Managing Countertransference in the Treatment of Personality Disorders

The clinical and technical difficulties presented by patients with personality disorders are well documented. This article focuses on the challenges faced by therapists when managing their emotional reactions, that is, their countertransferences, to patients with personality disorders. While leaving room for therapists' unique and idiosyncratic countertransferences to the patient with personality pathology, Kernberg emphasized the role of a more general form of countertransference, one reflective largely of the patient's conflicts and defenses, in the treatments of personality disordered individuals. Here, the nature of the patient's internal and external functioning can be seen to lead to similar reactions among different therapists, opening the possibility of utilizing countertransference to better understand the patient's difficulties. In transference-focused psychotherapy (TFP), countertransferences arising in the patient–therapist interaction are first identified and contained by the therapist and then utilized to clarify and explore how the patient's internal object relations are being enacted in the clinical process. This article describes this process and how TFP therapists work with their countertransference to help illuminate the patient's split representational world, paving the way for interpretation and integration.

Transference-Focused Psychotherapy for Adolescents With Personality Disorders

This article presents a conceptualization of personality disorders in adolescence and the adaptation of transference-focused psychotherapy (TFP) for personality disordered adolescents (TFP-A). The model of assessment and treatment presented is based on contemporary psychoanalytic object relations theory developed by Otto F. Kernberg and supported by findings from current evidence-based outcome research. We present a method of assessing personality disorders in adolescents that addresses the variability of personality disorder symptoms and traits among adolescents and their instability over time. We then present the goal of TFP-A and its major phases of implementation. A major focus is therapist interventions.

Perceived Caretaker Malevolence During Childhood Reported by Borderline Patients and Personality-Disordered Comparison Subjects: Description and Prediction

This study has two purposes. The first is to assess the rates of childhood malevolence by caretakers reported by a well-defined sample of inpatients with borderline personality disorder (BPD) and comparison subjects with other personality disorders. The second purpose is to determine the relationship between reported malevolence of caretakers and possible risk factors for this experience. Two reliable interviews were administered to 290 borderline inpatients and 72 personality-disordered comparison subjects to address these aims. Malevolence was reported by a significantly higher percentage of borderline patients than comparison subjects (58% vs. 33%). In multivariate analyses, severity of other forms of abuse, severity of neglect, and a family history of a dramatic cluster personality disorder were found to significantly predict perceived malevolence. Taken together, the results of this study suggest that experiencing malevolence is common and distinguishing for BPD, and that the risk factors for reported childhood malevolence are multifactorial in nature.

Self-cannibalism and cannibalism: a perverse defence against depression

This observational article describes three cases of self-cannibalism and cannibalism by patients in a secure setting. These are studies of severe personality disordered patients, each of whom have perpetrated terrible offences, usually on others. In our view, the inner world of the cannibalistic patient is committed to a narcissistic biting grip on his objects and is bent upon appropriating their good aspects. In our practice, we have observed a countertransference enactment that may be characterised as a roadblock to explore the past: to feel, to understand, and to repair. The aim of the perverse pact is to remain in a stuck state to protect the self from any awareness of feelings of depression. This is an enactment of the inherently deathly, inner relationship of the individual perpetrator. We believe it is essential to attempt to open up a space to explore the unthinkable act of cutting and eating flesh in the context of the person’s developmental history. Failure to do so within systems of care sets in motion a repeating cycle of a traumatic victim–victimiser dynamic associated with ever increasing risk.

Levels of Acceptance and Forgiveness Reported by Patients With BPD and Personality-Disordered Comparison Subjects Over 20 Years of Prospective Follow-Up

This study had two objectives: to determine the levels of acceptance and forgiveness reported by patients with borderline personality disorder (BPD) and personality-disordered comparison subjects and by recovered versus non-recovered patients with BPD over 20 years of prospective follow-up. Levels of acceptance and forgiveness were reassessed every 2 years. Patients with BPD reported levels of these states that were approximately 70% lower than comparison subjects at baseline. These states increased significantly over time for patients with BPD but not for comparison subjects. Recovered patients with BPD reported approximately three times the levels of these states than non-recovered patients with BPD. These levels increased for both groups over time; one state (accepting of myself) increased at a significantly steeper rate for recovered patients with BPD. These results suggest that patients with BPD report becoming more accepting and forgiving over time. Additionally, recovery status is significantly associated with increasing time in these states.