Abstract

Nursing research is continuously seeking to improve the quality of nursing care provided to clients to obtain the best possible outcomes for them. At the heart of psychiatric nursing is the therapeutic relationship between the nurse and client. This therapeutic relationship aims to optimise outcomes for those experiencing mental health difficulties. Helping them to overcome their difficulties and meet their full potential in their lives. However the largely interactive nature of the relationship can unconsciously evoke negative feelings within the nurse towards the client known as countertransference. If this is not recognised and managed by the nurse it may result in the nurse acting upon unconsciously motivated behaviour potentially having a negative outcome for the client. The management of countertransference has shown an improvement in client outcomes however to manage countertransference feelings and reactions is no easy endeavour. Countertransference feelings occur unconsciously and may go unrecognised by the nurse.

The aim of this research was to review the literature pertaining to this clinical issue and provide a succinct background to this issue. It aimed to identify a possible intervention to this clinical issue and conduct a comprehensive literature review. However there is a distinct gap within the nursing literature into this clinical issue of countertransference and its management. From this review mindfulness emerged as a potential tool for nurses to become aware and manage their countertransference. The PICO model was used to develop a client centred research question Could mindfulness be an effective tool for nurses to manage countertransferance and improve client outcomes? This research seeks to decrease the gap within nursing literature and also inform current practice within psychiatric nursing in Ireland.

To address this issue the research databases Ovid, Cinal, EBSCO, TRIP, Sciencedirect and Psych info were searched for the best up to date evidence available. Mindfulness is rooted within Buddhist traditions and more recently is applied to psychological

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health within western medical and mental health contexts. Its non judgemental awareness and acceptance of ones moment to moment experience are regarded as potentially effective antidotes against psychological distress. This concept has arisen as a potential approach to managing countertransference reactions. Within psychiatric nursing the nurse encounters raw emotions where clients fear rejection, distancing and negative judgment. Mindfulness could allow one to deal with experiences without being overwhelmed or pushing away which can occur in countertransference. It is also seen to help a nurse maintain professional boundaries and fosters non reactivity and cognitive flexibility. Acting out of countertransference is harmful and its management promotes a positive outcome for a client.

To consider the application of the findings of mindfulness as a potential tool in managing countertransference to improve client outcomes this was then compared to current practice within Ireland. A review of the psychiatric nurse education curriculum of Irish universities and institutes was considered the most appropriate method of doing so. Countertransference within the nurse client relationship was evidently apart of most curriculums but not strategies for managing same. Mindfulness did not appear on any curriculum. From researching this area it appears there is a lack of current protocols in place for nurses to manage countertransference. The degree to which practicing mindfulness can assist a nurse in managing countertransference is only evolving within the literature. There is an overall gap within the literature into countertransference and its management. Psychiatric nurses could consider their most valuable tool as therapeutic use of self to establish a therapeutic relationship. Helping clients grow, change and heal however this clinical issue of countertransference can potentially hinder and impede the relationship and outcomes of clients.

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Introduction

Within nursing research, Parahoo (2006) views its primary goal as to improve the quality of care given to clients. The nurse-client therapeutic relationship is viewed by Peplau (1952) as at the heart of the work within psychiatric nursing. Psychiatric nurses spend more time with their clients in comparison to those who work within a
medical field. Due to the largely interactional nature of the nurse client relationship unconscious feelings maybe evoked within the nurse towards the client and if not dealt with, may impact negatively on the therapeutic relationship. This may be known as countertransference, which is a concept derived from psychoanalytical theory. As the

nurse client relationship is at the heart of psychiatric nursing, countertransference may negatively intrude upon the relationship. This assignment aims to review the literature pertaining to this area and provide a succinct background to the clinical issue of countertransference within the nurse client relationship. It will review the literature with the aim of identifying a possible intervention to this clinical issue, using the PICO model it will formulate a client centred question and conduct a comprehensive literature review and consider the application of such findings to inform clinical practice.

