Problems Arising in Psychotherapy
Key points
- Five types of transference and countertransference problems often arise in the treatment of dependent personality disorder (Table 88-2).
- A second problem may occur when the patient repeatedly attempts to have the therapist both take responsibility for all decisions and tell the patient how to run his or her life.
- A third problem results when the patient avoids making real changes but stays in therapy to maintain the emotional attachment to the therapist.
- A fourth problem may occur with patients who have unsatisfying, punitive relationships, commonly referred to as masochistic or self-defeating.
Five types of transference and countertransference problems often arise in the treatment of dependent personality disorder (Table 88-2). First, the patient entering therapy may make many demands or requests of the therapist for advice, succor, or concrete help, which the therapist is unable to meet. One study showed that such patients often terminated therapy early and were rated as having had unsuccessful outcomes. The therapist should give special attention to helping modulate these patients' demands early in treatment to prevent overwhelming disappointment and dropout. These patients also invite a countertransference response of emotional withdrawal, which reinforces neurotic guilt about needs.
A second problem may occur when the patient repeatedly attempts to have the therapist both take responsibility for all decisions and tell the patient how to run his or her life. If the therapist assumes this directing countertransference role, he or she may become an external substitute for the patient's own will. A therapist may do this because of feeling exasperated by the patient's protestations of helplessness or because of a personal wish to assume an idealized role as wise and all-knowing. This reinforces the patient's emotional reliance on the therapist without helping the patient learn more independent ways of coping. Directive approaches may have a useful, but limited, role during crisis interventions, but even cognitive-behavioral therapies require the therapist to foster the patient's independent decision making.
Written and revised by
Andrey Nailor, M.D.
Our doctors write and review articles for accuracy and keep them up to date.
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