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Not all reactions need analysis

Vol. 8, No. 6 / June 2009

Drs. Muskin and Epstein bring much needed attention to the clinical usefulness of countertransference and to the challenges psychiatrists face in helping medical colleagues and staff deal with their reactions to “difficult” patients (“Clinical guide to countertransference,” Current Psychiatry). Their article, however, fails to recognize categories of reactions to patients other than countertransference, nor does it offer any systematic approach for preparing medical professionals to deal thoughtfully with their reactions to difficult patients.

For instance, projective identification is given mention only as a potential problem in working with borderline personality disorder patients. Furthermore, no specific mention is given to the range of reactions that would be considered justifiable and would not require additional reflection and analysis.

At Jefferson Medical College in Philadelphia, PA, we have developed a didactic conference entitled “Difficult patients and our reactions to them,” taught to third-year medical students during their psychiatry clerkship. The conference distinguishes among types of reactions students may have to patients, including justified reactions, projective identification reactions,1 and countertransference reactions. A key point emphasized to students is that not all of their reactions to patients are dictated by their subconscious.

Drs. Muskin and Epstein’s article provides an initial road map for acting as a consultant to other medical professionals’ problematic reactions. Our hope is to take the next step and expose future physicians in a range of specialties to a method of thinking through their reactions to difficult patients.

Robert F. McFadden, MD
Department of Psychiatry and Human Behavior

Alexandra H. Sawicki
Medical student
Jefferson Medical College
Philadelphia, PA


1. Akhtar S. Quest for answers: a primer of understanding and treating severe personality disorders. Northvale, NJ: Jason Aronson Publishing; 1995:57-58.

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