Psychotherapy with difficult patients: Personal narratives about managing countertransference
This project used a qualitative methodology to examine: (1) the types of patients that therapists experience as difficult, and their decisions regarding initiating psychotherapy with these patients; (2) the emergence and management of countertransference during the course of psychotherapy; and (3) therapists’ understanding of the impact of countertransference on the development of a therapeutic alliance with difficult patients. In addition, this project explored therapists’ preconceptions about difficult patients and their understanding of the impact of those preconceptions on the therapeutic alliance and psychotherapy process. Semi-structured interviews were conducted with ten experienced therapists. Interviews were transcribed and a clinical, narrative perspective was used to generate themes related to the research questions. In addition, narratives were reviewed for content consistent with the five-factor theory of countertransference management (VanWagoner, Gelso, Hayes, & Diemer, 1991), which posits that countertransference management consists of five interrelated factors: (1) therapist self-insight, (2) therapist self-integration, (3) anxiety management, (4) empathy, and (5) conceptualizing ability. Therapists described patients with a range of diagnoses and behaviors that they find difficult, including borderline personality disorder, narcissistic personality disorder, schizoid personality disorder, dissociative identity disorder, substance use disorders, high-risk behaviors and the avoidance of affect. Therapists’ narratives of countertransference with difficult patients reflected an intersubjective model of countertransference, with themes of difficulty related to aggression and withdrawal. With regard to managing countertransference, therapists emphasized the importance of self-care and personal psychotherapy, supervision and consultation, and clinical training and experience. Therapists’ narratives reflected themes of self-insight, self-integration, and anxiety management and, to a lesser extent, empathy and conceptualizing ability. Finally, most therapists viewed preconceptions as somehow related to countertransference, and they described managing preconceptions in much the same way that they described managing countertransference. Specifically, therapists emphasized the importance of awareness and understanding of preconceptions as a valuable source of information about the patient, themselves, and the intersubjective reality of the therapy situation.