Countertransference Reactions

to Cancer
RICHARD E. RENNEKER, M.D.

A GROUP OF ANALYSTS recently ter-

minated a Chicago Institute for Psychoanalysis
1. Countertransference phenomena in psy-
chosomatic research in general
project* investigating psychosomatic correla- 2. Countertransference phenomena in can-
tions in cancer of the breast.1 One phase of cer research in particular
the research involved the psychological treat- a. Before cancer recurrence
ment by four analysts of cancerous women by b. After cancer recurrence
the psychoanalytical technique and by psycho- A countertransference phenomenon, for the
analytically oriented psychotherapy. As the purpose of this paper, is defined as:
project progressed and became known, the 1. The analyst's neurotic reaction to the
author had access to clinical data beyond the patient's transference.
original research plan. Three analytical can- 2. The analyst's chronic transference feel-
didates individually approached him for su- ings, not in response to the patient's transfer-
pervisory assistance in the conduct of their ence, but as a direct manifestation of unre-
psychoanalytical psychotherapy with cancer solved neurotic conflicts in the analyst. These
patients. are the "regular" countertransference difficul-
This paper describes countertransference ties with which the neurotic analyst colors and
reactions on the part of the author and the disturbs most of his analyses.
other six analysts mentioned above, to cancer 3. The analyst's acute transference feelings
and to cancer patients. No attempt will be not in response to the patient's transference.
made to differentiate the experiences of the The awakening of sleeping dogs—stirring be-
project versus the non-project analysts. Insight cause of some unusual event in the life of the
gained from our reactions will be related to: analyst or of the patient. Most of the cancer
CO countertransference phenomena in gen- countertransference reactions were of this
eral analytical practice, and (2) the everyday type.
management of cancer patients by surgeons
and general physicians, in an attempt to better Countertransference Phenomena in
understand the unconscious basis for prevail-
ing practices in doctor-cancer patient relation- Psychosomatic Research
ships. The Chicago Institute for Psychoanalysis
The reactions of the analysts can be divided has conducted similar psychoanalytical re-
into two categories: search in other psychosomatic areas (i.e.,
From the Mount Sinai Hospital, Los Angeles, ulcer, ulcerative colitis, asthma, arthritis,
Calif. * * hypertension, neurodermatitis, thyrotoxicosis,
Read before the Society for Psychoanalytic Medi- etc.). We have always known that the analy-
cine of Southern California, on Feb. 7, 1957. ses of psychosomatic research patients were
Received for publication March 1, 1957. often complicated or blocked by a form of re-
* Robert Cutler, M.D., Garnet Bradley, M.D., sistance difficult to define. It has been de-
Jerome Hora, M.D., Catherine Bacon, M.D., and scribed as "difficulty in getting the patient
John Kearney, M.D., were also members of this re-
search team. into analysis."
VOL. XIX, NO. 5, 1957
410 COUNTERTRANSFERENCE REACTIONS TO CANCER
The patient has generally been thought of
as the source of resistance, but actually the
analyst also contributes.
Analytical research patients for psychoso-
matic projects are selected because: ( i ) they
meet criteria for analyzability, and (2) they
have the disease (active) under investigation.
Actually, the latter fact too often determines
selection and colors the therapeutic relation-
ship.
The analyst has a basic interest in the dis-
ease as well as in the patient. However, psy-
chological investigation of this organic disease
is the original analytical motivation. Finding
himself in the role of therapist and investi-
gator, he usually grasps the conflicting nature
of the two and struggles to he both without
affecting the course of analysis.
His more familiar identification with the
role of therapist plus his sense of responsibility
to the patient causes him to state that he is
more interested in the treatment of the person
rather than in the disease. I believe that this is
commonly stated, but is rarely correct.
