Departments of Psychology and Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
Correspondence: Professor Drew Westen, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA 30322, USA. E-mail: dwesten{at}emory.edu
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To examine the structure of patient relational patterns in psychotherapy and their relation with DSMIV personality disorder symptoms.
Method A random sample of psychologists and psychiatrists (n=181) completed a battery of instruments on a randomly selected patient in their care.
Results Exploratory factor analysis identified five transference dimensions: angry/entitled, anxious/preoccupied, avoidant/counterdependent, secure/engaged and sexualised. These were associated in predictable ways with Axis II pathology; four mapped on to adult attachment styles. An aggregated portrait of transference patterns in narcissistic patients provided a clinically rich, empirically based description of transference processes that strongly resembled clinical theories.
Conclusions The ways patients interact with their therapists can provide important data about their personality, attachment patterns and interpersonal functioning. These processes can be measured in clinically sophisticated and psychometrically sound ways. Such processes are relatively independent of clinicianstheoretical orientation.
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INTRODUCTION |
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METHOD |
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Participants
Participants were 181 experienced clinicians randomly selected from the
membership registers of the American Psychiatric and American Psychological
Associations. We requested mailing lists of clinicians with at least 3
years post-licensure or post-residency experience, who indicated that
they performed at least 10 hours per week of direct patient care.
Approximately 10% of solicited clinicians returned postcards indicating their
interest in participating in a project requiring approximately 4 h of their
time for an honorarium of US$85. Validity checks comparing psychologists with
psychiatrists, who responded at substantially different rates, uncovered no
significant difference on any variable of interest (13 t-tests and
analyses of variance, P<0.01), suggesting that the relatively
modest response rate (reflecting substantial time commitment for a token
honorarium) was unlikely to account for the findings (see Limitations).
Inclusion and exclusion criteria
To obtain a cross-section of psychotherapy patients seen in clinical
practice, we asked clinicians to describe a non-psychotic patient at least 18
years old who they had treated with psychotherapy for a minimum of eight
sessions (to maximise the likelihood that they would know the patient well
enough to provide a reasonably accurate description) and for a maximum of 2
years (to avoid confounds associated with substantial personality changes with
treatment). To minimise selection biases, we directed clinicians to select the
last patient they saw during the prior week who met study criteria. Each
clinician described only one patient, to minimise rater-dependent biases. We
stratified the sample to ensure equal numbers of men and women.
Procedure
Clinicians could participate either by pen and paper or on an interactive
website
(http://www.psychsystems.Net).
Clinicians provided no identifying information about the patient and were
instructed to use only information already available to them from their
contact with the patient, so that data collection would not compromise
confidentiality or interfere with ongoing clinical work.
Measures
Clinicians completed a large battery of measures. Those relevant to this
study are described below (more details are given by
Russ et al, 2003, and
at
http://www.psychsystems.Net).
Clinical Data Form
The Clinical Data Form (CDF) (Westen
& Shedler, 1999) assesses a range of variables relevant to
demographics, diagnosis and aetiology. Clinicians provide basic demographic
data about themselves, including discipline (psychiatry or psychology),
theoretical orientation, employment sites (e.g. private practice, in-patient
unit, school) and gender; the patient, including age, gender, ethnicity,
education level, socioeconomic status and Axis I diagnoses. Following basic
demographic and diagnostic questions, clinicians rate the patients
adaptive functioning and a range of aetiological variables (developmental and
family history of psychiatric disorders). Several studies have supported the
validity of CDF variables, such as adaptive functioning, developmental history
and clinician-reported theoretical orientation
(Westen et al, 2003;
Thompson-Brenner & Westen,
2005).
Psychotherapy Relationship Questionnaire
The Psychotherapy Relationship Questionnaire (PRQ;
Westen, 2000) is a 90-item
clinician-report questionnaire designed to provide a normed, psychometrically
valid instrument for assessing transference patterns in psychotherapy for both
clinical and research purposes. The items measure a wide range of thoughts,
feelings, motives, conflicts and behaviours expressed by patients toward their
therapist that have traditionally been described as both
transference and working alliance. We derived the
90 items of the PRQ by reviewing the clinical, theoretical and empirical
literature on transference, therapeutic/working alliance and related
constructs, and 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 equally well by clinicians of any theoretical orientation. For example,
to capture Kohuts concept of mirror and
twinships transference in patients with narcissistic disorders
(Kohut, 1968), we included
items such as Assumes that the therapist shares his/her point of view,
beliefs, values, etc., even where this is unlikely and Imagines
s/he and the therapist are much more similar than they really are; seems to
want to be "twins" with the therapist (a copy of the
measure can be obtained at
http://www.psychsystems.Net).
