ABSTRACT
This study addresses the impact of therapists’ personalities on psychotherapy process within the context of relational psychodynamic theory. The differential role of therapists’ interpersonal schemas of their mothers verses their fathers were assessed in relation to their ability to form a working alliance, and work through alliance ruptures. The role of the father tends to be less understood than that of the mother, with limited research addressing how therapists’ relationships with their fathers may impact their relational schemas and consequent impact on psychotherapeutic process. This study draws on findings from the child-development literature suggesting that fathers are important in the formation of conflict resolutions skills, and considers therapists’ interpersonal schemas of their fathers in relation to rupture resolution. Therapists interpersonal schemas of their mothers and fathers are assessed using the interpersonal schema questionnaire (N = 96), and then calculated along four different kinds of situations; Hostile, friendly, submissive and dominant. Interpersonal schemas along these four dimensions for mothers and fathers are then assessed in relation to therapists and patients reports of working alliance (Working Alliance Inventory), rupture resolution (Post-Session-Questionnaire), and session smoothness and depth of experience (Session Evaluation Questionnaire) across the first five psychotherapy sessions. Therapist introjects using the Intrex questionnaire were also assessed in relation to working and alliance and rupture resolution variables as a point of comparison to the interpersonal schema questionnaire. All therapists and patients were seen as part of the Brief Psychotherapy Research Program. Each therapist was seen by multiple and varying numbers of patients (ranging from 1-8, with a total of 186 patients in the overall sample). Multilevel modeling was employed to account for this “nesting,” while assessing the relationship between independent and dependent variables. Findings suggested that therapists’ interpersonal schemas of their fathers and mothers in friendly and dominant situations are predictive of rupture resolution. However, only the father was predictive of both patient and therapist ratings, as well as perceived smoothness and depth of experience during rupture sessions. Findings also suggested that therapists’ affiliative introjects are predictive of rupture resolution. Theoretical and clinical implications are discussed.
THERAPISTS’ CONTRIBUTION TO THE WORKING ALLIANCEAND RUPTURE RESOLUTION:
THE DIFFERENTIAL ROLE OF THERAPISTS’ INTERPERSONAL SCHEMAS OF THEIR MOTHERS AND FATHERS IN PSYCHOTHERAPY
by
Melanie Fox-Borisoff
Dissertation Submitted to the
New School for Social Research of New SchoolUniversity
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Philosophy
November 2009
Dissertation Committee:
Jeremy D. Safran, Ph.D.
J. Christopher Muran, Ph.D.
Howard Steele, Ph.D.
Claudia, Barrachi Ph.D.
Table of Contents
List of Tables...... iv
Introduction...... 1
CHAPTER 1: INTRODUCTION AND THEORETICAL BACKGROUND...... 3
The Role of the Therapist in Psychotherapy Process: The Working Alliance, Ruptures, and the Internalization of Self-Other Interactions 6
The Working Alliance and the Therapist’s Contribution to
Psychotherapy Process...... 3
A Two-Person Psychology: Me-You Representations...... 13
Sullivan’s Personifications of Self and Other: An Introduction
Two Person Psychology...... 13
Internal Working Models...... 17
Representations of Interactions that have been Internalized.....18
Interpersonal Schema Theory...... 19
The Interpersonal Circumplex: A Model for Psychotherapy Research
Within the Framework of A Two-Person Psychology.....22
Structural Analysis of Social Behavior: The Intrex...... 23
Kiesler’s Interpersonal Transaction Cycles and Circumplex
Model...... 25
Assessing Therapists’ Me-You Representations...... 29
The Interpersonal Schema Questionnaire...... 29
Reliability and Validity of the ISQ...... 32
Relevant Studies Applied to Psychotherapy Process...... 33
The Role of the Father and Interpersonal Schemas...... 36
CHAPTER II: CHILD DEVELOPMENT, THE ROLE OF THE FATHER, AND CONFLICT RESOLUTION 38
Child-Father Attachment Style and Children’s Social Competence.....38
Father-Child Conflict and Conflict Resolution with Peers...... 51
Affect-Regulation and Conflict Resolution: The Role of the Father.....58
Summary of Father vs. Mother Influences in Child Development...... 63
CHAPTER III: STATEMENT OF PURPOSE AND HYPOTHESES...... 64
Statement of Purpose...... 64
Hypotheses...... 66
CHAPTER IV: METHOD...... 67
Overview...... 67
The Brief Psychotherapy Research Program...... 69
Participants...... 71
Therapists...... 71
Patients...... 72
Measures of Therapist Internal Process (Independent Variables)...... 73
Interpersonal Schema Questionnaire (ISQ)...... 73
Intrex Questionnaire...... 74
Measures of Psychotherapy Process (Dependent Variables)...... 75
Working Alliance Inventory (WAI)...... 75
Post Session Questionnaire and Rupture Section...... 76
Session Evaluation Questionnaire (SEQ)...... 76
