Society for Psychotherapy Society for Psychotherapy ResearchResearch

SPR(UK) Chapter SPR(UK) Chapter ConferenceConference

14/03 - 16/03/200914/03 - 16/03/2009

Ravenscar Ravenscar

Therapists interpersonal Therapists interpersonal patterns and their effects on the patterns and their effects on the therapy processtherapy process

Too close for comfort:Too close for comfort: Therapists' self reported similarities Therapists' self reported similarities between their own and their patients' between their own and their patients' interpersonal problems are related to interpersonal problems are related to negative therapeutic processnegative therapeutic process

Thomas A Schröder Thomas A Schröder University of Nottingham & Derbyshire Mental Health University of Nottingham & Derbyshire Mental Health Services TrustServices Trust

John D Davis John D Davis Coventry and Warwickshire Partnership TrustCoventry and Warwickshire Partnership Trust

Therapist’s Interpersonal Patterns Therapist’s Interpersonal Patterns in Relation to Therapeutic in Relation to Therapeutic DifficultiesDifficulties

o Therapists’ ‘blind spots’ likely to contribute to Therapists’ ‘blind spots’ likely to contribute to countertransference difficulties.countertransference difficulties.

o Blind spots may originate from shared conflicts / Blind spots may originate from shared conflicts / traumata / phantasies.traumata / phantasies.

o Such conflictual material should express itself in Such conflictual material should express itself in specific interpersonal patterns.specific interpersonal patterns.

o Interpersonal patterns should be more accessible Interpersonal patterns should be more accessible to self-report than conflicts.to self-report than conflicts.

o Therapist-reported shared interpersonal patterns Therapist-reported shared interpersonal patterns should be associated with negative therapeutic should be associated with negative therapeutic process (‘unresolved countertransference’).process (‘unresolved countertransference’).

Therapist Difficulties StudyTherapist Difficulties Study(Schr(Schröder & Davis 2004)öder & Davis 2004)

o Convenient samples of 102 British and 30 German Convenient samples of 102 British and 30 German speaking therapists. Most results based on n=102 speaking therapists. Most results based on n=102 UK sample.UK sample.

o Sample Characteristics: Sample Characteristics: 60% female; median age: 60% female; median age: 46; median practice length: 12 years; 63% 46; median practice length: 12 years; 63% psychologists, main theoretical influences (in psychologists, main theoretical influences (in descending order): psychodynamic, humanistic, descending order): psychodynamic, humanistic, cognitive.cognitive.

o Each participant anonymously provided two Each participant anonymously provided two narratives of a therapeutic difficulty - with a narratives of a therapeutic difficulty - with a ‘difficult’ and a ‘not-so-difficult’ patient – together ‘difficult’ and a ‘not-so-difficult’ patient – together with other measures serving as correlates.with other measures serving as correlates.

Prompt for Eliciting Prompt for Eliciting

Accounts:Accounts: Please think of a situation which you have Please think of a situation which you have personally encountered in your practice of personally encountered in your practice of individualindividual psychotherapy and which you found psychotherapy and which you found difficult.difficult.

o What did you or your patient (client) do which made What did you or your patient (client) do which made the situation difficult?the situation difficult?

o What feelings or personal reactions did you What feelings or personal reactions did you experience in the situation?experience in the situation?

o How did you attempt to deal or cope with this How did you attempt to deal or cope with this difficulty?difficulty?

o How did this situation turn out?How did this situation turn out?

Therapist Difficulties StudyTherapist Difficulties Study(Schr(Schröder & Davis 2004)öder & Davis 2004)

o Three Difficulty categories - developed in previous Three Difficulty categories - developed in previous qualitative study – refined and manualised.qualitative study – refined and manualised.

o Trained raters judge ‘salience’ of each category Trained raters judge ‘salience’ of each category for each difficulty narrative. ICCs ranging from .73 for each difficulty narrative. ICCs ranging from .73 - .86.- .86.

o Replication Design:Replication Design: 200 narratives arranged into 200 narratives arranged into two independent arrays of 100 for correlational two independent arrays of 100 for correlational studies.studies.

Transient Difficulties:Transient Difficulties:

These are difficulties in which the situation These are difficulties in which the situation encountered exposes encountered exposes deficienciesdeficiencies in the therapist’s in the therapist’s knowledgeknowledge, technical , technical skillsskills or or experienceexperience. .

