22 HOW TO TREAT: COMMUNICATING WITH PATIENTS
22 HOW TO TREAT: COMMUNICATING WITH PATIENTS
13 FEBRUARY 2026 ausdoc. com. au that the patient has in addition to the presenting symptom. Examples appear in box 3.
PSYCHOLOGICAL CONCEPTS OF TRANSFERENCE AND COUNTER- TRANSFERENCE
TRANSFERENCE, in psychodynamic terms, is an unconscious phenomenon where the feelings, attitudes and wishes originally linked with important figures in one’ s early life are projected onto others who have come to represent them in current life. 20 Transference translates to“ a loose designation of all aspects of patients’ feelings and behaviour towards the physician”. 11, 20 Countertransference is the conscious or unconscious emotional response of the clinician to the patient. 21 It is largely determined by the clinician’ s inner needs rather than the patient’ s needs. If expressed, it may reinforce the patient’ s earlier traumatic history.
There is a need to put transference and countertransference into perspective, as understanding these concepts may enhance patient care and the patient’ s subjective experience of being cared for. It is important to be aware of the basis of transference but guard against working in transference; the clinician is dealing with the here and now, recognising their needs and those of the patients, and not being seduced into being other than a competent and caring clinician. 22 For example, with a seriously ill patient, the doctor may be viewed as being omnipotent, an all-healing person with powers and resources that they may not possess. Behind a transference of negative feelings of anger in realising that the clinician is not omnipotent and unable to bring about a‘ cure’, may be feelings of despair, anxiety and shame. An awareness of transference guides the clinician’ s best approach to intervention. Again, it is most important to work with the knowledge of transference but not in transference, the latter only being worked through in a therapeutic ongoing relationship. 23
As an example, the author recalls a 14-year-old girl who was admitted with multiple pseudoseizures or functional neurological disorder. Her mother was seemingly unperturbed by her daughter’ s ongoing school absence. The parents had been separated for the past six months. Their daughter’ s admission led to the father visiting, only to be met with anger from his daughter. Yet the daughter had successfully( though unconsciously) brought her parents together. Here, it is important for the attending clinician to observe and listen, saving any interpretations for another setting if the management progressed to ongoing psychotherapy.
Countertransference may be an important defence mechanism for clinicians and may also have a communicative value. Clinicians being aware of their own negative feelings, even if unsure as to their cause, may help in the management of their patients. It may be useful to recall an observation made by the author in a 1983 paper on understanding the child with pain:“ The physician, by understanding and listening to the child’ s pain, responds to the needs of the child. He or she must be able not to identify with the child in pain so closely that it affects his or her
Participation
Figure 6. GP supervision flowchart.
Supervision type Supervision content Supervision process
Patient specific
Diagnosis specific
Treatment specific
General supervision
• Assessment
• Management
• Treatment of particular patients
• Diagnosis
• Management
• Treatment of particular disorders
• Theory
• Rationale
• Implementation of particular treatment modality
• Patient
• Treatment
• Professional psychological issues arising
• Select 1-2 patients
• Follow for eight sessions
• Fortnightly supervision sessions
• Select diagnosis
• Choose appropriate patients
• Follow for eight sessions
• Fortnightly supervision sessions
• Select treatment
• Choose appropriate patients and diagnoses
• Follow for eight sessions
• Fortnightly supervision sessions
• Discuss issues as they arise from any of the above domains
• Semi-structured
• Eight fortnightly / monthly sessions
Figure 4. Clinicians themselves may also feel the pain of reaching a serious diagnosis, especially those caring individuals who know their patients well.
Figure 5. A Balint-type group provides a forum to discuss problematic patients.
Review