SPECIAL ARTICLES An Overview of Countertransference With Borderline Patients GLEN 0. GABBARD, M.D. Successful management of countertransfer- I feel used, manipulated, abused, and at the same time I feel responsible for her ence is critical to the psychotherapy of border- feelings of rejection and threats of sui- line patients. The author discusses the most cide, or feel made to feel responsible for common countertransference reactions en- them because I don’t have time for her countered in such treatments. A theoretical and don’t choose to be/cannot be always framework is also proposed that conceptual- available as a good object, nor as a stand- by part object. izes countertransference as a joint creation be- She has hooked me into thinking tween therapist and patient. It follows from love and friendship will heal her, as if this conceptual framework that therapists there were nothing wrong with her but must constantly monitor their own contribu- rather it was all of the people in her life tions from past relationships as well as the who were the problem. Then I come up with fatherly friendship, and her control aspects of countertransference evoked by the begins. She tells me, in different ways, patient’s behavwr. Countertransference in that I am different from the others. And the psychotherapy of borderline patients must just when I’m basking in “good objectiv- be viewed as a source of valuable diagnostic ity,” she really begins to control me by and therapeutic information and not simply telling me that I’m just like the rest, that I don’t care: “I see you looking at your as interference with the therapeutic process. watch. I know you want to leave. I know you have a life out there. It will be a long night. You don’t care. Nobody cares.” A s this quotation from a borderline pa- tient’s therapist vividly conveys, patients suffering from borderline personality disor- der tend to overwhelm the clinicians who treat them. A comprehensive treatment pro- gram for such patients often includes individ- ual psychotherapy or psychoanalysis, adjunctive pharmacotherapy with any one of a number of agents, brief or extended hospi- Received April 1, 1992; revised May 14, 1992; accepted May 15, 1992. From The Menninger Clinic and the Kansas University School of Medicine, Topeka, Kansas. Address reprint requests to Dr. Gabbard, The Menninger Clinic, P.O. Box 829, Topeka, KS 66601-0829. Copyright © 1993 American Psychiatric Press, Inc. JOURNAL OF PSHOTHERAPY PRACTICE AND RESEARCH 8 COUNTERTRANSFERENCE AND BORDERLINE PATIENTS talization, family or marital therapy, and therapists suffer for them.5 They seem to de- group psychotherapy. Regardless of the spe- mand that the therapist abandon the profes- cific form of treatment, however, counter- sional therapeutic role: anyone who attempts transference can be a major impediment to to treat them must share in their misery. successful therapeutic efforts.’ The treater’s Searles6 has cautioned that the traditional emotional reactions to the patient sweep analytic posture of evenly suspended atten- through the course of treatment like a tem- tion is neither viable nor appropriate in the pest with the potential to create havoc for psychotherapy of borderline patients. Thera- both patient and therapist. Although the pists who attempt to assume a detached, “ob- skillful management of countertransference jective” role vis-#{224}-visthe borderline patient is only one aspect of an overall treatment are at risk of projectively disavowing their own approach to borderline personality disorder, conflicts and anxieties and using the patient it constitutes the foundation of the treatment as a container to receive them. The classical on which all other efforts will rise or fall. notion of the therapist as “blank screen” is The primitive defenses of borderline pa- simply not applicable to the psychotherapy of tients, particularly splitting and projective borderline patients. identification, produce a kaleidoscopic array of complex and chaotic transferences in the S i E C I F I C therapeutic setting. As these varying configu- COUNTERTRANSFERENCE rations of self- and object-representations pa- R E A C T 1 0 N S rade before the therapist, they are further complicated by accompanying affective states Controversy over the diagnosis of borderline that are unusually intense and raw, often in- personality disorder persists despite the in- ducing in therapists a feeling that they are troduction of this category into DSM-III 12 trapped in a life-and-death struggle.2 Some years ago. The first systematic empirical study clinicians have even suggested that counter- of the disorder by Grinker et al.7 suggested transference reactions may be the most reli- that borderline personality disorder is a spec- able guide to