Therapists' experience of difficulties in their practice

Abstract

This thesis studies psychotherapists' experiences of difficulties in practice. Building on previous work establishing content, prevalence, and relationship to professional development of difficulties, it reports three studies based on two surveys investigating dimensions and correlates of the pervasiveness of such experiences, both within (specificity) and between therapists (universality). In a first survey, 57 British psychotherapists each contributed two written accounts of difficulties and completed measures developed to tap emotional concomitants of these experiences. The hypothesised co-occurrence of extreme levels of these measures was not observed. In a second study using the same data, written accounts were rated in terms of theoretically refined definitions of transient and paradigmatic difficulty types, joined by a third, 'situational' category, denoting difficulties arising from external sources and universally experienced as problematic. Separate studies established reliability and validity of ratings. A further study based on a survey of 100 British and 30 German speaking therapists confirmed reliability of the rating system and, using difficulty types as dependent variables, validated them through their predicted associations with measures of competency deficits, therapists' internal conflicts, and indices of therapist/patient similarity; using newly developed as well as established (IIP, SASB) measures. Situational difficulties were associated with difficult patients but did not dislodge therapists from their professional stance. Transient difficulties were related to self-reported competency deficits, which occurred earlier in therapists' careers and were experienced as unfamiliar. Paradigmatic difficulties were found to be idiosyncratic, have a high impact, evoke negative internal states in therapists, arouse their wish for hostile control in the absence of perceived patient hostility, and relate to therapists' internal attachment conflicts and indices of similarity with their patients. Consequences for supervision and models of therapist development are discussed