“Detoxification” of destructive clinical material in psychodynamic psychotherapy: A case study of how the therapists’ interpersonal skills are used in a challenging treatment case with a successful outcome

ABSTRACT

There is a need to gain more knowledge of how interpersonally skilled therapists handle demanding clinical situations to better understand therapist effects. The aim of this single-case study was to investigate how the therapist encountered challenging situations where her interpersonal skills were put to test and how her handling likely contributed to patient change. From a larger research project on learning processes, this case was selected since it was judged to be both challenging and with a good outcome. Interpretative phenomenological analysis of video-recordings of a 42 session long psychodynamic psychotherapy, was conducted. The analysis yielded one superordinate theme: The therapist “detoxifies” demanding clinical material, such as aggression and shame. Three constituent sub-themes expressed different ways in which this process took place (1: The therapist tolerates the patient’s skepticism and criticism in a non-defensive manner by focusing on the patient’s underlying feeling; 2: The therapist responds to the patient’s self-destructive behaviors in a non-judgmental and “containing” way that reduces shame; and 3: The therapist interprets the patient’s rejection as separation anxiety related to termination of the therapy). Our findings provide a more nuanced understanding on how the interpersonal skills of the therapist come into use in a specific, challenging therapy process.

KEYWORDS:

• Facilitative interpersonal skills
• containment
• therapist effects, psychodynamic psychotherapy
• Qualitative analyses

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Correction

To better understand the variation in therapeutic outcomes between patients, more studies have turned their attention to the person delivering the psychotherapy, i.e. the psychotherapist (Wampold & Owen, 2021). Recent studies convincingly show that some therapists achieve better outcomes than others (Castonguay & Hill, 2017). These effects, i.e. therapist effects (TEs) are not explained by variation in patients seen, by dyadic effects (i.e. the specific combination of patient and therapist), or by random error (Wampold, Baldwin, Holtforth, & Imel, 2017). TEs appear both in randomized controlled trials as well as in naturalistic studies (Baldwin & Imel, 2013; Johns, Barkham, Kellett, & Saxon, 2019). A pressing task for psychotherapy researchers today is to understand the nature of TEs (i.e. what therapist characteristics that explain differential therapist effectiveness). Prior studies in this realm have shown that objective characteristics such as age, gender, professional background, and adherence and competence in delivering a treatment manual, are not consistently related to patient variation in therapeutic outcomes (e.g. Beutler et al., 2004; Webb, DeRubeis, & Barber, 2010). Instead, therapists’ subjective (or “inferred”) professional (experiences in sessions; attitudes toward treatment) and personal (intrapersonal and interpersonal) characteristics are more promising (Heinonen & Nissen-Lie, 2020). Research on therapist characteristics indicates that more effective therapists are characterized by sophisticated interpersonal skills that are likely rooted in their personal lives and attachment history (Heinonen & Nissen-Lie, 2020).

This in-depth single case study was inspired by studies on facilitative interpersonal skills (FIS) conducted by Timothy Anderson and colleagues (Anderson, Crowley, Himawan, Holmberg, & Uhlin, 2016; Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009). The FIS paradigm is a particularly promising paradigm for studying therapists’ interpersonal abilities related to change in psychotherapy. Using professional actors to play out scripts of eight challenging interpersonal styles, Anderson, Ogles, Patterson, Lambert, and Vermeersch (2009) presented therapists with standardized video material of challenging clinical situations and had expert evaluators assess the therapist’s verbal fluency, responsiveness, emotional expressiveness, persuasiveness, warmth, positive regard, hopefulness, empathy, and capacity to form and repair alliances (Anderson, Crowley, Himawan, Holmberg, & Uhlin, 2016; Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009). The composite score of these skills predicted better OQ-45 outcomes of 25 experienced therapists seeing 1141 patients for a mean of 9 sessions. Thus, therapists’ facilitative interpersonal skills seem to promote growth and change in psychotherapy. However, as these studies rely on correlations between responses to a non-interactive stimulus and patient outcome, they do not explain how these aspects of the therapist’s interpersonal functioning come into play in actual clinical settings. In order to understand this, we need in-depth case studies which explore the dynamic interplay between patients and therapists in challenging therapy cases as they unfold over time. In demanding situations, for example with aggressive and withdrawn patients, therapists need a sophisticated set of psychological resources that enable them to accommodate, resist retaliation, or become defensive, and maintain a focus on the patient’s needs (Castonguay & Hill, 2017; Hayes, Gelso, Goldberg, & Kivlighan, 2018; Heinonen & Nissen-Lie, 2020).

Using a combination of a hermeneutical and phenomenological analytic procedure, in the current study, we aimed to explore processes that both theoretical and empirical work have pointed out as promising. A qualitative methodology has the advantage of capturing how therapists’ interpersonal skills are played out in clinical situations, and thus explore how therapists’ behaviors may affect the psychotherapeutic outcome (e.g. Bernhard, Nissen-Lie, H, & Råbu, 2020). Such an approach could strengthen the knowledge base of how change in psychotherapy takes place (Heinonen & Nissen-Lie, 2020; McLeod, 2013), generate new theoretical ideas about change processes in psychotherapy, or empirically confirm or nuance already existing findings.

