Taking into Account Transfer and Counter Transfer to be Able to Apply Them as a Placebo Effect on the Patient

The doctor-patient relationship has been and remains a keystone of medical care. But there are many ways of understanding, classifying and practicing the doctor-patient relationship [1]. One of the ways of looking at this doctor-patient relationship is from the psychodynamic point of view. The General Practitioner (GP) and the patient interact consciously and unconsciously; they are two different personalities. It must be remembered that the sick sees the doctor as a figure of structured authority according to their needs and fantasies; they look for a model that provides them with tranquility, confidence and recognition, someone that will restore their health, with hopes of healing and life. These are unconscious and neurotic experiences that the patient has in front of his doctor in relation to the childhood experiences and with the affective and / or authority figures. The feelings, attitudes and desires, originally linked to important figures of the first years of life, are projected on other people in this case in the doctor who represents those at the present time. The doctor is perceived as a father or a mother, or as both, from it derive the reactions of submission or defiance of authority [2]. So, freudian transference and countertransference reactions influence the doctor-patient relationship like any other interaction between humans [3,4].
Transference is a process in which individuals displace patterns of behavior that originate through interaction with significant figures in childhood onto other persons in their current lives. This is a powerful determinant of patient behavior in medical encounters [5]. The transference is expectation confident in the knowledge of the other. And it is the hope of the doctor of that rummaging into his ignorance, searching the medical history and his own knowledge, has a diagnosis and treatment for the patient. Each one expects confidence in the other and that is why the transference is reciprocal [6]. The effect described by Balint of “the doctor himself as a drug” (and that is the drug most frequently used by general practitioners: the doctor himself.) This effect Is related to that of transference and countertransference, and so, in the practice of general medicine, doctor should be considered as a drug, that is, that the concepts of pharmacology, such as overdoses, allergic reactions, side effects, etc., can be applied to transference and countertransference in the interaction between doctor and patient [7-10].
Both, doctor and patient are modified: one towards the other and vice versa. The doctor-patient relationship is a “combination.” When two bodies “combine” -a metaphor related to the therapeutic field-, not only the patient is involved, but also the therapist. When there is necessarily a reciprocal influence between the doctor and his patient, both are facing a dynamic and permanent process. It is not uncommon then, the appearance of ideas or thoughts in the therapist that are directly related to your listening. Moreover, GPs should not rule out, without being previously investigated, the appearance of some intuitive phenomenology in him, since they can be signaling paths to reach a better clinical understanding [2,11]. In general medicine the transference has connotations of placebo effect and nocebo. Placebos are “any therapeutic procedure (or a component of the therapeutic procedure) that is deliberately given to have an effect, or that unknowingly has an effect on the patient’s symptoms or illness, but that objectively does not have a specific activity for the treated condition.”
Within the transference, doctors are seen as authority figures, but ambiguous because they intersect with a maternal position of overprotection. The GP is perceived as an almost perfect figure with few human characteristics, unconsciously stands as a person who does not suffer, he does not get sick, or has no defects; an idealized character is created. The transference of the patient has the power to distort both reality and the doctor, to whom patient repeats his need for dependence, that he as a patient be directed by the doctor when he perceives him as a protective figure; or the reaction is of rebellion or challenge as a form of response to a imaginary reality. In the first case they are good patients, who admire the doctor, blindly obey the indications and adhere to the treatment, the relationships are long and fruitful, creating a therapeutic friendship. However, some patients have resistance reactions, which go against the relationship with the doctor, may constitute negative forces that favour non-adherence to treatment and medical indications. Patients who have problems with the authority react in this way: rebel, challenge and question it, do not react with submission, do not adhere to treatment as a manifestation of nonconformity and rebellion [12-14].
