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SPECIAL

ARTICLES

An Overview
With

Borderline
0.

GLEN

Successful
ence

is critical

common

author

in such

must

constantly

tions

from

aspects

and

patients

that

patient.

conceptual-

their

relationships

of countertransference
behavwr.

be-

from

therapists
own

contribu-

as well as the
evoked

by the

Countertransference

of borderline

the psychotherapy

creation

It follows
that

monitor

en-

A theoretical

as a joint

framework

past

the most

reactions

is also proposed

therapist

of border-

discusses

treatments.

izes countertransference
conceptual

I feel used, manipulated,


abused,
and at
the same time I feel responsible
for her
feelings
of rejection
and threats
of suicide, or feel made to feel responsible
for
them because
I dont have time for her
and dont choose
to be/cannot
be always
available
as a good object, nor as a standby part object.
She has hooked
me into thinking
love and friendship
will heal her, as if
there were nothing
wrong with her but
rather
it was all of the people
in her life
who were the problem.
Then I come up
with
fatherly
friendship,
and her control
begins.
She tells me, in different
ways,
that I am different
from the others. And
just when Im basking
in good objectivity, she really
begins
to control
me
by

of countertransfer-

to the psychotherapy
The

framework

this

M.D.

countertransference

countered

Patients

GABBARD,

management

line patients.

tween

of Countertransference

in

patients

must

be viewed
as a source
of valuable
diagnostic
and therapeutic
information
and not simply
as interference

with

the therapeutic

process.

telling

me

I dont

care: I see
I know you

watch.
you

have

night.

that

a life

You

s this

Im

out

dont

just

like

you
want

to

there.
care.

quotation

treat

gram

tend

to

Nobody

overwhelm

Received
May
15,

JOURNAL

OF PSHOTHERAPY

of agents,

April
1992.

Kansas

University

Address

reprint

brief

School

AND RESEARCH

papatients
disor-

clinicians

who

treatment
proincludes
individpsychoanalysis,
with any one
or extended

of Medicine,
to Dr. Gabbard,

14,

1992;
Clinic
Topeka,
The

P.O. Box 829, Topeka,


KS 66601-0829.
Copyright
1993 American
Psychiatric

PRACTICE

a long

a borderline

1, 1992; revised
May
From
The
Menninger
requests

I know
be

cares.

the

or

that

conveys,
personality

them.
A comprehensive
for such patients
often

a number

Clinic,

leave.

from

ual
psychotherapy
adjunctive
pharmacotherapy

rest,

at your

It will

tients
therapist
vividly
suffering
from
borderline
der

the

looking

of

hospi-

accepted
and
the
Kansas.
Menninger
Press,

Inc.

COUNTERTRANSFERENCE

talization,
family
group
psychotherapy.
cific form
transference
successful

the
with

to

course

the

potential

patient
and
skillful
management
is only
one
aspect
approach
it constitutes

the

patient

of treatment

both

on which
The

therapy,
of the

and
spe-

treatment,
however,
countercan be a major
impediment
to
therapeutic
efforts.
The treaters
reactions

through

marital
Regardless

of

emotional
pest

or

like

to create

a tem-

havoc

for

therapist.
Although
the
of countertransference
of an overall
treatment

to borderline
personality
the foundation
of the
all other
primitive

sweep

efforts
defenses

disorder,
treatment

will rise or fall.


of borderline

pa-

tients,
particularly
splitting
and
projective
identification,
produce
a kaleidoscopic
array
of complex
therapeutic

and chaotic
transferences
setting.
As these varying

in a life-and-death
struggle.2
Some
have even suggested
that counter-

transference

reactions

may

be

the

most

able guide
to making
the diagnosis
derline
personality
disorder.3
These
make
us come
alive
in a specific
heightens
our awareness
rience
of driving
over
narrow
Because

two-lane

they

reli-

of borpatients
way that

much
like the expea mountain
pass on a

road
without
a guard
rail.
are so sensitive
to the therapists

choice
of words
and nonverbal
nuances,
are able to evoke
a sense
of walking
on
shells,
narrow
impact,
their

they
egg-

as if our margin
of error
were
very
indeed.
Yet, in spite of this untoward
they

somehow

therapists4

and

become
inspire

special

to

a surprising

op-

timism
despite
a host of pessimistic
prognostic signs.3
Therapeutic
zeal
rises
like
a
phoenix
from the ashes
of previous
failures.
Borderline
patients
seem to have the peculiar
ability
to inflict
suffering
on their

a specific
therapists.

