Working Through Countertransference: Navigating Between Safety and Paranoia for a Client With Complex Trauma History and Borderline Personality Organization

ABSTRACT

The aftermath of complex trauma deeply impacts one's self-organization and interpersonal relationships, often resulting in clients who present to therapy with borderline characteristics and are typically labeled as difficult to treat. Further clinical complications with paranoid features may quickly place the therapist at a loss with respect to managing perceived and/or actual threats to client safety. Using psychodynamic theories, especially Kleinian understandings of psychosis and Winnicottian approaches to early disturbance and its impact on the emergence of self, this article provides a detailed case illustration that explores how a critical reflection of countertransference as “enactment,” “communication,” and “imagination” can help the therapist to understand the client's unconscious symbolic psychic struggles and to guide treatment selections in the therapy process.

KEYWORDS:

• countertransference
• enactment
• paranoia
• safety
• post-traumatic stress disorder (PTSD)
• borderline personality disorder (BPD)

Acknowledgments

The author appreciates thorough reviews and invaluable comments on the earlier version of this article from Drs. Kathryn Basham and Dennis Miehls, and Ms. Jessica Herschman, as well as the Editor (Dr. Jerry Brandell) and anonymous reviewers.

Note

Notes

1. All identifying details in this case are disguised to protect the client's confidentiality.