Countertransference Issues in Psychiatric Treatment

Countertransference, the clinician’s emotional reaction to the patient, is constantly present, strongly influences the therapeutic relationship, but often is overlooked. It is not limited to psychoanalytic treatment but exists in pharmacotherapy, consultation-liaison, forensic, and hospital psychiatric settings. For those psychiatrists who are not familiar with the newer developments in countertransference theory, this book, part of volume 18 in the Review of Psychiatry series edited by John M. Oldham, M.D., and Michelle B. Riba, M.D., will help them become acquainted with how their reactions to patients can be a potential problem but also how it can be extremely useful in treatment and consultation.

Many therapists are mostly familiar with Freud’s early work, in which he discussed the emotional reaction of the analyst to the patient. Freud saw countertransference narrowly and subjectively as stemming from the transference of the analyst’s unresolved issues onto the patient and thus an obstacle to treatment. This concept was in keeping with Freud’s one-person psychology, with the analyst needing to be objective and serving as a blank screen. Freud attempted to establish universal rules from which deductions could be made. This was in keeping with nineteenth-century thinking, which was linear and mechanistic.

The fine chapter by Glenn Gabbard reviews the work of Kleinian analysts, who embraced a two-person interactive psychology and established a broader or objective view of countertransference. They and others noted how some patients needed to induce the therapist through projective identification into unconsciously enacting aspects of the patient’s internal world of object relations. Now the rest of psychoanalysis has adopted this inductive empirical stance, which encompasses intrapsychic as well as interpersonal, family, group, cultural, and neuroscientific perspectives. Gabbard considers that the two forms of countertransference are not sharply demarcated, since the patient’s projective identification needs to find a hook in the therapist’s personality. This furthers the interpersonal approach, suggesting that countertransference is jointly created. Bion noted that in early child development the mother contains and detoxifies the infant’s behavior before the infant reinternalizes it. This seems to be the same process that occurs in psychotherapy, where the therapist contains, processes, and interprets countertransference, which then can be worked through verbally. If enactment by the therapist occurs, the patient’s pathology is reinforced and boundary violations can occur.

The chapter by John Maltsberger provides helpful information in treating the difficult problems with the suicidal patient with borderline personality disorder. These patients use splitting and projective identification to get rid of an aspect of the self and strive to induce clinicians to experience and enact this aspect as if it were their own. When seduction or idealization of the therapist occurs, it could lead to boundary violations; when provocative and demeaning behavior is expressed, it could result in the therapist being cruel or rejecting and lead to suicide. Another danger the author discusses is that these patients can try to give the therapist the responsibility for keeping them alive, which, if accepted, can lead to coercive bondage.

The chapter by Marcia Goin on countertransference in general psychiatry is useful in its discussion of a wide variety of psychiatric issues such as medication compliance, split treatment, hospitalization, assaultive patients, consultation-liaison, forensic psychiatry, reimbursement, and when the psychiatrist is ill. Countertransference issues exist even though the psychiatrist may not be aware of them, and sensitivity in dealing with them is crucial.

The chapter by John Lion on countertransference in the treatment of the antisocial patient deals with the vicissitudes of working with violent, narcissistic, and drug-addicted men as well as antisocial women. This is especially useful to the young clinician, who may be naive, may overidentify with, or be rejecting of these difficult patients.

The chapter by Francis Varghese and Brian Kelly deals with countertransference and assisted suicide. They point out the complexity of this situation, which cannot be solved by simply evaluating the competence of the patient. Evaluation alone limits the psychiatrist and undermines the frame so that further exploration of the motivation for wanting suicide is obstructed. Many of these patients are inadequately treated for pain or depression or feel abandoned by their social network. The countertransference of the physician may result in the wish to see the patient dead as a result of feeling helpless or the wish to achieve an illusion of mastery over death.

This is a clearly written and informative book that reviews the theory and technique of dealing with countertransference and contains much helpful information for the beginning and experienced psychiatrist and psychoanalyst. It deals with countertransference not only in analytic or psychodynamic therapy but also in a wide variety of other psychiatric settings. The book helps to sensitize the clinician and provides information regarding the recognition and treatment of the ever- present phenomenon of countertransference.