however, is a way of transcending some of the limitations inherent in clinical theories derived from case studies, in which a single clinician attempts to classify countertransference experiences or constellations based on his or her own experience with a limited number of patients. By using an instrument that provides a “common language” for describing a subtle clinical phenomenon, Betan and colleges can essentially pool the knowledge of dozens of clinical observers, identifying latent constructs (varieties of countertransference experience) that reflect patterns that individual observers themselves may not have recognized. Second, although every clinician and every therapeutic dyad is distinct, the significant correlations between the countertransference factors and personality disorder symptoms suggest that countertransference responses occur in coherent and predictable patterns. The associations between countertransference patterns and personality disorder characteristics support the broad view of countertransference reactions as useful in the diagnostic understanding of the patient’s dynamics, particularly those involving repetitive interpersonal patterns. To the extent that patients sharing diagnostic features on axis II have similar ways of thinking, feeling, and behaving interpersonally, one would expect them to evoke similar reactions from others, including therapists, and this appears to be the case. Third, data from clinicians of different theoretical orientations showed similar patterns vis-à-vis patients with particular kinds of pathology, suggesting that the results are not artifacts of clinicians’ theoretical preconceptions. What is striking about this finding is that coherent patterns of countertransference response emerge in treatments regardless of whether the clinician even “believes” in the concept of countertransference responses or has been trained to attend to them. Finally, the empirical portrait of countertransference responses toward patients with narcissistic personality disorder points to the way researchers can use this measure to create empirical prototypes of subtle countertransference constellations with patients presenting with specific types of personality disturbance. In principle, with a large enough sample, one could empirically map the terrain of countertransference patterns in response to multiple forms of personality pathology. One could also identify distinct constellations within diagnoses (e.g., different kinds of narcissistic patients) or to patients who share certain experiences (e.g., survivors of childhood sexual trauma) that may occur across treatments, at different points in therapy, or at different points in a single therapy hour. In working with survivors of childhood sexual abuse, for example, clinicians often face the opposite danger of pushing too much or too early for the patient to remember— and potentially recapitulating the patient’s subjective experience of unwanted penetration, abuse, or lack of boundaries—versus avoiding discussion of traumatic events in intimate detail for fear of traumatizing the patient— and potentially recapitulating the patient’s experience of unacknowledged but shared secrets or the inability or unwillingness of a caregiver who knew about the abuse to talk about it. Identification of such patterns as common constellations in the treatment of abuse survivors could be very useful in teaching clinicians about potential countertransference dangers inherent in working with abuse survivors in a way that is both clinically sensitive and empirically grounded. G$#.1/.\!
Ephi Betan, Ph.D. Amy Kegley Heim, Ph.D. Carolyn Zittel Conklin, Ph.D. Drew Westen, Ph.D.
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