In this study, the aim of the case was to gain insight on a micro level into how the therapist’s ability to handle demanding clinical material in challenging therapy situations contributed to a successful patient outcome. In order to explore how the psychotherapist makes use of her skills to optimally meet the challenges presented, the study was conducted as a part of a larger psychotherapy training project, and a case was selected which was judged to be both challenging and as achieving a positive outcome (see below). The exploration of the case was guided by the following research question: How does the therapist encounter challenging clinical situations where her interpersonal skills were put to test, and how did her handling contribute to patient change?

Method

The case was selected from a longitudinal study of learning processes involved in the clinical training of psychology students at the University of Oslo. The overarching aim of this project is to generate knowledge about therapists’ learning processes in therapy and supervision and elaborate on the concept of psychotherapeutic competence (University of Oslo, 2020). The current study is based on data of one psychodynamic psychotherapy process in this project. The selected case included all sessions (video-recorded) with a student therapist and a patient over a fixed period of eight months. She received supervision weekly during the process. To ensure methodological integrity (Levitt, Motulsky, Wertz, Morrow, & Ponterro, 2017), we used a phenomenological and hermeneutical approach that supported the research goal aiming to get close to the actual unfolding of the clinical process.

Selection of the case

In the selection of the current case, two of the authors made the choice based upon the criterium “a demanding psychotherapy process with a successful outcome”. We looked for a case where the therapist used her interpersonal skills in challenging situations to contribute to therapeutic change. In this case, the patient exposed a subtle judgmental side that student therapists usually respond to by being “caught off guard”, become defensive, or very insecure, or “retaliate”. However, the therapist’s ability to adequately respond, tolerate, and handle these situations when she was challenged, distinguished her from other therapists in the research project and made this case particularly interesting to explore further. To validate the choice, during the process the patient several times directly expressed to the therapist that he experienced the therapy as meaningful. In the post therapy interview, the patient expressed that the therapy had changed his life in terms of creating a positive spiral of beneficial relational experiences and made it possible to engage in less destructive relationships. Both therapist and patient referred to the psychotherapeutic process as highly beneficial in the post therapy, semi-structured interview with the first author after the paper was written. The clinical supervisor (one of the authors) had the same evaluation, especially after the turning point where the patient exposed his trust in the therapist by telling her about how he had humiliated himself (see below). Her opinion was substantiated by observations of the real interactions in the video recordings of the whole process. The same evaluation was made independently by the academic supervisor (one of the other authors).

Participants

To ensure the integrity of the involved participants both names and presentation of the participants were anonymized.

The therapist

The therapist is referred to as “Sara”. Sara is a female in her twenties. On video, she appeared warm, caring, and empathic. She had a casual appearance and could be taken for being younger than her age. Her use of bodily, nonverbal presence in the therapeutic work expressed an open and non-judgmental approach, but also signaled that she paid attention and emotionally adjusted to the patient.

The patient

The patient is a male some years older than the therapist. In this study, he will be referred to as “Christian”. At the outset of the therapy, he had some years earlier completed his higher education with top academic results and was working. He was single during therapy, but had previously been in four relationships, two of which had lasted over several years. In the first session, Christian expressed that he had gone through a serious break up the previous year. He found out that his former partner had an ongoing relationship behind his back, which triggered a psychological crisis with depressive symptoms, unhealthy alcohol and substance use, and compulsive series of suicidal thoughts.

Christian’s personal history included several losses of close relatives as a child. He grew up as the youngest sibling. When he was only a few years old, Christian lost his father. Later, he also lost two other relatives that had become important attachment figures for him. In recent years, Christian had thought that his mother must have had a great deal of responsibility to take care of the children alone. He recalled that his older brother took extra care of him as a child. Christian started hyperventilating in early school years. In his teens, he had panic attacks. As a child, Christian described himself as an anxious and quiet boy. Inside, he said he still felt anxious, but that others now would find him emotionally open, social, and outgoing.

Christian applied specifically for treatment at the Clinic for Dynamic Psychotherapy with a desire to find out more about himself and find a way back to the joy and purpose in his life. In therapy, Christian’s appearance was age appropriate. He had a somewhat cool and trendy attitude. His body posture was usually turned towards Sara, and he provided direct eye contact, except when he seemed to be anxious and insecure. During difficult moments, he could hold his head against his hands and stare out in the room with an “empty gaze”.

Researchers

The authors are all clinical psychologists. The last three are researchers, clinical trainers, and each has a small clinical practice mostly conducting psychoanalytic psychotherapy/psychoanalysis. The authors are trained in various forms of psychotherapeutic approaches with an emphasis on psychoanalytic psychotherapy and have from 2–20 years of clinical experience. To avoid contaminating the initial data analysis, she did not participate in the first part of the analytic process.

Data analyses

Methods of analyzing linguistic data must take account of the reflexivity and interpretative practice that characterize human communication (Finlay, 2011; McLeod, 2013). To ensure methodological integrity (Levitt, Motulsky, Wertz, Morrow, & Ponterro, 2017) and in line with the primary aim of getting as close as possible to the lived experiences of both the therapist and the patient, we based the video analysis on the framework of Interpretative Phenomenological Analysis (IPA) (Smith, Flowers, & Larkin, 2009).