Axis II diagnosis
To assess Axis II disorders, we asked clinicians to rate as present or
absent each criterion of each of the DSMIV Axis II disorders, randomly
ordered (American Psychiatric Association,
1994). This provides both a categorical diagnosis for each
disorder (obtained by applying diagnostic cut-offs) and a dimensional measure
(number of criteria met for each disorder).
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RESULTS |
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Factor structure of the PRQ
As a first step in identifying the factor structure of the PRQ, we
subjected the items to a principal components analysis using Kaisers
criteria (eigenvalues>1). We used the scree plot, percentage of variance
accounted for and parallel analysis (Horn,
1965; OConnor,
2000) to select the number of factors to rotate. The scree plot
indicated a break between five and six factors, and parallel analysis
indicated that five factors had eigenvalues larger than would be expected by
chance. Several factors emerged across algorithms and rotations, with the most
coherent solution emerging from a five-factor oblique (Promax) solution which
accounted for 45% of the variance (with factors each accounting for 2.5% to
26.4% of the variance); further details are available from the authors upon
request.
Table 1 describes the factors. To create factor-based (unit weighted) scores, we included items loading 0.50 or more for factor 1 and 0.40 or more for factors 25 to maximise reliability. Intercorrelations among the five factors ranged from 0.12 to 0.54, with a median of 0.14.
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Factor 1
Factor 1, angry/entitled (coefficient =0.94), is marked by items
indicating a tendency to make excessive demands of the therapist while
simultaneously being angry and dismissive. The items accord with clinical
descriptions of transference processes in patients with Axis II cluster B
disorders, notably narcissistic and borderline personality disorders.
Factor 2
Factor 2, anxious/preoccupied (coefficient =0.85), includes items
describing fear of the therapists disapproval, fears of rejection by
the therapist, an overly compliant and dependent attitude toward the
therapist, and a wish for the therapist to solve problems or take
care of the patient. This factor describes a style of relating to the
therapist that strongly resembles the adult attachment style labelled
preoccupied, which is related to the childhood classification of
anxious/ambivalent attachment (Main et
al, 1985).
Factor 3
Factor 3, secure/engaged (coefficient =0.86), is marked by items
describing the patients contribution to a positive working alliance and
a playful, comfortable, secure experience of the therapy relationship.
Factor 4
Factor 4, avoidant/counterdependent (coefficient =0.84), is marked
by items describing efforts to avoid meaningful connection with or dependence
on the therapist. It appears conceptually related to both the dismissing
(avoidant) adult attachment style and to dynamics common in obsessional and
socially withdrawn patients.
Factor 5
Factor 5, sexualised (coefficient =0.86), is marked by items
describing sexual feeling towards the therapist, including a tendency to act
in a seductive manner.
Ruling out theoretical bias
The factor structure described above is conceptually coherent;
nevertheless, an important question is the extent to which its coherence
reflects the nature of the patients described in the sample or the theoretical
beliefs of participating clinicians, particularly given that nearly half
shared a theoretical orientation that has emphasised transference phenomena
(psychodynamic). To evaluate this possibility, we conducted a second factor
analysis using the same procedures, this time eliminating all clinicians who
reported a psychoanalytic or psychodynamic orientation (remaining
n=120). (Confirmatory factor analysis was inappropriate, because
these were a subsample of the original sample.) The second factor analysis
yielded factors virtually identical to the first four factors of the original
factor analysis, with a median correlation between the two versions of each
factor of r=0.96. The primary difference between the second factor
solution and the solution using the entire sample was that several items from
the sexualisation factor loaded on the secure/engaged factor instead of
constituting a separate factor, probably because of the smaller sample size.
Thus, the factor structure does not appear to be an artefact of
clinicians theoretical preconceptions. Indeed, the first four factors
seem to map on to the disorganised/unresolved, secure, avoidant/dismissing and
anxious/preoccupied attachment patterns described in the developmental
literature, with which most clinicians are relatively unfamiliar (and which we
did not anticipate).
Transference and personality pathology
As a first test of the validity and clinical applicability of the PRQ, we
examined the relationship between each of the five factors and dimensional
measures of the DSMIV personality disorders. Because of the extensive
comorbidity of the Axis II disorders, we analysed the data at the cluster
level (clusters A, B and C) by summing the number of symptoms endorsed for
each of the disorders constituting each cluster. All three clusters were
represented in the sample: 15.5% met criteria for a cluster A disorder, 28.2%
for cluster B and 38.7% for cluster C. To control for comorbidity across
clusters (and for general severity of personality disturbance), we partialled
out the other two clusters in all analyses.
