Transference and countertransference in

communication between doctor and

patient
1. Patricia Hughes and
2. Ian Kerr
+Author Afliations
1. Patricia Hughes is a senior lecturer and consultant in
psychotherapy at St George's Hospital Medical School and
South West London and St George's Mental Health Trust (St
George's Hospital Medical School London SW1! "#$ Tel%
"1&1 !'( (('1)*1+ e,-ail% p.hughes.sgh-s.ac.u/0. She is
interested in teaching -edical students and in -a/ing
psychotherapy understanda1le to psychiatric trainees. 2an
3err is Senior #egistrar in Psychotherapy at and South West
London and St George's Mental Health Trust and the
Henderson Hospital. He is interested in the application o4
cogniti5e6analytic therapy (7AT0 in co--unity -ental health
tea-s and is researching 7AT in the treat-ent o4 antenatal
an8iety.
9The reasona1le -an adapts hi-sel4 to the :orld+ the unreasona1le one
persists in trying to adapt the :orld to hi-sel4; George <ernard
Sha:Maxims for Revolutionists.
Health care is a co-ple8 1usiness. Medical treat-ent could 1e so -uch -ore
relia1le i4 it :ere not co-pro-ised 1y the i-precise and unpredicta1le
nature o4 hu-an -oti5ation. <ut e5en the 1est treat-ent :ill not al:ays 1e
good enough and patients :ho hoped 4or a cure :ill 1e disappointed a4raid
and angry. So-e patients ha5e con4using e8pectations. Although rationally
:e /no: that 1eing ill or ha5ing poor relationships or not 1eing a1le to :or/
is unpleasant so-e people ha5e -i8ed 4eelings a1out losing their
sy-pto-s. Patients are not al:ays grate4ul 4or our honest atte-pts to help
the- and a 4e: e-erge al-ost triu-phant 4ro- a long treat-ent :ith
sy-pto-s intact. =octors cannot escape the 1urden o4 their o:n -oti5ation.
Most o4 us 1elie5e that the a1ility to 4eel 4or our patients is an i-portant
di-ension o4 treat-ent. This co-es at a price% :e ha5e our o:n needs and
desires and the therapeutic relationship is a 4ertile ground :here these -ay
1e played out.

>e8t Section
The therapeutic alliance
A cornerstone o4 treat-ent in -edicine is the therapeutic alliance :here1y
patient and doctor esta1lish a rational agree-ent or contract :hich supports
the treat-ent (Greenson 1?&(0. So the patient :ith a sore throat has the
rational e8pectation that the doctor is appropriately @ualiAed :ill do a
suita1le e8a-ination and in5estigation and :ill prescri1e rele5ant
treat-ent. The doctor e8pects that the patient :ho has sought treat-ent :ill
generally do his or her 1est to co-ply :ith the treat-ent re@uire-ents such
as collecting a prescription and ta/ing the prescri1ed -edication.
The therapeutic alliance in this transaction has a good chance o4 sur5i5al%
the negotiation is straight4or:ard and there is unli/ely to 1e a co5ert agenda.
Ho:e5er as the patient's needs 1eco-e -ore co-ple8 the therapeutic
alliance -ay 1e distorted 1y the :ishes and e8pectations o4 the patient and
e5en occasionally the doctor. These -ay 1e 4ully conscious and e8plicit or
-ay not 1e entirely conscious and so 1e co--unicated in a non,direct :ay
(<alint 1?(!0 (see <o8 1B0.
Box 1.
The therapeutic alliance
There are three parts to the therapeutic relationship: the
therapeutic alliance, the transference and the countertransference
The therapeutic alliance is the rational (iplicit! contract "et#een
doctor and patient
The contract a$ "e straightfor#ard #ith utual cooperation
The contract a$ "e coplicated "$ a co%ert agenda: the patient&s
unconscious and unspo'en #ishes and needs (the transference!
