Transference and Countertransference in Aging and Illness

Abstract

The concept of transference is a central idea in classical and contemporary psychodynamic theories. Often thought to be the bedrock of traditional psychoanalysis, to what extent transference interpretations function as the therapeutic action of the modern psychodynamic therapy encounter, especially with medically ill and aging patients, remains an open question. At the heart of the distinction between traditional and contemporary theory is the nature of involvement of the therapist. At its extremes, proponents of the traditional school hold that a therapist is a “blank screen” on which patient projections and ideas of transference occur; contemporary theorists on the other hand, have recently been advocating that emotional involvement by the therapist is an essential and unavoidable factor in all treatment modalities. The idea among many contemporary clinicians is that the emotions of both the patient and the therapist create a unique and intersubjective world between the two parties. Despite different perspectives about transference, there is perhaps no idea more fundamental to psychodynamic theory.

This chapter will explore methods for applying ideas related to transference in working with medically ill and aging patients, particularly how we can most effectively be attuned to a patient's emotional states, as well as understanding how transference can inform the way we talk with patients. Since transference theory has received considerable attention in psychoanalytic and psychodynamic writings, I will not attempt detailed discussion on this vast literature. Rather, following a discussion of some of the limitations of traditional ideas of transference and transference interpretations, we will focus on aspects of transference that are useful for medical and aging populations. Ideas regarding transference have been expanded in contemporary theory, beyond the level of traditional “genetic interpretations” which suggest that one views a situation based solely on an understanding of reported early childhood experiences. Modern ideas of transference are more complex and take multiple aspects of emotions as felt in the present into consideration. However, we will also consider the various ways that our patient population can be vulnerable to inaccurate interpretations, since bodily issues that affect these patients, especially pain, can elicit irrational ideas and beliefs which may not be related to past experiences or even unconscious fantasy. Finally, I will briefly discuss the difficulties encountered in working with aging and medically ill patients from the perspective of countertransference. Contemporary psychodynamic theory has magnified the importance and clinical utility of our own emotional reactions and thoughts when we are with patients; some of the pertinent challenges in dealing with our own emotional responses when working with this vulnerable population will be described.