© 2013 American Orthopsychiatric Association
DOI: 10.1111/ajop.12002
American Journal of Orthopsychiatry
2013, Vol. 83, No. 1, 115–125
It’s Not You, It’s Me: An Examination of Clinician- and
Client-Level Influences on Countertransference Toward
Borderline Personality Disorder
Rachel E. Liebman and Mandi Burnette
University of Rochester
Individuals with borderline personality disorder (BPD) appear more likely than individuals with other mental disorders to evoke negative countertransference reactions. The current study examined countertransference toward BPD across client- (e.g., client age and
gender) and clinician-level (e.g., age, discipline, clinical experience, training) factors. Participants (N = 560) completed an anonymous online survey in which they read case
information describing a client with BPD and answered questions to assess their reactions toward the client. The study used a 2 9 2 between-subjects design in which client
age and gender were experimentally manipulated. Despite receiving the same vignette, clinicians were more accurate in diagnosing the female client with BPD than the male client, and clinician reactions differed as a function of client age and clinician experience.
Speciﬁcally, clinicians viewed adolescent clients with BPD as less ill, less trustworthy,
and more dangerous than adults with BPD; more clinical experience among clinicians
was associated with more positive reactions to clients. Findings help to better understand
countertransference reactions and the ways they may impact diagnostic choices and treatment decisions. The implications of these ﬁndings for facilitating better clinician–client
matching, reducing clinician burnout, and improving treatment experiences for individuals with BPD are discussed.
T
modalities differ on the meaning of transference and countertransference dynamics, there is at minimum a consensus that
the strength of the relationship and the nature of the interactions between the client and therapist are the primary determinants of change (McHenry, 1994). According to many
theoretical models, the clinician–client dynamic reﬂects the
interpersonal dynamics within the client’s daily life. Reactions
elicited from the therapist are commonly believed to parallel
the reactions clients receive from other people in their lives.
Failure to address these reactions may hinder the treatment
progress by tacitly accepting a client’s dysfunctional behavior.
Clients may also interpret clinician reactions as signals of the
clinician’s empathy, understanding, and acceptance. Negative
countertransference reactions are likely to reinforce the clients’
self-critical feelings of worthlessness and hopelessness (Dinos,
Stevens, Serfaty, Weich, & King, 2004; Knight, Wykes, &
Hayward, 2003; Link & Phelan, 2006; Link, Struening, Rahav,
Phelan, & Nuttbrock, 1997; R€
usch, Lieb, Bohus, & Corrigan,
2006). As such, clinician reactions could affect a client’s willingness to seek or continue treatment.
Despite evidence that countertransference reactions can inﬂuence the therapeutic process, little research has examined which
characteristics of a client (e.g., age, gender) are most likely to
evoke negative reactions, or the clinician factors (e.g., training,
experience, contact) most associated with these reactions. At
the clinician level, reactions to a client may be inﬂuenced by
prior experiences, personality style, overidentiﬁcation with the
client, or they may be a reasonable response to the content a
he strength of the therapeutic relationship is one of the
best predictors of positive therapeutic outcomes (Shedler,
2010). Clinician countertransference reactions, deﬁned as
the therapists’ conscious and unconscious reactions to clients,
play a central role in the therapeutic process. Yet, little research
has examined what speciﬁc characteristics of the client (e.g.,
age, gender) are most likely to evoke negative reactions, or
which clinician factors (e.g., training, experience, contact) are
most associated with these reactions. The present study
addresses this need with regard to individuals with borderline
personality disorder (BPD).
Why Study Countertransference?
Countertransference reactions can inﬂuence treatment in a
multitude of ways. Freud (1910/1958) viewed countertransference as an obstacle that a therapist must overcome to maintain
a neutral stance in the therapeutic relationship. Since Freud,
the deﬁnition has been expanded to include any and all emotional reactions a therapist has toward a client (McHenry,
1994). Rather than being seen as a hindrance, many therapists
see countertransference as a useful and sometimes necessary
component of the therapeutic process. Although therapeutic
Correspondence concerning this article should be addressed to
Rachel Liebman, University of Rochester, Clinical and Social Sciences
in Psychology, RC Box 270276, Rochester, NY 14627. Electronic mail
may be sent to [email protected].
115
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LIEBMAN AND BURNETTE
client offers (McHenry, 1994). Burnout, characterized by distress and emotional exhaustion from the demands of clinical
work, may contribute to and result from negative reactions
(Schulze, 2007).
Countertransference and BPD
Research on countertransference reactions to speciﬁc disorders is sparse. Clients with BPD are frequent users of mental
health services and present with chronic symptom patterns
(Paris, 2005). Clients with BPD represent a particularly challenging population because of the interpersonal symptoms (e.g.,
emotional outbursts, acting-out behaviors, and self-harm or suicidal gestures) associated with the disorder (Aviram, Brodsky,
& Stanley, 2006; Cleary, Siegfried, & Walter, 2002; Fraser &
Gallop, 1993; James & Cowman, 2007; Markham & Trower,
2003). Many clinicians report feeling ill equipped and undertrained to effectively treat these individuals (Deans & Meocevic,
2006; Rossberg, Karterud, Pedersen, & Friis, 2007), and burnout rates are high for clinicians who work with this population
(Farber, 1990; Perseius, K
aver, Ekdahl, Asberg,
& Samuelsson,
2007). Under such pressures, clinicians may fall back on stereotypic diagnostic labels that carry connotations of dangerousness
and untreatability (Schulze, 2007). Stereotypes can foster distrust and weaken the therapeutic alliance (Aviram et al., 2006;
Markham & Trower, 2003). Beliefs that symptoms are within a
client’s control have been shown to foster unsympathetic attitudes toward the client (Lequesne & Hersh, 2004). For example, if clinicians assume acting-out behaviors are a bid for
attention rather than signs of illness, they may feel taken
advantage of or manipulated (Bradley & Westen, 2005). In
response, clinicians may be tempted to ignore or minimize the
severity of self-harm threats, which could have consequences
for client safety and well-being (McHenry, 1994).