selves

throughout

and

have

suffered

it is important

to

them

form of sweet
They
themto

BORDERLINE

PATIENTS

therapists
suffer
for them.5
They
mand
that the therapist
abandon
sional
therapeutic
to treat
them
Searles6

has

role: anyone
must
share
in
cautioned

that

simply
not
borderline

applicable
patients.
S

of

E C I F I C

COUNTERTRANSFERENCE

R
Controversy

over

A C

the

1 0

diagnosis

of borderline

personality
disorder
persists
troduction
of this category
years ago. The first systematic
of the disorder
by Grinker
that

borderline

despite
the ininto DSM-III
12
empirical
study
et al.7 suggested

personality

disorder

trum
that ranges
from
the
neurotic.
Kernberg89
argued
line

concept

is really

is a spec-

psychotic
to the
that the border-

a personality

organiza-

tion rather
than a specific
nosological
entity.
A variety
of different
personality
disorders,
including

paranoid,

antisocial,

schizoid,

fantile,
narcissistic,
and cyclothymic,
be subsumed
under
the overarching
ganization.
Gunderson,#{176}

on the

to identify

discriminating

distinguish

borderline

from

other

et al.
Kernbergs

related

Axis

classic

psychoanalytic

#{149}
WINTER

borderline

1993

Abend
about
of bor-

the successof such patients


technique

posed

that

would
disorder

II conditions.

by documenting
treatment

sought

that

personality

their

hand,

criteria

in-

all could
ego or-

raised
serious
questions
diagnostic
understanding

derline
patients
ful psychoanalytic
with

other

have

NUMBER

attenin the
Theraob-

to the psychotherapy

lives,

#{149}

traditional

jective
role vis-#{224}-visthe borderline
patient
are at risk of projectively
disavowing
their own
conflicts
and anxieties
and using
the patient
as a container
to receive
them.
The classical
notion
of the therapist
as blank
screen
is

their

who attempts
their
misery.
the

on traditional
conflict
theory.
sented
yet another
point
of

VOLUME

seem
to dethe profes-

analytic
posture
of evenly
suspended
tion is neither
viable
nor appropriate
psychotherapy
of borderline
patients.
pists who attempt
to assume
a detached,

in the
configu-

rations
of self- and object-representations
parade
before
the therapist,
they are further
complicated
by accompanying
affective
states
that are unusually
intense
and raw, often
inducing
in therapists
a feeling
that they are
trapped
clinicians

AND

patients

based

Adler2
view. He
could

best

preprobe

GABBARD

understood

as suffering

condition
Specifically,
sence
could
sence

rather
this

from

describing
aspects
of the psychotherapeutic
process,
attempts
to hold rigidly
to a dichotomous
view that prescribes
a
given
form of therapeutic
modality
to
specific diagnostic
entities
is neither
theoretically
sustainable
nor clinically
practical.
the therapist
needs to maintain
a position
of flexibility
and adaptability,
allowing
the selection
of available
techniques
from the range of psychotherapeutic
interventions
to deal with
the
problems
presented.
(p. 121)

a deficit-based

than
intrapsychic
condition
involved

of a holding-soothing
sustain
them
emotionally
of their
psychotherapists.

conflict.
the ab-

introject
that
in the abOther
clini-

..

cians
influenced
maintained
that

by self
psychology34
borderline
symptomatology

results
from breakdowns
in the empathic
latedness
between
therapist
and patient
should

therefore

be

reconceptualized

entity
that is definable
a relationship.
This controversy

only

of the

tion

that

context

of
The

diagnosis

is mir-

controversy
regardMany (though
not

differences

commodated

as an

in the

about

rored
in a corresponding
ing the optimal
treatment.
all)

reand

can

be ac-

by embracing

Meissners5

no-

borderline

diagnosis

the

of opinion

is

essentially
a spectrum
of conditions
that are
psychodynamically
related.
At the high end
of the spectrum
are patients
who have notable ego
the
are

can undergo
psychoanlittle
modification.
At

low end of the spectrum


are patients
prone
to psychotic
disorganization

cause
require

of prominent
ego
more
supportive
From

a clinical

spectrum
construct.
wide
tion.

and
with

strengths

treatment

alytic

weaknesses
approaches.

perspective,

who
be-

and

who

however,

in their
normal,

clinical
neurotic,

must

assume

to

and

a flexible
wherein

fro

continuum

along

the

according
moment.

point

and

has

to the

psy-

interventions

shift

expressive-supportive
to the

at a particular
of view

approach
their

patients

Meissner5
offered

following

observation:

this

JOURNAL

OF PSHOTHERAPY

of

depending
particular

upon
where
on
patient
stands.

univocal
spectrum

is important
countertransfer-

keep
in mind
that
the
may vary considerably

serves:
Countertransference
borderline
conditions

this

continuum

a
ob-

in relation
is therefore
not

phenomenon
of levels and

but rather
intensities

ence/countertransference

to
an

involves
of transfer-

interactions

that

can vary considerably


in both
quality
and
quantity
(p. 211).
With this caveat
in mind,
I will consider
several
common
countertransference
reactions
to borderline
patients.
Guilt
Borderline

Feelings

patients

have

an

uncanny

ability
to tune in to the
ities and exploit
them

therapists
vulnerabilin a manner
that in-

duces

guilt.