Though they may be troublesome, vexing, or Though they may be troublesome, vexing, or irritating at the time of their occurrence, they are irritating at the time of their occurrence, they are essentially essentially impermanentimpermanent in nature and are in nature and are potentially capable of being potentially capable of being remediedremedied through through further further training training andand experience experience. .

They are likely to be found difficult by They are likely to be found difficult by any therapistany therapist with with similarsimilar levels of levels of knowledgeknowledge, technical , technical skillsskills, , and and experienceexperience..

They do They do not not reflect the enduring reflect the enduring personal personal characteristicscharacteristics of particular therapists. of particular therapists.

Situational Difficulties:Situational Difficulties:

These are difficulties which are These are difficulties which are inherentinherent in the in the situationsituation encountered by the therapist. encountered by the therapist.

They would probably be experienced as difficult They would probably be experienced as difficult by by most therapistsmost therapists encountering the situation, encountering the situation, regardlessregardless of their level of technical of their level of technical skillsskills, , knowledgeknowledge or or experienceexperience..

They are They are not not reflective of the therapist’s enduring reflective of the therapist’s enduring personal characteristicspersonal characteristics and particular therapists. and particular therapists.

Though they may be attenuated, they Though they may be attenuated, they cannot be cannot be eliminatedeliminated through further through further training training andand experienceexperience. .

Paradigmatic Difficulties:Paradigmatic Difficulties: These are difficulties which arise out of the These are difficulties which arise out of the enduring enduring characteristicscharacteristics of the of the therapisttherapist experiencing them. experiencing them.

They may be coped with, accommodated to, or somewhat They may be coped with, accommodated to, or somewhat modified over time, but they are essentially modified over time, but they are essentially stablestable in in nature. nature.

They are They are idiosyncraticidiosyncratic and may be attributed to the and may be attributed to the therapist’s therapist’s internal conflictsinternal conflicts, , interpersonal styleinterpersonal style, or , or habitualhabitual ways of reacting. ways of reacting.

Their relatively unchanging character makes them Their relatively unchanging character makes them typical typical of a particular therapistof a particular therapist and the situation that evokes and the situation that evokes them would not be expected to cause similar difficulties them would not be expected to cause similar difficulties for therapists in general. for therapists in general.

It would require It would require far-reaching personal changefar-reaching personal change for the for the therapist to become therapist to become freefree of such difficulties. of such difficulties.

Paradigmatic Paradigmatic Difficulties…Difficulties…

o ……can be understood as ‘conscious (or pre-can be understood as ‘conscious (or pre-conscious) countertransference’.conscious) countertransference’.

o ……occur more frequently with patients perceived occur more frequently with patients perceived by therapists as similar to themselves.by therapists as similar to themselves.

o ……have high emotional impact on therapists.have high emotional impact on therapists.

o ……evoke internal states in therapists similar to evoke internal states in therapists similar to their worst and unlike their best self-their worst and unlike their best self-representations.representations.

o ……arouse in therapists a wish for hostile control arouse in therapists a wish for hostile control in the absence of perceived patient hostilityin the absence of perceived patient hostility

Paradigmatic Paradigmatic Difficulties…Difficulties…

……can be understood as ‘conscious can be understood as ‘conscious (or pre-conscious) (or pre-conscious) countertransference’.countertransference’.

Marker Variable ‘Specificity’:Marker Variable ‘Specificity’: How often have you experienced a difficulty of How often have you experienced a difficulty of

this kind in a situation this kind in a situation outsideoutside therapy (that is therapy (that is in a family, social or work relationship) ?in a family, social or work relationship) ?

Association with paradigmatic difficulties:Association with paradigmatic difficulties:

r = .25 / .26; combined p< .001 (one-r = .25 / .26; combined p< .001 (one-tailed)tailed)

Paradigmatic Paradigmatic Difficulties…Difficulties…

… …occur more frequently with patients perceived occur more frequently with patients perceived by therapists as similar to themselves.by therapists as similar to themselves.