The complex motivations in the analyst
which brought him to spend energy in re-
search must be carefully considered. The gar-
den variety of research motivations are:
1. Sublimated sexual curiosities
2. Reaction formation against asocial im-
pulses
3. A method of satisfying narcissistic needs
4. Identification with an idealized parent
figure who happens to be a researcher
5. Outlet for feelings of magical omnipo-
tence
6. Substitute for seeking deeper knowledge
of the self
7. Substitutive need for parenthood
These motivating factors all seek discharge
or gratification primarily through the role of
the successful researcher, not through being a
good therapeutic analyst.
I do not say that to be both is an impossi-
bility, only that the analyst who voluntarily
enters into a formal project brings with him
strong, unconscious motivations for research
which prevent him from functioning as a
therapeutic analyst in exactly the same man-
ner as with nonresearch patients. He main-
tains his cathexis in the object of the research
investigation of the psychosomatic aspects of
a particular disease. The patient is often rela-
tively depersonalized and treated as a vehicle
for reaching the research goal. Many trans-
ference reactions arise around the fact of the
analyst's continued cathexis of the disease.
One such reaction is often erroneously desig-
nated as the peculiar analytical reticence of
the psychosomatic patient, whereas actually
it is his sad, angry, resistive response to the
analyst's split cathexis (i.e., "You aren't inter-
ested in me for myself, only for my disease' ).
The patient may withhold, consciously and
unconsciously, all reference to the disease.
This can occur out of a hostile need to frus-
trate the analyst, or in an attempt to shift
attention away from the disease to himself. In
any case, patient withholding of such data
undermines the investigator part of the analyst
and can eventually produce countertransfer-
ence manifestations.
- The researcher who uses analysis usually
believes that there are psychosomatic aspects
of the disease under investigation. An analyst
might have varying ideas as to how the psy-
chosomatic effect occurs, but he rarely doubts
its existence. He believes in psychogenic cause
and somatic effect and therefore he usually
converts this into an unthought-through belief
that psychological treatment will favorably in-
fluence the somatic disease. Success of therapy,
then, is equated with permanent beneficial
effect upon the organic disease.
Research persons in all fields must be
viewed as biased investigators whose uncon-
scious motivating needs are best satisfied by
positive results (i.e., successful research). The
researcher trains himself to accept negative
results (i.e., unsuccessful research) but they
are not sought after, nor do they produce sat-
isfaction. This unconscious drive toward suc-
cess is a variable which should be controlled
against in all research.
The analytic investigator is in a particularly
favorable position unconsciously to influence
the field under investigation, so that the de-
sired positive results are obtained. There are
usually no external controls upon him and so
the positive transference patient, desiring to
PSYCHOSOMATIC MEDICINE
RENNEKER 411
please, can pick up the ingredients of the Our initial unconscious reaction, before pa-
analyst's pet theory for the thing under inves- tient selection, was anxiety over caring for
tigation and play it back to him as raw data. someone who might be close to the edge of
Many alleviations of somatic stress come about death. We compromised our unconscious re-
as "temporary transference cures" and not for luctance about getting too close, by intuitively
the reason the analyst might believe. Failure selecting patients who did not ask for care
to follow up the case leads to failure to chal- under any conditions.
lenge the cause-and-effect hypothesis. With We began the attempted analysis of the
such positive transference patients sometimes project patients with frequent reminders to
respond to the therapist's need to "cure" the ourselves and to each other that each was
disease by playing down severity of physical going to analyze a woman who just happened
symptoms. to have, or had had, cancer. There was no
Let us see how these general patterns and known connection between the emotions and
reactions were changed or added to by the cancer, either its inception or its progression.
special fact of cancer. We were well aware of this fact; however, we
did not accept it within ourselves. We were
Countertransference Phenomena biased researchers. Biased in the sense that we
believed, on the basis of our preliminary study
Before Cancer Recurrence of cancer of the breast, that there was a psy-
We had had virtually no experience, since chological trigger factor in some cases. Our
residency training, with the chronically ill, disregard of cancer knowledge was appalling.
