The interpersonal difficulties experienced by patients diagnosed with a personality disorder (PD) tend to pose great difficulty in negotiating a strong therapeutic alliance between patient and therapist (Muran, Segal, Samstag, & Crawford, 1994; Stern, 1938; Vaillant, 1992; Waldinger & Gunderson, 1984). Patients with PDs often generate intense and uncomfortable reactions in their therapists, sometimes producing iatrogenic therapist behaviors, sometimes referred to as countertransference (Bateman, 1998; Bateman & Fonagy, 2006; Levy, 2013). Forming a strong therapeutic alliance with clients with a PD diagnosis is challenging. For instance, therapists of patients diagnosed with Cluster B (i.e., “dramatic, emotional, erratic”) PDs often rate the alliance negatively, while patients with diagnoses of Cluster A (“odd-eccentric”) PDs may have difficulty establishing a working alliance at all (Lingiardi, Filipucci, & Baiocco, 2005). Furthermore, patients with Cluster B PD traits (e.g., impulsivity, dysregulation, and affective lability) have been found to experience more ruptures in the therapeutic alliance than non-PD patients, even after the relationship has been established (Tufekcioglu, Muran, Safran, & Winston, 2013), while patients diagnosed with Cluster C (“anxious-fearful”) PDs may not display more ruptures than other patients, but may take significantly longer to experience a repair of these ruptures, specifically in less interpersonally based treatments (e.g., CBT versus brief relational therapy; Lipner, Muran, Zilcha-Mano, Eubanks, & Safran, 2017). Given the interpersonal complexities associated with each cluster of PDs, some have suggested unique modifications to maintain an alliance with different presenting concerns. For instance, when working with patients with Cluster B traits, therapists may do well to be mindful of crossing interpersonal boundaries to avoid colluding with the poor boundary setting common among these patients (Bender, 2005; Levy in Magnavita, Levy, Critchfield, & Lebow, 2010). Directly addressing ruptures in the alliance when they occur has also been shown to improve outcome in psychotherapy for patients with PD diagnoses in Clusters B and C (Muran, Safran, Samstag, & Winston, 2005).

Given that working with patients with PDs presents a unique relational challenge, and that therapists may experience confusion, discomfort, or negative countertransference when treating these patients, we aim to provide an empirically contextualized clinical case example from a group psychotherapy with a PD patient (conducted by the first author). We focus specifically on areas of difficulty in fostering an alliance, the ability to repair alliance ruptures, the importance of developing empathy, and a willingness to tolerate difficult emotions in therapy. We point out specific therapeutic maneuvers, deriving from an alliance-focused treatment approach, that may help clinicians when working with patients with personality difficulties.

Patient Narrative: Vincent

Note: Client information has been de-identified to protect patient confidentiality.

Vincent is a 63-year-old, White, heterosexual male who was a member of an interpersonal process group co-lead by the first author. He had been a member of this group for three year when I joined the group, alongside a female co-leader. The group consisted of Vincent and three other female group members. He was initially referred to the group by his individual psychotherapist, with the goal of building upon his limited interpersonal skills and his ability to develop relationships, particularly with women.

Vincent’s presentation is complex and regularly evokes feelings in me of being overwhelmed and confused. Vincent was initially described to me as being “terrified of women.” This came to life early on, as I learned that, due to past experiences, Vincent develops strong, eroticized, reactions (or “transference”) to female group leaders and therapists, particularly when they are young and blonde—two criteria I met. In addition, Vincent presents at times as feeling hopeless and suicidal (e.g., “What’s the point to all of this?”). Alongside his depressed presentation, he exhibited significant Cluster B personality pathology in terms of suicidality, fear of abandonment, provocative statements to therapists, dissociative experiences, and so forth, as well as some dependent and avoidant features.

