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Understanding Countertransference with Patients with Borderline Personality Disorder

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Understanding Countertransference with Patients with Borderline Personality Disorder Philadelphia College of Osteopathic Medicine DigitalCommons@PCOM PCOM Psychology Dissertations Student Dissertations, Theses and Papers 2003 Understanding Countertransference with Patients with Borderline Personality Disorder : an Exploratory Quantitative Investigation Michelle Saxen Hunt Philadelphia College of Osteopathic Medicine, [email protected] Follow this and additional works at: http://digitalcommons.pcom.edu/psychology_dissertations Part of the Clinical Psychology Commons Recommended Citation Hunt, Michelle Saxen, "Understanding Countertransference with Patients with Borderline Personality Disorder : an Exploratory Quantitative Investigation" (2003). PCOM Psychology Dissertations. Paper 65. This Dissertation is brought to you for free and open access by the Student Dissertations, Theses and Papers at DigitalCommons@PCOM. It has been accepted for inclusion in PCOM Psychology Dissertations by an authorized administrator of DigitalCommons@PCOM. For more information, please contact [email protected]. Philadelphia College of Osteopathic Medicine Clinical Psychology Department ofPsychology UNDERST ANDING COUNTERTRANSFERENCE WITH PATIENTS WITH BORDERLINE PERSONALITY DISORDER: AN EXPLORATORY QUANTITATIVE INVESTIGATION by Michelle Saxen Hunt Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor ofPsychology August 2003 Committee Members' Signatures: Rosemary Mennuti, Ed.D., Chairperson Robert A. DiTomasso, Ph.D., ABPP Gina M. Fusco, Psy.D. Arthur Freeman, Ed.D., ABPP, Chair, Department of Psychology 111 Acknowledgments This project could not have been completed without the support and encouragement of Dr. Roe Mennuti. She believed in me and gave me the confidence I needed to keep going during my times of doubt that there would ever be a finished product. Roe always has a calming and nurturing effect on me and for this I am extremely grateful. I would also like to thank Dr. Bob Di Tomasso for helping me to formulate my topic and for keeping me grounded in reality throughout this process. His words of wisdom will never be forgotten: "You must work on your dissertation every day, even if it is just to sharpen a pencil." These words have helped to keep me focused on the end result (and with a desk stocked with sharpened pencils!) Additionally, I am grateful to Dr. Gina Fusco for her empathy and clinical input into the project. In summary, it has been a wonderful learning experience! Thank you to everyone! 1V Abstract Understanding Countertransference with Patients with Borderline Personality Disorder: An Exploratory Quantitative Investigation. Michelle Saxen Hunt Psy.D., August 2003 Philadelphia College of Osteopathic Medicine Rosemary B. Mennuti, Dissertation Advisor The present study surveyed 58 psychologists regarding their countertransference (CT) behaviors, CT management ability, empathy, and working alliances when treating patients with borderline personality disorder (BPD). Common positive and negative CT behaviors were identified when treating their typical patient with BPD. As predicted, results yielded negative correlations between therapists' CT behaviors and their CT management ability, working alliance, and empathy, as well as a positive correlation between therapists' CT management and working alliance, linking CT management to positive treatment outcomes. Therapists' level of experience and theoretical orientation were also examined, finding no significant impact on CT behaviors, CT management, or working alliance. Implications for training and supervision of therapists treating patients with BPD, suggestions for future research, and limitations of the study are discussed. v Table of Contents List of Tables VI Acknowledgments 111 Abstract IV Chapter 1: Introduction 1 Statement ofthe Problem 1 Purpose of the Study 3 Operationally Defining CT 6 Classical view 6 Totalist view 6 Complementary view 7 Operational definition in the present study: Schematic view 7 Operationally Defining BPD 9 Theoretical Background 11 Cognitive model and CT 11 Historical roots ofthe BPD diagnosis 14 Biosocial model ofthe etiology ofBPD 17 Rationale for the Present Study 19 Related Research 27 Conceptualizing the psychotherapy relationship 27 Research on the working alliance 32 Research on countertransference 37 Other psychotherapy outcome and related research 49 Specific Hypotheses 59 Chapter 2: Method 62 Participants 62 Measures 63 Inventory of Countertransference Behavior (rCB) 64 Adapted Inventory of Countertransference Behavior (rCB) 65 Countertransference Factors Inventory-Revised (CFI-R) 66 Adapted Countertransference Factors Inventory-Revised (CFI-R) 68 Working Alliance Inventory (WAI) 68 Adapted