Pre5ious Section >e8t Section
The covert agenda
We need and :ant a 5ariety o4 relationships throughout our li4e. Although
this pri-ary need is 1iologically deter-ined 1y genes that pro-ote sur5i5al
o4 the species the precise nature o4 the relationships :e see/ is hea5ily
inCuenced 1y our pre5ious e8perience. Dor e8a-ple attach-ent research
has conclusi5ely de-onstrated the eEect o4 a parent's attitude to
attach-ent on the in4ant's su1se@uent 1eha5iour :ith hi- or her (Donagy et
al 1??10 and a child's secure or insecure e8perience in in4ancy is highly
predicti5e o4 the @uality o4 later relationships :ith people other than the
parents (Srou4e 1?&*0.
So in ne: situations :e ha5e e8pectations that are partly deter-ined 1y our
realistic perceptions thoughts and 4eelings a1out the present and partly 1y
associated e8periences :e ha5e had in the past (Hughes 1???0. Most people
can usually e5aluate the e8pectation against the reality o4 the present and
adFust e8pectations accordingly. Ho:e5er in so-e circu-stances such as
:hen :e are highly an8ious this appears to 1e -ore difcult and :e -ay
cling de4ensi5ely to our preconceptions. 2n addition so-e people ha5e
ha1itual difculty in adFusting their inner :orld to -atch their perceptions in
the present. This is characteristic o4 so-e -ore rigid /inds o4 personality
including people :ith 1orderline personality 4eatures :here the person o4ten
has difculty in distinguishing :hat is e8pected 4ro- the internal -odel and
:hat is percei5ed in the e8ternal :orld (3ern1erg 1??G0.
Pre5ious Section >e8t Section
The place of projective mechanisms
We tend to see :hat :e e8pect to see (A1ercro-1ie 1?&?0. >ot only that
1ut :e -ay 1eha5e to:ards other people as though they are the people :e
e8pect the- to 1e. 2n the process :e gi5e su1tle non,e8plicit -essages
a1out :hat part they are playing and the other people are co5ertly in5ited
to adopt the role or 1eha5iour that is e8pected (Sandler 1?!H+ #yle 1??&0.
We proFect an e8isting -ental -odel on to the present and -ay then 1eha5e
in a :ay that is appropriate 4or the internal -odel 1ut that -ay 1e
inappropriate to the reality o4 the present e8ternal :orld.
Pre5ious Section >e8t Section
Unconscious expectations and transference
=r <reuer's alar-ing e8perience o4 1eing the o1Fect o4 Anna I's intense
aEection cannot ha5e 1een the Arst and certainly :as not the last ti-e a
patient 4ell in lo5e :ith his or her doctor (<reuer J Dreud 1&?(0. The
diEerence in <reuer's case :as the use to :hich Sig-und Dreud put the
e5ent. #ather than accepting it as one o4 those un4ortunate things that
happens to doctors he thought a1out :hat it -eant and persuaded a sha/en
and reluctant <reuer to colla1orate :ith hi- on a theoretical paper and a
1oo/. Studies on Hysteriadiscusses the pheno-enon in :hich a patient
strays 4ro- strictly pro4essional 4eelings to:ards the analyst and allo:s
personal 4eelings to intrude into the therapy. These patients had tended to
9trans4er on to the Agure o4 the physician; distressing ideas that arose 4ro-
the content o4 the analysis. These patients said Dreud had -ade a 94alse
connection; on to the analyst. Dreud Arst actually used the ter-
Ktrans4erenceL in relation to his patient =ora :hen he 1elatedly recognised
the arousal o4 4eelings to:ards hi-sel4 that related to her lo5er 6 :hich led to
=ora's a1rupt :ithdra:al 4ro- treat-ent and a therapeutic 4ailure (Dreud
1?"(0.
Pre5ious Section >e8t Section
Transference
Definition
Transference is the pheno-enon :here1y :e unconsciously trans4er 4eelings
and attitudes 4ro- a person or situation in the past on to a person or
situation in the present. The process is at least partly inappropriate to the
present (see <o8 'B0.
Box 2.
