Managing transference between patients and clinicians
Key Takeaways
Transference refers to feelings that the patient has about the physician, whereas countertransference refers to feelings that the doctor has about the patient.
Transference comes in many forms, which can be positive or negative based on how it affects the therapeutic dynamic.
When managing transference, the clinician must establish and adhere to boundaries while remaining empathetic.
The dynamic between the doctor and patient is the core of treatment. It’s important that the patient and the clinician gather insight into the feelings that they have for each other.
The patient’s reaction to the doctor is referred to as transference, and the physician’s feelings for the patient are referred to as countertransference. Appreciating these psychological phenomena can help guide interactions with patients and facilitate healing.
Types of transference
Repeated feelings and behaviors that arise early in the context of a therapeutic relationship can relate to transference.
According to an article by Don Ross, MD, in The Maryland Psychiatrist, “There is always a kernel of truth or reality in the transference. The patient does not create this out of thin air, but is picking up on something going on in the therapeutic relationship. However, transference also is regressive, and, to that extent, it is exaggerated or distorted by the childhood pattern.”[]
Regarding transference, the patient should feel unfettered to discuss their feelings about the clinician. Doing so can allow the patient to connect experiences from their earlier lives to the sentiments they currently feel. It’s important that the physician remains open, inquisitive, and nonjudgmental.
The authors of an article in the AMA Journal of Ethics pointed out that the doctor-patient relationship is fraught with emotions, writing, “The power imbalance in this relationship between a patient in need and a clinician looked to for help can revive patients’ memories of relationships with earliest caregivers and elicit powerful feelings of love, hate, longing, and dependency.”[]
Types of transference include:
Positive transference. This occurs when the patient feels that the physician is compassionate, trustworthy, or attentive.
Negative transference. This happens when the patient views the physician as untrustworthy, cold, or adversarial.
Sexualized transference. This involves thoughts that are intimate, romantic, and sensual.
Superego transference. This occurs when the patient views the physician as a strict and uncaring figure (like a parent during childhood) and works hard to win their approval.
Idealizing transference. The patient views the physician as a larger-than-life, great, benevolent protector (ie, an ideal parent), and wants to feel special.
Sexualized transference presents in two forms: erotic, which is positive, and eroticized, which is negative.
With erotic transference, although the patient has sexualized or romantic thoughts, they realize that they are unrealistic (ie, egodystonic).
This form does not interfere with treatment. On the other hand, eroticized transference is more intense, and the patient is irrationally preoccupied with sexual fantasies with the hope they come true.
According to Ross in The Maryland Psychiatrist, with erotic transference, “The patient ‘falls in love’ with the therapist … Often, the therapist must help the patient overcome considerable shame for having these wishes before they are openly expressed. Once expressed, they can be analyzed as the pattern of loving that has trapped the patient in their unhappy romantic life.”
Positive transference promotes the willingness of patients to discuss their feelings and form a therapeutic partnership with the physician. Conversely, negative transference poses challenges that interfere with treatment.
Deciphering countertransference
The physician also brings their memories to every clinical encounter.
These experiences can evoke emotion in the physician that, along with patient transference, could unconsciously shift the doctor’s reaction to the patient.
“Countertransference, when utilized correctly, can help the physician to understand how patients relate to others and experience the world around them,” wrote the authors of the AMA Journal of Ethics article.
"The key is to recognize, accept, and discuss these feelings, in supervision or consultation, if necessary."
— Noorani, et al.
Working with feelings
The clinician may have trouble keeping an open, accepting perspective if the patient expresses sexual or aggressive emotions targeting them. It’s important for the clinician to adhere to therapeutic boundaries while remaining empathetic so the patient doesn’t feel abandoned or rejected. By doing so, the therapeutic relationship won’t end prematurely.
The doctor should identify the transference and, if possible and prudent, discuss it with the patient. They can broach the subject by explaining that much can be gleaned from interpreting these emotions with regard to relationships with other people in the patient’s life. It’s also important to establish—and stress—boundaries.
Sexualized transference can derail the therapeutic alliance if managed improperly. The clinician must examine their own countertransference when addressing the patient’s sexual fantasies.
The doctor should realize that the patient’s fantasies are driven by the context of therapy, and not due to any personal characteristics.
This realization will limit potential feelings of guilt, shame, or narcissistic gratification.
If the doctor has sexual feelings for the patient, this can result in either providing too much attention to them or distancing themselves. Seek outside help if the doctor’s feelings interfere with care.
Another take on the value of recognizing and leveraging the power of transference and countertransference is to maximize the placebo effect and minimize the nocebo effect. This strategy is espoused in an article published in the Archives of Psychiatry and Mental Health.[]
The literature supports the ability of the physician to sway the sentiments of a patient towards medication and treatment. This phenomenon can play into the “how” of prescribing, wrote the article’s author, Jose Luis Turabian, MD, PhD.
“Even when there is a true pharmacological effect of the prescribed active drug, it should be expected that its effect will be modified considerably by the optimism or confidence expressed by the doctor before the treatment,” Turabian wrote.
"The results of the treatments are more dependent on the personality of the therapist than on the pharmacological effect or the technique used."
— Jose Luis Turabian, MD, PhD
What this means for you
As a clinician, it’s important to recognize that transference and countertransference are normal aspects of the therapeutic dynamic. The key is to recognize and explore these feelings, set boundaries, and remain empathetic. The hope is that this transference is positive and doesn’t interfere with treatment.