Countertransference: How to Set Aside Emotions for Sound Clinical Decision-Making

Recognizing the existence of transference and countertransference is critical for clinicians because both positive and negative feelings for patients can result in poor clinical decision-making.

A dermatologist’s countertransference — feelings for a patient beyond clinical concerns — can sabotage the patient-physician relationship. Sylvie Consoli, MD, a dermatologist who is also a psychoanalyst, says that both positive and negative feelings for a patient can affect clinical outcomes.1 Likewise, in transference, patients can develop feelings for their clinician beyond the traditional doctor-patient relationship, often with less than optimal results.1,2

Why Does Countertransference Happen?

Dermatologists are in a unique position because they can readily diagnose many skin lesions at a glance, yet patients expect a more nuanced approach to the doctor-patient encounter. Clinicians may not fully appreciate the role chronic skin disorders plays in patients’ diminished quality of life, which may add undue tension to the relationship.1 Moreover, the chronicity of certain diseases may make the dermatologist feel as if he or she has let the patient down, or, in some cases, blame the patient for nonadherence to therapy.1

“A great example is hair loss, as even when we do everything right, it can take a very long time for the patient and the MD [physician] to see noticeable changes,” said Adam Friedman, MD, associate professor of dermatology at the George Washington School of Medicine and Health Sciences in Washington, DC. “Patients are often anxious to see improvement quickly, and (rightfully so) can require a lot of time to go over all the ins and outs. The opposite is also true for a patient who is doing very well — success can foster a more informal interaction,” he told Dermatology Advisor.

Countertransference can be triggered by past experiences, such as a patient’s behavior or appearance evoking a memory of a previous similar encounter and producing a biased response — even when the clinician is unaware of this bias.1,3,4 To ease their cognitive load, clinicians may use heuristics, or problem-solving shortcuts, which may be based on prior patterns or experiences and in turn short-circuit rational thinking.2

Who’s Affected?

Whether positive or negative, the bias, a form of cognitive error, can affect patient safety and outcomes.3 “The highest rates of cognitive error are seen in specialties where diagnostic uncertainty is high: emergency medicine, family medicine, and internal medicine,” explained Pat Croskerry, MD, PhD, professor of emergency medicine and the director of the Critical Thinking Program at Dalhousie University Medical School, Halifax, Nova Scotia, Canada. “It is lowest in the visual specialties, anatomic pathology, dermatology, and radiology. Not all cognitive error is due to bias, but it is probably the largest factor.”

Because dermatology patients tend to be healthier than patients in other fields of medicine, their office visits are usually brief and infrequent so “dermatology does not ‘set docs up’ for failure in the way of countertransference, as other specialties might,” explains Whitney A. High, MD, JD, Meng, associate professor of dermatology and pathology and director of dermatopathology at the University of Colorado School of Medicine in Denver.

A clinician’s state of mind does affect patient outcomes and safety, as demonstrated in a study of depressed pediatric residents who were 6 times more likely to increase medication errors as their non-depressed counterparts.5

In another study, Rebecca Linn-Walton and Manjo Pardasani of Fordham University in New York, found that a clinician’s negative attitude toward a patient resulted in poor outcomes, and sought to determine how this manifests.6 In an ethnographic study of clinicians with difficult patients, some clinicians admitted that they engage in conflict, while other clinicians saw it as a challenge and learned to empathize with patients who may not have appropriate coping skills to handle adversity.6

Negative feelings toward a patient come in various forms: some physicians feel verbally and physically challenged by their patients, while other physicians dislike patients for not hitting expected clinical milestones or for questioning their clinical abilities. Developing a dislike for patients can be instantaneous or gradual. For some clinicians, general patient types — such as narcissists, teenagers, and belligerent personalities —instantly put them on edge:.6

Patients’ presentations and comorbidities affect clinicians’ performance as well as clinical outcomes. Dr Cristina Renzi of the Health Care Quality Research Unit, Rome, Italy, and colleagues found that in a sampling of 396 dermatology patients, 21% were found to have comorbid psychiatric illnesses, which was associated with poor adherence to their regimens.7

Strategies for Overcoming Bias

Metacognition, or simply the act of realizing how one thinks, might reduce the errors of thinking intuitively rather than rationally.2 “We need to teach about the various forms of bias, cognitive and affective, and coach clinicians on how to identify polarization of affect in themselves, as there is little doubt that it affects decision making. Various strategies to de-bias can then be enacted,” said Dr Croskerry.

Some strategies to mitigate countertransference and cognitive biases include:3

  • Be aware of the potential for countertransference. No specialty is immune to emotional involvement. Realize that rational thinking, rather than intuition, must be part of clinical decision making.
  • Address the role of emotional intelligence in clinical teaching. Openly discussing the importance of empathy and critical listening among instructors, medical students, and peers can sharpen a clinician’s insights.
  • Recognize the influence of emotional errors in clinical decision making. When students and experienced clinicians alike realize the effect their emotions can have on clinical encounters, they will be better able to adjust their approach.
  • Identify early warning signs of emotional distress. Remove barriers such as fear and stigma that are attached to medical professionals seeking psychological help.
  • Combat emotional dysregulation. Promote a culture of self-awareness that encourages clinicians to admit their biases. Recording patient encounters and candid peer review can uncover potential emotional blind spots.

Dr Friedman cautioned that “patients may sometimes try to break the physician-patient relationship and move beyond that. It is helpful to touch base with risk management at your institution and document everything!”

“Treat your patients as you or your family should be treated, do your job, and never let other feelings besides benevolence and a desire to insist intrude into the patient encounter,” advised Dr High.


  1. Consoli SG, Consoli SM. Countertransference in dermatology. Acta Derm Venereol. 2016;96(217):18-21. 
  2. Cohen JM, Burgin S. Cognitive biases in clinical decision making: a primer for the practicing dermatologist. JAMA Dermatol. 2016;152(3):253-254. 
  3. Croskerry P, Abbass A, Wu AW. Emotional influences in patient safety. J Patient Saf. 2010;6(4):199-205.
  4. Poot F. Doctor-patient relations in dermatology: obligations and rights for a mutual satisfaction. J Eur Acad Dermatol Venereol. 2009;23(11):1233-1239.
  5. Fahrenkoph AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336:488Y491. 
  6. Linn-Walton R, Pardasani M. Dislikable clients or countertransference: a clinician’s perspective. Clin Superv. 2014;33(1):100-121.
  7. Renzi C, Picardi A, Abeni D, et al. Association of dissatisfaction with care and psychiatric morbidity with poor treatment compliance. Arch Dermatol. 2002;138(3):337-342.