Literature suggests that individuals with BPD are more likely
than individuals with other Axis I and Axis II disorders to
evoke negative countertransference reactions (Brody & Farber,
1996; Lewis & Appleby, 1988; McHenry, 1994; McIntyre &
Schwartz, 1998; Rossberg et al., 2007). Clients with BPD have
been shown to elicit more feelings of frustration, indifference,
and disdain as compared to clients with either affective or
schizophrenic disorders (Fraser & Gallop, 1993; Markham &
Trower, 2003). Clinicians view clients with BPD as more dangerous and express more social rejection toward them than
those with either schizophrenia or depression (Markham, 2003).
Both client-level and clinician-level factors are likely to be
important in understanding countertransference reactions to clients with BPD. Literature pertinent to each is summarized
below.
Client-Level Characteristics
Gender
Women represent as many as 75% of the individuals diagnosed with BPD (Widiger & Weissman, 1991). Controversy
exists regarding whether true gender differences exist for BPD,
or whether there is a bias in the DSM criteria or their application. A recent study (Wirth & Bodenhausen, 2009) suggests that
reactions may be more negative toward individuals with mental
illness when their symptoms are viewed as more gender typical.
In this study, participants read a case summary of an individual
with either a male-typical (alcohol abuse) or female-typical
(Major Depressive Disorder) diagnosis, with both gender and
type of disorder orthogonally manipulated. Gender-typical
cases were viewed with more negative affect, less sympathy,
and less desire to help. Other research suggests that therapists
view female-typical behaviors (regardless of client gender) as
more dysfunctional than male-typical behaviors (Lopez, 1989;
Teri, 1982). In either case, one might predict that women with
BPD would be more likely to elicit negative reactions from clinicians than men with BPD.
Age
The Diagnostic and Statistical Manual (APA, 2000) prohibits
the use of the BPD diagnosis in individuals less than 18 years of
age. Yet, data suggest that, although the diagnosis may lack stability across development, continuity exists between continuous
measures of BPD precursors in children and adolescents and the
level of subsequent BPD symptoms (Meekings & O’Brien, 2004;
Miller, Muehlenkamp, & Jacobson, 2008; Rogosch & Cicchetti,
2005; Trull, Useda, Conforti, & Doan, 1997). However, the
accuracy with which clinicians identify BPD features in adolescents and their impact on clinicians’ negative reactions remain
unknown. One possibility is that clinicians may view younger
clients with BPD with more empathy, interpreting their symptoms
as either developmentally normative or transitory. Alternatively,
clinicians may view youth with BPD more harshly, as earlier
BPD symptoms may be seen as more severe or challenging to
treat.
Clinician-Level Characteristics
With regard to clinician-level characteristics, various professional (e.g., experience, discipline) and personal (e.g., age) attributes appear likely to inﬂuence the clinician’s reactions. Prior
clinical experience appears to foster positive countertransference
toward clients; that is, experienced clinicians, deﬁned as licensed
practitioners with more years of experience, react less negatively
to clients with BPD and are less susceptible to burnout than novice therapists (e.g., graduate students, interns, trainees; Brody &
Farber, 1996; McIntyre & Schwartz, 1998). Studies document an
association between clinician discipline and attitudes about treatment, such that mental health clinicians report more positive attitudes toward individuals with mental illness than do medical
professionals (Commons-Treloar & Lewis, 2008a). Findings are
mixed with regard to treatment setting, frequency of prior contact, and amount of specialized training. Although some studies
have shown that working in outpatient settings and having more
contact and training are associated with positive attitudes toward
clients with BPD (Commons-Treloar & Lewis, 2008a, 2008b),
others have found the opposite (Jorm, Korten, Jacomb, Christensen, & Henderson, 1999). Still others have shown no association
at all (Hugo, 2001).
With regard to personal attributes, Jorm et al. (1999) found
differing effects of clinician age on attitudes toward depression and schizophrenia. Younger psychiatrists predicted more
117
COUNTERTRANSFERENCE AND BORDERLINE PERSONALITY DISORDER
negative outcomes for both disorders than did older psychiatrists. However, others have failed to replicate these effects
(Hugo, 2001). Overall, understanding the characteristics of clinicians who are particularly susceptible to countertransference
reactions is critical to ensure that education and training initiatives are directed appropriately. Clearly, more research is
needed to parse apart these speciﬁc attributes, as it may help in
efforts to understand negative countertransference reactions.
Purpose
The current study examined clinician reactions toward individuals with BPD across client- (age and gender) and clinicianlevel (clinician demographics and clinical experience) factors.
Based on the existing research, we hypothesized the following.
Diagnostic Decisions
•
•
When presented with the same case information, clinicians
would diagnose BPD more often for a female than a male
client and more often for an adult than an adolescent client.
Clinicians with more experience and specialized training
would be more likely to accurately diagnose BPD than
those without.
Countertransference Reactions
•
•
•
Clinician countertransference reactions would be more negative toward clients diagnosed with BPD as compared with
other disorders.
Clinician reactions would be more negative toward adults
versus children and women versus men with BPD.
Older clinicians and those with more clinical experience
(i.e., more years of experience, more client contact, and
more specialized training) would have more positive countertransference reactions toward clients diagnosed with
BPD than do younger or less experienced clinicians.
Method
Participants and Procedure
The ﬁnal sample of 560 clinicians was recruited through
email solicitations, professional listserv advertisements, and
word of mouth, with care taken to target clinicians from
diverse racial and ethnic backgrounds, geographical locations,
and primary disciplines. Inclusion was limited to clinicians that
were currently providing mental health treatment to clients to
ensure that attitudes would be based on ongoing experiences
with clients. No compensation was provided. Demographic
data are shown in Table 1. Out of N = 560 clinicians, most clinicians were female and Caucasian, and their mean age was
50 years. The study was approved by the appropriate Human
Subjects Review Board.
