leaving her devastated and hopeless.
perceived their therapist to have. The researchers spec-
ulated that if therapists had unresolved grief, their
focus would be on themselves and they would have Melissa was challenging to work with in therapy.
fewer emotional resources available to empathize with She arrived late to nearly every session by at least
their patients. Conversely, if the grief had been suffi- 15 minutes. Her tardiness extended to other situations
ciently worked through, therapists would have more as well; she had been reprimanded at work, not only
capacity to empathize, especially with a client’s loss. for being late, but also for surfing the web. Invariably
Using their own losses as a guide, therapists who had her searches were pregnancy related. When confronted
resolved their grief were able to “reflect on their own about her ongoing late arrivals to our sessions, she
experiences to inform treatment decisions, make judi- became defensive: because this was “her time” she felt
cious self-disclosures, and offer genuine hope born of at liberty to do with it whatever she wished.
their own pain” [40, p. 347]. Melissa brought up a multitude of feelings in me.
In another study, subjects rated therapists by Her lateness was irksome as was her sense of entitle-
watching one of two videos in which the therapist ment. I understood her behavior as a way of acting out
either disclosed relatively resolved or relatively unre- feelings of depression and anger. I also saw it as a way
solved personal issues. Results indicated that when to defensively avoid the reality of her situation, that is,
therapist’s issues were resolved, they were found to she would most likely not be able to conceive a son and
be more attractive, trustworthy and instilled more have her dream come true. If I represented realism and
hope [42]. Applying these results to fertility coun- common sense, she was doing her best to evade it, and
seling, the therapist’s own reproductive history can that included dodging me.
either impede or facilitate the client’s therapy. As pre- It is very likely that Melissa’s behavior would evoke
viously discussed, if the therapist’s issues have not irritation in most counselors; it felt like we were in
been adequately resolved, disclosure may be more an ongoing standoff with little to no progress being
for the therapist than the client [14,33]; likewise, made. If I confronted her, she became defensive; if
where the therapist is in his/her own reproductive I empathized with her disappointment, she sobbed
story will have an impact on countertransference reac- uncontrollably, which also had the effect of keeping
tions and affect his/her ability to be able to remain me at a distance. I began to realize that my frustration
objective. with Melissa went deeper; I was forced to address my

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 247
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Section 5: Special topics in fertility counseling

negative countertransference towards her. I realized Fertility counselors and self-care

that we had several things in common: although my
son was considerably older than her daughter (the fact Working in the field of reproductive psychology can be
that I had a son was never discussed in therapy), we incredibly satisfying and meaningful. We help people
both had one child after primary infertility, we both in crisis move through the process of grieving; we help
wanted another child, and we both were “older” moth- them go from the depths of despair to feeling positive
ers who grappled with secondary infertility. This inter- about themselves and about their life, whether they
nal understanding helped me identify my anger: she are successful at having children or not. But working
tugged at my own loss. While I had long since resolved with this population is not without risk to the fertil-
pursuing another pregnancy, this was still a “sore-spot” ity counselor as we are confronted with trauma and
in my personal history that got called to light because loss, sadness and anguish, on a daily basis. This sec-
of Melissa’s issues. tion focuses on the need for self-care; the concepts of
It should be noted that I did not disclose any of vicarious trauma and compassion fatigue are explored,
my self-revelations to Melissa. However, by reflect- as are ways to prevent these from interfering with our
ing on my own experience, I felt that I understood work and our lives.
her better and could use it to better serve her. As my A trauma, by definition, is exposure to an “actual
anger abated, so did her defensiveness. It was at this or threatened death, serious injury, or sexual vio-
point in the treatment that she began to process her lence” that one witnesses or experiences, or learns
grief. Interestingly, she became more connected with has occurred to a close family member or friend [43,
her daughter and gained insight into her relationship p. 271]. Trauma, whether physical or psychological,
with her own frustrating and distancing mother. We overwhelms people’s ability to cope, and unlike other
were able to dig deeper into what it meant to have a traumas that are one-time incidents, it is the chronic
son (in her view, boys could not disappoint a mother nature of infertility and other reproductive events that
the way she felt she had let down her own; boys were overpowers clients’ coping resources [2]. Traumatized
powerful and could compensate for her own sense of people often try to avoid triggers of the traumatic expe-
weakness). Although she continued to come late to her rience [43], but it is virtually impossible for reproduc-
therapy appointments (it became a running joke tive clients to do so. They may try to steer clear of preg-
between us), she had a much better understanding of nant women and baby showers, but the inescapable
her issues with her own mother and was determined to reminder of a women’s monthly menstrual cycle, as
parent her daughter differently. well as the trauma from repeated intrusive treatments
This case made me appreciate the importance of which must be endured (and repeated) in order to
reflecting on my own defensive countertransference conceive, is a painful and unavoidable trigger of yet
reactions. Although my losses felt resolved to me, another loss.
this case brought to the forefront that reproductive By the nature of our work with clients struggling
losses change us in profound ways. As noted pre- with infertility, miscarriage, or other perinatal demise,
viously, when therapists’ internal conflicts are trig- we are exposed to a great deal of trauma and loss.
gered, they may react to their clients with anxious, These stories are difficult to hear; fertility counselors
angry, avoidant behaviors [41]. How fertility coun- repeatedly listen to accounts of sadness, defeat and
selors manage their countertransference reactions may death in our practices. When these stories include
be central to building and maintaining a good ther- unsuccessful cycles or failed pregnancies, the pain
apeutic alliance, thereby affecting clinical outcome. can be overwhelming not just for our clients, but for
If countertransference acting out is harmful to the us as well, especially poignant if we have experienced
working alliance, it stands to reason that manag- some aspect of the trauma ourselves. The need for
ing one’s countertransference constructively promotes therapist self-care is important no matter what issues
positive therapeutic effects. Fertility counselors can clients bring to therapy, but for fertility counselors,
use self-insight and mindfulness, through personal awareness of countertransference, vicarious trauma
therapy or supervision, to promote their own psy- and compassion fatigue are of particular importance.
chological health and, in turn, allow themselves to Understanding the differences among these phenom-
understand how their clients’ issues personally affect ena is important; although there may be overlap, each
them [39]. requires different forms of self-care. (See Table 17.2.)

