Specific personality traits evoke different countertransference reactions: an empirical study

Therapist reactions to patient personality: A pilot study of clinicians’ emotional and neural responses using three clinical vignettes from in treatment series

Introduction

Therapists’ responses to patients play a crucial role in psychotherapy and are considered a key component of the patient–clinician relationship, which promotes successful treatment outcomes. To date, no empirical research has ever investigated therapist response patterns to patients with different personality disorders from a neuroscience perspective.

Methods

In the present study, psychodynamic therapists (N = 14) were asked to complete a battery of instruments (including the Therapist Response Questionnaire) after watching three videos showing clinical interactions between a therapist and three patients with narcissistic, histrionic/borderline, and depressive personality disorders, respectively. Subsequently, participants’ high-density electroencephalography (hdEEG) was recorded as they passively viewed pictures of the patients’ faces, which were selected from the still images of the previously shown videos. Supervised machine learning (ML) was used to evaluate whether: (1) therapists’ responses predicted which patient they observed during the EEG task and whether specific clinician reactions were involved in distinguishing between patients with different personality disorders (using pairwise comparisons); and (2) therapists’ event-related potentials (ERPs) predicted which patient they observed during the laboratory experiment and whether distinct ERP components allowed this forecast.

Results

The results indicated that therapists showed distinct patterns of criticized/devalued and sexualized reactions to visual depictions of patients with different personality disorders, at statistically systematic and clinically meaningful levels. Moreover, therapists’ late positive potentials (LPPs) in the hippocampus were able to determine which patient they observed during the EEG task, with high accuracy.

Discussion

These results, albeit preliminary, shed light on the role played by therapists’ memory processes in psychotherapy. Clinical and neuroscience implications of the empirical investigation of therapist responses are discussed.

Associations between clinicians' emotion regulation, treatment recommendations, and patient suicidal ideation

OBJECTIVE

This study examines how clinicians' emotional responses to suicidal patients and their emotion regulation abilities are related to their treatment recommendations for these patients and to patients' concurrent suicidal ideation and at one-month follow-up.

METHODS

Adult psychiatric outpatients (N = 361) and the mental health professionals evaluating them for treatment (N = 43) completed self-report assessments following their first clinical meeting. Clinician emotion regulation traits, emotional responses to individual patients, and the recommended intensity of treatment were assessed. Patients were assessed for suicidal ideation immediately following the initial meeting and at a one-month follow-up. Moderation and mediation analyses were performed to examine the relationships between study variables.

RESULTS

Patient suicidal ideation at the initial clinical encounter was associated with increased negative emotions in clinicians with lower emotion regulation. Further, recommended treatment intensity was associated with clinicians' negative emotional responses but not with patient suicidal ideation among clinicians with lower emotion regulation.

CONCLUSIONS

Treatment intensification is related to clinicians' emotion regulation abilities. Clinicians' attention to their emotional responses may facilitate improved treatment process and ultimately may improve suicidal outcomes.

Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment

BACKGROUND

The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation.

AIM

To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD.

DESIGN

A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs.

RESULTS

The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations.

CONCLUSION

The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress.

Experience of Managing Countertransference Through Self-Guided Imagery in Meditation Among Healthcare Professionals

INTRODUCTION

As a part of the therapeutic relationship, a significant, well-established predictor of outcomes in psychiatric healthcare, healthcare professionals' emotional reactions to patients may affect treatment outcomes.

AIM

The aim of our study was to explore and describe healthcare professionals' experiences with managing countertransference using skills from a training program on self-guided imagery in meditation (SIM).

METHOD

Following an exploratory descriptive design, we conducted qualitative interviews with 10 healthcare professionals who care for patients with mental illness and subjected the collected data to thematic content analysis.

RESULTS

Participants reported that SIM had helped them to manage countertransference and had prompted changes that we categorized into three themes: managing personal vulnerability, setting clearer boundaries, and practicing self-care.

CONCLUSION

The results suggest that by cultivating wellbeing and dealing with unresolved inner conflicts, SIM can help healthcare professionals to manage countertransference.

Psychotherapists' emotional reactions to patients' personality trait in personality disorder treatment settings: an exploratory study

BACKGROUND

Therapist's emotional reactions toward patients in clinical facilities are a key concept in the treatment of personality disorders. Considering only clinical settings specialized in treatment of personality pathology the present paper aimed at: (1) assessing any direct relationship between patient symptom severity and therapist emotional response; (2) exploring patients' functioning configurations that can be associated with specific therapist reactions (3) investigating whether these relationships remains significant when accounting for other setting variables related to patients or therapist.