Working Alliance Inventory-Short (W AI-Short, Therapist Version) 70 Procedures 70 Vi Chapter 3: Results 73 Demographic Characteristics 74 Validity Check Items 74 Countertransference Behaviors 79 Countertransference Behavior and Countertransference Management 82 Countertransference Behavior and Working Alliance 85 Countertransference Behavior and Therapist Empathy 88 Years of Clinical Experience and CT Behavior, Working Alliance, and CT Management 88 CT Management and Theoretical Orientation 90 Overall CT Behavior, CT Management, and Working Alliance Ratings 91 Chapter 4. Discussion 92 Implications for Training, Supervision, and Clinical Practice 100 Limitations of the Study 109 Conclusions 113 References 117 Appendix 131 Vll List of Tables Table 1. Characteristics ofthe Sample 75 Table 2. Clinical Practice of the Sample 76 Table 3. Participants' Treatment of Patients with Borderline Personality Disorder 77 Table 4. Frequencies and Percentages of Validity Check Items 78 Table 5. Frequent CT Behaviors "Sometimes" or "Often" Typically Engaged in By Therapists Treating Their Typical Patients With BPD 80 Table 6. Mean Scores and Standard Deviations for the Items on the ICB 83 Table 7. MeanScores and Standard Deviations for the Items on the W AI -Short (Therapist Version) 87 Table 8. Correlations Between Participants' Total Scores on the ICB, W AI, and CFI-R 89 BPD Survey 1 Chapter 1 Introduction Statement ofthe Problem Encountering individuals suffering with Borderline Personality Disorder (BPD) is becoming increasingly common in the clinical setting. Available data show that approximately 10% of all psychiatric outpatients and 15% to 20% of psychiatric inpatients are estimated to meet criteria for BPD (Anonymous, 2001; Widiger & Frances, 1989). Additionally, these sources show that of patients with some form of personality disorder, 33% of outpatients and 63% of inpatients appear to meet BPD criteria. The diagnosis is estimated to be present in 2% of the general population (Anonymous, 2001). Statistics suggest that there is a high cost to patients with BPD, their families, and society. Data collected from longitudinal studies of patients with BPD cite that despite functional role attainment 10 to 15 years following admission to psychiatric facilities, only about one-half of the patients will have stable, full-time employment or stable marriages (Anonymous, 2001). Many ofBPD patients will attempt suicide. Completed suicide occurs in 8% to 10% of borderline individuals, a rate of 50 times higher than in the general population (Anonymous, 2001). Additionally, patients with BPD tend to have a greater lifetime utilization of a variety of medications and types of psychotherapy in comparison to patients with schizotypal, avoidant, obsessive-compulsive personality disorder patients, or those with major depression (Bender, et al., 2001). Consequently, BPD Survey 2 clinicians are often left feeling frustrated trying to find effective treatments to manage these patients in their clinical setting. Patients with a diagnosis ofBPD have come to be known in the psychiatric community as difficult to treat. They are known to elicit negative reactions from staff, resulting in poor therapeutic alliance, high therapy dropout rates, and negative treatment outcomes (Book, Sadavoy, & Silver, 1978; Marziali, Munroe-Blum, & McCleary, 1999; Gunderson, Najavits, Leonhard, Sullivan, & Sabo, 1997; Fraser & Gallop, 1993). A qualitative investigation of psychiatrists' views ofthe "difficult to treat patient," revealed that the diagnosis ofBPD was mentioned four times more frequently than the next most commonly mentioned category (Bongar, Markey, & Peterson, 1991). However, this difficulty may be a function of the impaired interaction between the patient and treatment provider, labeled as countertransference (CT). These doctors reported setting too many limits, denying anger, being overly cautious, discharging prematurely, and rejection of their patients (Bongar; et al., 1991). Book et al. (1978) outline common CT constellations noted from the experiences ofthe treatment teams on an inpatient psychiatric unit working with patients with BPD. They posit that four predominating types of CT reactions are elicited in staff when working with this patient population. These include: (1) Pejorative treatment toward patients; (2) viewing treatment outcome either overly optimistically or too hopelessly; (3) staff disagreements over treatment strategies, leading to severe breakdown of the treatment team; and (4) problems setting limits with patients. Another author outlines common CT reactions by therapists toward patients with BPD, including feelings of guilt, rescue fantasies, crossing of professional boundaries, rage and hatred, helplessness and BPD Survey 3 worthlessness, anxiety, and terror (Gabbard, 1993). A review ofthe existing literature on CT indicates
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