Therapists-in-Training Experiences of Working With Transfer Clients: One Relationship Terminates and Another Begins
Cheri L. Marmarosh and Barbara Thompson The George Washington University
Clara Hill The University of Maryland
Suzanne Hollman The Institute of the Psychological Sciences
Monica Megivern The George Washington University
Data from interviews with 12 graduate-level trainees about their experiences of working with clients who had been transferred to them from another therapist were analyzed using consensual qualitative research. Trainees reported a range of helpful and hindering aspects about the transfer experience related to the client (e.g., client had experienced a prior termination and transfer, client had severe character pathol- ogy), the prior therapist (e.g., prior therapist prepared client for transfer, prior therapists did not process their termination with client), themselves (e.g., participant was open to addressing grief, participant was fearful of rejection), supervision (e.g., the supervisor provided important feedback on dealing with loss, the supervisor failed to address the unique nature of transferring), training (e.g., there was not adequate readings on termination and transfer, there was no readings on transfers), and clinic practices (e.g., meeting with the prior therapist and current therapist facilitated process, having clients end treatment with debt hindered the development of the new relationship). Participants also provided recommendations for improving the transfer process. Implications of these findings for clinical practice, training, and research are addressed.
Keywords: transfers, terminations, training clinics, psychotherapy, therapeutic relationship
The literature on termination in psychotherapy often focuses on the ending of a therapy treatment, but it fails to address what happens when one treatment ends and the client is transferred. Transfers occur when therapists can no longer provide the necessary treatment, when therapists move or retire, or when the clinic provides training to therapists who rotate out of the setting. Clients are often transferred from one therapist to another when therapists-in-training leave the clinics at the end of their training year (Penn, 1990; Super, 1982; Wapner, Klein, Friedlander, & Andrasik, 1986). Given that this is the first clinical experience for many of these therapists, difficulties inevitably arise in understanding how to allow the transferred client to grieve the old relationship and establish a new relationship.
In a review of the client perspectives on the transfer process, Keith (1966) developed the term “transfer syndrome” to denote the difficult emotions and behavioral changes experienced by clients who end treatment with one therapist and begin treatment with another. Re- searchers and clinicians described clients’ feelings of abandonment, grief, and loss (Clark, Cole, & Robertson, 2014), anger/rage toward the transferring and new therapist (Penn, 1990), and feelings of unworthiness (Penn, 1990). Attachment theory has been used to understand why clients with anxious attachments experience aban- donment after the ending with a therapist, whereas clients with avoidant attachments detach and resume therapy as if nothing hap- pened (Holmes, 2006).
Clients are not alone in experiencing the transfer syndrome. Some therapists are able to tolerate clients’ experiences of termination and loss, whereas others who had prior personal losses struggle with termination process (Boyer & Hoffman, 1993) and probably with the transfer process. Unfortunately, we have minimal empirical informa- tion to guide us through this important ending and beginning. The purpose of the present study was thus to study the experiences of therapists-in-training with regard to their work with transfer clients who recently experienced the termination of a relationship.
The Impact of Transfers on Clients: Empirical Findings
Much of the transfer research has focused on how the transfer- ring of clients from one therapist to another can impact attrition (Tantam & Klerman, 1979), with some studies reporting a dropout rate as high as 69% after a transfer (Tantam & Klerman, 1979;
Editor’s Note. Mark J. Hilsenroth served as the action editor for this article.—MJH
Cheri L. Marmarosh, Professional Psychology, The George Washington University; Barbara Thompson, Graduate School of Education and Human Development, The George Washington University; Clara Hill, Counseling Psychology, The University of Maryland; Suzanne Hollman, Clinical Psychol- ogy, The Institute of the Psychological Sciences; Monica Megivern, Graduate School of Education and Human Development, The George Washington University.
Correspondence concerning this article should be addressed to Cheri L. Marmarosh, Professional Psychology, The George Washington University, 1922 F Street, Suite 3, Washington, DC 20052. E-mail: cmarmarosh@ gmail.com
Psychotherapy © 2017 American Psychological Association 2017, Vol. 54, No. 1, 102–113 0033-3204/17/$12.00 http://dx.doi.org/10.1037/pst0000095
Wapner et al., 1986). These findings indicate that many clients do not survive a transfer, and it is critical that we try to understand more about what goes on during this process to train clinicians to help prevent premature termination.
Two factors have been identified as relating to transfer success: (a) the length of time in treatment before the transfer, and (b) having had a prior transfer experience (Clark, Robertson, Keen, & Cole, 2011; Wapner et al., 1986). Those who have had a long relationship with a therapist before ending the relationship and transferring to a new therapist, or who had a past transfer experi- ence, were less likely to drop out after the transfer than their counterparts.
