Everyone is much more simply human than otherwise.

Sullivan, 1953, p. 32

Transference and countertransference are psychoanalytic concepts first identified by Sigmund Freud (1905/1955). Transference refers to the phenomenon in which patients transfer to the clinician feelings about persons who were important early in the patient's life. The American Psychological Association Dictionary of Psychology defines countertransference as the clinician's “unconscious reactions to the patient and to the patient's transference” (VandenBos, 2007, p. 239). Psychoanalytic theories, along with definitions of transference and countertransference, have evolved during the past century since Freud coined the terms. Today, relational psychological theory acknowledges that, as Stolorow and Lachmann (1995/2000) observed, “Transference and countertransference together form an intersubjective system of reciprocal mutual influence” (p. 42). This mutual influence can manifest as the clinician's countertransference. In relational psychological theory, countertransference is not seen as taboo in the patient–clinician relationship, but is seen instead as an instrument that is necessary to the relationship, as a means to inform the clinician's understanding.

Countertransference can arise for clinicians due to the nonreciprocal professional duty to care that is intrinsic to caring professions. Silver (1999) observed that while transference and countertransference exist in all human relationships, transference and countertransference are “most notable and potentially problematic in those relationships involving the 'imbalance of power' (p. 265) inherent in the 'power relationship of caring professions' ”
(p. 267). These professional relationships—relationships in which the obligations and duty of caring are one-sided—can invite misplaced emotional responses and countertransference. Nonreciprocal professional relationships include nurse–patient relationships (O'Kelly, 1998), doctor–patient relationships (Stein, 1985), and relationships between social workers and patients (Berzoff & Kita, 2010), among others.

According to Silver (1999) countertransference emanates from both professional training and personal experience. It is therefore important for clinicians to recognize that their history, including personal experiences and professional training, “filters, informs, and organizes” their perceptions and responsiveness to patients (Orange, 1995, p. 63). Orange parses further the clinician's responses to the patient and the clinical setting and proposes that we reserve the term “countertransference” for the clinician's “reactive emotional memories that interfere with empathetic understanding” and “optimal responsiveness” to the patient (1995, p. 74). In contrast to countertransference, Orange introduced the term cotransference to describe influences of the clinician's history and personality that help to empathetically understand the patient's experience “through our [the clinician's] own equally subjective experience” (1995, p. 66). Orange (1995) concludes: “We must know and acknowledge our cotransference, our point of view or perspective, if we are to become capable of empathy” (p. 71).

Another source of counterand cotransference can emerge from projection bias (Loewenstein, 2005). Projection bias occurs when one attempts to predict how another will behave, yet errs in the prediction as a result of underestimating or overestimating “differences between oneself and others” (Loewenstein, 2005, p. 99). In the case of ACP, the clinician may project his/her own projective biases into the ACP process.

One last yet important point about counterand cotransference as conceptualized by Orange (2006) is that the clinician's “self-expectations” are vital. The author reminds us, as she reminds herself that, at times, “there is no way to fix the situation or 'cure' the patient, so I must accept my own powerlessness to help” (p. 16).

Counterand cotransference are important in discussions about ACP because contemplating EOL care and facing mortality, whether one's own or that of another, can evoke existential anxiety, fear, and uncertainty in both the patient and the clinician. Attempting to maintain assumptions of objectivity, paternalism, and autonomy can camouflage the clinician's selfexpectations, projection biases, feelings of powerlessness, and unconscious death anxieties. If these hidden assumptions remain unidentified and unacknowledged, they can lead the clinician to, perhaps unwittingly, project his/her own values into the patient's ACP process. The clinician may also defend against his/her own anxieties and fears about death. As a result, rather than helping the patient develop and document advance care plans,
the clinician may unknowingly influence the patient's ACP formulation or avoid discussions about ACP, planning for EOL care, and death altogether.

Consequently, the IRMOC challenges clinicians to recognize the ways in which their self-expectations and personal views accompany, or are perhaps hidden by, assumptions from medical training and previous experiences. Relatedly, the IRMOC asks clinicians to reflect on the ways in which countertransference and projection bias can inadvertently influence the ability to facilitate communication about ACP with patients and their loved ones.

Reflective Practice: Discovering Countertransference and Cotransference

Counterand cotransference involve personal matters, which can have public implications. These dynamics may at times either hinder or help a clinician's ability to facilitate communication about ACP. Only when counterand cotransference are identified and understood can professionals ensure that they have made every effort to provide the best professional care assisting patients in developing their advance care plans. Therefore, clinicians must be able to identify the ways in which their personal experiences and professional training are impacting their clinical practice. At the same time, clinicians must both respect these experiences and advocate for the patient's advance care plans. To do this—specifically, to identify and address counterand cotransference—requires reflective practice.

Reflective practice is the act of reflecting on the clinical encounter with the intent to evaluate and continually improve the clinician's proficiency. Reflection has the intent to assess and search for meaning, and to understand how the clinician has been affected by, and has responded to, the patient (Johns & Freshwater, 2005; Ruth-Sahd, 2003). In the process, clinicians ask themselves questions along the lines of: How have I been affected by this encounter with this patient? How has my personal past and professional training influenced my clinical receptivity and my responsiveness to this patient? How have these affected my ability to engage in communication about ACP? In prompting these questions the IRMOC promotes moments of quiet introspection and encourages compassion for both the patient and for the clinician.

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