After reading an information letter describing the purpose of
the study, the clinicians completed an online survey. Web-based
surveys are a common method of recruiting professional
populations for psychological research and yield comparable
Table 1. Demographic Characteristics of the Study 2 Sample
(N = 560)
Gender
Male
Female
Race/ethnicity
Caucasian
Black
Hispanic
Asian/Paciﬁc Islander
Other
Primary discipline
Psychology
Psychiatry
Psychotherapy/social work
Years in profession
0–5
6–20
20+
Treatment setting
Residential/inpatient
Outpatient
Private practice
Years in treatment setting
0–5
6–20
20+
Number of BPD clients in career
0–5
6–20
20+
Special training (yes/no)
DBT
Mindfulness
CBT (e.g., STEPPS)
Psychotherapeutica
Education/skills
Otherb
N
% Yes
147
407
26.2
72.7
490
12
11
18
21
87.5
2.1
2.0
3.2
3.7
257
81
231
39.1
14.5
45.9
99
209
249
17.7
37.3
44.5
79
171
275
14.1
30.5
49.1
196
220
139
35.0
39.3
24.8
125
194
201
348
236
169
273
195
214
297
22.3
34.6
35.9
62.1
42.1
30.2
48.8
34.8
38.2
53.0
Note. Special training categories are not mutually exclusive.
BPD = Borderline Personality Disorder; DBT = Dialectical Behavior
Therapy; CBT = Cognitive Behavior Therapy; STEPPS = Systems
Training for Emotional Predictability and Problem Solving. aTransference-focused, schema-focused, mentalization-based therapies. bEye
Movement Desensitization and Reprocessing, trauma treatments, family
systems, etc.
results to paper and in-person assessments (Whitaker, 2007).
Each clinician read a vignette describing a client who met
DSM-IV criteria for BPD (no diagnosis was provided, but
symptoms were listed; see Appendix A for example vignette).
Vignettes were identical in all four conditions with the exception of gender and age of the client. The study used a 2
(age) 9 2 (gender) between-subjects design, with random
assignment to condition. Gender was modiﬁed through the use
of traditionally masculine or feminine names (Michael vs.
Jessica) and age was given as either 15 or 25 years in the vignette.
After reading the vignette, clinicians assigned the most
appropriate diagnosis for the client out of seven options (i.e.,
major depressive disorder, bipolar disorder, antisocial PD,
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LIEBMAN AND BURNETTE
histrionic PD, intermittent explosive disorder, borderline PD,
dissociative amnesia, other) and answered questions assessing
countertransference toward the client in ﬁve speciﬁc domains:
the extent to which the condition represented a behavioral
problem versus a mental illness (e.g., This client is not mentally
ill, he or she is just displaying bad behavior),1 distrust (e.g., I
would be concerned this client would lie to me), interpersonal
efﬁcacy (e.g., This client could make friends), empathy (e.g.,
How much do you empathize with this client), and chronicity
(e.g., This client’s condition is unlikely to improve over time).
Clinicians then received a second vignette in which the same client was facing legal charges for assault (see Appendix B) and
answered questions regarding the client’s level of dangerousness
(e.g., This client is a danger to others). Items were rated on a
4-point Likert scale, 1 (Strongly Disagree) to 4 (Strongly
Agree). Scale items were theoretically derived based on modiﬁed versions of existing surveys (Corrigan et al., 2002; Lewis &
Appleby, 1988) and were previously validated in a pilot sample
of N = 200 undergraduate students to provide support for the
six theoretically derived scales that were used in the current
study: empathy (n = 3; Cronbach’s alpha = .59), chronicity
(n = 4; Cronbach’s alpha = .71), conduct problems (n = 6;
Cronbach’s alpha = .69), distrust (n = 8; Cronbach’s alpha
= .72), interpersonal efﬁcacy (n = 6; Cronbach’s alpha = .82),
and dangerousness (n = 3; Cronbach’s alpha = .68). Hypothesized scales were conﬁrmed using principal factor analyses with
varimax rotation; components were chosen based on a combination of having eigenvalues >1 and upon examining the scree
plot (see Table 2 for a full list of items and factor loadings).
Final scores reﬂect the average of scale items. The scales correlations are shown in Table 3.
Finally, to assess differences in reactions across clinical experience, clinicians were asked to provide basic demographic
information (e.g., age, gender, race, or ethnicity); their discipline (e.g., psychiatrist, psychologist, master’s level therapist,
etc); treatment setting (e.g., private practice, inpatient, outpatient, etc); years of experience; and number of clients with BPD
treated.
Analyses
Analyses were conducted using SPSS version 16 (IBM, Chicago, IL). The ﬁrst set of analyses examined diagnostic decision-making. First, chi square tests assessed differences in the
accuracy of diagnostic choice across client age and gender.
Next, logistic regression analyses assessed whether clinician
characteristics signiﬁcantly predicted making an accurate versus
inaccurate diagnostic choice (BPD vs. Other). To examine
whether specialized training in treatment of BPD predicted
diagnostic accuracy, special training was included in this model
as a dichotomous (yes/no) variable. Then, to examine the differences in diagnostic accuracy across different types of special
training (e.g., dialectical behavior therapy [DBT], education, or
skills-based, etc.), a second logistic regression assessed the subsample of clinicians who indicated that they had received special training (n = 349).
1
Higher scores indicate more of a behavior problem.
