patient 1. Patricia Hughes and 2. Ian Kerr +Author Afliations 1. Patricia Hughes is a senior lecturer and consultant in psychotherapy at St George's Hospital Medical School and South West London and St George's Mental Health Trust (St George's Hospital Medical School London SW1! "#$ Tel% "1&1 !'( (('1)*1+ e,-ail% p.hughes.sgh-s.ac.u/0. She is interested in teaching -edical students and in -a/ing psychotherapy understanda1le to psychiatric trainees. 2an 3err is Senior #egistrar in Psychotherapy at and South West London and St George's Mental Health Trust and the Henderson Hospital. He is interested in the application o4 cogniti5e6analytic therapy (7AT0 in co--unity -ental health tea-s and is researching 7AT in the treat-ent o4 antenatal an8iety. 9The reasona1le -an adapts hi-sel4 to the :orld+ the unreasona1le one persists in trying to adapt the :orld to hi-sel4; George <ernard Sha:Maxims for Revolutionists. Health care is a co-ple8 1usiness. Medical treat-ent could 1e so -uch -ore relia1le i4 it :ere not co-pro-ised 1y the i-precise and unpredicta1le nature o4 hu-an -oti5ation. <ut e5en the 1est treat-ent :ill not al:ays 1e good enough and patients :ho hoped 4or a cure :ill 1e disappointed a4raid and angry. So-e patients ha5e con4using e8pectations. Although rationally :e /no: that 1eing ill or ha5ing poor relationships or not 1eing a1le to :or/ is unpleasant so-e people ha5e -i8ed 4eelings a1out losing their sy-pto-s. Patients are not al:ays grate4ul 4or our honest atte-pts to help the- and a 4e: e-erge al-ost triu-phant 4ro- a long treat-ent :ith sy-pto-s intact. =octors cannot escape the 1urden o4 their o:n -oti5ation. Most o4 us 1elie5e that the a1ility to 4eel 4or our patients is an i-portant di-ension o4 treat-ent. This co-es at a price% :e ha5e our o:n needs and desires and the therapeutic relationship is a 4ertile ground :here these -ay 1e played out.
>e8t Section The therapeutic alliance A cornerstone o4 treat-ent in -edicine is the therapeutic alliance :here1y patient and doctor esta1lish a rational agree-ent or contract :hich supports the treat-ent (Greenson 1?&(0. So the patient :ith a sore throat has the rational e8pectation that the doctor is appropriately @ualiAed :ill do a suita1le e8a-ination and in5estigation and :ill prescri1e rele5ant treat-ent. The doctor e8pects that the patient :ho has sought treat-ent :ill generally do his or her 1est to co-ply :ith the treat-ent re@uire-ents such as collecting a prescription and ta/ing the prescri1ed -edication. The therapeutic alliance in this transaction has a good chance o4 sur5i5al% the negotiation is straight4or:ard and there is unli/ely to 1e a co5ert agenda. Ho:e5er as the patient's needs 1eco-e -ore co-ple8 the therapeutic alliance -ay 1e distorted 1y the :ishes and e8pectations o4 the patient and e5en occasionally the doctor. These -ay 1e 4ully conscious and e8plicit or -ay not 1e entirely conscious and so 1e co--unicated in a non,direct :ay (<alint 1?(!0 (see <o8 1B0. Box 1. The therapeutic alliance There are three parts to the therapeutic relationship: the therapeutic alliance, the transference and the countertransference The therapeutic alliance is the rational (iplicit! contract "et#een doctor and patient The contract a$ "e straightfor#ard #ith utual cooperation The contract a$ "e coplicated "$ a co%ert agenda: the patient&s unconscious and unspo'en #ishes and needs (the transference! Pre5ious Section >e8t Section The covert agenda We need and :ant a 5ariety o4 relationships throughout our li4e. Although this pri-ary need is 1iologically deter-ined 1y genes that pro-ote sur5i5al o4 the species the precise nature o4 the relationships :e see/ is hea5ily inCuenced 1y our pre5ious e8perience. Dor e8a-ple attach-ent research has conclusi5ely de-onstrated the eEect o4 a parent's attitude to attach-ent on the in4ant's su1se@uent 1eha5iour :ith hi- or her (Donagy et al 1??10 and a child's secure or insecure e8perience in in4ancy is highly predicti5e o4 the @uality o4 later relationships :ith people other than the parents (Srou4e 1?