life-threatened, or dying patient. In the begin- We were pioneers moving into unexplored
ning, theoretical speculation was popular as territory where anything could happen. De-
to whether or not it would be possible for the spite our attempts at balance and analytical
cancer patient to find sufficient motivation perception, the therapeutic goal was clearly
and energy for psychoanalysis. Little attention the prevention of cancer recurrence, or the
was paid to the question of whether it would abolition of active cancer, through the suc-
be possible for the analyst to function ana- cessful, thorough analysis of the total person-
lytically. ality. The theoretical emotional catalyst had
Great difficulty was encountered in securing to be discovered, described, and uprooted.
"suitable patients" (i.e., cooperative patients Our task was monumental and impossible.
possessed of disturbing neurotic symptoms). We hoped to prevent or cure a disease whose
Eventually, after long delay, we all found etiology, development, and treatment are still
patients and the analytical therapy began. shrouded in ignorance and uncertainties. We
These patients were judged by the partici- were convinced that it could be a psychoso-
pating surgeons to have varied prognoses, from matic disease, but we had little idea how and
good to very poor. They were all in active why this came about. This need to believe the
clinical cancer therapy or had just terminated. psychosomatic connections in cancer and its
All these patients and those subsequently vulnerability to psychoanalytical treatment
treated were selfless, undemanding women. was an early universal reaction designed to
It seems clear, in retrospect, that this was a avoid facing the idea that our therapeutic
nonverbalized criterion for selection. Our pro- efforts might be in vain. Our original con-
crastination about beginning therapy, accom- scious and unconscious associations to cancer
panied by rationalizations about patient non- were the uncorrected ones of cancer as a dis-
availability, finally ended in each case by the ease which is uncontrollable, mutilating, and
individual selection of a woman who special- always ends in pain, hopelessness, and death.
ized in giving rather than in asking or taking. We denied the uncontrollability of cancer
There were other women in our anamnestic with the belief in our therapeutic powers.
interview pool who shared these qualities, but This is exactly the most common reaction of
rarely to the same high degree. cancer patients when confronted with cancer.
VOL. xix, NO. 5, 1957
412 COUNTERTRANSFERENCE REACTIONS TO CANCER
They react on the side of the instinct to live dividual attempts to cope with inner disturb-
and say to themselves: "I can beat it." ances precipitated by the cancer.
We had to have hope of affecting the can-
cer, or else we hesitated to come so close to Undermining of Omnipotence
such an emotionally exaggerated, uncontrolla- We all had to have a fair titer of serum
ble, and destructive force. omnipotence in order to hope that the course
Our own natural resistance to death was of cancer could be influenced psychothera-
mobilized through unconscious previews of peutically. In the beginning, our goal was
future months of partial identification with usually one of hoping to sustain the surgeon's
cancer patients. "cure" by preventing cancer recurrence
through the analytical reorganization and thus
This use of analysis as an investigative tool,
coupled with a hopeful orientation of posi- the elimination of cancer-susceptible predisease
tively influencing the disease under investiga-personality structure.
tion, is not a nourishing atmosphere for the This was still within the realm of theoretical
ready development of a functioning analytical possibility; however, after cancer recurred and
process; however, the analyses of these women the analytic process ceased, this original plan
proceeded until cancer recurred. The analyst's for influencing the cancer had to be discarded.