feelings

development
such a way
therapist.
apist

At the very

patient

cusations
they

attempt
professing

the

may

and

caring

that

of

moment

accuse

may
have

been

patient.

feelings
found

the

out.

in
the
ther-

disappear,

therapist

the

create

therapists
their
lack

would
the

of disliking

common

will behave
exasperate
when

patient

of not
Such

in

ac-

therapists

Under

may reproach
of professionalism

such
themand

to make
amends
to their patients
by
undying
devotion.
The
patients

accusatory
charges
may
row of the therapists

PRACTICE

is that a patient
as to infuriate
and

is wishing

conditions
selves
for

My own view is that, while the theoretical


discrimination
between
supportive
and
expressive
modalities
has a certain utility
from the point of view of articulating
and

of a spectrum

discussions
must
reactions

the
needs

shares
the

in

ence,
one
therapists

for

presentaand psy-

chotic
transferences
in the same
patient
in
the course
of one therapeutic
hour.6
A corollary
of this observation
is that
therapists
chotherapy,

concept

because,

the

must be regarded
as a metaphorical
Borderline
patients
are known

fluctuations
One can see

AND

RESEARCH

to the very marprofessional


identity

strike

10

COUNTERTRANSFERENCE

and

create

a form

transference4

of physiological

that

sympathetic
heart,
a dry

involves

discharge,
mouth,
and

Another

common

counter-

The

manifestations

of

such
as a pounding
trembling
limbs.
scenario

relatively
and

intact
seem

is that

progresses.

at the beginning
to unravel
as

Searles6

has

suggested

the

of treattherapy
that

origins

such

BORDERLINE

of

expressions
tional9
result

therapist
begins
to feel responsible
for apparent clinical
deterioration
in the course
of
psychotherapy.
Many borderline
patients
appear
ment

AND

this

proneness

of aggression

or secondary
is that therapists

apist may
disclosure,

extend
defer

fee

whatsoever,

ual

behavior

or engage
with

the

to the point
of madness.
that some
therapists
will

sation
because

patients

dured.
Suicide
threats
pists
to
justify
transgressions,
often
they had not deviated

guilty

that

the

more

provide
greater
fascination
or more
neurotic
areas
Rescue

psychotic
than
the
of the ego.

Fantasies

primitive

be

constitu-

patient

in physical

patient.

of professional
because
of the

as a victim

tices,

ther-

who

or sex-

In some

cases,

boundaries
is
perception
of the

is entitled

to compen-

in the form of extraordinary


of the suffering
he or

the

and

the session,
engage
in selfpayment
or not charge
any

ing a parental
He has noted
aspects
healthier

to

or intimidated
by the patients
volatility
potential
to explode.
To ward off the patients
anger,
the

this violation
rationalized

feel

may

to trauma,2#{176}but the end


often
feel threatened

guilt feelings
by therapists
may be related
to
unconscious
empathy
with the patients
child
self-representation,
who felt guilty about
drivfigure
also

PATIENTS

measures
has en-

she

may also lead theravarious


boundary
with
the claim
that if
from
their usual
prac-

patient

would

have

another

source

committed

sui-

17

Intimately

related

to guilt

feelings

evocation
of rescue
fantasies
in the
This
aspect
of the countertransference
volves

more

than

simply

are the
therapist.
in-

therapeutic

zeal.

It

also reflects
a perception
that the patient
is
essentially
helpless.
Therapists
often
feel that
they must do things
for the patient.
Borderline
patients
often
present
themselves
as
Dickensian
orphaned
waifs4 who
need
the
therapist
ther
to
parent

to serve
as a good
mother
up for the bad
or

responsible

for victimizing

Transgressions

The

third

ference

of specific
follows

first two. Borderline


for evoking
deviations
that lead
These

the

child.

Boundaries

form

reaction

absent

of

Professional

frame
ing.79

or fa-

make

countertrans-

naturally

patients
from

from

the

are notorious
the therapeutic

Still

gressions
relates
to
ment.
Many borderline
are

always

that

They
leads

are

known

to frequent

to have

a short

expressions

VOLUME

NUMBER

#{149}

of being

abandoned

sources
of nurturance
their parents,
lovers,

and supor thera-

demonstrate
their
sincere
concern.
these
demands
may
escalate
to
phone
calls, a rendezvous
outside

Because
late-night
the ther-

apy, and
borderline

who treat
as well as

ference

sexual
liaisons,
patients
have
need
pitfalls

A common
therapy

#{149}
WINTER

to understand

and

countertrans-

Hatred

phenomenon

of borderline

1993

therapists
an ethical

thoroughly.23
Rage

fuse

of rage.

verge

trans-

of abandonfeel that they

and is not simply


a prostitute
who receives
a
fee in return
for time and attention
may lead
therapists
to go to extraordinary
lengths
to

form
of entitlement
resulting
in demands
to
be treated
as exceptions
to the usual
procedures.

