Counter-transference and counter-reaction
Counter-transference refers to the develop- ment, in the physician, of positive or negative feelings toward the patient based on issues in the physician’s own life. For example, if a physi- cian is somewhat emotionally needy, he or she may become overly involved with a dependent patient, leading the physician to provide the patient with undue access to the physician (for example, giving out e-mail or cell phone num- bers). If the physician has an overly demanding parent, he or she may overreact with aggression and hostility toward a patient who shares the negative characteristics of that parent.
“Counter-reaction” needs to be differentiated from counter-transference, as this is usually a common or normal response to the patient’s emotions or behaviors. For example, when the patient becomes hostile toward the doctor, the doctor may wish to withdraw, or may feel anger in response. The physician has to try to figure out how to better respond to the patient’s feelings and responses, without personalizing them. This is easier said than done, as physicians, like their patients, are only human, and are subject to their own feelings and those of others toward them.
Characteristics of difficult patients
In his insightful article in the New England Journal of Medicine, titled “Taking Care of the Hateful Patient,” James E. Groves, MD, describes difficult patients as those who “kindle aversion, fear, despair or even downright malice in their doctors.”3 In trying to understand the nature of this situation, Dr. Groves classifies “hateful pa- tients” into the following categories: “dependent clingers,” “entitled demanders,” “help-rejecting complainers,” and “self-destructive deniers.”3 In placing the difficult patient into one of these categories, it is easier for a health care profes- sional to see their patient’s psychopathology more objectively. Once the surgeon conceptualizes the
patient’s pathology, coming up with a clinical ap- proach to deal with the patient’s difficult behavior fits more into the medical model of treating illness and symptoms.
Maladaptive responses to the difficult patient
• Ignoring phone calls
• Telling the patient to go to another doctor
• Being accusatory
• Getting angry
• Blaming the patient
• Telling the patient there is nothing wrong with him or her
• Telling the patient there is nothing more to be done for him or her
• Overmedicating the patient to silence him or her
• Dismissing the patient as a “malingerer”
• Handing the patient a “sign out against medical advice” form