Bridges and barriers in the psychodynamic treatment of personality disorders: two thematic analyses of therapist responsiveness and non-responsiveness from clinicians’ and patients’ perspectives

Introduction: Therapist responsiveness promotes favorable treatment outcomes and contributes to a deeper understanding of the mechanisms of change in psychodynamic psychotherapy for patients with personality pathology. At the same time, non-responsiveness may disrupt the clinical process and undermine the conditions for meaningful therapeutic progress. Design: This study examined therapist responsiveness and non-responsiveness in psychodynamic treatments of patients with personality disorders, integrating complementary perspectives from both clinicians and patients within a dual-perspective qualitative design. Methods: 54 clinicians and 54 patients each responded to two open-ended questions describing specific moments of responsiveness and non-responsiveness. Two separate thematic analyses were conducted within a critically realistic framework. Results: Therapists were perceived as responsive when patients felt deeply heard, recognized, and helped to develop greater self-awareness and new perspectives. Non-responsiveness was primarily associated with negative countertransference reactions, misattunement, and misalignments in expectations and shared understanding of the treatment. A substantial proportion of patients reported no experience of non-responsiveness—a finding interpreted in light of specific relational dynamics, social desirability bias, and idealizing transference processes. Conclusions: Therapist responsiveness is a fundamental clinical competence in the psychodynamic treatment of personality disorders, fostering a holding environment in which patients feel safe, accepted, and supported in developing insight and deeper reflective capacities. Training and supervision should focus on enhancing clinicians’ attunement, interpersonal sensitivity, countertransference awareness, and metacommunicative skills. Collaboratively negotiating expectations, priorities, and shared understandings of treatment may reduce alliance ruptures. In addition, helping clinicians recognize and work through non-responsive moments may transform perceived failures into opportunities for professional growth and improved patient engagement.