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Unconscious reactions

Vol. 8, No. 6 / June 2009

Although any attention to the intersubjective realm is welcome in a time dominated by a biological model, it was disappointing to read Drs. Muskin and Epstein’s “classic Freudian” approach to countertransference (“Clinical guide to countertransference” Current Psychiatry).

For at least 50 years, modern clinical theory has observed and incorporated the simple fact that the physician-patient interaction always involves 2 minds, with unconscious elements. Our ability to decipher the unconscious communication—often captured in what could be mistaken for distracted thoughts as well as intense emotional reactions—is what distinguishes clinicians from their patients.

Most clinicians—unlike consultation-liaison psychiatrists who have focused on this interpersonal domain—have come to accept the fact that the distinction between “the patient’s stuff” and “our stuff” is tricky to maintain. We always are working through our own internal world; it is always an interaction. Perhaps this article and audio was aimed at nonpsychiatric physicians and therefore was made more accessible and formulaic. Hopefully, in the future, a more sophisticated discussion can be offered.

Sara Hartley, MD
Clinical faculty
University of California School of Public Health
Berkeley, CA

Drs. Muskin and Epstein respond

We thank Drs. Hartley and McFadden and Ms. Sawicki for their comments regarding our article on countertransference. In the limited space, we could not cover all of the areas germane to the topic. Our approach permits consideration of what is transference and what is countertransference, particularly in the general hospital environment.

The directionality of the “stuff” Dr. Hartley mentions is important because some reactions to patients occur in the absence of any transference originating from the patient. This is unique to the nonpsychiatric environment but may play an important role in shaping the care of the patient. We are sorry that she is disappointed in our approach, as it is one that stands the test of time in its utility.

Philip R. Muskin, MD
Professor of clinical psychiatry

Lucy A. Epstein, MD
Postdoctoral clinical fellow in psychosomatic medicine
Columbia University
College of Physicians and Surgeons
New York, NY

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