248
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Chapter 17: The view from the fertility counselor’s chair

Table 17.2 Comparison of compassion fatigue, vicarious trauma and countertransference.

Counter-Fatigue Trauma
Compassion Vicarious Transference
Based on caring for those who are suffering Based on developing trauma secondary to Based on interaction between client’s
client’s traumatic experience world and clinician’s unconscious
Cumulative experience of care-giving Working with victims of trauma Pervasive to all clients
Feeling generally exhausted, burnt-out Reaction specific to trauma May be difficult but not exhausting
Can interfere with clinical work Can interfere with clinical work Can be used as a tool to enhance
clinical work
Self-care: A need to replenish: yoga, Self-care: In addition to the compassion Self-care: Self-reflection to understand
meditation, relaxation, connecting with nature, fatigue self-care, limit number of trauma intrapsychic roots of reactions to
exercise, creativity, social support, individual or clients clients, supervision, psychotherapy
peer supervision

As discussed, countertransference refers to a ther- While countertransference is a part of every clin-

apist’s unresolved personal issues that are evoked by a ical encounter and can be used constructively in our
client. Rather than serve as a detriment to the treat- work, vicarious trauma and compassion fatigue have a
ment, our own inner conflicts can help inform us of the negative impact. Saakvitne suggests that we ask our-
intrapsychic world of our clients. Vicarious trauma, selves, “How am I doing?” on a regular basis [44].
on the other hand, describes a counselor’s negative Making an assessment of our own well-being is imper-
transformation after being exposed to a client’s trauma ative if we are to be present and available to our
[44,45]. Listening to the details of a client’s traumatic clients. Essential for every fertility counselor is to
experience can affect us deeply; in essence their trauma find a balance among work, play and rest. Finding
can “rub off” on us. Hearing the specifics of a pre- time for enjoyable activities outside of work (physi-
mature birth, viewing photographs of a baby who has cal activity, meditation, vacations, spiritual and/or cre-
died, witnessing the anguish of an IVF that has failed – ative endeavors) is key. Making time to socialize with
these are all client traumas that have an impact on friends and family can re-energize and re-invigorate
us. Vicarious trauma is different than countertrans- one’s sense of self. Being able to talk with colleagues,
ference in that vicarious trauma “is a direct reac- as in a peer supervision group, helps to eliminate iso-
tion to traumatic client material and is not a reaction lation and can validate the demands of working with
to past personal life experiences” [45, p. 32]. Vicari- this population. It is also helpful to find a balance
ous trauma, however, can evoke countertransference within the workday itself. This may mean not schedul-
issues: when the traumatic experiences are shared or ing back-to-back clients who are emotionally draining,
similar, for example, if the therapist has had his/her building in breaks, and as obvious as this may seem,
own reproductive losses, the therapist is even more making sure to eat and hydrate. In order to be present
vulnerable. for our clients, fertility counselors must figuratively
Compassion fatigue occurs when a therapist is put their oxygen mask on first in order to help others.
overexposed to client suffering and becomes exhausted Additionally, it is important to know when to refer a
by the cumulative effects of this exposure. This can client to another clinician. If the client’s issues are too
happen to any counselor (as well as any medical care- close to one’s own, or if the clinician is in the midst of
giver) at any time; essentially, it is defined as a therapist a life-crisis, it may better serve the client to see another
who becomes tired of caring. When counselors expe- therapist.
rience compassion fatigue, they may feel worn out,
depleted and drained, may become impatient and irri-
table, may feel depressed, and may be less available Summary and reflection
to process their clients’ issues [46]. Although this can While working with infertility and reproductive loss
occur with all kinds of therapeutic issues, the concerns clients can be meaningful and rewarding, it is not
that reproductive clients raise, with multiple losses, for the faint of heart. There are times when fertility
medical traumas and psychological pain, can feel par- counselors are left with their own feelings of helpless-
ticularly emotionally draining. ness and sadness as they bear witness to the upsetting