knowledge that an active cancer was present When a forest fire is raging, one cannot wait
always produced disturbing conflicts within for the execution of plans to control future
himself and temporarily or permanently dis- fires by developing and growing fire-resistant
rupted the analytical process. trees. You use whatever is at hand and start
beating out the fire. We had no reference
frame to use and we were not in the surgeon's
Counter-transference Reactions After position. He could always use more excision,
Cancer Recurrence radiation, hormones, or a new, relatively un-
The normal Good Samaritan—physician re- tested research drug. We had to create our
sponse to active cancer was a human, emphatic own untested methods. This atmosphere fos-
response to an acutely troubled, anxious per- tered regressive returns to the original omnip-
son, seriously ill, physically threatened by otent, magical solutions of the child's painful,
frustrating oedipal realization that he is actu-
death, and usually riddled by sensations of ally biologically surpassed by father. Many
helplessness. The urge toward active help was things which he wants to do are impossible
colored by the analyst's medical background for him at that biological age. Time is the only
and by his reversion to the feeling role of a answer. He must wait, but he feels that he
medical man rather than that of an analyst cannot and so he supplies a quick fantasy
who was also a physician. solution through the development of feelings
He refreshed himself with information of magical omnipotence. These, of course, also
about the current cancer treatment procedures, arise as a pre-oedipal defense against feelings
eventually read enough to identify critically of helplessness in the face of potential danger
with the surgeon or radiologist. Patient hours to the self.
were punctuated by discussions of the medical The analyst reflected these emergency at-
aspects of the cancer, plus a change in the tempts at cancer treatment through many
interpersonal therapeutic climate to one of modifications of technique (i.e., daily hours,
"warm, worried" concern for the patient's daily multiple hours, daily total interpreta-
physical status. tions, pep talks, attempts to pass the magic
The countertransference reactions based in along through selling a personal philosophical
negative responses to active cancer in the pa- orientation to the patient, etc.).
tient were handled in a rather characteristic Such desperate miracle attempts in all fields
fashion. There was an average sort of pro- run a preordained course. No miracle occurs,
gression and development in the analyst's in- the realization of this is fought, resisted—
PSYCHOSOMATIC MEDICtNB
RENNEKER
finally sinks in. At this point, two major pos-
sibilities are in order:
1. You can allow reality to catch up with
yourself. Shake your head at your "unprece-
dented" behavior and sit down to figure out
that which can be done for the patient and is
realistically possible for you to perform. This
is clearly the job of helping the patient to
adjust to the cancer and the disruptive effects
produced within her life.
2. You must defend the omnipotence since
it is a nuclear defense within your own organ-
ization. This can only be achieved by distor-
tion of reality—denial of cancer progression,
projection of the blame to the patient who is
not trying hard enough, hostile provocation
of the patient into stopping therapy, or else
you can stop yourself with the major ration-
alization that the patient does not need help
anymore.
Narcissistic Injury and Threat to
Therapeutic Hope
Each analyst had a narcissistic investment
in the outcome of the analysis. This involved
the need to perform well because of the im-
portance of being thought well of by his fellow
analysts and by the Institute. All of us were
recent graduates and this was the first time
that we had worked as a group in an environ-
ment in which one's work was constantly re-
viewed by the other members. We were
therapeutic physicians, humanistically dedi-
cated scientists, but at the same time, there
was that core of narcissistic awareness. The
control analysis experience during training has
more of a practical artifact. One must do well
in order to graduate. The research analysis
experience in a group produces rather narcis-
sistic, competitive situations with other group
members; furthermore, it is not the usual
therapeutic one-to-one environment of private
analysis. This was research in a dramatic area
—cancer. Many people, beyond the research
group, were vitally interested in the outcome.
You dreamed of being a successful explorer.
You said that you were prepared for negative
findings, but who wanted them? You devel-
oped the aforementioned conviction of an
occasional connection between psychological
VOL. xix, NO. 5, 1957
413
factors and cancer. When your patient devel-
oped a recurrence or a metastasis, your dream
shattered. It meant that you had failed some-
how as a therapist. We tended within the
group to substantiate this by silently blaming
the analyst. We communicated this to each
other by look and corridor intimations. This
came about because we had to believe that our
therapeutic goal was possible. The patient's
personal tragedy of cancer return threatened
our therapeutic orientation; thus, to preserve
it we had to explain the outcome by feeling
that if the analyst had handled certain things
differently, the result would have been
changed. The unfortunate analyst, whose
patient took an unexpected turn for the worse,
thus actually received quiet censoring from
the group as well as from himself. He not
only lost his regressive dreams of blazing a
new medical path and suffered a loss in self-
esteem, but also felt the group's critical atti-
tude and experienced a sense- of dislocation
from them. We protectively banded together
to preserve the hope of attaining the previ-
ously described goal.