One likely contributor to the diametrically opposed feelings Vincent experiences towards women, fear and desire, is likely the extreme traumas he reported from his childhood. During the course of group, Vincent revealed that he had been sexually abused as a child by several women. Though these experiences may not be the sole explanation of Vincent’s psychopathology, it is understandable given his early traumatic experiences, which influenced the complexity of his feelings towards women. He has learned to fear them tremendously, and that he must be submissive to them, particularly towards women in roles of power (e.g., his therapists). At the same time, he longs to be able to “touch a cheek,” “be held,” or receive any physical contact he can from women. He has expressed in group a wish to “be submissive” to my co-leader and me, to “get on [his] knees, kiss [our] feet, and just worship [us].” This eventually led to his explicitly describing how attracted he was to me, while reassuring me that he would never do anything to threaten our professional relationship. Even more complex is his anger towards women for “doing what they did to me,” which manifests in secret violent fantasies that he did not share in the group, only in individual therapy. His admissions of attraction and desire to be submissive to me made me feel uneasy, and unsure of what to do or say. At the same time, I found myself able to empathize with his current difficulties given an awareness of his difficult childhood, which was an important factor in my ability to work effectively with Vincent in the face of feeling at times overwhelmed by his way of relating.

The impact of empathy—a moment of understanding. Vincent’s complex transference towards me did not develop immediately. In fact, during the first months of my joining the group as a co-leader, he would make statements frequently such as, “I look at [other co-leader] as completely, 100% dominant,” and then turn to me and say, “and I don’t know you yet, Lauren, but I’m sure you’ll get there.” During a group session approximately four months into my joining, Vincent was having difficulty explaining the paradoxical reaction he had to a phone call he had made to me, stating that he would not be able to come to group that week. My response over the phone was simply, “All right, no problem—see you next week.” To my surprise, he expressed in the following group feeling extremely disappointed by my reaction, stating that, in his experience, care for him was expressed through anger. The other group members were puzzled by the explanation of his reaction to my relatively mundane response, particularly why he wanted me to be angry with him, even though that would simultaneously upset him. I took this opportunity to jump in, and rephrase what I understood Vincent’s feelings to be to the group: “I think what Vincent is saying is that by not reacting in an angry or frustrated way that he would not be able to attend group, it seemed as if I did not care whether he came to group or not. But, if I had gotten angry and berated him for not coming, he would know that his presence in group mattered to me, even though he would feel badly that he had angered me.” Although Vincent initially did not respond to my comment, at the next group he stated: “There are very few people that I believe really, truly understand me. My therapist is one of them, but from what you said last week, I see that you also have her ability to peel my layers like an onion. I am so appreciative of that, but it’s petrifying.” It was at this point that Vincent had begun to see me as another dominant figure in the room, laden with feelings of fear and attraction.

My ability to find aspects of Vincent’s experiences with which I could empathize, in spite of my own challenging reactions to him, was crucial in allowing an admittedly complex alliance to begin to form between the two of us. While my initial comment on the phone (i.e., “no problem”), meant to assure him that missing group was okay, was experienced as upsetting and invalidating for Vincent, in my rephrasing of his conflictual feelings, I demonstrated that I understood him and his experience from his point of view. This led to his both recognizing me as a dominant force in the room, but also seeing me as a trusted protector. Though his transference appeared to be activated by this comment, becoming both fearful and enamored of me, this moment served to open up the space for work with his transference, which had not previously been a possibility. The use of interventions that capture the totality of a patient’s experience, rather than simply trying to assuage or reassure the patient, are an essential ingredient in both maintaining therapeutic alliance and opening the door to further exploration of the patient’s challenging and distressing experiences (e.g., Clarkin, Yeomans, & Kernberg, 2006).

Addressing the therapist’s difficult reactions. Although I am able to empathize with him, there is no doubt that Vincent’s expressions of his feelings towards me make me uncomfortable. How is one to respond to statements such as, “I would love to just kiss your feet”; “I’d give anything to touch your cheek”; “I would love to serve you, to get on my hands and knees and worship you”? Interestingly, Vincent experienced intense remorse after making such statements, and expressed fear of having destroyed the relationship as a result of behaving inappropriately. Vincent was right that these statements did make it challenging for me to work with him and potentially threatened our working alliance. This dynamic is characteristic of that experienced by many therapists of patients diagnosed with PDs, which may lead to negative reactions or behaviors on the part of the therapist, such as not rescheduling patients who miss appointments (Bateman, 1998; Levy, 2013). Clearly an awareness of these dynamics is vital in order to address them, and requires therapists to be attuned to their own emotional responses to their patients. In these moments, I had to make a decision: Do I forbid Vincent from sharing these thoughts, feelings, and fantasies with me and pretend as if they do not exist in order to decrease my own uneasiness? Or do I withstand my own discomfort and allow for him to bring up these complex emotions so that we can explore them in the therapy? I consistently aimed for the latter, which, while it was incredibly difficult—as it left me vulnerable in front of the group—in fact allowed for some of Vincent’s feelings to lessen in intensity as he was able to put words to the conflict he experienced regarding both desiring and fearing closeness with me.

