Countertransference refers to the emotional responses of a clinician to a patient. These responses have their origins in early relationships, most usually in relationships with one's parents, and which responses promote the reactivation of primitive defenses. Countertransference reactions are neither inherently bad nor good; they just are. Recognition and consideration of the countertransference offers clinical utility in a number of ways.
Countertransference can contribute significantly to the diagnostic refinement. The feelings and behaviors evoked in the clinician by the patient can be used to suggest and clarify a clinical diagnosis. Consider the "feeling" of being scrutinized, of being suspect, which is often evoked through interaction with an individual with Paranoid Personality Disorder.
The countertransferential experience enables insight into the phenomenology of the individual. How the clinician feels when with this individual, often reflects (mirrors) what the patient feels. For example, it is not unusual to feel the incipient rage of a person with Borderline Personality Disorder when they are talking about a relationship that triggers their anger dyscontrol.
Countertransference can serve as a microcosm of the patient's universe. As is true for all therapies, the therapy session represents and reflects the experiences the patient has outside of the session. This can help clarify the diagnosis. For example, the individual with Dependent Personality Disorder will act out the dependency in the session and the countertransference reactions might initially include feelings of competence and power, but develop over time to feeling drained and, ultimately, even useless and helpless.
The countertransference can suggest treatment options. It is the wise and experienced clinician who is able to identify the countertransference reactions, to utilize these diagnostically to better understand the phenomenology of the patient, and to choose the type and goals of the treatment based, at least in part, on the countertransference. For example, the individual who increasingly receives home care services, and feels distressed by the lack of control, can be coached and supported in adaptive ways to engage and interact with the helpers.
Managing the countertransference in clinical work with those with personality disorders is known to be exceptionally challenging. The countertransference reactions are characteristically reactive and intense. This is because individuals with a personality disorder often present clinically in crisis and with a history of frequent crises. They often demand urgent or excessive attention from the clinician and often lack awareness or respect for the feelings of others, including the clinician. When their needs are not adequately or promptly met, their symptoms and maladaptive behaviors are likely to escalate and intensify.
Countertransference feelings can be positive or negative. On the positive side are feelings of protectiveness, heightened self-esteem, specialness, and omnipotence. Negative feelings might include feelings of frustration, rage, depletion, or helplessness. These can contribute to considerable stress in the therapist and might result in the therapist acting out—behaving in a way that is a departure from his or her usual way of functioning as a clinician. The countertransference can impact the therapy in significant ways, including the development of a therapeutic impasse, a breach of the therapeutic alliance, and premature termination of the therapy.
Managing the countertransference in clinical work with personality disordered patients is a challenge, and supervision and consultation is highly recommended. Certain problem areas frequently emerge in work with the patient population and require clinical management attention.
Distance regulation refers to the clinician's ability to maintain an appropriate distance in the clinical relationship for the treatment to be effective. Personality disorders make maintaining this distance difficult. For example, the aloof and arelational stance of the Schizoid Personality Disorder interferes, and often precludes, the establishment of a therapeutic alliance. In another example, the affective lability of the Borderline Personality Disorder often is mirrored by a "distance lability" in relationship with the clinician, vacillating between becoming too close or too far apart.
Boundary management refers to the challenges to the clinician's ability to maintain the boundaries of the treatment. For example, the patient delays leaving the treatment room at the end of the session or contacts the clinician repeatedly between sessions. Clinical boundaries are frequently challenged, and sabotaged, by patients with Cluster B personality disorders, and also by those with Dependent Personality Disorder who seek excessive direction and reassurance.
Professional perspective is addressed through ongoing education around treatments which are best suited to which patient, keeping up with current thinking in the field, and awareness of what are (or are not) clinically realistic expectations of treatment. Supervision is mandatory in managing coun-tertransference, especially in work with personality disordered patients. The clinician's personal therapy is also valuable.
Care of the care provider cannot be overemphasized. The more difficult the patient, the more the clinician's usual way of practicing clinical work is challenged by the patient's psycho-pathology and the more self-care is indicated.
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