Psychopathic Personality Traits, Psychotic Symptoms, and Inpatient violence: Which Has a Stronger Influence on Countertransference?

Psychopathic Personality Traits, Psychotic Symptoms, and Inpatient violence: Which Has a Stronger Influence on Countertransference?

In a study of 89 patients in a forensic medium-security unit, psychopathic/antisocial personality traits were found to have a larger impact on countertransference in nurses and psychologists/psychiatrists than psychotic symptoms and inpatient violence. This is the bottom line of a recently published article in the Journal of Forensic Psychology Research and Practice. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Journal of Forensic Psychology Research and Practice | 2021, Vol. 21, No. 4, 301-316

Countertransference in Forensic Patients with Psychosis: Associations with Symptomatology, Inpatient Violence, and Psychopathic Personality Traits


Patrizio Di Virgilio, Centre Hospitalier Jean Titeca
Louis De Page, Centre Hospitalier Jean Titeca; Mediter, Expertise and Psychotherapy Center
Pierre Titeca, Centre Hospitalier Jean Titeca


Countertransference can instigate poor or even iatrogenic treatment effects. This study investigated the extent to which psychotic symptoms, inpatient violence and disruptive behavior, and psychopathic/antisocial personality traits are associated with countertransference. Eighty-nine patients with psychotic disorders in a forensic medium-secure unit were assessed twice for countertransference using the Therapist Response Questionnaire. We found that psychopathic/antisocial personality traits had a larger impact on countertransference in patients than did psychotic symptoms and inpatient violence and behavior. Although differences existed between psychologists/psychiatrists and nursing personnel, all patient-related variables were associated with increased negative countertransference and decreased positive countertransference. Differences in association magnitude and clinical implications are discussed.


Countertransference; inpatient violence; psychopathy; psychosis; therapist Response Questionnaire

Summary of the Research

“Countertransference (CT), defined as conscious and unconscious affective, cognitive, and behavioral reactions to a patient, is important to monitor in treatment settings…Previous reports suggested that, if CT is not addressed explicitly, it may induce negative outcomes such as staff acting-out, namely, using coercive measures…staff depletion and burnout, and distorted decision-making and risk assessment…In the current project, we took the investigation further by examining whether patient symptomatology, inpatient violence, and antisocial/psychopathic personality traits impact countertransference. First, we hypothesized…that symptomatology would have little effect on CT…Secondly, we expected negative associations between inpatient violence and positive CT, and positive associations between inpatient violence and negative CT…For our third hypothesis, we expected to replicate previously found associations between antisocial/psychopathic personality traits and CT, namely, negative associations with positive CT (e.g., protective and agreeable feelings)…and positive associations with negative CT (e.g., feelings of hostility, being used, and helplessness)…” (p. 301-303).

“A total of 89 patients were recruited across three units…from an MSU [medium-secure units] for rehabilitation…a psychiatric intensive care unit (PICU)…an acute inpatient psychiatric unit (AIPU)…countertransference was assessed twice within the same week for each patient, once by a nurse and once by a psychologist/psychiatrist. Staff participants…filled in the TRQ [Therapist Response Questionnaire] questionnaires…anonymously…Our hypotheses were confirmed, and our results are congruent with empirical and clinical literature…” (p.304-310).

“Positive and general symptoms of schizophrenia were more strongly associated with CT reactions than with negative psychotic symptoms. A distinct association emerged between psychotic symptoms and both helpless/inadequate and overwhelmed/disorganized feelings in psychologists/psychiatrists…We found that psychopathic personality traits were associated with negative CT feelings (e.g., Hostile/Mistreated CT subscale) and decreased positive CT…Psychiatrists are not only responsible for the wellbeing of the (psychopathic/antisocial) patients, but also for the wellbeing of their staff and other patients. Additionally, they must report to judicial courts for these patients…This is perhaps why psychopathic/antisocial personality traits are associated with greater disengaged and less parental/protective CT in psychiatrists/psychologists” (p.310-311).

“Inpatient violence and disruptive behavior were associated with negative CT (especially overwhelmed/disorganized CT) in both nurse and psychologist/psychiatric groups…Additionally, nurses’ CT was associated with hostile/mistreated reactions, possibly due to the nature of their job…Inpatient violence and disruptive behavior were also associated with the special/overinvolved dimension of CT in psychologists/psychiatrists…[this group] mentioned that they were concerned about patients who exhibited violence or disruptive behaviors…perhaps when these practitioners were absent…[Lastly,] Psychopathic personality traits had a larger effect on CT than did psychotic symptoms o[r] inpatient violence…” (p.311).

Translating Research into Practice

“…It is therefore important that staff members are trained in recognizing CT and knowing its determinants. The aforementioned determinants of CT all lead to negative CT, which might induce avoidance of patients for various reasons (e.g., fear, treat, hopelessness); this might, in turn, leave patients and staff in disarray instead of feeling supported in a well-managed, regimented, and caring environment. Unsystematic review and exploration of CT is known to lead to compassion fatigue and burn-out in staff…and to vicious cycles of aggression and acting-out of patients…” (p.312).

“Future research into inpatient settings should try to include group aspects of CT and its group management. Uncontrolled expressions of CT by a staff member might influence CT among other members. In contrast, severely disturbed patients are known to split staff members into good and bad individuals…A comprehensive study of CT in inpatient settings should address these group phenomena…In clinical practice, one should be aware that a patient’s psychopathic/antisocial personality traits will potentially be felt as the countertransferential level and that monitoring these feelings is important. At the management level, our findings suggest that there is an urgent need for education regarding countertransference and its effects in psychiatric services that admit acutely disturbed patients with psychosis who are violent and/or have antisocial/psychopathic traits” (p.312-313).

Other Interesting Tidbits for Researchers and Clinicians

“…The current results indicated that agreement in CT feelings between nursing personnel and psychologists/psychiatrists was rather small…There was agreement with respect to clearly negative CT (i.e., hostile/mistreated), but this agreement was lower or non-significant for other CT subscales…Therefore, patient characteristics, such as psychotic symptoms, have a common CT association in nurses and psychiatrists/psychologists but a different pattern of association. In interpreting these results, one must remember that these differences might reflect quantitative differences but might also partly reflect response bias…” (p.310).

“…The incremental impact of disruptive behavior (e.g., substance abuse, unauthorized leave, stalking) over inpatient violence (e.g., verbal or physical aggression) on CT could not be addressed in this study. Two recurring themes emerged when discussing these results with staff members: 1) substance abuse is probably a major determinant of CT…2) self-destructive behaviors (e.g., self-neglect, suicidal ideation, victimization) will engender different CT feelings than outwardly destructive and disruptive behaviors, such as stalking or verbal aggression…” (p.311).

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Authored by Amber Lin

Amber Lin is a clinical psychology doctoral student at Fairleigh Dickinson University. Her research interests include forensic assessment, competency to stand trial, and the refinement of instruments used to assess the psychological states of criminal defendants.

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