Expanding the Circle - Francesco Gazzillo, PhD
For this issue’s Expanding the Circle column we were fortunate and are grateful to have the first author of the original publication, Dr. Francesco Gazzillo, contribute to the newsletter.
Therapist emotional reactions as a useful aid for understanding patient’s dynamics
During the last twenty years, several empirical studies have shown how clinicians can use their emotional reactions to patients as a useful aid for understanding the personalities, inner dynamics, and in particular motivational dynamics of their patients. From a clinical perspective, this theme is similar to that of countertransference in psychotherapy, a subject that, since the fifties, has been very relevant and often addressed in psychodynamic literature.
Paula Heimann (1950), Heinrich Racker (1968) and Wilfred Bion (1962), from a Kleinian perspective, Donald Winnicott (1958) and Masud Khan (1974) (among the British Independents) and Joseph Sandler (1976), from the Anna Freudian point of view, were some of the first analysts to stress how the emotional reactions of the clinician can be quite informative for understanding what is happening in the “here and now” of the clinical exchange between patient and therapist. The use of clinician’s emotional reactions is also quite clear from an Interpersonal perspective.
Empirical literature, in particular on the association between patient personality and therapists’ emotional reactions, has the ability to support and refine these clinical intuitions. Although systematic empirical research provides the necessary methodological rigor to better understand these processes, it may lack the necessary complexity and nuances of the clinician reasoning on a specific patient-therapist couple in a given moment of their journey.
Most research on personality diagnoses has used the Diagnostic and Statistical Manual of mental disorders (DMS), or the Shedler-Westen Assessment Procedure-200 (Westen, Shedler, 1999a, b) for describing the personality of the patients. The research I conducted with my colleagues which was published in Psychotherapy, is the first to use personality diagnoses assessed using the Psychodynamic Diagnostic Manual (PDM; PDM Task Forces, 2006) and took into account both the personality style of the patients and their level of personality organization. Both these constructs were assessed with two empirical tools specifically developed for a PDM derived assessment, the Psychodiagnostic chart (PDC; Gordon & Bornstein, 2012) and the Psychodynamic Diagnostic Prototypes (PDP; Gazzillo Lingiardi, & Del Corno, 2012).
The main results of our empirical study, together with those of previous research synthesized in the introduction, is that, in general, the lower the level of a patient’s personality organization, the harder it is to develop a good therapeutic alliance with him/her and the easier it is to feel overwhelmed or helpless; moreover, a parental and disengaged response seems to be associated with the depressive, anxious, and dependent personality styles; an exclusively parental response with a phobic personality style; and a parental and critical response with a narcissistic personality style. A dissociative style tends to stir up a helpless and parental response in the therapist whereas somatizing disorders seems to elicit a disengaged reaction. An overwhelmed and disengaged response is associated with sadistic and masochistic personality disorders, with the latter also eliciting a parental and hostile/critical reaction; an exclusively overwhelmed response with psychopathic patients; and a helpless response with paranoid patients. Patients with histrionic personalities seems to evoke an overwhelmed and sexualized response whereas there was no specific emotional reaction associated with the schizoid and the obsessive-compulsive disorders.
Our next step will be to see if it is possible to individuate more specific associations between clinicians’ emotional reactions on the one hand, and specific personality subtypes and moments of the therapy on the other hand. In other words, as the reader would have noted, most of personality styles are associated with more than one kind of emotional reaction. For example, the narcissistic personality style is associated with both a parental and disengaged emotional response, and we would like to see if the parental response is mainly associated with covert narcissistic features while the disengaged response is associated with overt narcissistic presentations. Secondly, reflecting on the association between the dependent, depressive and anxious personality styles and the disengaged and parental reaction of clinicians, for example, we would like to see if the disengaged reactions become stronger when the therapy is longer, as suggested in the PDM.
