USING CTr EMPIRICALLY
CTR evolution of understanding
CTR elements
Westen article and its implications
Illustrations :1 strongarm 2
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“The prevailing medical paradigm
has no capacity to incorporate the
concept that a relationship is a
physiologic process as real and as
potent as any pill or surgical
procedure”
W B Strean Commentary CFP
2009; 55 :965-7
CONTEXT OF
COUNTERTRANSFERENCE
HX
QUOTE RE RELATIONSHIP
EMOTIONAL TRANSFER
MIRROR NEURONS
EMPATHY
MENTALIZATION
CTr Context cont’d
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humans are exquisitely sensitive to
others moods…below the
radar…understanding mood is a
mentalising process
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we are responsible for our
emotional reactions to patients
we are trained to ignore or mistrust
those reactions
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EMOTIONAL CONTAGION
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In the March 2005 issue of The
Journal of Applied Psychology,
Saavedra and colleague Thomas Sy
at California State University at Long
Beach examined the effects of a
leader’s mood on a group.
Result: The leaders’ moods ruled,
and negative moods ruled most. If a
leader was up, some team members’
moods also rose. But if he or she was
down, everyone was down.
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strong reactions by
md
• 1949 ‘HATE IN THE COUNTERTRANSFERENCE’
WINNICOTT
• 1978 ‘THE HATEFUL PATIENT’ GROVES
CLINGERS, DEMANDERS, HELP-REJECTERS,
SELF-DESTRUCTIVE DENIERS
• 1995 PHYSICIANS’ EMOTIONAL REACTIONS TO
PATIENTS RECOGNISING AND MANAGING
COUNTERTRANSFERENCE ; A.A. MARSHALL, R. C. SMITH
• 2001 USING ATTTACHMENT THEORY
HUNTER, MAUNDER
ARTICLE
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COUNTERTRANSFERENCE
PHENOMENA AND
PERSONALITY PATHOLOGY IN
CLINICAL PRACTICE: AN
EMPIRICAL INVESTIGATION
 AM
J PSYCHIATRY 2005; 162:
890-898
 BETAN/HEIM/CONKLIN/WESTEN
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the article addresses Professional
CTr not personal
it addresses specific qualities not
just positive or negative
Aims
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develop a specific measure of CTr
reactions
compare CTr factors with clinical
variables
specifically ascertain any CTr
factor correlation with narcissistic
PD
assess the use of CTr response as
a transtheoretical diagnostic tool
Method
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random 181 clinicians
random choice of patient
standardised patient demographic
use of CTr Questionnaire
use of DSM IV
Q-sort and Factor Analysis
partial correlation analysis of
Factors with Cluster symptoms
CTr Questionnaire
Factor Analysis
Mapping of CTr Factors
with Cluster B pathology
Implications
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specific disturbances elicit CTr
responses in a typical pattern
clinical awareness of such patterns
can help define clinical pathology
clinical awareness of CTr
experience can facilitate optimal
responsiveness by offsetting
feelings of persecution by MD
WHY BOTHER
• RISK MANAGEMENT
• SIGNIFICANT % OF
PATIENT POPULATION
• PROFESSIONAL
DEVELOPMENT
DUCK
• 2005 : 73000 NURSES
ATTACKED ie 30% OF
