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.