Managing acute paranoid transferences in severe personality disorders: A qualitative study of experienced psychodynamic therapists’ narratives.

What is it about?

This study explores what happens when people with severe personality difficulties begin to experience their therapist as threatening, hostile, or untrustworthy. During these moments, even an attempt to help may feel like criticism, control, or an attack. This can place considerable strain on the relationship and make it difficult for both patient and therapist to think clearly about what is happening. Drawing on accounts from 13 experienced therapists, the study examines how these situations unfold, what feelings they stir in therapists, and how therapists try to respond. Participants described feeling anxious, physically tense, helpless, angry, or pulled toward defending themselves, reassuring the patient, or correcting the patient’s view of events. Their accounts suggest that responding helpfully often starts with recognizing and managing these reactions. Therapists described the importance of slowing down, remaining curious, and taking the patient’s distress seriously without agreeing that the therapist is trying to cause harm. Keeping clear boundaries while maintaining an open and respectful attitude also appeared important. The study highlights responses that may deepen the difficulty, such as arguing over facts, offering reassurance too quickly, or becoming overly confrontational. It also explores how supervision can help therapists regain perspective and understand their own contribution to the interaction. Rather than testing which treatment works best, the paper offers a picture of challenging moments in psychotherapy. It suggests that the ability to remain thoughtful under emotional pressure is central to helping patients feel understood and creating opportunities to explore mistrust, repair the relationship, and continue therapeutic work.

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Photo by Leuchtturm Entertainment on Unsplash

Photo by Leuchtturm Entertainment on Unsplash

Why is it important?

When patients experience their therapist as threatening or untrustworthy, therapy can become difficult to sustain precisely when help is most needed. This study highlights how therapists’ emotional responses can shape these moments and why recognizing those reactions matters. Its findings may help clinicians respond more thoughtfully, avoid escalating mistrust, and preserve the relationship so that difficult feelings can be understood and worked through.

Perspectives