The more general consideration is that, even if our own emotional reactions cannot be the only or main source for understanding patients’ dynamics, the fact that they are (often very) informative is not surprising if considered from the perspective of contemporary neuroscience. We are all human animals, with common basic emotions (see, for example, the beautiful book written by Panksepp and Bien, 2012) and universal non-verbal ways for communicating them. And we are all equipped with mirror-neurons for feeling other people’s emotions and basic subcortical systems for responding to other people emotional cues (if you are in pain, I will take care of you; if you are threatening, I feel fear), and all these “brain tools”, together with our capacity of mentalization and symbolic thinking, are necessary for survival and adaption. From this perspective, as simple as it is, we can basically feel what other people are feeling so that we, as therapists, can use what we feel for understanding what is happening with our patients and between us and them. But, I repeat, these data cannot be the only ones to be taken into account for understanding and helping a patient. We also have to “clear our own psychic mirror” moment by moment from the dust of our idiosyncrasies, so that it can reflect our patients’ emotional life as best as possible.
References
Bion, W. R. (1962b). Learning from Experience. London: William Heinemann.
Gazzillo, F., Lingiardi, V., & Del Corno, F. (2012). Towards the validation of three assessment instruments derived from the PDM Axis P: The Psychodynamic Diagnostic Prototypes, the Core Preoccupations Questionnaire and the Pathogenic Beliefs Questionnaire. Bollettino di Psicologia Applicata, 265, 1–16.
Gordon, R. M., & Bornstein, R. F. (2012). A practical tool to integrate and operationalize the PDM with the ICD or DSM. Retrieved from http:// www.mmpi-info.com/pdm-blog
Heimann, P. (1950), On countertransference. International Journal of Psychoanalysis. Vol.31, 1950, p. 81-84
Khan, M.M.R. (1974). The Privacy of the Self. London: Karnac.
PDM Task Force (2006). The Psychodynamic Diagnostic Manual. Alliance of Psychoanalytic Organizations.
Racker, H. The meanings and uses of countertransference. Psychoanalytic Quarterly 26:3 (1957), 303-357.
Sandler, J. (1976). Countertransference and role responsiveness. International Review of Psycho-Analysis, 3:43-47
Westen, D., & Shedler, J. (1999a). Revising and assessing axis II, Part I: Developing a clinically and empirically valid assessment method. The American Journal of Psychiatry, 156, 258–272.
Westen, D., & Shedler, J. (1999b). Revising and assessing axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. The American Journal of Psychiatry, 156, 273– 285.
Winnicott, D.W. (1958). Collected Papers: Through Paediatrics to Psychoanalysis. London: Tavistock.
Therapist emotional reactions as a useful aid for understanding patient’s dynamics
During the last twenty years, several empirical studies have shown how clinicians can use their emotional reactions to patients as a useful aid for understanding the personalities, inner dynamics, and in particular motivational dynamics of their patients. From a clinical perspective, this theme is similar to that of countertransference in psychotherapy, a subject that, since the fifties, has been very relevant and often addressed in psychodynamic literature.
Paula Heimann (1950), Heinrich Racker (1968) and Wilfred Bion (1962), from a Kleinian perspective, Donald Winnicott (1958) and Masud Khan (1974) (among the British Independents) and Joseph Sandler (1976), from the Anna Freudian point of view, were some of the first analysts to stress how the emotional reactions of the clinician can be quite informative for understanding what is happening in the “here and now” of the clinical exchange between patient and therapist. The use of clinician’s emotional reactions is also quite clear from an Interpersonal perspective.
Empirical literature, in particular on the association between patient personality and therapists’ emotional reactions, has the ability to support and refine these clinical intuitions. Although systematic empirical research provides the necessary methodological rigor to better understand these processes, it may lack the necessary complexity and nuances of the clinician reasoning on a specific patient-therapist couple in a given moment of their journey.
Most research on personality diagnoses has used the Diagnostic and Statistical Manual of mental disorders (DMS), or the Shedler-Westen Assessment Procedure-200 (Westen, Shedler, 1999a, b) for describing the personality of the patients. The research I conducted with my colleagues which was published in Psychotherapy, is the first to use personality diagnoses assessed using the Psychodynamic Diagnostic Manual (PDM; PDM Task Forces, 2006) and took into account both the personality style of the patients and their level of personality organization. Both these constructs were assessed with two empirical tools specifically developed for a PDM derived assessment, the Psychodiagnostic chart (PDC; Gordon & Bornstein, 2012) and the Psychodynamic Diagnostic Prototypes (PDP; Gazzillo Lingiardi, & Del Corno, 2012).
