Journal Watch
A. Colli, A. Tanzilli, G. Dimaggio, & V. Lingiardi (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry 171:102–108. DOI: 10.1177/0003065114543187
Freud coined the term countertransference in letters to Jung in 1909 and first used it publicly in 1910, in “The Future Prospects of Psychoanalytic Therapy.” In both instances he was warning against the destructive potential of analysts’ unconscious reactions to their patients. Writing a decade later in 1919, Ferenczi radically proposed that psychoanalysts could use their emotional responses to foster the empathy and insight underlying the “corrective emotional experience” that motivates therapeutic change. The ensuing century witnessed much debate over the desirable role, if any, of the feelings experienced by psychotherapists during patient encounters. Today most psychoanalysts acknowledge the utility of their own reactions for understanding their patients, citing both clinical experience and case studies to support their convictions. Now they have another resource at their disposal: in a recent article published in the American Journal of Psychiatry, Colli and colleagues have reported a systematic and statistically significant relationship between patients’ personality traits and their therapists’ reactions to them. Colli et al. measured the correlation between therapists’ emotional responses and patients’ personality pathology in a random sample of 203 therapist-patient dyads in Italy engaged in weekly treatment of eight weeks’ to six months’ duration. The assessments consisted of the Therapist Response Questionnaire, which detects countertransference patterns, and the Shedler-Westen Assessment Procedure–200 (SWAP-200), which gauges personality and personality pathology. The primary outcome measure was the relationship between specific personality disorders (meeting DSM-IV-TR Axis II criteria) and the following countertransference reactions, attained via factor analysis: criticized/mistreated, helpless/ inadequate, positive, parental/protective, overwhelmed/ disorganized, special/overinvolved, sexualized, and disengaged. The secondary outcome measure was the relationship between countertransference reactions and therapist’s theoretical orientation (i.e., psychodynamic versus cognitive-behavioral). The tertiary outcome measure was the correlation
714
Journal Watch
between therapist response and patient’s global assessment of functioning (GAF). The therapist sample consisted of 203 Caucasians, 55 percent female (111/203), mean age 43 years (SD = 9, range = 34–52), exclusively psychiatrists (35%) or psychologists (65%) who practiced predominantly psychodynamic (N = 103) or cognitive-behavioral (N = 100) therapy. The patient sample consisted of 203 Caucasians, 58 percent female (118/203), mean age 34 years (SD = 4.5, range = 29.5–38.5), mean GAF 56 (SD = 11.9), with a variety of nonpsychotic Axis I diagnoses (28 generalized anxiety disorder, 25 panic disorder, 23 eating disorder, 15 substance use disorder, 14 dysthymic disorder) either alone or comorbid with an Axis II diagnosis. Eighty-one percent of therapists responded, and each selected the one patient from their private practice (70%) or public mental health institution (30%) whom they had seen most recently and who met study criteria. Colli et al. observed statistically significant positive correlations (partial r, two-tailed, whereby an absolute value that approaches 1.0 accounts for a greater degree of the variance and a value that approaches zero accounts for less of it) between the following patient personality disorders and therapist responses: paranoid and antisocial pathologies with a criticized/mistreated response (0.24 and 0.31, respectively); schizoid with helpless/inadequate (0.14); schizotypal with disengaged (0.39); borderline with helpless/inadequate (0.36), overwhelmed/ disorganized (0.51), and special/overinvolved (0.22); narcissistic with disengaged (0.16); avoidant with positive (0.16), parental/protective (0.28), and special/overinvolved (0.18); and dependent with helpless/ inadequate (0.14), parental/protective (0.27), and special/overinvolved (0.19). They detected significant negative correlations between dependent and histrionic pathology with disengaged response (-0.16 and -0.27), and obsessive-compulsive with special/overinvolved (-0.16). The therapists’ responses were independent of their theoretical orientation, as calculated by eliminating all psychodynamic clinicians from the sample (remaining N = 100). Therapists responded more negatively to lower-functioning patients (Pearson’s r, two-tailed) with significantly greater rates of criticized/ mistreated, helpless/inadequate, and overwhelmed/disorganized responses. These findings offer statistical evidence for the clinical observation that psychoanalysts’ emotional reactions can help elucidate patients’
715
Journal Watch
personality disorders. They also highlight the unfortunate reality that therapists react in more negative ways to more severely impaired patients. The strength of the correlations was not very robust, however (as reflected by r values generally closer to zero than to 1.0 or -1.0) and cannot replace the crucial role of therapists’ personal insight into their idiosyncratic responses to their patients. Nonetheless, these findings offer an intriguing opportunity for reflection on the interpersonal dynamics that constitute the cornerstone of the psychotherapeutic treatment. Sonya Martin
