Transference and Countertransference
J Psychiatr Ment Health Nurs. Apr;14(2) Transference in the nurse- patient relationship. Evans AM(1). Author information: (1)School of Nursing. The meanings that were generated led to the uncovering of patterns of The PMH nurse–patient relationship in acute inpatient psychiatry continues to the patient's ego defense mechanisms, anxiety and transference, and. aspects of countertransference and to identify their impact on a therapeutic relationship. 2. To gain a Term frequently used to denigrate nurses regarding their reactions to . A dysfunctional pattern of living, which emerges from repeated.
I knew that he had this fear of people coming to kill him. He came to the point where he recognized me. I was able to redirect him and do some reality orientation. This patient experienced hallucinations and delusions and acted out a scenario that the nurse only partially understood. Patients gave accounts of conflict with nurses. At the time of our conversations, Marie still did not comprehend the experience, and she had made little progress in working with her nurse in a more engaged manner.
Nurses reported that they continued to situate their searches for a place and time of engagement even when they themselves were experiencing anxiety and fear: Nurse Diane Furthermore, Nurse Samantha seemed to understand that she needed to think through her responses in a frontline encounter: There is always something going on in the back of my head.
Even though Samantha valued the emergence of any possibility of common ground, she continually reviewed her approach: A value such as personal safety came into the foreground and Samantha would question the route she was taking.
Nurse Hilary gave an account of a different reaction. She had been confronted by an angry patient and she responded in a manner that she later regretted: This patient has a propensity for. I forget what I said to her. I thought afterwards I could have handled it differently. This exchange revealed the challenge of enacting a mindful approach. I thought, just let her say it. She worked hard to uncover the possibility of a more engaged relationship in the future. I could kill you. So there are those conflicts, right?
Upon later reflection, Nurse Lydia recognized that her response did not conform to her own professional standards; she understood that in the social matrix of nursing practice, nurses do not always act in their own defense: You have to say, this is a person who is ill; this is not a personal attack.
Nurse Tim, who viewed much of his relational work as psychodynamic psychotherapy, understood that when patients uncover thoughts and feelings previously hidden, they often experience anxiety: In another account, Nurse Colleen also used language that illustrated the movement of nurse and patient in this shared relational space: These nurses understood the frontline as an experience filled with motion, at once a place of possible convergence and a place of disjuncture that participants constantly approached, held their positions in, retreated, and encircled.
Each highlighted a moment when the frontline shifted, and confrontation and explanation appeared to be replaced by a more comfortable connection. I used the term common ground to highlight this kind of relationship, where each person is more at ease with the other and the patient feels less of an object.
Patient Laura stated, When I talked to my nurse. We were engaging and we were on the same page.
- An Interpretation of Nurse–Patient Relationships in Inpatient Psychiatry
She was listening to me, and she gave me an intelligent answer back. Patient Elsie reported the value of this kind of exchange: He invited the patient to consider different truths and attempted to help the patient to understand a confusing experience. He had this thing that was important to him and he had a chain on it. He takes out this old pocket watch that he had. So obviously there was that commonality that I can see how much his grandfather meant to him and right away made that little bit of extra connect, people connection.
Charles illustrated how he explored his own intentions and motivations; he later articulated to me that he knew that his perspective was only one constituent of shared understanding. The notion of place seems to be particularly present in these experiences: How could nurses and patients create shared understanding when their worldviews appeared to be so different? Perhaps the answer lies in the overarching theme of mindful approaches. In this inquiry, the accounts of nurses and patients appeared to suggest that frontline encounters were often filled with tension and defensiveness.
It makes sense then that nurses and patients, having experienced the frontline encounters, would wish to uncover and inhabit a more shared, intersubjective space. Each would be able to understand the other and, without losing the identities of patient and nurse, create an encounter that more closely resembles a person-to-person connection.
It may be that nurses and patients who inhabit common ground are beginning to cocreate a new and more shared perspective, thereby setting the stage for a new relationship. Nurse Charles recounted the following: The patient, having satisfied himself that Charles was safe and trustworthy, approached him with curiosity, and the relationship changed. Nurse Joy gave an account of a relationship in which a shift occurred despite struggles to engage and ongoing conflict: There was a young fellow; he had a hard go of it.
So with patience I slowly got through to him. Both nurses and patients seemed to notice this relational shift. I am less tearful when I spill my guts and a bit more comfortable. I have control, so maybe I can talk to her. Before, what we talked about was always my suggestion, whereas once he started to feel a little bit better and we were able to link better to each other, I was able to ask him more. I remember a picture on his windowsill.
Do you get to visit him often? How do you feel after these visits? It looks like you have family gatherings—what is that like for you? Should they let their defenses down or should they put them back up? Patient Marie described how she experienced this kind of vulnerability as being on a pathway to recovery: At one point, I observed a nurse and a patient operating within this space of shifting vulnerability.
