http://ajp.psychiatryonline.org. Countertransference Phenomena and Personality. Pathology in Clinical Practice: An Empirical Investigation. Ephi Betan, Ph.D.
Article
Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation Ephi Betan, Ph.D. Amy Kegley Heim, Ph.D. Carolyn Zittel Conklin, Ph.D. Drew Westen, Ph.D.
Objective: This study provides initial data on the reliability and factor structure of a measure of countertransference processes in clinical practice and examines the relation between these processes and patients’ personality pathology. Method: A national random sample of 181 psychiatrists and clinical psychologists in North America each completed a battery of instruments on a randomly selected patient in their care, including measures of axis II symptoms and the Countertransference Questionnaire, an instrument designed to assess clinicians’ cognitive, affective, and behavioral responses in interacting with a particular patient. Results: Factor analysis of the Countertransference Questionnaire yielded eight clinically and conceptually coherent factors that were independent of clinicians’ theoretical orientation: 1) overwhelmed/ disorganized, 2) helpless/inadequate, 3)
positive, 4) special/overinvolved, 5) sexualized, 6) disengaged, 7) parental/protective, and 8) criticized/mistreated. The eight factors were associated in predictable ways with axis II pathology. An aggregated portrait of countertransference responses with narcissistic personality disorder patients provided a clinically rich, empirically based description that strongly resembled theoretical and clinical accounts. Conclusions: Countertransference phenomena can be measured in clinically sophisticated and psychometrically sound ways that tap the complexity of clinicians’ reactions toward their patients. Countertransference patterns are systematically related to patients’ personality pathology across therapeutic approaches, suggesting that clinicians, regardless of therapeutic orientation, can make diagnostic and therapeutic use of their own responses to the patient. (Am J Psychiatry 2005; 162:890–898)
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reud first introduced the concept of countertransference in 1910, noting that the patient’s influence on the analyst’s unconscious feelings can interfere with treatment. This early and relatively narrow view of countertransference as an impediment to treatment prevailed in the psychoanalytic literature for several decades. Over time, however, theorists broadened the concept, recognizing that the clinician’s reactions to the patient (conscious and unconscious, emotional and cognitive, intrapsychic and behavioral) may have diagnostic and therapeutic relevance and can, if properly used, facilitate rather than inhibit treatment (1–5). According to this expanded view, just as the patient’s behaviors with the therapist could provide in vivo insight into his or her repetitive interpersonal patterns and associated thoughts, feelings, and motives, so, too, could the clinician’s responses to the patient provide insight into patterns the patient wittingly or unwittingly evokes from significant others. Klein (6) suggested that the patient may induce the clinician to experience the feelings that the patient is having trouble acknowledging (7) or may draw the clinician into enactments that reflect the patient’s enduring expectations of relationships (8, 9). Sandler (10) introduced the concept of role responsiveness, in which the
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therapist acts in accordance with a role that is part of a relationship paradigm the patient unconsciously re-creates with the therapist. Wachtel (11, 12) proposed the similar concept of cyclical psychodynamics, by which patients’ fears, wishes, expectations, and behaviors often create self-fulfilling prophecies. Although the clinical literature on countertransference is rich and rapidly expanding, the corresponding empirical literature is limited (13–17). 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 (18) and that people who are sensitive to rejection tend (through needy, angry, and otherwise distancing behavior) to elicit rejection and hence to confirm and reinforce their internal working models of relationships (19). Giesler and colleagues (20) demonstrated that some of these processes occur in clinical settings as well. A series of analogue studies (21–26) 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, Am J Psychiatry 162:5, May 2005
BETAN, HEIM, ZITTEL CONKLIN, ET AL.
mislabeling, and changing the topic). Najavits and colleagues (27) developed the Ratings of Emotional Attitudes to Clients by Treaters scale, a clinically subtle measure of countertransference designed primarily to study therapists’ response to patients in treatment for substance abuse. 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. Although the concept of countertransference emerged from psychoanalytic theory and practice, our goal was to devise a measure that could be used by clinicians of any theoretical orientation, so that we could assess the extent to which particular countertransference responses are specific to certain forms of therapy and so that clinicians of any orientation who are trying to get a better diagnostic sense of the patient or a better understanding of what is happening in the therapeutic dyad can make use of the instrument by comparing their own responses to normed psychometric data. Our primary aims were 1) to describe the factor structure and reliability of a broadband measure of countertransference phenomena and 2) to examine associations between countertransference phenomena and patients’ personality pathology. Thus, our goals were to provide both initial validity data for the measure and a test of clinically derived hypotheses that have never been put to empirical test. In addition, to illustrate the potential clinical and empirical uses of the instrument, we derived a prototype of the “average expectable countertransference response” to patients with narcissistic personality disorder.
