The interpersonal difficulties experienced by patients diagnosed with a personality disorder (PD) can pose difficulty in negotiating a strong therapeutic alliance between patient and therapist (Muran, Segal, Samstag, & Crawford, 1994; Stern, 1938; Vaillant, 1992; Waldinger & Gunderson, 1984). 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 should 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 can present a unique relational challenge, and that therapists may experience confusion, discomfort, or negative reactions (sometimes referred to as “countertransference”) when treating these patients (Bateman, 1998; Bateman & Fonagy, 2006; Levy, 2013), we provide several empirically and theoretical grounded techniques that may help both new and experienced clinicians to navigate the therapeutic relationship with these patients. 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 with clinical material to contextualize these therapeutic suggestions.

Technique #1: Assess Early

Early diagnostic assessment for PDs can prepare the therapist for difficult interpersonal dynamics in therapy. Differential diagnosis can be especially important prior to treatment to alleviate the roadblocks of developing and maintaining a strong alliance. Is the patient experiencing posttraumatic sequelae of complex trauma? Or are they displaying features of a longstanding borderline personality disorder? Or both? An initial assessment providing such knowledge not only allows appropriate treatment referral, but it also enables the therapist to know where to direct interventions and understand patients’ complex presentations.

Case Example: Alex

“Alex” presented to outpatient treatment referred from the state hospital after a four-year stay in its psychiatric unit. She presented with severe distress associated with several childhood and adult sexual abuses, along with dissociative experiences she referred to as “blacking out” and hearing voices telling her to kill herself. Upon the completion of a complex intake process, prolonged by several hospitalizations, from which Alex received diagnoses of posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), recurrent major depression, and a rule-out schizoaffective disorder, she began individual dialectical behavior therapy (DBT) with the first author.

During her first session, she expressed her goals for treatment: “I want to talk about being raped. I want to focus on my PTSD.” This request immediately created a dilemma in the therapy: We could tackle her trauma, which clearly continued to cause her significant distress, but wouldn’t exposure therapy be too overwhelming for her because of her lack of effective emotion regulation skills and suicidality? I discussed this dilemma with Alex and, knowing that Alex experienced both PTSD and BPD, was able to simultaneously empathize with her desire to conquer her posttraumatic symptoms and with the need to first shore up her ways of coping with intense distress before doing so. We agreed to pursue PTSD treatment as a second phase of therapy, and first to begin with Distress Tolerance and Emotion Regulation DBT skills until Alex was able to effectively tolerate her emotions without becoming suicidal or needing hospitalization (Harned, Korslund, Foa, & Linehan, 2012). Clear and accurate diagnostic information, though it took months to obtain, was vital for me to be able to both understand Alex’s goals of addressing her PTSD and still engage in the necessary preliminary work that would allow us to successfully do so, rather than jumping into a treatment that may have proved debilitating for Alex.

Technique #2: Understand Development

PDs are longstanding disorders, often with complex and multifaceted origins. Models of personality pathology tend to reflect both genetic risks combined with environmental stressors (e.g., Linehan, 1993). As a result, it is important to understand the developmental history of PD patients in order to empathize with concerning behaviors, anger, attraction, and other challenging reactions that they may display in therapy or their everyday lives.

Case Example: Lynn

“Lynn” presented to treatment with depression and dissatisfaction in her marriage and relationships with others. She was married to an intellectually disabled man whom she cared for as a parent, rather than a spouse, shopping for him, telling him which friends he could and couldn’t have, and driving him to and from work every day. At work (a retail store) she similarly demanded of her coworkers perfection and was very frustrated if they did not follow the store manual flawlessly or appreciate her contributions and efforts. Similar to her difficulty in reflecting on her own imperfections, in session with me she would deflect discussion of her internal experience and repeatedly bring us back to superficial discussion of her frustrations with others. This concreteness clearly interfered with our goal of deepening her satisfaction in relationships and at work and made it difficult for me to empathize with Lynn’s frustrations with others.

One day, Lynn came into session saying that her youngest daughter, whom she had not spoken to in 20 years, had reached out to her over email. Lynn began to describe to me, tearfully, the context of their non-existent relationship. She had had four children early in life, only one of whom, her youngest son, still talked to her. Her second youngest, the daughter mentioned above, had been taken from her care at age two over two decades ago because Lynn had not been able to provide for her special needs. Her two oldest children moved in with their father, who was separated from Lynn, at a young age.

