Psychodynamic Lessons for Modern Cancer Care: The Role of Institutional Transference in the Psychiatric Care of Cancer Patients

Background: Institutional transference (patient feelings and attitudes toward the institution in which they receive treatment) was first described by Reider in 1953 and has largely been discussed in the literature in the context of treating patients with schizophrenia in psychiatric institutions and outpatient clinics. There is a paucity of literature on the role of institutional transference in medical specialty centers, such as academic cancer centers. Institutional transference, which can be understood in terms of object relations theory, is often intensified by existential concerns of patients seeking specialized cancer treatment.

We aim to discuss the role of institutional transference, and resulting countertransference, based in our experience treating patients at a large, academic cancer center.

Methods: We will briefly review the fundamentals of institutional transference as background for discussion of four themes, illustrated with case examples. These are 1) the role of institutional transference in transitions of care, 2) the idealized reputation of an academic care center, 3) boundaries and countertransference, and 4) patient characteristics that may intensify the role of institutional transference.

Discussion: We discuss a case of a patient who attempted suicide upon completion of treatment at the cancer center and transition to survivorship, and of an oncologist who remains the physician of record once patients transition to hospice. We review the patients’ idealization of the cancer center and how this can lead to hostility toward providers when cancer treatment fails, and splitting amongst different institutions. We review how porous boundaries between patients and oncologists can create difficulties in providing psychiatric care. We also discuss how patients with unstable attachments and/or internal objects may be more vulnerable to developing a powerful institutional transference.

Conclusion: The C/L psychiatrist who recognizes institutional transference at work after attending this presentation will be able to better serve as a liaison to the treatment team in navigating transitions of care, idealization and disillusionment in treatment, and countertransference reactions of those on the team. Recognition of patient characteristics which may intensify the institutional transference can help the C/L psychiatrist anticipate and navigate potentially fraught transference dynamics. Although drawn from our experience with patients at a cancer center, we believe these principles apply to work in any hyper-specialized, reputable treatment center (transplantation, rare disease, etc).


References:

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