Agitated Patients? They May Be Taking Their Cue From You

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


August 24, 2016

In This Article

Using Transference to Inform Therapeutic Interventions

Transference/countertransference dynamics pays attention to implicit cognitive/emotional processes. It does not necessarily imply the use of the spoken word. It relies in many instances on subtle cues, such as changes in facial expression, tone, inflection of speech, and body position.[19] Transference/countertransference is therefore mostly a process that occurs outside of awareness, or unconsciously. It relies not on language, but on symbols or representations that are coupled to emotion.[19] Language is a left-brain function, whereas emotional context of environmental input to form symbolic representations of the world around us is a right-brain function.

A successful psychotherapeutic relationship is characterized by affective attunement, whereby the therapist or clinician's affective response is in sync with the patient's own affect. Through the left-brain use of language, the patient tries to clarify her emotional state by way of accessing right-brain preverbal symbolic representations full of emotional meaning.[20] The therapist's guidance is therefore a key aspect of this process. The main goal is to help the patient to access concepts, symbols, and representations for which there are no words, but that are intimately related to affective tone by the anatomical and neurochemical proximity of the right brain's medial prefrontal cortex (anterior cingulate and orbitofrontal cortex) to limbic system structures, such as the amygdala. In other words, the therapist's function is to mediate the maximization of a patient's self-understanding by helping her put words to emotionally charged symbolic representations in order to regulate affect.

Applying the right balance of active empathic listening with well-timed confrontation, clarification, and interpretation is what characterizes the optimal patient/therapist relationship. The goal is for the patient to obtain an effective cognitive reappraisal of emotion by helping her achieve efficient left-to-right brain communication, with effective top-down regulation of limbic drives (right-brain modulation of limbic fear responses).[20,21] This is most effectively done with psychotherapies that aim to maximize self-awareness and understanding, such as psychodynamic psychotherapy, which pays special attention to transference dynamics as a way to reappraise abstract semantic meanings in order to regulate affect.[22] In other words, language puts words to that which the patient could not name, but that causes massive affective instability. As a result, an enhanced coupling of cognitive affective regulatory processes ensues (more effective top-down control of fear), thus helping the patient achieve more effective counterregulatory control of affect.


Affective dysregulation characterizes the majority of neuropsychiatric presentations. An uncoupling of frontal cortical areas with limbic primitive drives results in inefficient cognitive appraisal of amygdala-mediated excessive fear. Affective dysregulation results in less thought-out expression of anger, fear, or rage, without the balancing inhibition of context providing prefrontal cortex; the "thinking brain" is not working effectively to inhibit powerful primitive drives.

Transference-focused psychotherapeutic interventions are a way to pay attention to symbolic representations (semantic representations) that are devoid of language but that disrupt emotional tone or balance. It goes past language to focus on emotionally charged representations that heightens the stress response and worsens affective instability. Attention to transference dynamics in patient care not only maximizes diagnostic understanding, but also promotes recovery.


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