IPA is idiographic in that it studies the specific individual situation, phenomenological in its concern with individuals’ perceptions of objects or events, and hermeneutic in its recognition of the central role of the analysts in making sense of (observed) personal experience (Smith, Flowers, & Larkin, 2009, p. 4.). The process of analyzing the data was conducted in accordance with the recommendations made by Smith, Flowers, and Larkin (2009), which can be summarized in the following eight stages:

1. Initially, the first author reviewed the complete data material (i.e. all 42 therapy sessions) in chronological order to observe and obtain a basic sense of the therapeutic process and the interpersonal relationship between the therapist and patient. The first author also selected relevant data material from sessions (from 28 of the 42 sessions), transcribed the selected sequences, took notes, and wrote summaries to capture different aspects of the content. The notes and summaries addressed both the descriptive and linguistic level, e.g. recurrent themes, verbal and nonverbal language, and the conceptual level, which deals with the transcript data in an interpretative way, involving the researcher’s own reflections on the material.

2. After an initial review, the first author sorted out notes and transcripts into general categories, such as “the therapist’s handling of criticism”, “the therapist’s ability to facilitate emotional insight” and “the therapist’s ability to appear as a safe base”. Several of the sessions and transcripts have been reviewed together with the other authors to strengthen the validity of the study (Hill, 2012).

3. Video recordings and text segments that represented various aspects of the overall categories were presented, analyzed, and discussed together with the second author. In the discussion, some of the overall categories were found to be somewhat abstract. At this point in the analysis, the researchers had an overall perception of a therapist as capable of meeting the patient’s needs in a therapeutic way.

4. Subsequently, the first author conducted a second review of the data material to identify and conceptualize new overall categories. The second review involved going from the macro perspective of an overall impression of an interpersonally “skilled” therapist, to examine on a micro level how the therapist’s relational qualities came into play across different situations. During this part of the process, the first author took notes to capture new insights. Based on the second review, three overall categories were developed around how the therapist handled (a) criticism/critical feedback from the patient, (b) when the patient came up with shocking and shameful sexual episodes, and (c) anxiety to end the therapy. The first and second author reviewed, observed, and discussed sampled video clips, transcripts, and developed themes on several occasions. In this phase, the data was also put in context with relevant psychodynamic literature and increasingly focused on relational patterns and hypothesized unconscious processes. (5) The next step involved searching for connections across the developed themes that had been identified. The first author continued the analysis by looking for commonalities in how the therapist met (a) criticism/critical feedback from the patient, (b) clearly self-destructive (even “shocking”) experiences with sex and drug abuse and (c) anxiety about ending therapy which took form of rejection of the therapist. In this phase, data material that had no connection with the three themes were not included. The focus of the analysis was on the sequences/data that were perceived as the most potent to examine the research questions.

5. Finally, the selected material was reviewed, and themes discussed with second author on multiple occasions until an agreement about the number of themes and their descriptive names was reached.

6. When returning to the data analysis later, the last two authors were included in the process. The third and fourth author analyzed selected video material separately and then presented and discussed with the whole research group. Group discussion led to further revision of the results and the suggestion to include a post-therapy, semi-structured interview with the participants.

7. In the interviews, the first author initially asked open questions regarding the participants’ views of the process and outcome of the therapy and later probed their views regarding the research question of this project, that is the therapists’ handling of challenging situations.

8. To get the emotional reactions of the therapist, we looked at the video recordings of the supervision sessions where the therapist conveyed along the therapy process (until the turning point) that she felt the patient challenged her by testing her and by means of (subtly) devaluing comments about her and the process.

Reflexivity

In quantitative as well as in qualitative research, the researcher’s pre-existing intentions, assumptions, and theoretical affiliations give direction to the researchers’ interpretations (Finlay & Gough, 2003; McLeod, 2013). To enhance the awareness of the first author’s own pre-understanding of the object of the study, he wrote down summaries and intuitive thoughts, which the research group was then invited to discuss and reflect upon. Two potential pitfalls in this process that should be mentioned are that the first author already had a pre-interest in therapists’ relational qualities before the study began and that the case was selected by the criteria of being both challenging and having a successful outcome, which from the start indicate a certain therapist effect. The data analysis is therefore not entirely driven by a bottom-up approach, but still, was carried out with a self-instruction to have an open and unprejudiced position to endorse alternative perspectives. By participating in reflections and discussions with the second author, we sought to enhance transparency of the researcher’s interpretations and the analytic process, thus strengthening the methodological integrity of the study (Levitt, Motulsky, Wertz, Morrow, & Ponterro, 2017). All summaries, transcripts, drafts, notes, and other material are stored in a database which all authors had access to, in accordance with “the paper trail test”, as stressed by Smith, Flowers, and Larkin (2009).

Ethics

The overall project from which this in-depth case study was drawn, received ethical approval in 2019 from the Data Controller at the University of Oslo (Norway). The project received a Letter of Exemption in 2015 by the Regional Committee for Medical and Health Research Ethics (REC) (812015) which meant that it was not necessary to obtain a conventional approval of this study. All participants have signed a consent form for the study, and the video-files and transcribed materials are stored in the Services for sensitive data (TSD), specifically developed for personally identifiable information.

