Psycho-Babble Psychology Thread 960556

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personality disorders

Posted by emmanuel98 on August 29, 2010, at 21:38:27

This list has been so quiet that I thought I'd start a new thread. I was hospitalized in July after a suicide attempt. I am taking parnate and haven't been depressed -- in a vegetative state, unable to care for myself -- since I started a year ago. But my p-doc now says I have a personality disorder. That my fears of loneliness and abandonment and not being cared for are recurrent themes that have not gone away despite 5 years of dynamic therapy and remission of severe depression. I saw a consultant last year who told my p-doc I was the most disturbed patient he had ever seen.

I'm kind of disturbed by this tag of personality disorder. I know it's kind of a catch-all term for a whole slew of dysfunctional behaviors, but it freaks me out, frankly.

Have other people been tagged as having personality disorders?

 

Re: personality disorders emmanuel98

Posted by Deneb on August 29, 2010, at 21:53:24

In reply to personality disorders, posted by emmanuel98 on August 29, 2010, at 21:38:27

I sort of diagnosed myself with borderline personality and my pdoc agreed with me. I think I may have grown out of it now though. I never want to kill myself now or hurt myself. I'm not as sensitive to rejection now.

I'm pretty happy now. My life is not perfect, but that's OK. Life is fun and exciting.

I went from wanting to kill myself all the time and ODing and cutting to wanting to live to 120 and staying healthy with diet and exercise.

Lots of people love me and I feel loved. I feel safe and secure now. My next step is to be more productive in life.

 

Re: personality disorders

Posted by Dinah on August 30, 2010, at 4:23:52

In reply to personality disorders, posted by emmanuel98 on August 29, 2010, at 21:38:27

Did your pdoc tell you what the consultant said? Or your consultant?

My first pdoc as an adult believed I had schizotypal personality disorder. My second pdoc disagreed. My third one hasn't mentioned anything at all.

I don't like the term "personality disorder" and I wouldn't care much for "character disorder" either.

I think I have traits of more than one personality disorder. I sometimes find it useful to think in terms of those traits.

 

Re: personality disorders

Posted by violette on August 30, 2010, at 8:37:58

In reply to personality disorders, posted by emmanuel98 on August 29, 2010, at 21:38:27

> That my fears of loneliness and abandonment and not being cared for are recurrent themes that have not gone away despite 5 years of dynamic therapy and remission of severe depression.

Do you think he was saying you, in some ways, have integrated your illness with your identity?

> I saw a consultant last year who told my p-doc I was the most disturbed patient he had ever seen.

What an awful thing to hear. I am surprised your PDoc even told you something like that...did you get the notes of the consultant?

> I'm kind of disturbed by this tag of personality disorder. I know it's kind of a catch-all term for a whole slew of dysfunctional behaviors, but it freaks me out, frankly.

I don't think the term is useful and that PDs are mental illness too-not character defects-and usually intertwined with Axis I-not seperate. PD constructs don't necessarily have to include (adverse) behaviors necessarily-it can represent inner states. Plus those traits can serve a purpose preventing depression/anxiety/psychosis until someone is middle aged-then they will crash, and then more behavioral aspects come out, such as those related to MDD.

> Have other people been tagged as having personality disorders?

Many people are not assessed for them and might not know they have one. I have traits of several and found that reading about them more comprehensively has helped me a great deal. Also, many people with severe PDs would never voluntarily enter a therapist's office and might be oblivious to psychological problems.

I found people here don't generally like to talk about those aspects of the self. I posted a PD test here not too long ago-1 person aside from me posted their results (not that the test can accuratly attribute a PD to a person-but it can show your current tendencies).

Plus people read those DSM lists, which only represents a manifestation of symptoms of someone wiht the 'extreme version' of a PD. Many people tend to have traits of several and don't fit one or have some strong traits of another but only meet the critiria during a stressful life event, for example. The psychoanalytical literature describing the underlying context of the traits is worth knowing, imo, in order to be in remission from MI.

If you've been in psychodynamic therapy for 5 years, you might think about switching therapists. You seem to have a real good relationship with your therapist, but maybe a new therapist can address things he has not been keen on. Also, psychoanalysis seems to work better for certain PDs or traits than psychoanalytic therapy.

It might be uncomfortable to you to think of that 'label', but i'd consider you fortunate in many ways as i think there are many people with PDs or strong traits of them and don't even know it, so will likely never get better and continue suffering for a lifetime. At least if you have the dx, you can find out how to 'cure' it, and work towards recovery. :)

Always a topic of interest for me.