Table 2. Factor Loadings and Alpha Coefficients of Study 2
Scale Items
Scale
Factor loading
Empathy (a = .59)
How much do you like
How much do you want to help
How much do you empathize with
Chronicity (a = .71)
Is never going to get better
Condition is unlikely to improve over time
Behavior is a permanent pattern of
relating to others
Will probably always be this way
Conduct Problem (a = .69)
Behavior is typical of people same age
Behavior is just a phase
Is not mentally ill, just displaying bad behavior
Will outgrow these behaviors with age
Behavior is the product of mental illnessa
Is exaggerating symptoms
Distrust (a = .72)
I would be concerned client would lie to me
Is unlikely to comply with treatment
Could be manipulative
Is responsiblea
Is reliablea
I would take what client says at face valuea
I would seek independent corroboration of
what client tells me
How much do you ﬁnd client annoying
Interpersonal efﬁcacy (a = .82)
Could make friends
Could be well liked by peers
Could be a good friend
Could be compassionate
Probably has close friends
Can be successful in life
Dangerousness (a = .68)
Is a danger to the community
Is a danger to herself
Is a danger to others
.539
.525
.531
.563
.626
.489
.705
.502
.629
.585
.510
.451
.390
.619
.409
.517
.440
.477
.525
417
.416
.757
.775
.728
.652
.426
.446
.572
.559
.792
Note. Scales are scored in the direction of the name, 1 = strongly
disagree, 4 = strongly agree. aDenotes reverse scored items.
The remaining analyses examined the countertransference
reactions toward BPD; therefore, the sample was ﬁltered to
include only clinicians who agreed on the BPD diagnosis
(n = 480). Between-subjects multivariate analyses of variance
(MANOVAs) were used to assess differences in clinician attitudes (assessed using the scales described earlier) across accuracy of diagnostic choice (BPD vs. Other), client age and
gender, and clinician characteristics.
Results
Attitudes
Table 4 shows overall mean levels for attitude scales. Overall,
clinicians endorsed relatively positive attitudes toward the client
portrayed in the vignette, with means ranging from 3.05
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COUNTERTRANSFERENCE AND BORDERLINE PERSONALITY DISORDER
(SD = 0.53) of a possible 4 for empathy to 1.71 (SD = 0.42) of
a possible 4 for conduct problem. These scores indicate that, in
general, clinicians agreed that they liked the client and that the
client could make friends and disagreed that the client would
never get better or was displaying a behavior problem. At the
same time, clinicians agreed that the client was distrustful
(M = 2.79, SD = 0.38 out of 4) and dangerous to self and others (M = 2.76, SD = 0.42 out of 4).
cians who had treated more BPD clients were more likely to
diagnose the client with BPD (OR = 1.36, p = .055).
Among the clinicians who had received special training speciﬁc
to BPD, DBT, and educational or skills-based programs signiﬁcantly predicted BPD diagnoses. Clinicians with special training
in DBT were more likely to diagnose BPD (OR = 3.17, p = .001)
than those without DBT training, whereas those with educational
or skills-based experience were less likely than those without
(OR = .46, p < .01; see Table 7).
Client-Level Predictors of Diagnosis
Diagnoses were collapsed into BPD, Bipolar, and Other.
Consistent with Hypothesis 1, adults were more likely to be
diagnosed with BPD than adolescents, and female clients more
than male clients (see Table 5). There was an interaction of
gender and age such that the adult woman was more likely to
be diagnosed with BPD than the adolescent girl, whereas the
opposite was true in the male condition, v2(1) = 8.34, p < .01.
Clinician-Level Predictors of Diagnosis
There was a signiﬁcant omnibus effect of clinician characteristics, v2(11) = 41.27, p < .0001 (see Table 6); clinicians in outpatient settings were less likely to diagnose the client with BPD
than clinicians in private practice (OR = .56, p < .05), and clini-
Table 3. Bivariate Pearson’s Correlations Between Scales
1
1. Empathy
2. Chronicity
3. Conduct
problem
4. Distrust
5. Interpersonal
efﬁcacy
6. Dangerousness
1.00
.37***
.07
2
3
1.00
.05
1.00
4
.28***
.25***
.32***
.33***
.02
.25***
1.00
.31***
.02
.10*
.20***
.24***
5
6
1.00
.21***
1.00
Countertransference by Diagnosis
There was a multivariate effect of diagnosis on clinician reactions, Wilks’ k = .973, F(7, 529) = 2.08, p < .05. As predicted,
clinicians who assigned a diagnosis of BPD were less empathic,
F(1, 537) = 4.16, p < .05; M = 3.03 (.03), and thought the
client’s condition was less of a conduct problem, that is, more
ill, F(1, 537) = 5.74, p < .05; 1.69 (.02), than those who
assigned other diagnoses, empathy: M = 3.13 (.15); conduct
problem: M = 1.79 (.04).
Client-Level Predictors of Countertransference
Among the clinicians who agreed on the BPD diagnosis
(n = 480), there was a multivariate effect of age, Wilks’
k = .904, F(7, 470) = 7.15, p < .0001. Clinicians rated the adolescent client as having more conduct problems than the adult,
F(1, 476) = 12.46, p < .0001; M = 1.76 (.03), conduct problem:
M = 1.64 (.03). They also rated the adolescent as less trustworthy, F(1, 476) = 17.14, p < .0001; M = 2.86 (.03), and more
dangerous, F(1,476) = 7.28, p < .01; M = 2.82 (.03), than the
adult, distrust: M = 2.72 (.02); dangerousness: M = 2.71 (.03).
Contrary to our expectations, client gender was not associated
with clinician reactions.
Clinician-Level Predictors of
Countertransference
As shown in Table 8, there were also effects of clinician age,
Wilks’ k = .880, F(7, 383) = 7.46, p < .0001, primary discipline,
*p < .05. ***p < .001.
Table 4. Overall Attitude Scale Means (N = 560)
M (SD)
Empathy
Chronicity
Distrust
3.05 (0.53)
1.87 (0.42)
2.79 (0.38)
Conduct problem
Interpersonal efﬁcacy
Dangerousness
1.71 (0.42)
2.72 (0.42)
2.76 (0.42)
Note. Items rated on 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree).