Procedures...... 77
Pilot Study...... 77
Current Study...... 83
CHAPTER V: ANALYSES...... 82
CHAPTER VI: RESULTS...... 87
Descriptives of Ratings...... 87
Multilevel Modeling...... 88
Hypothesis I: Therapist ISQ, Working Alliance and Rupture Resolution. 88
Hypothesis II: Therapist ISQ and Session Smoothness and Depth97
Hypothesis III: Therapists’ Introjects...... 101
Random Effects...... 103
Summary of Regression Coefficients...... 104
CHAPTER VII: DISCUSSION...... 105
Rupture Resolution...... 105
Working Alliance...... 108
Therapist Introjects and Rupture Resolution...... 109
Limitations and Future Directions...... 110
Conclusion...... 113
REFERENCES...... 116
APPENDIX A...... 133
APPENDIX B...... 136
APPENDIX C...... 138
LIST OF TABLES
Table 1: Preliminary Results for Therapist ISQ and Rupture Resolution...... 79
Table 2: Preliminary Results for Therapist ISQ and Working Alliance...... 80
Table 3: Summary of Dependent Variable Ratings...... 87
Table 4: Summary of Therapist-ISQ Quadrant Ratings for Desirability...... 88
Table 5: ISQ-Mother in Friendly Situations and Therapist/Patient Rupture Resolution 90
Table 6: ISQ Mother in Dominant Situations and Therapist/Patient Rupture Resolution 92
Table 7:ISQ Father in Friendly Situations and Therapist/Patient Rupture Resolution 94
Table 8:ISQ Father in Dominant Situations and Therapist/Patient Rupture Resolution 96
Table 9:ISQ-Father in Dominant Situations and Perceived Session Smoothness..98
Table 10:ISQ-Father in Friendly Situations and Depth of Experience in Session..100
Table 11:Therapists’ Affiliative Introjects and Rupture Resolution...... 102
Table 12:Summary of Regression Coefficients for all Main Effects of ISQ/Intrex…104
1
Introduction
Psychotherapy research has for the most part devoted it’s time to assessing patient characteristics and patient contributions to psychotherapy process. However, there is a burgeoning interest in how the therapist’s personality impacts psychotherapy process. Although these studies are still limited, there is evidence supporting further research in this area and that therapist’s interpersonal histories may impact their effectiveness as psychotherapists. In particular, preliminary studies have demonstrated on a couple of occasions that therapists’ relationships with their fathers are important determinates of psychotherapy therapy process and outcome (Nelson, 2000; Fox-Borisoff, unpublished MA thesis). In particular, therapists’ interpersonal schemas (expectations in social interactions) with their fathers may be important predictors of their ability to resolve ruptures (moments of tension or deterioration of therapist-patient communication) with patients during therapy, while the relationship with the mother may be more important for the formation of the therapeutic alliance. Convergent with these findings, recent research within the child development domain is suggesting that fathers may play an important and distinct role in the formation of mental structures that help maintain healthy relationships. For example, research is suggesting that fathers’ are particularly important for the formation of social competency skills, particularly conflict resolution, while mothers may be more important to the development of feelings and skills such as empathy that aid in the initial formation of relationships. The first chapter reviews the history of the working alliance concept and the role of the therapist, interpersonal theory, and reviews a few studies addressing how therapists’ own interpersonal schemas of their fathers’ verses their mothers’ affect psychotherapy process. In the second chapter, a review of the child development literature on social competency formation supports and hopefully deepens the understanding of the relationship between fathers verses mothers, interpersonal schema formation, and subsequent abilities to establish trusting relationships and confront conflict in everyday life as well as in psychotherapy.
Chapter I
The Role of the Therapist in Psychotherapy Process: The Working Alliance, Ruptures, and Internalization of Self-Other Interactions
The Working Alliance and the Therapist’s Contribution to Psychotherapy Process
The concept of the therapeutic alliance can be traced back to Freud (1912) who suggested that the analyst maintain “serious interest” and “sympathetic understanding” of their patient so that the patient’s healthy self can form a positive relationship with their analyst. Freud initially hypothesized that this accepting stance of the therapist, and the patient’s attachment to therapist would result in a “positive transference” that needs to be interpreted. For example, Freud believed that the patient would begin to associate their positive relationship with their therapist to other affectionate people in their life, and although beneficial, this would not reflect the real relationship between the patient and the therapist. However, in his later writing, Freud seemed to modify his view of the “positive transference” and suggested that a positive attachment to the therapist could be based in reality and may in fact facilitate the healing process.