In a qualitative study, Clark et al. (2014) interviewed 11 clients about their personal experiences of being transferred at some time during their treatment. Most clients indicated that they felt some anxiety, fear, sadness, and anger about the transfer. They noted that it was helpful when the new therapist and clinic were sup- portive of their reactions and helped them cope with their feelings. Successful transfer clients felt that their new therapists’ compe- tencies and effectiveness facilitated their ability to navigate their transfers. These clients were able to have a positive attitude and form a strong alliance with the new therapist.
The Impact of Transfers on Therapists-in-Training: Empirical Findings
Schen, Raymond, and Notman (2013) asked 23 psychiatric residents to complete a 20-item questionnaire about their experi- ences working with transfer patients in psychotherapy. They found that transferring residents felt guilty, sad, anxious, and even re- lieved to transfer their patients. In contrast, transferred-to residents felt badly about being compared with prior residents, felt over- whelmed when patients were grieving the loss of their prior clinicians, and feared transfer patients’ negative emotions about repeating an intake, rehashing the past, or starting over.
The Schen et al. (2013) study is useful because it exposes some of the challenges of working with transfer clients. Not surprisingly, working with a transfer client can be very stressful for therapists- in-training who have limited experience exploring grief and toler- ating clients’ negative/ambivalent feelings toward them. Because novice therapists are often overwhelmed with their own anxieties about being evaluated and seeing clients for the first time (Hill, Sullivan, Knox, & Schlosser, 2007), they may not be the best candidates for taking on these cases without necessary training and supervision.
Although the Schen et al. (2013) study opened the door to understanding the critical impact of transfers on trainees, it is limited because it is unclear how the researchers developed items for their questionnaire for assessing transfer attitudes, and no psychometric data were reported. To analyze the results, it appears that the authors qualitatively identified major themes by reviewing the responses to the questionnaire, but they did not report any method used to understand these data. In addition, given that the study involved beginning psychiatrists, we do not know if the results would generalize to psychologists and counselors-in- training who have more psychotherapy training.
Purpose of the Current Study
The primary purpose of the current study was to explore how therapists-in-training experienced their work with their first trans- fer clients. We were interested in the topic not only for practical reasons (i.e., how to make the transfer process smoother for therapists and clients) but also for theoretical reasons (i.e., what might account for different client and therapist reactions to the transfer process). We were most interested in what client and therapist characteristics influenced the transfer process, how the experience with transfer clients influenced the identity of begin- ning therapists, and how transfer clients were experienced differ- ently from nontransfer clients. In addition, we wondered about what recommendations therapists-in-training would have for su- pervisors and training clinics where terminations and transfers occur regularly.
We chose to use a consensual qualitative research method (CQR; Hill, 2012; Hill et al., 2005; Hill, Thompson, & Williams, 1997) so that we could learn more in-depth about the topic to help us develop better clinical strategies and design better empirical studies to answer the emerging theoretical questions. CQR is a rigorous approach that allows for an in-depth examination of inner experiences.
Data Set and Description of Clinics and Client Population Served
Participants were therapist trainees from two university-based clinics, both of which served the same urban population. One of the clinics was housed in the Professional Psychology Program (PP clinic) and one was in the School of Education (SE clinic) at the same private Mid-Atlantic U.S. University. Both training clin- ics provided sliding scale, low fee, time-unlimited psychotherapy to diverse clients. When looking at the demographics of the trans- fer clients in this study, four clients were reported by the partici- pants as being African American, six clients were reported as being Caucasian, and two were not known. The racial background was similar between the two clinics. Specifically, in the PP clinic, two of the clients were African American, three were Caucasian, and one did not identify race. In the SE clinic, two clients were African American, three were Caucasian, and one did not identify race. There were more males seen in the SE clinic compared with the PP clinic. Seven clients were male (two in the PP clinic and five in the SE clinic) and five were female (four in the PP clinic and one in the SE clinic).
Similarly, the training clinics both serve a diverse range of clients with diverse presenting concerns. Formal diagnoses of clients were not assessed given the focus was on the trainee’s experience of the transfer, and the clinics did not require formal assessment of diagnoses. We determined the range of client func- tioning from the descriptions of the clients made by the partici- pants. According to the participants, clients ranged from unem- ployed individuals with serious chronic mental illness (six clients with personality disorders, severe depression, and chronic disabil- ity) to higher functioning clients (six clients with relationship issues, depression, anxiety, and/or family difficulties). In the PP clinic, three were described as higher functioning, with depression
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