Background Countertransference was first described by Freud (1910) who used the term to name the unconscious feelings influenced by the client within the therapist generated during analysis. Little (1951) suggests countertransference represents all of the therapists reactions to the client; where all reactions are important and should be studied and understood. Within the context of psychiatric nursing there appears to be a lack of nursing research on this subject area, as highlighted by OKelly (1998) which is one of the most recent studies within the literature. Definitions of countertransference in

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nursing literature have been mainly derived from psychoanalytical theory. According to OKelly (1998) nurse authors widely agree that recognition of countertransference is useful to the nurse-client relationship. Countertransference feelings are not immediately apparent to the nurse as it occurs out of their awareness in their unconscious (Shroder 1985). Countertransference responses are viewed as having a quality of intensity that distinguishes them from other feelings within a relationship. According to Gelso et al. (2002) countertransference reactions occur frequently in interactions with clients. If therapists fail to manage their countertransference reactions, they place themselves at risk for acting out on their own unresolved conflicts during the therapeutic work thus failing to be of service to clients. Within their study which is the first study of this nature, Gelso et al. (2002) showed management of countertransference has an improvement in client outcome. There was an overall reported improvement in clients feelings, behaviour and self understanding. However the generalizibility of this result is limited due to small sample size. Also the use of trainee therapists as opposed to experienced therapists as participants within the study was highlighted as a drawback. Clients from a symptom perspective who are less resistant to change appear to evoke higher levels of negative countertransference feelings within therapists (Rossberg et al. 2010). Negative feelings such as, being on guard, overwhelmed and inadequate are evoked within therapists. Symptom change was positively correlated with positive countertransference feelings. According to Rossberg et al. (2010) if

countertransferance reactions are not handled appropriately, it may lead to premature discharge of clients. For positive therapeutic outcome, the therapists awareness of countertransference feelings is important. In reviewing the policies on a forensic unit there appeared to be no protocol in place for managing countertransference. This initiated an area of interest to the author, given the potential negative outcomes for clients and nurses. The author reviewed the literature around this clinical issue for a tool for nurses to become aware and manage countertransference. From a review of the literature a number possible interventions emerged, however this assignment will focus on Mindfulness. Mindfulness is defined

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by Davis and Hayes (2011) as a moment to moment awareness of ones experience without judgement (p.198). The author then compared this possible intervention to current practice to recognising and managing countertransference. The most appropriate method of reviewing current practice within Ireland was considered to be within the nurse education curriculum. In doing this the author hoped to inform current practice within psychiatric nursing in Ireland with a view to potentially improve outcomes for clients. Using the PICO model the following research question was formed: Could mindfulness be an effective tool for nurses to manage countertransference and improve client outcome? PICO Format: Problem Intervention Comparison Outcome Countertransference within nurse client relationship Mindfulness Current practice Improved client outcome

The research databases Ovid, Cinal, EBSO, TRIP, Sciencedirect and Psych Info were searched for the best evidence to address the clinical nursing issue of countertransference. The key words countertransference and psychiatric nursing, managing countertransference and mindfulness, mindfulness and psychology mindfulness and nursing were used. There was limited research within this subject area within the nursing literature so therefore the literature search was not exclusive to nursing and extracted literature from psychology, psychotherapy and counselling. There was an original 5 year date restriction implemented on the initial literature search however there was a lack of literature. Therefore this restriction was lifted resulting in some older and seminal literature being reviewed.

Mindfulness The concept of mindfulness is rooted within 3,000 year old Buddhist traditions. Its application to psychological health in western medical and mental health contexts is a recent phenomenon beginning largely in the 1970s (Kabat-Zinn 1982). Mindfulness is

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commonly cited in the literature as defined by Kabat-Zinn (1994) as the awareness that arises through paying attention in a particular way: on purpose, in the moment, and non-judgementally (p.4). It is viewed by Keng et al. (2011) as having two primary key elements which are awareness of ones moment to moment experience non-judgementally and with acceptance. These key elements are regarded as potentially effective antidotes against common forms of psychological distress such as rumination, anxiety, worry, fear, anger. These involve the maladaptive tendencies to avoid, suppress or over engage with ones distressing thoughts and emotions (Hayes and Feldman 2004). Mindfulness focuses on the awareness of objects as they appear in the mind and changing elements of thought (Williams et al. 2008). Mindfulness is also viewed as involving conscious attention, aiming at awareness of what is happening as you observe, notice and attend to sensations, perceptions, thoughts and feelings. The process of mindfulness allows for the awareness of wandering thoughts which interfere on the focus of here and now. Mindfulness allows for the return of the here and now to attend to the present moment without judging your thoughts (Wegner and Zanakos 1994). It is impossible to disown or transcend unwanted thoughts therefore mindfulness allows for the ending of effort of avoiding thoughts replacing it with the awareness of interdependence and non separation.