Table 5. Frequency Data and Chi Square Results for Clinician Diagnosis Across Vignette Age and Gender (N = 560)
Borderline Personality Disorder
Bipolar
Other
Male N (%)
n = 274
Female N (%)
n = 285
200 (73.0)
52 (19.0)
22 (8.0)
229 (80.4)
34 (11.9)
22 (7.7)
v2
4.24*
5.33*
0.02
Adult N (%)
n = 267
Adolescent N (%)
n = 292
218 (81.6)
31 (11.6)
18 (6.7)
211 (72.3)
55 (18.8)
26 (8.9)
Note. Other includes Antisocial PD, Histrionic PD, Intermittent Explosive Disorder, MDD, SUD, etc.
*p < .05. **p < .01.
v2
6.89**
5.59*
0.90
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LIEBMAN AND BURNETTE
Table 6. Logistic Regression Clinician Demographics and Professional Experience Characteristics Main Effects on Diagnosis
(Borderline Personality Disorder [BPD] vs. Other; n = 475)
Item
Standard
Error
95% CI
1.75*
1.57*
0.22
0.22
1.13–2.72
1.02–2.43
0.63
0.81
0.77
0.98
1.36
0.97
0.56*
1.73
0.74*
1.36†
1.45
0.40
0.41
0.26
0.01
0.29
0.36
0.27
0.37
0.13
0.16
0.25
0.29–1.36
0.37–1.81
0.47–1.27
0.96–1.00
0.78–2.39
0.48–1.95
0.33–0.95
0.84–3.58
0.57–.96
0.99–1.86
0.89–2.36
OR
Step 1: v (2) = 11.94, p < .01
Vignette age
Vignette gender
Step 2: v2(4) = 29.33, p = .001
Therapist (vs. Psychiatrist)
Psychologist (vs. Psychiatrist)
Therapist (vs. Psychologist)
Clinician age
Clinician gender
Inpatient (vs. Private practice)
Outpatient (vs. Private practice)
Inpatient (vs. Outpatient)
Years in treatment setting
BPD clients in during career (vs. none)
Special training (vs. none)
2
†
p = .06. *p < .05.
Table 7. Logistic Regression Specialized Training Main Effects
on Diagnosis (Borderline Personality Disorder vs. Other) for
Clinicians With Any Specialized Training (n = 349)
Item
Step 1: v2(2) = 3.99, p > .05
Vignette age
Vignette gender
Step 2: v2(6) = 28.55, p < .0001
Dialectical behavior therapy
Mindfulness
Cognitive behavior therapy
specialized
Psychotherapeutic
Educational/skills
Other
OR
Standard
Error
95% CI
0.70
0.70
0.26
0.26
0.42–1.17
0.42–1.17
3.17**
0.98
0.69
0.34
0.34
0.32
1.63–6.19
0.50–1.92
0.37–1.28
1.51
0.46**
0.53
0.29
0.29
0.35
0.86–2.64
0.26–0.81
0.27–1.04
**p < .01.
Wilks’ k = .941, F(14, 766) = 1.70, p = .05, special training,
Wilks’ k = .944, F(7, 383) = 3.23, p < .01, and number of clients with BPD treated throughout their career, Wilks’ k = .962,
F(7, 383) = 2.17, p < .05. There was a signiﬁcant multivariate
effect of educational or skills-based trainings, Wilks’ k = .948,
F(7, 285) = 2.23, p < .05. Later, speciﬁc scale-level effects were
summarized by countertransference domain.
Empathy
There was a signiﬁcant main effect of primary discipline,
F(2, 389) = 4.71, p = .01; master’s level therapists were more
empathic toward clients with BPD than psychiatrists (p < .01).
Clinicians with special training related to BPD were more
empathic than those without, F(1, 389) = 12.29, p = .001; prior
educational or skills-based trainings were associated with higher
empathy, F(1, 291) = 4.12, p < .05.
Chronicity
Clinicians who had treated more clients with BPD,
r2 = .12, F(1, 389) = 7.02, p < .01, and those who had special
training, F(1, 389) = 5.31, p < .05, felt that the client’s condition was less chronic than those without such experience or
training with this disorder. Prior training in both mindfulness,
F(1, 324) = 7.98, p < .01, and other modalities (e.g., eye movement desensitization and reprocessing, trauma treatments, family systems, etc.) F(1, 291) = 7.22, p < .01, was associated with
lower chronicity.
Conduct Problem
Older clinicians felt that the client was less of a conduct
problem (i.e., more ill) than younger clinicians, r2 = .24,
F(1, 389) = 14.64, p < .0001.
Distrust
There was a signiﬁcant effect of discipline on distrust, F(2,
389) = 3.40, p < .05; psychologists and master’s level therapists
viewed the client as less trustworthy than psychiatrists
(p < .01). Clinicians with BPD-related training felt that the client was more trustworthy than those without, F(1, 389) = 5.27,
p < .05.
Interpersonal Efficacy
Older clinicians, r2 = .33, F(1, 389) = 14.51, p < .0001, felt
that the client was less interpersonally efﬁcacious than younger
clinicians. Prior training in psychotherapeutic techniques,
F(1, 291) = 5.32, p < .05, was related to beliefs of lower interpersonal efﬁcacy, but educational or skills-based training,
F(1, 291) = 6.83, p < .01, was associated with higher interpersonal efﬁcacy.
Dangerousness
Older clinicians felt that the client was more dangerous than
younger clinicians, r2 = .18, F(1, 389) = 12.03, p = .001. However, treating more clients with BPD was related to lower dangerousness, r2 = .07, F(1, 389) = 5.03, p < .05, as was prior
training in DBT, F(1, 291) = 7.58, p < .01.
