Society for Psychotherapy Research SPR(UK) Chapter Conference 14/ /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 oTherapists’ ‘blind spots’ likely to contribute to countertransference difficulties. oBlind spots may originate from shared conflicts / traumata / phantasies. oSuch conflictual material should express itself in specific interpersonal patterns. oInterpersonal patterns should be more accessible to self-report than conflicts. oTherapist-reported shared interpersonal patterns should be associated with negative therapeutic process (‘unresolved countertransference’).

Therapist Difficulties Study (Schröder & Davis 2004) oConvenient samples of 102 British and 30 German speaking therapists. Most results based on n=102 UK sample. oSample Characteristics: 60% female; median age: 46; median practice length: 12 years; 63% psychologists, main theoretical influences (in descending order): psychodynamic, humanistic, cognitive. oEach participant anonymously provided two narratives of a therapeutic difficulty - with a ‘difficult’ and a ‘not- so-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. oWhat did you or your patient (client) do which made the situation difficult? oWhat feelings or personal reactions did you experience in the situation? oHow did you attempt to deal or cope with this difficulty? oHow did this situation turn out?

Therapist Difficulties Study (Schröder & Davis 2004) oThree Difficulty categories - developed in previous qualitative study – refined and manualised. oTrained raters judge ‘salience’ of each category for each difficulty narrative. ICCs ranging from oReplication Design: 200 narratives arranged into two independent arrays of 100 for correlational studies.

Transient Difficulties: 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. 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 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. They do not reflect the enduring personal characteristics of particular therapists.

Situational Difficulties: 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 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. 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. Though they may be attenuated, they cannot be eliminated through further training and experience.

Paradigmatic Difficulties: 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 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. 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. 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. It would require far-reaching personal change for the therapist to become free of such difficulties.

Paradigmatic 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… 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) ? 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… Paradigmatic Difficulties… …occur more frequently with patients perceived by therapists as similar to themselves. …occur more frequently with patients perceived by therapists as similar to themselves. Variable: IIP Dissimilarity Index Variable: IIP Dissimilarity Index Absolute difference between therapist-rated patient scores and therapist scores Absolute difference between therapist-rated patient scores 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- based and circumplex subscales; the strongest are for ‘too dependent’ subscale, and ‘compete’ and ‘elicit care’ factors) (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… Paradigmatic Difficulties… …have high emotional impact on therapists. Variable: Emotional Impact Scale 9-item empirically derived scale; 9-item empirically derived scale; psychometric properties established in English and German versions; psychometric properties established in English and German versions; alpha =.90 alpha =.90 Association with paradigmatic difficulties: r =.25 /.32; combined p<.001 (one-tailed)

Paradigmatic Difficulties… 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 General therapist Introject at best/at worst compared with difficulty-specific Introject Metric: Euclidean distance between combined affiliation and autonomy scores (Quintana & Meara, 1990) 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… 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 SASB INTREX Cluster Scores Hostility (negative affiliation) scores (see next slide) 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 *** T. Active with Pt * T. Reactive to Pt *** Pt. Active with T *** Pt. Reactive to T **

Conclusions oTherapists' self reported similarities between their own and their patients' interpersonal problems are related to negative therapeutic process. oSupervision can usefully distinguish between difficulty types and refer then to different resources. oInterpersonal patterns may be more accessible to supervisee self-report than internal conflicts.