Countertransference issues in staff caregivers who work to rehabilitate catastrophic-injury survivors.

Countertransference reactions experienced by caregivers who work to rehabilitate victims of catastrophic physical lesions arise from the fundamental characteristics of catastrophic lesions: they are life threatening, life altering, anatomy altering, and restoration to pre-illness normalcy virtually never occurs. No true preparation is possible: Major physical and psychological work is required to rebuild a traumatized personality and a damaged body so that a life of quality is possible. Countertransference refers to (therapist's) unconscious reaction to patient transference, i.e., to aspects of the patient's behavior that are the product of unconscious factors in the patient's personality, as well as the meanings attached by caregivers to patient's impairment and rehabilitation struggles. Countertransference reactions arise in caregivers from two sources: (1) Socially universal sources: the demands posed by patients' regression; patients' misplaced aggression; patients' thwarting of staff's (narcissistic) professionalism; the threat of obligatory identification; staff disgust at patient's body damage. (2) Individualized sources: individual residues of caregivers' own developmental experience (conscious and unconscious) with issues such as dependency, aggression, sexuality, self-esteem and autonomy. Solutions involve understanding and mastering the distinction between feelings and actions, and sparing patients from two actions: Assault or abandonment. Suggestions for management include better knowledge of basic psychodynamics; working toward continuous self-awareness; special group meetings; and selective use of educationally oriented psychiatric consultations. Three case examples are offered.