When the Therapist Dislikes the Patient

The following was originally posted to the HCPLive network blog Psychiatry Talk.

What should psychotherapists do if they realize that they don’t like a particular patient who has come to them for help?

First of all, we should realize that it is a virtue that a therapist can recognize and acknowledge to themselves negative feelings towards a particular patient. One can’t expect to like every person you meet and just having some negative feelings isn’t necessary a contraindication to working with someone. If the feelings are minor it should not interfere with the treatment and the therapist would keep these feelings in mind but proceed with the treatment. In fact as will be described, the awareness of such feelings may actually assist the therapist in carrying out effective therapy.

Therapists are usually trained to reflect on their own feelings as they work with a patient, particularly when they are aware of strong positive or negative feelings. In the case in question, where the therapist is becoming aware that he or she doesn’t like the patient, the self oriented question is “Why don’t I like this patient?” The answer may be obvious, such as the patient is inconsiderate, self centered, prejudiced , anti my political or religious beliefs etc. One doesn’t necessarily dislike a person who meets such criteria and therapists in their self reflection need to include the contemplation of “What do I know about myself that might help me to understand these feelings?” It may be that the patient reminds you of a significant person in your life or certain situations which have occurred to you. One more additional self directed question should be “Can I work with my own feelings and try to help the patient or are these feelings too strong for me to objectively work with the patient? Also, am I just not inclined to work with the patient even if I understand why I feel this way?”

If the awareness of the dislike for the patient comes during the initial consultation and the therapist is not inclined to work with the patient, it may be relatively easy to refer the patient to a a colleague. A therapist not uncommonly will refer a patient to another therapist after the initial consultation if a therapist with special expertise might be better suited to treat the patient or if the therapist and the patient’s schedules don’t mesh for setting up ongoing therapy. On occasion, the consulting therapist might feel, after an initial consultation, that the therapy should be by a person of another sex, background or age. While these situations are less common, it may happen. Therefore referring the patient to someone else whom you feel will work better with the patient after you have initially examined the patient is ethically proper. Our guideline is to do no harm to the patient and do everything in the patient’s best interest. Therefore it most likely would only be hurtful to the patient to explain that you don’t like the them and that is why you are making the referral, therefore you shouldn’t do that. This may put you in the position of having to tell a “white lie” by saying that your schedule doesn’t work or that you are sending them to another therapist whom you feel is better suited for them (although this may technically be the truth). The therapist has to make the decision whether to discuss the reason for the referral. If the reason was one which there was a good possibility that another therapist might have the same problem ( ie. The patient was a member of the Klu Klux Klan or was a psychopath etc,) it would be best to discuss this with the potential new therapist in order to find someone who could separate their own personal feelings and work with the patient. When the reasons were totally personal (the patient reminded the therapist of someone or some personal situation ) such a discussion would not be necessary. In such case, a general reason or a scheduling problem could be given for the referral or you could share this information with the new therapist.

When the awareness of the dislike for the patient occurs during ongoing therapy, referring the patient to someone else becomes more complicated as interrupting the therapy would have to be weighed against the therapist concluding that they can’t help the patient due to their own feelings. Psychodynamically trained therapist are usually trained to recognize and work with their own countertransference and this would be the preferred mode of operation. This approach not only facilitates insight into self but also has the opportunity to facilitate the ongoing therapy. The therapist should always have the option to seek the assistance through a consultation with a colleague, a clinical supervisor or their own therapist and certainly if they themselves are in ongoing therapy — this situation should be closely examined. Therapists should be constantly monitoring their own feelings and the awareness of some negative feelings about the patient is not unusual.

In fact the experienced therapist knows the kind of issues which push their own buttons and an emotional reaction to the patient may be the first opportunity to identify some conflict within the patient that both the therapist and the patient may not have had a conscious awareness.