Patient personality and therapist emotional responses in the psychotherapy with adolescents: An empirical investigation

Introduction: Therapist’s emotional responses to the patient (or countertransference) are more and more considered as an important component of the patient-therapist relationship that are able to play a critical role in the psychotherapy process and outcome across different treatment approaches (Hayes, Gelso, & Hummel, 2011; Hayes, Nelson, & Fauth, 2015; Norcross, 2011). The classical psychoanalytic concept of countertransference—originally defined as the analyst’s transference to the patient’s transference, and considered a disruptive obstacle to the therapeutic process (Freud, 1910, 1912)— has evolved considerably becoming a valuable source of information about patient’s intrapsychic and interpersonal dynamics (Heimann, 1950). According to this totalistic perspective (Kernberg, 1965), all the clinician’s reactions to the patient can be helpful to make accurate diagnostic formulations and provide effective therapeutic interventions, especially in the treatment of personality pathology (Bateman & Fonagy, 2016; Beck, Davis, & Freeman, 2004; Dahl et al., 2014; Gabbard, 2014; Lingiardi & McWilliams, 2017; Yeomans, Clarkin, & Kernberg, 2015). To date, empirical investigations have examined the relationships between patient’s personality styles/syndromes and therapists’ responses showing that they are not arbitrary. Countertransference patterns were related to personality disorders and dimensions in clinically coherent and systematically predictable ways (e.g., Betan, Heim, Zittel Conklin, & Westen, 2005; Colli, Tanzilli, Dimaggio, & Lingiardi, 2014; Tanzilli, Lingiardi, & Hilsenroth, 2018; Tanzilli, Muzi, Ronningstam, & Lingiardi, 2017). However, these studies were mostly based on clinicians’ subjective experience to adult personality-disordered patients. Only a few studies have explored the associations between countertransference and specific styles/syndromes of personality in the psychotherapy with adolescents (e.g., Knaus et al., 2016; Satir, Thompson-Brenner, Boisseau, & Crisafulli, 2009; Tishby & Vered, 2011). The aims of this study were to: 1) examine the stability of the factor structure and psychometric properties of the Therapist Response Questionnaire – Adolescent Version (TRQ-A; Satir et al., 2009); 2) investigate the relationship between therapists’ emotional responses and specific emerging personality patterns of their adolescent patients. Methods: A national sample of psychiatrists and clinical psychologists (N=140) completed the TRQ-A to identify patterns of therapist response, as well as the Shedler–Westen Assessment Procedure–II-A (SWAP-II-A; Westen et al., 2014) to assess personality styles/syndromes regarding an adolescent patient currently in their care. An exploratory factor analysis (EFA) was carried out to identify the factor structure of the TRQ-A. Reliability of the TRQA’s scales was calculated using the Cronbach’s alpha coefficients. Bivariate correlations between the TRQ-A’s scales and personality styles/syndromes were conducted to assess the criterion validity of the TRQ-A and examine the associations of countertransference dimensions with patients’ personality pathology. Results: EFA revealed six distinct countertransference scales that were conceptually coherent and psychometrically robust: (a) hostile/devaluated, (b) positive, (c) bored/failing, (d) overwhelmed/scared, (e) overinvolved, and (f) sexualized. This factor solution accounted for about 51% of the variance, and the six scales were well marked by at least five items each, suggesting a stable factor structure unlikely to be substantially affected by sample size (Fabrigar, Wegener, MacCallum, & Strahan, 1999). The scales of the TRQ-A’s current version showed excellent reliability and validity. Their internal consistencies were: hostile/devaluated (α=.87), positive (α=.93), bored/failing (α=.84), overwhelmed/scared (α=.90), overinvolved (α=.85), and sexualized (α=.89). They were significantly associated with distinct personality styles/syndromes. Notably, more severe level of personality functioning was related to the bored/failing and overwhelmed/scared countertransference. Narcissistic and antisocial/psychopathic personality styles/syndromes were associated with the hostile/devaluated and overwhelmed/scared therapist responses, and borderline style/syndrome was related to the overwhelmed/scared and overinvolved countertransference. Schizoid personality style/syndrome was associated with the bored/failing countertransference, while impulsive/histrionic style/syndrome was related to the sexualized therapist response. Positive countertransference was related to the obsessional personality style. Conclusions: The TRQ-A is a very useful instrument to evaluate countertransference reactions in clinically sensitive and psychometrically robust ways. Moreover, adolescents’ emerging personality styles/syndromes were consistently associated with specific emotional responses, which suggests that clinicians can make diagnostic and therapeutic use of their responses to patients. This study supports the potential strengths of the TRQ-A’s use in both clinical and empirical contexts. It could be employed by therapists or supervisors of different theoretical orientations for making accurate case formulations and planning effective therapeutic interventions at the beginning of treatment, or for monitoring possible changes in the personality and the ways of interacting of adolescent patients during the psychotherapy process. In empirical terms, its applicability is equally relevant to examine countertransference across different clinical populations, or in the field of process-outcome research. References Knaus, S., Grassl, R., Seidman, C., Seitz, T., Karwautz, A., & Löffler-Stastka, H. (2016). Psychiatrists’ emotional reactions: Useful for precise diagnosis in adolescence?. Bulletin of the Menninger Clinic, 80(4), 316-325. doi:10.1521/bumc.2016.80.4.316. Satir, D. A., Thompson-Brenner, H., Boisseau, C. L., & Crisafulli, M. A. (2009). 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