716
A. Colli, A. Tanzilli, G. Dimaggio, & V. Lingiardi (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry 171:102–108. DOI: 10.1177/0003065114543187
Freud coined the term countertransference in letters to Jung in 1909 and first used it publicly in 1910, in “The Future Prospects of Psychoanalytic Therapy.” In both instances he was warning against the destructive potential of analysts’ unconscious reactions to their patients. Writing a decade later in 1919, Ferenczi radically proposed that psychoanalysts could use their emotional responses to foster the empathy and insight underlying the “corrective emotional experience” that motivates therapeutic change. The ensuing century witnessed much debate over the desirable role, if any, of the feelings experienced by psychotherapists during patient encounters. Today most psychoanalysts acknowledge the utility of their own reactions for understanding their patients, citing both clinical experience and case studies to support their convictions. Now they have another resource at their disposal: in a recent article published in the American Journal of Psychiatry, Colli and colleagues have reported a systematic and statistically significant relationship between patients’ personality traits and their therapists’ reactions to them. Colli et al. measured the correlation between therapists’ emotional responses and patients’ personality pathology in a random sample of 203 therapist-patient dyads in Italy engaged in weekly treatment of eight weeks’ to six months’ duration. The assessments consisted of the Therapist Response Questionnaire, which detects countertransference patterns, and the Shedler-Westen Assessment Procedure–200 (SWAP-200), which gauges personality and personality pathology. The primary outcome measure was the relationship between specific personality disorders (meeting DSM-IV-TR Axis II criteria) and the following countertransference reactions, attained via factor analysis: criticized/mistreated, helpless/ inadequate, positive, parental/protective, overwhelmed/ disorganized, special/overinvolved, sexualized, and disengaged. The secondary outcome measure was the relationship between countertransference reactions and therapist’s theoretical orientation (i.e., psychodynamic versus cognitive-behavioral). The tertiary outcome measure was the correlation
714
Journal Watch
between therapist response and patient’s global assessment of functioning (GAF). The therapist sample consisted of 203 Caucasians, 55 percent female (111/203), mean age 43 years (SD = 9, range = 34–52), exclusively psychiatrists (35%) or psychologists (65%) who practiced predominantly psychodynamic (N = 103) or cognitive-behavioral (N = 100) therapy. The patient sample consisted of 203 Caucasians, 58 percent female (118/203), mean age 34 years (SD = 4.5, range = 29.5–38.5), mean GAF 56 (SD = 11.9), with a variety of nonpsychotic Axis I diagnoses (28 generalized anxiety disorder, 25 panic disorder, 23 eating disorder, 15 substance use disorder, 14 dysthymic disorder) either alone or comorbid with an Axis II diagnosis. Eighty-one percent of therapists responded, and each selected the one patient from their private practice (70%) or public mental health institution (30%) whom they had seen most recently and who met study criteria. Colli et al. observed statistically significant positive correlations (partial r, two-tailed, whereby an absolute value that approaches 1.0 accounts for a greater degree of the variance and a value that approaches zero accounts for less of it) between the following patient personality disorders and therapist responses: paranoid and antisocial pathologies with a criticized/mistreated response (0.24 and 0.31, respectively); schizoid with helpless/inadequate (0.14); schizotypal with disengaged (0.39); borderline with helpless/inadequate (0.36), overwhelmed/ disorganized (0.51), and special/overinvolved (0.22); narcissistic with disengaged (0.16); avoidant with positive (0.16), parental/protective (0.28), and special/overinvolved (0.18); and dependent with helpless/ inadequate (0.14), parental/protective (0.27), and special/overinvolved (0.19). They detected significant negative correlations between dependent and histrionic pathology with disengaged response (-0.16 and -0.27), and obsessive-compulsive with special/overinvolved (-0.16). The therapists’ responses were independent of their theoretical orientation, as calculated by eliminating all psychodynamic clinicians from the sample (remaining N = 100). Therapists responded more negatively to lower-functioning patients (Pearson’s r, two-tailed) with significantly greater rates of criticized/ mistreated, helpless/inadequate, and overwhelmed/disorganized responses. These findings offer statistical evidence for the clinical observation that psychoanalysts’ emotional reactions can help elucidate patients’
715
Journal Watch
personality disorders. They also highlight the unfortunate reality that therapists react in more negative ways to more severely impaired patients. The strength of the correlations was not very robust, however (as reflected by r values generally closer to zero than to 1.0 or -1.0) and cannot replace the crucial role of therapists’ personal insight into their idiosyncratic responses to their patients. Nonetheless, these findings offer an intriguing opportunity for reflection on the interpersonal dynamics that constitute the cornerstone of the psychotherapeutic treatment. Sonya Martin
716
