8 | COUNTERTRANSFERENCE
Countertransference is the set of cognitions, affects, and behaviors that the physician experiences towards the patient.24Countertransference is a useful tool to infer the subjective experience of the patient and its recognition by the health care provider helps to better understand the affects and the self and object representations of the patient25 and it decreases the risk of the practitioner deviating from the professional framework due to the strong countertransference reactions that some of the patients can induce. The nature of the countertransference is determined, mainly, and as long as the clinician’s emotional state is stable and not very intense,26 by the token of the activated object relation dyad in the patient’s mind23; however, in some occasions, particularly when the clinician’s affective state is intense, it can be determined by the activation of an object dyad of the physician’s mind; namely, the origin of countertransference is primarily the patient, but, sometimes, it can originate in the health care provider.19 The process through which countertransference originates is unconscious.
Every countertransference can be classified as concordant or complementary. When a concordant countertransference is experienced, the practitioner identifies with the self representation that the patient has activated, therefore, the clinician takes the patient’s perspective, empathizes cognitively and affectively with the patient — he or she would think, for example: “If I were in the patient’s situation, I would probably believe, feel, and act in a similar way” and his or her affects would become similar in quality to those of the patient, therefore, if the patient experiences sadness, the physician could also feel it­.27,28 When a complementary countertransference is experienced, the health care provider identifies with the object representation that the patient has activated, therefore, the practitioner’s cognition, affects and behaviors would be similar to those that the patient perceives and expects from the clinician.26 In addition, in the same way that transference is classified, it is useful to classify countertransference based on the affect it includes in positive and negative countertransference. Intense positive and negative countertransferences imply a risk that the physician will reassure inappropriately —such as affirming a patient that there is no problem because they have not taken their medication, when there actually is— or attack the patient, respectively.27 In medical settings, negative countertransferences can be particularly problematic and possibly carry a greater risk of legal problems.
To diagnose the qualities and the kind of countertransference that the health care provider experiences, he must take a pause and reflect: what do I think of this patient? what does this patient make me feel? and how am I behaving with this patient? Let us return to the example of the hypertense patient with poor adherence to drug treatment and suppose that during the interaction with the patient, and prior to the intervention of reduction of negative transference, the practitioner asks him or herself the previous questions and realizes that he thinks that the patient is irresponsible for not taking his medications, feels annoyed and critical of him or her, and raises a bit his voice in disgust —this last manifestation corresponds to behavior— therefore, the clinician concludes that his countertransference is complementary and that he or she is acting precisely the representation of the critical, and perhaps inconsiderate physician, that the patient has perceived —and probably unconsciously induced— in him or her.
Proper management of countertransference in medical settings, such that health care providers do not run the risk of acting in response to it, includes self-insight, anxiety management, empathy, and conceptualizing ability. Self-insight is the ability to know at any given moment what we feel, think, and how we behave; anxiety management is the ability to control anxiety associated with the countertransference so that it does not affects the practitioner’s behavior; empathy is the ability to take the patient’s perspective of a given situation; and conceptualizing ability is the ability to make use of the theory —for example, the theory presented herein— to understand the role of the patient in the physician-patient interaction.29 As the reader will see, these three techniques overlap and interact with each other.
Self-insight should be used whenever the clinician detects that his or her mood is more intense than what is normal for him or her. When this happens, the physician should take a pause and ask him or herself: what do I think of this patient? what does this patient make me feel? and how am I behaving with this patient? This is the most essential factor in managing countertransference.
The management of anxiety associated with countertransference includes the normalization of thoughts and feelings that the health care provider experiences towards the patient and to control breathing. To normalize the countertransference experience, it is useful to remember that it is normal, expected, and healthy to have feelings and thoughts directed at patients as people with their own personalities,26 not only as people with diseases, regardless of whether these feelings and thoughts are pleasant or unpleasant; in addition, the practitioner should not take the patient’s behavior as something against him or her as a person, but as behavior that is secondary to the functioning of the patient’s mind and to his or her way of relating to others. Finally, the author has found useful in daily practice, especially in intense countertransference situations, to focus on controlling breathing to decrease its frequency. Adhering to these two techniques, the intensity of anxiety associated with countertransference should decrease considerably.
In the event that the clinician presents a complementary countertransference, that is, when he or she identifies with the object representation included in the dyad activated in the patient’s mind, the physician must make a cognitive effort to develop empathy, to acquire their perspective. For this, it is useful to remember that the patient is also a human being with all the virtues and defects that the health care provider can have30 and should ask him or herself: If I were in the patient’s situation, how would I feel? what would I think? how would I behave? and how would I like to be treated by my doctor? When the practitioner presents a concordant countertransference, empathy will be implicit, and it will not be necessary to develop it; what he or she should be wary of is over-identification with the patient’s self representation, since this may cause the clinician to give the patient just what he or she wants, not what he or she needs. To avoid this, the physician must make an effort to think that in the physician-patient relationship there must be a certain healthy emotional distance between the health care provider and the patient and that every patient precisely looks for that in a practitioner, a professional who will guide them to solve their health problems.
Conceptualizing ability corresponds to the use of psychodynamic theory to understand the countertransference reactions of clinicians towards their patients.30 After transference and countertransference have been diagnosed, the physician must ask him or herself: how does my countertransference relate to the activated object relation in the patient’s mind that dominates the interaction between my patient and me? is it a complementary or concordant countertransference? Doing so will reduce the anxiety and confusion of the physician-patient interaction31 and will allow the physician to carry out the appropriate technique for transference management.
At last, there will be occasions when the countertransference is so intense that it could not be handled properly, being a high risk that the health care provider will deviate from the professional framework. Because a good physician-patient relationship is necessary for any successful treatment and the risk of iatrogenesis due to deviation from the professional framework is high, an uncontrollable countertransference is a rational reason to refer a patient with a colleague. However, before doing this, the practitioner should try to repair the relationship, if this countertransference has its origin in objective characteristics of the patient, the clinician should discuss this with him and give him the opportunity to change. If this last intervention is not effective or if the cause of the countertransference is personal characteristics of the physician, the health care provider must apologize for his or her professional limitations, express that the patient deserves to receive better care than he or she could receive with him or her and, finally, offer a referral to another practitioner.32