 

i think its a condemnation

Posted by Christ_empowered on August 30, 2010, at 8:51:30

In reply to personality disorders, posted by emmanuel98 on August 29, 2010, at 21:38:27

mental illness labels are bad enough, but a lot of the "personality disorders" strike me as condemnations of an individual couched in therapeutic jargon.

I was diagnosed by 2 shrinks as having a personality disorder instead of a mental illness. 1 shrink went so far as to say that I was faking psychiatric symptoms so I could feel "special" and "unique". Fast forward 2 years: after spending a lot of time off meds (I figured, if they don't think I'm crazy, why take meds?) and ending up in a mental hospital, I was told by another psychiatrist that she "always knew it was really bipolar"

I think its worth noting that, in my case, my relationship with the shrink who diagnosed bipolar was far better than my relationship with the shrink who diagnosed a personality disorder. Shrinks act as if they're objective, but really all sorts of variables affect what diagnosis you end up with.

 

Re: i think its a condemnation Christ_empowered

Posted by maya3 on August 30, 2010, at 12:01:24

In reply to i think its a condemnation, posted by Christ_empowered on August 30, 2010, at 8:51:30


>>1 shrink went so far as to say that I was faking psychiatric symptoms so I could feel "special" and "unique".

Why would someone want to fake psychiatric symptoms in order to feel special? Unfortunately, people with psychiatric problems often fear they will be considered "special" in negative terms, if at all . It would make more sense to assume that people already suffering from such problems might develop secondary defense mechanisms involving feeling "special" in order to ward off feelings of depression, inferiority, etc.

>>Shrinks act as if they're objective, but really all sorts of variables affect what diagnosis you end up with.

How true.


 

Re: personality disorders violette

Posted by emmanuel98 on August 30, 2010, at 21:38:27

In reply to Re: personality disorders, posted by violette on August 30, 2010, at 8:37:58

I could never switch p-docs. I am much too attached to him and how honest and straightforward he is. I feel we have an excellent rapport. But we had stopped therapy (at my suggestion) when I fell apart 5 months later, partly because I felt so abandoned by him. We made a lot of progress. I had severe trauma issues I had never dealt with -- just put them aside, refused to discuss or think about them. My adolescence was a nightmare -- homelessness, institutions, prostitution. I just put that aside and never talked about it or thought about it. I talked to him about things I had never told anybody, not even my husband. We did a lot of good work together.

But now he thinks his role is to be supportive while I focus on DBT skills and not slipping into despair everytime I feel lonely or rejected. So I am back to seeing him once a week and seeing a DBT therapist once a week. They talk every few weeks. I am also starting a DBT group this week, which has helped me in the past.

So I don't think the problem is him and I don't think I need a more analytical form of therapy. I'm overly intellectual and need to gain more control over my emotional responses.

> If you've been in psychodynamic therapy for 5 years, you might think about switching therapists. You seem to have a real good relationship with your therapist, but maybe a new therapist can address things he has not been keen on. Also, psychoanalysis seems to work better for certain PDs or traits than psychoanalytic therapy.

 

Re: personality disorders

Posted by violette on August 31, 2010, at 10:50:24

In reply to personality disorders, posted by emmanuel98 on August 29, 2010, at 21:38:27

"I saw a consultant last year who told my p-doc I was the most disturbed patient he had ever seen."

J. Shedler, a modern PA, said even when it came to his most 'disturbed' patient, he saw some aspects of them in himself...

 

Re: i think its a condemnation

Posted by violette on August 31, 2010, at 11:04:02

In reply to i think its a condemnation, posted by Christ_empowered on August 30, 2010, at 8:51:30

"Shrinks act as if they're objective, but really all sorts of variables affect what diagnosis you end up with"

I believe that too. There's pros and cons of the subjectivity too. Unfortunately some psychiatrists are biological reductionists. It's just my opinion there are more cons than pros with using that model.

I think of PD traits much like the Meyers Brigg tests-everyone's personality traits fit into a pattern of some sort...the degree is important, but understanding one's own pattern by learning about the underlying dynamics, can be empowering, not condemning.

I can't say whether or not getting a specific dx itself is 'empowering' as i can see the stigma surrounding some, but you are the same person regardless of what one subjectively dx's you with. The more accurate (accurate meaning describing the illness in totality), the better.

In many ways, a person can make a choice to be empowered by it, condemned by it, or simply disavow it.