Based on the item content of the factors, we made three a priori predictions: that the cluster A (odd/eccentric) disorders would be associated with the avoidant/counterdependent factor; that the cluster B (dramatic/erratic) disorders would be associated with the angry/entitled and sexualised factors; and that the cluster C disorders (anxious/fearful) would be associated with anxious/preoccupied transference. The second and third hypotheses were strongly supported by the data (Table 2). Findings were weaker for the first of these hypotheses, which showed a trend toward significance (P=0.08). In addition, the cluster A (odd/eccentric) disorders showed a negative correlation with secure/engaged.
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To illustrate the clinical uses of the instrument, and to examine the extent to which it can be used to create empirical prototypes of common transference patterns in specific types of disorder, we created a composite description of the transference patterns of patients in the sample who met DSMIV criteria for narcissistic personality disorder. (We chose the latter disorder because we wanted to bring to bear empirical methods on a disorder that has generated substantial clinical theory, particularly with respect to transference, but relatively little research.) We standardised the items across patients and then averaged the item scores of patients meeting DSMIV criteria for narcissistic personality disorder from the Axis II checklist. By standardising items (setting means to 0) before aggregating, we reduced the salience of items descriptive of all patients in the sample (narcissists included) but not specific to narcissistic personality disorder. Table 3 presents the items most and least descriptive of therapist descriptions of transference processes in patients with narcissistic personality disorder (n=13). The composite description is remarkably similar to theoretical accounts of narcissistic transferences (e.g. Kohut, 1968; Kernberg, 1975). Interestingly, the composite excluding clinicians reporting a psychodynamic orientation was virtually identical, once again suggesting that the findings do not reflect clinicians biases or expectations.
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DISCUSSION |
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Relationship of PRQ dimensions to attachment styles and personality pathology
A striking and somewhat unexpected finding is the extent to
which these dimensions map on to adult attachment styles identified using the
Adult Attachment Interview (AAI; Main
et al, 1985). The AAI is a narrative-based interview that
codes attachment status based on the extent to which the person can speak
freely and coherently about relationships with present and past attachment
figures. Although clearly not all therapy relationships are attachment
relationships (which are characterised by features such as desires for
proximity to, and discomfort with physical or psychological distance from, an
attachment figure), the findings support the view that the therapy
relationship, as an intimate, emotionally charged, asymmetrical and typically
nurturant relationship, is likely to activate many attachment-related patterns
of thought and feeling and affect regulation, motivation, conflict and so
forth (see Fonagy et al,
1996; Seligman,
2000). To the extent that this is the case, examination of these
patterns in vivo can provide insight into some of the patients
central dynamics in close interpersonal relationships; and, by extension, as
argued for a century by psychodynamic theorists (and more recently by others;
e.g. Safran & Muran, 2000;
Ryle, 2001), changes in
patterns of responding in the therapy relationship may generate changes in
extratherapeutic relationships and their intrapsychic concomitants.
Although all patients have their own idiosyncratic ways of responding, the latent dimensions that emerged describe a range of ways patients respond not only to an intimate relationship but to the inherent dilemmas posed by most forms of psychotherapy: seeking v. fearing change, hiding v. disclosing ones flaws and vulnerabilities, depending v. not depending on an authority figure in an asymmetrical relationship, and so forth. Thus, some patients become angry at even minor threats to their self-esteem, demand that the therapist be perfectly responsive, and simultaneously overvalue and dismiss both the therapist and what the therapist can offer. Other patients feel inadequate, unlovable or unworthy, and fear that the therapist will be so repulsed, bored or angry that she or he will ultimately reject them; such patients tend to be anxious and vigilant about the therapists feelings and intentions, and to display many of the features described in the literature on anxious or preoccupied attachment. Some patients fear being vulnerable or out of control in therapy and consequently work hard to keep their distance, keep one foot out of the door or hold the therapist emotionally at bay. Still other patients (not well characterised by the attachment literature, given its origins in infant research) may sexualise the therapy relationship to try to establish some form of connection, repeat or try to work through a past trauma, or fear that the therapist will sexualise it.
