1.29 The answer is C
1.30 The answer is A
1.31 The answer is A
1.32 The answer is B
Doctors and patients may have divergent, distorted, and unrealistic views about each other, about what happens during a clinical encounter, and about what the patient has a right to expect. Transference and countertransference are terms originating in psychoanalytic theory. They are purely hypothetical constructs, but they have proved extremely useful as organizing principles for explaining certain developments of the patient–doctor relationship that can be upsetting and that can interfere with good medical care.
Transference describes the process of patients unconsciously attributing to their doctors aspects of important past relationships, especially those with their parents. A patient may come to see the doctor as cold, harsh, critical, threatening, seductive, caring, or nurturing, not because of anything the physician says or does, but because that has been the patient’s experience in the past. The residue of the experience leads the patient to unwittingly “transfer” the feeling from past relationships to the doctor. The transference can be positive or negative, and it can swing back and forth—sometimes abruptly—between the two.
Transference reactions may be strongest with psychiatrists, for a number of reasons. For example, as part of intensive, insight-oriented psychotherapy, the encouragement of transference feelings is an integral part of treatment. In some types of therapy, a psychiatrist is more or less neutral. The more neutral or less information the patient has about the psychiatrist, the more transferential fantasies and concerns are mobilized and projected onto the doctor. Once the fantasies are stimulated and projected, the psychiatrist can help patients gain insight into how these fantasies and concerns affect all the important relationships in their lives.
Physicians themselves are not immune to distorted perceptions of the patient–doctor relationship. When doctors unconsciously ascribe motives or attributes to patients that come from the doctor’s past relationships, the process is called countertransference. Countertransference may take the form of negative, disruptive feelings, but it may also encompass disproportionately positive, idealizing, or even eroticized reactions. Just as patients have expectations for physicians—for example, competence, objectivity, comfort, and relief—physicians often have unconscious or unspoken expectations of patients. Most commonly patients are thought of as “good” patients if their expressed severity of symptoms correlates with an overtly diagnosable biological disorder, if they are compliant and generally nonchallenging with treatment, if they are emotionally controlled, and if they are grateful. If these expectations are not met, even if this is a result of the unconscious unrealistic needs on the part of the physician, the patient may be blamed and considered unlikable, untreatable, or “difficult.”