METHODS

The present study included 43 outpatients with personality disorders who underwent a psychotherapy treatment in two Italian facilities dedicated to outpatients with personality disorders and their 19 psychotherapists. The Symptom Checklist-90-Revised (SCL-90R) was used to explore clinical severity condition. Psychotherapists completed the Therapist Response Questionnaire (TRQ) to identify pattern of therapists' response and the Shedler-Westen Assessment Procedure-200 (SWAP-200) in order to assess personality traits of the patients.

RESULTS

No significant relationship between the clinical severity of the symptoms and the therapist' responses was found. Even when controlled for clinical severity condition, duration of the treatment, age and educational level of the patient or years of therapist experience, most of SWAP-200 traits appeared to be significant predictors of therapist' emotional responses.

CONCLUSIONS

The present study confirms the value of therapists' emotional response as a useful tool in understanding psychological processes related to clinical practice highlighting its context-dependent dimension.

Countertransference Processes in Psychodynamic Therapy with Dependent (Anaclitic) Depressed Patients: A Qualitative Study Using Supervision Data

Although Blatt's two-polarity model of depression has suggested that patients' interpersonal styles may shape countertransference phenomena in psychotherapy, empirical research on this topic has remained scarce. This article provides an in-depth study of countertransference processes in clinical work with dependent (anaclitic) depressed patients using a qualitative methodology. Thematic analysis of narrative material of psychodynamic therapists discussing patient cases during supervision (n = 7) resulted in four recurrent themes: "empathy, compassion, and support," "anxiety, feeling overwhelmed, and protection," "frustration, irritation, and confrontation," and "inadequacy, incompetence, and fatalism." We found that these countertransference processes mainly revolved around perceived adaptive and maladaptive aspects of patients' relational functioning. Regarding clinical practice, our study suggests that therapists can use countertransference to determine in which position they are maneuvered by patients, although we caution against the exclusive use of subjectively informed data as a benchmark in the diagnostic and treatment process. We conclude that further in-depth research on countertransference and personality styles is needed to identify pitfalls in the treatment of depression.

Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review

Despite the importance of psychotherapists' subjective experiencse working with patients with mental issues, little is known about the relationship between therapists' emotional reactions and patients' personality problems. The present study is a systematic review of quantitative research on the association between patients' personality pathology and psychotherapists' emotional, cognitive and behavioural reactions in individual psychotherapy setting. A systematic database search (from January 1980 to August 2019) supplemented by manual searches of references and citations identified seven relevant studies. Significant and consistent relationships were found between therapist reactions and specific personality traits or disorders. In general, odd and eccentric patients tend to evoke feelings of distance and disconnection; emotionally dysregulated patients tend to evoke anxiety and incompetence, and anxious and withdrawn patients tend to evoke sympathy and concern. However, the relatively small sample of studies and methodological inconsistencies across studies limit firm conclusions and suggest the need for more systematic research. Findings from this review indicate that patients who share the same personality disorder or symptoms tend to evoke specific and similar cognitive, emotional and behavioural reactions in their therapists. This suggests that therapists overall reactions toward patients may be source of valuable diagnostic information.

Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation

BACKGROUND

Mental health clinicians frequently experience intense negative emotional responses to suicidal patients, which have been related to treatment outcome. This study examines the therapeutic alliance as a mediator of the relationship between clinicians' negative emotional responses at the initial encounter and patients' suicidal ideation (SI) concurrently and 1 month later.

METHODS

We assessed 378 adult psychiatric outpatients (62.7% female; mean age = 39.1 ± 14.6 years) and their 61 treating clinicians. Following the initial encounter, self-report questionnaires assessed clinicians' emotional responses to their patients, patients' and clinicians' perception of the therapeutic alliance, and patients' SI. The SI was reassessed 1 month after the initial visit. Multilevel mediation analyses were performed.

RESULTS

Patients' (but not clinicians') perception of the therapeutic alliance mediated the relationship between clinicians' negative emotional responses to patients and patients' SI 1 month following the initial visit (indirect effect estimate = 0.015; p < .001).