 

Re: personality disorders violette

Posted by Phillipa on August 31, 2010, at 12:38:34

In reply to Re: personality disorders, posted by violette on August 30, 2010, at 8:37:58

Violette what do you mean by protect the person til middle age? What is the age to you of middle age and why would they crash? That's the time of menopause for females and empty nest syndrome if it applies and signs of aging couldn't it be that? Or are you saying that you can so to speak keep it together til middle age and then have the old term nervous breakdown? Phillipa

 

Re: personality disorders

Posted by emmanuel98 on August 31, 2010, at 20:07:58

In reply to Re: personality disorders violette, posted by Phillipa on August 31, 2010, at 12:38:34

I lasted til middle age. 45 to be exact. I think for women, children aging and needing less and less and the onset of perimenopause tend to break down even very strong defenses. A male friend of mine had a student who was raped, but said she was fine about it. He said, wait til you're forty. I told him, for women, forty five or fifty was more likely the age at which things would fall apart.

 

Re: personality disorders emmanuel98

Posted by Phillipa on August 31, 2010, at 22:26:52

In reply to Re: personality disorders, posted by emmanuel98 on August 31, 2010, at 20:07:58

Why do you think that is? I know it's true for me. Phillipa

 

Re: personality disorders

Posted by violette on September 1, 2010, at 13:27:41

In reply to Re: personality disorders violette, posted by Phillipa on August 31, 2010, at 12:38:34

Violette what do you mean by protect the person til middle age? What is the age to you of middle age and why would they crash? That's the time of menopause for females and empty nest syndrome if it applies and signs of aging couldn't it be that? Or are you saying that you can so to speak keep it together til middle age and then have the old term nervous breakdown? Phillipa

Hi Phillipa,

Middle age can be relative, but there are some commonalities of things associated with middle age which are the obvious.... Why a person would crash is something unique to each person and can likely be determined in therapy. But there are some reoccuring scenerios I've read about:

People sometimes hold an idealized image of themself..when something happens, it can cause a person's reality to no longer 'match' how they viewed themself...this is sort of a 'midlife crisis'. This can happen when someone starts to age and loses looks, energy, etc. People often get divorced at this age. Someone left by a spouse starts to think about what they are now lacking-where before, they did not see it. This breaks the idealized image and a person gets depression. Sometimes it can be overcome (much like losses in general), but if not, there were probably ongoing emotional problems, and the relationship filled a void within that person. The void is now wide open, unfilled, and in the person's cognitive awareness....before it was unconscious. Major depression.

Same with work. A person middle aged would have a higher probability of being an experienced worker...and an experienced person in their career who views themself as a hard worker, dedicated employee, intelligent, maybe workaholic in their career-gets passed up for the promotion. They start to question themself, seeing things they are lacking, where before, it was masked. Again, the job filled a void in a person's self esteem. The void was there all along, but the person sort of merged their identiy a bit with work to escape painful emotions associated with low self-esteem.

Losses affect most people in all different ways. But it's important to determine if the loss triggered ongoing, but unconscious, issues or is 'normal' grieving. There is no right/wrong way to grieve, but if the loss was integrated into your identity, depending upon the extent you used whatever filled a void, or how deep the void is, you can have a mental breakdown because now your maladaptive coping mechanism is gone...

Empty nest scenerio:

Someone with codependent traits spent much of their life taking care of others, tending to others' needs while unconsciously denying their own needs as it can be very painful to acknowledge unmet emotional needs if they surfaced in awareness...so taking care of others can fill a void. When the kids move out, they no longer have that role to mask emotional pain and begin to feel empty, useless...If there's enough emotional health to begin with, a person will adapt and overcome those feelings in healthy ways. If there were ongoing emotional problems, a person will either stay in that state or decline if emotional issues are still ignored....

A 'nervous breakdown' can be related to the above, where a person's reality they created is shattered, and they fragment. Another way to illustrate 'keeping it together' until middle age is using defense mechanisms and internal confict. I've talked about this alot, so I'll just mention that it sucks up alot of mental energy to defend against emotions; eventually the brain gets tired and people start to get concentration or memory problems, lack of motivation, dysthmia and other symptoms.

Internal conflict is basically defending against emotions that have no outlet because you disavow them at the same time (in all sorts of ways). For the empty next scenerio, the lack of getting one's own needs met is trying to surface-unackowledged and unfulfilled dependency needs-while your mind has been trying to prevent those emotions from surfacing for years. Before, it was easier to focus on others' needs (children). Now, it's more difficult to contain those emotions, because the 'outlet' is gone. Those emotions, such as dependency needs, if not discharged, try harder to surface-the internal conflict gets stronger. In other words, your mind is fighting itself...It can be exhausting.