&*0. So in ne: situations :e ha5e e8pectations that are partly deter-ined 1y our realistic perceptions thoughts and 4eelings a1out the present and partly 1y associated e8periences :e ha5e had in the past (Hughes 1???0. Most people can usually e5aluate the e8pectation against the reality o4 the present and adFust e8pectations accordingly. Ho:e5er in so-e circu-stances such as :hen :e are highly an8ious this appears to 1e -ore difcult and :e -ay cling de4ensi5ely to our preconceptions. 2n addition so-e people ha5e ha1itual difculty in adFusting their inner :orld to -atch their perceptions in the present. This is characteristic o4 so-e -ore rigid /inds o4 personality including people :ith 1orderline personality 4eatures :here the person o4ten has difculty in distinguishing :hat is e8pected 4ro- the internal -odel and :hat is percei5ed in the e8ternal :orld (3ern1erg 1??G0. Pre5ious Section >e8t Section The place of projective mechanisms We tend to see :hat :e e8pect to see (A1ercro-1ie 1?&?0. >ot only that 1ut :e -ay 1eha5e to:ards other people as though they are the people :e e8pect the- to 1e. 2n the process :e gi5e su1tle non,e8plicit -essages a1out :hat part they are playing and the other people are co5ertly in5ited to adopt the role or 1eha5iour that is e8pected (Sandler 1?!H+ #yle 1??&0. We proFect an e8isting -ental -odel on to the present and -ay then 1eha5e in a :ay that is appropriate 4or the internal -odel 1ut that -ay 1e inappropriate to the reality o4 the present e8ternal :orld. Pre5ious Section >e8t Section Unconscious expectations and transference =r <reuer's alar-ing e8perience o4 1eing the o1Fect o4 Anna I's intense aEection cannot ha5e 1een the Arst and certainly :as not the last ti-e a patient 4ell in lo5e :ith his or her doctor (<reuer J Dreud 1&?(0. The diEerence in <reuer's case :as the use to :hich Sig-und Dreud put the e5ent. #ather than accepting it as one o4 those un4ortunate things that happens to doctors he thought a1out :hat it -eant and persuaded a sha/en and reluctant <reuer to colla1orate :ith hi- on a theoretical paper and a 1oo/. Studies on Hysteriadiscusses the pheno-enon in :hich a patient strays 4ro- strictly pro4essional 4eelings to:ards the analyst and allo:s personal 4eelings to intrude into the therapy. These patients had tended to 9trans4er on to the Agure o4 the physician; distressing ideas that arose 4ro- the content o4 the analysis. These patients said Dreud had -ade a 94alse connection; on to the analyst. Dreud Arst actually used the ter- Ktrans4erenceL in relation to his patient =ora :hen he 1elatedly recognised the arousal o4 4eelings to:ards hi-sel4 that related to her lo5er 6 :hich led to =ora's a1rupt :ithdra:al 4ro- treat-ent and a therapeutic 4ailure (Dreud 1?"(0. Pre5ious Section >e8t Section Transference Definition Transference is the pheno-enon :here1y :e unconsciously trans4er 4eelings and attitudes 4ro- a person or situation in the past on to a person or situation in the present. The process is at least partly inappropriate to the present (see <o8 'B0. Box 2. Transference Transference is unconscious It is at least partl$ inappropriate to the present It is the transferring of a relationship,nota person (nl$ an aspect of a relationship, not the entire relationship, is transferred Points to note 1. The process o4 trans4erence is not conscious and the patient un:ittingly proFects a needed