One group session, I arrived dressed in a black sweater dress, black tights, and tall black boots. The group began as usual, each member providing us with a quick update. As Vincent took his turn to speak, his storytelling grew increasingly convoluted and difficult to follow. When another member asked him for clarification, Vincent suddenly stopped, looked at me, and said “I have a real problem with tall, black boots.” I was suddenly hit by the realization that my outfit resembled to him that of a dominatrix, and perhaps those he had interacted with in clubs many times in the past. Immediately, I clapped my hand to my mouth, feeling exposed and ashamed. I felt guilty for having been so thoughtless as to wear something so clearly triggering for Vincent. Before thinking further, I blurted out, “I’m so sorry, Vincent. I will keep this in mind going forward, and would never intentionally do or wear something to make you uncomfortable,” a feeble attempt to erase the moments that had just occurred. I spent the rest of the hour tucking my feet under my chair as far back as they would go.

In retrospect, this moment provided a missed opportunity to explore Vincent’s dynamics. In my impulse to allay my own shame and discomfort, I quickly apologized and promised not to repeat the mistake. However, had I been prepared to withstand the uncomfortable feelings evoked in me, I could have asked him what my boots meant to him, or to take an even larger risk, I could have noted that I would likely wear them again and ask what his reaction to this might be, or even gently inquiring of him his sense of how his comments might make me feel. Rather than further increasing my sense of shame and guilt as my apologizing had done, any of these scenarios could have prompted Vincent to acknowledge my own subjective experience, to come to a clearer understanding of his own experience, and increase his awareness of his role as a member of a therapeutic dyad. Though this would have been difficult for Vincent, I imagine it would also have been consoling to learn that our relationship would not fall apart, nor would he be punished, for expressing genuine thoughts about me, even if they were uncomfortable for the two of us.

Five Specific Recommendations

In summarizing the case above, we reiterate several treatment principles that have also been proposed in the literature for working with patients with PD diagnoses, specifically regarding building and maintaining an alliance, generating empathy, and addressing the therapist’s own difficult feelings in this work:

1. Early diagnostic assessment for PDs can aid the therapist in being prepared for difficult interpersonal dynamics in therapy.
2. It is important to understand the developmental history of PD patients in order to empathize with challenging behaviors, anger, attraction, etc., that they may display in therapy.
3. The most empathic comments for a patient are often those that capture the conflicts or dilemmas that they experience, rather than simply aiming to reassure an explicit (often surface-level) concern that they share.
4. Therapists working with challenging patients must pay attention to their own emotional responses to their patients, as these can negatively influence the work of therapy and can also be important tools for exploring the patient’s own inner world and effect on others.

Dynamics between therapist and patient that risk destroying the therapeutic alliance or effective psychotherapy must be addressed appropriately and gently, rather than ignored or reflexively acted upon.

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Lauren M. Lipner, Ph.D.

Lauren M. Lipner graduated from Adelphi University with her Ph.D. in clinical psychology in May 2020, after completing her pre-doctoral internship at Pennsylvania Hospital/University of Pennsylvania Health System. At Adelphi, she worked under the mentorship of Dr. J.C. Muran, and worked closely with Dr. Catherine Eubanks, Dr. Jeremy Safran, Dr. Bernard Gorman and Dr. Jacques Barber to develop her research interests in methodological inquiries into the identification of ruptures in therapeutic alliance. She recently began her post-doctoral research fellowship at the Brief Psychotherapy Research Program at Mount Sinai Beth Israel in New York City.