Consultation-liaison (CL) psychiatry, a term that is sometimes used interchangeably with psychosomatic medicine, is a subspecialty of psychiatry, with fellowship training programs first established in 2004 by the American Board of Psychiatry and Neurology (ABPN). CL practice emerged informally during the mid-18th century in the United States when Philadelphia’s Pennsylvania Hospital was founded to care for both psychiatric and medical patients.1 Although the scope of CL psychiatry is broad, one of the widely accepted core competencies, as established by a 2008 collaboration of the American Psychiatric Association (APA), the Academy of Psychosomatic Medicine (APM), and the American Board of Psychiatry and Neurology (ABPN), is that psychosomatic medicine psychiatrists shall “skillfully manage transference and countertransference issues that arise between patients with psychiatric disorders and/or interpersonal conflicts and their caregivers in general medical settings.”2 A similar call for trainee competence in transference and countertransference management as part of training in CL psychiatry has also been issued in Europe.3
Limited formal guidance exists concerning this role of the CL psychiatrist, although interpersonal dynamics among medical teams and the patients they treat affect clinical landscapes in undeniable ways. The best documented manifestations of this phenomenon include negative countertransference reactions.4 Poor quality of care and increased conflicts among clinical staff have been recognized as primary and secondary outcomes, respectively, of countertransference in the medical setting.5 Clinical scenarios involving negative countertransference reactions have also been linked to outpatient treatment dropout rates and negative outcomes.6Such emotional reactions have also been recognized as contributing to passive aggressive, self-defeating, and avoidance behaviors toward patients, which can in turn result in patient-perceived abandonment and punishment.7 In terms of consultant-consultee relations, triangular conflicts involving patient, clinician, and CL psychiatrist have been conceptualized as unconscious projections of disavowed feelings from patient to provider and from provider to consultant.8
In this study, we explored such forces assuming that they are relevant and important for CL practitioners to consider at all times. Terms used by cognitive and behavioral therapists that may in some ways correspond to the term countertransference include maladaptive schemas, automatic negative thoughts, or dysfunctional core beliefs.9 In addition, a significant body of literature explores the notion of unconscious physician bias,10 with numerous studies revealing disparities in physician care of patients based on ethnic, racial, socioeconomic, gender, and religious parameters. As such, researchers have shown how a physician’s conscious and unconscious beliefs directly influence his or her interpersonal behavior in the medical encounter.11 For the sake of clarity, because it is taught loosely to all medical students, and given the use of the term by the academic bodies mentioned above, we chose the term countertransference (defined below in the “Methods” section) as a singular, unifying concept in an attempt to assess current trainee experiences in navigating interpersonal dynamics within the medical setting. We recognize the inherent difficulties in using this term, but we ultimately chose it over the narrower cognitive-behavioral concepts and the potentially stigmatizing construct of bias. Thus, psychodynamic terminology is emphasized in this study, although we acknowledge how cognitive-behavioral and other models can be similarly descriptive and relevant.
The objective of this survey study was to sample resident attitudes and practices with regard to management and mediation (or lack thereof) of countertransference in non-psychiatrists from the perspective of the CL trainee.
METHODS AND MATERIALS
Participants and Survey
Current psychiatry trainees in psychiatry residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) across the United States were invited to complete an Internet-based (www.surveymonkey.com) 20-item questionnaire (combining Likert-scale and qualitative items) that asked about practices and opinions about CL countertransference management and training (see Appendix). The survey was completely voluntary and confidential, with no traceable demographic information included in order to protect the anonymity of subjects. Exempt-status Integrated Scientific and Ethical Review Board (ISERB) approval was obtained from St. Vincent Catholic Medical Center. A national e-mail listserv of chief psychiatry residents from all ACGME-accredited training programs in the United States was obtained. The survey website link was e-mailed to these chief residents along with instructions asking them to distribute the survey among their residents but specifically not to circulate it to fellows or attending physicians. Respondents were asked to complete the survey only if they had participated in a CL rotation for at least some period of time. Collection of data was completed over 6 weeks (April to May 2010).