The patient thus is in danger of becoming
the symbol for a traumatic ego experience.
The tendency is to avoid such symbolic or
direct reminders of failure.
One analyst in a later attempt at analysis
with a different cancer patient tried to avoid
these difficulties through burying all hope of
influencing the cancer. This nonverbalized,
hopeless, helpless attitude regarding the can-
cer was picked up and negatively reacted to
by the patient. This woman, though cancer-
free, never got into therapy. She identified the
hopeless attitude and wisely refrained from
deeper therapeutic involvement, intuitively
recognizing that some degree of hope in the
analyst is an essential ingredient for the thera-
peutic process to take place.
This analyst was unconsciously refraining
from getting involved in the therapeutic proc-
ess of a cancer patient. The previous analysis
had been a traumatic event for him and ho
was not having any more.
Therapist Reactions to Threat of Death
The terminal status not only interrupted a
414 COUNTERTRANSFERENCE REACTIONS TO CANCER
patient's material but also provided specifi Misidentification of the Dying Patient
problems for the analyst. 1. One therapist's countertransference in-
Disruption in Identification volved misidentification of the patient with his
mother. Threat of the patient's death through
The therapeutic process is largely based cancer renewal was reacted to by the analyst
upon identification. One aspect is the thera- with a separation anxiety and strong feelings
pist's free use of feeling into the patient's of guilty responsibility.
material so that he can understand it better. 2. A surgeon, in analysis, revealed a pattern
This is a partial therapeutic identification of of unconscious misidentification of a male
the free, movable portion of the analyst's ego cancer patient with the doctor's father. The
with various ego states and experiences of the postoperative death of the patient was fol-
patient. lowed by a guilt-laden depression, based upon
This essential phenomenon was seriously his unresolved death wishes toward father.
interfered with by the terminal patient. The We had no male patients, but this certainly is
analyst resisted putting himself into the posi- a potential countertransference complication
tion of a dying person. We say it is impossible for a psychotherapist as well as a surgeon.
to imagine ourselves dead. So also it was im-
possible to freely lend ourselves to dying Reactions to Specific Meanings of Cancer
through identification. The therapist instinc-
tively stopped the further investment of him- Cancer—Primitive Id Impulses
self when he sensed that it was truly hopeless A reflection of this equation is perhaps seen
(i.e., barring a miracle of sorts). This was in the horror with which cancer is commonly
self-preservative, since it decreased the degree viewed. The expression "being eaten up by
of personal investment "lost with the patient's cancer" is incorrect but popular. The disease
death," which would subsequently have to be progresses by cellular multiplication, invasion,
reclaimed through mourning. There was also and metastasis; not4 by "eating up" the host.
an economic motive. The urge to recapture This one expression reflects the association of
one's investment before death. This was like cancer with primitive, destructive oral im-
the impulse to leave a sinking ship in time pulses—out of control. Analytic material of
and with all your valuable possessions—easier both patients and analysts showed this to be
for the company representative to take along true for at least some people. Dreams of pa-
the gold bullion than to have to dive for it tients with active cancer utilized manifest
later. material such as threats from carnivorous ani-
Those who dealt with terminal patients mals, armies of menacing crabs, etc. These
confessed to reaching a point where they had reflected not just the cancer but also alien id
the wish that the patient would "hurry up impulses threatening to erupt. The patient
and die.'' This was rationalized by such things with active cancer feels physically out of con-
as: "she was suffering such pain," but when trol and can become anxious over potential
carefully examined never conformed to what loss of ego controls. Something inside is physi-
the patient herself clearly desired (i.e., to cally out of control, so watch out for the
live). The death wishes arose out of the dis- controlled, repressed, psychic things within.