To ensure the data were treated with utmost care and respect, names and private details about the participants have been anonymized. Some information about the patient has been altered and/or withheld. Following a practice of process consent which is widely used in situations of ethical sensitivity and potential participant vulnerability (Speer & Stoke, 2014), both participants read the final version of the paper to ensure that their experiences were conveyed in a suitable manner throughout the presentation of the case and to give their consent of the anonymization and presentation. Both participants approved of the manuscript and expressed that they felt they recognized how the therapy processes was presented.

Results

The data analysis yielded one superordinate theme: I The therapist detoxifies demanding clinical material, such as aggression and shame. Three constituent sub-themes expressed different facets of how the therapist’s detoxification took place (i.e., (a): The therapist tolerates the patient’s skepticism and criticism in a non-defensive manner by focusing on the patient’s underlying feeling; (b) The therapist responds to the patient’s self-destructive behavior with sex, drugs and alcohol in a non-judgmental and “containing” way that reduces shame; and (c) The therapist interprets the patient’s rejection as separation anxiety related the termination of the therapy.

In the following, the superordinate theme and the three sub-themes will be described in detail (see Table 1), with the purpose of answering the research question: How does the therapist encounter challenging therapy situations where her ability to handle and work with demanding psychological material is put to the test in a psychotherapy with a good outcome?

Table 1. Illustrations from transcripts.

Superordinate theme		The therapist «detoxifies» destructive clinical material
Sub-themes	The therapist tolerates the patient’s skepticism and criticism in a non-defensive manner by focusing on the patient’s underlying feeling.	The therapist responds to the patient’s self-destructive behavior with sex, drugs and alcohol in a non-judgemental and “containing” way that reduces shame	The therapist interprets the patient’s rejection as separation anxiety related the termination of the therapy.
Examples	- I think it makes sense … I’m someone you do not know and one you experience as innocent and stuffy maybe … Ehm … that you may think that I can’t understand or judge you in on top of it - Yes that would be in a way not to understand who you are … It may be less tempting to go back and put it together - Yes because it sounds like … or it may be the case that you have two sides that do not fit together. It’s like [it is] it is impossible for you to be a nice guy, jovial, funny because they do not fit together … So it gets very scary to feel anger or to be angry because you see yourself as an angry person instead of a person who can get angry when someone hurts you	- You are completely left alone I see it - No one took care of you - That the shame is both (related to) what actually happened, what you did, and also the motivation was to punish yourself?	- That someone dies can be experienced as being abandoned for a child, even if it was not the intention from anyone. And that ehm… It wouldn’t be so strange if terminating the therapy could feel a bit like that - Because I just started to wonder if it was related to us talking so much about ending in the previous session? And that it could be a reaction to the fact that we are beginning to separate from each other, it hurts - Maybe we should look a bit more at what your thoughts about my thoughts about you are … Is it possible that I care about you, could it be that I think of you?

Superordinate theme: The therapist “detoxifies” demanding clinical material, such as criticism and shame

Through ongoing observation and reflection of the data, a common feature across the three sub-themes occurred to us, i.e. that the therapist consistently encountered the patient’s different demanding emotional states and anxiety in a steady, accepting, and empathic way, even when the content could be provocative, or create a great deal of shame and/or overwhelming anxiety in the patient. The therapist accepted the destructive feelings and projective communications from the patient and responded in a manner that made the emotional experiences more tolerable for the patient. This made us think about the term “detoxification” suggested by Wilfred Bion (e.g. Bion, 1962), as an overarching concept that was relevant across different situations. In line with this, the overarching theme was thus termed: The therapist “detoxifies” demanding clinical material, such as aggression and shame.

(A) The therapist tolerates the patient’s skepticism and criticism in a non-defensive manner by focusing on the patient’s underlying feeling

This sub-theme illustrates how the therapist encounters situations when she receives criticism from the patient.

Early in the process, Christian talked about the backdrop for the break-up between him and his ex-partner. Christian stated that he may not have allowed himself to feel the grief of love. Sara asks whether Christian will be able to feel the grief of love in the therapy. Christian seems ambivalent, like something is holding him back. Sara explores what makes Christian anxious.

T:

Is there anything specific about me that you are thinking about?

P:

No, yes (laughs) yes I think that you are all right and good and (T: Yes) ehm … a person that, I don’t know you, but my first impression was that you live a life that is more conventional then what I do, have done and will do too.

T:

Yeah,(you feel that) the discrepancy is so great that it is strange to tell perhaps?

By daring to address whether there is something distressing in their therapeutic relationship, Christian admits that he sometimes feels that Sara prevents him from speaking freely. That Christian seems Sara as all right, good, and perceives that she live a life that is more conventional than him, could pose a challenge in the therapeutic work. On a subconscious level, his words can be understood as a skepticism against her and an expression of insecurity. His laughter has a trivializing touch, but there is something about the undertone that is perceived as if he questions whether Sara really can understand him. Sara points out that the discrepancy can be so great that it is strange to tell her about this. By letting the underlying accusation against her come to light and hold up some of the resistance between them, she shows that she can tolerate Christian’s subjective reality and emotions.

In the further dialogue, it is clear that Christian wants to elaborate on what he finds challenging in their therapeutic relationship. In his narrative, it seems that the patient believes that Sara is an “innocent girl” who cannot understand him and his lifestyle. From an observer’s perspective, we sensed a deeper subtext of insecurity and anxiety about how Sara might experience his personal history and the emotional baggage he carries. Implicitly, it is as if Christian needs to put Sara to the test, to find out if she can understand, tolerate, and accept him for who he is.