Managing Countertransference with Mindfulness Self awareness and insight into countertransference feelings is not simply enough, according to Williams et al. (2008) its rather what one does with their self awareness is whats important. Williams et al. (2008) views in managing countertransference, acceptance is a critical component. The concept of Mindfulness according to Morgan (2005) has arisen as a potential approach to managing countertransference reactions. Within psychiatric nursing the nurse encounters raw emotions from clients, where clients fear rejection, distancing and negative judgement (Benjamin 2003). Using mindfulness practice, Siegal (2007) suggests one can deal with experiences without getting lost in the experience, being over whelmed or pushing it away. These

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overwhelming and distracting experiences are considered to be countertransference. Gelso and Hayes (2007) suggest countertransference can result in one engaging in unconsciously motivated behaviour that can be detrimental to the therapeutic process and outcome. According to Scheick (2011) unacknowledged unmanaged countertransference impedes empathy and the therapeutic ability to respond to the client needs and not ones own. Self aware mindfulness can help one thrive in a high pressure field such as psychiatric nursing and help a nurse monitor professional boundaries lessening countertransference. Scheicks (2011) study on mindfulness to manage

countertransference in the nurse client relationship, from a nursing perspective was one of the few studies to emerge within the literature. This two part study involved 15 nursing students and 7 final semester nursing students as a control group. Within the study a multifaceted self awareness template was developed by committees comprised of nursing and psychology curriculum expertise. The STEDFAST S-AM model was developed incorporating mindfulness, aliveness, self control and self awareness throughout. Within this students who engaged in the STEDFAST S-AM reported it helped monitor for countertransference when in response to something related to the client, personal thoughts or more intense feelings from within. Components of the template have been endorsed for official inclusion in psychiatric nursing courses (Scheick 2011). The sample within this study was convenient, nonrandom and small. Due to this, the results must be interpreted with caution as the strength of Schneicks (2011) findings is weakened and the generalizability of the findings is limited. Mindfulness according to Gelso and Hayes (2007) should help one respond more freely and less defensively to their clients. As mindfulness fosters non reactivity and cognitive flexibility, Gelso and Hayes (2007) believe it is plausible it may manage countertransference. In contrast, within Kholoocis (2008) study who found the more mindfulness a therapist perceives themselves to be, the less aware they are of their countertransference. A study conducted by Grepmair et al. (2007) showed that counsellor trainees who practiced a form of mindfulness meditation reported higher

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self awareness to those trainees that didnt partake in meditation. More significantly, clients of the trainees displayed greater reductions in overall symptoms, faster rates of change, scored higher on measures of well being and perceived their treatment to more effective than clients of non meditating trainees. Therefore nurses who practice mindfulness may have the potential to improve their client outcomes. In this study it did not outline whether this was due to managing countertransference. However it shows that mindfulness has positive benefits on the counsellor which in turn may have positive results on client outcome. A meta-analysis of the literature conducted by Hayes et al. (2011) outlines that acting out of countertransference is harmful and countertransference management promotes a positive outcome for a client. From their research, behaviours such as using self insight, self integration and work on ones psychological health are fundamental to managing countertransference. A review of empirical studies conducted by Keng et al. (2011) outlines mindfulness as positively associated with psychological health. According to Bruce et al. (2011) empirical evidence is beginning to show a relationship between mindfulness and a healthy attitude toward self. In a randomized control design by Brown and Ryan (2005) a significant correlation between scores on mindfulness and a measure of self esteem. Health care professionals participated in a mindfulness based stress reduction course, reported a statistically significant increase in self compassion in comparison to the control group. In light of these findings, one may argue that based on the evidence, mindfulness practices promote such behaviours. A central component of mindfulness is viewed by Creswell et al. (2007) as labelling of ones emotions through words which promotes more recognition of, detachment from and regulation of affective experiences. Within a study conducted by Creswell et al. (2007) using functional neuroimaging has shown that verbally labelling affective stimuli activates right ventrolateral prefrontal cortex of the brain and attenuates responses in the amygdala; a region of the brain associated with negative affective states. Dispositional mindfulness was shown to be associated with greater widespread amygdala responses during affect labelling. Participants high in mindfulness had a strong inverse relationship between activity in pre frontal cortex regions and right

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amydala, in contrast to participants low in mindfulness did not show these effects. The findings within the study indicated a strong association between dispositional mindfulness and activation of the medial prefrontal cortex, a neural area founded to be activated during self relevant tasks such as monitoring ones emotional state. This process of verbally labelling affective stimuli may disrupt or inhibit automatic affective response reducing their intensity and duration. These findings may have some potential benefits in nursing. As, if a nurse practices mindfulness then these findings may imply that potential negative countertransference feelings that are evoked within the nurse, maybe reduced in terms of intensity and duration thus managing countertransference.

