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| Transference and Countertransference? Schonhoff Gardens, Austria |
There are few topics as salient to the beginning psychiatry practitioner as that of countertransference. Many questions without clear-cut answers arise: What if I don’t like my patient? How emotionally involved is it appropriate to be with a patient? Can I cry with them? Laugh with them? Hug them? As a beginning practitioner, I am still finding answers to these questions and am starting to learn that where someone sets their own personal professional boundaries is as much a product of the practitioner as the particular therapeutic relationship that practitioner has with a patient. For example, you might find yourself touching a depressed patient on the arm who begins crying while they are telling a particularly poignant and heartfelt story while you would never dream of doing that with a hyper-sexualized borderline patient, no-matter how emotionally difficult the issue.
What exactly is countertransference?
Merriam-Webster defines countertransference as:
psychological transference especially
by a psychotherapist during the course of treatment; especially : the
psychotherapist's reactions to the patient's transference.1
But it is perhaps the secondary
definition of countertransference that is more instructive:
the complex of feelings of a
psychotherapist toward the patient. 1
How we define, describe, and, in fact,
view countertransference has undergone many epochal shifts over the last two centuries since Freud first
set up a couch in Vienna. Freud, as the first psychoanalyst, was indeed
also the first practitioner to struggle with the idea of countertransference.
In Freud’s own writings, as well as all of the early literature on
psychoanalytic theory, countertransference was seen as fundamentally the
product of a weakness in the practitioner. It was described as primarily
his or her unconscious emotional reaction to a patient and seen as
fundamentally arising from the practitioner. The role of the patient in
this emotional exchange was believed to be immaterial. 2
Current views on countertransference
are more generous. Countertransference is no longer seen as simply a deficiency in a practitioner
who needs to exercise more control in reining in his or her feelings, and it is
no longer seen as inevitably detrimental to the therapeutic process.
Countertransference is now viewed as the product of both the practitioner
and the patient. Given this particular
combination of patient and practitioner, countertransference can be primarily
patient-driven, therapist-originated, or interactive. Moreover, and
perhaps more importantly, countertransference is no longer viewed as inevitably
detrimental, and there is increasing recognition that countertransference can
lead to invaluable patient insights.
While these complex and shifting views of countertransference are
instructive in their own right, they do not really address the fundamental
questions facing all new psychiatric practitioners: What do I do in these
situations, and how do I ensure that I maintain professional boundaries while
responding appropriately? Though much has been written on the
origin of countertransference, comparatively little exists in the literature
about what to actually do when you encounter specific instances of countertransference.
This dearth of published literature on these topics perhaps reflects the
discomfort that practitioners themselves feel in these emotionally charged situations,
and, indeed, countertransference, as the definition reflects, is an unconscious
process that can often result from the unexpressed desires or needs of the
therapist, perhaps leading to under-recognition or embarrassment.
The first step in effectively dealing
with countertransference is, of course, to recognize it. By transforming
the therapist’s reaction from an unconscious reaction to a state of
conscious awareness, the practitioner similarly transforms countertransference
from a state of ineffective, non-therapeutic emotionality into a useful tool
that can potentially lead to greater understanding of your therapeutic style
and your patient. Patient-driven countertransference in particular can
lead to further useful diagnostic information and help a practitioner better
understand a patient’s unstated motivations and needs. A good model for
how to systematically think through a countertransference reaction was proposed
by Dr. Steven Reidbord in Psychology Today. Dr. Reidbord suggests
that, when a practitioner becomes aware
that they are experiencing a countertransference reaction, they characterize
the reaction by considering the following four aspects:
(1) Is this feeling characteristic,
i.e., does the resident have it much of the time? If so, it may say a lot about
the resident, but probably nothing about his or her patient.
(2) Is the feeling triggered by
something unrelated to the patient? Feelings caused by hunger,
one's personal life, bureaucracy in the medical center, and so forth are not
useful data for helping the patient.
(3) Is the feeling related to the
patient in an obvious way? Feeling put off by a patient who is screaming
obscenities and viciously destroying the office is countertransference of a
sort, but not very illuminating. And finally,
(4) Is the feeling uncharacteristic of
the therapist, a reaction to one particular patient, and yet the exact trigger
is not immediately obvious? These are the most helpful feelings to notice in
oneself, as they often shed light on subtle yet important dynamics in the
patient.”4
By thinking through your reactions
towards a patient with this systematic characterization of a feeling, a
beginning therapist can not only
begin to identify their own pitfalls as a practitioner, but also, and
more importantly, “[countertransference]
examination sharpens the therapist’s sensitivities and contributes to
improved therapeutic outcomes.”2
What if I don’t like my patient?