Transference
Transference is unconscious
It is at least partl$ inappropriate to the present
It is the transferring of a relationship,nota person
(nl$ an aspect of a relationship, not the entire relationship, is
transferred
Points to note
1. The process o4 trans4erence is not conscious and the patient
un:ittingly proFects a needed aspect o4 a pre5iously e8perienced
or :ished,4or relationship on to the doctor (see <o8 *B0. <ecause
it is a relationship that is 9trans4erred; the patient and doctor are
e8pected to ta/e co-ple-entary roles. So a patient :ho is a4raid
that he or she is seriously ill -ay adopt a helpless child,li/e role
and proFect an o-nipotent parent,li/e @uality on to the doctor
:ho is then e8pected to pro5ide a solution.
Box ).
Pro*ection and transference
Transference in%ol%es the pro*ection of a ental
representation of pre%ious experience on to the present
(ther people are treated as though the$ are pla$ing the
copleentar$ role needed for the pro*ected relationship
There are su"tle (unconscious! "eha%ioural +nudges, to
ta'e on these feelings and "eha%iours
'. A relationship o4 the co-ple8ity o4 say a -other and son is not
li/ely to 1e 4ully re,enacted. More li/ely is that some aspect o4 the
relationship is played out in the trans4erence 6 4or e8a-ple a
-other :ho sorts things out :hen her son is helpless or a -other
:ho criticises ho:e5er hard he tries.
*. The person proFected in the trans4erence relationship -ay not 1e
historically accurate 1ut is the current mental representation o4 a
pre5iously e8perienced relationship. This is li/ely to 1e a -i8ture
o4 the real historical relationship the child's interpretation o4 this
at the ti-e and perhaps so-e re5ision -ade since the original
-odel :as laid do:n.
G. The trans4erence proFection -ay 1e considered
a communication o4 a patient's needs that cannot 1e 5er1ally
e8pressed 1ut that is instead enacted.
Trans4erence is part o4 the :ay :e relate to each other inside and outside
psychotherapy psychiatry and -edicine and :e ha5e to -anage it as 1est
:e can. Much o4 the ti-e it is si-ply a part o4 the co-ple8ity o4 any
relationship and is not a pro1le- 4or either party. Dor e8a-ple a Funior
-e-1er o4 staE -ay ad-ire a senior colleague and unconsciously -odel his
or her pro4essional 1eha5iour on his or her senior. Strictly spea/ing this
-ight 1e considered to include an ele-ent o4 trans4erence% the Funior -ay
need a parental Agure to idealise. This -ay 1e help4ul in the short ter- and
in the long ter- is li/ely to resol5e as he or she gains conAdence and status.
There is no reason to interpret the 1eha5iour and :e generally regard this as
a nor-al part o4 the process o4 training. In the other hand i4 this particular
ad-iration leads the Funior to denigrate other seniors or to adhere rigidly to
one approach it is unhealthy and the trainers :ould :ish to discourage it.
Si-ilarly in a therapeutic relationship the patient -ay sho: so-e -ildly
inappropriate 4eelings 6 either positi5e or negati5e 6 :hich do not seriously
inter4ere :ith treat-ent. Although these -ay 1e trans4erence 4eelings i4
they do not i-pair treat-ent then there is no need to challenge the- 1y
interpretation nor to change the treat-ent approach. At other ti-es the
patient's inappropriate 4eelings and 1eha5iours -ay do-inate the
relationship and i-pede the :or/ to 1e done. To the e8tent that trans4erence
4eelings represent an unconscious agenda 4or the patient it is use4ul 4or staE
to recognise it as 4ar as possi1le so that an understanding o4 :hat the
patient :ants or e8pects can 1e used in planning clinical -anage-ent.
=escri1ing this interpretation to the patient is not al:ays use4ul (see 1elo:0.
Perception and misinterpretation
Trans4erence is pro-oted 1y unconscious e8pectations and :hat :e percei5e
:ill 1e coloured 1y our e8pectations. Thus distortions -ay ta/e place in the
patient's understanding o4 an interaction.