Current Practice To compare mindfulness as a potential tool in managing countertransference thus improving client outcome the author compared this to current practice. The psychiatric nurse education curriculum of Irish universities and institutes was reviewed (Appendix 1). Countertransference was evident within the nurse client relationship but not strategies in managing same. Mindfulness did not appear on any curriculum however self awareness and reflection appeared. However it wasnt outlined whether they were strategies in managing countertransference. These results are not inclusive as it was based on the available information in the college curriculums online. Based on this and clinical experience to date as a 4th year psychiatric nursing student, there appears to be a lack current protocols in place for managing countertransference. Psychiatric nurses must manage highly complex intensive relationships with their clients on a daily basis (Kay 2009). A client according to Boyd (2008) can be psychologically vulnerable and emotionally dependent on a nurse. Therefore it is imperative nurses manage countertransference to prevent it from eroding boundaries and affecting client outcome. Those who work within psychotherapy and counselling field have support of professional supervision and engagement in personal therapy (ICP 2011). It is not the purpose of this assignment to compare nursing to a different

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field. Although one may question as to why nurses are left, perhaps to fend for themselves without any support or tools to manage countertransference. In light of these findings, the degree to which practicing mindfulness can assist a nurse in managing their countertransference is only evolving within the literature. There appears to be a lack of empirical evidence pertaining to this area. However authors within the literature appear to be promoting this area for further research due to its promising potential results (Davis and Hayes 2011, Bruce et al. 2011, Scheick 2011). In reviewing the literature there appears to be an overall gap in nursing research in to the area of countertransference and managing it. It appears that it is widely accepted and proven that countertransference reactions can have a negative outcome on a client. Based on this, it is essential nurses have a tool to manage their countertransference to avoid them engaging in their unconsciously motivated behaviour and affecting client outcome. As there is a lack of clinical practice or recognition given to the management of countertransference, these results may inform standard operating procedures. This may give psychiatric nurses support within such an intense field to be better able to identify countertransference feelings towards a client, avoiding acting on same thus improving their client outcome. Psychiatric nurses could consider their most valuable tool as therapeutic use of self to establish a therapeutic relationship with a client. This concept developed by Peplau (1952), viewed therapeutic use of self to help clients grow, change and heal. However this clinical issue of countertransference appears to hinder it thus impeding the therapeutic relationship and outcome.

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Conclusion The evidence shows mindfulness may have a potential benefit in managing countertransference (Scheick (2011), Creswell et al. (2007)). However a lot of this review was based on psychotherapy, psychology and counselling literature. So its applicability to nursing may be weakened as they are different professions. There is a gap within the literature and clinical practice in the area of countertransference and management of it. One may question this, as nurses spend more time with their clients than any other member of the MDT. This maybe an area for research within nursing and an opportunity for nurses to develop their own body of knowledge. To introduce this into clinical practice, there would need to be a substantial amount of research conducted into the use of mindfulness into managing countertransference. This may be difficult to implement as standard operating procedures, as mindfulness occurs at a personal level and some may not choose to practice mindfulness. In terms of my internship in implementing change within practice I feel in reviewing the literature I am more knowledgeable of this clinical issue and can educate other members of the clinical team. This may allow for a supportive, nurturing environment to grow and allow each member to be empowered for the benefit of the client.

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Reference List

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Freud S. (1910) Future prospects of psychoanalytic therapy. In The standard ed of the complete works of Sigmund Freud (Strachey J. Ed.), Hogarth Press, London, pp. 139151.

