Countertransference: A Lost Art

Countertransference is defined as a therapist’s internal and external reactions to a client that are influenced by the therapist’s personal vulnerabilities and unresolved conflicts.

While transference and countertransference are elements of psychiatrists’ everyday work, there are moments when the definition and management of transference can be especially useful to review.

I recently encountered a patient who stirred up some pretty strong negative emotions, including anger, frustration, disappointment, sadness, and fear. It was an opportunity to review and practice how to handle transference. I needed to spend some time doing introspection. What was it about this person, this life story, this medication management approach, this encounter that pushed buttons? I had to practice affect regulation and frustration tolerance, perhaps more than in a typical meeting. I needed to make sure I spent some time reviewing the literature and making sure I was practicing evidence-based medicine. I had to make sure I sought supervision and found out how other physicians and staff in the clinic felt. I had to consider when we as therapists need to weather the turbulent storm and when we need to draw the line because a patient has become abusive or requires an alternate level of care.

I had to practice putting myself into someone else’s shoes. I was reminded of a line from David Brook’s recent book How to Know a Person: The Art of Seeing Others Deeply and Being Deeply Seen: “How you see a situation depends on what you’re capable of doing in a situation.” The patient’s experience of the visit was quite different from mine. Embedded in this difficult moment was a lesson about empathy. I needed to become better adept at hearing his pain—especially when I considered that however much pain, annoyance, and disappointment I felt, the patient was suffering even more deeply. I had to continue to be empathetic and listen to his/her discomfort.

The visit was so powerful. I started to envision how this power could impact more than individual patient visits but also entire health care systems. Are policy changes within institutions shaped to fit the most likeable and agreeable patients? Does this extend to employees? Are rules bent and exceptions made when certain affects, both positive and negative, are stirred up?

Just like returning to basics to manage countertransference is important for patient care, it is also important for understanding the larger world of evolving health care systems. We can look for outside advice about changes in an institution. We can consider our own motivation and the institution’s motivation about the constant shifts. Sadly, profit has become a looming force in health care. We can pivot to micro adjustments that are within our control and step away from drastic changes that are out of our control. ■

Elina Maymind, M.D., is an assistant professor of psychiatry at Rowan-Virtua School of Osteopathic Medicine.