Placebo and nocebo effects are psychobiological events imputable to the therapeutic context, among them, the transference and countertransference [15,16]. When the transference is positive it gives rise to a placebo phenomenon and is thus an important aid in adherence to treatment and in the healing process; The GP is a mirror in which the patient projects fantasies, desires and needs, but also bad relationships, such as anger, disqualification, rebellion, abandonment of treatment, even legal medical conflicts. The transference is not stable, it is changeable and goes from one pole to another; at a given time the doctor can be wonderful or the one who knows everything, which facilitates adherence to treatment; but later it may be the worst of the doctors, so the treatment or consultation is abandoned. The GP must maintain a good professional and personal behavior, and as a response, the patient must generate a good transference relationship that would result in a positive therapeutic placebo effect, in which he becomes aware of himself, the disease and everything It can be done to collaborate with the doctor in his healing process [17].
Patients can project intolerable and negative feelings about the GP and force him to identify with what has been projected, allowing them to indirectly take control of GP emotions. The GP subsequent reactions can unsettle the physician – patient relationship. The GP need to be attuned to this process and recognize what the patient is provoking within him. Once doctor understand the process, he can realize that this is how he deal with others under similarly stressful conditions, and so he can react in a more supportive and healthy manner, rather than reviling your patients and negatively impacting the therapeutic relationship [18]. The transference of the patient generates a countertransference of the doctor. If the GP does not have the sensitivity to perceive the phenomenon of countertransference, he sometimes reacts with anger, contained or manifest, when the patient does not submit or question it. Countertransference can disturb healing, since no doctor goes beyond what their own complexes and resistances allow, so it is convenient for the GP to know their unconscious conflicts beforehand [6].
The positive countertransference allows the doctor the energy needed to understand the patient and generates a placebo effect on the patient; the refusal, on the other hand, interferes with the motivation and objectivity of the doctor to perform his interventions, and exerts a nocebo effect. To avoid negative effects, the doctor must take an alert attitude to sublimate his countertransference and keep it positive, that is, he must adopt an attitude of affection towards the patient despite the aggressions that he infers. Countertransference is like the spontaneous reaction of the doctor to the patient’s personality. The process is resolved in unconscious formations, which reach expression in the attitude of the GP, an attitude that in turn produces changes in the transference of the patient. The patient is the mirror in which the doctor is reflected, one of the frequent mistakes of the GP is not to consider his own conflicts (personal, unresolved, manifest) in the countertransference with his patients [17].
All GPs encounter patients who press their countertransference buttons and generate negative feelings, such as anger, frustration and inadequacy. These patients are known as “hateful” or “difficult” because they interrupt the treatment alliance. We are quick to point our fingers at such patients for making our jobs harder, being noncompliant, resisting the therapeutic alliance, and in general, being “problem patients.” However, the physician – patient relationship is a 2-way street. Although our patients knowingly or unknowingly play a role in this dynamic, we could be overlooking our role in adversely affecting this relationship. We may have negative feelings towards a patient based on our personalities and / or if the patient reminds us of someone we may not like, which could lead us to overprescribe or under prescribe medications, conduct unnecessary medical workups, distance ourselves from the patient, etc. Accepting our disdain for certain patients and understanding why we have these emotions will allow us to better understand them, ensure that we are not impeding the delivery of appropriate clinical care, and improve rapport [18].
If the doctor does not find an organic cause to the symptomatology of his patient, he can react, among other things with disinterest, discomfort or insecurity, feelings that are likely to generate unconscious attitudes of rejection with the consequent difficulty to engage in a dialogue that clarifies the psychological problem of the person who consults it [19]. Also, the GP can see a patient who may resemble his father, or the patient can feel like that is treated by who his son may be. In negative countertransference, patients are taken as objects to meet the personal needs of the doctor, such as narcissism or patient activate his own fears. This causes a nocebo effect in the patient, which can cause negative effects in the consultation, including iatrogenic behaviors and poor treatment results. The negative countertransference of a serious diagnosis, of the bad news with the patients, the treatment with terminal patients and the panic of announcing the death of the patient to the family can cause fears in the patient and family.
Thus, Countertransference, both positive and negative, can tarnish the work of the GP, even block it, it can become manipulative, with dictatorial intentions to submit the patient and the family, under an authoritative control that gratifies the doctor with the power to decide for others. Therefore, it is always relevant for the doctor to identify it. Projections (transference and countertransference) can also obscure the doctor’s judgment only to a small extent, of course, since otherwise all therapy would be impossible. Although we can justifiably expect that doctor to knows at least the effects of the unconscious on his own person. The only way in practice is to try to achieve a conscious attitude that allows the unconscious to cooperate instead of being led to opposition [2].