Variable: IIP Dissimilarity IndexVariable: IIP Dissimilarity Index Absolute difference between therapist-rated patient Absolute difference between therapist-rated patient

scores and therapist scoresscores and therapist scores

Association of total scores with paradigmatic difficulties:Association of total scores with paradigmatic difficulties:

r = -.24 / -.30; combined p< .001 (one-tailed)r = -.24 / -.30; combined p< .001 (one-tailed)

(negative associations were consistently observed over factor- (negative associations were consistently observed over factor- based and circumplex subscales; the strongest are for ‘too based and circumplex subscales; the strongest are for ‘too dependent’ subscale, and ‘compete’ and ‘elicit care’ factors)dependent’ subscale, and ‘compete’ and ‘elicit care’ factors)

Paradigmatic Paradigmatic Difficulties…Difficulties…

……have high emotional impact on have high emotional impact on therapists.therapists.

Variable: Emotional Impact ScaleVariable: Emotional Impact Scale 9-item empirically derived scale; 9-item empirically derived scale; psychometric properties established in English psychometric properties established in English

and German versions; and German versions; alpha = .90 alpha = .90

Association with paradigmatic difficulties:Association with paradigmatic difficulties:

r = .25 / .32; combined p< .001 (one-r = .25 / .32; combined p< .001 (one-tailed)tailed)

Paradigmatic Paradigmatic Difficulties…Difficulties… ……evoke internal states in therapists similar to evoke internal states in therapists similar to

their worst and unlike their best self-their worst and unlike their best self-representations.representations.

Variable: SASB INTREX Therapist Introject DistanceVariable: SASB INTREX Therapist Introject Distance

General therapist Introject at best/at worst compared General therapist Introject at best/at worst compared with difficulty-specific Introjectwith difficulty-specific Introject

Metric: Euclidean distance between combined Metric: Euclidean distance between combined affiliation and autonomy scores affiliation and autonomy scores (Quintana & Meara, (Quintana & Meara, 1990)1990)

Association with paradigmatic difficulties:Association with paradigmatic difficulties:

At best: r = .19 / .22; p< .001 (two-tailed)At best: r = .19 / .22; p< .001 (two-tailed)

At worst: r = -.18 / -.26; p < 001 (two-tailed)At worst: r = -.18 / -.26; p < 001 (two-tailed)

Paradigmatic Paradigmatic Difficulties…Difficulties…

……arouse in therapists a wish for hostile arouse in therapists a wish for hostile control in the absence of perceived control in the absence of perceived patient hostilitypatient hostility

Variables: SASB INTREX Affiliation Scores Variables: SASB INTREX Affiliation Scores

SASB INTREX Cluster ScoresSASB INTREX Cluster Scores

Hostility (negative affiliation) scores (see next Hostility (negative affiliation) scores (see next slide)slide)

Predominant association with ‘Hostile Control’ Predominant association with ‘Hostile Control’ cluster scores.cluster scores.

Associations of SASB Affiliation Scores with Associations of SASB Affiliation Scores with Paradigmatic and Situational DifficultiesParadigmatic and Situational Difficulties

* p < .02* p < .02 ** p < .005** p < .005 *** p < .001 (two- *** p < .001 (two-tailed)tailed)

Par.Par. Diff.Diff. Sit.Sit. Diff.Diff.

T. IntrojectT. Introject -.14-.14 -.41-.41 ****** -.09-.09 .10.10

T. Active with PtT. Active with Pt -.14-.14 -.23-.23 ** .00.00 -.07-.07

T. Reactive to T. Reactive to Pt.Pt.

-.14-.14 -.39-.39 ****** -.14-.14 .03.03

Pt. Active with Pt. Active with T.T.

.07.07 -.10-.10 ****** -.24-.24 -.30-.30

Pt. Reactive to Pt. Reactive to T.T.

.02.02 . 04. 04 **** -.21-.21 -.23-.23

ConclusionsConclusions

o Therapists' self reported similarities between Therapists' self reported similarities between their own and their patients' interpersonal their own and their patients' interpersonal problems are related to negative therapeutic problems are related to negative therapeutic process.process.

o Supervision can usefully distinguish between Supervision can usefully distinguish between difficulty types and refer then to different difficulty types and refer then to different resources.resources.

o Interpersonal patterns may be more accessible Interpersonal patterns may be more accessible to supervisee self-report than internal to supervisee self-report than internal conflicts.conflicts.