Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation

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Countertransference Phenomena and Personality
Pathology in Clinical Practice An Empirical
Investigation

• by
• Brandi Hankins MD

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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

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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.

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• 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 patients 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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).

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• 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.

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• 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.

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• 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

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Now, a little fun
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And this one?
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And, what about this one..?
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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 (31 response rate)

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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.)

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• 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.

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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.

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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 patients
  adaptive functioning, developmental history and
  family history.

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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).

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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

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• 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 Ive
  been pulled into things that I didnt realize
  until after the session was over.

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Results

• Sample Characteristics
• Clinician sample 141 (77.9) psychologists and
  40(22.1) psychiatrists 58.6 (N106) of the
  clinicians were male.
• The majority saw patients in private practice
  (N145, 80.1), but also worked in other setting
  including IP units (N57, 31.5), forensic (N15,
  8.3), clinic (N14, 7.7), or school (N9, 5.0)
  settings

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• The most common self-reported theoretical
  orientations included psychodynamic (N73,
  40.3), eclectic (N55, 30.4), and cognitive
  behavioral (N37, 20.4)
• One-half of the patients were male and one-half
  were female, with an average age of 40.5 years
• Predominately Caucasian (N168, 92.8)
• Most middle class (N102, 56.4), 2.5 rated as
  poor, 24.3 as working class and 16.6 as upper
  class

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• Mean GAF was 58.0 (SD12.9)
• 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 (N89, 49.2), dysthymic
  disorder (N68, 37.6), and adjustment disorder
  (N45, 24.9)

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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

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• 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.

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• 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

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• 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

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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
  (N108), 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.

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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.

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• 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

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• 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
• plt0.05. plt0.01. plt0.001.

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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.

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• In secondary analyses, they hypothesized that
  borderline personality disorder would show the
  expected association with the special/overinvolved
  factor. This hypothesis was supported (partial
  r0.23, df170, p0.002). 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 r0.30, df170, plt0.001).

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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.

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• Table 3 presents the items most and least
  descriptive of
• therapists descriptions of countertransference
  responses
• to patients with narcissistic personality
  disorder (N13).
• 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

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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

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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

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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
  therapists own dynamics, responses evoked by the
  patient, and the interaction of patient and
  therapist.

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• 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.

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• 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
  clinicians history and the interaction of the
  patients and the clinicians dynamics) but also
  elicit what we might call average expectable
  countertransference responses, which likely
  resemble responses by other significant people in
  the patients life.

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• 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.

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• 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

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• 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.

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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.

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• 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
  patients 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.

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• 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.

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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.

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• www.narcissism.operationdoubles.com
• Journal of Psychotherapy Practice and Research
  8155-161 April 1999 Robert T Waska, M.S., MFCC

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