Not “liking” a patient is, of course, a very broad and ill-defined
feeling, and there will be many and multifarious ways that this could be
expressed in different patient-practitioner relationships. Unfortunately, and
perhaps inevitably, not liking a patient is all too common in psychiatry.
Many of our patients are referred to us for that very reason,
because they are embroiled in conflict, refusing to conform to societally
established norms of behaviors, essentially because they are “unlikable.”
As with all countertransference examples, it is important to go through
Dr. Reidbord’s four steps of characterizing the response and bringing it into
conscious awareness. Once
you’ve consciously identified your negative reaction to the patient and examined
the underlying reason, you can then determine if this is an example of
countertransference that would be useful to further explore with the patient or
an instance where applying your own mature coping strategies might better serve
you. This has been elegantly stated by Dr. Beitman and Dr. Yue in their
text Learning Psychotherapy:
Patient-originated countertransference
provides the therapist with an opportunity to experience the kinds of feelings,
thoughts, and behaviors that the patient arouses in others during his
real-world interactions. This understanding can be used to teach the
patient how he affects the therapist and the other people in his family,
social, and career networks. 2
Regardless of the source of the
countertransference, it is important to recognize and resolve the
countertransference so that it does not interfere with the therapeutic process.
One of the more difficult situations is
that in which a patient is not just unlikable, but is actually directly
hostile. How exactly does one go about addressing not just a patient’s
negative affect, but directed aggression? Dr. Markowitz and Dr. Milrod
have postulated a direct approach where one “must recognize what is happening,
abide the affect, understand it in context, and address it.”3 A directed
approach towards directed aggression allows the therapist to diffuse a potentially
volatile situation while potentially furthering self-reflection and awareness
in the patient.
Still, there are exceptions when
addressing a negative affect must, by necessity, be postponed. One such example is when a
patient is not in an emotionally-ready state to confront such an unpleasant
truth about themselves. Essentially this is the art of “waiting until the
patient is ready to hear and possibly accept the intervention.”2
How emotionally involved is it
appropriate to be with a patient?
Some emotional attachment is essential
to the establishment of a successful,
working relationship and therapeutic alliance with a patient. A therapist
who remains unemotional and disengaged will ultimately be ineffective in
engaging the patient’s own agency in their therapy.
In fact, attachment theory has been
used to strengthen the therapist-patient bond in order to promote just such an
optimal working alliance.
Given that the therapeutic relationship
appears to have a strong influence on the outcome of therapy, attachment theory
can also assist the clinician in understanding and concentrating on those
aspects of relationships most likely to promote a strong working alliance in
accordance with a client’s relational style.5
However,
using attachment to promote a therapeutic alliance with a patient poses a
particular danger in child psychiatry, where disorganized attachment patterns
might lead to transference. While “some transference-countertransference
components may be helpful in establishing a working alliance, good rapport in
the real relationship is exaggerated, inappropriate, and excessive, it may
become countertransference...”2 So even if a positive transference appears to
be promoting patient progress, the clinician must always remain guarded for
transference or countertransference that reaches a level where objectivity and
efficacy of the therapist are negatively impacted. Particular scenarios
the new clinician should be wary of include excess in any of the following: looking forward to seeing the
patient, excessively over-identifying with the patient, or being impressed with
the patient.2 While it might be normal to look forward to a pleasant patient who is making progress, if the level of anticipation begins to approach what one would normally feel looking forward to seeing a friend or family member that would qualify as excess and require examination. Similarly, identification and being impressed with patients can happen during the course of therapy, but it is important to be aware of the intensity of these emotions and guard against excess that can impair efficacy of the therapeutic relationship. Transference can also result from a
poorly regulated patient-therapist relationship, which can equally threaten the
therapeutic alliance. Some examples of excessive attachment and transference include:
the patient asking for special privileges, exceptions to payment, hugs, asking
to see the therapist socially, or sending gifts.2
Can I cry with them?
In a word, “yes.” Or at least if
you do, you’re not alone. In a recently administered questionnaire about
therapists crying in therapy (TCIT), 72% of respondents reported having cried
with their patients.6
Despite these impressive numbers, no clear consensus exists in the
psychiatric community about the appropriateness of crying. In fact, it is
conspicuously absent from most literature on countertransference and
patient-therapist emotional attachment interactions. Perhaps surprisingly,
screening tools administered concurrently with the questionnaire about TCIT
found no association between empathy, gender, or crying in daily life, but
instead found that years of experience and therapy style were the two major
predictors of whether a therapist had ever been moved to tears as part of a
therapy session. Now, the finding that tears are common in therapy is not
particularly instructive as to whether or not they are appropriate, and that,
of course, requires a somewhat more nuanced approach. Most therapists who
reported crying did not feel like their tears had adversely impacted the
working alliance, and, in fact, the majority felt like it had strengthened the
relationship they had with their patient.6 There has been some
suggestion that whether tears are appropriate and even potentially helpful
depends in large part on the strength of the positive working relationship with
the patient. If the patient views their connection with the therapist as
superficial, the expression of tears could be detrimental and seen as false or
self-serving. This would be consistent with previous observational
studies by Myers and Hayes (2006). They found that when independent
observers rated therapists, those who made personal disclosures were viewed as
more skilled, but only when a positive therapeutic alliance already existed.