the

issue
patients

pists.2122
Some
patients
interpret
any
communication
from
the therapist-except
unconditional
love-as
having
an implicit
threat
of rejection.2
These
patients
demands
for reassurance
that one really
cares

a clinical

to ill-advised
boundary
crosspatients
may feel a specific

on

by significant
port,
typically

of boundary

the

patients

in the
is their

psychoalley-

11

GABBARD

tension

ating

by

feelings
into
has
termed
Whereas

evacuating

or

the therapist:
a lavoratoric

neurotic

patients

superego

constellations

borderline

patients

primitive

dumping

tend
into

project

to

therapist,

the

sick

or

bad
self in a primitive
split-off
form.92526
Volkan26
has described
the feeling
of being
choked
by the externalization
of such primitive and negatively
charged
affects
and introjects.
One
can
hardly
avoid
feeling
rage,
hatred,

and

resentment

this way by the


suicide
threats
late-night
for

lead

being

calls

and

extraordinary

unceasing

to profound

feelings

Helplessness

and

can

of seething

mands

are

these
patients
contemptuous

rather

can shift
transferences

from

form
hanced

of

tients

countertransference
by the expertise

at

exploiting
ing out

identifying

and

their
de-

gratified,

is further
borderline

vulnerable

withdrawal

enpa-

areas

are

postures
devaluing

of the therapist
attacks,
but

face the
petence

feelings
of helplessness
are prominent.
Anxiety

and

often

in the throes
underneath

and

tioned
thing
ment,

and

misidentify

Regardless

this

anxiety

of what

borderline
therapist

therapists

often

up to the
efforts.

clinical

are

many

else

THE

As the
moved

concept
to center

and

varied.

JOURNAL

At the

choanalytic
transformation

OF PStHOTHERAPY

not

in their

OF

ence
placed

as a disruptive
obstacle
has
by a view of countertransference

ened
interest
relationship
enactments
ological
replaced

has
psy-

discourse,
it has undergone
in meaning.
Countertransfer-

Accompanying

most

are simply
failing

of countertransference
stage in contemporary

if not

on in the

they

or are

Finally,

throughout
feeling
that

NATURE

standing.

almost
always
The sources
of

that

task

runs
the

COUNTERTRANSFERENCES

essential,

source
this

in how
serves

of past
search
for
by careful

by-moment

is going

that
from

have

valuable,

incom-

patient
men-

anxiety.

anxiety
arises

overt
of such
the sur-

in many
treatment
of guilt and respon-

countertransference

an overriding
the treatment

pointDefen-

Terror

patients
anxious.

belonging

that one will say the wrong


the patient
to explode,
fragwalk out of the office
also

shift

been
of

reas a

under-

is height-

the patient-therapist
as a forum
for

experiences.
the buried
attention

reverberations

and

treatment,
make
the

feelings

in the therapist
instead.
or fusion
may be ex-

by the borderline
worries.
The previously

concern
and cause
or abruptly

creates

that awareness
by constantly
weaknesses
to the therapist.

siveness

as residing
of merger

induced
such

incompetent,
about
it. This
of

may

to them
A feeling

sibility
amplifies

idealizing
to
in the twinkling

unskilled,
anything

patients

dealso

of an eye. They tend to indulge


in pars pro toto
thinking
in which
one becomes
all bad for
even a minor
transgression.
The result is that
therapists
often
feel
and helpless
to do

con-

therapists

is ever
present
and the sense

resent-

than

lead

suicide
processes,

Worthlessness

frustrated

patients

may

to
by

ment.

Borderline
patients
tend to devalue
therapists
efforts.2
Also,
when
their

borderline

in

used

treatment

the

boundaries

tremely
unsettling
to the therapist
in such
situations.
A common
response
is to distance
oneself
from the patient
and become
aloof.27
The
anxiety
that
the patient
will commit

patient.
Being
held hostage
or driven
to distraction

phone

mands

when

about

to feel a primal
terror
related
to the concern
that they will be swallowed
up by their patient
and annihilated.
In psychotic
transferences,

project

the

level,

fusion

what Rosenfeld24
transference.

re-

The archaepast has been


to the moment-

between

therapist

patient.28
Freuds
original
definition
of countertransference
was narrowly
focused
on the
analysts
transference
to the patient.
In other
words,
countertransference
involved
feelings

PRACTICE

AND

RESEARCH

12

COUNTERTRANSFERENCE

that belonged
displaced
onto

to the analysts
past but were
the patient
in the same
way

that the patient


displaced
feelings
from
the
past onto
the analyst.
This view conceptualized countertransference
as an interference
or obstacle
that needed
to be removed
by
rigorous
analysis
of the analyst.
Paula
Heimann3#{176} altered
the landscape
of psychoanalytic
thinking.
In her view, countertransference
much

needed

broader

form

to be construed

as all the feelings

analyst
experiences
plicit
in Heimanns
tertransference
was

empathic
(i.e., the

link between
therapist
therapist
identifies
with

subjective

affective

state

or

has
the

focused
recipient

in-

tification.