Hope that helps. Just my take on it. :)

 

Re: personality disorders. violette

Posted by Free on September 2, 2010, at 3:01:44

In reply to Re: personality disorders, posted by violette on September 1, 2010, at 13:27:41

Violette,

This post really resonates with me, and it could not have come at a better time. Your analysis clarifies my fundamental issues and gives me much needed insights into my recent losses. Being inside my head too often has made it difficult to see through the painful fragmentations, so, thank you for indirectly helping me get through a very tough day. Your post will be my agenda for therapy next week.

I enjoy your frank, no-nonsense style by the way. :)

>
>
>
>
>
>
>
> Hi Phillipa,
>
> Middle age can be relative, but there are some commonalities of things associated with middle age which are the obvious.... Why a person would crash is something unique to each person and can likely be determined in therapy. But there are some reoccuring scenerios I've read about:
>
> People sometimes hold an idealized image of themself..when something happens, it can cause a person's reality to no longer 'match' how they viewed themself...this is sort of a 'midlife crisis'. This can happen when someone starts to age and loses looks, energy, etc. People often get divorced at this age. Someone left by a spouse starts to think about what they are now lacking-where before, they did not see it. This breaks the idealized image and a person gets depression. Sometimes it can be overcome (much like losses in general), but if not, there were probably ongoing emotional problems, and the relationship filled a void within that person. The void is now wide open, unfilled, and in the person's cognitive awareness....before it was unconscious. Major depression.
>
> Same with work. A person middle aged would have a higher probability of being an experienced worker...and an experienced person in their career who views themself as a hard worker, dedicated employee, intelligent, maybe workaholic in their career-gets passed up for the promotion. They start to question themself, seeing things they are lacking, where before, it was masked. Again, the job filled a void in a person's self esteem. The void was there all along, but the person sort of merged their identiy a bit with work to escape painful emotions associated with low self-esteem.
>
> Losses affect most people in all different ways. But it's important to determine if the loss triggered ongoing, but unconscious, issues or is 'normal' grieving. There is no right/wrong way to grieve, but if the loss was integrated into your identity, depending upon the extent you used whatever filled a void, or how deep the void is, you can have a mental breakdown because now your maladaptive coping mechanism is gone...
>
> Empty nest scenerio:
>
> Someone with codependent traits spent much of their life taking care of others, tending to others' needs while unconsciously denying their own needs as it can be very painful to acknowledge unmet emotional needs if they surfaced in awareness...so taking care of others can fill a void. When the kids move out, they no longer have that role to mask emotional pain and begin to feel empty, useless...If there's enough emotional health to begin with, a person will adapt and overcome those feelings in healthy ways. If there were ongoing emotional problems, a person will either stay in that state or decline if emotional issues are still ignored....
>
> A 'nervous breakdown' can be related to the above, where a person's reality they created is shattered, and they fragment. Another way to illustrate 'keeping it together' until middle age is using defense mechanisms and internal confict. I've talked about this alot, so I'll just mention that it sucks up alot of mental energy to defend against emotions; eventually the brain gets tired and people start to get concentration or memory problems, lack of motivation, dysthmia and other symptoms.
>
> Internal conflict is basically defending against emotions that have no outlet because you disavow them at the same time (in all sorts of ways). For the empty next scenerio, the lack of getting one's own needs met is trying to surface-unackowledged and unfulfilled dependency needs-while your mind has been trying to prevent those emotions from surfacing for years. Before, it was easier to focus on others' needs (children). Now, it's more difficult to contain those emotions, because the 'outlet' is gone. Those emotions, such as dependency needs, if not discharged, try harder to surface-the internal conflict gets stronger. In other words, your mind is fighting itself...It can be exhausting.
>
> Hope that helps. Just my take on it. :)

 

childhood attachment and maladaptive traits Free

Posted by violette on September 2, 2010, at 23:18:31

In reply to Re: personality disorders. violette, posted by Free on September 2, 2010, at 3:01:44

Hi Free,

Glad it helped you see things in a new way. :)

Here's an article that explains how people develop maladaptive traits from childhood:

http://www.heartcenteredtherapies.org/go/docs/Journal%205-1%20Attachment.pdf

I didn't read through the whole thing-it's long! But I scanned through it..it does show how people develop maladaptive traits from childhood, which end up becoming long-standing emotional issues in adulthood. It also discusses adult losses related to whatever childhood attachment pattern is developed. Your personality as an adult has alot to do with how your parents related to you during childhood.

