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Snuff Medicine
For some time, Dr No has been troubled by a particular aspect of the suicide of Kerrie Wooltorton. It is an aspect that has received little coverage, perhaps because it is a complex and murky area, but it is nonetheless important. It is countertransference, and how it may have influenced Wooltorton’s treatment, even to the extent that it may have contributed to her death.
Much psychobabble surrounds countertransference, but at its most straightforward, it is the name given to the feelings and emotions generated in a helper by the person being helped. You help a little old lady across the road, she pats your hand and thanks you, and you feel good about yourself: that’s positive countertransference. You cook supper for a depressed friend, and every time you do so he barely touches it, leaving you feeling: you ungrateful sod. That’s negative countertransference.
Countertransference is an everyday fact of life for those who help others for a living. The wise helper keeps an eye on countertransference. Too much positive countertransference can all too easily lead to meddling and over-interference, while negative countertransference, all the more so if it is repressed, as it often is, can result in acting out those negative emotions in ways that are harmful.
Wooltorton was a patient with a long history of difficult problems and diagnoses – a complex gynaecological condition, depression, emotionally unstable personality disorder and numerous suicide attempts.
Such patients are well known to engender negative feelings – a negative countertransference - and antagonistic behaviour – acting out, say by an aggressive execution of a stomach pump – in health care staff. Patients who repeatedly harm themselves, and patients with personality disorders, are especially at risk. Wooltorton, of course, was just such a patient.
Not all negative countertransference need be acted out in obvious ways. It is not seemly for doctors to go about dusting up their patients. But the negative countertransference remains, and if not dealt with – which usually means being aware of it, and managing it – it will fester and emerge in other ways; ways which, although less visible, can be just as if not more sinister than openly expressed aggression.
And so the doctor loaded with repressed negative countertransference may make subtle, and so less obvious, changes to the way he cares for his patient. He may not go the extra mile; he may omit to do what he can and should do. He may, instead of acting out in an openly hostile way, adopt a passive aggressive manner towards his patient.
Now, what troubles Dr No is the extent to which a negative countertransference, acted out through a passive aggressive stance, contributed to Wooltorton’s death. He doesn’t know the answer, but it seems to him a vital question to ask when there is open talk of allowing patients to die, of assisting suicide, and of euthanasia; and where allowing these things would provide a channel for acting out a negative countertransference.
Could it be that the hospital staff experienced what amounts to a mass negative countertransference, and acted it out in a passive aggressive manner? It wouldn’t be difficult to do – and, with a little outside help, it could even be made to look as if they were acting in their patient’s best interests. Passive aggression to perfection.
All that was needed was to cut a few corners; to omit a few steps. No need for a current psychiatric opinion, because we have spoken to the psychiatrist. Presume capacity, because that is what the law says we must do, and back that up with a legal opinion that confirms we must do as the patient tells us, and then – sit back and watch her die.
Like watching a snuff video.
Of course, it could never happen in the real world, where real doctors treat real patients.
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Thank you for this thoughtful addition to the discussion about the motivation behind the actions/inactions of the professional staff.
It is certainly something that needs to be factored in - if only to be sure it played no part then or plays no part in the future (should that ever prove possible!)
Even without taking the law into account, it now seems to be politically correct not to bring into play the tactics of persuasion and paternalism, and economically correct not to spend an undue length of time with the patient. These are the only mechanisms I can think of that may change a mind and so save a life. So, nowadays, a passive approach could be regarded as the acceptable norm whereas in the past it may have been an indicator of negative countertransference. i.e. the latter may now be impossible to detect.
Most parents would save their own child in these circumstances. The ethics folk would probably consider it “wrong” to treat the patient as if he or she was your own son or daughter. Too much positive countertransference is bad is what they would say.
It is probably still OK to smile at a patient though. Maybe that is the only tool we have left at our disposal, even although it may not be appropriate if a patient is committing suicide before your eyes.
The conscience is another important tool. Of course, the fact that it floats around the brain or in the thin air of the aura surrounding the head means it’s best not to take it too seriously.
Apparently
You're so spot on. A doctor's perceptions of you as a person affect dramatically how you treat that person. I had a rectus sheath haematoma whilst on holiday in Austria - with no fat medical notes available I was treated with respect. On return to the UK as I had a fat medical file with "no diagnosis" I was told that it was psychogenic purpura and "I had even managed to get myself admsiited to hospital on holday" and that my "GP needed to get my mental status checked out." Well no - actually I had aquired Von Willebrands - and now I am treated once more with repsect -but before - I think in the above situation I would have been left to die.
That's how I felt about the situation. Self harmers are not popular in A&Es, especially if they've done it nine times already, and it's the whole thing about the staff feeling manipulated and entered into a big drama. They might have decided that they were going to call her bluff, so to speak.
I can well remember what it was like years ago working flat out as a junior doctor from Friday morning until Monday night with your head hardly touching the pillow. Overwork bringing about physical and mental exhaustion must surely allow thoughts of negative countertransference to creep in. Even then, a combination of conscience and what you have been taught as a professional seems to keep your motives for the patient on the right track even although efficiency will be low, judgement impaired and mistakes liable to be made.
So, even in dire situations, it seems to me the professional will usually attempt to do the right thing. The question then is what is the right thing? If someone tells you when you are in a state of negative countertransference that the law says what you are doing is the wrong thing, then it is over to your conscience. If the ethical academics have told you as a medical student to ignore your conscience because it is just a bundle of unexamined prejudices, then in certain circumstances you may well become the obedient technician - the servant of the state, working for the state’s fickle and perhaps faulty perception of “the greater good.”
Doctors and nurses are human; and they play their part against a particularly rich tapestry of life and death. Anyone who has walked the wards will know that there are times when you think the unthinkable; but, as the Witch Doctor points out, training, habit and that bundle of unexamined prejudices make sure that the thoughts remain as thoughts, and not action. Usually.
The danger I see, and what this post is primarily about, is that as we move, as we appear to be moving, towards a state where Autonomy Rules OK, and Anything Goes, we open a channel through which largely repressed negative countertransference can escape - and cause great harm. I'm not so much suggesting the doctors and nurses in Norwich consciously and deliberately intended and wanted to kill KW (although that is of course possible - but that is another matter for another day); more that the loosening of moral boundaries brought about by the current changes in the moral and legal climate may have allowed them to act out a repressed negative countertransference that in earlier times would have been held at bay by the firmer moral boundaries of that earlier time.
Personality disorders have never got to the status of being diseases. Scientists like to classify, and the PDs are labels for clusters of thought and behaviour patterns. But that doesn't make them diseases. I sometimes think it might have been better if psychiatrists had never strayed into PDs - but that begs the question of who then would get involved?
Overt aggression towards patients who have PD labels and who self-harm is a big problem but this post is about negative, passive aggressive, often (semi-)subconscious harming. It is insidious, and of course harder to spot, but the end result is the same - a harmed, or in KW's case dead, patient.
Negative countertransference isn't by a long shot the only toxic process that can affect what should be a therapeutic relationship - as you have learnt from bitter experience. Overt abuse I have already mentioned; and then there are things like co-dependency between the doctor and the patient; and then there is the whole question of whether doctors, by interfering in people with PD labels when they don't really have much to offer actually make things worse - in other words might (some) people with PD labels manage life better without medical interference.
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