Definition of Countertransference
Multiple definitions of the construct of countertransference have been proposed in the literature.12–15 Traditionally, these definitions focused on the psychotherapeutic patient-analyst dyad; however, more recently they have encompassed nuances of all interpersonal interactions. For our survey, the classic and narrower Freudian perspective was chosen, which was indicated at the beginning of the survey where countertransference was defined as “the physician’s unconscious emotional reactions to the patient as influenced by past relationships and/or unresolved conflicts.”16 Respondents were asked to keep this definition in consideration throughout while they completed the survey. Data on level of CL exposure as indicated by months of rotation time were also collected. For each item in the survey, an effort was made to explain that countertransference pertained to the primary medical/surgical team, not to the CL resident or psychiatric team.
Data from the survey were aggregated and analyzed for basic trends by the authors based on percentages of responses to individual questions. Replies to open-ended questions were also collected (see Table 1 for sample responses) and are discussed where appropriate in the results.
Of 192 respondents, 162 (84%) reported having participated in a rotation on the CL service for at least some period of time and were therefore eligible to complete the survey, while 136 (71%) reported having completed at least 2 months of rotations on the CL service. It should be noted that the nationwide ACGME-accredited psychiatry resident census for the study period (2009–2010)17 was approximately 4848, although a substantial portion of these residents (including all first-year interns) were not eligible to complete the survey because they had not completed CL rotations.
Approximately 80% of respondents identified a frequent need to address countertransference reactions in the primary medical/surgical treatment team. Respondents listed a number of motivations (Figure 1) for addressing such reactions, including the thought that “it could be clinically helpful” (84.5%), that the resident “felt the consult itself was primarily motivated by countertransference reactions” (60%), and that the resident was “instructed” to do so by a “superior/supervisor” (30.3%). Furthermore, one resident indicated that addressing reactions was warranted when “the primary team was interested in examining or improving their countertransference.”
Less than a quarter (21%) of the respondents opposed openly addressing the primary team’s countertransference reactions (Figure 2); of these, 34.6% felt that doing so might “worsen the relationship between CL consultant and the primary team.” In addition, 19.2% of these respondents reported they had “not been sufficiently trained in this aspect of CL” and/or felt uncomfortable with the task. Despite this sense of inadequacy, only one respondent felt it was not the role of the CL resident. Interestingly, 30.8% of these respondents felt the practice of addressing countertransference was futile and that “the primary team is probably not receptive.”
When asked what the perceived outcomes of addressing such countertransference reactions were, the respondents appeared divided, with approximately a third (37.9%) reporting that “clinical care seemed to improve,” a third (38.6%) saying “the relationship between CL consultant and the primary team improved,” and a third (31.4%) feeling that it “depended on the nature of the case.” These last respondents were asked to elaborate and the majority (16 of 27 collected explanations) felt the clinical outcome of addressing countertransference varied according to the characteristics of the primary team. This sentiment was evidenced by statements such as “it depended on the capability of the medical team to reflect on this” or “it depended not on the nature of the case but more on the physician.” Alternatively, one respondent explicitly described the outcome as dependent on patient traits (severity of illness, genuine pathology versus malingering of symptoms), while two respondents felt that a combination of provider and CL consultant characteristics was most important in determining the results of any CL intervention. Table 1 illustrates a sampling of these resident responses.
Regardless of the overwhelming support for addressing countertransference in the primary medical/surgical team, a separate survey item revealed that over three-quarters (76.6%) of respondents rarely or never did so in clinical practice. Only six respondents reported addressing countertransference the “majority of the time” when they consulted on cases, and no respondents said that they “always” addressed countertransference (Figure 3).
While the responses discussed in the preceding section establish the importance of countertransference to the average CL resident, the data further suggest a dearth of training encounters on the CL service devoted to the matter (Figure 4). Indeed, a full 95% of respondents indicated that CL didactics (defined as classes or lectures outside of clinical rounds and supervision) addressing countertransference management would be at least somewhat “clinically beneficial” as opposed to ineffective or detrimental. Conversely, two-fifths of those surveyed reported “very few” of their didactics addressed countertransference and nearly one in four of the 136 respondents had never been exposed to didactics on such issues.
Subsequent questions addressed other forums for discussing countertransference management on the CL service. Between rounds, case conferences, and supervision, only 11% of respondents denied exposure to any discussion of countertransference issues. Two-thirds of respondents indicated that only “some” or “very few” case conferences addressed this area, while 81% identified comparable frequencies of discussion of countertransference management during clinical rounds. In contrast, one in five residents used “most” of their CL supervision sessions to discuss countertransference and its implications or techniques for management in some capacity, once again indicating the principal role played by individual supervision in training.
