Society for Psychotherapy Research
UK Chapter
24th Annual Meeting
25/03 - 27/03/2010
Ravenscar
Difficult Moments with Difficult Patients
The Therapist’s Experience
and Negative Process
Thomas A Schröder
Institute of Work, Health & Organisations
University of Nottingham
Thanks to:
John D Davis
Coventry and Warwickshire Partnership Trust
Paul Gilbert
Mental Health Research Unit, Derby, UK
Therapeutic Difficulties
o Three perspectives on difficulties in psychotherapeutic
practice: Therapist, patient, observer.
o One approach to studying the therapist’s perspective:
Collecting and analysing retrospective accounts.
o Initial investigation: Davis et al. (1987) – qualitative
study resulting in taxonomy of therapist difficulties.
o Taxonomy transformed into questionnaire format and
included in ISDP.
o Further data collections of difficulty narratives
(anonymously to encourage candour).
o Current data base of approx. 1000 difficulty accounts
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
o Three Difficulty categories, developed in
previous qualitative study, were refined
and manualised.
o Trained raters judged ‘salience’ of each
category for each difficulty narrative.
ICCs ranging from .73 - .86.
o Replication Design: 200 narratives were
arranged into two independent arrays of 100
each for correlational studies.
Transient Difficulties:
Related to deficits in knowledge,
skills and experience.
Not central to this paper.
Situational Difficulties:
(abbreviated definition)
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…
They are not reflective of the therapist’s
enduring personal characteristics.
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’. (Marker variable: ‘Specificity’)
o …have high emotional impact on therapists.
(Metric: Emotional Impact Scale)
o …occur more frequently with patients perceived by
therapists as similar to themselves.
(Metric: IIP Dissimilarity Index)
o …evoke internal states in therapists similar to their
worst and unlike their best self-representations.
(Metric: SASB INTREX Therapist Introject Distance)
o …arouse in therapists a wish for hostile control in the
absence of perceived patient hostility.
Paradigmatic Difficulties…
…arouse in therapists a wish for hostile control in
the absence of perceived patient hostility
Variables:
SASB INTREX Cluster Scores
Predominant association with ‘Hostile Control’ quadrant.
SASB INTREX Affiliation 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
*
T. Reactive to Pt.
-.14
Pt. Active with T.
.07
Pt. Reactive to T.
.02
-.09
.10
.00
-.07
-.39
***
-.14
.03
-.10
***
-.24 -.30
. 04
**
-.21 -.23
Extreme Case Analysis
o Negative process cases:
All cases where the sum of affiliation scores
for ‘therapist active with patient’, ‘therapist
reactive with patient' and ‘therapist introject’
is negative.
o Rare Occurrence:
Only 11% of cases (n=10 in cohort 1 and
n=12 in cohort 2) fall into this category.
Difficulty Categories and
Negative Process
Median salience (0-4) difficulty ratings
for negative process cases:
Transient:
1.3
(1.0 / 1.6)
Situational:
1.55 (1.7 / 1.4)
Paradigmatic:
2.45 (2.5 / 2.4)
Therapists’ Self-conscious Emotion
Experiences (Schröder & Gilbert 2005)
Raters judge salience of four categories for each
difficulty narrative. Four-rater ICCs: .82 - .93.
1. Guilt (empathic concern about having done harm to
another)
2. External Shame (concern about having created a
negative image of self in mind of other)
3. Internal Shame (concern about private negative
evaluation of self)
4. Humiliation (concern about being unjustly
denigrated by other)
Self-conscious Emotion Experiences
and Negative Process
Median salience (0-4) difficulty ratings
for negative process cases: (n=100)
Guilt:
.3
External Shame:
1.2
Internal Shame:
1.0
Humiliation:
1.0
Prototypical Case Account
1. Negative Process Case.
2. Introject and Transitive Affiliation Scores all
negative.
3. Predominantly Paradigmatic salience
ratings
4. Short enough to fit on a slide.
MALE CLINICAL PSYCHOLOGIST
PSYCHODYNAMIC / COGNITIVE ORIENTATION
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 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 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 seemed to have
gathered quite a lot of info about her appearance, personality, job etc.
The information was all flattering to my wife and to me but.....
b) It felt like a huge boundary breakdown and he was getting all
chummy/friendly with me. Felt intrusive.
c) I told myself this was about jealousy and envy and he wanted what I had
and what I had not lost.
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 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 and destroying
what I had.
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 prefer.