For sessions in which a positive therapeutic alliance was absent, self-disclosure
was viewed as “shallow.”6
Hug them?
Interestingly, the issue of whether doctors hugging patients is acceptable
has been explored in the lay press, and not just from the perspective of doctors,
but also from the perspective of patients. It seems there is discomfort,
confusion, and uncertainty surrounding this issue from indeed all parties.
Unfortunately, although a lot has been written on the topic, almost all
of what is written waffles from acceptability, given the correct circumstances,
to a generally risky practice that could just leave all parties feeling
equivocal about the encounter. Seemingly, almost all of the 937,000,000
blogs and websites Google associates with the issue of patients and hugging can
be summarized by the following:
“Is it appropriate? This
to a large degree depends upon the patient and the particular relationship that
the physician has with the patient,”7
While this is an answer, and perhaps in
it’s broad and all-encompassing
nature, the only truly correct answer, it is so vague as to be essentially
meaningless. The standards I have thus far adopted for myself based on
discussions I have had with more senior practitioners, and what seems like
common sense to me are as follows:
1) Never hug a patient in which you
suspect any level of sexual transference.
2) Likewise, you should never hug a
patient for whom you have even the slightest countertransference of attraction.
3) You should, in general, not hug or
touch any patient who has been the victim of sexual abuse or the victim of a
sexual crime.
4) All hugs should be patient-initiated.
5) Hugs should not be a routine part of
practice, but reserved for important or emotionally-charged news and patients
leaving your care and/or retirement.
For the beginning practitioner, there
are many murky situations to navigate as they also work to develop their skills
and master the art of treating patients. The variability of patients and
practitioners makes clear-cut answers to what constitutes best practices in
these situations, at best, vague platitudes that rarely help actually guide a
budding clinician’s behavior. The result is that dealing with these
complex situations is often, if not almost always, passed down by word-of-mouth.
While this may be an ideal situation in which senior clinicians familiar
with both the patient and their junior trainee might be able to determine the
one best course in that particular situation, there is vulnerability in that
scenario that the junior trainee might be embarrassed by their own uncertainty or the situation; and
arising countertransference could pass unexamined. This review seeks to
gather what currently constitutes the clearest guidelines in the literature as
to what constitutes best practices for difficult situations of
countertransference and offers some specific guidelines of our own where no
clear answers appear to exist. In sum, it is important to remember that
countertransference is inevitable if one is actually doing therapy, and that it
is the response of the practitioner that determine whether this
countertransference is detrimental to the therapeutic relationship and the
patient’s progress or can help aid and guide our treatment.
E. Fenstermacher MS IV Washington University in St. Louis
Bibliography
1. “Countertransference”. 2013.
In Merriam-Webster.com.
Retrieved
July 2, 2013, from http://www.merriam-webster.com/dictionary/countertransference
2. Beitman B, Yue D. (2004)
Learning Psychotherapy: a time-efficient, research-based, and
outcome-measured psychotherapy training program 2nd ed.
New York, N.Y. W.W. Norton & Company, Inc.
3. Markowitz JC, Milrod BL. The
importance of responding to negative affect in psychotherapies.
Am J Psychiatry. 2011
Feb;168(2):124-8.
4. Reidbord,
S. (2010, March 24) Countertransference, an overview. Psychology
Today. Retrieved July 9, 2013 from http://www.psychologytoday.com/blog/sacramento-street-psychiatry/201003/countertransference-overview.
5. Zilberstein K. The Use
and Limitations of Attachment Theory in Child Psychotherapy. Psychotherapy
(Chic). 2013 Feb 11.
6. Blume-Marcovici AC, Stolberg
RA, Khademi M. Do therapists cry in therapy? The role of experience and other
factors in therapists' tears. Psychotherapy (Chic). 2013
Jun;50(2):224-34.
7.
Pisano, A. (2012, Jan 11) The hugging doctor: Comforting or creepy. Medill
Reports Chicago. Retrieved July 11, 2013 from
http://news.medill.northwestern.edu/chicago/news.aspx?id=198258
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