COMMENTARY

Agitated Patients? They May Be Taking Their Cue From You

Derick E. Vergne, MD; Sivan Mauer, MD, MS; Kristina Gaud, MD

Disclosures

August 24, 2016

In This Article

Interpersonal Dynamics in the Clinical Context

Transference dynamics pays attention to the ongoing interpersonal clinical relationship between physicians and patients from the point of view of the actual participants in real time, and in the context of their own personal developmental history. The reader could imagine, for example, how a physician with a personal/sociocultural history (eg, a family-oriented background) that values familial opinion on every decision might react to a patient whose main concern is how she feels about her mother's perceived "intrusion" in every decision she makes. The physician's reaction might potentially be biased, depending on his or her level of training, awareness, and empathy.

How can we begin to understand the significance of transferential dynamics in the hospital setting where our particular clinical scenario takes place? The patient is frustrated. She feels misunderstood and rejected (oppressed) by the young resident physician, who was less empathic than he usually is (an oppressor). The word "empathy" has its origins in the German Einfuhlung, or literally "in-feeling."[1] In this case, the physician's transferential reaction to this patient yielded the opposite to the "in-feeling" of empathy, because the end result was a worsening of the patient's affective dysregulation. Not only was there no consonance in the relationship, but both members were in complete dissonance. Transference made a naturally difficult relationship an impossible one, with the patient storming out of the room.

"Transference" is the redirection to the physician/therapist of emotions that were originally felt in childhood. It was described by Freud as "the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool."[2,3] In our case, a 19-year-old woman has been conceptualized as having bipolar disorder, when there is no clear evidence that this is so. Irritability, mood lability, and impulsivity are certainly constructs that depict the clinician's understanding of the situation in front of him. Our physician's understanding of these constructs was biased by his feelings toward the patient. Clearly, he appeared to be annoyed and taken aback at the patient's sudden response that, in his mind, is uncalled for. He thereby concluded that there is "clear evidence for bipolar disorder in its hypomanic phase."

The young physician's response, or countertransference, is the other side of the coin. "Countertransference" refers to the clinician's reactions and feelings brought up by the combination of the patient's affect/actions toward him or her and the clinician's affective response derived from their own emotionally charged life experiences that are awakened by the patient's affectively intense remarks. Countertransference feelings can be helpful to the therapist in understanding the patient's psychological functioning. Astute clinicians would ask themselves, "Why am I feeling this now? What can my emotional reaction to the patient tell me about the patient's mode of relating, differential diagnosis, and potential treatment plan?" The analysis of transference/countertransference can therefore add another level of understanding that can make a notable difference in conceptualizing the right diagnosis in difficult cases.

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