Countertransference in the Treatment of Borderline Personality Disorder

The emotional responses of clinicians deserve special attention in the treatment of patients with Borderline Personality Disorder (BPD) . Much has been written in the clinical and conceptual literature regarding the tendency for powerful countertransference feelings to emerge in response to the behaviours associated with BPD. Problematic countertransference reactions can generate difficulties for patients in treatment, for the clinicians involved in treating them, and for patients with BPD overall. Indeed, Aviram, Brodsky, and Stanley note that negative countertransference has at least partially contributed to the broader stigmatization of patients with BPD.

Countertransference is a technical construct that originated in psychoanalytic theory, referring simply to the therapist’s transference (i.e., emotional reactions) to the patient. Originally, countertransference was conceptualized as being based largely in the therapist’s own unresolved psychological conflicts, resulting in distortions of the material presented by the patient and to potential treatment difficulties. This is often referred to as the narrow model of countertransference.

The concept of countertransference has undergone considerable expansion since the early days of psychoanalysis. Within contemporary psychoanalysis, countertransference now tends to be thought of as constituting a broad range of emotional responses to the patient, as well as being co-constructed by both patient and therapist. In other words, the therapist’s emotional reactions are comprised of a mixture of responses evoked by the patient’s attitude and behaviour as well as the subjectivity – including conflicts and anxieties – of the therapist. This contemporary view holds that countertransference, if reflected upon, can serve to inform the therapist regarding unspoken aspects of the patient’s experience.

In considering countertransference and BPD, our emphasis is on the more problematic aspects of therapists’ emotional responses. Attention to the obstructive potential of countertransference has recently generated interest beyond psychoanalytic therapists, including psychotherapy researchers. Research has begun to sketch out some the common countertransference difficulties encountered in the treatment of personality disorders. A study of 155 therapists found that patients with BPD were perceived as being more dominant and hostile, compared to patients with major depressive disorder. A study of 11 clinicians working with 71 patients found that reactions toward patients with cluster B personality disorders – which includes BPD – tended to be negative, especially when patients dropped out of treatment. Another study (N = 181) found that patients with cluster B disorders were strongly associated with reactions that included feeling overwhelmed / disorganized and criticized / mistreated, and were negatively correlated with positive countertransference.

Other research efforts have examined countertransference and its management in relation to treatment outcome. Research in this area emphasizes the contributions of therapists to countertransference – the therapist’s conflicts, anxieties, and unresolved issues – as they bear upon the psychotherapy process. A recent meta-analytic review has found that (1) countertransference (in the narrow sense) is modestly associated with adverse outcomes in psychotherapy, and that (2) management of countertransference can lead to improved therapy outcomes. Management refers to the prevention of acting out upon countertransference responses, and includes efforts to increase self-awareness and insight, as well as activities aimed at improving therapists’ boundaries, self-integration, and health.

An entire volume deals with the issue of managing countertransference in the psychotherapy of BPD. Although therapists’ own psychological factors heavily determine countertransference, the interpersonal and behavioural challenges associated with BPD exert particular pressure on therapists’ emotional responses. Gabbard & Wilkinson suggest that a fluctuating range of common countertransference reactions may be experienced by therapists involved in treating BPD. These include feelings of guilt and irrational responsibility, wishes to rescue the patient, anxiety and helplessness, and angry and resentful feelings toward the patient. Such responses are considered expectable; their emergence reflects various dynamics within the course of psychotherapy and requires containment and reflection on the part of the therapist. Inadequate management of countertransference, however, can increase the risk of boundary problems (See page on Boundaries and BPD) and adverse treatment outcomes. Supervision or consultation is an essential “life raft” amidst the emotional intensity of psychotherapy for BPD, a point explicitly recognized in the treatment manuals of structured approaches such as Dialectical Behaviour Therapy (DBT) and Mentalization-Based Treatment (MBT).