Whereas

and patient
the patients

self-representa-

the

effected
largely
interpersonal
tient.
Projective
patients,

this

discussion,

mechanisms
takes

the

pa-

and

I will

by border-

importance

for

elaborate

on

it

below.
One
about

implication

of this

shift

countertransference

analysts

conflicts

tainer
patient
those

internal
transference

object

in thinking
is

Racker viewed
this complemenas an instance
in which
the
by the

con-

that

used

on crucial

the therapist.
tary
reaction

activated

remains

therapist
produces
to conform
to the
These
changes
are

analysts
response
to the
great
deal of information

were

concept

through
powerfully
coercive
pressure
exerted
by the paidentification,
as one of the

defense

line

of

on changes
in
projective
iden-

or affect

tient
projects
into
the
changes
in the therapist
nature
of that projection.

tions).
Complementary
countertransferences
involve
identifications
with an internal
object-representation
of the patient
that has
been projectively
disavowed
and attributed
to

own

concept
Although

controversial,
there
is a general
that
the split-off
self-representation,

central
an

PATIENTS

as used
by Klein
infantasy
rather
than an
the modern
usage

to a great
extent
of the patients

object-representation,

Concordant
involving

those

the original
concept
volved
an intrapsychic
interpersonal
coercion,

the

that

BORDERLINE

of interest
in the Kleinian
identification.69253

in a

the feelings
the analyst
experiences
are
duced
by the patients
behavior.
Racker3
divided
such
patient-induced
reactions
into concordant
and complemenare

pouring
projective

highly
sensus

toward
the patient.
Imunderstanding
of counthe notion
that some
of

tary
countertransferences.
countertransferences

AND

patient
about

that

world.
Moreover,
entails
first serving

to receive
and
then
projections.

projected
studying
Sandler45

the

provides
the patients

counteras a con-

aspects
of the
the contents
of
suggested
that

patients
projections.
Grinberg32
took this notion
one
step further
with
the concept
of
projective
coun teridentification,
in which

the analysts
supplemented

the analyst
introjects
object-representation
from
the patient.

determines
what
complementary
role
is
being
coerced
by the patients
words
and
behavior.
This influence
from the British
school
of

Winnicott,33

a reaction,
feeling,
or
that
comes
entirely

in his classic

paper

tertransference
hate,
spoke
form
of countertransference
analyst
manner
sistent

reacted

the patient.

patient

persons
This

the

According

patients
might
hate in other
the

to

patient

evoked
by the
across
all people

past.
shift

a specific

to this schema,

about
in

in

patient
that was
who interacted

consistently
people
that

than

on coun-

of an objective
in which
the

the

thinking

induce
reflect

conwith

certain

feelings
of
more
about

analysts
led

or other
to

VOLUME

an

out-

NUMBER!

#{149}

ness

involving

object
Atlantic
the

free-floating
attention
by a free-floating
a form

relations
theory
and has had

classical

overview
nique,
tion

has traveled
a significant

originating

of understanding
has now become

WINTER

1993

that

across
impact
school,

the
on
cre-

interest
in concepts
such
enactment.4#{176}
In a recent

of countertransference
Abend5
acknowledged

countertransference

#{149}

of introspection

or ego-psychological

ating
considerable
as interaction
and

must
be
responsive-

with

Klein
can

and
that
that

the

techno-

the

analysts

be a crucial

source

the patients
inner
universally
accepted.

world
As part

13

GABBARD

of this acceptance,
of the analyst
have

the self-analytic
activities
come
to be regarded
as a

systematic
effort
at collecting
data
about
ones
analysand.
The analyst
must be particularly attuned
to subtle
or not-so-subtle
forms

and patient
vary according
to the severity
of
the psychopathology.
In general,
projective
identification
or objective
countertransferences occur with sicker patients,
such as those
suffering

from

of acting
in, whereby
the patients
internal
object
relationships
are enacted
in the clinical setting
between
patient
and analyst.
In

der, whereas
tertransferences

speaking

many

of enactments,

An

analyst

catches

ing

reacts

himself

regains

Chused
to his
in

his analytic

himself

and

the

the

so

to

and

patient,

speak,

in observ-

increases

his

understanding
of the unconscious
fantasies and conflicts
in the patient
and himself

which

(p.

