Personality disorders: Managing clinician reactions
All primary care providers should be aware of the concept of countertransference. Strictly speaking, countertransference is the reaction a clinician has to a patient that mirrors significant past conflicts the clinician has experienced. However, it is a good idea for clinicians to consider all the reactions that patients evoke.
Sometimes the first diagnostic signal that a patient may have a personality disorder is when the clinician sees the patient's name on the schedule and thinks, "Oh no, not again, so soon." This should be a flag to the clinician to review whether the patient may have a personality disorder that has been overlooked.
The patient with a personality disorder may be someone who by virtue of their temperament and difficulties commonly induces negative feelings in the clinician. Understanding those feelings helps the clinician to understand the patient's dynamics.
Being aware of these negative feelings also helps clinicians to avoid treatment mistakes that can occur when they do not recognize these feelings:
- Inappropriate medication: Clinicians who do not understand their reactions risk either underprescribing medication (by not diagnosing a comorbid diagnosis) or overprescribing medication (to quell behaviours the clinician finds disturbing).
- Frequency of therapy: Countertransference can affect whether patients are seen regularly, too infrequently or too often. These patients can elicit rescue fantasies and we may see them more often than we are comfortable with, or too rarely for them. The appropriate frequency is sometimes not as often as the patient wishes and not as infrequently as the clinician wishes.
- Clinical reactions: Failing to recognize feelings such as irritation can subtly colour the clinician's reactions in therapy. Some patients respond to slight modulations in tone or hesitation in responding to comments by overreacting and disrupting treatment. Others who feel that the clinician has passed different tests they have set for them never want to leave that clinician and may develop dependence on them, which poses its own counterreactions.
Unrecognized clinician reactions may cause boundary violations. These violations exist on a continuum, from excess sessions, excess medications and favours (i.e., writing letters of support that are not consistent with the clinical facts), all the way to sexual boundary violations. Patients with personality disorders, because of their complicated histories and needs, are overrepresented among patients who become involved with their health care providers.
Such involvements may reflect different psychodynamics. However, the crucial point for primary care providers is to maintain strict boundaries. Doing things they do not do for other patients is an early sign that there are boundary issues that require attention. It is best for clinicians to see their role as a "coach" – stay on the sidelines and do not get in the game (Gutheil & Alexander, 1992).
Borderline personality disorder: recognition and management (NICE guideline CG78, 2009)
Antisocial personality disorder: prevention and management (NICE guideline CG77], 2008)
Clinical Practice Guideline for the Management of Borderline Personality Disorder (National Health and Medical Research Council, 2012)
Treatment guidelines for personality disorders (Project Air, 2015)