Patients who shock us

When psychiatrists talk with patients, they occasionally encounter a patient who shocks them with a point of view that is radically different from their own. It is a challenge to one's professional role and therapeutic intentions, and it may seem provocative. Using two hypothetical case examples, the author explores how one responds at the moment of encounter and in subsequent therapeutic work. Starting with addressing the prevailing affect and the importance of maintaining the therapeutic relationship, efforts to identify defenses and deeper concerns may then lead to insight, relief, and greater mastery. Throughout the clinical work run elements of transference and counter-transference, including the patient's multi-layered motivations for shocking the doctor. Consultation may be valuable in this situation. On the rare occasion of fundamental incompatibility, it may be best to refer the patient to another therapist.