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