An in,patient has 1eco-e 5ery attached to the senior house ofcer (SHI0
:ho has 1een seeing her :ee/ly. She tells hi- that she 4eels 5ery depressed
1ecause people do not li/e her :hen they get to /no: her. He says that
perhaps she 4eels that :ay a1out hi- also and she agrees. He assures her
that he really does li/e her. To his dis-ay he then hears 4ro- the nurses that
she has told another patient that he K4anciesL her.
What is not transference?
7rying Ktrans4erenceML can 1eco-e the de4ence o4 the doctor (or other health
care :or/er0 against a patient's FustiAa1le 4eelings to:ards the tea- or a
-e-1er o4 it. >ot all 4eelings that a patient has to:ards his or her therapist
are trans4erence 4eelings. Dor e8a-ple a patient's hostility or anger -ay 1e
an appropriate response to his or her situation. 24 the doctor or the tea- is
regularly late insensiti5e or inconsistent then the patient -ay reasona1ly 1e
angry or disappointed. Ir i4 the patient is a:are that a tea- -e-1er has
put a lot o4 :or/ into the treat-ent he or she -ay 1e grate4ul and 4eel real
:ar-th to:ards this /ey:or/er. These appropriate 4eelings do not constitute
trans4erence.
So-e patients are especially sensiti5e to 4ailures in care so there -ay 1e an
ele-ent o4 trans4erence coe8isting :ith FustiAa1le anger or disappoint-ent.
The -ost appropriate :ay to deal :ith this is 4or the doctor to ac/no:ledge
his or her lateness inconsistency etc. apologise and i4 rele5ant e8plore
:hy it is especially difcult 4or this patient.
$@ually a patient -ay ha5e real and appropriate aEection -i8ed :ith
idealisation and a :ish 4or an inti-ate relationship. 2nterpretation -ay not 1e
appropriate as it -ay hu-iliate the patient and da-age the positi5e aspects
o4 their :or/ing relationship. 2nstead the therapist should recognise the
patient's 4eelings and treat hi- or her :ith respect continuing care 1ut
-aintaining a strict attention to 1oundaries so that the patient is not
encouraged to 4eel that his or her aEection is reciprocated or that his or her
4antasies ha5e a place in reality.
Factors that increase transference
Three things can pro-ote trans4erence% the situation o4 1eing in need and
dependent on the doctor or tea-+ the setting o4 a relationship :here
dependency needs are recognised and -et+ and particular types o4
personality :here the internal :orld is co-pellingly proFected on to the
present (see <o8 GB0.
Box -.
.actors that increase transference
/ulnera"le personalit$, especiall$ people #ith "orderline features,
#ho a$ rigidl$ pro*ect their expectations on to the present
The patient&s anxiet$ a"out his or her ph$sical or ps$chological
safet$ (e.g. #hen sic' and afraid!
.re0uent contact #ith a ser%ice or #ith a 'e$#or'er
Situation
Situations in :hich a person is relati5ely helpless or a4raid :ill increase his or
her need o4 a protecti5e relationship. Since this applies to -ost patients in
the care o4 a psychiatric tea- :e should e8pect there to 1e a trans4erence
ele-ent to -ost treat-ents. Ho:e5er the ter- Kprotecti5eL does not do
Fustice to the co-ple8ity o4 such a relationship. A person -ay long 4or
inti-acy 1ut also 4ear it 1e intensely dependent 1ut hate his or her
dependency 1eco-e deeply attached 1ut una1le to trust the o1Fect o4 his or
her attach-ent.
Setting
Any therapeutic setting :here a person is seen 4re@uently (and so-eti-es
e5en in4re@uently0 and his or her e-otional needs attended to pro-otes
trans4erence. The patient -ay de5elop a trans4erence relationship :ith a
person :ith a tea- or e5en :ith an institution. Dre@uent changes o4
/ey:or/er are unli/ely to a5oid the de5elop-ent o4 trans4erence 4eelings 1ut
-ay displace the- to the institution :hich -ay 1e e8perienced as an
unpredicta1le and 4rustrating other. A relationship :here the patient 4eels
recognised and understood i-pro5es cooperation+ repeated changes o4
therapist are li/ely to i-pair it.