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 249
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Section 5: Special topics in fertility counseling

details of clients’ lives. These feelings may be inten- 11. Gutheil TG, Brodsky A. Preventing Boundary
sified if the therapist has had his/her own difficulties Violations in Clinical Practice. New York: Guilford
in having children. Regardless of the counselor’s per- Press, 2008.
sonal reproductive story, the events of one’s life have 12. Stricker G. The many faces of self-disclosure. J Clin
an impact on interactions with clients. Whether the Psychol 2003; 59: 623–30.
clinician chooses to disclose or not, drawing on one’s 13. Zur O. Therapist self-disclosure. In: Bloomgarden A,
internal narrative and emotions will bring increased Mennuti RB, eds. Psychotherapist Revealed. New York:
understanding and depth to the therapy. Just as impor- Routledge. 2009; 31–51.
tant as it is to attend to the client’s needs, it is equally 14. Knox S, Hill CE. Therapist self-disclosure:
important to attend to our own. Seeking consulta- Research-based suggestions for practitioners. JCLP
2003; 59: 529–39.
tion, especially if a case touches on the therapist’s own
losses, is highly recommended. 15. Freud S. Recommendations to physicians practicing
Writing this chapter has enabled me to reflect on psycho-analysis. In: The Standard Edition of the
Psychological Works of Sigmund Freud. London:
my own life experiences, my own reproductive story Hogarth Press. 2000; 1–120 (Original work published
and my clinical work; as such, I have learned a great 1912).
deal. My hope is that reading this will do the same
16. Gelso CJ. The Real Relationship in Psychotherapy.
for you. Washington, DC: American Psychological
Association. 2011.
17. Bloomgarden A, Mennuti RB. Therapist
References self-disclosure: Beyond the taboo. In: Bloomgarden A,
1. Nouwen H. The Wounded Healer. Garden City, NY: Mennuti RB, eds. Psychotherapist Revealed. New York:
Image. 1972. Routledge. 2009; 3–15.
2. Jaffe J, Diamond MO. Reproductive Trauma: 18. Gerson B. An analyst’s pregnancy loss and its effects on
Psychotherapy with Infertility and Pregnancy Loss treatment. In: Gerson B, ed. The Therapist as a Person:
Clients. Washington, DC: American Psychological Life Crises, Life Choices, Life Experiences, and Their
Association. 2011. Effects on Treatment. New York: Routledge. 2009;
3. Leibowitz L. Reflections of a childless analyst. In: 55–69 (Original work published 1996).
Gerson B, ed. The Therapist as a Person: Life Crises, Life 19. Barrett MS, Berman JS. Is psychotherapy more
Choices, Life Experiences, and Their Effects on effective when therapists disclose information about
Treatment. New York: Routledge. 2009; 71–87 themselves? J Consult Clin Psych 2001; 69: 597–603.
(Original work published 1996).
20. Patton J. Engendering a new paradigm: Self-disclosure
4. Hill CE, Knox S. Self-disclosure. Psychotherapy 2001; with queer clients. In: Bloomgarden A, Mennuti RB,
38: 413–17. eds. Psychotherapist Revealed. New York: Routledge.
5. Hill CE, Knox S. Self-disclosure. In: Norcross JC, ed. 2009; 181–92.
Psychotherapy Relationships That Work: Therapist 21. Filetti L, Mattei S. To share or not to share:
Contributions and Responsiveness to Patients. New Self-disclosure in the treatment of borderline
York: Oxford University Press. 2002; 255–65. personality disorder. In: Bloomgarden A, Mennuti RB,
6. Henretty JR, Levitt HM. The role of therapist eds. Psychotherapist Revealed. New York: Routledge.
self-disclosure in psychotherapy: A qualitative review. 2009; 71–83.
Clin Psychol Rev 2010; 30: 63–77. 22. American Psychological Association. Ethical
7. Hill CE, Knox S. Processing the therapeutic principles of psychologists and code of conduct. APA;
relationship. Psychol Res 2009; 19: 13–29. 57: 1060–73. Retrieved from http://www.apa.org/
8. Gutheil TG. Ethical aspects of self-disclosure in ethics/code2002.html. Accessed October 2014.
psychotherapy: Knowing what to disclose and what 23. Barnett JE. Psychotherapist self-disclosure: Ethical
not to disclose. Psychiatr Times 2010; 27: 39–41. and clinical considerations. Psychother 2011; 48:
9. Peterson ZD. More than a mirror: The ethics of 315–21.
therapist self-disclosure. Psychother 2002; 39: 24. Hanson J. Should your lips be sealed? How therapist
21–31. self-disclosure and non-disclosure affects clients.
10. Ulman KH. Unwitting exposure of the therapist: Couns Psychother Res 2005; 5: 96–104.
Transferential and countertransferential dilemmas. 25. Myers D, Hayes JA. Effects of therapist general
J Psychother Pract Res 2001; 10: 14–22. self-disclosure and countertransference disclosure on

