Transference and countertransference

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Transference and countertransference in communication between doctor and patient
Patricia Hughes and Ian Kerr APT 2000, 6:57-64. Access the most recent version at doi: 10.1192/apt.6.1.57

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Transference and countertransference Advances in Psychiatric vol. 6, p. 57 APT (2000), Treatment (2000), vol. 6, pp. 57–64

Transference and countertransference in communicationbetween doctor and patient
Patricia Hughes & Ian Kerr

“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself“ George Bernard Shaw, Maxims for Revolutionists.

Health care is a complex business. Medical treatment could be so much more reliable if it were not compromised by the imprecise and unpredictable nature of human motivation.But even the best treatment will not always be good enough, and patients who hoped for a cure will be disappointed, afraid and angry. Some patients have confusing expectations. Although rationally we know that being ill or having poor relationships or not being able to work is unpleasant, some people have mixed feelings about losing their symptoms. Patients are not always grateful for our honestattempts to help them, and a few emerge almost triumphant from a long treatment with symptoms intact. Doctors cannot escape the burden of their own motivation. Most of us believe that the ability to feel for our patients is an important dimension of treatment. This comes at a price: we have our own needs and desires, and the therapeutic relationship is a fertile ground where these may be playedout.

patient with a sore throat has the rational expectation that the doctor is appropriately qualified, will do a suitable examination and investigation, and will prescribe relevant treatment. The doctor expects that the patient who has sought treatment will generally do his or her best to comply with the treatment requirements such as collecting a prescription and taking the prescribedmedication. The therapeutic alliance in this transaction has a good chance of survival: the negotiation is straightforward and there is unlikely to be a covert agenda. However, as the patient’s needs become more complex, the therapeutic alliance may be distorted by the wishes and expectations of the patient and even occasionally the doctor. These may be fully conscious and explicit, or may not be entirelyconscious and so be communicated in a non-direct way (Balint, 1957) (see Box 1).

The covert agenda
We need and want a variety of relationships throughout our life. Although this primary need is biologically determined by genes that promote survival of the species, the precise nature of the relationships we seek is heavily influenced by our previous experience. For example, attachment researchhas conclusively demonstrated the effect of a parent’s attitude to attachment on the infant’s subsequent behaviour with him or her (Fonagy et al,

The therapeutic alliance
A cornerstone of treatment in medicine is the therapeutic alliance, whereby patient and doctor establish a rational agreement or contract which supports the treatment (Greenson, 1985). So the

Patricia Hughes is a seniorlecturer 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 SW17 0RE, Tel: 0181 725 5521/31; e-mail: She is interested in teaching medical students and in making psychotherapy understandable to psychiatric trainees. Ian Kerr is Senior Registrar in...