Method Participants Participants were 181 clinicians who constituted a random national sample of experienced psychiatrists and psychologists from the membership registers of the American Psychiatric Association and American Psychological Association. We requested mailing lists of clinicians with at least 3 years’ postlicensure or postresidency experience who indicated that they performed at least 10 hours per week of direct patient care. As in prior research with this method, psychologists responded at a substantially higher rate than did psychiatrists to the solicitation, allowing us to assess for biases imposed by differential training or response rates. We found no differences between patients described by psychologists and those described by psychiatrists on any variable of interest despite a roughly 3:1 response rate ratio. (Variables of interest included age, sex, race, socioeconomic status, education level, treatment length, and countertransference factor scores [14 t tests, not significant at p30%) for the psychiatrists; we found no differences between the samples of patients. Together, these data suggest that any potential biases in the tendency to respond had minimal imAm J Psychiatry 162:5, May 2005
pact on the representativeness of the sample (see also the discussion of limitations in the Discussion section).
Inclusion and Exclusion Criteria To obtain a cross-section of psychotherapy patients seen in clinical practice, we asked clinicians to describe a nonpsychotic patient at least 18 years old whom they had treated for a minimum of eight sessions (to maximize the likelihood that they would know the patient well enough to provide a reasonably accurate description of the patient). To minimize selection biases, we directed clinicians to consult their calendar to 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 approximately 10%.
Procedure Clinicians could participate either by pen-and-paper forms or on an interactive web site (http://www.psychsystems.net). Web versus paper participants did not differ on any variable studied here (e.g., countertransference factor scores; eight t tests). Clinicians provided no identifying information about the patient (such as name, initials, or social security number) and were instructed to use only information already available to them from their contacts with the patient so that data collection would not compromise patient confidentiality or interfere in any way with ongoing clinical work.
Measures We employed a number of measures in standardized sequence. We describe those of relevance to the present study here. Clinical Data Form. The Clinical Data Form (see references 28, 29) assesses a range of variables relevant to demographics, diagnosis, and etiology. Clinicians first provide basic demographic data on themselves, including discipline (psychiatry or psychology), theoretical orientation, employment sites (e.g., private practice, inpatient unit, school), and sex, and then provide data on the patient’s age, sex, race, education level, socioeconomic status, axis I diagnoses, etc. After completing basic demographic and diagnostic questions, clinicians complete ratings of the patient’s adaptive functioning, developmental history, and family history (which will not be described further here). Axis II diagnosis. To assess axis II disorders, we asked clinicians to rate as present or absent each criterion of each of the DSM-IV axis II diagnoses, randomly ordered. This procedure provides both a categorical diagnosis of each disorder (obtained by applying DSM-IV cutoffs) and a dimensional measure (number of criteria met for each disorder). Our research group and others have successfully used similar measures in a number of investigations (29–31). Countertransference Questionnaire. The Countertransference Questionnaire (32) is a 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. (The instrument can be downloaded at http://www.psychsystems.net/lab.) The items measure a wide range of thoughts, feelings, and behaviors expressed by therapists toward their patients. We derived the 79 items by reviewing the clinical, theoretical, and empirical literature on countertransference and related variables and by soliciting the advice of several experienced clinicians to review the initial item set for comprehensiveness and clarity. We wrote the items in everyday language, without jargon, so that the instrument could be used comparably by clinicians of any theoretical orientation. Items assess a range of responses, from relatively http://ajp.psychiatryonline.org
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COUNTERTRANSFERENCE specific feelings (e.g., “I feel bored in sessions with him/her.”) to complex constructs such as “projective identification” (e.g., “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.”).
Results Sample Characteristics The clinician sample consisted of 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 they also worked in other settings, including hospital (N=57, 31.5%), forensic (N=15, 8.3%), clinic (N=14, 7.7%), or school (N=9, 5.0%) settings. (As might be expected, psychiatrists were more likely to have primary or secondary employment in hospital settings.) 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%). Reflecting our efforts to obtain a patient sample stratified by sex, about one-half of the patients were male and one-half were female, with an average age of 40.5 years (SD=13.4). The sample was predominantly Caucasian (N= 168, 92.8%). Most were middle class (N=102, 56.4%), with 2.8% (N=5) rated as poor, 24.3% (N=44) as working class, and 16.6% (N=30) as upper class. The mean Global Assessment of Functioning Scale score 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 major depressive disorder (N=89, 49.2%), dysthymic disorder (N=68, 37.6%), generalized anxiety disorder (N=46, 25.4%), and adjustment disorder (N=45, 24.9%).
Factor Structure of the Countertransference Questionnaire To identify the factor structure of the Countertransference Questionnaire, we first subjected the items to a principal-component analysis using Kaiser’s criteria (eigenvalues >1). We used the scree plot, percentage of variance accounted for, and parallel analysis (33–35) to select the number of factors to rotate. The scree plot indicated a break between eight and nine factors, and parallel analysis indicated eight factors with eigenvalues larger than would be expected by chance (p