CONCLUSIONS

The association between clinicians' negative emotional response and patients' prospective SI appears to be transmitted, at least partly, through the patients' perception of the poorer early quality of the therapeutic alliance. Thus, clinicians' awareness and management of their emotional states appear essential both for the identification of suicidal risk and to enhance therapeutic alliance and treatment outcomes.

"Will you treat me? I'm suicidal!" The effect of patient gender, suicidal severity, and therapist characteristics on the therapist's likelihood to treat a hypothetical suicidal patient

The purpose of our study was to broaden the understanding regarding mental health professionals' willingness to treat and likeliness to refer suicidal patients to other professionals. More specifically, our aim was to examine the effect of the patient's gender and suicidal severity, as well as the mental health professionals' personal and professional characteristics, on the willingness to treat and likeliness to refer. A total of 331 mental health professionals were randomly exposed to one of four case descriptions of a hypothetical patient in a crisis. The cases shared a common background story; however, they differed in terms of the patient's gender and suicidal condition (high vs. low). The exposure was followed by questionnaires aimed to reflect the subject's evaluation of the patient's suicidal severity, the subject's sense of competence and responsibility, willingness to treat or likeliness to refer, emotional contagion, and depression. The results indicate a lower willingness to treat and higher likelihood to refer suicidal patients compared with depressed patients. In addition, subjects exposed to the high suicidality cases showed a greater willingness to treat and refer female patients compared with male patients. A sense of competence was found as the strongest predictor of mental health professionals' willingness to treat and likelihood to refer, and emotional contagion was found as a predictor of likelihood to refer. It is important that mental health professionals be aware of the low tendency to treat suicidal patients especially if they are male. Further research should explore suitable training programmes and their application in the mental health curriculum.

Countertransference Processes in Psychodynamic Therapy with Dependent (Anaclitic) Depressed Patients: A Qualitative Study Using Supervision Data

Although Blatt's two-polarity model of depression has suggested that patients' interpersonal styles may shape countertransference phenomena in psychotherapy, empirical research on this topic has remained scarce. This article provides an in-depth study of countertransference processes in clinical work with dependent (anaclitic) depressed patients using a qualitative methodology. Thematic analysis of narrative material of psychodynamic therapists discussing patient cases during supervision (n = 7) resulted in four recurrent themes: "empathy, compassion, and support," "anxiety, feeling overwhelmed, and protection," "frustration, irritation, and confrontation," and "inadequacy, incompetence, and fatalism." We found that these countertransference processes mainly revolved around perceived adaptive and maladaptive aspects of patients' relational functioning. Regarding clinical practice, our study suggests that therapists can use countertransference to determine in which position they are maneuvered by patients, although we caution against the exclusive use of subjectively informed data as a benchmark in the diagnostic and treatment process. We conclude that further in-depth research on countertransference and personality styles is needed to identify pitfalls in the treatment of depression.

Manifestações Contratransferenciais no Processo Terapêutico de uma Paciente com Personalidade Borderline

Resumo Pacientes com transtorno de personalidade borderline (TPB) são tipicamente instáveis e intensos em seus afetos e comportamentos, facilmente despertando reações emocionais negativas em seus terapeutas. Desse modo, manejar a contratransferência é fundamental para a psicoterapia com esses pacientes. Este estudo de caso sistemático visa descrever as manifestações contratransferenciais no processo terapêutico do primeiro ano de uma terapia psicanalítica de uma paciente com TPB, ampliando o conhecimento empírico sobre como a contratransferência interage com as variáveis do paciente. As sessões (n = 59) foram codificadas por duplas de juízes independentes treinados com o Psychotherapy Process Q-Set (PQS), um q-sort de 100 itens que fornece descrição das variáveis do paciente, do terapeuta e da interação terapêutica que caracterizam o tratamento. Experts em psicoterapia psicanalítica selecionaram seis itens do PQS como indicadores de reações contratransferenciais e 12, como indicadores de estados mentais e comportamentos característicos de pacientes com TPB. Esses itens foram examinados em relação ao tempo. Os achados revelam a predominância de atitudes terapêuticas compatíveis com uma contratransferência positiva. As implicações clínicas dos achados são discutidas.