With the backdrop of her developmental history, we relabeled her controlling behaviors as “caregiving to a fault”, driven by a wish to rectify a history of failed caregiving experiences. Her narcissistic demands for recognition and respect from others and her need to control interpersonal interactions and to take care of others to the point of fighting with them both pointed to a drive to be needed, to be seen as able to provide for others, of which she felt she had always fallen short. My having seen the developmental context of Lynn’s current interpersonal style allowed us to develop a shared language that promoted compassion for Lynn (both my own and hers for herself) and moved us towards new ways to meet her needs without damaging her relationships.

Technique #3: Empathize With All Sides

There is almost nothing more natural than wanting to reassure a demoralized patient. Yet, often the most empathic comments are those that capture the patient’s conflicts or dilemmas, rather than simply aiming to reassure an explicit (often surface-level) concern. PD patients often have difficulty understanding themselves or their wishes and goals. Being able to hold a patient’s opposing opinions and reactions simultaneously and gently explore with them their disparate experiences of themselves, the world, or their desires can be validating and empathic at a deep level. Yet this process can be challenging and even punishing, in the short term, to the therapist.

Case Example: Vincent

“Vincent”, a man displaying Cluster B PD traits, as well as some dependent and avoidant features, was a member in a group therapy conducted by the second author. Vincent had experienced a significant trauma history, revolving largely around sexually abusive women who were also responsible for his care, leaving him with significant ambivalence around being seen by female therapists.

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, in which he had stated 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 and seemingly disappointed that I had not been angry with him. The other group members were puzzled by his reaction to my relatively mundane response, and particularly why he apparently wanted me to be angry with him, even though he also noted that my being angry would simultaneously have upset him. I took this opportunity to 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.”

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. 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. However, in my rephrasing of and capturing his conflictual feelings, I demonstrated that I understood him and his experience from his point of view. 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).

Technique #4: Address One’s Own Reactions

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 when not addressed and may even lead therapists to behave in ways that are counter-therapeutic. However, the therapist’s reactions to a patient can also be an important tool for exploring the patient’s own inner world and their effect on others. For instance, a therapist may feel a sense of relief when a difficult and generally irritable patient no-shows a session, leading the therapist to not call to reschedule as they would for a different patient. Such therapist “enactments” may be quite subtle, such as refraining from speaking to a very talkative patient for fear of upsetting them, or becoming sleepy in session with an anhedonic and lethargic patient or even when feeling frustrated by a patient. Notably, PD patients especially frequently evoke difficult feelings on the part of the therapist. Supervision and consultation are often key to a successful therapy with PD patients, to address therapists’ reactions and prevent both negative therapist behaviors and reduce burnout (e.g., Clarkin, Yeomans, & Kernberg, 2006; Linehan, 1993; Levy in Magnavita et al., 2010).

Case Example: Brady

The second author’s work with “Brady,” a man with BPD and diabetes, captures some of the challenging reactions therapists often have in response to PD patients. Although my emotional response to working with Brady shifted over time, as I will describe below, I regularly felt confused with him, a feeling that seemed to stay with me long after our sessions ended. At first, this confusion was tied to why Brady was seeking treatment in the first place; he spent the first couple months of therapy discussing seemingly nothing: what he had bought when he was out shopping, the party he was planning to attend that weekend, or his plans to pick up his friend after work that day. Soon, I noticed that I was beginning to dread our sessions, and became annoyed with him, as he seemed to have nothing to discuss that affected his life in any real way. I also found myself becoming very sleepy during his ramblings, and I was frustrated with him when he did not attend session without prior notice, which happened frequently. I became further confused after learning of his diabetes, and yet he would discuss the cinnamon buns, cookies, cupcakes, and sugary beverages he would regularly consume. When I would ask about this, he would be quick to add that he only used Equal to bake or sweeten his coffee, that he would request for “half sugar” when he was out, or that his blood sugar had been stable recently so he was not concerned.

Eventually, after the most recent description of his latest favorite movie, I finally asked whether he felt he needed to continue psychotherapy, given that we had had several months without him expressing any concerns or distress in his life. Brady appeared shocked and hurt by my question. Therapy, he said, provided him a sense of safety if something bad were to happen in his life. Did I not realize our sessions were essential for him to not slip back into depression and suicidal thoughts? I immediately recognized that my comment had been driven in large part by my own feeling fed up with Brady. Of course he still needed therapy, his relationships were few and relatively superficial, his medical conditions were a constant plague for him, and he was desperate for support and care from others in his life, including me. I became instantly aware of how my confrontations had recently become marked by a skeptical and accusatory tone, and even my face as I sat across from Brady would sometimes twist into an expression of confusion or disbelief. I felt it was possible that my subtle reactions might in part have been contributing to Brady avoiding serious discussion, for fear of my truly reacting negatively or dismissing him if he was to actually talk to me about true concerns in his life.