Personality
A person :ho has little capacity to reCect on his or her o:n state o4 -ind
4eelings and needs is 5ulnera1le to acting upon 4eelings rather than
reCecting or discussing :hat he or she :ants.
24 the patient has a 5ulnera1le personality is ill and a4raid and has the
attention o4 a /ey:or/er or tea- he or she is there4ore especially li/ely to
de5elop trans4erence 4eelings to:ards one or -ore people.
Pre5ious Section >e8t Section
Managing transference
2n dyna-ic psychotherapy one o4 the ai-s o4 therapy is to Kresol5e the
trans4erenceL that is to help the patient recognise and -anage the
unconscious 4eelings and e8pectations :hich he or she 1rings to ne:
relationships. The patient has to 1e a1le to -o5e 4ro- a less reCecti5e to a
-ore reCecti5e state o4 -ind :here he or she can 1ring thought to 1ear on
his or her 4eelings rather than enacting his or her e8pectations. >ot all
psychiatric patients :ill 1e a1le to do this% so-e :ill 4eel puNNled
-isunderstood hu-iliated or o5er,e8cited i4 their 4eelings and 1eha5iours
are interpreted in ter-s o4 underlying :ishes and needs. I4ten the
psychiatrist and the tea- ha5e to -anage the trans4erence relationship
:ithout e8plicit interpretation o4 the trans4erence.
When the patient is una1le to understand and use interpretation then
-anage-ent should include recognition o4 his or her 4eelings to:ards the
/ey:or/er and tea- :ith strategies intended to pro-ote a secure and
cal-ing relationship. 24 the patient cannot al:ays recognise the pro4essional
nature o4 the relationship it is i-portant that the therapist and tea- can
hold on to it. The patient should 4eel KheldL :ithout 1eing o5er,sti-ulated
that is he or she should 4eel that so-eone recognises his or her pro1le-s
and 4eelings and is concerned and that the :or/ing relationship is
reasona1ly sta1le and predicta1le (see <o8 (B0.
Box 1.
2anaging transference
3ecognising the iportance of the relationship to the patient
3elia"ilit$
2aintaining professional "oundaries and clear liits in treatent
Interpretation, "ut onl$ #hen the patient can understand and use it
ecognition of the importance of the relationship
2t is essential that the doctor)/ey:or/er recognises that this relationship is
i-portant to the patient (see <o8 HB0. Dor the doctor it -ay 1e a routine
part o4 the :ee/'s :or/ and he or she -ust constantly 1e a:are that the
relationship is s/e: and that the patient's e-otional needs al-ost ine5ita1ly
go 1eyond the rational contract o4 the therapeutic alliance.
Box 4.
5h$ recognise transference in general ps$chiatr$6
7upports sta8 "$ helping the understand #hat is going on in the
relationship #ith the patients, so reducing anxiet$ and o%er9
responsi"ilit$
Ipro%es patient anageent "$ recognising #ishes that are not
clearl$ articulated
:nticipates pro"le areas for patients and so ore appropriate
therapeutic pro%ision
Helps a%oid sta8 acting9out and ipro%es "oundar$ aintenance
Mr A has long,standing personality pro1le-s and is ad-itted to a psychiatric
:ard a4ter ta/ing a li4e,threatening o5erdose. He is seen :ee/ly 1y =r < SHI
on the :ard and rapidly co-es to 4eel that she is so-eone he can trust. =r <
goes on holiday :ithout :arning hi- and he ta/es another o5erdose.
eliabilit!
$sta1lishing a relationship :ith a dependent patient is a necessary part o4
treat-ent and the ine5ita1le trans4erence -ust 1e sensiti5ely handled. 24 the
doctor or /ey:or/er is unrelia1le this :ill not lessen the trans4erence 1ut :ill
co-plicate it. Ma/ing and /eeping appoint-ents is pro4essional and is
cal-ing 4or the patient. Onrelia1ility increases an8iety and apart 4ro- the
discourtesy to the patient is li/ely to intensi4y insecurity increase patient
hostility and under-ine the therapeutic alliance and patient co-pliance.
