November 2021 Communication Tip
Transference and Countertransference
This month’s Communication Tip is about some of the psychological stuff that lies under the patient-clinician relationship and the quality of communication that emerges from there.
I’ve wanted to write about transference and countertransference for a while and a wonderful paper was just published in the Journal of Palliative Medicine that creates a great Communication Tip opportunity. It’s entitled “The Meaning of Together: Exploring Transference and Countertransference in Palliative Care Settings.” (JPM 2021;24:11). The title includes palliative care settings (the case is a patient with cancer), but, as you know, I consider you all palliative care clinicians so this really does apply to all of us.
The paper explores the “in-between spaces of the clinical encounter” and argues that a “successful interpersonal relationship is the essential factor” in good clinical outcomes. Furthermore, that “the patient and clinician form a relationship that is complex, partially nonverbal, and rich with potential for healing as well as misunderstanding.
The authors recognize that identifying and managing transference (the patient’s feelings toward the clinician based on their previous significant relationships and experiences) and countertransference (the clinician’s reciprocal feelings about the patient) allows the clinical relationship to be most effective, enhancing empathy and connection.
You might notice that at the core of the clinical encounter, there are “two people in the room” – that is, two people in the same time and same place, face to face with the powerful reality of serious illness. Both of those people (patient and clinician) bring their own histories, own experiences, own mood, and own patterns to the encounter. As the authors state, “Whenever two people encounter one another, there is an immediate rush of initial impressions, many of which are based on intuition, inclination, and reminiscence.”
Becoming more aware of transference and countertransference allows the clinician to do what I’ve argued for in this column previously: to notice and choose. If you can notice what’s going on, you can choose how to behave, rather than just acting out of old patterns and well-practiced, but perhaps not currently particularly effective habits.
For example, when someone is angry at you (perhaps starting when you were a child), do you typically just get angry yourself? Do you feel inadequate? Do these feelings tend to lead you to work harder or less hard on a patients’ behalf?
This is not about being a patient’s psychotherapist, it’s just about noticing what’s in the room so you can do your job as well as possible.
This month, try to identify patient behaviors that appear to be transference from old patterns onto you. Try to recognize your own behaviors that may be countertransference from you onto your patient. Once you have noticed what is going on, you can choose how to behave.
Noticing allows you to make good use of the psychological clues in the relationship and to use them to help direct your behavior (and your communication). It is actually exhausting not to understand the psychological underpinnings of an encounter or another’s behavior. “The more effectively we can process our own experiences, the more resilient we can be for the next patient.”
Ultimately, recognition of transference and countertransference makes a little space in the clinical encounter for some self-compassion. As the authors point out, in recognizing expectations and old, inevitable patterns, “we gain perspective and often are able to soften our expectations for what a good-enough clinical encounter could be.”
Enjoy being one of the two people in the room, just for that one moment in space and time. You are enough.
Best,
Mike