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.
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.
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
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.
This case shows the irrationality and ignorance of the medical profession in dealing with emotional problems and the moral decline into which we have sunk. That woman should never have been allowed to die. Doctors should save life ..no ifs and buts
I have said this before, and I will say again, where is the evidence that personality disorders exist? The now notorious Dr Russell Reid commented at one point that I have met more psychiatrists than anyone else he knows; what I can say about them is that I have never met one who has been the slightest use. Reid saved my life couple of times but not through any special expertise on his part.
He’s a nice chap even if he lacks insight. I told him in 2007 when he was being courtmartialed at the GMC that my experience was closest to that of Jan Morris. He objected that she was much older than me when she did it and had been married. I pointed out that she was born in the 1920s …I just wanted to bang my head on the table.
I deeply resent having had my life controlled by a gang of sadistic bullies who knew nothing about me or what it means to be a woman. My GP acknowledged that I had left traumatised by them in 1996. So do personality disorders exist?
Dr Rita Pal has just put up a post on NHS exposed on the profile of the serial bully. In my experience many psychaitrists fit this profile. I don’t know whether one characterises this behaviour and character profile as a ‘personality disorder’ but whatever else it is these people are a danger to a civilised society. They seem to have an arrested development at about the age of three. Whether they can be treated or not is a good question.
Rita, on the other hand, is a heroine because she is interested in people and interested in learning. I think everybody feels better when somebody listens to what he/she has to say and shows an interest. You and Dr Helen Bright have also said nice things about me. Thank you.
Labelling that young woman as having an ’emotionally unstable personality disorder’ is likely to have contributed to her death. Suggesting that there was something inherently wrong with her personality provokes negative reactions in healthcare staff. Equally, Borderline PD is allegedly untreatable. The ‘symptoms’ are extremely similar to ‘manic depression and also trauma from psychological/psychiatric damage. Trauma is treatable.
The known effects of being bullied or being subjected to psychological trauma are mood swings as well as depression and other effects of psychological injury. This is why Judith Lewis Herman argues for a diagnosis of complex ptsd. This is particularly relevant to all kinds of situations; bullying at work, domestic violence, child abuse … It goes back to Freud finding high levels of sexual abuse amongst women in Vienna – and then chickening out because the interests of the male establishment were not served by pointing it out. It became women’s ‘fantasies’ instead. A huge betrayal.
I sent out an email last night on the 27th anniversary of my feminist rebellion against the male authorities at Radley College. The email to members of the Old Radleians society began ‘Hello Boys’ ! and had an attached scan of my Guy Fawkes night letter in which I refer to the tendency of adolescent girls to ‘play up’ and Anarchy.
It also had attached scans of a suicide diary I wrote after brutal bullying and an assault by ‘Doctor’ Deenesh Khoosal in the Warneford Hospital Oxford after I had been referred there ‘upset’ and ‘vulnerable’ by the school doctor, Dr Thorne. The diary was found in the archives in the Warneford after I had finally lost patience with the medical profession and gone to the police in 2007. The diary records all the symptoms of severe psychiatric injury caused by assault.
The attack and my first suicide attempt appear to have been entirely premeditated. On 17th November 82, I met Khoosal and was judged to be completely sane and asking to be referred to specialist. On 18th he wrote a outrageous sub-literate letter to the school doctor about blow jobs and masturbation. On 22 November my housemaster wrote to my father about the terrible state I was in and the doctor I had seen was ‘concerned’ about me. On 25th November, Khoosal assaulted me without consent as I described to CID twenty five years later. He has recorded the attack in the notes and the effect he had on me! On 3rd December I told him and he wrote in the notes that I had told my housemaster that I felt like slashing my wrists and wanted to be taken seriously. I had an ‘expectation’ that he would listen to me. Not unreasonable considering the agreement with the school was ‘expert counselling’ not an unconsented assault – a criminal offence.
That morning Dr Thorne had written an excellent letter to my mother at my request in which he said the problems I had with the authorities seemed to relate in my own mind to the ‘free expression of my personality’and that he thought the problem was deepseated and serious. Three days later I made my first attempt at suicide on the evening of 6th December in my study. I was told in 1983 that I would never recover and have no constructive assistance from the NHS over something that should never have happened.
The next day I was ‘assessed’ by the ‘famous Oxford professor’ Anthony Storr. He ignored the diary which he has been sent for his ‘perusal’, met me with a barrage of abusive questions and forced me to write a letter apologising to a homosexual (according to Reid) who had just attacked me. I see he wrote in the notes that I had ‘threatened’ to commit suicide. Actually it was injury caused by a bully and sexual deviant at one of the most vulnerable times in my life and an honest refelection of how I felt.