A senior nurse :as as/ed to ta/e o5er a :ard 4or patients :ith personality
disorder :here there had 1een a high rate o4 Kunto:ard incidentsL. He :as
shoc/ed to And that there :as no 4oru- 4or diEerent disciplines to -eet no
agreed clinical -anage-ent rules and that KpsychotherapyL appoint-ents
:ere -ade on a casual 1asis and 4re@uently changed at short notice. He
esta1lished a strict syste- o4 rules 4or the :ard and the unto:ard incident
rate dropped su1stantially.
"ttention to boundaries
The pro4essional 1oundaries o4 the doctor6patient relationship pro5ide the
structure :ithin :hich treat-ent can ta/e place. This includes -onitoring
and setting li-its on 1oth the patient's and the doctor's 1eha5iour. So-e
patients long 4or a personal relationship :ith the doctor or /ey:or/er and
there -ay 1e pressure to pro5ide the responses o4 a 4riend rather than a
pro4essional.
Ms 7 :as an articulate and engaging patient :ho pleaded that her therapist
sho: his care 4or her :ith a physical gesture not Fust :ith :ords. The
therapist :as -o5ed 1y her distress and se5eral ti-es held her :hen she
:as so11ing during a session. Ms 7 4ound these occasions deeply satis4ying
and hoped that this :ould lead to a 4riendship. When therapy ended she 4elt
hurt and hu-iliated that the therapist could lea5e her.
Transference in reverse
P%What's the diEerence 1et:een God and a doctorQ
A% God doesn't thin/ he's a doctor.
24 trans4erence o4 e8pectations 4ro- pre5ious relationships can happen in all
relationships :e should e8pect it to aEect doctors too. We all /no: doctors
:ho apparently thin/ they are God and e8pect patients and Funior staE to
4ulAl the corresponding role. We also /no: doctors :ho are co-pulsi5e
-others or :ho are a4raid o4 patients' de-ands or :ho are e8cited 1y high,
ris/ treat-ents. Aside 4ro- these e8tre-e e8a-ples :e each ha5e
situations in our :or/ that :ill trigger unthin/ing reaction at the e8pense o4
thought4ul response and -anage-ent.
>aturally :e :ant to recognise our o:n preconceptions and 4oi1les so that
:e do not i-pose the- too -uch on relati5ely helpless patients (or e5en
colleagues0. Honest discussion :ith tea- -e-1ers can 1e a help 6 so can
the training e8perience o4 super5ised psychotherapy :here our o:n
assu-ptions can 1e re5ie:ed. So-e psychiatrists ha5e personal therapy to
e8plore attitudes and 1elie4s that are not entirely conscious.
Pre5ious Section >e8t Section
#ountertransference
Definition
7ountertrans4erence is the response that is elicited in the recipient
(therapist0 1y the other's (patient's0 unconscious trans4erence
co--unications (see <o8 !B0. 7ountertrans4erence response includes 1oth
4eelings and associated thoughts. When trans4erence 4eelings are not an
i-portant part o4 the therapeutic relationship there can o15iously 1e no
countertrans4erence.
Box ;.
<ountertransference
Includes the feelings e%o'ed in the doctor "$ the patient&s
transference pro*ections
These can "e a useful guide to the patient&s expectations of
relationships
The$ are easier to identif$ if the$ are not congruent #ith the
doctor&s personalit$ and expectation of his or her role
:#areness of the transference=countertransference relationship
allo#s re>ection and thoughtful response rather than unthin'ing
reaction fro the doctor
The degree to :hich the proFected role is congruent :ith so-e aspect o4 the
personality o4 the recipient :ill aEect the li/elihood o4 his or her adopting it.
1. (a0 A proFected role -ay 1e 5ery diEerent 4ro- any aspect o4 his
or her personality and the recipient is a1le to recognise that this
perception o4 his or 4eelings or 1eha5iour is a product o4 the
patient's -ind.