comfort of the therapist who was duty-bound Cancer then is not just a threat to physical
to accompany the patient to the brink of life, but is sometimes experienced as though
death, was threatened by the proximity and it were a threat to one's identity. Previously
wanted to get away. The only "honorable stabilized ego boundaries threaten to dissolve
way" was through the patient's death. I have and to be replaced by troublesome primitive
discussed this with many physicians and they oral impulses. Interestingly enough, better
almost all admitted the same feelings regard- organized dreams dealing with the same theme
ing the terminal patient. as above dealt with repetitious dining experi-

PSYCHOSOMATIC MEDICINE
RENNEKER
ences in which the patient was sitting at the
table, eating.
The analyst too can react in a similar fash-
ion through his therapeutic identification with
the patient. He is dealing with a process out-
side himself (cancer) which is uncontrolled
and primitive. To the degree that he is iden-
tified with the patient, the process is now
inside himself and is then reacted to as anxiety
over his own primitive impulses and their
control. His reaction is somewhat like the
anxiety of some first year medical students
when thrown into close contact with primitive
biological material.
Cancer, Bad Luck, and Fate
Patients and therapists alike commonly re-
acted to cancer return as evidence of had luck.
The bad luck was after associated as coming
from a cruel fate directed by the hand of
God (parent). This linkage of cancer with
God's (parent's) will provoked feelings of
being punished or rejected. Old reactions to
feeling unloved were stimulated. One such
reaction was the arousal of an ancient, de-
structive rage at the successful competitor
(siblings), currently cast as all those without
cancer. The patient wished everyone to have
cancer with her. This eventually merged over
into a depression. A therapist had a similar re-
action to the patient's cancer. Fate smiled on
other therapists, who were therefore associated
with successful competitors. A depressive re-
action also followed.
Unconscious Therapist Response to Specific
Fantasy of Cancer Patient
Eissler" describes the identification problem
of the dying patient. The feeling is: "I feel
different from the healthy. I am removed
from them. I am lonely. I want contact. I wish
the therapist too had cancer, then we could
truly share this experience together. We
could be close and I could use his strengths
for this last phase."
We observed a therapist response to exactly
such a patient need. One analyst developed
an obsessive preoccupation with the idea that
he had cancer. This was an exceptionally in-
tuitive, sensitive, therapeutically oriented ana-
VOL. xix, NO. 5, 1957
415
lyst who keenly felt his inability to reach and
help his patient. His "symptomatic" reaction
represented an attempt to narrow the distance
between himself and the cancer reoccurrence
patient. It was thus an unusual emergency
measure of the ego in response to his frus-
strated and great therapeutic drive.
Countertransference Cycle
The particular countertransference reac-
tions described were generally seen as part of
a vicious cycle (Fig. 1) which each therapist
flayed with breaking nonadaptivity but al-
ways ended by solving on the adaptive side of
the ledger.
The adaptive solutions and non-adaptive
attempts at breaking the cycle can be listed as
follows:
Nonadaptive Solutions (from Standpoint of
Assistance to Patient)
1. Provokes patient into quitting
2. Rationalizes self into believing therapy
should be interrupted because:
a. Patient is so well off
b. Patient will not or cannot work
c. In any case it is best for patient
3. Decreases number of hours with same
rationalization
4. Continues therapeutic motions with con-
flictful wish for patient's early death
5. Depressive reaction in therapist
6. Development of various other (individ-
ualistic) neurotic and/or behavioral dis-
turbance in therapist
Adaptive Solutions
1. Face and work through dynamics of
countertransference reaction by self-analysis,
supervisory consultation, or return to one's
own personal analysis
2. Reorientation of treatment goals
3. Ideally follow this by discussing with
the patient the specific countertransference
experience and its resolution. This reestab-
lishes communication and provides the pa-
tient with a frame of reference for her work
of adjusting herself and her life to the new
problems created by the fact of the concer
4. Should (1) be impossible, then refer pa-
tient to another therapist
416 COUNTERTRANSFERENCE REACTIONS TO CANCER
Cancer return
in patient
Directs attention
back to cancer
return
Pseudoreaction Formation
of pathological Good
Samaritan-physician
response ** -
Fig. 1. Countertransference cycle.