Often, an insecure childhood attachment can lead to PD traits, not PDs. They are really called maladaptive traits; the reason I say 'PD traits' is only because I'm not sure if people would know what I'm talking about. Of course, they can become PDs as well. But maladaptive traits are what are often known as avoidant, OCPD, borderline, narcissistic, etc., traits-and we all have some mixture of them, but to different degrees.

I have a disorganized attachment myself, but there really is no distinct diagnosis that correlates with my overall symptom history other than C-PTSD, which only fits sometimes, while other times, just GAD or panic attacks. I don't even think my therapist recognizes C-PTSD or knows much about it-but he doesn't need to anyway as his training/education in childhood development is inclusive of all those issues. In extreme form, someone who had a disorganized childhood attachment often expresses as borderline as an adult.

Hope you had a better day today!
Violette

 

Re: childhood attachment and maladaptive traits

Posted by emmanuel98 on September 3, 2010, at 19:46:23

In reply to childhood attachment and maladaptive traits Free, posted by violette on September 2, 2010, at 23:18:31

I read about attachment theory and I definitely have avoidant attachment. As a child, I walked away from my mother in a department store and walked to the car to wait for her, because I couldn't stand being around her. I was 3. At 5, I tried to run away from home. All my life, I avoided attachment (with two exceptions - my husband and my daughter) but by the time I was in my forties, all the defenses and rationalizations I used to deal with this maladaptive behavior came crashing down and I felt so lonely and depressed I couldn't bear it. I got addictied to drugs and that helped me hold on for a few years longer/ Then the drugs stopped working and I sought therapy. I immediately became so attached to my therapist that I would fall apart if he went away for a long weekend.

Therapy and getting attached like that helped me a lot. Going to AA and making friends for the first time in my life also helped a lot. But I still regard solitude, which I cultivated, working at research and academic jobs, as intolerable. I'm trying to get past that with DBT and am changing careers so I have a more social work environment.

 

Re: childhood attachment and maladaptive traits emmanuel98

Posted by Phillipa on September 3, 2010, at 20:36:44

In reply to Re: childhood attachment and maladaptive traits, posted by emmanuel98 on September 3, 2010, at 19:46:23

What type of career field you thinking about? Phillipa

 

Re: childhood attachment and maladaptive traits violette

Posted by Free on September 6, 2010, at 15:47:14

In reply to childhood attachment and maladaptive traits Free, posted by violette on September 2, 2010, at 23:18:31

> Hope you had a better day today!
> Violette

Thanks, Violette, I am slowly feeling better these days. Doing at least one nurturing thing for myself everyday, and staying away from toxic people and vices seems to be working.

And thanks for posting yet another helpful article. This is all very relevant to myself. You seem to have a knack for psychology --are you in the psych field? Great reading your thoughts around here. Peace and chocolate.

 

Personality Disorders Come of Age

Posted by violette on September 8, 2010, at 22:47:10

In reply to personality disorders, posted by emmanuel98 on August 29, 2010, at 21:38:27

Personality Disorders Come of Age
Glen O. Gabbard, M.D.

Personality disorders have often been relegated to stepchild status within psychiatry. Insurance and managed care companies may incorrectly assert that they are not treatable and, therefore, that treatment of these patients is not reimbursable. Psychiatrists themselves often confine their diagnoses to axis I syndromes. Research dollars for randomized, controlled trials of personality disorder treatments have been hard to come by.

A quarter-century after the creation of the DSM axis II, however, personality disorders have come of age. They have their own international organization devoted to studying them, and treatments of proven efficacy have been developed (1,2). A respected personality disorders journal has been in press for nearly two decades. Intellectual ferment has never been more active in the personality disorders field.

Three articles in this issue of the Journal reflect this ferment and contribute to the ongoing dialogue about the future direction of personality disorders, especially in light of the anticipation of major changes in DSM-V. McGlashan and colleagues provide yet another significant contribution from the Collaborative Longitudinal Personality Disorders Study on the fate of four DSM-IV personality disorders: borderline, schizotypal, avoidant, and obsessive-compulsive. In 24-month blind follow-up assessments, the investigators were able to identify certain traits that were relatively fixed, whereas other criteria appeared to be more reactive and behavioral. In borderline personality disorder, for example, the authors suggested that the more stable criteria, such as anger and impulsivity, may represent the biogenetic core of borderline personality disorder, and the identification of these features may help with the modification of diagnostic criteria in future renditions of the DSM. They also speculated that the least stable criteria, such as self-injury and abandonment concerns, may be better targets for psychosocial interventions, while the core biological criteria may be the best targets for biological treatments. These suggestions have to be considered tentative, however, because, despite the authors efforts to take treatment into account (3), the details of which patients received which treatments were not specified.