aspect o4 a pre5iously e8perienced or :ished,4or relationship on to the doctor (see <o8 *B0. <ecause it is a relationship that is 9trans4erred; the patient and doctor are e8pected to ta/e co-ple-entary roles. So a patient :ho is a4raid that he or she is seriously ill -ay adopt a helpless child,li/e role and proFect an o-nipotent parent,li/e @uality on to the doctor :ho is then e8pected to pro5ide a solution. Box ). Pro*ection and transference Transference in%ol%es the pro*ection of a ental representation of pre%ious experience on to the present (ther people are treated as though the$ are pla$ing the copleentar$ role needed for the pro*ected relationship There are su"tle (unconscious! "eha%ioural +nudges, to ta'e on these feelings and "eha%iours '. A relationship o4 the co-ple8ity o4 say a -other and son is not li/ely to 1e 4ully re,enacted. More li/ely is that some aspect o4 the relationship is played out in the trans4erence 6 4or e8a-ple a -other :ho sorts things out :hen her son is helpless or a -other :ho criticises ho:e5er hard he tries. *. The person proFected in the trans4erence relationship -ay not 1e historically accurate 1ut is the current mental representation o4 a pre5iously e8perienced relationship. This is li/ely to 1e a -i8ture o4 the real historical relationship the child's interpretation o4 this at the ti-e and perhaps so-e re5ision -ade since the original -odel :as laid do:n. G. The trans4erence proFection -ay 1e considered a communication o4 a patient's needs that cannot 1e 5er1ally e8pressed 1ut that is instead enacted. Trans4erence is part o4 the :ay :e relate to each other inside and outside psychotherapy psychiatry and -edicine and :e ha5e to -anage it as 1est :e can. Much o4 the ti-e it is si-ply a part o4 the co-ple8ity o4 any relationship and is not a pro1le- 4or either party. Dor e8a-ple a Funior -e-1er o4 staE -ay ad-ire a senior colleague and unconsciously -odel his or her pro4essional 1eha5iour on his or her senior. Strictly spea/ing this -ight 1e considered to include an ele-ent o4 trans4erence% the Funior -ay need a parental Agure to idealise. This -ay 1e help4ul in the short ter- and in the long ter- is li/ely to resol5e as he or she gains conAdence and status. There is no reason to interpret the 1eha5iour and :e generally regard this as a nor-al part o4 the process o4 training. In the other hand i4 this particular ad-iration leads the Funior to denigrate other seniors or to adhere rigidly to one approach it is unhealthy and the trainers :ould :ish to discourage it. Si-ilarly in a therapeutic relationship the patient -ay sho: so-e -ildly inappropriate 4eelings 6 either positi5e or negati5e 6 :hich do not seriously inter4ere :ith treat-ent. Although these -ay 1e trans4erence 4eelings i4 they do not i-pair treat-ent then there is no need to challenge the- 1y interpretation nor to change the treat-ent approach. At other ti-es the patient's inappropriate 4eelings and 1eha5iours -ay do-inate the relationship and i-pede the :or/ to 1e done. To the e8tent that trans4erence 4eelings represent an unconscious agenda 4or the patient it is use4ul 4or staE to recognise it as 4ar as possi1le so that an understanding o4 :hat the patient :ants or e8pects can 1e used in planning clinical -anage-ent. =escri1ing this interpretation to the patient is not al:ays use4ul (see 1elo:0. Perception and misinterpretation Trans4erence is pro-oted 1y unconscious e8pectations and :hat :e percei5e :ill 1e coloured 1y our e8pectations. Thus distortions -ay ta/e place in the patient's understanding o4 an interaction. An in,patient has 1eco-e 5ery attached to the senior house ofcer (SHI0 :ho has 1een seeing her :ee/ly. She tells hi- that she 4eels 5ery depressed 1ecause people do not li/e her :hen they get to /no: her. He says that perhaps she 4eels that :ay a1out hi- also and she agrees. He assures her that he really does li/e her. To his dis-ay he then hears 4ro- the nurses that she has told another patient that he K4anciesL her. What is not transference? 