The development of active cancer is disrup-
tive to the analytic process because of both
patient and analyst reaction. Riding out the
countertransference storm in the manner out-
lined put the therapist into a choice position
from which to be of real psychotherapeutic
benefit to the patient. Return to analysis is
dependent upon patient's posttreatment status
regarding cancer presence or absence, amount
of available energy, and re-evaluation of need
for analysis.
The countertransference reactions described
in this paper represent acute versions of
milder therapist countertransference responses
in some general analytical cases. They illus-
strate well the ever-present "primitive" in-
stinctual baseline needs in the analyst which
must be met or protected before he is free to
fully participate in the therapeutic process.
The example of a therapist equating his
unsuccessful psychological treatment of a can-
cer patient with a traumatic ego experience to
be avoided in the future can be applied to
give new insight into the common analyst
statement of: "I treat some patients (types)
better than others and thus I work in those
areas." This commonly refers to an early un-
successful analytic attempt felt by the thera-
pist to be a traumatic ego experience. The
particular type of patient problem "responsible
for" this bad analyst experience becomes a
potential source of future pain and is thus to
be avoided with the rationalization of: "I
work better—or not as well—with certain pa-
tients." Older analysts who come back to
these "problem" patients and work through
\
Particular countertransference
reaction of individual analyst
Flight impulse (i.e., desire to
terminate treatment)
Guilt and/or shame
the traumatic associations usually experience
a sense of widened therapeutic capacities.
The nonadaptive solutions to the counter-
transference cycle can be detected in the ter-
mination stories of some patients who seek
"another analysis." I have seen several such
patients newly arrived in town from a distant
city, where they "had been analyzed." They
had clearly reacted to the analyst's conscious
or unconscious wish for them to take matters
into their own hands, and terminate treatment
through moving away. They thus interrupted
the sort of vicious cycle described above.
These were both patients who had patterns of
unconsciously perceiving and gratifying con-
flictful parent wishes which could not be
verbalized.
Countertransference Reactions in
Surgeons to Cancer Patients
I believe that everything in this paper can
also pertain to the dynamics of the surgeon's
responses to the cancer patient. We gained a
much greater respect for the immense and dis-
turbing task which confronts him in his daily
care of cancer patients. He, too, starts his pro-
fessional career young, hopeful and filled
with therapeutic ambition. He pitches in to
fight and defeat cancer. He becomes emo-
tionally involved with a number of critically
threatened cancer patients. He has his disturb-
ing countertransference reactions.
At this point, there are several alternatives
i. He becomes a surgeon who functions
well with patients because:
PSYCHOSOMATIC MEDICINE
RENNEKER
a. His hopes of therapeutic success are
geared to the reality of his experi-
ences
b. He has learned to accept therapeutic
failure without disruptive personal
reactions
c. He has learned to adjust to con-
tinued exposure to death or threat of
death
d. He has learned his own limitations
regarding energy investment in pa-
tients, type of patient personality
with which he works poorly, etc.
e. He operates within these known
limitations
2. He becomes a surgeon who functions
poorly from the patient's standpoint be-
cause the traumatic emotional experi-
ences with the original patients remain
unworked through. He works out the
following nonadaptive patterns of pro-
tecting himself from re-experiencing the
trauma anew.
a. He reverses the original unrealistic
therapeutic hope into not allowing
himself any hope for the patient.
