The members of a treatment team typically identify the person who will lead it, usually the senior physician, who then designates how the work will be divided, and how responsibilities will be assigned. This structure helps the patient and family know which team member is best equipped to address their questions or concerns about the diagnosis or treatment. As they have had similar professional career paths, members of a given treatment team have certain characteristics in common. They share the goal of working toward healing patients; they have been cognitively flexible when learning the importance of biopsychosocial issues; they have regularly used mature defense mechanisms in the academic and clinical spheres; they have a predominantly secure attachment style when interacting with colleagues and patients, with the ability to manage different opinions; they have had an easy/flexible or slow-to-warm-up temperament that allows them to be active participants in learning and listening to patients; and they have the capacity to mentalize (Chap. 2), the ability to interpret behavior as meaningful and based on the mental states of oneself and of others, understanding what is expected of them by teachers and patients. In spite of the similarities among medical providers, however, there will be variability in areas of strength. For example, a colleague with a preference for working independently, with limited patient contact, pursues a career in radiology or pathology, while another colleague who excels at the complexities of diagnosis and treatment of medical conditions chooses to become an internist, and finally, a colleague who is readily able to mentalize, empathize, and is curious about how the human mind works, becomes a psychiatrist, child psychiatrist, psychologist , or social worker.

Having suggested some of the strengths within the members of a given treatment team , we will now review some of the possible areas of weakness. Although teams frequently and successfully struggle with patient and family conflicts, certain patients and families are able to elicit strong reactions from team members, which may interfere with the team’s ability to provide the care expected. In this regard, members of treatment teams, however similar their goals, may be divided into two categories based on their ability to tolerate conflict, to allow for psychological closeness, and to mentalize. There are (1) practitioners who are skilled in working with patients but maintain psychological distance and avoid feelings of closeness and (2) practitioners who genuinely connect with their patients and are empathic and psychologically attuned to them.

Sympathy , unlike empathy , is the capacity to feel for someone’s experience without necessarily being in their shoes (Irwin et al. 2008). Common examples of this are seen in everyday life when people send sympathy cards to family members and friends to express sorrow for either a difficult experience or a loss. When a treatment team offers or expresses sympathy to a patient or family, the recipient generally finds this approach supportive, although it may also be experienced by certain patients as insincere, patronizing, and judgmental. In the care of pediatric patients, sympathy often takes the form of reassurance. In such instances, the physician, resident, or nurse expresses sympathy to decrease their anxiety while examining the ear of a child with otitis media or when vaccinating a child who is frightened. As discussed in Chap. 2, when the patient and or family has an easy/flexible temperament , secure attachment style , and cognitive flexibility, the sympathy-based approach is well received and appreciated. However, this is often not the case in difficult psychiatric consultations, where the patient may have limited cognitive and affective flexibility, insecure attachment style , and a difficult/feisty temperament.

When treatment-team members who are accustomed to calming patients with sympathy interact with psychologically difficult patients, the patient’s affective state can become difficult for the members to tolerate. For these patients or families, sympathy is not enough, as it leaves a degree of uncertainty and ambivalence about their care. The patient and/or family may feel isolated and, believing that team members are unable to grasp their state of mind, may begin to direct derogatory comments toward the team. The patient and family may then begin to challenge treatment recommendations, although they unconsciously are hoping for team members to contain their anxieties by making the disavowed negative projections of the self somewhat bearable and less frightening (Chap. 2). The treatment team , in turn, may unconsciously reject these projections, follow their inclination toward action over expression, and, in minimizing direct dialogue with patient and or family, distance themselves still further from the family’s anxieties, although they continue working to provide the best-practice medical care to the patient. This will continue until there is a treatment impasse between patient, family, and the treatment team, at which point they will seek a psychiatric consultation.

Excessive sympathy may interfere with the objectivity required to deliver a diagnosis and recommend treatment for an illness that has a poor prognosis (Hojat et al. 2002). A physician who, out of sympathy, withholds negative information about the severity of the patient’s illness to prevent the patient and family undue distress will quickly learn that this was not helpful and may lead to dysfunctional interactions among the patient, family, and treatment team . This situation, withholding negative information, can occur when the physician identifies with a patient who reminds him or her of their own close family member (age, name, and temperament ) or of a prior patient who had a negative outcome.

Empathy reflects the ability to share the feelings that another person experiences, whether they be feelings of excitement or sadness. Webster’s Unabridged Dictionary defines empathy as “the projection of one’s own personality into the personality of another in order to understand the person better; ability to share in another’s emotions, thoughts, or feelings” (Random House 2001).

