What we’ve said about Countertransference

“We all have baggage. Patients have baggage. Clinicians have baggage. We bring it into the room and it's going to alter how we perceive or notice or act clinically. And so if we're not aware of that, we're in trouble”

“That's a concordant countertransference where the patient is evoking in you what the patient typically feels. Am I feeling what other people felt toward the patient”

“Projective identification is also a very important mechanism. That somebody's intense feelings or expectations about other people can create a corresponding reaction in that person. Okay, like if a patient thinks that everyone hates them and then that makes them act very guarded and unpleasant towards all the clinicians”

“paying attention to the subtle micro moves that we can see or also our own internal reactions. Right. Like your sense, something's a little off or I'm a little uncomfortable or I'm a little bored or whatever. That's an opportunity to be curious”

“one of my mentors would always ask during staffing, okay, but what was it like to be with this patient, okay? That's an important question to ask yourself simply as practice with every particular patient”

“if you pay attention to what it's like to be with a patient, what do you the clinician feel inside emotionally, you're going to find trends for yourself with certain subtypes of patients”

“It's not a diagnosis. It's just a sign that you can reflect within yourself that says, perhaps I should question or get more history on this particular slice of possible psychopathology”

“You should be doing a mental status exam, right? You observe the patient and how they act, what they say and what they don't say, in addition to the literal information that they're telling you. On top of that, you observe how they interact with you”

“I should not feel stupid during an intake so that if I am, that's diagnostic information as to what's going on”

“even if your individual response can be unique or outsized in terms of your internal emotional feelings, those feelings, the countertransference, are being provoked by something objectively identifiable”

“when someone is, you know, on the more psychotic range and it's more apparent and they're not trying to dissimulate it, my countertransference, and Nancy McWilliams writes about this a little bit, is almost like maternal”

“A lot of times you get put in these crazy situations, and if you don't take the time to reflect, if you just kind of stay on the surface level of what's occurring, you might be missing what's underlying it”

“particular diagnoses carry real implications in terms of understanding transference and countertransference. And this is where the psychoanalytic side of me comes out, where if you're not thinking in this sort of way, you may really miss what's going on right before your eyes”

“any patient who evokes a strong pull to either rescue or over-involve yourself, or on the flip side, to detach and just give up on a patient. Those are the two things that he warns about”

“If you have intense counter transferential feelings of any type, that's a sign of self and interpersonal functioning. And that can, especially under distress, be quite dangerous”

“I don't say to myself, like, hey, like, Dr. Malzberg, you can't be angry with a patient, like, you have to be curious and say, I wonder why that is”

“if your patient is conscious only of sadness, and you find yourself angry about somebody that's hurt them, you can say, I get that you're very sad. Is there any anger there? I'm feeling a certain kind of anger”

“I'm less likely to jump in and say something by my own misinterpretations where it's like, oh, no, no, no. They, of course, discharged me”

“Usually in the moment, I can't identify what the defense is. It's only kind of after the appointment's over and I have some time to reflect that I'm able to maybe put words to what i was experiencing or identify what the specific defense was”

“The first few years that you're doing interviews, everyone, for me to maintain the structure, I was super rigid, was asking checklist questions, was going through very specific steps. And my entire working memory was trying to get through those questions and get the answers”

“regardless of which one you are, I would recommend that you try to go left a little bit. You try to go into your weakness a bit and practice for whichever one you're more uncomfortable with, because we do have both”

“I think that the conversation going well or good is not about so much the specific words you use. It's about what you feel inside. If you truly feel care and that you want to help, patients”

“it's usually some version of therapist anxiety right something is is getting kicked off in me that's getting in the way of me accessing my empathic abilities um so so i see a lot of our alliance focused training not so much about giving people alliance skills”

“Let's think about it more as, you know, they're going to happen. They can be small. They present opportunities. And I think that attitude helps us approach them with openness, non-defensiveness, curiosity”

“Helping therapists recognize when that's happening, giving them these ideas that might help them reframe some of that away from I'm being a bad therapist or they're being a bad patient to this is just human interaction and we can talk about it”

“we often see transference and countertransference issues play out around medicine. Where the prescriber... if he doesn't or she doesn't agree to prescribe something as seen as a withholding persecutor, as someone who says he wants to help me, but really wants to hurt me”

“knowledge is not enough. to guard you against the enactments and the misbehaviors that may happen in complex treatment. Uh, you gotta be aware of your feelings. It sounds like, uh, because people are feeling compelled to act even when they know better reflection of the patient's experience”

“Yeah, simply follow the rules. So number one, know the rules. Number two, follow the rules. Number three, do a medical assessment”

“My thoughts or my politics or considerations of whether or not someone should have time off or whether or not... uh someone should be getting paid while they're not working or whether or not they're i dislike them because of their personality disorder simply should that should not be any sort of that should not be involved whatsoever”

“by having this framework, you know, I stopped projecting my ideas of all the problems of the world and work with the patient in a way that works for both of us”

“You have to know population norms. Got to ask, what would most ordinary people, what do the majority of the population, what would they think, do, or feel in the same situation? And is the patient different from that”

“They go off their countertransference rather than digging up and evaluating the clinical data across the lifespan”

“The main problem in the clinical treatment of personality, in my opinion, is clinician feelings, the counter-transference feelings about the conditions, about themselves, and about a lot of different things”

“I believe that stigma exists primarily because of clinician reactions, which are sometimes understandable to difficult patients. Let's face it, some patients are simply more difficult than others”

“If you're expecting that the treatment's going to fail, if you're expecting that you're not going to get along with the patient, you're going to make that true to some extent, or you're going to make it more likely for it to be true”

“As a provider, you can't resent certain types of patients because you'll actually manifest the difficult situation, not the patient”

“That patient may then project or rather attribute their paranoia. fear, aggression to you. They may start acting in a way that's maybe a little dicey or maybe even overtly aggressive, maybe yelling or being very oppositional”

“It's possible for both on the clinician end and on the patient end to hyper focus, hyper energize on one topic or particular problem. And in a way that obscures another, maybe deeper or at least parallel and important problem”

“a therapist and the patient of the same culture may both mutually ignore some glaring aspect of the clinical situation because for both of them, it's a cultural norm”

“I think it's a natural instinct to distance ourselves from the problem. And like, you know, identify, oh, that was a big mistake. That was a huge mistake”

“if we don't communicate our emotions and experience them, then they're going to turn it to something else, stress, anxiety, tension or actions. And so one of the global principles I have is that you should find people in your life that you can safely communicate your emotions to”

“complaining wasn't a helpful thing. Like if I if I was just complaining about the different emotions I was having or problems, it wasn't productive. It increased my anxiety and it made me feel worse overall”

“as providers, it's important to really reflect on. what it is that we're doing, the reason for what we're doing. It's important to have supervisors, to have our own therapists, to be able to reflect on”