Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Systems

“Difficult patients are difficult because they generate difficult feelings in us” (p 88).

Health care professionals working in secure forensic settings encounter challenges that are unique to these environments. These practitioners seek resources designed to enhance the quality of mental health care delivery to mentally ill offenders, including those who have committed reprehensible acts against society. Forensic psychotherapists John Gordon and Gabriel Kirtchuk have edited a book titled, Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Systems, that is one such reference.

The book, which is part of Karnac Books’ Forensic Psychotherapy Monograph Series, is divided into a foreword, an introduction, and a conclusion that are authored by the books’ editors, along with six chapters contributed by various British forensic psychiatrists and psychologists.

The thrust of this book is that countertransference has an everyday effect on the hospital system and the multidisciplinary staff who work with a most difficult group of patients—inmates with mental illness.

Contributors to this book are psychoanalytically trained mental health professionals who work in a variety of forensic settings. They draw on analytic concepts, including object relations theory, to examine the multidisciplinary forensic mental health team as a system of care for mentally ill offenders. The authors review how a patient's primitive character defenses, including acting out and passive aggression, affect the functioning of the mental health care system on all levels. The analytic approach is both a strength and weakness of the book.

In the book, countertransference is defined as a “potential block, distortion or impasse which threatens the professional task” of advancing the therapy. The analytic approach to forensic mental health care reminds the reader of the defenses, transference, countertransference, and the primitive coping skills of many of the patients. The recent emphasis in psychiatry of neurobiology, including neurotransmitters, molecular biology and brain function, has sometimes evolved at the expense of the dynamics associated with a patient's experiences, the subtleties of interpersonal interactions, and discovering the reasoning behind the choices made by a person. I do not wish to downplay the benefits that biological psychiatry has brought to many patients; however, our profession has diminished the value of concepts such as transference, countertransference, emotional contagion, parallel processes, and projective identification. My own experience in forensic work indicates that we ignore these concepts at our own and our patients’ peril.

Weaknesses of the book are also evident. Although psychoanalytic concepts (including the analytic insistence on self-understanding) can help mental health professionals develop greater insight into the patient, the authors appear dismissive of the use of cognitive-based interventions, which they say create a defensive distance between clinicians and patients. Also, the authors seem to be unaware of how psychoanalytic techniques can be misused by clinicians who fail to examine their motives, both conscious and unconscious. This caveat also applies to other therapeutic modalities, including cognitive behavioral therapy and pharmacotherapy, both with consent of the patient and despite the patient's objection. Good therapists do not hide behind technique.

The editors’ decision to limit the book's content to the influence of patients’ behavior on the mental health care delivery system is another shortcoming. A discussion of how the larger system in which the hospital is contained can have its own deleterious impact on patient care and staff would have been a beneficial addition. At times, the limited expertise of bureaucrats who fund and oversee the hospital system can create a top-down process that, while subtle, may have a detrimental effect on the functioning of the hospital.

As a public sector inpatient psychiatrist, I envy the authors’ ability to function as consultants to well-staffed hospitals where time can be dedicated to multidisciplinary team and single-discipline group meetings in which the mental health care professionals can examine their reactions to individual patients. The authors’ descriptions of the strengths and weaknesses of this model made for interesting reading. However, I found myself wondering about another set of boundaries, those between an employee's personal life and work life. Of even more concern would be the sequelae of exposing one's personal vulnerabilities in a dysfunctional (i.e. politically challenging) workplace.

The use of nursing assistants or aides for daily and constant interaction with patients is a common practice that assigns the least trained people to perform the most difficult jobs. They and their supervisors are often not trained in the emotional realities of working with people with severe psychiatric disorders. I wish the authors had described in greater detail how they train direct care staff to manage stress that can arise during day-to-day interactions with patients.

The concise clinical case descriptions, which helped illustrate key teaching points, were a valuable addition to the book. The authors’ emphasis on being sensitive to the trauma histories of forensic patients should be stressed to all members of the mental health team.

Despite its limitations, I found the book stimulating and helpful in my own work. I also was affected by the following statement (p 93): “The fundamental task, in my view, of the mental health institutions is to take very great care of the mental states of the mental health staff.” All in all, I would recommend this book to mental health professionals who work in difficult systems.

• American Academy of Psychiatry and the Law