Countertransference in the Patient-Doctor Relationship

Psychiatrist Dr. Martin Greenwald talks about countertransference in the patient-doctor relationship.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Martin Greenwald talking about countertransference.

[00:00:11] Dr. Greenwald: More often than not, I see referrals as serving the purpose of a doctor getting rid of a patient that he finds irritating and dressing it up in a noble, you know, "I'm not good enough to care for you. I need to send you to someone better."

[00:00:30] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.

I'm Adam Cifu, and today I'm joined by Dr. Martin Greenwald. Martin is a graduate of St. John's College in Annapolis and the Pritzker School of Medicine here at the University of Chicago. An interesting pedigree, which we can talk about. He stayed on for his residency at the University of Chicago Medical Center and then sought additional training at the Chicago Psychoanalytic Institute.

His current practice combines inpatient psychiatry and a small private psychotherapy practice. His interests and expertise are wide-ranging to say the least. Martin, thanks so much for taking the time to talk with me today.

[00:01:26] Dr. Greenwald: Thank you. It is a pleasure and honor to be here.

[00:01:29] Dr. Cifu: So before we talk about my sort of internist view of countertransference, I want to actually talk to you as an actual psychiatrist, not for therapy, but just to define terms. Um, so what is countertransference and kind of why is it important?

[00:01:45] Dr. Greenwald: Right. So, in thinking about countertransference, it may be helpful to start thinking about what it's counter to, and traditionally understood this is the patient's transference. Without going too deeply into the history, a little background I think will help.

So the early theories of transference and countertransference, which go back to Freud, understand transference to refer to the unconscious mapping of emotions, fantasies, feelings, relational models, patterns, patterns of being and living from the patient's past onto the therapist and the current therapist-patient relationship, which often leads to the patient responding to the therapist with say, expectations or emotions that are in some ways anchored in prior relationships.

And often this mismatch can lead to conflict or symptoms. And it had, and still has a central importance in psychoanalysis, uh, because the analyst being able to recognize the transference, contain it, manage it, and interpret it for the patients was, in a correct way, thought by Freud and many subsequent analysts to be the crucial factor in psychoanalysis, the curative factor, the healing factor.

So countertransference originally was thought of by Freud roughly as the situation where the analyst's own unconscious has been either stimulated or influenced by the patient, often by the patient's own transference towards the analyst.

This could be the result of unconscious conflicts from within the analyst, or even the fact that analysts are human too. And Freud viewed countertransference as very, very dangerous for a few reasons. First, Freud did believe that the analyst always needs to maintain some control of his emotions.

It doesn't mean not showing emotions or not being spontaneous, but he said something to the effect of it always needed to be measured. And the unconscious is decidedly not measured. And in some ways they wrote about it like a primitive beast that could creep in and kind of take hold.

[00:03:52] Dr. Cifu: Sure. Got it.

[00:03:53] Dr. Greenwald: Wreak havoc. Second, especially in the early days, patient transference was often erotic. And when you have a situation with this new field, most analysts were men, many of the patients were women, with intense erotic feelings coming up, an analyst with either insufficient training, character defects or others, can and were led into inappropriate relationships with patients.

[00:04:18] Dr. Cifu: Right.

[00:04:18] Dr. Greenwald: Often thinking they were doing the right thing, they were swept up or in the grip of countertransference. And so in that way it could really just be detrimental to the whole project of analysis and needed to be controlled. So as thinking about transference and countertransference developed through the 20th century, both concepts widened generally, and although there's still disagreement about details, I would say, there's a lot of disagreement, transference still basically means the things the patient brings to the current relationship, usually from the past, which are some way either dysfunctional or worth understanding. Debates about the unconscious part of it are less central now than the fact that the patient seems unaware of it for one reason or another and it's causing trouble.

[00:05:00] Dr. Cifu: Okay.

[00:05:01] Dr. Greenwald: Countertransference has also broadened in its meaning. I think a lot of psychodynamic therapists would basically say it refers to the various emotions or other reactions from the therapist, or even referring to the total person of the therapist as viewed in the context of the therapist-patient diad.

And that the source of the therapist countertransference comes from the patient's transference and our response to it, what we might call the real relationship, the non-transferential relationship, as well as the therapist's own history. And if the therapist's own baggage gets in the way and he can't deal with it, then we start going down the avenue that Freud feared with the negative transferences that...

