Stefana, A., Bulgari, V., Youngstrom, E.A., Dakanalis, A., Bordin, C., & Hopwood, C. (2020). Patient personality and psychotherapist reactions in individual psychotherapy setting: A systematic review. Clinical Psychology and Psychotherapy.
Countertransference is one of the oldest concepts in psychotherapy. An over-inclusive definition refers to all of the therapist’s emotional reactions to a patient that is evoked by the patient’s behaviors, thoughts, or feelings in the therapy. However, a more contemporary and integrated definition defines countertransference as a subset of therapist reactions. In this view, countertransference is the internal and external reactions of a psychotherapist evoked by the patient, such that patient behaviors interact with unresolved issues of the therapist. In a previous meta-analysis, countertransference reactions of the therapist was associated with poorer patient outcomes, and therapists’ successful management of countertransference was associated with improved patient outcomes. The clinical literature often reports that patients with a personality disorder often evoke troublesome emotional reactions in therapists. In this systematic review, Stefana and colleagues provide a comprehensive evaluation of the relationship between patient personality problems and psychotherapists’ emotional, cognitive, and behavioral reactions in individual therapy. Seven studies were included in their review. Fifty-three percent of therapists were psychodynamically-oriented, most therapists had more than 3 years of experience, and all patients had a personality disorder or were assessed for problematic personality traits. Overall, the authors found that patients with Cluster A personality traits (paranoid, schizoid, schizotypal) tended to evoke therapist responses of feeling criticized, unappreciated, dismissed, or devalued by the patient. Patients with Cluster B personality traits (borderline, histrionic, narcissistic) tended to evoke therapist responses of feeling overwhelmed, helpless/inadequate, sexualized (experiences of sexual tension), and disengaged toward the patient. Patients with Cluster C personality traits (avoidant, dependent, obsessive-compulsive) tended to evoke parental/protective responses in the therapist. Looking at specific personality traits: paranoid personality traits evoked therapists feeling criticized, schizoid personality traits evoked therapists feeling inadequate, schizotypal or obsessive compulsive or narcissistic personality traits evoked therapists feeling disengaged, antisocial personality traits evoked therapists feeling devalued, borderline personality traits evoked therapists feeling overinvolved, avoidant or dependent personality traits evoked therapists feeling parental.
The research appears to show that patients with certain personality traits, and thus certain ways of thinking, feeling, and reacting tend to evoke specific reactions in therapists. Therapists patterns of reactions appeared to be independent of theoretical orientation, suggesting that all therapists tend to have emotional reactions that may affect the therapeutic relationship and patient outcomes. Therapists can manage countertransference by remaining vigilant to their internal reactions, using self-awareness during sessions, consulting with colleagues and supervisors, and engaging in personal therapy.