Abstract:
The concept of countertransference (CT) emerged out of psychoanalysis and is commonly understood as therapists’ cognitive-affective reactions to clients. CT is widely considered an important therapeutic tool in psychodynamic therapies. More recently, some scholars and therapists from other therapeutic orientations, such as Cognitive Behavioural Therapy, have adopted the term CT. There is evidence that CT is a common experience that can have detrimental effects on the therapeutic relationship and therapy outcomes if poorly managed. There are few studies exploring the nature of therapists’ CT reactions when working with clients with Borderline Personality Disorder (BPD), and little is known about how therapists conceptualise and manage CT. This thesis is a qualitative exploration of therapists’ understanding and experiences of countertransference (CT) when working therapeutically with clients diagnosed with Borderline Personality Disorder (BPD) in New Zealand. In particular, this study investigated the types of CT reactions experienced by therapists working with clients with BPD and the way therapists conceptualised their CT reactions. It also investigated the ways they managed and utilised these reactions.
Thirteen therapists with at least three years’ experience working therapeutically were recruited for this study. All therapists were trained in DBT and twelve therapists used DBT as their primary therapy approach with this client group within community mental health services. Prior to DBT, the majority of therapists were trained in CBT and some were trained in psychodynamic therapies. Ten identified as female and three identified as male. All therapists worked with clients with BPD and had between five and thirty five years of practice. The therapists were interviewed about their experiences of CT when working with BPD. The therapists were also asked about the types of CT reactions they had experienced, as well as the ways they conceptualised, managed and utilised their reactions. The data from the interviews were analysed using thematic analysis.
Six types of emotional reactions were identified: anxiety, frustration/anger, sadness, disconnection, hopelessness and joy/pride. Therapists described anxiety as common early in their career, often in response to the perceived chaos of their clients’ lives. They highlighted anxiety in response to clients’ suicidal behaviour as well as feeling threatened by their clients. Feelings of frustration and anger were reported in response to clients’ slow progress, receiving clients’ verbal attacks from clients, and clients’ suicide attempts/behaviours. Therapists
reported CT reactions of sadness in response to their clients’ suffering, and in some cases, therapists described wanting to rescue their clients. Feelings of disconnection were described in response to clients disconnecting from their emotions or from therapy. Some therapists spoke about feeling despair in response to their clients’ ongoing self-injurious or suicidal behaviour and in response to their clients’ despair. Lastly, many therapists described joy or pride as a common CT reaction when their clients made therapeutic progress.
All therapists viewed CT as an important aspect of the therapeutic relationship. Differences emerged regarding the ways the therapists conceptualised CT and this appeared to be influenced by their training and preferred therapeutic models. CT was understood as a common reaction in response to either something their clients “pulled” or “evoked”, something in the therapists’ personal history, or a combination of both. Surprisingly, none of the therapists used the term CT in their work settings because they either preferred to use other language to describe their experiences, or because they felt they needed to be cautious about the language they used in a Mental Health System that favoured behavioural models and behavioural language. Therapists predominantly practiced from a DBT framework, and preferred to use terms emotional responses or reactions rather than CT.
Therapists described a number of ways they managed their CT reactions. DBT consultation teams and using DBT skills were spoken about as being helpful ways of managing CT reactions. Engaging in self-care and talking with supervisors, colleagues and their own therapists were also emphasised as important CT management strategies. Some therapists described utilising their CT responses in therapy if they thought that it would be therapeutically helpful to do so. Therapists spoke about naming or disclosing their responses to their clients for the purposes of checking in with the client, problem solving with the client, or to communicate therapists’ limits to the client.
The findings of this study are discussed in relation to the existing literature on CT and BPD. The study considers the implications for therapists’ training, clinical practice, limitations and future research directions.