[00:05:45] Dr. Cifu: Sure.

[00:05:45] Dr. Greenwald: I'm sorry, the countertransferences that could lead to acting out or other problems.

[00:05:51] Dr. Cifu: I like to hear about how things have broadened out in the 20th century because as you went back to the original definitions, when I get to my definition, it made me feel like I was sort of practicing some sort of pop psychiatry.

So let me sort of say, you know, when I think about countertransference, and I think it's actually the way my peers who are not psychiatrists, I really think about it as just my reaction to the patient, which seems, you know, very conscious or at least really manifest. There's just a whole lot of people who, you know, I react strongly to, maybe not a whole lot, I think it's a small number of my patients.

And the reactions, you know, can be positive, can be negative, it sounds like a little bit what you talked about, but like given that the reactions to these patients are strong, these are visits that I feel like I need to be most mindful about. You know, am I responding to the patient, or am I responding to my feelings to my uncle, you know, who the patient kind of reminds me of or sounds of, or whatever. So when you think about this, and maybe either in your own practice or if you think of, you know, just an internist who's managing hypertension and diabetes, like, how do you think about kind of managing your own reactions to a patient?

[00:07:10] Dr. Greenwald: Yeah, good question, and I think this is a question for all physicians. It's easy to go over the counterproductive ways to deal with this. So the counterproductive ways, you can ignore the emotions, blame it on the patient, right? So you might say, "My countertransference is that my patient's a jerk," which is not very helpful.

Um, and these usually lead to a treatment failure, or in extreme cases, especially when with a patient with significant issues could lead to boundary violations as well. On the positive side, so the first thing to do is exactly what you said, which is noticing that something is happening, being aware that you're having a particular response to a particular patient, and that it says something both about you and the patient.

It's not always just I was having a bad day, or this patient was difficult. Sometimes it's that, but often there's more on there, there's more layers.

[00:08:00] Dr. Cifu: So do you ever use it, you know, almost diagnostically that you know, "Boy, this patient is making me feel X and I feel like that when I'm with someone who's depressed or someone who's particularly, you know, narcissistic or whatever," and that you can read it and at least use it as a clue to say, "Am I dealing with, you know, X, Y, or Z?"

[00:08:21] Dr. Greenwald: Right. Psychoanalyst and psychotherapists have thought for a long time that one of the essential skills to learn is not just recognizing the patient's transference, but one's own countertransference. And at least in theory, if one has sufficient insight and is experienced enough with therapy, and especially has had one's own therapy so that you can distinguish between your own issues and things occurring within the treatment that being able to recognize this is a countertransference that is diagnostic.

[00:08:54] Dr. Cifu: Got it.

[00:08:54] Dr. Greenwald: Versus this is a countertransference that is a sign of a personal issue within me that I need to work on. And I would encourage, it doesn't take going into therapy for a physician to do this, just reflecting on your temperament and relational patterns. So thinking, how much do you need to be seen as always caring, never losing hope, always being in control.

Maybe you fall somewhere on the martyr, you know, spectrum of the martyr complex, and if you can recognize these tendencies in yourself and also spot which patients tend to bring them out, that can be a useful way of connecting with the patient. Specifically, it can give you a window into what the patient is bringing into the encounter.

So often if there's a very difficult patient and it seems after repeated visits we're just banging our heads against the wall or frustrated or something else, instead of looking at the content of what the patient is telling us, we can at least hypothesize maybe the patient is trying in some desperate, unconscious way to get us to feel and experience the pain and distress they're in. Right? And sometimes that's by frustrating us to a very high degree. And other times it could be a window into seeing "Hmm, the way that I'm interacting with this patient is starting to sound like all of those abusive ex-boyfriends that she had."

"And is there a dynamic here that we're both unwittingly playing into? Not just the patient, not just me, but both of us." That if we can spot it in the moment and talk about it, that actually gives us room to move forward, instead of, you know, the relationship just disintegrating.

[00:10:34] Dr. Cifu: It's interesting to hear you talk about it in that depth, because I've always been suspicious of using my feelings about someone diagnostically, like, how could you possibly, you know, get the test characteristics and draw out an RCS curve to like, you know, how good is that chest pressure for diagnosing an anxiety disorder?