Dropout in schema therapy for personality disorders

Schema therapy (ST) is a relatively new, but promising, psychotherapy approach. Able to be implemented in both individual and group settings, research findings suggest that ST is a highly effective treatment for personality disorders. As in other treatments for personality disorders, some patients decide to drop out from treatment, feeling they did not benefit. To date, there has been no study in the literature that investigates the dropout rates across ST studies specifically. Consequently, this study systematically researched eight different ST studies in which dropout rates were reported. Together, these studies featured both individual and group therapy settings, inpatient and outpatient settings, and different personality disorder diagnoses. The weighted mean dropout rate was 23.3%, 95% CI (14.8-31.7%) across these studies. Although this finding is very similar to those meta-analyses that obtained their dropout rates from different orientations and diagnoses, namely psychotherapy in general, ST’s dropout rates might be significantly lower than studies that included personality disorders in particular.

Emotional Responses to Suicidal Patients: Factor Structure, Construct, and Predictive Validity of the Therapist Response Questionnaire-Suicide Form

BACKGROUND

Mental health professionals have a pivotal role in suicide prevention. However, they also often have intense emotional responses, or countertransference, during encounters with suicidal patients. Previous studies of the Therapist Response Questionnaire-Suicide Form (TRQ-SF), a brief novel measure aimed at probing a distinct set of suicide-related emotional responses to patients found it to be predictive of near-term suicidal behavior among high suicide-risk inpatients. The purpose of this study was to validate the TRQ-SF in a general outpatient clinic setting.

METHODS

Adult psychiatric outpatients (N = 346) and their treating mental health professionals (N = 48) completed self-report assessments following their first clinic meeting. Clinician measures included the TRQ-SF, general emotional states and traits, therapeutic alliance, and assessment of patient suicide risk. Patient suicidal outcomes and symptom severity were assessed at intake and one-month follow-up. Following confirmatory factor analysis of the TRQ-SF, factor scores were examined for relationships with clinician and patient measures and suicidal outcomes.

RESULTS

Factor analysis of the TRQ-SF confirmed three dimensions: (1) affiliation, (2) distress, and (3) hope. The three factors also loaded onto a single general factor of negative emotional response toward the patient that demonstrated good internal reliability. The TRQ-SF scores were associated with measures of clinician state anger and anxiety and therapeutic alliance, independently of clinician personality traits after controlling for the state- and patient-specific measures. The total score and three subscales were associated in both concurrent and predictive ways with patient suicidal outcomes, depression severity, and clinicians' judgment of patient suicide risk, but not with global symptom severity, thus indicating specifically suicide-related responses.

CONCLUSION

The TRQ-SF is a brief and reliable measure with a 3-factor structure. It demonstrates construct validity for assessing distinct suicide-related countertransference to psychiatric outpatients. Mental health professionals' emotional responses to their patients are concurrently indicative and prospectively predictive of suicidal thoughts and behaviors. Thus, the TRQ-SF is a useful tool for the study of countertransference in the treatment of suicidal patients and may help clinicians make diagnostic and therapeutic use of their own responses to improve assessment and intervention for individual suicidal patients.

Translation and cross-cultural adaptation of the Rating Scale for Countertransference (RSCT) to American English

Abstract Introduction: The Rating Scale for Countertransference (RSCT) - originally, Escala para Avaliação de Contratransferência (EACT) - is a self-administered instrument comprising questions that assess 23 feelings (divided into three blocs, closeness, distance, and indifference) that access conscious countertransferential emotions and sentiments. This paper describes the process of translation and cross-cultural adaptation of the RSCT into American English. Methods: This study employed the guidelines proposed by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force for Translation and Cultural Adaptation which define 10 steps for translation and cross-cultural adaptation of self-report instruments. Additionally, semantic equivalence tools were employed to select the final versions of terms used. The author of the RSCT gave permission for translation and took part in the process. The instrument is available for use free of charge. Results: Analysis of the back-translation showed that just seven of the 23 terms needed to be adjusted to arrive at the final version in American English. Conclusions: This study applied rigorous standards to construct a version of the RSCT in American English. This version of the RSCT translated and adapted into American English should be of great use for accessing and researching countertransferential feelings that are part of psychodynamic treatment.

Systematic review of studies about countertransference in adult psychotherapy

INTRODUCTION

Countertransference, the emotional reaction of a psychotherapist toward a patient, is an important technical element of psychotherapy. The purpose of this systematic review was to identify and describe the main findings of studies that evaluated countertransference in adult psychotherapy.

METHODS

A search was conducted of the databases Embase, PubMed, PsycINFO and Web of Knowledge to retrieve data published in any language at any time.

