Countertransference in Palliative Care Practice: What’s a Clinician to Do?

Many palliative care clinicians come to the field with a desire to be present for others. While everyone’s reasons for entering the field are different, many people may find that this stems from historical personal experience(s). The act of serving others within any helping profession can bring about lots of complicated emotions, and may even call up past, unresolved trauma for those engaging in this work.

Palliative care is one of those professions that allows us to be intimate with patients. While we are firmly committed to providing the best possible care, we may not always understand or even appreciate two psychoanalytic concepts that can occur and significantly influence the therapeutic process of care—transference and countertransference. Both concepts originated from more traditional therapy processes, but we see these dynamics at play in the relationships between health care providers and patients.

In order to really dig in and understand the role of countertransference in our clinical interactions, we should first define the alternate process, transference. After all, without transference feelings, countertransference would not be present. Transference is the unconscious redirection of a patient’s feelings, attitudes, and desires—often regarding a close personal relationship in their earlier life—onto the clinician. For example, a patient may over-identify with a young clinician who reminds them of their own child, and then subconsciously interact with them in a parental way, dismissing their professional expertise and recommendations for care.

Countertransference is the unconscious redirection of a clinician’s feelings, attitudes, and desires about a close, personal relationship onto the patient. This is a direct response to the transference exhibited by a patient. Following the transference example, the young clinician may then respond to that transference by interacting with the patient in a way that reflects their own relationships with their own parents. Perhaps this means spending more time at the bedside or feeling the need to prove themselves as a professional.

These responses can often be confusing to clinicians as they manifest in ways that seem out of sync with normal patient interactions. Countertransference is typically subconscious and often subtle, prohibiting one from realizing what is really happening. As palliative care professionals, we develop the capacity to be ‘comfortable with discomfort’. We hold space for silence and have difficult conversations. Despite this tolerance and expertise, it’s important to remember that we are also human and experience a wide range of emotions and feelings.

Countertransference happens to clinicians regardless of their years of experience. Take a moment and consider your own experience. Have you inadvertently avoided spending time with a certain patient or shortened your visit? Maybe your body responded in an interesting way when you walked into a patient room. What do we do when we find ourselves avoiding these very encounters we typically embrace? Hang tight—we will get to that.

At times, yes, it can be. It may disclose painful or unwanted parts of ourselves that need attention. It may evoke strong emotions within us, that without conscious examination, lead to behave in ways that are not therapeutically beneficial to the patient. But the experience of countertransference may not always be negative. Countertransference is positive in many ways, and can be a therapeutic tool in one’s work, providing a basis for compassion, empathy, and understanding.

As clinicians, we are bound by our ethical obligations and must uphold professional boundaries. Even when countertransference proves to be beneficial in a clinical relationship, it is vital that we maintain these professional boundaries and are selective with our own self-disclosure.

One area of concern that has grown among health care professionals since the beginning of the pandemic is moral injury. It is important to acknowledge its prevalence and relatedness to countertransference, while also recognizing this topic deserves further discussion and attention.

Moral injury is harm that arises when one perceives they have neglected their own core values. This harm can manifest itself through various aspects of the human condition—socially, psychologically, and spiritually. Moral injury was a term first introduced in the 1990’s by Dr. Jonathan Shay, based on his work with veterans.

Moral injury has entered the conversation with health care providers and health care systems since the onset of the pandemic. Clinician values and ethics have been tested and many have been asked to practice in ways that may not align with their own personal values. The connection we find between moral injury and countertransference is that both concepts originate within a clinician as a response to a patient expression, decision, or behavior. We can see the potential relatedness when a clinician is offering care to a patient that they may not have chosen for themselves.

Take for example, the nurse who is caring for a patient with metastatic cancer. This nurse’s mother died from metastatic cancer. She was her mother’s primary caregiver. This nurse is now caring for a patient who in many ways reminds her of her mother—same age, same type of cancer, similar side effects. The nurse witnessed her own mother suffering at the end of life and feels moral injury when the patient is offered additional treatment options, which are not aligned with the nurse’s own personal values. She is experiencing both moral injury and countertransference. However, the countertransference she is facing allows her to remember and appreciate the difficulty of her mother’s decision to stop treatment, and can offer understanding, compassion, and support for the patient’s perspective.

These patient experiences are not uncommon to those of us in palliative care. They provide a reminder of our humanity—that we are not exempt from feelings of sadness, loss, and maybe even despair in our personal and professional lives. Here are a couple helpful tips that we as clinicians can embrace, which will inform our practice:

Check in with your own emotions. If you are feeling particularly triggered by a patient interaction or finding yourself more deeply connected to one patient over another, this is a good time to do a self-check in. We cannot adequately address issues if we are not aware of them.

It is important to name the emotion, as the very act of recognition can take away shame and guilt, which often accompany uncomfortable feelings (e.g., frustration, annoyance). Investigating our own responses can also be a very useful tool in continuing to work with patients that may be unconsciously setting off alarms within us. We may not always be at a place where naming our emotions is available to us. In these circumstances, it may be useful lean on your team and request that another colleague step in to assist with patient care needs, so you can attend to your own needs.

It can be scary and uncomfortable to open dialogue around our own emotions. Find a trusted mentor, therapist, or even colleague in the context of your team. Palliative care teams are dedicated to their interdisciplinary care approach; use your team members’ perspectives. Opening this line of communication may help one feel less alone—it may even help other team members discuss their own feelings. It is also vital for team leaders to create the space to have these conversations with one another. Only then, can we support each other in a compassionate way and build connections with one another. At times it may be important to encourage one another to pursue more intensive therapeutic support as needed.

The process of countertransference really challenges the clinician to interrogate their emotions and feelings. By bringing awareness and exploration into these interactions with patients, we allow ourselves the opportunity to become more resilient, less exhausted clinicians. Through this examination, we also give ourselves opportunity to look at situations and challenges from an alternate lens.

As clinicians, we often shy away from doing our own internal work for fear of uncovering things that feel as though they lead us down a path we may not wish to go. However, doing our own work to show up for ourselves will reflect in the provision of optimal care for our patients.

• CAPC's Emotional PPE Resources
• How to Support Your Organization's Emotional PPE Needs During COVID-19
• Cultivating Moral Resilience
• Transference and Countertransference in Communication between Doctor and Patient
• Countertransference and its Impact on Patient Care