Countertransference

The term countertransference is a clunky one; put simply, it refers to how people pick up, sense, intuit information about the state of minds of others communicated non-verbally. It has survival value; all animals who live in social groups need to be highly attuned to each other in order to detect states such as aggression, hunger, satiation, lust and fear. In infancy, experiences of desperation, terror and helplessness are projected into the caregivers depended on to ensure a timely response in keeping with the level of distress. We continue to project aspects of our emotional experiences throughout life and this increases at times of anguish and extreme anxiety. At these times, we all need the minds of others to contain us and to bring us back to ourselves. Phrases such as ‘driving me mad’, ‘going round the bend’ and ‘losing the plot’ attest to the awareness of our own ‘frail walls against […] dissolution and madness’ (Remarque Reference Remarque1929: ch. XI).

Yet we can seem to put these skills at the door of psychiatry or – worse – consider our emotional responses to the work as somehow unprofessional. Gibbons’ article makes clear the perils of not using the tools that make us human – our ability to sense, to intuit and to receive the projections of others – and foregrounding these as essential to our craft as psychiatrists. The genesis of psychotic processes – illustrated in the article as a fundamental aspect of human life and latent within us all – and with the aim of denying difficult realities – are clearly described. It requires an advanced level of understanding to translate complex-seeming ideas into everyday language so that their relevance across psychiatry can be clearly seen; Gibbons achieves this with a pithy summary of the evolution of psychoanalytic models to better understand what happens to the mind in psychosis.

Psychotic and non-psychotic parts of the personality

A central model of there being a psychotic and non-psychotic part of the personality in precarious balance with each other is key, along with the hallmarks of psychotic functioning being denial, rationalisation, loss of contact with reality and inappropriate affect. You don’t need to be frankly delusional or hallucinating in order to be operating under the persuasive pull of psychotic processes – in clinical practice our countertransference responses can be activated into operating in keeping with the reality-denying part of the psychotic process and this can be amplified across the organisations we work in. The case vignettes in Gibbons’ article illustrate these processes vividly and convincingly.

To return to the key worker in my vignette, the ‘lapse’ could be seen as a loss of contact with the part of her that knew how ill the patient was and their history of evading care. She had responded to the request for a plaster as if in the presence of ordinary mental activity, when in fact this was a rationalisation from the psychotic part of the patient hell bent on escape. Her countertransference had been to be entirely unconcerned about leaving her patient, despite her knowledge of their history. The ‘trouble’ shows how harsh and persecutory the superego can be in psychotic states, berating the non-psychotic part for not standing up to the cover up of the underlying delusional system. The rationalisation had been accepted and history denied, allowing for agreement to act in keeping with the cover up/plaster. The organisational response and potential for disciplinary proceedings represents an amplification of persecutory processes and a continuation of working on a psychotic/non-mentalising wavelength. What is urgently needed beyond investigatory processes are approaches to practice that are ‘mind-based’ and opportunities to learn about how our capacities to think can come under fire when working with psychiatric illness. Without such an approach we risk losing focus on the complex communications between staff and patients as key clinical tools and our care becomes concrete and action based.

Challenging paradigms

Gibbons’ article challenges some of our existing paradigms within psychiatry and will likely meet resistance. We may like to think we operate as rational, highly trained professionals with robust decision-making capacities, but when working with disturbed states of mind we are all heavily influenced by our own responses to projections and how we interact with others through unconscious mechanisms. The test of any such project is whether or not these ideas are helpful and translate into something useful in everyday practice. I would ask the sceptics whether the clinical scenarios described in the article resonate with their own experiences – and whether the psychoanalytic models help shed light on some of the paradoxes in our work.

There is a welcome and increasing dialogue about the therapeutic value of relationships in clinical care, but the reality is that these relationships are complex, that different parts of our patients may communicate with us in different ways and that we can be powerfully affected in clinical encounters in ways that disrupt our own thinking. Furthermore, psychotic symptoms and delusional belief systems may be ways to manage realities that seem unbearable to face and may be deeply attached to; we can all be pulled into the seductive influence of psychotic functioning and behave in ways that deny painful reality.

Gibbons’ article ends by making a strong case for reflective spaces as an ordinary part of care and their value in focusing on the underlying relational dynamics in care. In my workplace these are routinely offered in a range of settings and the more members of the team who attend the more we are able to piece together a deeper understanding of the patient and the projective processes at play. This is not a luxury – it is essential in providing the deeper formulation needed for safe and effective care.

When the emotional impact of the work can be captured and understood, clinical care is deepened and good decision-making processes are strengthened; I would argue that Gibbons’ article shows the importance of the countertransference in our work as a key part of the clinician’s tool kit, the perils of not being trained to attend to it and that it should be an ordinary part of the mental state examination. And for those who would like to read more, I highly recommend Richard Lucas’s book The Psychotic Wavelength (Lucas Reference Lucas2009), based on his many years as an adult psychiatrist and a psychoanalyst, which further details the key ideas in this expansive article.