The patient is viewed as already
dead, thus anything accomplished is
all to the good and anything not ac-
complished is simply expected. The
surgeon is free to do his best, without
later self-recriminations or responsi-
bility. This orientation makes it eas-
ier for the surgeon, but not for the
patient
The patient perceives the surgeon's hope-
lessness, fails to understand it as a generalized
piece of personality equipment essential to his
continuing practice, misidentifies it rather as
the physician's specific response to the patient's
individual case. She thus gets the erroneous
impression that the surgeon really believes
that her case is hopeless, but is avoiding say-
ing so. She is thus robbed of the support of
whatever real hope is actually present.8
b. He avoids interpersonal contact with
the patient as much as is possible,
through wrapping his white cloak of
scientist-surgeon about him. He
VOL. xix, NO. 5, 1957
417
rarely tells the patient about the can-
cer, and, if so, discourages discussion
or emotional reactions. He deperson-
alizes the patient and patient con-
tacts through tending to treat and
see a detached instead of a human-
ized cancer.
Viewed in this light, it is easy to understand
the discrepancy between polls5'G of cancer
and noncancer patients indicating that they
prefer (by 87 per cent and 98 per cent, respec-
tively) to be told of their cancer versus the
surgeons' popular attitude of it being usually
better not to tell.
The patient wants help, free communica-
tion with others, whereas the surgeon wants
to avoid emotional involvement with the pa-
tient and all intrapersonal consequences as
described in this paper. He was once trauma-
tized, hurt, recovered, and now he instinc-
tively feels that he must avoid other tcaumas.
So he keeps his distance.
The surgeon should be free to admit these
human limitations and to also admit the great
need of life-threatened cancer patients for
psychotherapy. Social workers, psychiatrists,
clergymen can all fill some part of this need;
however, more work is needed towards clari-
fication of the problems involved in the man-
agement of patients with active cancer.
The surgeon has one factor commonly re-
garded as part of his patient problem which
is actually operating in his favor. He treats
many people with cancer, as opposed to our
great investment on a one-to-one basis. He can
put his eggs into many baskets instead of our
one.
Summary
This paper has described various counter-
transference manifestations observed within
a group of seven analysts engaged in a re-
search project based in the psychoanalysis or
psychoanalytical psychotherapy of women
with cancer of the breast. Countertransference
problems were discussed with regard to psy-
chosomatic research in general, and cancer
research in particular. The major counter-
transference manifestations stem from the
418 COUNTERTRANSFERENCE REACTIONS TO CANCER
peculiar interaction of the particular uncon-
References
scious research motivation of the analyst in
1. RENNEKER, R., et al. A psychosomatic theory
combination with characteristic unconscious of cancer of the hreast. To be published.
meanings attributed to the cancer process. 2. BACON, C , RENNEKER, R., and CUTLER, M. A
Typical examples are given of this interaction psychosomatic survey of cancer of the breast.
with particular emphasis upon the adaptive Psychosom. Med., 1952.
3., RENNEKER, R., and CUTLER, M. Psychological
and nonadaptive solutions of the counter-
problems of adjustment to cancer of the breast.
transference cycle. Insight gained in this area ].A.M.A., 1952.
has been applied in a brief discussion of sur- 4. THAWICK, J. D. The Psychiatrist and the Can-
geons' problems with cancer patients and cer Patient. Dis. Nerv. Syst. n , 1950.
countertransference phenomena in general 5. KELLY, W. D.,' and FRIESEN, S. DO cancer
patients want to be told? To tell or not to tell.
analytic practice. Current Med. Dig., 1955.
8720 Beverly Blvd. 6. EISSLER, K. R. The Psychiatrist and the Dying
Los Angeles 28, Calif. Patient. New York, Internat. Univ. Press, 1955.

PSYCHOSOMATIC MEDICI1 —