Of course, the GP has to keep in mind that the feelings he feels may not be his. The processes of transference and countertransference are unconscious. Classically it is said that doctors should recognize these forms of relationship but not get involved in them. But their recognition can allow the doctor to use them to produce placebo effects and avoid nocebos effects. Not only will the transference be of importance, but also the countertransference since both are at the very basis of the therapeutic creative act. Rather than approach every patient in a uniform way, tailoring the approach to fit the relationship needs of the individual patient is advocated. Such tailoring would affect whether the physician is collaborative or prescriptive, how much personal information he or she shares, and how close or distant he or she is. Transference issues can also affect level of somatization and patient adherence to medical regimens [5].
In summary, the transference and countertransference (positive and negative) in the hands of the doctor becomes the most powerful of the therapeutic instruments and plays an important role in the healing process. Therefore, the transference and countertransference must not only have one cause (which should be recognized by the doctor), but also one purpose: to be used to obtain better therapeutic results.

1. Turabian JL (2019) Doctor-patient relationships: A puzzle of fragmented knowledge. J Family Med Prim Care Open Access 3: 128.
2. Jung CG (1954) The practice of psychotherapy. Essays on the psychology of the transference and other subjects. Bollingen Foundation Inc, New York, USA.
3. Serrano González MI (2002) 21^st century health education. Madrid: Díaz de Santos.
4. Duarte García-Luis J (2002) The doctor-patient relationship in neurological diseases.
5. Zinn WM (1990) Transference phenomena in medical practice: Being whom the patient needs. Ann Intern Med 113(4): 293-298.
6. Volnovich JC (2003) Countertransference throughout history. The countertransference of the neutral analyst, the committed analyst, the disenchanted analyst, the analyst involved. Topía Revista.
7. Balint E, Norell JS (1973) Six minutes for the patient: interactions in general practice consultations. Tavistock Publications, London, UK.
8. Balint M, Hunt J, Joyce D, Marinker M, Woodcock J (1984) Treatment or diagnosis. A study of repeat prescriptions in general practice. Tavistock Publications, London, UK.
9. Turabián Fernández JL, Pérez Franco B (2010) The concept of treatment in familiy medicine: A contextualised and contextual map of a city hardly seen. Aten Primaria 42(5): 253-254.
10. Turabian JL (2018) Doctor-patient relationship in pharmacological treatment: Discontinuation and adherence. COJ Rev & Res 1(5).
11. Suárez F (2006) Around the idea of "situation diagnosis". Congreso Internacional “Actualidad del Grupo Operativo” Madrid, 24-26 febrero.
12. Marcus ER (2007) Transference and countertransference to medication and its implications for ego function. J Am Acad Psychoanal Dyn Psychiatry 35(2): 211-218.
13. van Marle HJ (2016) The patient rules; the power of transference in the doctor-patient relationship. Ned Tijdschr Geneeskd 160: D1219.
14. Goldberg PE (2000) The physician-patient relationship. Three psichodinamic Concepts that can be applied to primary care. Arch Fam Med 9: 1164-1168.
15. Chavarria V, Vian J, Pereira C, Data-Franco J, Fernandes BS, et al. (2017) The placebo and nocebo phenomena: Their clinical management and impact on treatment outcomes. Clin Ther 39(3): 477-486.
16. Testa M, Rossettini G (2016) Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Man Ther 24: 65-74.
17. Méndez R, Hernández CI, Hernández-TI, Fernández-O, Irigoyen A (2015) Psychodynamic analysis of transference and countertransference in the formation of family physicians in Mexico. Aten Fam 22(2): 58-61.
18. Joshi KG (2017) Difficult patients: How to improve rapport. Curr Psychiatr16(8): 49.
19. Sánchez M (2006) Thought disorders and psychosomatic diseases. Revista Medicina 28(4) (75): 161-179.