making the diagnosis of bor- trum that ranges from the psychotic to the derline personality disorder.3 These patients neurotic. Kernberg8’9 argued that the border- make us “come alive” in a specific way that line concept is really a personality organiza- heightens our awareness much like the expe- tion rather than a specific nosological entity. rience of driving over a mountain pass on a A variety of different personality disorders, narrow two-lane road without a guard rail. including paranoid, antisocial, schizoid, in- Because they are so sensitive to the therapist’s fantile, narcissistic, and cyclothymic, all could choice of words and nonverbal nuances, they be subsumed under the overarching ego or- are able to evoke a sense of walking on egg- ganization. shells, as if our margin of error were very Gunderson,’#{176} on the other hand, sought narrow indeed. Yet, in spite of this untoward to identify discriminating criteria that would impact, they somehow become “special” to distinguish borderline personality disorder their therapists4 and inspire a surprising op- from other related Axis II conditions. Abend timism despite a host of pessimistic prognos- et al.” raised serious questions about tic signs.3 Therapeutic zeal rises like a Kernberg’s diagnostic understanding of bor- phoenix from the ashes of previous failures. derline patients by documenting the success- Borderline patients seem to have the pe- ful psychoanalytic treatment of such patients culiar ability to inflict a specific form of “sweet with classic psychoanalytic technique based suffering” on their therapists. They them- on traditional conflict theory. Adler’2 pre- selves have suffered throughout their lives, sented yet another point of view. He pro- and it is important to them to have their posed that borderline patients could best be VOLUME 2 #{149}NUMBER 1 #{149}WINTER 1993 GABBARD 9 understood as suffering from a deficit-based describing aspects of the psychothera- condition rather than intrapsychic conflict. peutic process, attempts to hold rigidly Specifically, this condition involved the ab- to a dichotomous view that prescribes a given form of therapeutic modality to sence of a holding-soothing introject that specific diagnostic entities is neither the- could sustain them emotionally in the ab- oretically sustainable nor clinically prac- sence of their psychotherapists. Other clini- tical. .. the therapist needs to maintain cians influenced by self psychology’3’4 a position of flexibility and adaptability, maintained that borderline symptomatology allowing the selection of available tech- results from breakdowns in the empathic re- niques from the range of psychothera- latedness between therapist and patient and peutic interventions to deal with the should therefore be reconceptualized as an problems presented. (p. 121) entity that is definable only in the context of a relationship. The concept of a spectrum is important This controversy about diagnosis is mir- because, in discussions of countertransfer- rored in a corresponding controversy regard- ence, one must keep in mind that the ing the optimal treatment. Many (though not therapist’s reactions may vary considerably all) of the differences of opinion can be ac- depending upon where on this continuum a commodated by embracing Meissner’s’5 no- particular patient stands. ob- tion that the borderline diagnosis is serves: “Countertransference in relation to essentially a spectrum of conditions that are borderline conditions is therefore not an psychodynamically related. At the high end univocal phenomenon but rather involves a of the spectrum are patients who have nota- spectrum of levels and intensities of transfer- ble ego strengths and can undergo psychoan- ence/countertransference interactions that alytic treatment with little modification. At can vary considerably in both quality and the low end of the spectrum are patients who quantity” (p. 211). With this caveat in mind, are prone to psychotic disorganization be- I will consider several common countertrans- cause of prominent ego weaknesses and who ference reactions to borderline patients. require more supportive approaches. From a clinical perspective, however, the Guilt Feelings spectrum must be regarded as a metaphorical construct. Borderline patients are known for Borderline patients have an uncanny wide fluctuations in their clinical presenta- ability to tune in to the therapist’s vulnerabil- tion. One can see normal, neurotic, and psy- ities and exploit them in a manner that in- chotic transferences in the same patient in duces feelings of guilt. A common the course of one therapeutic hour.’6 A cor- development is that a patient will behave in ollary of this observation is that therapists such a way as to infuriate and exasperate