Despite that Christian repeatedly needs to test her, Sara remains steady. Without getting defensive or overly pleasing or vindictive, she accompanies him with a warm appearance, smile, eye contact, and validates his difficult feelings. This way she shows that she listens and validates Christian’s feelings. Sara perceives that Christian does not want to change his lifestyle, but is helping him to regulate his painful feelings.

T:

Yes, I think it makes sense (P: Mm) both things you have said. I’m someone you do not know and one you experience as innocent and stuffy maybe (P: Laughs). Ehm … that you may think that I can’t understand or judge you on top of it … (P: Mm yes) and that I can’t understand that this is really good, (P: Yes) this is something you want.

P:

Yes. (T: Yes) And I want it in a way like I have control of it. (T: Mm) I think I have felt it that way. (T: Mm) So if I can be quite concrete about what I can think is disturbing is that, and I know you are a professional, but it is as if I get a “wow” reaction to something that I do not think is “wow”.

To us, this transcript illustrates how Sara validates Christian’s anxiety of not being understood by her and provides a sensible and soothing response to his concerns. To be met this way, seems to pave the way for a deeper emotional connection between the two. It seems that Christian has feared that Sara would reject him when he opens up about his innermost experiences. Instead, Sara validates and then points out Christian’s emotional struggle:

T:

Yes (P: Yes) that would be in a way not to understand who you are.

P:

Yes. (T: Mm) I am also afraid of the thing we talked about last time. That the character that we put together, (T: Mm) (laughs) I feel is a cheap version [of me] (laughs)

T:

It may be less tempting to go back and put it together.

Here, we see Sara has “translated” the initial accusations of being “too conventional” and “stuffy” as an expression of not being understood; she has established that it can be difficult to open up to a person if one is anxious about being judged. By being open and understanding to him, Sara creates a space for his difficult feelings to come to light, be processed, and to be given meaning to.

Later in the therapy, Sara formulates a hypothesis that Christian may carry a lot of anger in him, an anger unconsciously directed at his mother because he finds her submissive, deficient, and emotionally unavailable because of the losses of Christian’s attachment figures. But instead of directing his feelings toward her, Christian returns the anger towards himself. At first, Christian seems dismissive of Sara’s interpretation. As the therapy proceeds, anger, irritation, and Christian’s difficulties with conflicts become a recurrent theme. At one point, Christian starts to confront Sara with what he assumes is her impressions of him. From an outside perspective, Sara smiles and behaves calmly, but there is something about her that seems a little surprised. Christian repeatedly asks for Sara’s opinions. There is something in the intensity of his questioning that indicates an urgent need for confirmation and to be seen. Despite Sara’s attempts and invitations to reflect on the underlying emotions behind Christian’s repeated demands, Christian remains intrusive. Eventually, he becomes confrontational. This can be seen as if he feels threatened and anxious. Sara tries to process and make sense to his frustrations:

T:

Ehm, well the reason for the link with the anger was because I don’t perceive you as angry, (P: No) and I got the impression that people in general don’t perceive you as angry either, (P: No) but that the mental images or sensation are so raw (K: Mm) and grotesque (P: Mm) that it could bear witness of something more … that … that was what started the hypothesis, (P: Mm) that you can’t show your anger in a normal way. (P: Yes) So the anger is instead directed inwards and becomes … (P: Yes) and [that] is why it becomes so violent (P: Mm) because you don’t show it (P: Anger outwards) anger outwards. (P: Mm). That was my hypothesis but then I understood that you didn’t think it quite fit, but I don’t know if you have thought a bit more about it?

By providing a container function for Christian’s projective confrontations, Sara provides an emotional understanding and also gently invites him to reflect and explore his emotional state. The perceived intense and distressed atmosphere seems to diminish. Sara communicates the importance of expressing anger. She points to anger as a self-demarcating feeling and as an important emotional signal. Then, she returns the projections back in a more empathic way:

T:

Yes, because it sounds like … or it may be the case that you have two sides that do not fit together. (P: Mm, yes it’s very much like that). It’s like [it is] impossible for you to be a nice guy, jovial, funny (P: Mm) because they do not fit together.

P:

Yes … I feel it (T: Mm) or it’s … yes …

T:

So it gets very scary to feel anger or to be angry because (P: Yes) you see yourself as an angry person instead of being a person who can get angry when someone hurts you.

P:

Yes, (sighs) yes …

T:

What do you feel at this moment?

P:

No, it’s just that I’m a bit emotionally activated. (T: Yes) Ehm, I think that we are at the core of something important here.

In summary, this theme highlighted how the therapist was able to handle hostile feelings and projective confrontations against her in a way that enabled a corrective emotional experience. Christian lost his father early in life, and his mother may have been overwhelmed and at times unavailable to him after the loss. Later, there were two other losses of father figures. These losses are likely to have left Christian with much anger and grief. Sara helps him to get in contact with this anger and points out the conflict he feels between being the person he wants to be and being angry. She modifies Christian’s unconscious relational perception of being abandoned when he is angry and provides a potential corrective emotional experience when she meets his anger with understanding, care, and continued support.