I immediately sought out supervision about my work with Brady and my supervisor suggested I focus on the process, rather than content, of our work together. I began helping Brady to acknowledge his behaviors that functioned to keep people, including myself, at a distance, and improve his ability to communicate his genuine emotional experience, as well as to articulate how he relates to his interpersonal relationships, and how deeply they affect him. I was even able, at times, to gently share with him more of my own experience and reaction to him, to point out to him how confused I felt at times by his meandering stories, or how frustrating it was to feel as if I did not have a good understanding of him at all at times. We began to develop a deeper connection and Brady began to share more personal concerns about his interpersonal world and lack of close friendships.

Technique #5: Lean In To the Rupture

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. Although it can feel a daunting task to discuss a patient’s angry feelings towards the therapist, or to dive into a patient’s feelings of hopelessness about ever getting better, such acts can be highly therapeutic and facilitate effective therapy. In fact, significant research suggests that while untended ruptures in therapy may risk the success of a treatment or even contribute to premature dropout (Muran, et al., 2009), resolved ruptures are opportunities for progress and growth in therapy (Eubanks-Carter, Muran & Safran, 2010). Yet, noticing and addressing therapy ruptures is not always straightforward or simple and can require several sessions of careful monitoring and subsequent addressing.

Case Example: Christina

After about a year of transference-focused psychotherapy with the first author, “Christina,” a patient with a history of bipolar disorder and significant BPD features, came to session clearly with some amount of anxiety. She seemed inhibited in her conversation with me and eventually, about halfway into session, said she wanted me to read something she had written in her journal. Noting her apparent anxiety, before agreeing I wondered what her concerns might be about reading her journal entry. “You’ll know when you read it”, she said, mysteriously. I then agreed, but she told me she wanted to step out of the room as I read because it would be too uncomfortable to sit and watch me. As she stood up to leave, she hesitantly handed me her open journal and quickly left the room.

I soon learned through her writing that she had romantic feelings for me. When she returned, she sat down and couldn’t look at me. “Can I ask what’s going on for you right now?” I queried. She described feeling completely embarrassed and ashamed, to the point of asking if she could see a new therapist or even might have to drop out altogether. As the session ended, in a way that felt premature to me, she dismissed these feelings, noting: “I’m glad I said it, I’m over it now. We can keep working together.”

After consultation with my supervisor, I met with Christina again. I wanted very much not to distress my patient by talking more about her feelings towards me—after all she had ended our previous session saying things were fine. But were they? What about her wanting to end therapy moments before? My supervisor noted that Christina’s expression of interest in me was actually an important lens into her broader desires regarding relationships and that exploring these feelings in the context of the therapy relationship was actually quite important. With this in mind, in my next session with Christina, I asked her how she was feeling about our previous session. She said she felt very uncomfortable and awkward about what she had shared. I continued by gently wondering if we could talk about what her interest in me might reveal to us about her wishes from others in relationships more generally. This began a fruitful conversation about how she did not feel she could share deep feelings or concerns with anyone else in her life at present except myself, and how much she wished to have relationships with others that had the depth and vulnerability she was able to experience with me. In returning to and engaging in this conversation with Christina, I both showed her that her thoughts and feelings were not things to be avoided, and confirmed for her “feelings are not facts,” which opened up a productive vein of our work together in which we explored her desire to be heard and understood in relationships and her own tendency to not share herself with others, for fear of being judged.

Summary

There is no doubt that working with patients with personality disorders presents unique challenges that can make building a strong therapeutic alliance challenging. While they are by no means comprehensive, the five techniques that we have outlined may help therapists to navigate the sometimes complex therapy relationship and, as a result, improve the effectiveness of therapy. Early diagnostic information may facilitate treatment targets and identifying shared goals. Exploring patients’ developmental history can increase understanding and shared language. True empathy often consists of capturing the internal conflicts a patient experiences, leading to a feeling of being truly understood on a deeper level. Therapists’ reactions merit their own consultation and can be important sources of information in the therapy. And finally, when ruptures inevitably occur, addressing these directly, albeit gently, can be essential for continued growth. We hope these techniques will prove helpful to novice and expert therapists alike, as they have in the course of our own work as therapists.

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Benjamin N. Johnson, M.S.

Ben is a graduate student in the Clinical Psychology PhD program at Penn State University. He was born in CA, but spent most of his life in the sunny South, near Atlanta, GA. He received his B.A. from Emory University in 2012 with a double major in Psychology and English. Afterwards, he spent two years as a Research Coordinator in the Emory Child and Adolescent Mood Program working with adolescents and young adults with symptoms of borderline personality disorder (BPD). His current research focuses on identifying subtypes of BPD and understanding the heterogeneity in this disorder. His recreational interests include cooking, writing, playing piano and guitar, and being barefoot.