616)

have

Borderline
enactments
affect
and
resentations
apist.
assume

prompted

patients,

him

ference

reactions

patient.
must
be

In my
thought

are

simply

evoke

erroneous
countertransaspects

neurotic

patients.

tertransference

Although

reactions

with

are overwhelming
in
not neglect
more
elusive
that also occur
throughof psychopathology.
out that even aspects
of

sciously
determined
and therapist.
This
modernization

through
the sheer
power
of the
the primitive
self- and object-repthat are projected
into the ther-

However,
it would
be
that all of a therapists

or
coun

disorcounwith

the standard
analytic
or therapeutic
posture,
such
as neutrality
or silence,
can become
involved
in subtle
enactments
that are uncon-

to action.

in particular,

healthier

personality

narrow
or subjective
are more
prominent

borderline
patients
intensity,
we must
forms
of enactment
out
the
spectrum
Jacobs49
has pointed

patient-but

act,

stance,

notes:

borderline
the

to

of the

view,
countertransference
of as a joint
creation,

in

by issues
of

in both
the

countertransference
has led some
that the term
has been
so greatly
as to lose its specificity.
Natterson,53
ample,
makes
countertransference

a differentiation
and the

patient

concept

of

to believe
expanded
for ex-

therapists

between
own

subjectivity.
He prefers
the language
of intersubjectivity
because
the therapist
initiates
as
well as reacts.
It is my view, however,
that in

which
both
the therapists
past conflicts
and
the patients
projected
aspects
create
specific
patterns
of interaction
within
the therapeutic

actual
practice
the interactions
between
therapist and patient
are so inextricably
bound
up
with one another
that what is initiative
and

process.
Indeed,
a central
feature
of the
therapists
role with such patients
is to engage
in an introspective
process
that attempts
to

what is reactive
dissect.
Meissner5

differentiate
those
of

or

ones
own
the patient.2M

order
within

to find the
ourselves.

points
within

to the fact
the session

mentary

sources

The therapist,
intrapsychic
in an effort
the patient
If one
transference
that
the

patient
This

contributions
Bollas52

that there
are
and therefore
of free

notes:

we must
process

from
In

look for him


inevitably
two patients
two comple-

association

then,
must
maintain
focus and an interpersonal

the

premise

is ajoint
creation,
relative
contributions

JOURNAL

that
it

In his view,

therapist
should

experiences
be construed

(p. 202).

to the

assigned

both

regarded

counter-

also follows
of therapist

OF PSIHOTHERAPY

role

to impossible

argued

definition

ference.

that
patient

an
focus

be next

has also

limited

He proposed
ence to the

to sort out what is going


on within
and bear it within
himself.47
accepts

more

may

to

for a narrower
of countertrans-

not

all reactions

that

the

toward
the patient
as countertransference.
only
and

the analysts
the analysts

by the

as countertransference.

patient

transferreaction
should

be

In this con-

ceptualization,
reactions
that
involve
the
therapeutic
alliance
and the real
relationship
(outside
of technique)
between
therapist
and
patient
are
not
necessarily
countertransferential.
Again,
this distinction
may be extremely
difficult
to tease out in the

PRACTICE

AND

RESEARCH

14

COUNTERTRANSFERENCE

heat

of the

derline

affective

storms

by bor-

patient

that
I have
been
advocating
great responsibility
on therapists

themselves
whose
own

as both
clinicians
issues
enter
into

arena.6255253
Self-analysis,
mount
importance
in
countertransference.
served,
My view.

. .

tegration
ment

into
an

of

self-analysis

R 0

J E C T

model

delineated

rein-

the

projector
with

transcends

feels

the

the

for projective

1)

movethat
of

that
or union

recipient

simple

pur-

pose of defense.
As Scharff42
has eloquently
summarized,
four
distinct
purposes
can

Defense:

to

unwanted
one

(p. 339).
T

by the

form.

projection.

This

o bof

is a systematic

the psychoanalytical
exiled
function:

stressed

of oneness

of the

PATIENTS

of them

in modified

also

sense

is of paramanaging

Indeed,
Bollas54
is that contemplation

countertransference

Ogden

here
to see

and patients
the therapeutic

then,
effectively

BORDERLINE

to a reintrojection

patients
in psychotherapy.
The
conceptualization
of countertrans-

ference
places

the

generated

AND

I V E

distance

part

else,

2)

or

understood

cipient

to experience
own,

3)

with

a recipient
the

make
the

re-

of feelings

like

Object-relatedness:

to

separate

projection

the

in some-

pressing

a set

teract
receive

from

it alive

to

by

ones

to

oneself

to keep

Communication:

oneself

be

identification:

in-

enough

yet

undifferen-

IDENTIFICATION

tiated

enough

tion

In light of the
tive identification
borderline

central

importance
of projecthe psychotherapy
of

in

patients

and

in the

term,

I view

the

concept

cal

conceptualiza-

of projective
for

To

begin
with,
be regarded

aspect
avowed
someone

2.

3.

of the

in

be

the

the

sense

of

psychologi-

transformed

by

projection

the

after

recipient,

mother-infant
or

for

as

its

occurs

relationship,
patient-therapist

in
rela-

29)

(p.

