“She’s doing it again,” nurse X said.
“What is it she’s doing?” I said.

“You know—scratching on herself, trying to get attention. You’d think she’d want to grow up someday!” Nurse X said.

“Are you sure she’s just doing it to get attention?” I was getting annoyed.

“Why else would she do it?” nurse X demanded.

“Maybe she wants to kill herself, but can’t get up the nerve to do it,” I was playing devil’s advocate.

“Oh she does not want to kill herself!”

This conversation actually occurred between a nurse and I one night when I was on call. She was experiencing countertransference, which is common, and occurs when a patient evokes feelings in a caregiver. The process is unconscious. The patient and caregiver each experience the other, unconsciously, as someone from the past. When a patient begins to experience their therapist, physician, nurse, etc., as someone from the past, they are demonstrating transference. In psychotherapy, it is routine to analyze this transference, because it is a demonstration of coping mechanisms that a particular patient uses because of certain interactions with others.


The countertransference, which is what the caregiver experiences, requires vigilant monitoring because it can be a strong diagnostic tool, particularly for personality disorders. Its use, therapeutically, is valuable because it reveals a great deal about the patient’s internal world. Countertransference may also occur over the course of a single conversation with a patient. For example, when I meet a patient who makes me feel extremely maternal towards them, I hypothesize that this patient has a dependent personality style. Should I feel bad about having these feelings? NO! Emotions occur naturally and are NOT bad. What happens when we act on those feelings can be potentially “bad.”


Back to our patient who tends to scratch on herself. Generally, these patients can create havoc on an inpatient psychiatric ward because of their surprising talent for viewing anything or anyone in the environment as either good or bad. There are no gray areas for these patients. Because they fear rejection and because they have a disordered sense of personal boundaries, they often engage in splitting, which results in caregivers feeling manipulated. Often, the patient seems to have the uncanny ability to play both ends against the middle. At worst, the medical staff is pitted against the nursing staff, causing great conflict. Sometimes, the nurses of one shift are pitted against the nurses of another shift. It may even occur between groups of nurses on the same shift. Other patients may even find themselves “caught in the middle.”


When we act on our countertransference, we are not considering the patient’s best interests. If the reaction is in the best interests of the patient, it is purely by coincidence. For example, if nurse X above acts on her countertransference and is then snotty to the patient, the patient will no doubt feel rejected. Patients with Borderline Personality Disorder fear rejection above all else. What the patient does next will be in response to this fear, which is a routine set up long ago during childhood when she developed the maladaptive coping style. Nurse X, if she doesn’t realize it, will continue to respond with more snootiness, and the resulting vicious cycle becomes more and more intense.


In the past, when I have tried to educate other caregivers about countertransference, I’ve found that people tend to become very defensive, as though they expect to be chastised for experiencing the emotions in the first place. I’ve been working out a strategy for successful education on countertransference of nursing staff because I’ve been assigned to hold a workshop on this topic. I think I’ll open the discussion by encouraging the staff to not only recognize their feelings, but also verbalize their feelings and desired actions. Then, I’ll very briefly discuss the areas of the brain that MRI studies have demonstrated to be active during the experience of such emotions. For the next part of the discussion, we’ll talk about what to do when these feelings arise, and then we’ll talk about the potential diagnostic value of these feelings. If I can turn it into a form of entertainment, I’ll capture not only their attention, but their enthusiasm for learning about this topic.




Copyright © “Dr. W,” 2006


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