Discussion
We examined clinicians’ countertransference toward BPD
across client-level (client age and gender) and clinician-level (clinician demographics and professional experience) factors. Consistent with past research, we found evidence that the BPD
label was associated with negative countertransference reactions
(Gallop, Lancee, & Garﬁnkel, 1990; Markham & Trower, 2003;
Rossberg et al., 2007). Speciﬁcally, despite the fact that all clinicians in the study read an identical vignette describing a client
with BPD, those clinicians who accurately labeled the client as
BPD exhibited lower levels of empathy toward the client and
also viewed the client as more ill (i.e., less of a conduct problem) than clinicians who chose other diagnoses. The study also
121
COUNTERTRANSFERENCE AND BORDERLINE PERSONALITY DISORDER
Table 8. MANOVA of Clinician Demographics and Professional Experience Main Effects on Attitudes for Clinicians Who Diagnosed
Borderline Personality Disorder (n = 480)
Scale
Primary discipline
Psychologist
Psychiatrist
Therapist/LMSW
Special training
Yes
No
DBT
Yes
No
Mindfulness
Yes
No
CBT specialized
Yes
No
Psychotherapeutic
Yes
No
Educational/skills
Yes
No
Other
Yes
No
Race/ethnicity
Caucasian
Non-Caucasian
Empathy
M (SD)
Chronicity
M (SD)
Conduct
M (SD)
Distrust
M (SD)
IE
M (SD)
Danger
M (SD)
3.02 (.51)
2.85 (.52)**
3.10 (.50)**
1.88 (.41)
1.96 (.48)
1.86 (.41)
1.83 (.45)
1.59 (.44)
1.64 (.38)
2.77 (.36)**
2.91 (.37)**
2.77 (.38)**
2.76 (.39)
2.57 (.48)
2.74 (.43)
2.72 (.42)
2.76 (.44)
2.80 (.42)
3.11 (.47)***
2.90 (.54)***
1.82 (.43)*
1.99 (.40)*
1.69 (.40)
1.71 (.43)
2.75 (.38)*
2.86 (.36)*
2.77 (.41)†
2.63 (.43)†
2.73 (.41)
2.81 (.43)
3.15 (.51)
3.04 (.43)
1.79 (.43)
1.90 (.40)
1.70 (.39)
1.67 (.42)
2.71 (.39)
2.83 (.34)
2.81 (.40)
2.67 (.42)
2.69 (.42)**
2.83 (.38)**
3.19 (.51)
3.04 (.46)
1.73 (.42)**
1.92 (.40)**
1.68 (.42)
1.70 (.38)
2.70 (.38)
2.80 (.37)
2.82 (.40)
2.71 (.42)
2.74 (.41)
2.73 (.41)
3.12 (.56)
3.12 (.47)
1.89 (.42)
1.81 (.42)
1.75 (.43)
1.68 (.39)
2.78 (.37)
2.74 (.38)
2.84 (.41)
2.75 (.41)
2.67 (.43)
2.75 (.40)
3.09 (.50)
3.14 (.49)
1.83 (.42)
1.82 (.43)
1.64 (.40)
1.74 (.40)
2.78 (.37)
2.72 (.39)
2.70 (.43)*
2.83 (.39)*
2.74 (.39)
2.73 (.43)
3.21 (.48)*
3.06 (.49)*
1.77 (.41)
1.85 (.43)
1.68 (.43)
1.70 (.39)
2.75 (.38)
2.75 (.38)
2.87 (.39)**
2.71 (.41)**
2.76 (.40)
2.72 (.42)
3.13 (.44)
3.12 (.50)
1.65 (.44)**
1.85 (.42)**
1.65 (.42)
1.70 (.40)
2.71 (.28)
2.75 (.39)
2.80 (.39)
2.77 (.41)
2.71 (.47)
2.74 (.40)
2.76 (.41)*
2.96 (.43)*
1.89 (.43)
1.86 (.41)
1.69 (.43)
1.79 (.41)
2.79 (.37)
2.77 (.40)
2.71 (.43)
2.81 (.42)
2.76 (.42)
2.73 (.43)
Note. IE = Interpersonal Efﬁcacy; LMSW = Licensed clinical social worker; DBT = Dialectical Behavior Therapy; CBT = Cognitive Behavioral Therapy;
PT = Psychotherapeutic interventions. Asterisked values in adjacent cells within the same column are signiﬁcantly different from each other at
* p = .05. ** p < .01. *** p < .001.
expanded upon prior literature by examining clinician- and client-level factors that were associated with these reactions, with
results suggesting client age, client gender, and several clinicianlevel factors may all inﬂuence the way clinicians respond to clients with BPD.
Age
Our ﬁndings highlight some potential concerns with regard
to the use and impact of the BPD label among youth. As
expected, clinicians were less likely to diagnose BPD in adolescents versus adults presenting with BPD symptoms. Lower
rates of diagnosis may be because of a failure to accurately
identify the symptoms as BPD or may reﬂect unwillingness to
“prematurely” label the adolescent with a personality disorder
before his or her personality has fully developed. In addition,
BPD tendencies may also be conﬂated with normative adolescent “storm and stress” and thus not identiﬁed as indicative of
early BPD. Regardless of the cause, research increasingly suggests that early identiﬁcation of BPD in youth, while fraught
with some costs, may provide some beneﬁt. Several studies
show that without treatment, BPD symptoms are moderately
stable over development (Crick, Murray-Close, & Woods, 2005;
Meekings & O’Brien, 2004; Miller et al., 2008; Rogosch &
Cicchetti, 2005; Shiner, Masten, & Tellegen, 2002). Therefore,
to the extent that failure to diagnose BPD may hinder access to
appropriate interventions, this could negatively impact the
treatment of youth with BPD. Even more troubling, among clinicians who applied the BPD diagnosis, those in the adolescent
condition rated their client as less ill, less trustworthy, and
more dangerous than those in the adult condition. Such ﬁndings suggest that clinicians may be more inclined to view youth
with BPD as “bad” rather than “ill” as compared to adults and
to exhibit more negative attitudes toward them. Future research
is warranted to evaluate the direct inﬂuence of these negative
attitudes on therapist–client relationships.