(B) The therapist responds to the patient’s self-destructive behavior with sex, drugs, and alcohol in a non-judgmental and “containing” way that reduces shame

This sub-theme highlights how the therapist works with the patient’s self-destructive experiences with sex, drugs, and alcohol.

In the beginning of therapy, Christian started to talk about how he and his former partner met. He quickly opened up about their sex life, including that they started experimenting having sex with other couples. Gradually their relationship became more and more boundless. After a while, Christian’s former partner wanted to have sex with others without Christian present. At first, Christian felt reluctant, but still agreed to try it out. This leads to an experience that Christian refers to as “completely f***** sick”. His use of words points to something shocking and overwhelming. Then, Christian begins to talk about a night out when he and his former partner were hit on by another couple and decided to head home. However, Christian was so intoxicated that he was out of control:

P:

I remember that they just left the night club without me. And I remember I went to the toilet and puked, completely out of control because I’m so insanely, insanely drunk. (T: Mm) And I remember that I thought: I’m dying, and they just left me.

T:

You were completely left alone, I see it.

P:

Yes, and I went out of the bar, slipped again and again and puked, [I] remember that other people passed by who did not help me.

T:

Pretty degrading situation.

P:

Yes, extremely degrading.

Sara is inclined to be empathic when being confronted with Christian’s despair and challenging emotions. Despite his heavy use of alcohol and casual sex, Sara sustains an open-minded therapeutic attitude and contains the destructive material and remained focused on his emotions related to being left alone and vulnerable. With her comment “pretty degrading situation” she put herself in his shoes and verbalizes his feelings of being in a humiliating position, but not in a judgmental manner. Her ability to facilitate an atmosphere of being understood seems to give Christian a safe space to open up further. He recounts waking up in the morning in his own house, after sleeping alone in bed, while his partner had been intimate with the two strangers in his living room:

P:

Yeah, and among them, they laughed about how drunk I had been the day before. (T: Mm) Luckily, they disappeared quite fast so I didn’t have to talk with them.

T:

No one took care of you.

P:

No one took care of me and I was with my loved one who should have taken care of me. (T: Mm) And we had been together for such a long time that it was well known that I could get totally wasted and out of control, must have been hard to handle that … but it was very, I felt it, I remember it was a huge betrayal.

Christian’s saying “Yeah, and among them, they laughed about how drunk I had been the day before” is told in a sarcastic tone. It turns out that he felt a “huge betrayal”. These words is expressed painfully and sounded like a breach of trust. Christian felt that he didn’t matter, that he was put away in favor of casual sex. In parallel, the therapeutic strategy of following, validating, and containing the content in a non-judgmental way seemed to offer him an opportunity to explore his personal experience. Gradually, Sara begins to connect the material coming to highlight something about his destructive tendencies that she has become aware of:

T:

Because you say that you felt abandoned and ashamed. (P: Mm) You also say at the same time that you did not understand it then that he was like that. (P: Mm) Ehm, because in a way it might sound like you understood it a bit, but you just … you didn’t notice.

This quote illustrates how Sara acknowledges and confirms the subjective experience of grief and shame in Christian. At the same time, she identifies a form of destructive relational pattern that she brings up for reflection.

Throughout the process, his destructive relational tendencies becomes a recurrent theme. After the break-up, Christian initiated in a lot of casual sexual relationships. He describes how he used sex as a driving force to confirm himself as a shameful individual. Shortly after the break-up, Christian began dating an older man whom he knew from before and who had a “dark side” with a heavy use of drugs. Gradually, their relationship was marked by partying, illegal substance use, mood swings, and jealousy. Christian noticed that he was being followed and monitored, and tried to cut contact, which turned out to be a difficult process. During his story, Sara remains steady and in a position of actively listening with nods and validations (“hmm”). After absorbing his story, she begins to sort out and returns back a response about what she thinks Christian seems to be struggling with:

T:

I just think that there are some similarities in both the story about your ex and this story. (P: Yes) When you told me about it, there were some danger signals you should have seen.

P:

Yes, that is true.

T:

I don’t know if you thought about it?

P:

No. (laughs)

Instead of focusing on the self-destructive content, she offers context and meaning to his unbearable feelings and relational difficulties. From the outside, it may sound like she relates the self-destructive tendencies to an active search for feeling ashamed and to confirm himself as a shameful individual who is not worthy of being loved, but to be abandoned and left in shame. The grief, anger, and shame are expressed in relentless sexual compulsions and become a way to ward off disturbing feelings and need of intimate and reciprocal relationships. It is as if Sara helps him nuance, sort-out, and get in touch with the painful feelings he carries, and probably is too afraid to feel. Sara creates a safe space for whatever comes forth in a consistently warm and understanding manner. This leads up to Christian telling her that he has humiliated himself sexually:

T:

Yes, because I’ve been wondering if there are things that you still hold back?

P:

(Sighs) Ehm, yes … yes it’s kind of a thing I hold back, but I don’t know if it’s possible to talk about it.

T:

Is it possible to say something about why it’s not possible to get to it?

P:

Yes (laughs) because it’s so shameful … yes … and because it was very ehm, ehm, no it may well be that we can get to it, but it’s very shameful and very destructive, very (…) that self-punishment pattern.

