Society for Psychotherapy Society for Psychotherapy ResearchResearch

UK ChapterUK Chapter

2424thth Annual Meeting Annual Meeting

25/03 - 27/03/201025/03 - 27/03/2010

Ravenscar Ravenscar

Difficult Moments with Difficult Difficult Moments with Difficult PatientsPatients

The Therapist’s Experience and Negative

Process

Thomas A Schröder Thomas A Schröder Institute of Work, Health & OrganisationsInstitute of Work, Health & OrganisationsUniversity of Nottingham University of Nottingham

Thanks to:Thanks to:

John D DavisJohn D Davis Coventry and Warwickshire Partnership Coventry and Warwickshire Partnership TrustTrust

Paul GilbertPaul GilbertMental Health Research Unit, Derby, UKMental Health Research Unit, Derby, UK

Therapeutic DifficultiesTherapeutic Difficulties

o Three perspectives on difficulties in psychotherapeutic Three perspectives on difficulties in psychotherapeutic practice: Therapist, patient, observer.practice: Therapist, patient, observer.

o One approach to studying the therapist’s perspective: One approach to studying the therapist’s perspective: Collecting and analysing retrospective accounts.Collecting and analysing retrospective accounts.

o Initial investigation: Davis et al. (1987) – qualitative Initial investigation: Davis et al. (1987) – qualitative study resulting in taxonomy of therapist difficulties.study resulting in taxonomy of therapist difficulties.

o Taxonomy transformed into questionnaire format and Taxonomy transformed into questionnaire format and included in ISDP.included in ISDP.

o Further data collections of difficulty narratives Further data collections of difficulty narratives (anonymously to encourage candour).(anonymously to encourage candour).

o Current data base of approx. 1000 difficulty accounts Current data base of approx. 1000 difficulty accounts

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

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

o Sample Characteristics: Sample Characteristics: 60% female; median age: 46; 60% female; median age: 46; median practice length: 12 years; 63% median practice length: 12 years; 63% psychologists, main theoretical psychologists, main theoretical influences (in descending order): psychodynamic, influences (in descending order): psychodynamic, humanistic, cognitive.humanistic, 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 personally Please think of a situation which you have personally encountered in your practice of encountered in your practice of individualindividual psychotherapy and psychotherapy and which you found difficult.which you found difficult.

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

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

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

Therapist Difficulties StudyTherapist Difficulties Studyo Three Difficulty categories,Three Difficulty categories, developed in developed in

previous qualitative study, were refined previous qualitative study, were refined and manualised. and manualised.

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

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

Transient Difficulties:Transient Difficulties:

Related to deficits in Related to deficits in knowledge, skills and knowledge, skills and experience.experience.

Not central to this paper.Not central to this paper.

Situational Difficulties:Situational Difficulties: (abbreviated definition)(abbreviated definition) These are difficulties which areThese are difficulties which are inherentinherent in in thethe situationsituation encountered by the therapist.encountered by the therapist.

They would probably be experienced as They would probably be experienced as difficult bydifficult by most therapistsmost therapists encountering encountering the situation…the situation…

They areThey are not not reflective of the therapist’s reflective of the therapist’s enduringenduring personal characteristicspersonal characteristics. .

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

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

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

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

It would requireIt would require far-reaching personal changefar-reaching personal change for the for the therapist to becometherapist 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’. (Marker variable: (Marker variable: ‘Specificity’)‘Specificity’)

o ……have high emotional impact on therapists. have high emotional impact on therapists. (Metric: Emotional Impact Scale)(Metric: Emotional Impact Scale)

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. (Metric: IIP Dissimilarity Index)(Metric: IIP Dissimilarity Index)

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. (Metric: SASB INTREX Therapist Introject (Metric: SASB INTREX Therapist Introject Distance)Distance)

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

Paradigmatic Paradigmatic Difficulties…Difficulties… ……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 Variables: Variables: SASB INTREX Cluster ScoresSASB INTREX Cluster Scores Predominant association with ‘Hostile Control’ Predominant association with ‘Hostile Control’

quadrant.quadrant.

SASB INTREX Affiliation ScoresSASB INTREX Affiliation 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 .10.10T. Active with T. Active with Pt.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

Extreme Case AnalysisExtreme Case Analysiso Negative process cases:Negative process cases:

All cases where the sum of All cases where the sum of affiliation scores for ‘therapist active with affiliation scores for ‘therapist active with patient’, ‘therapist reactive with patient' patient’, ‘therapist reactive with patient' and ‘therapist introject’ is negative.and ‘therapist introject’ is negative.

o Rare Occurrence:Rare Occurrence: Only 11% of cases (n=10 in cohort 1 Only 11% of cases (n=10 in cohort 1 and n=12 in cohort 2) fall into this and n=12 in cohort 2) fall into this category.category.