This
model
of projective
identification
ries with it a spirit of therapeutic
optimism.

with

identification
than
simply

is projectively

dis-

placing

it in

therapists
patients,
a

else.
interpersonal
the other

to

mispercepthe

Pathway

by

tionship.

the

self

exerts
coerces

foster

the

marriage,

develop-

by unconsciously

The projector
pressure
that

change:

modification

defense
mechanism
of borderline
patients.
OgdenTM
has defined
it as a three-step
procedure
in which
the following
events
occur:
1.An

4)

some

identi-

understanding

projective
as more

and

allow
to

reintrojecting

ments
in the psychotherapy
of patients
borderline
personality
disorder.
should

occur

oneness,

tion of countertransference
as I have defined
it, a more
careful
consideration
may be helpful in clarifying
my use of this term.
Despite
the controversy
over confusing
usages
of the
fication
as essential
transference-countertransference

to

to

person

to experience
or unconsciously
with what has been
projected.
The recipient
of the projection
therapeutic
situation)
processes
contains
the projected
contents

VOLUME

can bear
they offer

tients
transform
containment

and

jections

affects

and

therapists
Some

the
the

jected,
arguing
the definition

projections
of their
hope
of helping
pa-

their internal
modification
in

countertransference.
critics
of this

the

the
third
Kernberg8

gard

identification

projective

crucible

of

the

have

ob-

has broadened
original
intent
step
involving
preferred
to

re-

as a primitive

identify

defense
tolerable

(in the
and
leading

pathy
with
the
projected
contents,
attempting
to control
the object,
and unconsciously
inducing
the object
to play the role
of what is projected
in the actual
interaction

#{149}
NUMBER!

WINTER

#{149}

mechanism
aspects

world
through
of those
pro-

model374

that Ogden38
beyond
Kleins

by including
reintrojection.

carIf

1993

involving
projecting
of the self, maintaining

inem-

15

GABBARD

between

the

projector

and

the

recipient.

ment

Sandler4
also objected
to extending
the
projective
identification
concept
to include
the therapeutic
actions
of containment,
detoxification,

and

modification

as described

Ogden.TM
However,
Sandlers45
responsiveness
is very much
the first two
with my view
creation

steps
of Ogdens
of countertransference

of patient

Very

often

analyst,
science
blind

and

concept

therapist.

He

the irrational
response
which
his professional
leads him to see entirely

spot

of his

own,

may

by

notion
of role
in keeping
with

process.

Patients

and

Although

therapist
over, she

that

an import-

reintrojection

of negative

Scharff42

shares

engage
places

that
patient

I am
and

in a mutual
process.
greater
emphasis
on

identification

therapist
who
The therapist

broadened

the

projective
identification
she stresses
that the

trojective

Morethe in-

component

of

the

receives
aspects
of the patient.
may respond
in a concordant

or complementary
manner,
according
to
Rackers3
distinction,
but Scharff
also notes
that introjective
identification
is determined

be

may

believed

element
of projective
identipatients
observation
that
nor patient
is destroyed
by

projection

said:

in part
respond

Of those who write about


projective
identification,
most agree
that control
is a central
of the

the

view of
endorsing,

usefully
regarded
as a compromise
formation
between
his own tendencies
and
his reflexive
acceptance
of the role which
the patient
is forcing
on him. (p. 46)

feature

Boyer

affects.

and
as joint

of the
conas a

sometimes

process.

ant therapeutic
fication
is the
neither
therapist

experi-

what
words,

by the therapists
own
in an identificatory
is projected
by the
some
projections

good
enced

fit, whereas
as alien and

propensity
manner

to
with

patient.
In other
may
represent
a

others
discarded.

may be
Finally,

experiScharff

ence
the depositing
of aspects
of themselves
in the therapist
as forging
a powerful
link

observes
that
patient/projector

the reintrojective
may promote

between

containment
made
slight

by the therapist/recipient
modifications
that
can

be

cepted

the limits

capac-

the

two members

of the

dyad,

giving

them
the illusion
of influence
over the therapist.
Often
the power
of this control
is
recognized
only
after
the therapist
has responded
in the specific
manner
that has been
unconsciously

projective

by the
Therapists

programmed

identification.

patients
of bor-

derline
patients
must
transference
enactments

accept
are

that counterinevitable.
By

rigorously
therapists

internal
regroup

responses,
and process

what

monitoring
can at least

has happened

with

the patient
construed
in the

Ogden.TM
patients

such

has written
that
of what has been

In fact,
reintrojection

the

distorted
patients
change.

with

he

projective
manner

also

projection

of the patients

be pathological,
is returned

form
anxiety
Certainly

by the
if the
has
ac-

however,
in

if

a completely

that
does
not
modify
the
or lead
to psychological
in nontherapeutic
settings

the aspects
that are projected
are routinely
crammed
back
down
the patients
throat
rather
than
contained
or modified,
often

following

enactments.
Boyer55
has
also
identification
broadly

within

ity to change.
This can

process
change

of
the
pro-

considerably

panded
sumes

containment
should
be

affect.