RESULTS

Of the 1,081 studies found in the databases, 25 were selected. Most were about psychodynamic psychotherapy, and results indicated that positive countertransference, that is, feelings of closeness to the patient, are associated with positive outcomes, such as symptom improvement and good therapeutic alliance.

CONCLUSIONS

Although few studies were found in the literature, countertransference seems to be an important source of knowledge about several aspects, such as treatment outcomes, attachment style, therapeutic alliance, patient symptoms and diagnoses.

Stigma towards borderline personality disorder: effectiveness and generalizability of an anti-stigma program for healthcare providers using a pre-post randomized design

BACKGROUND

Stigmatization among healthcare providers towards mental illnesses can present obstacles to effective caregiving. This may be especially the case for borderline personality disorder (BPD). Our study measured the impact of a three hour workshop on BPD and dialectical behavior therapy (DBT) on attitudes and behavioral intentions of healthcare providers towards persons with BPD as well as mental illness more generally. The intervention involved educational and social contact elements, all focused on BPD.

METHODS

The study employed a pre-post design. We adopted the approach of measuring stigmatization towards persons with BPD in one half of the attendees and stigmatization towards persons with a mental illness in the other half. The stigma-assessment tool was the Opening Minds Scale for Healthcare Providers (OMS-HC). Two versions of the scale were employed - the original version and a 'BPD-specific' version. A 2x2 mixed model factorial analysis of variance (ANOVA) was conducted on the dependent variable, stigma score. The between-subject factor was survey type. The within-subject factor was time.

RESULTS

The mixed-model ANOVA produced a significant between-subject main effect for survey type, with stigma towards persons with BPD being greater than that towards persons with a mental illness more generally. A significant within-subject main effect for time was also observed, with participants showing significant improvement in stigma scores at Time 2. The main effects were subsumed by a significant interaction between time and survey type. Bonferroni post hoc tests indicated significant improvement in attitudes towards BPD and mental illness more generally, although there was a greater improvement in attitudes towards BPD.

CONCLUSIONS

Although effectiveness cannot be conclusively demonstrated with the current research design, results are encouraging that the intervention was successful at improving healthcare provider attitudes and behavioral intentions towards persons with BPD. The results further suggest that anti stigma interventions effective at combating stigma against a specific disorder may also have positive generalizable effects towards a broader set of mental illnesses, albeit to a lessened degree.

Assessing clinician's subjective experience during interaction with patients

BACKGROUND

While psychiatric literature has shown renewed interest in fine psychopathological investigation, little study has been devoted to the clinician's subjective experience with the patient, which is highly valued by the phenomenological and psychodynamic traditions. We aimed at developing a valid and reliable instrument to measure such experience.

SAMPLING AND METHODS

First, 104 self-report items were developed, based on daily clinical practice and references from the literature on clinician's subjective experience. Of these, 46 were retained after pilot testing and exclusion of items with poor psychometric properties. Thirteen psychiatrists and 527 first-contact patients participated in the validation study. Psychiatrists completed the 'Assessment of Clinician's Subjective Experience' (ACSE) instrument and the Brief Psychiatric Rating Scale (BPRS) after the visit and the Profile of Mood State (POMS) before and after it. The ACSE was completed again for 60 patients with stable BPRS scores over a short retest interval. Principal component analysis with orthogonal rotation was performed. The internal consistency and test-retest stability of ACSE factorially derived scales were calculated. Convergent validity was tested by examining the correlations between ACSE scores and change in POMS scores during the visit.

RESULTS

Five factors (interpreted as tension, difficulty of attunement, engagement, disconfirmation, impotence) accounting for 57% of total variance were extracted. All ACSE scales showed high internal consistency and stability, and correlated with conceptually related POMS scales.

CONCLUSIONS

The pattern of subjective experience identified by the ACSE is consistent with classical psychopathological descriptions and previous related studies. Despite limitations such as the relatively small number of psychiatrists studied and the exclusively self-report nature of the instrument, this study supports the validity and reliability of the ACSE and suggests that it may be a valuable tool for training, research and possibly diagnostic purposes.