250
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018
 Chapter 17: The view from the fertility counselor’s chair

ratings of the therapist and session. Psychother: Theory, 37. Mendelsohn EM. More human than otherwise:
Res, Pract, Train 2006; 43: 173–85. working through a time of preoccupation and
26. Barnett M. What brings you here? An exploration of mourning. In: Gerson B, ed. The Therapist as a Person:
the unconscious motivations of those who choose to Life Crises, Life Choices, Life Experiences, and Their
train and work as psychotherapists and counselors. Effects on Treatment. New York: Routledge. 2009;
Psychodynamic Practice 2007; 13: 257–74. 21–40 (Original work published 1996).
27. Weingarten K. Intersecting losses: Working with the 38. Chasen B. Death of a psychoanalyst’s child. In: Gerson
inevitable vicissitudes in therapist and client lives. B, ed. The Therapist as a Person: Life Crises, Life
Psychother: Theory, Res, Pract, Train 2010; 47: 371–84. Choices, Life Experiences, and Their Effects on
Treatment. New York: Routledge. 2009; 3–20 (Original
28. Jackson SW. The wounded healer. B Hist Med 2001; 75: work published 1996).
1–36.
39. Hayes JA, Gelso CJ, Hummel AM. Managing
29. Bloomgarden A, Mennuti RB. Lessons learned from countertransference. Psychotherapy 2011; 48: 88–97.
adolescent girls. In: Bloomgarden A, Mennuti RB, eds.
Psychotherapist Revealed. New York: Routledge. 2009; 40. Hayes JA, Yeh Y, Eisenberg A. Good grief and
101–14. not-so-good grief: countertransference in bereavement
therapy. J Clin Psychol 2007; 63:
30. Covington SN, Marosek KR. Personal infertility 345–55.
experience among nurses working in reproductive
medicine and mental health professionals. Fertil Steril 41. Rosenberger EW, Hayes JA. Therapist as subject: A
1999; 72:S129. review of the empirical countertransference literature.
J Couns Dev 2002; 80: 264–70.
31. Marrero SJ. The role of the psychologist in reproductive
medicine. Unpublished doctoral dissertation. Rutgers 42. Yeh YJ, Hayes JA. How does disclosing
University, New Jersey. 2013. countertransference affect perceptions of the
therapist and the session? Psychother 2011; 48:
32. Zerubavel N, Wright MO. The dilemma of the 322–29.
wounded healer. Psychother 2012; 49: 482–91.
43. American Psychiatric Association: Diagnostic and
33. Gelso CJ, Hayes JA. Countertransference and the Statistical Manual of Mental Disorders, Fifth Edition.
Therapist’s Inner Experience: Perils and Possibilities. Arlington, VA: American Psychiatric Association.
Mahwah, NJ: Erlbaum. 2007. 2013.
34. Lazar S. Patients’ responses to pregnancy and 44. Saakvitne KW. Shared trauma: The therapist’s
miscarriage in the analyst. In: Schwartz HJ, Silver AL, increased vulnerability. Psychoanal Dialogues 2002; 12:
eds. Illness in the Analyst. Madison, CT: International 443–49.
Universities Press. 1990; 199–226.
45. Trippany RL, Kress VEW, Wilcoxon SA. Preventing
35. Comstock DL. Confronting life’s adversities: vicarious trauma: What counselors should know when
Self-disclosure in print and in session. In: working with trauma survivors. J Couns Dev 2004; 82:
Bloomgarden A, Mennuti RB, eds. Psychotherapist 31–7.
Revealed. New York: Routledge. 2009; 257–73.
46. Berzoff J, Kita E. Compassion fatigue and
36. Patterson JE. A birth gone awry. In: McDaniel SH, countertransference: Two different concepts. Clin Soc
Hepworth J, Doherty WJ, eds. The Shared Experience Work J 2010; 38: 341–49.
of Illness. New York: Basic Books. 2003; 23–9.

Downloaded from https://www.cambridge.org/core. University of Birmingham, on 20 Aug 2018 at 12:02:26, subject to the Cambridge Core terms of use, available at 251
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781107449398.018