Mr = :as a young -an :ith a long history o4 unsta1le
relationships depressi5e episodes and alcohol -isuse attending a
day hospital. He :as o4ten hostile to his /ey:or/er :ho- he
accused o4 not caring :hether he li5ed or died. The /ey:or/er
:as an e8perienced co--unity psychiatric nurse and :as
conAdent that she :as neither negligent nor uncaring a1out her
patient. She :as a:are that Mr = proFected a scenario in :hich he
:as neglected and at ris/ :hile she :as e8perienced as a callous
uncaring parent. Her recognition o4 this trans4erence allo:ed her
to re-ain cal- and supporti5e and not to retaliate.
'. (10 A role -ay 1e congruent :ith an aspect o4 the therapist's
personality and he or she -ay unconsciously accept and collude
:ith the proFection.
Ms $ had a long history o4 repeated treat-ent episodes 4or eating
disorder depression and relationship pro1le-s. Dollo:ing a -o5e
to uni5ersity the uni5ersity general practitioner re4erred her to
the local psychiatric ser5ice 4or treat-ent. She conAded in the
young SHI that he :as the Arst doctor to :ho- she had 1een
a1le to tal/ 4reely and that she had told hi- things she had ne5er
told pre5ious doctors. The doctor enFoyed this idealisation and
accepted that he had a special relationship :ith the patient. (See
also 9Trans4erence in re5erse; a1o5e.0
Patients who do not get better
Patients :ho appear to ha5e 1ypassed the rational therapeutic contract and
:ho resist reco5ery o5er a long period o4 ti-e despite getting good
con5entional treat-ent -ay 1e a particular source o4 4rustration. So-e
4ran/ly :ant a si-ple contact relationship :ith the doctor and ha5e no
interest in treat-ent or cure. 24 the doctor gets angry and reFecting it is li/ely
to increase the patient's an8iety and intensi4y his or her de-ands or cause
the- to go to a colleague. Most doctors or tea-s resol5e this pro1le- :ith
li-ited 1ut relia1le non,inter5entionist contact.
Ms D :as a (",year,old :o-an :ho had -any depressi5e episodes and
so-atic co-plaints throughout her li4e. She :as a 4re@uent attender at her
general practitioner's (GP's0 surgery. The GP 4ound that a 1(,-inute -onthly
appoint-ent /ept her relati5ely :ell and that her de-ands did not escalate.
So-e patients ha5e a -ore destructi5e agenda :ith a :ish to engage the
doctor in a therapeutic endea5our :ith the ulti-ate ai- o4 pro5ing that he or
she the patient is untreata1le. This interaction re@uires a help4ul person
:ho /eeps trying. Such patients -ay lea5e a string o4 4ailed therapists in
their :a/e.
Mr G is a -an o4 *" :ho li5es :ith his parents and despite high intelligence
:or/s in a lo:,paid clerical Fo1. He has had -any treat-ents 4or depression
and 9ina1ility to sort RhisS li4e out;. Whate5er is ad5ised and :hate5er
interpretations -ade he returns to the ne8t session to e8plain :hy any
change has 1een i-possi1le. At the end o4 his -ost recent 4ailed therapy he
says sy-pathetically 92 don't :ant you to 4eel 1ad doctor 2'5e de4eated A5e
therapists 1e4ore you;.
eaction and reflection
#eaction -ight 1e called therapist acting,out. 2t happens :hen :e either
play the role unconsciously gi5en to us 1y the patient or :hen :e are a:are
o4 not 1eing seen as :e are and respond :ith an8iety or anger. Much o4 the
ti-e :e ha5e to tolerate not understanding :hat is going on :ithout
panic/ing. We should not 1e pro5o/ed into precipitate and pre-ature action
si-ply to reduce our o:n an8iety.