7rying Ktrans4erenceML can 1eco-e the de4ence o4 the doctor (or other health care :or/er0 against a patient's FustiAa1le 4eelings to:ards the tea- or a -e-1er o4 it. >ot all 4eelings that a patient has to:ards his or her therapist are trans4erence 4eelings. Dor e8a-ple a patient's hostility or anger -ay 1e an appropriate response to his or her situation. 24 the doctor or the tea- is regularly late insensiti5e or inconsistent then the patient -ay reasona1ly 1e angry or disappointed. Ir i4 the patient is a:are that a tea- -e-1er has put a lot o4 :or/ into the treat-ent he or she -ay 1e grate4ul and 4eel real :ar-th to:ards this /ey:or/er. These appropriate 4eelings do not constitute trans4erence. So-e patients are especially sensiti5e to 4ailures in care so there -ay 1e an ele-ent o4 trans4erence coe8isting :ith FustiAa1le anger or disappoint-ent. The -ost appropriate :ay to deal :ith this is 4or the doctor to ac/no:ledge his or her lateness inconsistency etc. apologise and i4 rele5ant e8plore :hy it is especially difcult 4or this patient. $@ually a patient -ay ha5e real and appropriate aEection -i8ed :ith idealisation and a :ish 4or an inti-ate relationship. 2nterpretation -ay not 1e appropriate as it -ay hu-iliate the patient and da-age the positi5e aspects o4 their :or/ing relationship. 2nstead the therapist should recognise the patient's 4eelings and treat hi- or her :ith respect continuing care 1ut -aintaining a strict attention to 1oundaries so that the patient is not encouraged to 4eel that his or her aEection is reciprocated or that his or her 4antasies ha5e a place in reality. Factors that increase transference Three things can pro-ote trans4erence% the situation o4 1eing in need and dependent on the doctor or tea-+ the setting o4 a relationship :here dependency needs are recognised and -et+ and particular types o4 personality :here the internal :orld is co-pellingly proFected on to the present (see <o8 GB0. Box -. .actors that increase transference /ulnera"le personalit$, especiall$ people #ith "orderline features, #ho a$ rigidl$ pro*ect their expectations on to the present The patient&s anxiet$ a"out his or her ph$sical or ps$chological safet$ (e.g. #hen sic' and afraid! .re0uent contact #ith a ser%ice or #ith a 'e$#or'er Situation Situations in :hich a person is relati5ely helpless or a4raid :ill increase his or her need o4 a protecti5e relationship. Since this applies to -ost patients in the care o4 a psychiatric tea- :e should e8pect there to 1e a trans4erence ele-ent to -ost treat-ents. Ho:e5er the ter- Kprotecti5eL does not do Fustice to the co-ple8ity o4 such a relationship. A person -ay long 4or inti-acy 1ut also 4ear it 1e intensely dependent 1ut hate his or her dependency 1eco-e deeply attached 1ut una1le to trust the o1Fect o4 his or her attach-ent. Setting Any therapeutic setting :here a person is seen 4re@uently (and so-eti-es e5en in4re@uently0 and his or her e-otional needs attended to pro-otes trans4erence. The patient -ay de5elop a trans4erence relationship :ith a person :ith a tea- or e5en :ith an institution. Dre@uent changes o4 /ey:or/er are unli/ely to a5oid the de5elop-ent o4 trans4erence 4eelings 1ut -ay displace the- to the institution :hich -ay 1e e8perienced as an unpredicta1le and 4rustrating other. A relationship :here the patient 4eels recognised and understood i-pro5es cooperation+ repeated changes o4 therapist are li/ely to i-pair it. Personality