The

and modification
noted
that close

transference

JOURNAL

contain-

OF PSItHOTHERAPY

PRACTICE

that

AND

RESEARCH

the like may

goals.
(It
parents,

resentation

therapists

and

aswhich

apeutic
in the way they contain
what
has
been
projected
into them
even though
a formal psychotherapy
process
is not involved.)
The joint-creation
model
of counter-

the

spouses,

are
friends,

ex-

jected
into the therapist
is a neglected
aspect
of the process.
For example,
when
they project hostility
into
their
therapists,
these
patients
may benefit
from
the detoxification
of the affect and associated
self- or object-repthrough

lovers,

intensified

model
of projective
identification
a therapeutic
context
in

I believe

also be ther-

is most

apposite

16

COUNTERTRANSFERENCE

for the
depends

psychotherapy
heavily
on

projective
Ogden,TM

of borderline
expanded

the

identification
Boyer,
Scharff,42

crucial
importance,
keep in mind
the

as
and

however,
metaphorical

exchange
of mental
contents.
ing mystical
about
projective
When
patients
coerce
us into
iors

or

they

have

feelings

that

into

repressed
as troops

be called

into

service

described
others.

by
It is of

jective
identification,
els have been used

with

entrenched

what

have

simply

or split-off
aspects
far from the front
specific

of
may

forms

of

pattern

THE

ROLE

Francis
Bacon
ories are better

the most

some

parallel

OF

once
than

to theory
emphasizes
are perhaps
most
gling
with intense
ings.
They
bring

aspect

counterpart

by unconsciously
role of the child

said that even wrong


chaos.
My attention

themselves

for
time.

intense
transferhas noted
that
involves
conthe psychotherapist
One dimension

the application
of theory
to the clinical
situation is that it also is applying
balm
to soothe
the therapists
anxiety.
ory

Nevertheless,
as absolute

Theories

are

only

countertransference,

as valuable

as their

I have borrowed
from
in my conceptualization
and

specifically

VOLUME

clinical
object
of
of pro-

active
trauma

model
analyst;

the
the

the affect
is
it is simply

patient.
Rhine57

from

approached
projective
a self psychological
per-

to be used

by the

need
for the
to the pamust
allow

patient

for

psy-

The therapists
selfobject
allowing
mirroring,
ideal-

ization,
and twinship
in the patients
ences.
Adler
and Rhine
described
a
patient
who insisted
that her therapist
tion as a selfobject
by accepting
her
tions and projections.
They pointed

transfercase of a
funcprovocaout that

the containing
and
jective
identification

modifying
aspect
of proconverges
with
self-

object
therapist

in

to be

functioning
understands
used

by the

tient verbalize
them.
Different
same

are

situations
and tolerates

patient

and

where
the

helps

the
need

the

feelings
rather
than acting
theories,
the authors
essentially

clinical
issues.
Most
therapists

struggling
use

on
sug-

with

multiple

pa-

the
mod-

els.M6162
Rigid
adherence
to only one theoretical
frame
when
the clinical
data do not fit

one must never


regard
theor allow it to become
reified.

utility. Although
relations
theory

and

growth.
include

gested,
of

In Porders
into
the

spective.
Kohut5#{176} stressed
the
therapist
to serve
as a selfobject
tient.
In other
words,
therapists
chological
functions

thehere

between

casting
the analyst
in
while the patient
assumes

by the

in

that theoretical
models
useful
when
one is strugcountertransference
feelorder
to the
chaos
of

discomfort
deal of the

induced

of

THEORY

overwhelming
affect
and
ence
distortions.
Friedman56
the practice
of psychotherapy
siderable
a good

bizarre

of relatedness

child and parent.


The patient
achieves
mastery
over a passively
experienced

Adler
identification

that

Projective
identification,
in
is an identification
with
the
is a chronic
repetition
of an

view,
that

sense
of self. We all have sadists
and murderers lurking
in our depths
as well as saints and
heroes.
Considerable
insight
is gained
in conceptualizing
the psychotherapeutic
process
as involving
two patients
rather
than
one,
has

modclini-

perspective.
Porders
aggressor

parental
role.
not projected

the patient
ourselves.6

other
theoretical
to explain
the same

There
is nothidentification.
specific
behav-

battle
need
to be fought.
We all possess
myriad self-representations
that
are integrated
into a more
or less continuously
experienced

understanding

PATIENTS

that therapists
nature
of the

us, they

when

BORDERLINE

cal phenomena.
Porder4#{176} shares
OgdensTM
view that projective
identification
is not simply a defense
mechanism.
However,
he explains
it from a traditional
ego-psychological

correspond

projected

stimulated
ourselvesjust

patients
model
of

AND

#{149}
NUMBER!

the theory
contemporary

is an unfortunate
practice
that

phenomenon
privileges

in
theory

over clinical
observation.
misused
to rationalize
acting
out.23 One can

Theory
can also
countertransference
use self psychology

rationalize

of idealization

#{149}
WINTER

enjoyment

1993

be
to

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