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Psychiatrists need to be aware of the types of transference that can take place when they're evaluating patients who belong to the same culture or ethnic group, said Hassan Naqvi, MD, at the American Academy of Psychiatry and the Law annual meeting.

Drawing on the work of , Naqvi, a law and psychiatry fellow at the Yale University School of Medicine in New Haven, Connecticut, outlined four categories of transference and countertransference:

• Omniscient/omnipotent transference. "This type of transference involves a complete idealization of the clinician, and the fantasy of reunion with the perfect, all-good parent," Naqvi said. This can take two forms: the "savior" scenario or the "folk hero or heroine" scenario. In the "savior" scenario, "the patient believes that the clinician has championed mainstream society and they have come to save them from whatever peril they are in," he said. In the "folk hero or heroine" scenario, on the other hand, the evaluee appreciates the clinician's higher education "and the fact that they left their oppressed community and they're socially successful, and they focus on this mythology of someone who made it." An example of the savior scenario is a Korean patient being forensically evaluated who tells their Korean psychiatrist, "We both have the same roots, and that really helps a lot in his evaluation. You'll get me; you're such a great doctor ... You're going to make me better." This attitude might be helpful in that the evaluee "may be more willing to discuss details they wouldn't have discussed with another evaluator," but it could also mean that "they could be more open to their detriment; they could give details of a crime or details as part of an asylum evaluation that might put them in more legal trouble," Naqvi said.
• The traitor. "This is really summed up by the phrase, 'I don't like you, because you are like those people,'" said Naqvi. Rather than idealizing the evaluator, "this is the complete devaluation of the evaluator or the clinician ... The patient exhibits resentment and envy of the clinician's success, and equates it with betrayal or selling out." For example, a Muslim patient might say to his psychologist who has an Arabic-sounding name, "'How could you work for a Western institution? You pay taxes to this country for bombs that destroy Muslim countries and Muslim communities,'" said Naqvi. What impact does this have on a forensic evaluation? "These patients may be more likely to disengage from an evaluation early on," he said. "These patients will often be more withdrawn; they will withhold information -- and they may appear to have psychiatric symptoms, such as paranoia or disorganization, due to the feelings of anger and resentment, so keep an eye out for that." Naqvi recommended starting with a social history and practicing empathic listening as ways to improve the relationship.
• The autoracist. This patient thinks, "'I don't like you because you are like my people,'" said Naqvi. "Patients with this reaction may not want to work with a clinician of their own ethnocultural group because they experience strong negative feelings towards themselves, and then project them on to the ethnically similar clinician." For instance, a Pakistani immigrant being evaluated by an ethnically Pakistani psychiatrist for an asylum claim may say, "'I don't want to work with you. You're Pakistani and I know what Pakistanis are like; they're lazy and they like to gossip. I want a white psychiatrist instead,'" he said, adding that as with the "traitor" form of transference, these patients "might be more withholding. They might have feelings of anger or resentment that mimic psychiatric symptoms ... And because they have strong negative feelings towards themselves, there is a strong degree of shame here, and it's something to really keep in mind. They might have difficulty discussing trauma; they might have difficulty discussing substance use or other topics that are swept under the rug within their own cultural background."
• Ambivalence. "This is probably the most challenging scenario," said Naqvi. In this case, identifying with the clinician is provocative for the patient, "and they feel both comfortable and fearful of too much psychological closeness," he said. "This creates this subtle but profound ambivalence within them ... The evaluee may be more willing to share some information and less willing to share other information. An important part of this is understanding the hesitancy: what sort of conflict is there in the patient that's leading to this ambivalence? If you can identify that, sometimes you can get ahead of it, and you can get the information you need, and help the patient."

Then there is countertransference. Naqvi asked the audience to think about how they behave during a forensic evaluation of someone in their own ethnocultural group. "Do you have a warm demeanor during your evaluations? I hope so, but is that creating this scenario of the omniscient/omnipotent transference where you are the rescuer?" he said.

One other issue to consider when working with a patient of the same ethnoculture is parts of the culture that are not shared, such as gender. "For example, if you have a male Pakistani evaluee and a female Pakistani evaluator, in this culture, sharing of negative emotions between males and females doesn't happen," Naqvi said. "So the male evaluee may be less likely to share feelings of depression or thoughts of suicide with the female evaluator."

"The therapeutic relationship of the forensic evaluator and the evaluee is replete with opportunity for misunderstanding that can compromise treatment and objective evaluation," he concluded. "Keep in mind these four transference scenarios and attempt to identify them early on; early identification can guide your approach to evaluation."

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