Clinical guide to countertransference: Help medical colleagues deal with ‘difficult’ patients
Recognizing a patient’s personality type may help clinicians predict their countertransference when interacting with that patient.
Patients with medical illness
Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.
Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.4 The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.
Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas5 describe basic coping mechanisms common to most patients ( Table ).6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.8
Table
Patients’ response to illness,
with common countertransference by medical staff
| Patient’s coping mechanisms | Staff’s countertransference |
|---|---|
| Dependent personality | |
| • Unconsciously wishes for unlimited care • Depends on others to feel secure • May make excessive requests of staff | • Gratification at being able to take care of patient’s needs • Resentment if patient’s needs seem insatiable |
| Obsessional personality | |
| • Meticulous self-discipline • Illness represents loss of control • Will try to gain mastery over illness by focusing on details, information | • Relief at patient’s willingness to actively participate • Power struggle is possible |
| Histrionic personality | |
| • Outgoing, colorful, lively • Attractiveness and sexuality important • Needs to feel the center of attention • Illness represents defect, loss of physical beauty | • Warm initial engagement • Fear of crossing boundaries • Wonder about veracity of complaints |
| Masochistic personality | |
| • Satisfies unconscious needs by suffering • Needs to play victim role | • Frustration when reassurance does not help • May unconsciously play into patient’s need for punishment |
| Paranoid personality | |
| • Pervasive doubt of others’ motivations • Often questions motives for interventions • Illness represents threat to safety | • Wary of lack of alliance • Anger that patient questions treatment motives • Frustrated at inability to form a trusting relationship with patient • Unsettled by lack of connection |
| Narcissistic personality | |
| • Grandiose sense of self, which protects against shame, humiliation • May demand superior care, insult junior team members | • May feel flattered by ability to treat patient as VIP • May alternately feel devalued, wonder about competence |
| Source: References 6,7 | |
CASE CONTINUED: No longer ‘grandmotherly’
Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.
Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.
Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.
Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.
If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.