A sad and angry patient expressed puzzlement at a question the nurse posed, and then his eyes filled with tears. In the ensuing conversation, the patient recounted specific aspects of his story that were clearly uncomfortable and anxiety-provoking and that had not previously been a focus of their conversation.
At the end of the conversation, the nurse understood the patient in a different way; he had both articulated and argued for his vision of his future, and the nurse considered the experience to signify a change in their relationship. Within each of the subthemes of frontline, common ground, and shift, patient-participant accounts highlighted changes in openness to engagement, willingness to share uncomfortable experiences, and visions of the future. Patient experiences with unknowing and defensiveness inhabited the subtheme of frontline.
Transference in the nurse-patient relationship.
The importance of being viewed as a person and not an object inhabited the subtheme of common ground. The subtheme of shift highlighted the significance to the patient of a safe connection where his or her perspective could be fully articulated and given meaning.
In contrast, nurse-participant accounts across all themes highlighted the importance of being alert to changes in patient experience and committed to achieving shared understanding. The care face is the place where PMH nurses are directly engaged with patients for aims that are unique to nursing practice Barker et al.
In this inquiry, the frontline was one example of the care face. It was a place of active approach and exchange of perspectives, in which patients and nurses seemed to jostle for position, sometimes to seek advantage or exercise power and sometimes to open a window of opportunity or declare a temporary truce.
For their part, patients want nurses to recognize and anticipate their needs Barker et al. In frontline exchanges and while finding common ground, nurses worked actively to uncover feelings, helping patients to understand what was happening to them and using this understanding to frame their experiences.
It may seem counterintuitive to uncover the notion of nurse as counselor in the theme of mindful approach when so many encounters were enacted in moments of acute distress.
Counseling is conventionally understood to take place over a longer time period and within the context of a formally contracted therapeutic relationship with specific goals. Furthermore, Peplau stated, Counseling in nursing has to do with helping the patient to remember and to understand fully what is happening to him in the present situation, so that the experience can be integrated with, rather than dissociated from, other experiences in life.
In accounts of mindful approach, nurses sought this kind of exploration. As I discussed this work with colleagues, a few suggested that the frontline subtheme too strongly evoked an image of battleground and war, but as I reviewed the accounts, I continued to see strong evidence of confrontation. I have yet to uncover a more peaceful metaphor for the mindful approach, which after all is only one dimension of the PMH nurse—patient relationship: Strengths and Limitations The inquiry had both strengths and limitations.
The research design and data collection process support my claim that the study meets the criterion of dependability. I ensured that participants knew that I was not connected in any formal way with their clinical team or nursing supervisors.
I conducted interviews in a formal interview room and adhered to the interview guide, bringing the interview to a close if researcher boundaries were threatened. I reviewed initial accounts before secondary interviews, and I engaged in reflective writing. After data collection was completed, I sought feedback from my peers by presenting some accounts to a national conference of PMH nurses and a seminar of graduate students.
An Interpretation of Nurse–Patient Relationships in Inpatient Psychiatry
There were a number of challenges in conducting this inquiry. Prior to study initiation, two of the units were changed from acute care to rehabilitation, thus reducing the pool of acute psychiatric inpatient nurses and patients.
On any given day, there were more patients on the study units who were certified as incapable of consenting than were certified as capable. Sample size is typically small in studies of this nature, but in this inquiry, the sample size was both small and unevenly distributed: Although rich and meaningful texts emerged from conversations with both groups, many may consider that the nurse perspective at times overwhelmed the patient perspective.
Although I do not hold that the results of this study are transferable or generalizable in the postpositivist sense, and some may assess this as a study limitation, I attempted to make firsthand accounts the centerpiece of this work so that readers can understand both the context of the inquiry and how participants interpreted the phenomena.
Implications for Nursing Practice and Research In this inquiry, nurses and patients revealed that in a psychiatric inpatient setting, it is possible to create knowing and transformative relationships. Nurses approached patients with the intention of creating meaningful encounters even when they were uncertain of the potential for intimacy and long-term engagement. Patients responded to nurses by meeting them at the frontline, seeking recognition, and working with nurses to find meaning in their experiences.
Despite the fact that acute inpatient PMH nurses experience serious constraints on their ability to work relationally with patients, they continue to find ways to engage patients in therapeutic work.
This is the kind of evidence that acute inpatient PMH nurse leaders will need in order to make a strong case for program funding that supports nurse—patient engagement in acute inpatient settings and leads to more effective utilization of inpatient services.
Acknowledgments The author gratefully acknowledges the guidance of Dr. Franco Carnevale, who supervised this research. Footnotes Declaration of Conflicting Interests: Relationships between patients and nurses in psychiatric wards.
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Journal of Psychiatric and Mental Health Nursing, 12, — The original sin of mental health nursing? Inappropriate meanings are assigned to the relationship by the patient. For example, Strayhorn 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 Knieslthe 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.
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: Countertransference Countertransference involves the same principles, except the direction of the transference is reversed.
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.