One of the dimensions that emerged (secure/engaged) seems to describe not only a style of attachment in which the patient feels comfortable, secure and able to talk freely and with affect about emotionally significant experiences, but also a dimension frequently described as the working alliance (Greenson, 1965; Bordin, 1979), which has been shown empirically to be one of the best predictors of treatment outcome in psychotherapy (Horvath & Symonds, 1991; Martin et al, 2000). That items reflecting a positive working alliance and items resembling secure attachment loaded on a single factor probably reflects the fact that working alliance and transference involve similar cognitive processes involving activation of representations, affects and affect regulation strategies based on the match between the current situation or relationship and prototypes from the past (Westen & Gabbard, 2002). Thus, although the distinction between working alliance and transference may be heuristically useful, the patients response in both cases is based on a combination of prior expectations and current situational primes.
An additional finding is that patterns of transference appear to be systematically related to enduring personality styles, supporting a fundamental hypothesis first advanced by Freud decades ago, that the patterns emerging in the therapeutic relationship are not arbitrary. To what extent they mirror childhood relationships cannot be determined from these data, but they clearly reflect patterns seen elsewhere in patients lives that can be crucial to address. Of particular note is that the empirical portrait of transference patterns in patients with narcissistic personality disorder strongly resembles clinical descriptions of narcissistic transferences. This is especially striking given that most of the patients diagnosed with narcissistic personality disorder were not described by clinicians with a psychodynamic orientation, and the same portrait emerged when we did not include descriptions by dynamically oriented clinicians.
Limitations
This study has three primary limitations. The first is the exclusive
reliance on a single informant (the treating clinician), a design flaw shared
with most studies of psychopathology, which typically rely on patients rather
than clinicians as the sole informant. The failure to identify systematic
biases associated with theoretical orientation renders explanations based on
clinician bias unlikely; however, future research using this measure should
clearly assess its validity and correlates using data provided by other
observers. Some of the most important research in this area has involved
observer ratings of interaction patterns in psychotherapy, which do not rely
on clinicians accurate reporting of events in the consulting room. The
most sustained efforts along these lines have used Luborskys Core
Conflictual Relationship Theme method
(Luborsky & Crits-Christoph,
1990), which is designed to capture the patients wishes,
the expected or actual response from the clinician, and the patients
reactions to that response. This method has numerous advantages, most
importantly objectivity (an outside observer) and reliability of measurement
(the use of multiple observers to obtain interrater reliability). Its primary
difficulty is that it is labour-intensive and requires extensive training to
use reliably.
The second limitation is response rate. Although this is a genuine concern, three factors limit the likelihood that the results reflect response rate biases. First and foremost, it is hard to imagine a response rate hypothesis that could explain the pattern of results. By virtue of their willingness to donate 34 h of their time for a modest honorarium, clinicians who participated in the study might have differed from their colleagues on untold variables, but it is difficult to see how any of these variables could have produced the obtained findings. Second, clinicians who agreed to participate were unaware that transference was one of the constructs we intended to study. Third, psychologists responded at more than twice 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.
A third potential objection is sample size, given the possibility of some instability of factor structure with a 2:1 ratio of cases to items. However, recent thinking about factor analysis, based on data from Monte Carlo simulations and other studies, suggests that factor solutions stabilise with far fewer cases than previously believed (typically by 100 cases) as long as the factors are well marked by a sufficient number of items with loadings above 0.40 or 0.50 (as they were here), and that conventional case-to-item ratios do not take into consideration a range of variables that qualifies them in one direction or the other (see Fabregar et al, 1999; Russell, 2002). The next step in this research is a replication study with a larger sample, using confirmatory factor analysis, observer ratings of tape-recorded sessions and external ratings of variables such as personality disorder diagnosis and treatment outcome independent of the clinicians reports.
Implications
Transference phenomena are neither mysterious nor unmeasurable. They
reflect the tendency of the brain to map current on to past experience and to
craft responses that represent a combination of automatic activation of
procedures and mental representations from the past, integration of current
with past data and experience to generate responses that reflect the
coactivation of old and new neural networks, and creative problem-solving
activities. The PRQ represents an effort to develop a relatively
easy-to-administer measure designed for expert clinical observers (clinicians
or clinically trained coders listening to audiotapes or videotapes) that
reflects shared clinical wisdom in its item content and statistical
wisdom in its factor structure. The development of
clinician-report measures such as this may be useful not only for research but
for practice, allowing clinicians to rate patients on normed instruments with
known correlates, and hence to turn clinical phenomena such as transference
responses into quantifiable dimensions that can be examined and used as
indices of clinically meaningful change.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication February 10, 2004. Revision received September 23, 2004. Accepted for publication September 30, 2004.
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