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Gelso C.J., Latts M.G., Gomez M.J. & Fassinger R.E. (2002) Countertransference management and therapy outcome: an initial evaluation. Journal of Clinical Psychology. 23(2), 21-26. Gelso C.J. & Hayes J.A. (2007) Countertransference and the therapists inner experience: persils and possibilities. Lawrence Erlbaum Associates Inc, New Jersey. Grepmair L., Mietterlehner F., Loew T., Bachler E., Rother W. & Nickel N. (2007) Promoting mindfulness in psychotherapys in training influences the treatment results of their patients: A randomized double-blind, controlled study. Psychotherapy and Psychosomatics. 76,332-338. Hayes J.A., Gelso C.J. & Hummel A.M. (2011) Managing countertransference. Psychotherapy. 48(1), 88-97. Hayes A.M. & Feldman G. (2004) Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in therapy. Clinical Psychology: Science and Practice. 11, 255-262.

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display.php?prog_code=TL_NMNUR_B&stage=all&sem=all, (Accessed 2 December 2011). Morgan S.P. (2005) Depression: Turning toward life. In Mindfulness and Psychotherapy (Germer G.K., Siegel R.D. & Fulton P.R. Eds.), Guilford Press, New York, pp. 130-151. Kabat-Zinn J. (1982) an outpatient program in behavioural medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry. 4, 33-47.

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Kabat-Zinn J. (1994) Wherever you go there you are: Mindfulness meditation in everyday life. Hyperion, New York. Kay M. (2009) Managing hate: the nurses countertransference. In Therapeutic Relationships with Offenders: An Introduction to the Psychodynamics of Forensic Mental Health Nursing. (Aiyegbusi A. & Moore-Clarke J. Eds.), Jessica Kingsley Publishers, London, pp.33-42. Keng S.L., Smoski M.J. & Robins C.J. (2011) Effects of mindfulness on psychological health: a review of empirical studies. Clinical Psychology Review. 31, 1041-1056. Kholooci H. (2008) An examination of the relationship between countertransference and mindfulness and its potential role in limiting therapist abuse. Dissertation Abstracts International: Science B: Science and Engineering.68, 6312. Little M. (1951) Countertransference and the patients response to it. International Journal of Psychoanalysis. 32, 32-40. O Kelly G. (1998) Countertransference in the nurse-patient relationship: a review of the literature. Journal of Advanced Nursing. 28(2), 391-397. Parahoo K. (2006) Nursing Research Principles, Process and Issues. 2nd edn. Palgrave MacMillian, London. Peplau H.E. (1952) Interpersonal relations in nursing. G.P. Putmans Sons, New York. Rossberg J.I., Karterud S., Pedersen G. & Friis S. (2010) Psychiatric symptoms and countertransference feelings: an empirical investigation. Psychiatry Research. 178, 191-195. Scheick D.M. (2011) Developing self-aware mindfulness to manage

countertransference in the nurse-client relationship: an evaluation and developmental study. Journal of Professional Nursing. 27(2), 114-123.

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Schroder P.J. (1985) Recognising transference and countertransference. Journal of Psychosocial Nursing. 23(2), 21-26. Siegal D.J. (2007) The mindful brain: Reflection and attunement in the cultivation of well being. Norton, New York.

Trinity College Dublin. (2011) 4 Year Nursing Degree Programme (BSc Cur )B.Sc. (Cur.) Psychiatric Nursing. (Internet) Available at: http://www.nursing-midwifery.tcd.ie/undergraduate/pre-registration/udergrad-bsc-curpsyc-modules.php, (Accessed 2 December 2011).

University College Dublin. (2011) DN120 and DN121 Nursing (Psychiatric) (NSS2). (Internet) Available at: https://sisweb.ucd.ie/usis/w_sm_web_inf_viewer_banner.show_major?p_term_code= 201000&p_cao_code=DN120&p_major_code=NSS2, (Accessed 2 December 2011).

Wegner D.M. & Zanakos S. (1994) chronic thought suppression. Journal of Personality. 62, 615-640. Williams M., Teasdale J., Segal Z., & Kabat-Zinn J. (2007) The mindful ways through depression: Freeing yourself from unhappiness. Guilford Press, New York. Williams E.N., Hayes J.A. & Samstag L.W. (2008) Therapist self awareness: inter disciplinary connections and future directions. In Handbook of Counseling Psychology (Brown S.D., Brown S.D. & Lent R.W. Eds), John Wiley and Sons, New Jersey, pp. 303-319.

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Appendix

College Curriculum Outline

College

Managing Countertransference

Reflection

Self awareness

Mindfulness

CYIT NUIG UCC DUC UCD WIT TCD ITT

Unknown Unknown Unknown X X X X X X X X X X X X X

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