A person :ho has little capacity to reCect on his or her o:n state o4 -ind 4eelings and needs is 5ulnera1le to acting upon 4eelings rather than reCecting or discussing :hat he or she :ants. 24 the patient has a 5ulnera1le personality is ill and a4raid and has the attention o4 a /ey:or/er or tea- he or she is there4ore especially li/ely to de5elop trans4erence 4eelings to:ards one or -ore people. Pre5ious Section >e8t Section Managing transference 2n dyna-ic psychotherapy one o4 the ai-s o4 therapy is to Kresol5e the trans4erenceL that is to help the patient recognise and -anage the unconscious 4eelings and e8pectations :hich he or she 1rings to ne: relationships. The patient has to 1e a1le to -o5e 4ro- a less reCecti5e to a -ore reCecti5e state o4 -ind :here he or she can 1ring thought to 1ear on his or her 4eelings rather than enacting his or her e8pectations. >ot all psychiatric patients :ill 1e a1le to do this% so-e :ill 4eel puNNled -isunderstood hu-iliated or o5er,e8cited i4 their 4eelings and 1eha5iours are interpreted in ter-s o4 underlying :ishes and needs. I4ten the psychiatrist and the tea- ha5e to -anage the trans4erence relationship :ithout e8plicit interpretation o4 the trans4erence. When the patient is una1le to understand and use interpretation then -anage-ent should include recognition o4 his or her 4eelings to:ards the /ey:or/er and tea- :ith strategies intended to pro-ote a secure and cal-ing relationship. 24 the patient cannot al:ays recognise the pro4essional nature o4 the relationship it is i-portant that the therapist and tea- can hold on to it. The patient should 4eel KheldL :ithout 1eing o5er,sti-ulated that is he or she should 4eel that so-eone recognises his or her pro1le-s and 4eelings and is concerned and that the :or/ing relationship is reasona1ly sta1le and predicta1le (see <o8 (B0. Box 1. 2anaging transference 3ecognising the iportance of the relationship to the patient 3elia"ilit$ 2aintaining professional "oundaries and clear liits in treatent Interpretation, "ut onl$ #hen the patient can understand and use it ecognition of the importance of the relationship 2t is essential that the doctor)/ey:or/er recognises that this relationship is i-portant to the patient (see <o8 HB0. Dor the doctor it -ay 1e a routine part o4 the :ee/'s :or/ and he or she -ust constantly 1e a:are that the relationship is s/e: and that the patient's e-otional needs al-ost ine5ita1ly go 1eyond the rational contract o4 the therapeutic alliance. Box 4. 5h$ recognise transference in general ps$chiatr$6 7upports sta8 "$ helping the understand #hat is going on in the relationship #ith the patients, so reducing anxiet$ and o%er9 responsi"ilit$ Ipro%es patient anageent "$ recognising #ishes that are not clearl$ articulated :nticipates pro"le areas for patients and so ore appropriate therapeutic pro%ision Helps a%oid sta8 acting9out and ipro%es "oundar$ aintenance Mr A has long,standing personality pro1le-s and is ad-itted to a psychiatric :ard a4ter ta/ing a li4e,threatening o5erdose. He is seen :ee/ly 1y =r < SHI on the :ard and rapidly co-es to 4eel that she is so-eone he can trust. =r < goes on holiday :ithout :arning hi- and he ta/es another o5erdose. eliabilit! $sta1lishing a relationship :ith a dependent patient is a necessary part o4 treat-ent and the ine5ita1le trans4erence -ust 1e sensiti5ely handled. 