Difficulty Categories and Difficulty Categories and Negative ProcessNegative Process Median salience (0-4) difficulty Median salience (0-4) difficulty

ratings for negative process cases:ratings for negative process cases:

Transient:Transient: 1.3 1.3 (1.0 / 1.6) (1.0 / 1.6)

Situational:Situational: 1.551.55 (1.7 / 1.4) (1.7 / 1.4)

Paradigmatic:Paradigmatic: 2.45 2.45 (2.5 / 2.4) (2.5 / 2.4)

Therapists’ Self-conscious Therapists’ Self-conscious Emotion Experiences Emotion Experiences (Schröder & (Schröder & Gilbert 2005)Gilbert 2005) Raters judge salience of four categories for Raters judge salience of four categories for

each difficulty narrative. Four-rater ICCs: .82 - each difficulty narrative. Four-rater ICCs: .82 - .93..93.

1.1. GuiltGuilt (empathic concern about having done harm (empathic concern about having done harm to another)to another)

2.2. External ShameExternal Shame (concern about having created (concern about having created a negative image of self in mind of other)a negative image of self in mind of other)

3.3. Internal ShameInternal Shame (concern about private (concern about private negative evaluation of self) negative evaluation of self)

4.4. HumiliationHumiliation (concern about being unjustly (concern about being unjustly denigrated by other) denigrated by other)

Self-conscious Emotion Self-conscious Emotion Experiences and Negative Experiences and Negative ProcessProcess Median salience (0-4) difficulty Median salience (0-4) difficulty

ratings for negative process ratings for negative process cases: cases: (n=100)(n=100)

Guilt:Guilt: .3 .3

External Shame:External Shame: 1.2 1.2

Internal Shame:Internal Shame: 1.0 1.0

Humiliation:Humiliation: 1.01.0

Prototypical Case AccountPrototypical Case Account

1.1. Negative Process Case.Negative Process Case.

2.2. Introject and Transitive Affiliation Introject and Transitive Affiliation Scores all negative.Scores all negative.

3.3. Predominantly Paradigmatic salience Predominantly Paradigmatic salience ratingsratings

4.4. Short enough to fit on a slide.Short enough to fit on a slide.

MALE CLINICAL PSYCHOLOGISTMALE CLINICAL PSYCHOLOGIST

PSYCHODYNAMIC / COGNITIVE ORIENTATIONPSYCHODYNAMIC / COGNITIVE ORIENTATION The patient in question had entered into a 16 session contract aimed at The patient in question had entered into a 16 session contract aimed at

looking at themes of loss in his life (of which there were several). He looking at themes of loss in his life (of which there were several). He was at the time also attending a language clinic for speech therapy.was at the time also attending a language clinic for speech therapy.

a) the patient remarked he'd heard my wife was very nice, he had told a) the patient remarked he'd heard my wife was very nice, he had told his speech therapist that he was coming to see me, and the speech his speech therapist that he was coming to see me, and the speech therapist told him about my wife (who is a speech therapist). He therapist told him about my wife (who is a speech therapist). He seemed to have gathered quite a lot of info about her appearance, seemed to have gathered quite a lot of info about her appearance, personality, job etc. The information was all flattering to my wife and personality, job etc. The information was all flattering to my wife and to me but.....to me but.....

b)b) It felt like a huge boundary breakdown and he was getting all It felt like a huge boundary breakdown and he was getting all chummy/friendly with me. Felt intrusive.chummy/friendly with me. Felt intrusive.

c)c) I told myself this was about jealousy and envy and he wanted what I I told myself this was about jealousy and envy and he wanted what I had and what I had not lost.had and what I had not lost.

d) I couldn't get into it, I felt rattled. Instead I merely interpreted along d) I couldn't get into it, I felt rattled. Instead I merely interpreted along the lines of him trying to distract our session content away from the the lines of him trying to distract our session content away from the theme of loss. Later I realised that I was frightened that his emptiness theme of loss. Later I realised that I was frightened that his emptiness could ''lose'' my wife. He was projecting his neediness inside of me could ''lose'' my wife. He was projecting his neediness inside of me and destroying what I had.and destroying what I had.

A very powerful transference from a previously ''not difficult'' client.A very powerful transference from a previously ''not difficult'' client.I don't like the fusion of my personal and work life. This is one split I I don't like the fusion of my personal and work life. This is one split I

preferprefer..