Despite Freud’s statement that the therapist should maintain a position of sympathetic understanding towards the patient, Freud also warned against countertransference and ardently advised analysts to go through their own analysis so that they could maintain neutrality with the patient, and essentially act as a mirror capable of reflecting the patient’s neurosis. This contradiction has led theorists to argue what the actual extent of the therapist’s contribution to the formation of an alliance is and should be, verses how much of this alliance is as Freud originally proposed, a “positive transference” resulting from the patient’s personality (e.g., Brenner, 1979).
Zetzel (1956) introduced the term “therapeutic alliance” in describing the relationship between the patient and therapist, and is generally credited as being the first to map out this concept. She viewed the therapeutic alliance as distinct from transference neurosis and believed that it was a recapitulation of the infant-mother relationship, whereas the patient turns to the therapist for help like an infant turns to the mother for help. Zetzel proposed that the alliance differs from transference neurosis in that the alliance is based upon a patient’s solid object relations from infancy, and consists of the non-neurotic component of the patient-therapist relationship. She argued that a healthy analysis consists of the patient oscillating between moments dominated by the working alliance and moments dominated by the transference, and that the alliance allows the patient to step back and reflect upon differences between relationships with others, verses the real nature of the relationship with the therapist. Overall, Zetzel emphasizes the impact of the patient’s personality for forming a patient-therapist relationship, rather than how the therapist’s qualities may contribute to this process. Zetzel acknowledges the role of the therapist in the formation of the alliance, for example, she proposes that the analyst be like a good mother creating a supportive environment that fosters underlying trusts, and is capable of making “intuitive adaptive responses”. However, she does not consider that the therapist’s object relation development may also be important for a real relationship to occur.
Greenson (1965) was the first to use the term “working alliance”. He extended Zetzel’s work in suggesting that the transference neurosis and the working alliance were separate concepts, both requiring equal attention. Greenson argued that a positive working alliance needs to be present in order for transference neurosis to be analyzed. He stated that “for a working alliance to take place, the patient must have the capacity to form object relations since all transference reactions are a special variety of them” and that the patient’s contribution to the working alliance depends on adequate ego strength. For example, he stated that working alliance depends on “his [the patient’s] capacity to maintain contact with the reality of the analytic situation and also his willingness to risk regressing into his fantasy world. It is the oscillation between these two positions that is essential for analytic work.” However, Greenson also considered the therapist’s contribution to the formation and maintenance of the working alliance. For example, he argued that analysts often take Freud’s suggestion of maintaining neutrality to an extreme and consequently come across as cold, authoritarian and rigid, smug and aloof to their patients. Greenson argued that in order for an alliance to form, analysts need to work in a manner that is “realistic and reasonable” and to maintain respect for patients as humans, and show “consistent concern for the rights of the patient throughout the analysis.”
In contrast to those who proposed that the working alliance is a distinct construct, several theorists (e.g., Brenner,1979; Curtis, 1979; and Hanly,1992) criticized the above ego psychologists and felt that it is purposeless, and at times counterproductive to consider an alliance as separate from the transference. For example, Brenner (1979) felt that the alliance concept may lead analysts to leave important material unexplored and ultimately limit the therapeutic process. Similarly, Hanly (1992) suggested that the alliance concept may result in an overvaluation of rational therapeutic processes, while leaving unconscious material unattended too (In Safran & Muran, 2000). Overall, these theorists believed that the alliance concept may mask resistances and unconscious conflicts such as a wish for the therapist to be like a parental figure, or an attempt to maintain equal ground with the therapist.
Athough the concept (and the controversy over) the therapeutic working alliance has generally arisen out of the psychodymanic school of thought, other areas of psychology have hinted at similar ideas, and place an increased emphasis on the role of the therapist. For example, interpersonalists such as Harry Stack Sullivan (1953), and Clara Thompson (1964) emphasized the importance of the real relationship between the patient and the therapist. In addition, by assuming a two-person psychology where the therapist is embedded in the therapeutic process, interpersonalists were in a way expressing an implicit concern for a working alliance without mentioning the term itself.
