by Brandi Hankins MD

1. Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation by Brandi Hankins MD

2. Objectives • History of countertransference • Definition of countertransference and projective identification • Discussion of article • Application to clinical practice • Brief mention of follow-up article recently published by same author

3. History • Freud – first introduced the concept of countertransference in 1910 where it was viewed as a hindrance in therapy that would serve to only disrupt the therapeutic alliance. • Overtime, it became mainstream for theorists to believe that recognizing their reactions to the patients behaviors, actions and verbalizations could have diagnostic and therapeutic relevence.

4. Klein in 1946 suggested that the patient may induce the clinician to experience the feelings that the patient is having trouble acknowledging or may draw the clinician into enactments that reflect the patient’s enduring expectations of relationships. • Sandler in 1976 introduced the concept of role responsiveness, in which the therapist acts in accordance with a role that is part of a relationship paradigm the patient unconsciously re-creates with the therapist.

5. Projective identification was introduced by Melanie Klein in 1946 in the following way: “Much of the hatred against parts of the self is now directed toward the mother. This leads to a particular form of identification which establishes the prototype of an aggressive object-relation. I suggest for these processes the term ‘projective identification.’ ”

6. Basically, in projective identification, parts of the self and internal objects are split off and projected into the external object, which then becomes possessed by, controlled and indentified with the projected parts. • Put another way, the individual deals with emotional conflict or internal or external stressors by falsely attributing to another his or her own unacceptable feelings, impulses or thoughts.

7. Unlike simple projection, the individual does not fully disavow what is projected. Instead, the individual remains aware of his or her own affects or impulses but misattributes them as justifiable reactions to the other person. Now infrequently, the individual induces the very feelings in others that were first mistakenly believed to be there, making it difficult to clarify who did what to whom first.

8. Although the clinical literature on countertransference is rich and rapidly expanding, the corresponding empirical literature is limited. • Research with largely nonclinical samples has provided indirect support for some of these ideas, demonstrating that depressed people tend to elicit criticism from significant others that matches their own self-criticism and that people who are sensitive to rejection tend (through needy, angry and otherwise distancing behavior) to elicit rejection and hence confirm and reinforce their internal working models of relationships.

9. A series of studies attempted to operationalize the concept of countertransference, defining countertransference responses as therapists’ reactions to patients’ that are based on the therapists unresolved conflict and operationalizing countertransference in terms of avoidant behaviors (e.g. disapproval, silence, ignoring, mislabeling and changing the topic).

10. One similar study was conducted by Najavits and colleagues in 1995 where they developed the Ratings of Emotional Attitudes to Clients by Treaters scale, a clinically subtle measure of the countertransference designed primarily to study therapists’ response to patients in treatment for substance abuse.

11. The present study provides initial data on the reliability and factor structure of a clinician-report measure of countertransference processes designed to assess countertransference, broadly defined to include the range of cognitive, affective and behavioral responses therapists have to their patients.

12. As we know, the concept of countertransference emerged from psychoanalytic theory and practice, the goal of this study was to devise a measure that could be used by clinicians of any theoretical orientation. • This study aimed to describe the factor structure and reliability of a broadband measure or countertransference phenomena and to examine associations between countertransference and patients’ personality pathology

13. Now, a little fun…

14. And this one…?

15. And, what about this one..?

16. Method • 181 clinicians who were either psychiatrists or psychologists with at least 3 years postlicensure or postresidency who indicated that they performed at least 10 hours a week of direct patient care. • Psychologists responded at higher rate than did psychiatrists (3:1 response rate)

17. Inclusion and exclusion criteria: • Clinicians were asked to describe a nonpsychotic patient at least 18 years old whom they had treated for a minimum of 8 sessions (to maximize the likelihood that they would know the patient well enough to provide a reasonably accurate description of the patient.)

18. To minimize selection biases, they directed clinicians to consult their calendar and select the last patient they saw during the prior week who met study criteria. • Each clinician described only one patient in order to minimize rater-dependent biases • Clinicians received a modest honorarium ($85) for a procedure that took 3-4 hours to complete, with a response rate of 10%.

19. Procedure • Clinicians could choose pen-and-paper forms or interactive website. • Clinicians provided no identifying information about the patient and were instructed to use only information already available to them from their contacts with the patient so that data collection would be compromise patient confidentiality or interfere in anyway with ongoing clinical work.

20. Measures • Clinical Data Form: • Clinicians provided info on themselves (psychiatry or psychology, theoretical orientation, employment sites (private practice, IP unit or school) and sex. • Clinicians provided data on patient that included their age, sex, race, education level, socioeconomic status, Axis 1 diagnosis, etc. and they also completed ratings of the patient’s adaptive functioning, developmental history and family history.

21. Axis II diagnosis • To assess Axis II disorders, they asked clinicians to rate as present or absent each criterion of each DSM IV Axis II diagnosis, randomly ordered. • This procedure provided both a categorical diagnosis (obtained by applying DSM IV cutoffs) and a dimensional measure (number of criteria met for each disorder).