24 the doctor or /ey:or/er is unrelia1le this :ill not lessen the trans4erence 1ut :ill co-plicate it. Ma/ing and /eeping appoint-ents is pro4essional and is cal-ing 4or the patient. Onrelia1ility increases an8iety and apart 4ro- the discourtesy to the patient is li/ely to intensi4y insecurity increase patient hostility and under-ine the therapeutic alliance and patient co-pliance. A senior nurse :as as/ed to ta/e o5er a :ard 4or patients :ith personality disorder :here there had 1een a high rate o4 Kunto:ard incidentsL. He :as shoc/ed to And that there :as no 4oru- 4or diEerent disciplines to -eet no agreed clinical -anage-ent rules and that KpsychotherapyL appoint-ents :ere -ade on a casual 1asis and 4re@uently changed at short notice. He esta1lished a strict syste- o4 rules 4or the :ard and the unto:ard incident rate dropped su1stantially. "ttention to boundaries The pro4essional 1oundaries o4 the doctor6patient relationship pro5ide the structure :ithin :hich treat-ent can ta/e place. This includes -onitoring and setting li-its on 1oth the patient's and the doctor's 1eha5iour. So-e patients long 4or a personal relationship :ith the doctor or /ey:or/er and there -ay 1e pressure to pro5ide the responses o4 a 4riend rather than a pro4essional. Ms 7 :as an articulate and engaging patient :ho pleaded that her therapist sho: his care 4or her :ith a physical gesture not Fust :ith :ords. The therapist :as -o5ed 1y her distress and se5eral ti-es held her :hen she :as so11ing during a session. Ms 7 4ound these occasions deeply satis4ying and hoped that this :ould lead to a 4riendship. When therapy ended she 4elt hurt and hu-iliated that the therapist could lea5e her. Transference in reverse P%What's the diEerence 1et:een God and a doctorQ A% God doesn't thin/ he's a doctor. 24 trans4erence o4 e8pectations 4ro- pre5ious relationships can happen in all relationships :e should e8pect it to aEect doctors too. We all /no: doctors :ho apparently thin/ they are God and e8pect patients and Funior staE to 4ulAl the corresponding role. We also /no: doctors :ho are co-pulsi5e -others or :ho are a4raid o4 patients' de-ands or :ho are e8cited 1y high, ris/ treat-ents. Aside 4ro- these e8tre-e e8a-ples :e each ha5e situations in our :or/ that :ill trigger unthin/ing reaction at the e8pense o4 thought4ul response and -anage-ent. >aturally :e :ant to recognise our o:n preconceptions and 4oi1les so that :e do not i-pose the- too -uch on relati5ely helpless patients (or e5en colleagues0. Honest discussion :ith tea- -e-1ers can 1e a help 6 so can the training e8perience o4 super5ised psychotherapy :here our o:n assu-ptions can 1e re5ie:ed. So-e psychiatrists ha5e personal therapy to e8plore attitudes and 1elie4s that are not entirely conscious. Pre5ious Section >e8t Section #ountertransference Definition 7ountertrans4erence is the response that is elicited in the recipient (therapist0 1y the other's (patient's0 unconscious trans4erence co--unications (see <o8 !B0. 7ountertrans4erence response includes 1oth 4eelings and associated thoughts. When trans4erence 4eelings are not an i-portant part o4 the therapeutic relationship there can o15iously 1e no countertrans4erence. Box ;. <ountertransference Includes the feelings e%o'ed in the doctor "$ the patient&s transference pro*ections These can "e a useful guide to the patient&s expectations of relationships The$ are easier to identif$ if the$ are not congruent #ith the doctor&s personalit$ and expectation of his or her role :#areness of the transference=countertransference relationship allo#s re>ection and thoughtful response rather than unthin'ing reaction fro the doctor The degree to :hich the proFected role is congruent :ith so-e aspect o4 the personality o4 the recipient :ill aEect the li/elihood o4 his or her adopting it. 1. (a0 A proFected role -ay 1e 5ery diEerent 4ro- any aspect o4 his or her personality and the recipient is a1le to recognise that this perception o4 his or 4eelings or 1eha5iour is a product o4 the patient's -ind. Mr = :as a young -an :ith a long history o4 unsta1le relationships depressi5e