HOSPITAL NURSES AND
50% OF LONG TERM CARE
• HEALTH CARE RISK OF
INJURY UP TO 12 TIMES
MORE THAN ANY OTHER
INDUSTRY
DOCTOR’S EXPERIENCE
• NEGOTIATION IMPOSSIBLE
• NO REDEEMING QUALITIES SEEN
IN PATIENT
• DREAD PATIENT’S VISIT, FEEL
OVERWHELMED
• RESCUE URGENCY
• OFFERS TOO MUCH
OR TOO LITTLE
Literature Review
n = 500 outpatients -- 15% rated as difficult
Mental disorder (incl. sub. use )
> 5 somatic symptoms
Severe symptoms
Poorer functioning
High Dissatisfaction
High Utilisation
Hahn, Kroenke,J. of Gen Int Med 1996
Jackson,Kroenke, Archives Int Med 1999
Literature Review
n = 500 outpatients -- 15% rated as difficult
Mental disorder (incl. sub. use )
> 5 somatic symptoms
Severe symptoms
Poorer functioning
High Dissatisfaction
High Utilisation
Hahn, Kroenke,J. of Gen Int Med 1996
Jackson,Kroenke, Archives Int Med 1999
MD-rated difficulty
• Difficulty increases with increasing score on
personality disorder criteria
• Difficulty increases markedly with :
More than 1 of somatization, personality
disorder, psychiatric disorders
(Hahn, 1994)
ASYMMETRY OF
POWER
Psychiatric Model POV :
‘Black Box’
Relational Model POV
DIFFICULT PATIENT
RELATIONSHIP
A POWER
STRUGGLE:
COMPROMISED
WORKING
RELATIONSHIP
CONTRACTUAL
UNDERSTANDING
PATIENT-DOCTOR
RIGHTS
RESPONSIBILITIES
ROLES
PET PSYCHIATRIST……..
DR URSUS’ PATIENT
DR URSUS’ PATIENT ISSUES
• BOUNDARIES
• Dr’s Reactions
• POWER STRUGGLE
• PSYCHOLOGY
DISORGANISED PATIENT
CLINICAL PHENOMENA
• LOW REFLECTIVE FUNCTION
• BOUNDARY
TRANSGRESSIONS
• EMOTIONALLY CHAOTIC
• CHRONIC SUICIDALITY
• DISSOCIATION
The Matrix Reloaded
Show your face you are the mirror itself
The Healthy Matrix
SUSTAINING RELATIONSHIP
ABILITY TO SELF-SOOTH
REFLECTIVE CAPACITY
PLEASURE CAPACITY
EMPATHIC CAPACITY
TRUST CAPACITY
Failures in the Matrix
• Caregiver UNAVAILABLE
INTRUSIVE
• INCONSISTENT UNRESPONSIVE
• POOR FIT care-giver/child
• ABUSE TRAUMA
• DEFICIT of MENTALISATION
• ATTACHMENT INSECURITY
ATTACHMENT STYLES
• SECURE
• INSECURE
ANXIOUS
AVOIDANT
FEARFUL
DISORGANIZED
• AFFECT EXPRESSION MODULATION
• COHERENCE
• REFLECTIVE ABILITY
•IMPLICATIONS FOR MANAGEMENT
PRIMITIVE COPING
MECHANISMS
• Black/White Feeling States
• PROJECTION
• ENACTMENTS
GOOD WILL HUNTING
GOING FOR THE
THROAT JUST
WON’T DO
Direct Emotional
Direct Emotional Transfer
NEUROPHYSIOLOGY:
MIRROR NEURONS
PSYCHOANALYSIS: PROJECTIVE
IDENTIFICATION
SOCIAL PSYCHOLOGY:
EMOTIONAL CONTAGION
Emotional Transfer
･Neumann R, Strack F.
participants who expected to be tested for text
comprehension listened to an affectively
content-neutral speech spoken in a sad or happy
voice. …the emotional expression induced a
congruent mood state in the listeners.
J Pers Soc Psychol. 2000 Aug;79(2):211-23.
Stephen Jay Gould
variation itself is
nature’s only
irreducible essence
BE A GENIUS
MIRROR NEURONS
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At London’s University College,
psychologist Tonia Singer used brain
scans to explore empathy in 19
romantic couples. The experiment
was simple. Both individuals were
hooked to brain scans. One was
given a slight electric shock while the
other watched. Scans showed
identical brain reactions. One partner
was shocked, but the other partner’s
pain center lighted up as if he or she
had also been jolted.