Zittel Conklin and Westen provide another type of data about borderline personality disorder. In a continuation of previous work (46), these investigators sought to characterize borderline personality disorder patients in the community, compared to those who are studied in academic centers. Using the Q-sort method of providing personality descriptions, they found that borderline personality disorder patients seen in everyday practice appear to have more distress and emotional dysregulation than what is captured by the DSM-IV criteria. The two items most descriptive of the borderline personality disorder patients in their study were "tends to feel unhappy, depressed, or despondent" and "emotions tend to spiral out of control."

These findings will resonate with psychiatrists who attempt to treat this group of patients. Often people with borderline personality disorder are dismissed as "manipulators" or regarded pejoratively as "splitters." What these findings underscore is that these people are in pain and feel that they are at the mercy of a maelstrom at the core of their being. Clinicians must be trained to recognize this pain and to get beyond the negative and alienating features of borderline personality disorder patients in order to endure the emotional roller coaster ride that often accompanies the treatment.

The investigators emphasize the value of data provided by experienced clinical observers who see a patient over time. Research instruments that assess an individual at one snapshot in time are fraught with problems in the assessment of personality disorders (7). Patients with borderline personality disorder may be kaleidoscopically different from one week to the next based on their affective state and the vicissitudes of their object relationships (8).

A classic New Yorker cartoon from the early 1960s depicts a peacock with its spectacular tail in full splendor saying to a smaller bird with no tail whatsoever, "Now lets talk about you." The humor in the cartoon derives from the fact that every reader knows how it feels to be on the receiving end of a narcissistic display of self-importance. Indeed, in the third contribution on personality disorders featured in this issue of the Journal, Betan et al. report an empirically based description of countertransference responses to narcissistic patients that strongly resembles theoretical and clinical accounts. In a random sample of 181 psychiatrists and clinical psychologists from North America, the investigators tested a new questionnaire and found that it yielded eight clinically and conceptually coherent factors that were independent of the clinicians theoretical orientation. As one might anticipate, the eight factors were associated in predictable ways with axis II pathology. As part of their data analysis, they created a composite description of countertransference patterns in the treatment of patients who met the criteria for narcissistic personality disorder. They found that clinicians reported feeling resentment, anger, and dread in their interactions with the patient and tended to feel devalued and criticized by the patient. During their appointments with such patients, they felt distracted and avoidant and wished to end the treatment.

Clinicians have long known that patients with personality disorders re-create their characteristic mode of relatedness in their relationship with the clinician and impose a certain way of thinking, feeling, and reacting on the clinician. A problem for clinicians in systematically using this information diagnostically is that countertransference draws from the clinicians own conflicts and past experiences as well as from the feelings induced by the patient (9,10). Nevertheless, what the data from this investigation illustrate is that there is an "average expectable countertransference" that may transcend the highly specific individual feelings brought to the clinical setting based on ones own personal background. Professionals who work in group treatment settings, such as day treatment units or day hospitals, know that there are consistent reactions to certain types of patients, reflecting potential problems in the treatment.

A dilemma posed by the contemplation of including countertransference responses as an aid to the diagnosis of personality disorders, however, is that some forms of countertransference are largely unconscious. Often clinicians become aware of their feelings toward the patient only through small enactments, such as starting appointments late, getting sleepy to the point where the patient notices it, or making sarcastic comments in the guise of confrontation. Hence countertransference may be a discovery based on careful self-scrutiny that emerges in the course of the treatment.

Finally, if, as Betan et al. suggest, countertransference should be given the position of importance that it so richly deserves in the understanding and treatment of psychiatric patients, a formidable obstacle must be addressed. Self-reflection is no longer emphasized in residency training programs as it was in decades past. Trainees are not necessarily encouraged to have a personal psychotherapy experience to examine their own conflicts. Hence the realm of countertransference may be an unexplored continent. Psychiatry has long distinguished itself from other medical specialties by its attention to the clinicians feelings as an important diagnostic and therapeutic tool in its armamentarium. To effectively treat patients with personality disorders, that tool must not disappear through disuse atrophy.

http://ajp.psychiatryonline.org/cgi/content/full/162/5/833


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