episodes and alcohol -isuse attending a day hospital. He :as o4ten hostile to his /ey:or/er :ho- he accused o4 not caring :hether he li5ed or died. The /ey:or/er :as an e8perienced co--unity psychiatric nurse and :as conAdent that she :as neither negligent nor uncaring a1out her patient. She :as a:are that Mr = proFected a scenario in :hich he :as neglected and at ris/ :hile she :as e8perienced as a callous uncaring parent. Her recognition o4 this trans4erence allo:ed her to re-ain cal- and supporti5e and not to retaliate. '. (10 A role -ay 1e congruent :ith an aspect o4 the therapist's personality and he or she -ay unconsciously accept and collude :ith the proFection. Ms $ had a long history o4 repeated treat-ent episodes 4or eating disorder depression and relationship pro1le-s. Dollo:ing a -o5e to uni5ersity the uni5ersity general practitioner re4erred her to the local psychiatric ser5ice 4or treat-ent. She conAded in the young SHI that he :as the Arst doctor to :ho- she had 1een a1le to tal/ 4reely and that she had told hi- things she had ne5er told pre5ious doctors. The doctor enFoyed this idealisation and accepted that he had a special relationship :ith the patient. (See also 9Trans4erence in re5erse; a1o5e.0 Patients who do not get better Patients :ho appear to ha5e 1ypassed the rational therapeutic contract and :ho resist reco5ery o5er a long period o4 ti-e despite getting good con5entional treat-ent -ay 1e a particular source o4 4rustration. So-e 4ran/ly :ant a si-ple contact relationship :ith the doctor and ha5e no interest in treat-ent or cure. 24 the doctor gets angry and reFecting it is li/ely to increase the patient's an8iety and intensi4y his or her de-ands or cause the- to go to a colleague. Most doctors or tea-s resol5e this pro1le- :ith li-ited 1ut relia1le non,inter5entionist contact. Ms D :as a (",year,old :o-an :ho had -any depressi5e episodes and so-atic co-plaints throughout her li4e. She :as a 4re@uent attender at her general practitioner's (GP's0 surgery. The GP 4ound that a 1(,-inute -onthly appoint-ent /ept her relati5ely :ell and that her de-ands did not escalate. So-e patients ha5e a -ore destructi5e agenda :ith a :ish to engage the doctor in a therapeutic endea5our :ith the ulti-ate ai- o4 pro5ing that he or she the patient is untreata1le. This interaction re@uires a help4ul person :ho /eeps trying. Such patients -ay lea5e a string o4 4ailed therapists in their :a/e. Mr G is a -an o4 *" :ho li5es :ith his parents and despite high intelligence :or/s in a lo:,paid clerical Fo1. He has had -any treat-ents 4or depression and 9ina1ility to sort RhisS li4e out;. Whate5er is ad5ised and :hate5er interpretations -ade he returns to the ne8t session to e8plain :hy any change has 1een i-possi1le. At the end o4 his -ost recent 4ailed therapy he says sy-pathetically 92 don't :ant you to 4eel 1ad doctor 2'5e de4eated A5e therapists 1e4ore you;. eaction and reflection #eaction -ight 1e called therapist acting,out. 2t happens :hen :e either play the role unconsciously gi5en to us 1y the patient or :hen :e are a:are o4 not 1eing seen as :e are and respond :ith an8iety or anger. Much o4 the ti-e :e ha5e to tolerate not understanding :hat is going on :ithout panic/ing. We should not 1e pro5o/ed into precipitate and pre-ature action si-ply to reduce our o:n an8iety. 2n the :ee/ly :ard round the consultant sees that a patient :ith personality disorder has 1een an in,patient 4or si8 :ee/s. He 4eels that the patient is e8ploiting the ser5ice. He says angrily that the patient is getting dependent and -ust 1e discharged 1y the end o4 the :ee/. (See also KTrans4erence in re5erseL a1o5e.0 #eCection de-ands a reasona1le le5el o4 a:areness o4 one's o:n thoughts