22. Countertransference Questionnaire • 79-item clinician-report questionnaire designed to provide a normed, psychometrically valid instrument for assessing countertransference patterns in psychotherapy for both clinical and research purposes. • http://www.psychsystems.net/lab

23. The 79 items that measure the clinicians range of thoughts, feelings and behaviors toward their patients were derived from previous clinical, theoretical and empirical literature on countertransference and by soliciting the advice of several experienced clinicians to review the item set for comprehensiveness and clarity. • E.g., “I feel bored in sessions with him/her.” “More than with most patients, I feel like I’ve been pulled into things that I didn’t realize until after the session was over.”

24. Results • Sample Characteristics • Clinician sample – 141 (77.9%) psychologists and 40(22.1%) psychiatrists; 58.6% (N=106) of the clinicians were male. • The majority saw patients in private practice (N=145, 80.1%), but also worked in other setting including IP units (N=57, 31.5%), forensic (N=15, 8.3%), clinic (N=14, 7.7%), or school (N=9, 5.0%) settings

25. The most common self-reported theoretical orientations included psychodynamic (N=73, 40.3%), eclectic (N=55, 30.4%), and cognitive behavioral (N=37, 20.4%) • One-half of the patients were male and one-half were female, with an average age of 40.5 years • Predominately Caucasian (N=168, 92.8%) • Most middle class (N=102, 56.4%), 2.5% rated as poor, 24.3% as working class and 16.6% as upper class

26. Mean GAF was 58.0 (SD=12.9) • Length of treatment averaged 19 months (SD= 30.0), with a median of 13 months, indicating that the clinicians knew the patients very well. • The most common diagnoses reported by the clinicians were MDD (N=89, 49.2%), dysthymic disorder (N=68, 37.6%), and adjustment disorder (N=45, 24.9%)

27. Factor Structure of the Countertransference Questionnaire • Factor 1 - overwhelmed/disorganized • Factor 2 – helpless/inadequate • Factor 3 – positive • Factor 4 – special/overinvolved • Factor 5 - sexualized • Factor 6 - disengaged • Factor 7 – parental/protective • Factor 8 – criticized/mistreated

28. Factor 1 – overwhelmed/disorganized: marked by items indicating a desire to avoid or flee the pt and strong negative feelings (dread, repulsion and resentment). These items accord with countertransference reactions to pts with borderline PD and narcissistic PD • Factor 2 – helpless/inadequate; items describing feelings of inadequacy, incompetence, hopelessness and anxiety.

29. Factor 3 – positive; marked by items indicating the experience of a positive working alliance and close connection with the pt • Factor 4 – special/overinvolved: a sense of the pt as special, relative to other pts and “soft signs” of problems in maintaining boundaries like inducing self-disclosure, ending sessions on time, and feeling guilty, responsible or overly concerned about the pt

30. Factor 5 – sexualized: sexual feelings toward the pt or experiencing sexual tension • Factor 6 – disengaged: feeling distracted, withdrawn, annoyed, or bored in sessions • Factor 7 – parental/protective: a wish to protect and nurture the pt in a parental way, above and beyond normal positive feelings toward the pt. • Factor 8 – criticized/mistreated: feelings of being unappreciated, dismissed or devalued by pt

31. Ruling out Theoretical Bias as a Rival Hypothesis • There was some question that factor analysis simply reflect the theoretical beliefs of the participants, because 40% of them reported a psychodynamic orientation • Excluding those with psychodynamic orientation (N=108), factor analysis reproduced the same factor structure as in the complete sample. Thus the factor structure does not appear to be an artifact of clinicians’ theoretical preconceptions.

32. Countertransference and Personality Pathology • They examined the relationship between each of the eight factors and dimensional measures of the DSM-IV personality disorders. • The data on personality disorders were grouped in clusters A, B or C by summing the number of symptoms endorsed for each of the personality disorders in each cluster.

33. Based on the item content of the factors, the following predictions were made: • Cluster A (odd/eccentric) would be associated with the disengaged factor and secondarily with the criticized/mistreated factor • Cluster B (dramatic/erratic) would be associated with overwhelmed/disorganized, helpless/inadequate, special/overinvolved, and sexualized factors • Cluster C (anxious) would be associated with parental/protective factor

34. TABLE 2. Cntranf Factor Cluster A Cluster B Cluster C Overwhelmed/disorganized 0.13 0.43d*** -0.02 Helpless/inadequate 0.10 0.16d* 0.14 Positive -0.12 - 0.22** 0.06 Special/overinvolved 0.08 0.08d 0.13 Sexualized -0.02 0.24d*** -0.09 Disengaged 0.10d 0.24*** 0.14 Parental/protective 0.07 0.03 0.24d*** Criticized/mistreated 0.17d* 0.38d*** -0.01 *p<0.05. **p<0.01. ***p<0.001.

35. Table 2 findings • As predicted, cluster A showed a significant association with the criticized/mistreated factor, although it was not correlated with the disengaged factor. • The data strongly supported the associations for cluster B, except for the special/overinvolved factor. The cluster B disorders showed an additional (unpredicted) association with the disengaged factor and a negative correlation with positive countertransference. • The data supported the hypothesis for cluster C.

