The management of chronic kidney disease requires attention to physiological abnormalities, treatment adherence, comorbidities, and clinical outcomes. Yet kidney disease extends beyond its biological disturbances. Patients must accommodate changes in bodily functioning, dependency, autonomy, family relationships, and expectations for the future. These psychological dimensions influence adaptation to illness, treatment engagement, and the therapeutic relationship.

In his CANSWA webinar on psychonephrology, Dr. Gavril Hercz examines the emotional and relational processes underlying kidney care. Drawing on psychodynamic concepts and clinical experience, he emphasizes that effective treatment requires attention to both the patient’s medical condition and the emotional experience of illness.

Watch the video here

A central distinction is that between disease and illness. Disease refers to identifiable biological pathology, whereas illness encompasses the patient’s subjective experience. Individuals with comparable renal diagnoses may demonstrate markedly different psychological responses, reflecting their developmental histories, attachment patterns, coping mechanisms, and previous experiences of dependency or loss. For some, dialysis represents security and survival; for others, it evokes helplessness, diminished autonomy, or vulnerability.

These differences have clinical implications. Apparent treatment resistance, withdrawal, irritability, or difficulty with decision-making may reflect anxiety, depression, grief, or unconscious conflicts rather than inadequate understanding or unwillingness to cooperate. A psychodynamic perspective encourages clinicians to consider the psychological meaning of these behaviours while recognizing medical, cognitive, and socioeconomic contributors.

The therapeutic relationship becomes an important component of care. Patients with advanced kidney disease develop sustained relationships with nurses, nephrologists, and allied health professionals. These relationships provide stability but may also reactivate earlier relational experiences. Dependency on treatment and caregivers can evoke fears of abandonment, mistrust, anger, or ambivalence about receiving help.

Dr. Hercz highlights the clinician’s emotional participation in these encounters. Feelings of frustration, helplessness, excessive responsibility, protectiveness, or withdrawal may emerge during difficult interactions. Within a psychodynamic framework, these responses can be understood partly through countertransference: the clinician’s emotional reactions to the patient and therapeutic relationship.

Countertransference is not inherently problematic. When recognized and reflected upon, it may provide information about interpersonal dynamics. When unexamined, however, it can contribute to defensive communication, premature reassurance, excessive intervention, or avoidance. Reflective practice allows professionals to distinguish patients’ needs from their own emotional responses while maintaining therapeutic boundaries.

Psychological vulnerability may become particularly pronounced during treatment transitions. Dialysis initiation, modality changes, transplantation, and graft failure involve substantial changes in bodily experience, identity, and perceived control. These transitions may reactivate earlier experiences of loss, separation, or dependency. Patients may simultaneously experience relief at receiving treatment and resentment toward its limitations.

An important clinical concept is containment. Derived from psychodynamic theory, containment refers to the capacity to receive, recognize, and respond thoughtfully to another person’s emotional distress without becoming overwhelmed or immediately attempting to eliminate it. In kidney care, this may involve tolerating uncertainty, acknowledging anger or fear, and remaining emotionally available when no immediate solution exists.

This differs from reassurance that prematurely minimizes distress. Well-intentioned statements may discourage disclosure when patients perceive their concerns as dismissed. Attentive listening, emotional validation, and appropriately paced discussion can help patients articulate experiences that might otherwise emerge through withdrawal, conflict, or difficulties with treatment engagement.

Dr. Hercz also emphasizes the clinical value of ordinary conversation. Brief exchanges about family, daily routines, or personal interests strengthen therapeutic continuity and provide insight into psychological functioning. Such interactions establish familiarity, support trust, and create opportunities to recognize changes in mood, coping, or interpersonal behaviour.

The psychological demands of kidney care extend to multidisciplinary teams. Repeated exposure to suffering, deterioration, dependency, and death can generate cumulative emotional strain. Without opportunities for reflection, clinicians may develop defensive detachment, interpersonal conflict, or diminished empathic engagement.

Reflective meetings informed by the Balint group model offer opportunities to examine challenging clinical relationships. Rather than concentrating exclusively on medical decisions, these discussions explore the emotional experiences of patients and clinicians, including interpersonal dynamics influencing care. Such secure reflective spaces support professional awareness, collaborative understanding, and more considered responses.

Dr. Hercz also considers digital technologies and artificial intelligence. Although these developments improve access to information and clinical efficiency, they cannot fully reproduce the rich interpersonal connection through which patients experience recognition, trust, and emotional security.

Psychonephrology integrates psychological understanding into routine nephrology practice, recognizing how emotional processes, unconscious meanings, and therapeutic relationships influence chronic illness.The challenge is not choosing between technical excellence or psychological care, but integrating both. Effective kidney care requires biomedical expertise, clinical judgment, and the capacity to understand the person whose illness is being treated.