الفهرس 
CountertransferenceOnly 14 pages are availabe for public view
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Abstract
During the past fifty years the concept of countertransference has become a topic of considerable interest. In order tounderstand the developmentsthat have occurred in the history of the use of the term, it ishelpful to consider first the evolution and disagreements that haveoccurred in the development of the concept of transference.The term transference was first defined by Freud as a false connection; a transitory phenomenon interfered with the therapeutic process. The transference involves more than the patient’s reliving an earlier relationship. Thetransference relationship implies a ”rational,” positive transference, which brings inhibited drives into play with the aim of the transference relationship. At the same time, the patient’s experience of hostile and aggressive feelings towards the analysts is manifestations of negative transference.
There is no single accepted definition of countertransference to date. Freud stated that counter-transference arises in the analyst as a result of the patient’s influence on his unconscious feelings.Countertransferencewas seen as the analyst’s awareness of negative affects towards his patient orthe patient’s unconscious unexpressed emotions. So, countertransference could be seen as a source of important information, which could be employed significantly to enhance the analyst’s understanding of the patient’s unconscious.
So, the conclusion is that transference (defined as a distorting influence in the present that relates to the individual’s past) can apply to both members of the therapeutic dyad. Countertransference (defined here as the unconscious capacity to perceive and understand the other) could also be considered to be something inherently attributable to the patient as much as to the therapist.
Countertransference is now regarded as inevitable and minor enactments of countertransference may provide valuable information about what is being recreated in the therapist-patient dyad.Thetherapist’s integrated awareness of their own erotic and murderous impulses enables them to reduce the likelihood of needing to project these feelings onto others, also plays an important role in the therapeutic process, and enables the development and maintenance of appropriate levels of intimacy and separateness between both parties.
Threespecific categories of counterresistance could be defined. The first, ‘countertransference resistance’, emerges only in response to certain patients and is related to the patient’s resistances. The second, ‘characterologicalcounterresistance’, is seen as entirely related to the personality of the therapist and to resistances that are characteristic of the therapist in all areas of their life. The third category of counterresistance is not linked to the therapist’s past but is cultural – ‘a displacement and projection of social pressures and values onto the patient’
Clinical ethics refers to the principles of proper professional conduct concerning the obligations of physiciansto their patients, to other health professionals in relation to their patients, and to healthcare organizations concerning thedelivery of patient care.Ethics in mental health care is exceptionally complex because of the nature of mental illnesses which affect an individual’s most fundamental human capacities, relationships, social roles,behaviors and therapeutic interactions with patients. Of the key ethical principles are beneficenceand aphorism.
Countertransference and transference are helpful concepts for understanding these deeper aspects of doctor–patient interaction. Understanding and monitoring such countertransference responses can then become an important tool to gain a better understanding of the patient.
The most difficult ethical conflicts are those involving the narcissistic exploitation of another, such as exploiting patients sexually or financially. Theneurotic sexual countertransference and unconscious identity are the main reasons for unethical enactments.
Many ethical problems of a sexual nature occur when the analyst fails to understand the patient’s past deprivations and unconsciously identifies with the problem and attempts to meet the deprivation by trying to be the ideal parent that neither the patient nor the analyst actually had.It is the function of the analyst to identify the patient’s desire in order to analyze it, not to gratify it, to meet the desire with words and to frustrate its enactment. The task is to convert a neurotic sexual countertransference into a conscious sexual countertransference so that the clinical situation can be effectively worked on.
Interactions with old age patients are shaped by doctors own values and their life experiences. Countertransference with older patients is unique in that therapists tend to responds to the elder as if they were a grandparent. Individual autonomy is highly valued. regulations allow contact with others when medically indicated, but obtaining patient agreement always respects autonomy and protects the clinician. It is appropriate to override autonomy if the immediate risk of harm to the person or others is high.
Ethical dilemmas in end-of-life care, such as the request for assisted suicide, must be understood in the context of the relationship that exists between patients and the clinicians treating them.Psychological and social factors are the chief determinants of the wish to hasten death. These factors include levels of depression, hopelessness, lower levels of social support, and strength of religious belief. The doctor’s relationship and communication with a patient are important determinants of patient well-being. Lesserreligious belief, less competence in symptom management, thepotential impact of demoralization among clinicians, and diminished empathy in clinicians were significant predictors of willingness to endorse assisted suicide.
Clinical situations such as the care of the dying patient can represent a powerful challenge to the sense of efficacy, value, and worth of a doctor, and can confront this particular sense of responsibility. Although good communication in end-of-life care is clearly very difficult for many doctors to provide, the confrontation with the limitations of medical interventions to reverse disease progression may present a specific challenge to the doctors’ sense of effectiveness and self-esteem. The doctor’s inclination or lack of inclination, to examine the full range of psychological and interpersonal factors that have a bearing on a wish to die may then be affected by countertransference feelings toward the dying patient. The failure of the clinician to be alert to psychiatric morbidity such as depression, or the failure to carefully assess such needs, may represent a countertransference enactment of feelings such as hopelessness and nihilism about the terminally ill patient. So, establishing guidelines for the assessment and response to a request for assisted suicide may assist clinicians.Guidelines regarding the clinician’s response to a request for assisted suicide must place such a request in the context of a broader range of tasks in communication with the patient and family and consideration of the doctor–patient interaction and relationship, alongside the clinical treatment issues to be addressed.
There is a great need for improved communication between doctors and patients during end-of-life. Communication skills must include listening skills, including the capacity to remain alert to both conscious and unconscious factors, and listening to one’s own emotional responses and reflecting on their meaning.