2n the :ee/ly :ard round the consultant sees that a patient :ith personality
disorder has 1een an in,patient 4or si8 :ee/s. He 4eels that the patient is
e8ploiting the ser5ice. He says angrily that the patient is getting dependent
and -ust 1e discharged 1y the end o4 the :ee/. (See also KTrans4erence in
re5erseL a1o5e.0
#eCection de-ands a reasona1le le5el o4 a:areness o4 one's o:n thoughts
and 4eelings and a sound grasp o4 :hether these de5iate 4ro- good
pro4essional 1eha5iour. Good practice includes%
a @uestioning attitude to:ards one's o:n 4eelings and -oti5es
recognition that :e all ha5e K1lind spotsL
an understanding that staE are aEected 1y patients
an understanding that patients are aEected 1y staE 1eha5iour
a recognition that patients o4ten ha5e strong 4eelings to:ards staE.
Dealing with countertransference
Wor/ing :ith people :ho ha5e psychotic or chaotic -ental states can 1e
stress4ul. Such patients ha5e a po:er4ul a1ility to proFect pain4ul states o4
-ind into the people :ho treat the-. We -ay 4eel con4used despairing
angry or e5en -urderous. This /ind o4 stress can contri1ute to lo: -orale
and 1urn,out and it is i-portant that :e And :ays to deal :ith it. Ose4ul
strategies include%
reCection% see a1o5e
using the tea- to clari4y :hat a difcult patient proFects into the
treat-ent relationship 6 o4ten se5eral -e-1ers o4 the group can
contri1ute to an understanding o4 the patient's trans4erence to
the tea- or to indi5iduals (3err 1???0
using a specialist psychotherapist to help understand :hat the
patient is unconsciously co--unicating in his or her 1eha5iour
undergoing personal therapy to 1eco-e -ore a:are o4 one's o:n
unconscious needs and 4ears.
Pre5ious Section >e8t Section
#onclusion
An understanding o4 trans4erence and countertrans4erence is essential to
good practice in general psychiatry and -ay 1e help4ul in general -edical
practice especially general practice. <eing a:are o4 the hidden agenda in
the clinical relationship :ill help the doctor recognise so-e o4 the patient's
:ishes and 4ears :hich are not 4ully conscious and :hich can contri1ute to
conCict or intense dependency. The doctor is then -ore li/ely to 1e a1le to
stand 1ac/ a little 4ro- the patient's e-otional de-ands and a5oid getting
caught up in an agenda :here he or she too reacts e-otionally rather than
thought4ully. This is therapeutic 1oth 4or the patient :hose clinical
-anage-ent :ill 1e in4or-ed 1y a greater understanding o4 his or her needs
and -oti5es and 4or the doctor :ho is less 5ulnera1le to 1eing e8hausted
1y unrecognised and intrusi5e proFections.
Pre5ious Section >e8t Section
Multiple choice $uestions
1. Trans4erence%
1. is an unconscious process
'. is al:ays related to a pre5ious parental relationship
*. is usually inappropriate to the present
G. is o4ten part o4 relationships outside psychiatry.
'. Trans4erence%
1. is al:ays da-aging to the doctor6patient relationship
'. should al:ays 1e interpreted to the ptient
*. is o4ten intense in patients :ith 1orderline personality
disorder
G. can 1e a5oided 1y 4re@uent change o4 therapists.
*. Dactors that are i-portant in dealing help4ully :ith the
trans4erence relationship include%
1. relia1ility o4 the doctor or /ey:or/er
'. attention to 1oundaries in the relationship
*. recognising the i-portance o4 the relationship to the
patient
G. discharging the patient @uic/ly to a5oid dependency.
G. #ecognising trans4erence in the therapeutic relationship%
1. increases the :or/load o4 the /ey:or/er
'. supports staE 1y helping the- understand :hat is going
on
*. encourages dependency in difcult patients
G. anticipates pro1le- areas 4or patients.
(. 7ountertrans4erence 4eelings%
1. -ay 1e stress4ul 4or the doctor
'. can 1e a use4ul tool in understanding the patient
*. should 1e interpreted to the patient
G. -ay 1e clariAed 1y tea- discussion.
Pre5ious Section
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