Institutional Countertransference: The Matrix of Social Structure and Psychic Structure

No longer the “dirty little secret” of psychoanalysis, countertransference has become respectable. A psychological phenomenon that was formerly seen as an impediment to psychoanalytic work is now considered an important tool in the therapist's armamentarium. Appreciation of the usefulness of countertransference has come hand-in-hand with an expansion of its meaning and range of application. Many contemporary therapists now consider countertransference to include their total emotional responses to their patients, finding too limited the earlier view that confined countertransference to the therapist's unconscious reaction to the patient's transference.

In this broad sense, countertransference encompassing the full range of emotional and behavioral responses to patients, has been discussed intermittently as one of the complicating factors in the care of patients in institutional settings. The complication is immediately evident—the therapist's dictum to “monitor one's countertransference” becomes a more daunting enterprise when the “therapist” in question may be a hydra-headed treatment team with innumerable countertransference reactions in the heads of each of its members. When one adds to the multitude of emotional reactions to any patient the multitude of staff reactions to other staff members, one has an exceedingly complex web in which treatment is to take place. The effort to provide coherence and consistency of treatment to patients is perhaps the central challenge in institutional care, in part because such care is delivered through the vehicle of many personalities, many persons, each responding to a given patient in his or her own unique fashion. The institutionalized patient is thus the object, or at least the recipient of an enormous array of reactions from a wide range of staff members—some subtle, some not so subtle, but withal a