Khoosal has been arrested once and I shall keep going until I get him to explain himself in court or the GMC. We are all vulnerable to dishonest doctors who think they rule by divine right.
The attitude to unfortunate women like KW needs to change. If her shrink was like as useless and lacking in empathy, knowledge and common sense as those I have met then they killed her with neglect.
30 years after being sexually assaulted at the age of 13, I am discussing it with someone nice from Rape Crisis. The medical profession first put it my notes in 1985 – they are useless. Being violated is upsetting. I am publicising it because I am not ashamed any more. I am not the one who should be ashamed:
http://katemiddleton-lsu.blogspot.com/2009_10_01_archive.html
http://katemiddleton-lsu.blogspot.com/2009_10_01_archive.html
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.
Thank you for your thoughtful comment about ‘toxic helpers’.
I see from the notes in Anthony Storr’s handwriting on 7th December 1982 that he asked me ‘Do you want help?’
I replied that I was looking for ‘practical guidance’ and information and he recommended Jan Morris’s ‘Conundrum’. That is all I required at seventeen and it was obvious to me that regardless of the medical problem one has, life goes on and one still needs to pass exams, earn a living and make a positive contribution to society.
Interference, crimes against me and abuse and neglect by the medical profession cost me my planned career and health. Nonetheless I am still alive to tell the tale and have learnt a good deal from the experience – I am now wise enough to know how much i have to learn – and this is when life gets interesting. I think it is important to be candid in order to improve matters for other people.
I am afraid I do not regard the majority of psychiatists as ‘scientists’, particularly when it comes to women. What does a male psychiatist know about being a woman? What is a woman anyway? Some exceptions to this rule are Helen Bright and Rita Pal who are both psychiatrists.
Rita wrote an excellent article on NHS exposed about my case on September 5th and learns from people: ‘Educating Rita’ and I have just left a comment on ‘secular psychiatry’ about the rarity of psychiatrists learning from their patients like Helen.
That was also my approach when working with a young man who had, among other things been diagnosed with autism/Asbergers. Some of my colleagues were obsessed with labels, my own approach was to listen carefully and try identify ways I could be of constructive assistance. It was interesting that he turned to me one day after his clipboarded ‘counsellor’ mentor had left and said ‘isn’t she creepy?’ I agreed!
He was quite capable of telling when he was being patronised and said to me one day ‘You are not like the rest of them, you don’t hate me’. He was used to being examined by ‘professionals’ whose objective was to find out what was wrong with him, not what was right with him.
In 2004, after being bullied out of this job, I managed to acquire a ‘diagnosis’ of ‘taking up a position against all psychiatrists, viewing them all in the same poor light and suggesting none of them are any use unless one is mentally ill’ from ‘Doctor’ Deborah Hutchinson.
My GP had written to her to say that I felt I was not mentally ill but needed expert help to deal with trauma……… including ‘traumatic encounters with medical professionals who she perceives as misguided and ill-informed.’ !
The Wicked Witch, who runs a psycho/the/rapy department where they systematically abuse people who have already been abused as children, was so flagrantly dishonest and slanderous that my GP opened my medical records, confirmed that I do not have a psychiatic problem and finally allowed me access to my medical records so I could starting out the mess that had been made of my life by doctors. I certainly did not want them interfering in my life and doing things to me without consent – rapists. When I want a good bit of fiction to read, I turn to the GMCs good practice gudielines.
Many of your collegues don’t seen to think the principle of ‘informed consent’ applies to them.
Turning to KW and people like her, I would certainly have liked to hear her story. Let me just comment on what you have said about about her problems above:
‘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.’
My immediate impression is that all of these factors are likely to be interlinked. The best book on this topic that I have read is The Wise Wound, the meaning and myths of menstruation’.
It is particularly good on unfortunate medical encounters and the ‘howlback effect’. The label of ‘personality disorder’ is likely to produce negative transference in itself and one can see that effect in some of the comments above – including those by women.
I asked Judith Green, Cambridge counselling examiner if she had read ‘The Wise Wound’ in 2006 and she said, ‘Brilliant..Brilliant’. I told her about my meeting with Peter Redgrove and she said ‘Amazing ..Amazing’.
What we should be doing is not just giving out pills, but reading lists etc ..more later