This quote shows how Sara confronts Christian about whether there is something he holds back in the therapy. Just before the confrontation, they have talked about how terminating the therapy activates anxiety in Christian and that he has felt that Sara genuinely cares about him. Seen from the outside, it seems that Sara has managed to establish a trustful relationship between them, which allows her to be rather direct. Christian appears reluctant at first, it seems like he is on the verge of telling something of high importance. Little by little he begins to open up. He does not go directly into the specific incident, perhaps it feels too overwhelming for him. Instead, he points out the “self-punishing pattern” that he and Sara have identified. Sara helps him sort out:

T:

The shame is both (related to) what actually happened, what you did, and also that the motivation was to punish yourself?

P:

Yes.

T:

Mm.

P:

Yes, how much time do we have, ten minutes left, uhm, now I feel it’s difficult not to say it.

T:

Mm, you choose.

P:

Mm (sighs), at my worst moments last year, I just wanted to feel more and more and more that things were bad and horrible (sighs) and then I got an offer from a guy (sighs) who wanted to buy sex. (T: Mm) I thought that this is the ultimate shame, shit, I can do to myself and very far below my dignity and something I was absolutely sure would be bad.

Here we see how Sara nuances that the shame involves several levels: Both what he did and his underlying motivation. Further, she holds up the “destructive pattern” as a theme, and in that way she expresses that she can tolerate him. In a longer story, Christian reveals that he prostituted himself 5–6 times to confirm his own self-hatred. Throughout the story, Sara tunes in and expresses short “mm’s to convey that she listens actively. Furthermore, she does not act to the possible need to avoid the demanding psychological material Christian comes up with, but lets his story come out without interrupting. Eventually, she begins to sort out and make sense of his experiences.

T:

Yes, and also what you searched for?

P:

Yeah, yeah I approached it … it sounds completely idiotic but I looked for total destruction and that everything should go to hell so I could get picked-up.

T:

Mm, it was a punishment in it?

P:

It should have been a punishment in a way … I think … when teens cut themselves, I wanted to have it similar to them, (T: Mm) a very, very, very painful emotional reaction.

Again, we see Sara recognizing a similar destructive relational pattern that has emerged in the sessions earlier in the therapy. Implicitly, it is as if his need for intimacy and care has been reduced to a “primitive form of sex” and an active way of confirming himself as a contemptuous individual. Sara seems to genuinely tolerate Christian’s destructive actions. She does not condemn him, but instead continues to emphasize his experience, feelings, and what prostitution did to him.

P:

I haven’t told that to anyone.

T:

Nobody knows.

P:

No.

T:

How was it to open-up now?

P:

It was worse before I did it (laughs) or the buildup I mean.

This theme illustrates how the therapist approaches the patient’s self-destructive material in a non-judgmental and empathic way that gives Christian a possible corrective experience, to discover that there are people with whom he can share shameful experiences without risking being rejected or abandoned.

(C) The therapist interprets the patient’s rejection as separation anxiety related to the termination of the therapy

This sub-theme presents how the therapist makes sense of the patient’s rejection of her by interpreting it as an underlying anxiety of being abandoned.

T:

That someone dies can be experienced as being abandoned for a child, even if it was not the intention from anyone. (P: Yes) T: And that ehm … It wouldn’t be so strange if terminating the therapy could feel a bit like that (P: Yes (laughs)) or arouse some of the same feelings?

P:

I think it may be something like that. (T: Yes) And I recognize it in myself in a way, I kind of start to prepare (T: Yes) and it’s … yeah … it’s … it’s tough. (T: Yes) Because in many ways, we’ve been more intimate than anyone I have been with before in my life.

T:

Yes. And as we have talked about opening-up, making yourself vulnerable and in a way becoming dependent or attached. (P: Mm) And even if the settings are like this and that, it can feel a bit strange.

The ability to draw lines to Christian’s personal history and put it in relation to present experiences seems to highlight how Sara understands and offers a meaning to the anxiety of what terminating evokes in him. By showing how the traces of his past are brought to life in the therapy room, Christian recalls that being separated from important others hurt him. “We have been more intimate than anyone I have been with before in my life”, says Christian. This quotation illustrates how important the therapy has been for him and implicitly, how painful it can be to be separated from the therapist. Sara contains and allows him to embrace how tough it is to be attached to someone, but still have to let go. It seems like she addresses that it is not surprising that the ending is sad. Furthermore, she tries to show him the importance of feeling the grief and that they are preparing for the end to be emotional.

Around two months before termination, Christian goes for a weekend trip with some friends. When coming back, he expresses that he’s tired after partying the whole weekend. At the same time, he seems unusually dismissive and frustrated towards Sara for not being able to create the usual emotional connection between them, despite that Sara is trying to explore his reactions to her contribution to their interaction. Christian conveys a feeling of rejection and disappointment, told in a slightly condescending tone as if Sara does not understand:

T:

On top of that you experienced that I got a reaction (P: (Laughs)) that you have talked about?

P:

I have to correct you, because I did not experience that the “wow” reaction was the most important thing. (T: No) But what I think was the most important thing about the last time was that I somehow did not feel that I got in touch with myself, neither with my mind nor emotions (T: Mm) but just talked about bla bla bla without being connected. But then I also felt that we didn’t get connected and that was the most important thing.

