Transference and Countertransference

by Lisa Marie Hilz

Outline


Introduction

Transference and countertransference are both normal phenomena that may arise during the course of the therapeutic relationship. Understanding these phenomena in nursing is important because the primary focus of nursing is the nurse-patient relationship (Imura, 1991). This discussion will describe how these phenomena occur, and how they may manifest in the nurse-patient relationship. Furthermore, this discussion will highlight nursing interventions in these situations, in order to provide insight into how nurses can maintain and improve the therapeutic focus and environment.

Transference

Transference is the "transference" of past feelings, conflicts, and attitudes into present relationships, situations, and circumstances. According to psychoanalytic theory, transference evolves from unresolved or unsatisfactory childhood experiences in relationships with parents or other important figures (Wilson & Kneisl, 1996). From the behavioral orientation, people may be considered habit-forming in how they relate and interact with others. These habits involve the development of attitudes and preconceived ideas based on the learning and retention of information from past relationships. This may precipitate behavioral and thought patterns in subsequent relationships, even though certain actions and attitudes may be inappropriate for the current interaction (Strayhorn, 1982). As nurses generally have the most consistent and frequent contact with patients as compared with other disciplines, the potential for nurses to be objects of transference is significant.

Meanings and Role Casting

Transference, in essence, is the casting of roles (Taylor, 1994). Inappropriate meanings are assigned to the relationship by the patient. For example, Strayhorn (1982) discussed a patient who experienced anxiety around his father as a child. The father was a doctor, critical and impersonal, and generally demanded perfection from his son. As an adult, this patient consistently felt discomfort around male doctors. The more similar in personality a male physician was to his father, the more likely and intense was the transference. A nurse may unknowingly remind the patient of significant figure from their past, although the patient may not be fully aware of this. Also, one individual alone may not always be the object of transference. The patient may assign inappropriate meanings to their relationship with a group of nurses, or the entire unit staff.

Nursing Interventions

Nurses need to intervene in cases of transference when it becomes apparent that the patient's therapeutic progress is inhibited due to the effects of the phenomenon. It is important to mention that in some cases transference is positive, positive in the sense that the transferred feelings and attitudes toward the nurse result from past fulfilling experiences and relationships. According to Wilson and Kniesl (1996), the therapeutic relationship is usual able to progress throughout its course in positive transference. However, most transference involves both positive and negative aspects. The negative may heavily outweigh the positive in some situations. For example, a patient may react in a therapeutically antagonistic manner, expressing excessive dependency or angry, bitter, or contemptuous feelings towards a particular nurse or group of staff. Thus, discomfort arises in both parties. The patient may be uncomfortable in expressing these feelings in such a negative manner, and the nurse will usually dislike being the object of such expression.

In cases of transference, the relationship does not usually need to be terminated (e.g., assigning another primary nurse to care for the patient), except when the transference poses a serious barrier to therapy or safety. The nurse should work with the patient in sorting out the past from the present, and assist the patient into identifying the transference and reassign a new and more appropriate meaning to the current nurse-patient relationship. In addition, if the patient is having a problem with the nurse due to transference, the patient often has or will have problems with other people in their lives who represent individuals in past conflicts. The goal is to guide the patient to independence by teaching them to assume responsibility for their own behaviors, feelings, and thoughts, and to assign the correct meanings to relationships based on present circumstances instead of the past. Helping the patient work through the transference is beneficial in two important ways: the therapeutic value of the relationship may be restored and even improved, and the patient may also learn to identify this behavior in other relationships, thus improving interpersonal skills.

Countertransference

Countertransference involves the same principles, except the direction of the transference is reversed. Countertransference, a normal occurrence as well, involves the nurse’s reactions, behaviors, thoughts, and feelings toward the patient (Wilson & Kniesl, 1996). Unresolved conflicts from the nurse’s past may evolve as countertransference. For example, a patient who displays childlike dependency toward a nurse may evoke a parental attitude from that nurse, depending on the meaning that he or she assigns to the relationship with the patient, and if past conflicts are significant to the present situation. Nurses may be completely unaware or only minimally aware of the countertransference as it is occurring.

Interventions

Interventions for countertransference involve identification, observation, and feedback by other nurses and staff members. Once again, the relationship usually should not be terminated in the presence of countertransference. Rather, the nurse or staff member experiencing the countertransference should be supportively assisted by other staff members to identify his or her feelings and behaviors and recognize the occurence of the phenomenon. The therapeutic relationship can often be improved by offering the nurse or other staff member feedback about the progression of the relationship. It may be helpful to have evaluative sessions with the nurse or staff member after their encounters with the patient, in which both they and other staff members (who are observing the interactions) discuss and compare the exhibited behaviors in the relationship. Importantly, a staff member who is helped to identify their own countertransference in dealing with a particular patient might be able to recognize and manage this on their own when they encounter other patients later on who evoke similiar personal reactions.

It is important to recognize the effects of transference and countertransference on the patient and the staff. The phenomena also can affect the entire therapeutic environment if not managed properly, as the rest of the therapeutic community of patients and staff may perceive the relationship in a positive or negative manner. Facilitating staff awareness and education regarding these phenomena is essential to help ensure the quality of therapy and to preserve the integrity of the therapeutic, nurse-patient relationship.

References

Imura, S.(1991). Transference and countertransference in nursing. Emphasis Nursing,1, 77-81.

Strayhorn, J.M.(1982).Foundations of Clinical Psychiatry. Chicago: Yearbook.

Taylor, C.M.(1994).Essentials of Psychiatric Nursing,14th ed. St. Louis: Mosby.

Wilson, H.S. & Kniesl, C.R.(1996).Psychiatric Nursing,5th ed. New York: Addison-Wesley.