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Gordon, R.M.(1997). “Handling Transference and Countertransference Issues with the Difficult Patient” The Pennsylvania Psychologist Quarterly, February 1997.

Gordon, R.M.(1997). “Handling Transference and Countertransference Issues with the Difficult Patient” The Pennsylvania Psychologist Quarterly, February 1997.

Handling Transference and Countertransference Issues with the Difficult Patient

Robert M. Gordon, Ph.D., ABPP

If I were to develop an MMPI type "Lie" scale just for psychologists, two items would be:
"Did you ever have sexual feelings toward a patient?'
"Did you ever feel like cursing at a patient"?"
As with the MMPI Lie scale items, they mean different things in different contexts. That is, therapists would have problems with impulse and boundaries if they acted these items out. But on the other hand, I wouldn't trust a therapist who said "False" to any of the above. I'd consider that therapist too defensive and insightless about Countertransference feelings to be a good therapist. I'd also fear that such a therapist will eventually become symptomatic, by acting out or burning out.
These Countertransference feelings, that is the triggering of the therapist's own conflicts while doing therapy, are common. The therapist is a trigger for the patient, i.e. "transference", and the patient is a trigger for the therapist, "Countertransference". And when therapists get into trouble with difficult patients, it is usually because they mismanaged the transference and Countertransference.
I might ask myself why a patient is being seductive with me. Does she have an impulse problem? Is she trying to get control over the treatment? Is she trying to master Oedipal- developmental issues ? What is she repeating with me that she is not yet able to use insight and express in conscious language?

When I'm feeling anger at a patient, I wonder why is this patient infuriating me? Does he fear me? Is he trying to get me to reject him? Does his need to fight with me, his way of testing my ability to stand him? 
I consider what feelings are being stirred up in me and how they might be affecting my timing, tone, objectivity and interventions. All this is using the transference and Countertransference to better understand the patient and myself. 
I had a classical analysis. More than any part of my professional training, my analysis has been the most useful part of my ability to do good work. When I get stirred up by a difficult patient, I know and can get to my issues and self soothe, and go back to my patient without acting out, getting too upset or saying something dominated more by Countertransference than empathy. 
I'm not saying that every therapist should have an analysis, but I do believe that all therapists should know what triggers them, and what are their areas of vulnerability and conflict. This is necessary to do good work.
I have been working with psychotherapists for several years. When they act out, or start to burn out, it's largely due to the issues that get stirred up inside of them, causing more symptoms than insight. I consider it important for every therapist from time to time to have a mental health check up, regardless of what kind of psychological treatment the therapist is offering, since any treatment will suffer according to the therapist's blind spots and personal issues. 

Therapists are the toxic waste dump of their patients. It is very stressful, and therapists, like anyone else, use denial and rationalization when they are needy and regressed. Many therapists were reared in the role of a therapist within their family of origin, where they were expected to deny their own needs in favor of caring for others. Many therapists don't know when they are needy and that they are in trouble until they actout their Countertransference -with sophisticated rationalizations. They get caught in the powerful web of the transference and Countertransference dynamics, and may end up hurting people and destroying their professional lives.

The phenomena of transference doesn't know a theoretical orientation.
In transference, we unknowingly transfer the past onto the present. We all do it to some degree most of the time. Transferences are particularly activated with differences in power, such as care giver- receiver, teacher- student, boss-subordinate type relationships. With greater degrees of commitment and dependency, the stronger the transference. The helping relationship recapitulates the powerfully ambivalent child -parent relationship, a powder keg of transference feelings. The patient doesn't care whether you are doing biofeedback, behavior therapy or psychoanalysis, you will get the same transferences. It just may not be as overt as in analytic therapy. Never the less, the patient will still go through the same periods of honeymoon idealization, then devaluation, resistances and acting out. Just as children start out in love with their parents and by adolescence become profoundly disappointed in them, so will our patients go through similar stages and repeat the same traumas with revenge.

When patients see us, they are also distorting us in terms of everything that's unresolved in them and their past. This is regardless of your interest in this phenomena. A psychoanalytic therapist uses these distortions as the focus of the treatment. But the non-analytic therapist gets the same reactions, and these reactions, though not interpreted, should be understood and managed for the sake of the patient.
I often assess psychologists who have gotten in trouble due to a failure to understand and manage transference and Countertransference. They often say that they never learned much about it in graduate school, or learned that it was just applicable to Freudian theory and if they didn't believe in it, or didn't practice it, then they need not concern themselves with it. That's like physicians saying that since they do not practice as did Louis Pasteur,they need not concern themselves with germs. 

Some psychologists may not believe in transference and Countertransference, but the malpractice courts do. "Mishandling transference and Countertransference " is often considered as an act of unprofessional conduct by state licensing boards and is considered an issue of malpractice by the courts.

While an analytic therapist would be expected to interpret and work with transferences, the non-analytic therapist is expected to understand and manage transference. Managing transference starts with the acknowledgment that all relationships are objective and subjective, real and symbolic at the same time. Your patients may stay with you through their distortions, because they sense the reality of your maturity, fairness, warmth and empathy. This may help them master their aggression when they need to hate you in the transference. As an analytic psychologist, I let this develop and then carefully interpret it's meaning. But if I were doing behavior therapy, I would manage the transference aggression, by clarifying roles, what the treatment is, and the ground rules and goals of treatment. 

A hostile patient might say: " You are using me, taking my money and I am getting worse!"
The therapist must realize that while in the transference the patient no longer has a sense of the reality the therapist. The therapist is perceived as a dangerous object to the patient. This calls for a "reality clarification" by the therapist. The reality clarification serves to restore the reality of the person and role of the therapist and the reality of the therapeutic work. This is the primary way for any therapist to manage the transference. Only in analytic therapy is this an opportunity to go deeper into interpreting an unconscious memory. Otherwise , just restore the reality of your relationship and go on with your work, whatever your theoretical orientation.
Therapist : " You are clearly upset with me about the very symptoms you came to me complaining about when you first sought my help. Your symptoms wax and wane.I can try to help only by your coming to these sessions, here in my office and following our agreed plan of treatment. Now tell me more about what's upsetting you. I will try to help you the best that I can."
This clarification has the key elements of reminding the patient (they all forget) that you are a psychologist, that they are a patient, that they came to you for help for their symptoms, and that you do some sort of humble treatment, and your are not their mother, father, bad self or lover. You clarify the reality of the roles, tasks, boundaries and ground rules of treatment. This will be need to be repeated over and over with patients who have poor reality testing. You bring them back to the present from feelings transferred from their past child-parent relationship.

All therapists must understand that the patient will transfer feelings, memories, perceptions and dramas from the past on to them. Managing transference means reminding the patient about the reality of the present therapeutic relationship. This will be a fairly constant need with the difficult patient who would rather repeat the past with you than change. I am convinced that regardless of the type of treatment you do, the more you understand transference and Countertransference, the more empathy you will have for your patients, the more you will enjoy your work, with less chance of trouble.

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