But when you bring into it that it's also, you know, my reaction to the individual and everything that goes with that, rather than maybe just their anxiety, you get the feeling that you really need to know what you're doing before you start using that.

[00:11:07] Dr. Greenwald: I think so, and I would certainly caution against any kind of reflexive attitude of assuming that your own frustrations are just a mirror of the patients.

But one way that this can be approached, I think, without too much training beyond what most physicians have is if you feel that there is something going on, that the doctor-patient relationship isn't quite functioning as it should, just bringing it up with the patient, and saying, for example, um, "Hey, I've noticed that over the last few appointments you and I have seem to be getting into fights over who's in more control."

Or that "You say you're feeling better, but things aren't looking better. Can we... And I've been feeling frustrated about it. I wonder, are you feeling frustrated too?" Right? And that doesn't put any onus on the patient. It leaves open the possibility that you can take the blame if things are going wrong, and it gives them an outlet to say, "You know, yeah, I am frustrated actually."

But if that's not brought up, it's hard to know how I could...

[00:12:07] Dr. Cifu: Yeah. That's a great thing to hear. I'm always a big fan of sort of naming emotions in the doctor-patient relationships, the, you know, "You feel, you sound angry, what are you worried about?" Um, but putting it on the table, and I like the way you put it, that it may sort of open a path in the relationship, even if it's, "Yeah, boy, this isn't working. I need a new physician." Right?

[00:12:32] Dr. Greenwald: Exactly. And I think it also opens up a path to thinking about transference and countertransference in ways that are even more useful for non-psychiatrists. So recently there's a lot, been more and more been written about patients' transference to and from medications. That we don't only have transferential relationships to other people, but also to things.

So I think we all know of patients who might hold their medications with either unusual esteem or fear or just emotions that seem out of proportion to what you're dealing with. And the patient's reactions to those medications are important and how we use them. So most of us have probably had an encounter where we leave the office visit saying, "You know, I really gave that prescription to shut them up."

[00:13:21] Dr. Cifu: Yeah.

[00:13:21] Dr. Greenwald: Right? And if we can analyze those situations when our behavior, our prescribing habits deviate from the norm, we can look closer and see, "Hmm, are those situations where the patient and I are subtly getting wrapped up in a drama that I'm not fully aware of?"

[00:13:39] Dr. Cifu: Got it. And it's complicated because how we use medications, you know, we all know that basically any pill, 20% of its effect or thereabouts, you know, is the placebo of giving a pill.

And so it's separating, you know, maybe the good you're doing by providing this medication beyond just, you know, the pharmacology of the medications. But I understand what you're saying, that there can certainly be a danger there, if you're giving them medication for a reason, you know, which is sort of incorrect, right?

[00:14:12] Dr. Greenwald: Right.

[00:14:12] Dr. Cifu: I do though, you know, I have a lot of people who say after we've, I'll use a psychiatric medication as example, you know, after we've weaned off their benzodiazepine that they've been on for sleep, that they're like, "As long as the bottle's in the house, I sleep well."

[00:14:27] Dr. Greenwald: Mm-hmm.

[00:14:27] Dr. Cifu: "You know, if it's not there, and I know it's not an option to take, I kind of fall apart."

[00:14:32] Dr. Greenwald: Yeah. I've had a patient once tell me, we were doing split treatment where I was prescribing his medications and he was seeing a psychoanalyst for intensive treatment and he reported something very similar that his use of benzodiazepines had been slowly decreasing. And I asked what he attributed it to and he said, "Well, when the bottle's in my pocket, my analyst is in my pocket." Right? His analyst was being carried around with him in what was at that time a comforting, useful, supportive way. Perhaps later that would need to be... The training wheels will need to come off, but yeah the medications are a very close part of the doctor-patient relationship, almost a third member in some cases, I think.

[00:15:14] Dr. Cifu: I think the early Protestants would like object to the idolatry of having your therapist in your pocket as a bottle.

[00:15:21] Dr. Greenwald: Probably.

[00:15:21] Dr. Cifu: So one last question, which you I think kind of alluded to a little bit, you know, are there instances when, and I'm going to stick with countertransference as an internist, you know, where your reaction to a patient can be so strong that you can't kind of reach that, like effective neutrality that we're supposed to have with patients, right?

