7 | TRANSFERENCE
Transference is the set of cognitions —thoughts and perceptions— and
affects that the patient experiences about the
practitioner.18 The nature of the transference is
determined by the token of activated object relation dyad in the
patient’s mind that represents the interpersonal relationship formed
with the health care provider.16 Every transference
can be classified, based on the affect that it includes, in positive or
negative.19 Positive transferences include affects
such as love, fondness, respect, gratitude, etc. Negative transferences
include affects such as anger, hatred, distrust, disdain, contempt,
envy, etc. Imagine a patient who has activated a dyad that contains a
self representation of a sick person, who needs to be taken care of, in
interaction with an object representation, the practitioner, who tries
his or her best to heal him or her and therefore has a feeling of
appreciation and gratitude; this is a classic example of a positive
transference activated by a patient in interaction with their clinician.
Now imagine a patient who activated a dyad that includes a self
representation of an ill person that requires help, but in relation to a
representation of the physician as cold and without interest in helping
him or her, therefore, the affect it contains is frustration and anger;
this would be an example of a very prevalent negative transference in
everyday medical practice.
To diagnose the activated dyad in the transference, namely, self and
object representation and the associated affect, it is necessary for the
physician to pay attention to three sources of information: the
patient´s verbal communication, non-verbal communication and the
countertransference of the practitioner. Verbal communication includes
the information that the patient transmits through speech; nonverbal
communication includes the nature of speech —tone, intensity, speed
and fluctuations in these parameters— and body language —facial
expression, body posture and directed and non-goal-directed behavior—;
and countertransference includes the affect that the clinician
experiences when interacting with the patient.16,20
Each one of you must find the most effective personal way to diagnose an
activated dyad using the aforementioned three sources of information.
However, a simple and pragmatic method consists of diagnosing the
patient’s affect through nonverbal communication: Does the patient’s
facial expression correspond to what would be socially interpreted as an
expression of positive or negative affects? is he or she laughing or
frowning? is he or she very expressive or dour? what is the patient’s
posture? is he or she straight and firmly seated against the back of the
chair or sprawled in his seat? does he or she play with their fingers
showing anxiety or do they lie quietly on an object or a patient´s body
part?, etc. Once the activated affect has been diagnosed, the diagnosis
of self and object representations involved must be made; these
representations can be inferred from the patient´s verbal communication,
either directly, when the patient speaks about him or herself or about
the health care provider with which he or she interacts, or indirectly
when the patient does not talk about him or herself or the health care
provider but of material that is not directly related to the
physician-patient interaction.21 In the section “Self
and object representations”, examples of the inference of self and
object representations through direct verbal communication have been
presented. To exemplify the diagnosis of an activated dyad in the
transference when the patient uses “indirect” verbal communication,
imagine a patient in follow-up for systemic arterial hypertension who
presents in the clinic with high blood pressure, the practitioner asks
routinely if he or she has taken their medication correctly, and the
patient, rushing to answer, says yes, however, the clinician notices
tension and discomfort in the patient´s voice and facial expression
—use of nonverbal communication— and decides to point it out: “I
noticed you felt uncomfortable when I asked if you had taken your
medication, could it be that you have forgotten it sometimes and you are
embarrassed to tell me?” so the patient answers yes —we have the
affect: shame—, the physician then explores the motivation for not
taking the medication and the patient answers: ”this new drug that you
prescribed was very expensive and I couldn´t afford it. I´m sorry,
doctor ” —indirect verbal communication—, from this comment it can
be inferred that the activated self representation corresponds to the
misbehaved patient associated with a negative affect, that is, shame,
coupled with an object representation that corresponds to the critical
clinician —and perhaps inconsiderate for prescribing expensive drugs.
In general, positive transferences strengthen the therapeutic alliance
and do not require any intervention.22 In case of
finding a negative transference in one of our patients, the practitioner
should express in words the active transference to obtain confirmation
from the patient that precisely, this hypothesis of the physician
regarding the transference, corresponds to the patient’s experience.
Once the transference hypothesis has been confirmed by the patient, the
health care provider could request subjective and objective proofs, in
favor and against, that the patient has to support the veracity of his
or her transference. With the information obtained through these
interventions, the practitioner can now reduce the intensity of the
negative transference by declaring the reality of the physician-patient
interaction, the way the clinician experienced this interaction with the
patient and recognize his or her potential contribution to the biased
perception of the patient. Finally, in the event that the health care
provider is aware that this transference has been activated in previous
interactions with other physicians and that it has hindered the
patient’s treatment, the physician can point out this similarity with
the objective that, in future occasions, the intensity of the same
negative transference will be smaller.23 Let us
continue with the example of the hypertense patient mentioned before;
the practitioner, after having diagnosed the activated dyad in the
transference, verbally expresses it to the patient to obtain
confirmation: “I get the impression that at this moment you feel as if
you have misbehaved and you’re embarrassed by this, and as if I were
being harsh or critical of you for not taking your medication, is that
so?”, the patient answers affirmatively and then the health care
provider asks for evidence for or against this perception, resulting in
the patient being unable to provide any, finally, the clinician reduces
the intensity of the negative transference by stating: “I understand
that sometimes it is difficult for patients to properly take their
medications. Don´t worry. We will try to think of a solution to make it
easier for you to comply with the treatment, although it is true that I
did not think about your being able to pay for this new medicine ”,
ending here the intervention to reduce the intensity of the negative
transference.