Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”
What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.
What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?
This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.
The therapeutic dyad
Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:
- a biological component because part of personality is genetic
- a psychological component based upon experiences throughout life ( Box 1 ).1
Genetic factors play a role in personality formation. A child’s personality, which emerges early in life, shapes interactions with people who are significant during childhood. Predispositions shape those experiences and influence what people internalize from those relationships.
In adults, many aspects of what we understand as transference—the experience someone has of a figure from the past—originate from the limitations with which children perceive and interpret their experiences. Transference is not truth about a significant past relationship; it is truth as the person experienced other people and now remembers or reacts to individuals who are reminiscent of those from the past.1
Not all psychotherapeutic treatments—and thus not all therapists—use the concept of transference as a therapeutic component. Some therapists who employ transference in treatment will discuss how the patient interacts with the therapist only when the phenomenon interferes with therapy. Interpretation of transference is a therapeutic modality of psychoanalysis and psychodynamic psychotherapy. Discussion of how the patient interacts with the therapist is not the same as a transference interpretation. Because transference exists in all human relationships, transferential aspects in a relationship may have positive or negative effects on interactions outside the therapeutic environment. Whether acknowledged or ignored, transference—and thus countertransference—is present.
Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:
- the patient’s transference
- the therapist’s unique psychodynamics
- the real relationship in the therapeutic dyad.2
In the therapeutic setting, some reactions to the patient are experienced as unusually powerful, out of keeping with our self-image, or as consciously disturbing. Such reactions to a patient—while still countertransference—might result from projective identification. This type of countertransference is most commonly, but not exclusively, encountered in therapy of patients with borderline personality organization.3
We suggest that the term countertransference be restricted to therapeutic situations (any relationship in which one person has the role of treating or helping the other person), including all patient-physician or patient-provider relationships. They have a transferential component because the physician occupies a role of authority/knowledge/power from which the patient seeks to benefit.
Outside of therapeutic situations, reactions to other people are our transferences to them, evoked by our internalized past relationships. We may have an emotional response to how someone behaves toward us (their transference), but that is a counter-transference, not countertransference.