That you can't sit there and think about medicine because so many other thoughts are coming in, your feelings are so strong, you know, whether positive or negative, that you would say, "Huh, maybe this is someone that it's not right for me to take care of because I'm likely to make an error because of everything else is going on in my head."

[00:16:05] Dr. Greenwald: There's a few answers to this, I think the broadest general answer is no. I think those situations are actually quite rare. This is quite debatable, but at least in mental health, there's been more and more of a trend towards patients requesting therapists and psychiatrists who might match up with them in particular things, either, you know, by sex or race or something, or religion and similarly psychiatrists or therapists offering, you know, services catered to that and the evidence is not so good that that actually improves anything.

[00:16:39] Dr. Cifu: Okay.

[00:16:39] Dr. Greenwald: And really helps or helps the patients. Um, and I think we're getting into the risky waters, would be physicians using this justification of overwhelming countertransference to get rid of patients they find inconvenient or just don't like. In my opinion, in my experience in teaching and working with other psychiatrists, the vast majority of cases of countertransference that seem like they are going to be so significant that they would derail treatment really mean the therapist is in need of consultation and supervision and has things to work out, and then it usually works out fine.

And I think for any physician, psychiatrist or not, you know, one of the first things to do if you think you're in this situation is A) consider the fact that when your emotions are already high, you may have already made some errors and you may be already in the grip of some kind of enactment with the patient, and that's something to be aware of and that can be very informative if you pick up on it.

Another thing to do is seeking consultation from colleagues if necessary, ones even outside the institution, to prevent institutional biases from creeping in, and I suppose at the very end of the day, if you really feel that something is prohibiting you from treating the patient, you know, the right thing to do would be referring them in a responsible way, but more often than not, I see referrals as serving the purpose of a doctor getting rid of a patient that he finds irritating and dressing it up in a noble, you know, "I'm not good enough to care for you. I need to send you to someone better." So I think it's something to do thoughtfully. One other thing I would say is...

[00:18:14] Dr. Cifu: Let me just cut in.

[00:18:15] Dr. Greenwald: Sure.

[00:18:15] Dr. Cifu: It's interesting, there was a discussion on a previous episode of this podcast with Dr. Scott Stern talking actually about terminating care with patients. And in that conversation we did sort of talk about, you know, the real risk of bias since physicians have so much power when they decide to terminate a relationship, and should really say like, "Is there one group of patients who I'm ending the relationship with more frequently?" I think, what you say is really correct because that tends to happen so infrequently in practice and it's usually from such obvious egregious occurrences, events, that something as subtle as what we're talking about is seldom, if ever, the driving force.

[00:19:02] Dr. Greenwald: And I think even in those cases, if you feel that treatment is being derailed, in almost all cases, and I can talk about an exception, it may be worth bringing it up to the patient at a point saying, "Hey, it looks like things haven't been going well. I'm worried the treatment's getting derailed. Is this something we can talk about?"

[00:19:16] Dr. Cifu: Right.

[00:19:17] Dr. Greenwald: The one exception, and I think this is admittedly a rare case, is if a physician felt that there was some issue of sexual attraction, or other kind of sexual boundary issue that was interfering with treatment. That is something I believe, and I think most psychiatrists would agree with me, should really never be disclosed to the patient, that kind of countertransference. It's one thing to say, "I felt frustrated by what you were doing." It's another thing to indicate that there might be something sexual because that's just too close to seduction and flirtation. And that would be something to keep from the patient, but I think also, thankfully, those are rare cases, when that kind of thing happens and usually represents an impairment on the part of the physician, as with something like alcoholism or addiction. And those are cases where you don't want to bring in countertransference as an excuse. The physician then just needs to deal with his own problems.

[00:20:07] Dr. Cifu: Right. Right. I get that. You almost get to the point where the harm of carrying on a relationship, you know, outweighs the benefit of it, and you need to step away at that point.

Martin, thank you so much for talking to me today. This was a really interesting conversation and I think one of those things that, as I step away from it, I will think about in my own clinical care, which doesn't happen a lot on a podcast. So that's helpful.

[00:20:28] Dr. Greenwald: Me too. And thank you again for having me. It was tons of fun.

[00:20:32] Dr. Cifu: Thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for clinical excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.