Text adapted from: "The adult patient with a personality disorder," in Psychiatry in primary care by Michael Rosenbluth, Matthew Boyle & Lucille Schiffman (CAMH, 2019).
The concept of countertransference is important for primary care practitioners to understand. Generally, countertransference refers to the reaction a clinician has to a patient that mirrors significant past conflicts the clinician has experienced. However, a more useful and pragmatic definition involves considering all reactions that a patient elicits in the clinician. Being aware of these reactions provides insights into patients and serves as a valuable therapeutic tool.
Sometimes a clinician’s reaction to a patient can signal the presence of an undiagnosed personality disorder. Seeing a patient’s name on your schedule and thinking, “Oh no, not again, so soon,” might mean that you should consider exploring whether this patient has an overlooked personality disorder
The challenging presentation of patients with a personality disorder commonly induces negative feelings in clinicians. Understanding those feelings in turn helps the clinician to understand the patient’s dynamics. By being aware of those feelings, you avoid the treatment mistakes that can occur when the feelings are not recognized. When you meet people who feel “short-changed” by life, countertransference or counter-reactions naturally ensue.
Countertransference can manifest in subtle reactions that patients are sensitive to. For example, a clinician who feels irritated by a patient may make comments in a tone the patient picks up on. Some patients respond to slight modulations in a clinician’s tone or to hesitation by overreacting and disrupting treatment. Other patients who feel that the clinician has passed the “tests” they have set for them will never want to leave treatment with that clinician and may become dependent on them, which triggers its own counter-reactions.
Failing to recognize countertransference can lead to inappropriate or inadequate treatment. For example, there is a risk that medication will be either underused (by not diagnosing the comorbid Axis I diagnosis) or overused (to quell behaviours the clinician finds disturbing).
Countertransference can affect whether patients are seen regularly, too rarely or too often. These patients can elicit rescue fantasies and you may see them more frequently than you are comfortable with, or conversely, too infrequently for them. The appropriate frequency is sometimes not as often as the patient may wish and not as infrequently as you may wish.
Clinicians’ unrecognized reactions may cause boundary violations. Boundary violations range from excess sessions, medications and favours (e.g., writing letters of support that are not consistent with the actual clinical facts) to inappropriate sexual behaviour. Because of their complicated histories and needs, patients with personality disorders can be overrepresented among those patients who become involved with their treatment providers.
This kind of inappropriate involvement can reflect different psychodynamics. The crucial point for primary care practitioners is to maintain strict boundaries. The responsibility for maintaining them rests with you. If you find yourself doing things that you do not do for other patients, this is an early sign of boundary issues that require attention. To avoid types of engagement that constitute boundary violations, it can be helpful to think of your role as that of a coach—staying on the sidelines and not getting in the game (Gutheil & Alexander, 1992).