Relational psychoanalysis forgoes the concept of real verses unreal relations and argues that there are multiple truths at any given time and based on social construction, thus the idea that there are real verses unreal aspects of the therapeutic relationship is a “meaningless concept” (Safran and Muran, 2000). According to Safran and Muran, the therapeutic emphasis in relational psychoanalysis is more on mutuality, enactments and spontaneity than it is on neutrality and objectivity. They suggest that for this reason the working alliance concept is not as necessary to relational psychotherapists, however, they also suggest that is essentially what underlies mutuality between therapist and patient, and that most analysts take it for granted as a primary medium for change.
Zetzel and Greenson acknowledged the need for the therapist to be supportive and respectful of their patients in order for an alliance to form. However, they assumed that given this even, and as some would argue maternal-like stance (Zetzel, 1966; Friedman, 1969, Sandler and Colleagues, 1969) the patient’s ego capacities would ultimately determine the outcome of the alliance. Interpesonalists, and relational analysts place more emphasis on the role of the therapist, however, traditionally they have only considered the working alliance insomuch as an implicit part of the change process. In contrast, Edward Bordin’s (1979) conceptualization of the working alliance offered a pan-theoretical application of the concept and has been responsible in part for renewed interest in the topic, as well as a closer look at the contribution of the therapist in terms of the alliance across psychotherapy modalities. Bordin’s broad definition builds on Zetzel’s and Greenson’s earlier work in further clarifying the distinction between the working alliance and the patient’s unconscious projections, and proposed that the working alliance is essential for therapeutic change regardless of the modality. In addition, his formulation emphasized the positive collaboration between the patient and the therapist. He identified three components of the alliance: tasks, bonds, and goals. In defining tasks, Bordin expanded on Menninger’s (1958) concept of a contract between patient and therapist. Bordin defined the tasks of therapy as the specific activities or behaviors that both the patient and therapist engage in. The specific tasks may differ according to the therapeutic modality. For example, in gestalt therapy the patient is asked to attend to action, in psychoanalysis the patient is asked to fee associate. The specific tasks of the therapist may also differ depending on the modality. For example, relational therapy may ask for more self-disclosure, whereas humanistic therapy may require more empathic support. In order for the alliance to be strong, both parties must view the therapeutic tasks as efficacious. The goals of therapy are generally agreed upon desired outcomes. Again, the goals may differ depending on the therapeutic modality whereas cognitive-behavioral therapy may have a goal to reduce a specific behavioral symptom, and psychoanalysis may aim to resolve underlying conflicts. The bond includes elements of mutual trust and acceptance and confidence and reflects the overall quality of the patient-therapist relationship. Overall, Bordin’s broad conceptualization of the alliance offers a flexible definition that can be applied across modalities and across individual patient and therapist characteristics. Bordin acknowledged differences between therapy types and that each one varies in emphasis on tasks, goals, and bond. He suggested that the extent to which the therapist and patient agreed upon these emphases would determine the strength of the alliance. In addition, Bordin recognized the importance of interpersonal negotiation between the patient and the therapist for the formation of the alliance, and that each patient and therapist has varying styles and needs.
In addition to Bordin’s conceptualization of the alliance bringing renewed attention to the topic, psychotherapy research also began suggesting that psychotherapy outcome does not significantly differ amongst various modalities (Luborsky, Singer & Luborsky, 1975; Stiles, Shapiro & Elliot, 1986). Researchers took this to mean that there may be underlying factors, such as the alliance, common to all forms of therapy that are responsible for change (Horvath & Luborsky, 1993). Given the importance of the alliance for psychotherapeutic change, breaches in the alliance become a major concern for the efficacy of therapy (Safran & Muran, 20000). Binder and Strupp (1997) conducted a meta-analysis of negative process in psychotherapy and concluded that negative processes were unavoidable in forms of psychotherapy, and that positive outcomes rely on the therapist’s ability to effectively handle these alliance ruptures (In Ackerman & Hilsenroth, 2001). However, much of the research that addresses this issue focuses on only the patient’s personality, thus reflecting previous thinking that the quality of the alliance is ultimately an intra-psychic process, (rather than a transactional process) dependent on the patient’s personality. Several reasons have been given for this one-sided focus, for example, there are simply many more patients than therapists making it much more efficient to look at patient variables, and there are logistical difficulties with collecting confidential data from therapists (Najavits & Strupp, 1994). In addition to these more practical reasons though, Kiesler (1996) suggests that therapist’s are often not studied due to an assumption that therapists are all conducting “psychotherapy”, and are thus more or less interchangeable in research (Kiesler, 1996). In addition, Strupp (1982) suggests that many researchers may mistakenly believe that therapists are essentially superior to patients in their adaptive functioning. Nonetheless, there have been some seminal studies that have addressed how therapists’ characteristics impact the therapeutic alliance.