As an example, when a parent consoles a child after he or she has lost in a competition he or she had spent months preparing for, the parent may draw on an understanding of how they themselves have been disappointed in the past. The shared feeling allows for the sense of having been “in their shoes,” which is reflective of empathy and mentalizing abilities. The parent may constructively say, “I’m sorry you didn’t win. I can imagine how frustrated you must be,” with added reassurance that their relationship remains solid: “Let’s celebrate all the hard work you put into this competition.” Empathy is a blending of one person’s past with another person’s present, an overlapping of two emotional landscapes.

In the medical field, empathy is described as a multidimensional concept with variability among physicians due to differing personality styles, as is the case with sympathy. Hojat and colleagues (2002) developed the Jefferson Scale of Physician Empathy , a psychometrically validated tool that measures empathy in medical personnel. His tool was used with 1,007 physicians of multiple specialties in Philadelphia, and his results indicated that female physicians scored higher in empathy than their male counterparts. Psychiatrists, when controlled for gender, scored significantly higher than physicians specializing in anesthesiology, orthopedic surgery, neurosurgery, radiology, cardiovascular surgery, obstetrics and gynecology, and general surgery. Interestingly, Hojat observed no significant differences on empathy scores among physicians in psychiatry, internal medicine, pediatrics, emergency medicine, and family medicine. This is empirically consistent with the fact that treatment-team members who have the ability to sympathize, yet who have difficulty empathizing with patients’ ambivalent and fearful feelings about their medical conditions, asked for psychiatric consultations more often. The request for consultation was primarily due to the conflicts that the patients and families had over the delivery of care from treatment teams. Cases frequently discussed by consultation-liaison psychiatrists at national conferences and in publications involve the psychiatric consultant encouraging the parties involved to have empathy for each other’s dilemmas. In a review of the literature, Hojat et al. (2002) found that empathy is linked to many personal attributes in physicians, such as dutifulness, moral reasoning, good attitudes toward elderly patients, and that those physicians who employ empathy experience a reduction in malpractice litigation, greater patient satisfaction, better therapeutic relationships, and good clinical outcomes. Other research has provided support for what seems to be intuitively known—that female physicians express empathy and assume caring attitudes more than male physicians (Eagly and Steffen 1984; Reverby 1987).

Psychiatrists are familiar with the concept of countertransference and may easily recall the times in which they used the term. Until recently, countertransference was understood as an intrapsychic unconscious process in which there is a reawakening of conflicted childhood experiences evoked by the patient’s transference to the psychiatrist. With the emergence of theories about intersubjectivity and affective attunement, we now believe that countertransference reactions do not exist in a vacuum and are best understood as a collection of the subjectivities between the patient and psychiatrist in the context of a here-and-now moment that creates a mutually shared experience. For example, a patient who receives the results of laboratory or diagnostic testing results and diagnosis of their illness reacts negatively, experiencing the physician delivering the information as insensitive and unempathic. The patient’s reaction leads the physician to feel upset and does not allow time for discussion of the results and diagnosis. During the interaction, the physician, who may be tired or preoccupied with other patients, could be unaware of the fact that in the here-and-now moment with the patient, he or she actually came across as demanding. The patient, of course, has no way of knowing that the reasons for the physician’s tone are not related to the patient him- or herself and thus they are unconsciously reminded of their demanding caregivers, which evoke a transference reaction to the forceful and unempathic physician. Consequently, when the physician experiences the patient as unappreciative, he or she may be unconsciously reminded of early childhood caregivers that were unappreciative of accomplishments, and a countertransference reaction to the patient transference may ensue. To take the analysis further, when theories of intersubjectivity are applied to the interactions between the patient and physician, the here-and-now moments that create a mutually shared experience of the two persons’ “realities” can no longer be understood as solely in terms of transference and countertransference. The dance that occurs between two human subjective experiences, when mutually understood, can lead to great outcomes. When the shared experiences are opposed and complex, it leads to intertwined negative outcomes. If the physician has the capacity to take a step back and review with the patient what may have happened between them that led to the negative reactions, doing so can prevent conflicts from developing. Some physicians are more able than others to engage in this process. As Wachtel (2010) skillfully observed, “It is certainly true that each of us enters any interaction with certain proclivities, and that those proclivities have a strong bearing on how things proceed.”