The survey results presented here reveal significant trends among current psychiatric trainees. They suggest that residents have a strong desire to address countertransference in non-psychiatrist clinicians but the respondents also expressed considerable apprehension and hesitation about doing so. Limited instruction in this area, as indicated by the data, is a tempting singular explanation for this phenomenon; other factors also appear to be involved including perceptions that the exercise may be futile or that the success of intervention depends mostly on the receptiveness of the primary medical/surgical team rather than on the CL trainee’s abilities. The data we collected also revealed limited discussion of countertransference in a number of teaching settings, including didactics, clinical rounds, and case conferences, although the respondents notably recognized the role of individual supervision in providing guidance to trainees in conceptualizing countertransference.
Strengths and Limitations
The study’s strengths include a sizable sample, distribution across all ACGME-accredited psychiatry residencies (although it is uncertain which programs responded as this identifying information was not collected), and items exploring attitudes as well as practices. A limitation of the study was lack of control over who responded, with distribution spread among chief residents across the nation. The response rate was also lower than we had hoped for, and it is suspected that a response bias existed primarily in terms of higher responses from the home institutions of the authors. We also recognize difficulties in universalizing what is meant by counter-transference, but ultimately we believe that its use in this study was preferable to the use of other terms such as bias, cognitive distortion, or other terms that are associated with inherent problems of their own. In addition, despite our efforts, the possibility that items were answered based on a consideration of the psychiatrist’s as opposed to the non-psychiatrist’s countertransference is very real.
Despite its limitations, our survey revealed a number of important clinical and academic realms in CL psychiatry that appear to be suffering from incomplete attention or guidance. The demonstrated dichotomy between attitude and practice, whether due to lack of training or a sense of futility, suggests that residents may be unable to fulfill their CL expectations. Without appropriate or concrete guidance, CL residents find themselves unable to grapple effectively with countertransference issues and are often confused as to whether the task is even their own.
The findings from our study suggest potential strategies that could be developed to train CL residents in how to think about and approach countertransference in medical settings. Such interventions could take a number of forms, ranging from general medical education on the inevitable unconscious biases to which all physicians are predisposed,18 to specific educational initiatives tailored to the CL psychiatrist’s role.
CL psychiatrists have used various approaches to encourage house staff to address their emotional reactions toward patients and each another. One technique involves ombudsmen rounds in which a medical attending physician and a psychiatrist incorporate staff into a team-based, biopsychosocial approach to care, with emphasis on staff interactions with patients and with one another.19 In 1970, Massachusetts General Hospital famously implemented weekly “autognosis” or “self-awareness” rounds managed by the CL service that eventually grew to involve medical house staff rotating in the intensive care unit. These interactions encouraged non-psychiatrists to identify their subjective reactions to clinical scenarios, learn how to utilize emotions clinically, appreciate how to mitigate potentially negative sequelae of such reactions, and to discuss these feelings with other staff. This led to the recognition of body sensations in trainees as an indicator of potentially problematic countertransferential reactions and to the creation of “The Red Book,” a forum whereby members of the house staff were encouraged to document and share feelings induced by their hospital work.20
The question of whether these tactics could or should be implemented at a national, board-regulated level in the context of third-party payer systems and other systemic, financial, and clinical constraints remains relevant. A disparity in attitudes versus practices is the most telling finding from the study presented here, and it begs several questions regarding potential obstacles to the CL resident trainee approaching the primary team with counter-transference interpretations. In a separate article,21 the authors explore in depth a number of systemic and interpersonal variables that may contribute to difficulties among CL trainees in managing non-psychiatrist countertransference. There appear to be immense difficulties in conceptualizing, articulating, and ultimately teaching CL countertransference interventions. Nevertheless, the authors feel that a call for formal training and development of guidelines is warranted and have begun to develop measurable curricula22 utilizing both psychodynamic and cognitive-behavioral approaches to elucidate less-formalized liaison competencies.
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22. Jimenez XF, Azzam P Assessing and improving consult psychiatry resident competencies in liaison roles and countertransference management on medical/surgical services. Poster presented at University of Pittsburgh Medical Center 10th Annual GME Leadership Conference, Pittsburgh, PA, February 25, 2011