and 4eelings and a sound grasp o4 :hether these de5iate 4ro- good pro4essional 1eha5iour. Good practice includes% a @uestioning attitude to:ards one's o:n 4eelings and -oti5es recognition that :e all ha5e K1lind spotsL an understanding that staE are aEected 1y patients an understanding that patients are aEected 1y staE 1eha5iour a recognition that patients o4ten ha5e strong 4eelings to:ards staE. Dealing with countertransference Wor/ing :ith people :ho ha5e psychotic or chaotic -ental states can 1e stress4ul. Such patients ha5e a po:er4ul a1ility to proFect pain4ul states o4 -ind into the people :ho treat the-. We -ay 4eel con4used despairing angry or e5en -urderous. This /ind o4 stress can contri1ute to lo: -orale and 1urn,out and it is i-portant that :e And :ays to deal :ith it. Ose4ul strategies include% reCection% see a1o5e using the tea- to clari4y :hat a difcult patient proFects into the treat-ent relationship 6 o4ten se5eral -e-1ers o4 the group can contri1ute to an understanding o4 the patient's trans4erence to the tea- or to indi5iduals (3err 1???0 using a specialist psychotherapist to help understand :hat the patient is unconsciously co--unicating in his or her 1eha5iour undergoing personal therapy to 1eco-e -ore a:are o4 one's o:n unconscious needs and 4ears. Pre5ious Section >e8t Section #onclusion An understanding o4 trans4erence and countertrans4erence is essential to good practice in general psychiatry and -ay 1e help4ul in general -edical practice especially general practice. <eing a:are o4 the hidden agenda in the clinical relationship :ill help the doctor recognise so-e o4 the patient's :ishes and 4ears :hich are not 4ully conscious and :hich can contri1ute to conCict or intense dependency. The doctor is then -ore li/ely to 1e a1le to stand 1ac/ a little 4ro- the patient's e-otional de-ands and a5oid getting caught up in an agenda :here he or she too reacts e-otionally rather than thought4ully. This is therapeutic 1oth 4or the patient :hose clinical -anage-ent :ill 1e in4or-ed 1y a greater understanding o4 his or her needs and -oti5es and 4or the doctor :ho is less 5ulnera1le to 1eing e8hausted 1y unrecognised and intrusi5e proFections. Pre5ious Section >e8t Section Multiple choice $uestions 1. Trans4erence% 1. is an unconscious process '. is al:ays related to a pre5ious parental relationship *. is usually inappropriate to the present G. is o4ten part o4 relationships outside psychiatry. '. Trans4erence% 1. is al:ays da-aging to the doctor6patient relationship '. should al:ays 1e interpreted to the ptient *. is o4ten intense in patients :ith 1orderline personality disorder G. can 1e a5oided 1y 4re@uent change o4 therapists. *. Dactors that are i-portant in dealing help4ully :ith the trans4erence relationship include% 1. relia1ility o4 the doctor or /ey:or/er '. attention to 1oundaries in the relationship *. recognising the i-portance o4 the relationship to the patient G. discharging the patient @uic/ly to a5oid dependency. G. #ecognising trans4erence in the therapeutic relationship% 1. increases the :or/load o4 the /ey:or/er '. supports staE 1y helping the- understand :hat is going on *. encourages dependency in difcult patients G. anticipates pro1le- areas 4or patients. (. 7ountertrans4erence 4eelings% 1. -ay 1e stress4ul 4or the doctor '. can 1e a use4ul tool in understanding the patient *. should 1e interpreted to the patient G. -ay 1e clariAed 1y tea- discussion. Pre5ious Section http%))apt.rcpsych.org)content)H)1)(!.4ull
(Oxford Medical Publications) Graham, Philip Jeremy - Turk, Jeremy - Verhulst, Frank C-Child and Adolescent Psychiatry - A Developmental Approach-Oxford University Press (2007)
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