When we talk about the therapeutic relationship , we also talk about the emotional experiences and mental representations that the clinician experiences in front of the patient.
This peculiar element of the psychotherapy setting has been conceptualized in different ways within the most well-known theoretical-methodological models: the authors spoke of countertransference (Racker, 1957), projective identification (Ogden, 1982) or interpersonal cycles (Safran, 1984) .
Beyond the terminology, these constructs share the central idea that part of the therapist’s internal experience in the session derives from the patient’s relational patterns and that knowing and modulating this internal experience contributes to determining the quality of the process and the outcome of the treatment. , and that this is especially true when there are personality disorders or severe symptoms of axis I. But what are the factors that can influence the emotional responses of the psychotherapist ?
Some empirical studies of the last decade have identified typical patterns of emotional response of the therapist in the session and then evaluate the relationship with the pathological personality patterns found in patients.
The results indicated a correlation between personality disorders of Cluster A and reactive patterns of a critical / mistreating type, between cluster B and emotions of impotence, hostility, detachment and oppression and finally between pictures of the patient’s Cluster C and warm and protective emotional patterns. of the therapist (Betan et al., 2005).
In a recent Italian survey (Colli et al., 2014) even more detailed data emerged according to which patients with paranoid or antisocial personality disorder tend to elicit critical or abusive responses while subjects with borderline personalities induce feelings of helplessness in the therapist or hyper-involvement.
Responses of inadequacy and impotence were also frequent in front of subjects with schizoid personalities while the hyper-involvement reactions were also induced by patients with obsessive-compulsive personality . Finally, if on the one hand schizotypic patients correlated with distancing and rejection reactions of their therapist, on the other hand positive countertransference emotions were instead significantly associated with subjects with avoidant personalities .
Parallel to this trend, other authors (Rossberg et al., 2010) have investigated the relationship between the severity of the patient’s symptoms and countertransference emotions, finding a positive association between the entity of the symptomatology and feelings of inadequacy and rejection experienced by the clinician during psychotherapy. .
The countertransference reactions of trust were also found to correlate in a negative way with the severity of the psychopathology of axis I. Only recently an interesting investigation (Lingiardi, Tanzilli & Colli, 2015) has evaluated what relationship may exist between all the aforementioned elements, hypothesizing, in particular , that the severity of the patient’s symptoms can be considered a variable capable of mediating the relationship between the psychopathology of the patient’s personality and the therapist’s negative emotional reactions.
The authors – taking into consideration a sample of 198 Italian psychotherapists with different methodological approaches – actually confirmed many of the previous research data, finding significant associations between the level of entity of symptoms and the degree of negative emotional responses of therapists such as: frustration, impotence, inadequacy and above all overwhelming / disorganization.
Furthermore, the clinicians reported intense countertransference reactions of apprehension and fear capable of hindering the management of the therapeutic relationship, and these reactions were shared by all professionals, beyond the reference psychotherapeutic approach and independently of other variables of the therapist (age, gender, level of experience).
The hypothesis that the extent of symptoms could mediate the relationship between the patient ‘s personality disorder and elicited emotions in clinicians has been only partially confirmed.
While for some disorders (dependent, narcissistic, schizoid, paranoid, antisocial and obsessive-compulsive) the mediating role of symptoms was totally absent, when the patient was affected by a schizotypic, borderline, histrionic and avoidant personality disorder, the severity of the symptoms the probability of negative countertransference reactions increased, even if the symptoms appeared to be a partial and moderate impact mediation role (on average 30%).
The only exception was that of borderline personality disorder for which the presence of symptoms seemed to play an important role in its association with the therapist’s feelings of helplessness or overwhelming / disorganization: in this case, in fact, the severity of the symptoms more that the personality structure that elicited the countertransference (accounting for 58-63% of the total association).
In conclusion, the line of investigations carried out on the association between the patient’s psychopathology (axis I and axis II) and the therapist’s emotions during treatment confirmed the presence of a significant correlation between these elements. However, the main limitation of these studies was that they only evaluated a linear association model, when – by definition – two subjects in a relationship influence each other.
Future research could include more complex analyzes of the therapeutic relationship where countertransference reactions and symptomatology are considered to be variables within a very complex and equally fascinating circular system.