Training issues in the treatment of severely disturbed patients.

When beginning psychotherapists undertake the treatment of severely disturbed patients, we see a confluence of factors involving both patients and therapist which predispose to the development of predictable countertransferential responses. These have a strong impact on patient treatment as well as therapist training. Patients may bring to this process their difficulty establishing a working alliance, use of primitive ego defenses, and ambivalence about closeness. Therapists may bring their identification with patients, lack of professional identity, and limited development of introspective capacity. Supervisors, therefore, need to maintain an awareness of the unique needs of inexperienced therapists, and pay careful attention to the parallel process as a reflection of the therapist's identification with patient, facilitate a teaching-learning alliance which meets the student's needs both for praise from and emulation of a powerful therapeutic role model, grant permission for countertransferential feelings, and finally acknowledge joint responsibility between patient and therapist for such responses.