Countertransference: A Psychological Aspect of Nutritional Counseling

A Challenging Case

I met “Emma” (not her real name) at a time when I was new to the field of eating disorders. She was a bright, articulate woman, 24 years of age, who was in her second year of law school. Emma had lived with severe bulimia nervosa since leaving home to begin her studies at the university. She had a love/hate relationship with her eating disorder. Although she despised it, binge-eating and purging allowed her to cope with the demands of school. Defiantly, she told me she did not need nutritional counseling. She stressed that she knew how to eat properly; she just had to get her act together. Her husband and her physician had made her come.

By then I had worked in the area long enough to know that it wasn’t unusual for patients to resist treatment. But, in Emma’s case, it was particularly difficult for me to accept. She was 17 weeks pregnant and deteriorating right before my eyes. As a result of her constant fears of gaining weight, her binge-eating and purging behaviors escalated. She had been unable to make any changes to her eating pattern; and, after two months of nutritional counseling, her weight was lower than when she first became pregnant.

Although I knew I was carrying out my professional responsibilities as a dietitian, I still felt incompetent. Even more difficult to acknowledge were the other emotions I felt toward Emma: I was angry and frustrated with her. She was in complete denial that her pregnancy was considered high risk. I felt hopeless that I would be able to help Emma make any progress.

My dietetic education had not prepared me for this counseling experience. I was unsure whether my reaction to Emma was normal or a sign that I was not cut out for this line of work. I was concerned that my feelings would threaten our therapeutic alliance and affect my ability to continue providing nutritional care.

A Personal Reaction

For guidance I approached a colleague, Suja Srikameswaran, PhD, R.Psych, a psychologist with the Eating Disorders Program at St. Paul’s Hospital. Suja helped me to understand that I was experiencing countertransference. Simply put, countertransference refers to the therapist’s (or in this case, the nutrition professional’s) personal reaction to what the client is saying or doing in the nutrition session. In this situation, Emma’s pregnancy and her difficulty changing her eating patterns led me to feel angry and frustrated with her, and to feel ineffective as a dietitian.

The Impact of Countertransference on the Client and Dietitian

Countertransference can affect the patient-dietitian relationship in various ways. The dietitian may find herself communicating, overtly or covertly, her anger and frustration to the patient. This may be manifested in critical or judgmental comments made to the client about her lack of progress. In Emma’s case, a nutrition professional might be tempted to lecture the client about the irresponsibility of her actions, given her pregnancy. The dietitian could then find herself “pushing” or threatening the client to change.

Anger and frustration to the client might include: keeping the patient waiting for her appointment, ending the session early, withdrawing from the therapeutic interaction, or otherwise letting the client know her/his displeasure and frustration.

Managing Countertransference

Countertransference is a common psychological dynamic that occurs within the counseling process. Yet many dietitians are not adequately trained to cope with this issue in clinical practice.

Dr. Srikameswaran provided the following suggestions to help nutrition professionals manage countertransference in their sessions with eating-disordered patients:

• Be honest with yourself about the feelings that come up as a result of working with particular clients. The first step in managing countertransference is to identify when it occurs and under what circumstances. It may be that in terms of your own personal values, beliefs, and experiences, you are not best suited to provide nutritional counseling for a particular patient group.
• Be realistic in your own self-expectations. While it is not necessary to like every client you treat, it is necessary to provide a safe and respectful environment for all of them. Explore, with a trusted colleague, what you would have to change about your attitude or stance toward the client to help provide a supportive therapeutic environment.
• Create a support group with team members to discuss the potential impact personal life events could have on nutrition counseling sessions with clients. For instance, counseling a pregnant patient may be an emotional challenge for a dietitian who is trying to become pregnant herself. Getting together with other team members provides an opportunity to develop strate
• gies to cope with feelings.
• Finally, ask for professional supervision from a psychologist or psychiatrist who works in the area. Often, this professional’s experience can enhance the development of your therapeutic skills, which may help you deal more effectively with countertransference.

— Linda M. Watts, MA, RD