Gender
Consistent with prior literature (Becker & Lamb, 1994;
Hartung & Widiger, 1998; Kaplan, 1983), our ﬁndings do suggest potential gender biases in the application of the BPD label.
Despite receiving the same vignette except for the client’s name,
clinicians were more accurate in diagnosing the female client
with BPD while tending to misdiagnose the male client.
Thus, expanding on literature demonstrating a gender-biased
122
LIEBMAN AND BURNETTE
overdiagnosis of BPD in women, our data suggest that there
may also be a bias toward underdiagnosing BPD in men. This
ﬁnding raises concerns regarding treatment delivery, particularly for men. Namely, if clinicians fail to diagnose BPD when
indicated, men may not get the treatment they need.
In contrast to literature highlighting gender as a moderator of
attitudes (Henry & Cohen, 1983; Klonsky, Jane, Turkheimer, &
Oltmanns, 2002; Wirth & Bodenhausen, 2009), we did not ﬁnd
differences in clinicians’ reactions to the male and female clients
with BPD. Although this may suggest that clinicians do not
react differently to clients with BPD on the basis of gender,
another explanation for this discrepancy may be that clinicians
do not feel comfortable admitting to negative attitudes toward
this population and were conscious of the social undesirability
of explicitly admitting to gender-based assumptions of BPD
symptoms. Although the anonymous nature of an online survey
helps to provide a safe environment for clinicians to report
their true feelings, nonetheless, self-report assessments of attitudes rely on the willingness of respondents to answer honestly,
even though doing so may be undesirable. Demand characteristics may preclude clinicians from admitting to or even being
aware of stigmatizing attitudes. Indeed, examining overall mean
attitude levels for the sample shows that clinicians tended to
rate the client positively, with mean levels generally falling at
around 2.70, indicating that they agreed with statements assessing empathy and interpersonal effectiveness and disagreed that
the client would never get better. Studies using implicit measures to test attitudes might be more effective at circumventing
these social desirability factors.
Interestingly, there was also an interaction of gender and
age, such that adult females and adolescent males were the
most likely to be diagnosed with BPD. Although this ﬁnding
warrants replication, it raises some questions with regard to
the conﬂuence of gender norms and adolescent development.
Following from the Klonsky et al. (2002) ﬁnding that genderatypical behaviors may be interpreted as indicative of BPD,
our ﬁndings may imply that, for men, this relationship exists
only for those who present with BPD symptoms early in development. Adolescent males may be more likely than adult males
to express female-typical symptoms such as affective lability,
unstable interpersonal relationships, and suicidal or self-harming
gestures, and thus, may be more likely to be diagnosed with
BPD. Future research is needed to look at the impact of gender
across age before any conclusive statements can be made.
Clinician Factors
The present study identiﬁed a number of clinician characteristics that appear to play a role in countertransference toward
clients with BPD. Consistent with past research (CommonsTreloar & Lewis, 2008b; Hugo, 2001; Jorm et al., 1999), master’s level therapists, psychologists, and individuals who treated
more clients with BPD or who had training speciﬁc to BPD
endorsed more positive reactions. Older clinicians and, to a
smaller extent, psychiatrists were more negative. These factors
are likely to play an important role in the therapeutic relationship such that by being cognizant of their personal and professional characteristics that may contribute to negative reactions,
clinicians may be better able to manage countertransference
dynamics that could adversely impact treatment.
For instance, it is notable that psychologists and master’s
level therapists, although more empathic, viewed their clients’
symptoms as more of a conduct problem and were less trusting
of them than psychiatrists. To understand this ﬁnding better,
we conducted post hoc analyses to examine whether differences
in training and experience across clinician discipline might help
explain this pattern. With the given literature suggesting a link
between personal contact and positive attitudes toward mental
illness (Commons-Treloar & Lewis, 2008a, 2008b), our ﬁrst
thought was that psychiatrists may have less direct contact with
this population. A one-way ANOVA of the number of clients
treated by clinician discipline revealed that psychiatrists
reported treating signiﬁcantly more clients with BPD than psychologists or master’s level therapists, F(2, 515) = 12.67,
p < .0001, over the course of their careers, indicating that the
amount of contact alone may not fully explain countertransference. We next examined the differences in diagnostic accuracy
across discipline, hypothesizing that differences in the degree to
which clinical disciplines emphasize diagnostic classiﬁcation
may impact attitudes. A one-way ANOVA of diagnosis by discipline indicated that, while psychiatrists and psychologists did
not differ in their accuracy, master’s level therapists were significantly less likely to diagnose BPD than the other two groups,
F(2, 553) = 3.14, p < .05. These analyses seem to support our
original hypothesis that differences in attitudes may reﬂect differences in the theoretical perspectives emphasized in each discipline. Namely, in utilizing a medical model, psychiatrists may
focus more on diagnostic criteria to conceptualize clients,
whereas master’s level therapists, who often lean more toward
a person-centered approach, put more weight on individual
symptom presentations in making their clinical impressions. In
doing so, psychiatrists may overemphasize the client’s actingout behaviors, which may result in a more distrustful attitude
toward them. Of course, these ﬁndings are purely exploratory,
and further research is needed to understand these differences
better.
However, the results of the present study also make salient
the complex interplay between these many clinician characteristics and the need for further research to parse apart the speciﬁc
aspects of each professional characteristic that are most closely
associated with negative countertransference. As an example,
our ﬁndings highlight the importance of distinguishing between
clinician experience and age. Whereas the former reﬂects active
hands-on practice and training, the latter may point to individuals who have not had specialized training as recently as or as
often as younger clinicians. Clinicians would be wise to take
these subtleties into account when reﬂecting on the personal
factors that might be playing into their reactions to clients.