Countertransference in the general hospital setting: implications for clinical supervision

Psychiatry residents completing their consultation-liaison (CL) rotations are implicitly expected to recognize and consider countertransference reactions when offering clinical recommendations. Residents often lack formal guidance in this role, as there exists limited examination of clinical scenarios from a psychodynamic perspective. The authors present a historical review of the literature on countertransference with the medically ill and describe a clinical vignette illustrating the vicissitudes of liaison work. The case involves a psychotic patient with mental retardation and acute renal failure. Through refusal of care and a tumultuous clinical course, this patient elicited various countertransferential reactions from the primary care and CL teams, in turn adversely impacting treatment. The case illustrates how clinicians' failure to collaborate led to hospital administrators having to take on the liaison role. (1) A review of literature corroborates the importance of CL psychiatrists' assistance in the management of countertransference. At the same time, it is notable for a paucity of guidance in teaching these skills to psychiatry trainees. The psychiatry resident-in-training faces challenges and shortcomings in the management of countertransference. Formal training in this aspect of psychiatric consultation is lacking, as evidenced by extant publications. The authors propose future directions for research and teaching, with emphasis on clarifying the liaison component of CL psychiatry and advocating for establishment of psychodynamic psychotherapy training guidelines in the general hospital setting.

Development and initial validity of the Object Relations Rating Scale

The aim of this study was to report on the development and the initial validation of the Object Relations Rating Scale (ORRS), which is a measure of in-session enactments of object relations that draws on a psychodynamic conceptualization of personality organization. Forty participants were included in the study, distributed among neurotic, borderline and psychotic personality organizations (PO). Results showed that the interrater reliability of this new measure is good. Two tests of criterion validity support the validity of the measure: the ORRS discriminates well between the three PO groups and it correlates in expected ways with five PO dimensions. Finally, ORRS scales that pertain to the degree of in-session object relation enactments correlated with a measure of transference intensity (convergent validity), and correlations with therapists experience were low as expected (discriminant validity).

Medical countertransference and the trainee: identifying a training gap

OBJECTIVE

Although consultation-liaison (CL) psychiatrists are implicitly expected to recognize and consider interpersonal dynamics in clinical settings when offering recommendations, few guiding principles have been established, strongly suggesting the presence of a training gap.

METHODS

Trainees in psychiatry residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) were invited to complete an Internet-based, 20-item, Likert scale questionnaire assessing practices and opinions concerning countertransference management and training.

RESULTS

Of 192 respondents, 162 (84%) reported having participated in a rotation on the CL service for at least some period of time and were eligible to complete the survey; 136 (71%) reported having completed at least 2 months of CL rotations. Approximately 80% identified a frequent need to address countertransference reactions when working with primary medical/surgical teams, but less than a quarter reported doing so regularly. The motivation for addressing such issues in over half of the respondents was the belief that it would be "clinically beneficial" to patients, although 40% of respondents also feared that this practice could "worsen the relationship between the CL consultant and the primary team." Regarding training, 95% of respondents felt didactics addressing counter-transference would be "clinically beneficial"; however, three fifths of the respondents reported that "very few" to none of their didactics explored this issue.

CONCLUSIONS

Results of this study suggest that discrepancies exist between trainee perceptions of the utility of countertransference management in CL psychiatry and actual training in this area. The authors discuss possible explanations for these discrepancies and advocate for the establishment of formal guidelines in training CL residents in such aptitudes. (Journal of Psychiatric Practice 2012;18:109-117).

Can countertransference at the early stage of trauma care predict patient dropout of psychiatric treatment?

OBJECTIVES: To investigate the association between feelings of countertransference (CT) at the early psychiatric care provided to trauma victims and treatment outcome. METHOD: The Assessment of Countertransference Scale was used to access CT after the first medical appointment. Fifty psychiatric residents cared for 131 trauma victims of whom 83% were women, aged 15 to 64 years. Patients had been consecutively selected over 4 years. Were evaluated the clinical and demographic characteristics of patients and the correlation with the therapists' CT feelings. Patients were followed-up during treatment to verify the association between initial CT and treatment outcome, defined as discharge and dropout. RESULTS: The median number of appointments was 5 [4; 8], absences 1 [0; 1], and the dropout rate was 34.4%. Both groups, namely the discharge group and the dropout group, shared similar clinical and demographic characteristics. A multivariate analysis identified that patients with a reported history of childhood trauma were 61% less likely to dropout from treatment than patients with no reported history of childhood trauma (OR = 0.39, p = 0.039, CI95% 0.16-0.95). There was no association between initial CT and treatment outcome. CONCLUSIONS: In this sample, CT in the initial care of trauma victims was not associated with treatment outcome. Further studies should assess changes in CT during treatment, and how such changes impact treatment outcome.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.