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Society for Psychotherapy Research
SPR(UK) Chapter Conference
14/03 - 16/03/2009
Ravenscar
Therapists interpersonal patterns and
their effects on the therapy process
Too close for comfort:
Therapists' self reported similarities between
their own and their patients' interpersonal
problems are related to negative therapeutic
process
Thomas A Schröder
University of Nottingham & Derbyshire Mental Health Services Trust
John D Davis
Coventry and Warwickshire Partnership Trust
Therapist’s Interpersonal Patterns in
Relation to Therapeutic Difficulties
o Therapists’ ‘blind spots’ likely to contribute to
countertransference difficulties.
o Blind spots may originate from shared conflicts /
traumata / phantasies.
o Such conflictual material should express itself in specific
interpersonal patterns.
o Interpersonal patterns should be more accessible to
self-report than conflicts.
o Therapist-reported shared interpersonal patterns should
be associated with negative therapeutic process
(‘unresolved countertransference’).
Therapist Difficulties Study
(Schröder & Davis 2004)
o Convenient samples of 102 British and 30 German
speaking therapists. Most results based on n=102 UK
sample.
o Sample Characteristics: 60% female; median age: 46;
median practice length: 12 years; 63% psychologists,
main theoretical influences (in descending order):
psychodynamic, humanistic, cognitive.
o Each participant anonymously provided two narratives
of a therapeutic difficulty - with a ‘difficult’ and a ‘notso-difficult’ patient – together with other measures
serving as correlates.
Prompt for Eliciting Accounts:
Please think of a situation which you have personally
encountered in your practice of individual psychotherapy
and which you found difficult.
o What did you or your patient (client) do which made the
situation difficult?
o What feelings or personal reactions did you experience in
the situation?
o How did you attempt to deal or cope with this difficulty?
o How did this situation turn out?
Therapist Difficulties Study
(Schröder & Davis 2004)
o Three Difficulty categories - developed in previous
qualitative study – refined and manualised.
o Trained raters judge ‘salience’ of each category for each
difficulty narrative. ICCs ranging from .73 - .86.
o Replication Design: 200 narratives arranged into two
independent arrays of 100 for correlational studies.
Transient Difficulties:
These are difficulties in which the situation encountered
exposes deficiencies in the therapist’s knowledge,
technical skills or experience.
Though they may be troublesome, vexing, or irritating at
the time of their occurrence, they are essentially
impermanent in nature and are potentially capable of
being remedied through further training and experience.
They are likely to be found difficult by any therapist with
similar levels of knowledge, technical skills, and
experience.
They do not reflect the enduring personal characteristics
of particular therapists.
Situational Difficulties:
These are difficulties which are inherent in the situation
encountered by the therapist.
They would probably be experienced as difficult by
most therapists encountering the situation, regardless
of their level of technical skills, knowledge or experience.
They are not reflective of the therapist’s enduring
personal characteristics and particular therapists.
Though they may be attenuated, they cannot be
eliminated through further training and experience.
Paradigmatic Difficulties:
These are difficulties which arise out of the enduring
characteristics of the therapist experiencing them.
They may be coped with, accommodated to, or somewhat
modified over time, but they are essentially stable in nature.
They are idiosyncratic and may be attributed to the
therapist’s internal conflicts, interpersonal style, or habitual
ways of reacting.
Their relatively unchanging character makes them typical of
a particular therapist and the situation that evokes them
would not be expected to cause similar difficulties for
therapists in general.
It would require far-reaching personal change for the
therapist to become free of such difficulties.
Paradigmatic Difficulties…
o …can be understood as ‘conscious (or pre-conscious)
countertransference’.
o …occur more frequently with patients perceived by
therapists as similar to themselves.
o …have high emotional impact on therapists.
o …evoke internal states in therapists similar to their
worst and unlike their best self-representations.
o …arouse in therapists a wish for hostile control in the
absence of perceived patient hostility
Paradigmatic Difficulties…
…can be understood as ‘conscious
(or pre-conscious) countertransference’.
Marker Variable ‘Specificity’:
How often have you experienced a difficulty of this
kind in a situation outside therapy (that is in a family,
social or work relationship) ?
Association with paradigmatic difficulties:
r = .25 / .26; combined p< .001 (one-tailed)
Paradigmatic Difficulties…
…occur more frequently with patients perceived by
therapists as similar to themselves.
Variable: IIP Dissimilarity Index
Absolute difference between therapist-rated patient scores
and therapist scores
Association of total scores with paradigmatic difficulties:
r = -.24 / -.30; combined p< .001 (one-tailed)
(negative associations were consistently observed over factor- based
and circumplex subscales; the strongest are for ‘too dependent’
subscale, and ‘compete’ and ‘elicit care’ factors)
Paradigmatic Difficulties…
…have high emotional impact on therapists.
Variable: Emotional Impact Scale
9-item empirically derived scale;
psychometric properties established in English and
German versions;
alpha = .90
Association with paradigmatic difficulties:
r = .25 / .32; combined p< .001 (one-tailed)
Paradigmatic Difficulties…
…evoke internal states in therapists similar to their
worst and unlike their best self-representations.
Variable: SASB INTREX Therapist Introject Distance
General therapist Introject at best/at worst compared
with difficulty-specific Introject
Metric: Euclidean distance between combined affiliation
and autonomy scores (Quintana & Meara, 1990)
Association with paradigmatic difficulties:
At best: r = .19 / .22; p< .001 (two-tailed)
At worst: r = -.18 / -.26; p < 001 (two-tailed)
Paradigmatic Difficulties…
…arouse in therapists a wish for hostile control in
the absence of perceived patient hostility
Variables: SASB INTREX Affiliation Scores
SASB INTREX Cluster Scores
Hostility (negative affiliation) scores (see next slide)
Predominant association with ‘Hostile Control’ cluster
scores.
Associations of SASB Affiliation Scores with
Paradigmatic and Situational Difficulties
* p < .02
** p < .005 *** p < .001 (two-tailed)
Par. Diff.
Sit. Diff.
T. Introject
-.14
-.41
***
T. Active with Pt
-.14
-.23
*
-.09
.10
.00
-.07
-.14
.03
T. Reactive to Pt.
-.14
-.39
***
Pt. Active with T.
.07
-.10
***
-.24 -.30
. 04
**
-.21 -.23
Pt. Reactive to T.
.02
Conclusions
o Therapists' self reported similarities between their
own and their patients' interpersonal problems are
related to negative therapeutic process.
o Supervision can usefully distinguish between
difficulty types and refer then to different
resources.
o Interpersonal patterns may be more accessible to
supervisee self-report than internal conflicts.