Likewise, although our study highlights the importance of
hands-on practice early in training, the question of what
“hands-on practice” entails has yet to be answered. Perhaps the
difference in attitudes between psychiatrists and master’s level
therapists could be attributed to differences in the length or
intensity of the relationship with the client. Master’s level therapists can work closely with a client for years conducting case
management and intensive psychotherapy multiple times a
week, whereas psychiatrists are limited to a 30-min session
COUNTERTRANSFERENCE AND BORDERLINE PERSONALITY DISORDER
often less than once a month. Depending on which characteristics
prove most inﬂuential, the type, structure, and intensity of the
training model that is best will vary.
Our ﬁndings suggest that direct exposure to this population
early in clinical training and continuing throughout one’s career
is beneﬁcial to enhancing feelings of competence, which, in
turn, fosters positive countertransference. Although this recommendation may be counterintuitive given the common view that
novice therapists should not receive difﬁcult patients before
they have accumulated the experience to handle them, our
results suggest that early experience when supervision is more
consistent and intensive may be the most effective means of
building competence with difﬁcult populations.
The present study has a number of important strengths and
weaknesses. The emphasis on both client and clinician factors as
well as speciﬁc domains of countertransference toward BPD clients is unique. This approach allowed us to understand the discrete factors that play into clinicians’ reactions to these difﬁcult
clients, which, in turn, provided a more in-depth understanding
of factors that both strengthen and challenge the therapeutic
relationship. In constructing the vignette, we took care to
include no additional information beyond the DSM symptoms
of BPD to avoid unduly biasing the clinicians’ attitudes. At the
same time, the online self-report format of the survey limited
the conclusions that could be drawn from our results. Using a
convenience sample, we were not able to ensure equal cell sizes,
making it difﬁcult to examine moderating effects of clinician
characteristics. Likewise, our sample size precluded us from
being able to examine more intricate pathways between different
context variables. In understanding the null results obtained for
some of our main hypotheses (e.g., gender differences), it is also
likely that a vignette design is simply not a strong enough
manipulation to accurately assess clinicians’ implicit biases
toward BPD. Instead, the association between gender and negative attitudes toward BPD may be more accurately assessed
implicitly (i.e., using a computerized implicit association task)
in which the purpose of the study is less transparent (Peris,
Teachman, & Nosek, 2008; Stier & Hinshaw, 2007; Teachman,
Wilson, & Komarovskaya, 2006). Clients with BPD are a particularly difﬁcult population to serve because of their high sensitivity to rejection, need for acceptance, and associated self-harming
gestures. However, the population is only one of many trying
clientele with which clinicians interact. We focus on this disorder because it is commonly encountered in clinical settings.
However, these ﬁndings are likely to apply to other disorders,
and further research is needed to conﬁrm generalizeability to
other clinical populations. Finally, data were cross-sectional and
causality cannot be inferred.
Nonetheless, the ﬁndings of the present study are noteworthy. The diagnostic classiﬁcation system exists as a framework to guide treatment efforts, but this framework is only
as effective as the diagnostician using it. Our results suggest
that there may be both age and gender biases in the way
that clinicians apply the BPD label. We also found systematic differences in attitudes based on different aspects of clinician experience and training. Together, these ﬁndings
suggest that more education in the form of hands-on practice
is necessary to improve clinicians’ familiarity and comfort
with the BPD diagnosis.
123
Conclusions
The current study is an important addition to the BPD literature, as it highlights the fact that clinician attitudes are not a
black-and-white issue, but rather are a mixture of complex
reactions based on both the client’s and the clinician’s personality and experiences as well as the interaction between the
two. Our ﬁndings suggest a number of client- and clinicianlevel factors that impact clinicians’ countertransference reactions toward borderline personality disorder. Education efforts
should be tailored accordingly to address these factors. For
example, novice clinicians may beneﬁt from more specialized
training to address burnout, increase competence, and facilitate
awareness of implicit reactions. A more in-depth investigation
of the methods seasoned clinicians use to manage their negative
countertransference would be helpful for less experienced clinicians who are at a greater risk of burnout (Farber, 1990).
More education on the developmental appropriateness of recognizing BPD symptomology in youth and discussion of gender biases underlying the disorder would also foster a deeper
awareness of common misattributions that may facilitate negative reactions. Understanding these factors serves to inform
education efforts to facilitate better clinician–client matching, ease rapport building, and ultimately increase treatment
efﬁcacy.
Keywords: clients with borderline personality disorder; therapists; countertransference; self-harm; borderline personality disorder; client–clinician dynamic; clinician bias; gender-typical
behavior; dialectical behavior therapy
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COUNTERTRANSFERENCE AND BORDERLINE PERSONALITY DISORDER
Appendix A
BPD Vignette
Jessica is a 15-year-old girl who lives at home with her parents and is getting ready to start high school. In general, Jessica
is impulsive and doesn’t think about the consequences of her
actions. When she goes out, she tends to binge-drink and often
ends the night with one-night stands. She has a pattern of
unstable relationships with people very close to her, alternating
over the course of a day between loving them one moment and
hating them the next. Moreover, she has a fear of being left by
people close to her and is known to do whatever she can to
keep people from leaving her.
Jessica describes having rapid mood swings over the course
of a day. She reports feeling like she doesn’t know who she is
from day to day and talks about feeling sad and empty most of
the day. Jessica has trouble controlling her anger. She fre-
125
quently blows up at people unnecessarily and she reports that
she is often unable to remember what happened afterwards.
She periodically talks about killing herself and has a history of
cutting herself.
Appendix B
Dangerousness Vignette
You have been seeing Jessica for 2 weeks. In the third week
Jessica tells you that she has gotten into some legal trouble.
Jessica had been drinking and got into a ﬁght with another person who she thought was ﬂirting with her boyfriend. She claims
she doesn’t remember what happened, but the police showed
up at her door saying that the victim is pressing charges against
her for assault. They also tell her the victim was being treated
for a broken collarbone and a concussion and has since been
released from the hospital.