-transference- phenomenon by which patient's unconscious feelings about
a significant person in their life are experienced consciously as
feelings about the therapist. -Freud felt that this allowed for
patients to become aware of strong emotional feelings. In the
countertransference relationship, the patient puts something into the
therapist which the therapist experiences as his or her own.
adapted from the original for the average borderline reader
Without question the most important ingredient in the therapeutic matrix is
the therapist. The therapist's personality enters into the
therapeutic process in a more significant way in the treatment of borderline
patients than with any other group of patients, who are continually pushing
or pulling the therapist into countertransference positions. The therapist's
own susceptibility to responding in countertransference terms or to getting
embroiled in a transference/countertransference interaction is in part a
function of his own personality structure.
Clearly the ideal therapist does not exist, not for any kind of therapy and
especially not for the therapy of borderline patients. All therapists have
their relative strengths and weaknesses, their skills and blind spots. The
balance of strengths and weaknesses is often brought into stark relief by
the work with difficult borderline patients. The most important strength
for therapists undertaking this work is the capacity to remain steady on
course despite the howling winds and raging seas that can so readily be
whipped up in these patients. The therapist's ability to resist
countertransference pulls and to maintain a balanced sense of his own
personal and professional identity is what helps provide an environment
within which the patient can feel secure.
It is also important for the therapist to recognize and accept his own
limitations. For none of these patients does any therapist have all the
answers. There are inherent limitations to what a given therapist can or
is willing to tolerate. This requires thoughtful
consideration of what is involved in his role as therapist and a capacity
to stick to those boundaries. Efforts to draw him out of this therapeutic
role are a constant aspect of the therapeutic process with borderline
patients, and the therapist must be alert to these pressures and steer his
course accordingly.
The matter of therapist-patient fit may have considerable importance in the
treatment of borderline patients. For lower-order borderlines who show a
significant degree of instability, lability, and tendencies to act out,
some therapists do better in maintaining a therapeutic structure, setting
appropriate limits, maintaining the parameters of the therapeutic relation,
keeping the patient at the therapeutic task, avoiding countertransference
traps, and reinforcing the patient's responsible involvement in the treatment.
Other therapists find success in maintaining a nurturant, empathic, holding
environment within which patients have the opportunity to gain important
self-enhancing inputs that have been lacking in their developmental experience.
For most borderline patients, it is safe to say that they need both
structure and empathic support. A given therapist may have a greater
capacity to provide one dimension than another, and this is a function of
his own personality, developmental history, maturity, unresolved conflicts,
and values. This dimension cannot be changed by training.
In the treatment of patients within the borderline spectrum, no single
approach is possible, not only because of the variety of the range of
pathology but also because of the variability from session to session, from
moment to moment, in the therapeutic work. Effective treatment of these
patients requires that the therapist be able to assess the nature of the
patient's basic pathology and to adapt the therapeutic approach to the
characteristics and needs of that level of pathology.
Depending on the lability and instability in the patient's personality
structure, the clinical presentation can vary considerably. In relatively
unstable patients, the personality structure may shift quickly from an
objective, reasonable, thoughtful, ego-based orientation to one that is
regressive, or even shift rapidly back and forth between them. The patient may
suddenly and unexpectedly become paranoid, or depressed, distrustful, or
angry. In the face of these
variations, the therapist must be ready to shift accordingly and to meet
the needs of the patient at that moment, becoming more or less active,
setting limits when useful, focusing on the distortions in the therapeutic
alliance, providing the necessary degree of holding, and so forth. The good
therapist must learn to bob and weave and roll with the punches.
The therapist needs time to unwind from
often demanding and stressful sessions, time to gear up for other sessions
that he knows will be difficult and challenging. He needs to take
appropriate breaks, both during the course of the day's work and in the
form of vacations. This is often difficult when working with borderline
patients because of their marked sensitivity to separation and feelings of
abandonment. There is a certain responsibility to meet the patient's need
in this regard but it must be limited. The therapist must be able to
schedule vacation periods adequate to meet his own needs; the difficulties
created for the patient by these separations must be managed in whatever
way is appropriate. There is no room for guilt in this matter. Not only is
the therapist entitled to vacation breaks, but they are a necessary part of
his continuing to work effectively. The therapist needs to pay attention to
the quality of his life experience. A balanced and satisfying life is a
powerful contributory factor in maintaining the capacity to work with
difficult patients.
Even for therapists who have mastered many of the basic techniques
of psychotherapy, experience with borderline patients becomes an education
in the fluctuations of countertransference and
transference/countertransference interaction, and in the basic
understanding of the nature of the therapeutic process.
Books on the subject of transference
How does countertransference work?
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23 Dec 1998
