Countertransference in the General Hospital Setting: Implications for Clinical Supervision

Abstract

Psychiatry residents completing their consultation-liaison (CL) rotations are implicitly expected to recognize and consider countertransference reactions when offering clinical recommendations. Residents often lack formal guidance in this role, as there exists limited examination of clinical scenarios from a psychodynamic perspective. The authors present a historical review of the literature on countertransference with the medically ill and describe a clinical vignette illustrating the vicissitudes of liaison work. The case involves a psychotic patient with mental retardation and acute renal failure. Through refusal of care and a tumultuous clinical course, this patient elicited various countertransferential reactions from the primary care and CL teams, in turn adversely impacting treatment. The case illustrates how clinicians' failure to collaborate led to hospital administrators having to take on the liaison role. (1) A review of literature corroborates the importance of CL psychiatrists' assistance in the management of countertransference. At the same time, it is notable for a paucity of guidance in teaching these skills to psychiatry trainees. The psychiatry resident-in-training faces challenges and shortcomings in the management of countertransference. Formal training in this aspect of psychiatric consultation is lacking, as evidenced by extant publications. The authors propose future directions for research and teaching, with emphasis on clarifying the liaison component of CL psychiatry and advocating for establishment of psychodynamic psychotherapy training guidelines in the general hospital setting.

Approaching differential diagnosis and decisional capacity assessment in the context of COVID-19 conspiracy beliefs: A narrative review and clinical discussion

“…For example, primary teams may have the misconception that all irrational COVID-19 beliefs suggest incapacity; however, explaining our diagnostic impression along with how patients may retain capacity if non-cognitive factors are the foundation of the patient's decision mechanism, such as in the case of medical mistrust, can help reduce potential knowledge gaps. Mitigating challenges related to provider countertransference in the medical setting have been described elsewhere and remain a barrier not only to interdisciplinary collaboration but potentially adequate optimization of the patient's abilities [ 81 ].…”

Falling into an identity crisis: Integrating identity into the assessment and management of falls in older adults

“…2 Further, consideration of clinician countertransference during interviews may inform management. 14 An illustrative vignette is provided in Box 2.

Illustrative vignette: incorporating identity challenges into falls managementHelen*, an otherwise fit and healthy 76-year-old widow, was referred to the Consultation-Liaison (CL) Psychiatry Service of a tertiary hospital. Helen was under the care of the Geriatrics Rehabilitation Team following a mechanical fall associated with a shoulder injury.

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Book Essay of Handbook of Psychodynamic Approaches to Psychopathology; The Psychiatric Interview in Clinical Practice

“…I highlight this volume's focus on the importance both of the therapeutic relationship and of the need for clinicians be as aware as possible of their inevitable countertransference reactions, especially with very ill patients. This is an extremely important contribution, because too often mental health personnel, especially trainees, are not educated on the value of understanding transference and, especially, countertransference responses (Jiménez, Thorkelson, and Alfonso 2012). Similarly, the concept of countertransference has been neglected by the child psychiatry community.…”