36. In secondary analyses, they hypothesized that borderline personality disorder would show the expected association with the special/overinvolved factor. This hypothesis was supported (partial r=0.23, df=170, p=0.002). They also hypothesized that narcissistic personality disorder would account for the correlation between cluster B disorders and the disengaged factor and this too was supported (partial r=0.30, df=170, p<0.001).

37. Countertransference Responsesto Narcissistic Personality Disorder Patients • To illustrate the uses of the Countertransference Questionnaire in clinical practice and to examine the extent to which it could be used to create empirical prototypes of common countertransference patterns in specific types of pathology, they created a composite description of countertransference patterns in the treatments of patients who met the DSM-IV criteria for narcissistic personality disorder.

38. Table 3 presents the items most and least descriptive of therapists’ descriptions of countertransference responses to patients with narcissistic personality disorder (N=13). Clinicians reported feeling anger, resentment, and dread in working with narcissistic personality disorder patients; feeling devalued and criticized by the patient; and finding themselves distracted, avoidant, and wishing to terminate the treatment

39. Examples of items MOST descriptive of therapists’ response to patients with Narcissistic PD • I feel annoyed in sessions with him/her • I feel used or manipulated by him/her • I lose my temper with him/her • I feel mistreated or abused by him/her • I feel resentful working with him/her • I talk about him/her with my spouse or significant other more than my other patients • I feel I am “walking on eggshells” around him/her, afraid that if I say the wrong thing s/he will explode, fall apart, or walk out • When checking my phone messages, I feel anxiety or dread that there will be one from him/her • I feel unappreciated by him/her

40. Examples of items LEAST descriptive of therapists’ response to patients with Narcissistic PD • I like him/her very much • I feel compassion for him/her • I am very hopeful about the gains s/he is making or will likely make in treatment • I look forward to sessions with him/her • She/he is one of my favorite patients

41. Discussion The eight countertransference dimensions that discussed are dimensions that are clinically and theoretically coherent, representing diverse reactions clinicians may have toward patients that likely reflect a combination of the therapist’s own dynamics, responses evoked by the patient, and the interaction of patient and therapist.

42. What this study suggests, is a way of transcending some of the limitations inherent in clinical theories derived from case studies, in which a single clinician attempts to classify countertransference experiences or constellations based on his or her own experience with a limited number of patients. By using an instrument that provides a “common language” for describing a subtle clinical phenomenon, we can essentially pool the knowledge of dozens of clinical observers, identifying latent constructs (varieties of countertransference experience) that reflect patterns that individual observers themselves may not have recognized.

43. They also stated that countertransference factors and personality disorder symptoms suggest that countertransference responses occur in coherent and predictable patterns. Patients not only elicit idiosyncratic responses from particular clinicians (based on the clinician’s history and the interaction of the patient’s and the clinician’s dynamics) but also elicit what we might call average expectable countertransference responses, which likely resemble responses by other significant people in the patient’s life.

44. To the extent that patients sharing diagnostic features on axis II have similar ways of thinking, feeling, and behaving interpersonally, one would expect them to evoke similar reactions from others, including therapists, and this appears to be the case.

45. Third, data from clinicians of different theoretical orientations showed similar patterns vis-à-vis patients with particular kinds of pathology, suggesting that the results are not artifacts of clinicians’ theoretical preconceptions. What is striking about this finding is that coherent patterns of countertransference response emerge in treatments regardless of whether the clinician even “believes” in the concept of countertransference responses or has been trained to attend to them

46. Finally, one could identify distinct constellations within diagnoses (e.g., different kinds of narcissistic patients) or to patients who share certain experiences (e.g., survivors of childhood sexual trauma) that may occur across treatments.

47. Limitations • This study used self-reported measures of countertransference – it would have been useful to have ratings of therapy process by an independent observer to identify patterns of clinicians’ behavior that would likely converge with the clinicians self-reports in some ways and diverge them in others.

48. A related concern is that clinicians provided all the data and that their diagnosis of narcissistic personality disorder may not have been independent of their observations of the patient’s behavior in the room with them. It would have been preferable to collect diagnostic data independently of clinicians’ reports of their countertransference responses, and future research should clearly do so.

49. Another limitation was clinicians’ response rate to request for participation (approximately 10%). The clinicians who participated in the study may have been characterized by greater interest in research, altruism, financial distress compared with colleagues that did not participate. Clinicians were from all over North America and were unaware that countertransference was one of the constructs intended to be studied. Also, psychologists’ response rate was almost three times the rate of psychiatrists, yet the two sets of informants provided similar data, suggesting that neither training nor response rate was responsible for the findings.

50. Implications The Countertransference Questionnaire represents an effort to develop a readily administered measure that reflects shared clinical wisdom in its item content and statistical “wisdom” in its factor structure. This measure is germane to future research on countertransference phenomena, as well as to practice, allowing clinicians to clarify the diagnostic relevance and utility of their reactions by comparing their own responses to normed psychometric data.