The main results of our empirical study, together with those of previous research synthesized in the introduction, is that, in general, the lower the level of a patient’s personality organization, the harder it is to develop a good therapeutic alliance with him/her and the easier it is to feel overwhelmed or helpless; moreover, a parental and disengaged response seems to be associated with the depressive, anxious, and dependent personality styles; an exclusively parental response with a phobic personality style; and a parental and critical response with a narcissistic personality style. A dissociative style tends to stir up a helpless and parental response in the therapist whereas somatizing disorders seems to elicit a disengaged reaction. An overwhelmed and disengaged response is associated with sadistic and masochistic personality disorders, with the latter also eliciting a parental and hostile/critical reaction; an exclusively overwhelmed response with psychopathic patients; and a helpless response with paranoid patients. Patients with histrionic personalities seems to evoke an overwhelmed and sexualized response whereas there was no specific emotional reaction associated with the schizoid and the obsessive-compulsive disorders.
Our next step will be to see if it is possible to individuate more specific associations between clinicians’ emotional reactions on the one hand, and specific personality subtypes and moments of the therapy on the other hand. In other words, as the reader would have noted, most of personality styles are associated with more than one kind of emotional reaction. For example, the narcissistic personality style is associated with both a parental and disengaged emotional response, and we would like to see if the parental response is mainly associated with covert narcissistic features while the disengaged response is associated with overt narcissistic presentations. Secondly, reflecting on the association between the dependent, depressive and anxious personality styles and the disengaged and parental reaction of clinicians, for example, we would like to see if the disengaged reactions become stronger when the therapy is longer, as suggested in the PDM.
The more general consideration is that, even if our own emotional reactions cannot be the only or main source for understanding patients’ dynamics, the fact that they are (often very) informative is not surprising if considered from the perspective of contemporary neuroscience. We are all human animals, with common basic emotions (see, for example, the beautiful book written by Panksepp and Bien, 2012) and universal non-verbal ways for communicating them. And we are all equipped with mirror-neurons for feeling other people’s emotions and basic subcortical systems for responding to other people emotional cues (if you are in pain, I will take care of you; if you are threatening, I feel fear), and all these “brain tools”, together with our capacity of mentalization and symbolic thinking, are necessary for survival and adaption. From this perspective, as simple as it is, we can basically feel what other people are feeling so that we, as therapists, can use what we feel for understanding what is happening with our patients and between us and them. But, I repeat, these data cannot be the only ones to be taken into account for understanding and helping a patient. We also have to “clear our own psychic mirror” moment by moment from the dust of our idiosyncrasies, so that it can reflect our patients’ emotional life as best as possible.
References
Bion, W. R. (1962b). Learning from Experience. London: William Heinemann.
Gazzillo, F., Lingiardi, V., & Del Corno, F. (2012). Towards the validation of three assessment instruments derived from the PDM Axis P: The Psychodynamic Diagnostic Prototypes, the Core Preoccupations Questionnaire and the Pathogenic Beliefs Questionnaire. Bollettino di Psicologia Applicata, 265, 1–16.
Gordon, R. M., & Bornstein, R. F. (2012). A practical tool to integrate and operationalize the PDM with the ICD or DSM. Retrieved from http:// www.mmpi-info.com/pdm-blog
Heimann, P. (1950), On countertransference. International Journal of Psychoanalysis. Vol.31, 1950, p. 81-84
Khan, M.M.R. (1974). The Privacy of the Self. London: Karnac.
PDM Task Force (2006). The Psychodynamic Diagnostic Manual. Alliance of Psychoanalytic Organizations.
Racker, H. The meanings and uses of countertransference. Psychoanalytic Quarterly 26:3 (1957), 303-357.
Sandler, J. (1976). Countertransference and role responsiveness. International Review of Psycho-Analysis, 3:43-47
Westen, D., & Shedler, J. (1999a). Revising and assessing axis II, Part I: Developing a clinically and empirically valid assessment method. The American Journal of Psychiatry, 156, 258–272.
Westen, D., & Shedler, J. (1999b). Revising and assessing axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. The American Journal of Psychiatry, 156, 273– 285.
Winnicott, D.W. (1958). Collected Papers: Through Paediatrics to Psychoanalysis. London: Tavistock.