In particular, Christian touches on a specific episode from the previous session where he perceived that Sara had an aversion and had a “wow reaction” against him. Although there is an intense atmosphere between them, it is as if Sara still is able to digest what is happening, and attends to the underlying dynamic behind the expressed rejection:

T:

Because I just started to wonder if it was related to us talking so much about ending in the previous session? (P: Mm yes) And that it could be a reaction to the fact that we are beginning to separate from each other, it hurts (P: Yes) because ehm … we are not going to terminate yet. (P: No) I don’t know if it has something to do with that or what do you think?

P:

Well maybe … it may sound familiar. A bit strange to compare with the dating situation (laughs) but it’s like when you notice that something does not work in a relationship, when you notice that something should end, it can be an easy way to mark a distance.

By staying present and taking into account Christian’s anxiety of being rejected/abandoned, Sara reflects upon his projections. This quote shows how Sara interprets his anxiety and makes sense of what his feeling of “not being emotionally connected” may reflect, on a deeper level. It seems that, behind the rejection, there is a longing for attachment and possibly a grief because he knows that termination is inevitable. Seen from the outside, it is likely that the experiences from early childhood have left deep traces in Christian, and some of the same relational scenarios come to the surface in the therapy. However, it also seems that Sara manages to modify his implicit relational expectation of being dismissed:

T:

Yes … maybe we should look a bit more at what your thoughts about my thoughts about you are (P: (Laughs)) if you understand what I mean … Is it possible that I care about you, could it be that I think of you?

P:

Yes, now I’m getting emotional. (laughs)

T:

Yeah …

P:

(Crying) without knowing why … … … Yes, I’m basically thinking that it might be a good idea.

Here, we see how Sara challenges Christian’s maladaptive expectation of being abandoned. In her intervention, she appears warm and empathic, but at the same time convincing and unwavering. Her body posture is steady with a gaze directed at Christian as they talk. Christian starts to cry, a moment that feels genuine. Together with Sara, he has been in contact with genuine feelings, made himself vulnerable, and it feels painful to be separated from this contact with her.

A central part of Sara’s work in the terminating phase is to get in touch with Christian’s emotional needs to regulate painful and disturbing states:

T:

It coincides with the termination situation that we have here.

P:

Yeah true. (Sighs) Yeah, there’s just four times left after this one. (T: Mm) Two next week and also two after the holiday. (T: Mm) It still feels right, but now I really feel that I count down.

T:

Mm, and we have also talked a bit about that this touches right into a sensitive topic for you (P: Yeah yeah yeah (laughs)) like … the last time you were abandoned … that was when it also started …

The primary aim for Sara seems to be to share how she connects Christian’s personal life and history to how he relates to separating from her. By highlighting that: “It touches right onto a sensitive topic for you … the last time you were abandoned … that was when it also started”, she puts the nightmares into a broader relational context, contains and gives meaning to why the separation is felt so intense:

T:

I think it’s not so stupid at all (P: I know you [do] (laughs)) to cry a bit, in a way.

P:

Yes, that’s probably true, to stay present in it, that’s a nice thing.

Despite Christian’s often trivialization and humorous response, Sara offers him an opportunity for deeper emotional insight. In so doing, she gives him comfort and a space in which to feel grief, promoting a healthy separation from her and the therapy.

Discussion

The aim of this single-case study was to gain more insight into how the therapist was able to meet demanding clinical material in a challenging but fruitful therapy process and how her successful handling might have led to a favorable therapeutic outcome. This was demonstrated through both the patient’s and the therapist’s self-report, the two authors’ clinical assessment selecting this case, and a data analysis involving multiple researchers to analyze the data. The findings point out how the therapist emotionally accommodated to the patient’s needs and “detoxified” different forms of destructive or “poisonous” material in a way that seemed to have made the patient feel tolerated and cared for, and also to understand more of his own defenses.

The results in the case study occurred primarily in a psychodynamic therapy context. A substantial amount of psychoanalytic literature has emphasized the parallel between parent-child relationship and the therapist-patient dyad (Joseph, 1987; Klein, 1949; Sandler, 1976; Stern, 2004). The term “detoxification”, which we felt was useful in understanding the therapist’s special emotional capabilities, is taken from Bion’s (1962) theoretical concept of “container-contained” from early parent-child communication. In the same way as safe caregivers, skilled therapists may function as a container for the patient’s projected anxieties, fears, and painful inner states. Being able to tolerate these projections and respond to them in an empathic way, rather than with retaliation or denial, is of crucial importance to facilitate a favorable therapeutic outcome (Bion, 1970; Green, 1975). Furthermore, John Bowlby (1969) has argued that therapeutic change only occurs if the patient experiences the therapist and the therapy room as a safe base. The data analysis of this case bears witness to the patient’s ability and courage to open up and share his personal history, also the shameful, overwhelming, and incomprehensible experiences, and how the therapist acts as an emotional container who tolerates and returns the destructive material in a way that is understandable and “digestible”. From a theoretical point of view, the therapist is able to receive the patient’s projections, and to respond to them in an empathic way that may facilitate corrective emotional experiences of the patient’s maladaptive relational expectations (Alexander & French, 1946). In moments of accusations, skepticism, and dismissive behaviors, the therapist was able to take in, tolerate, and reflect upon some of the patient’s destructive devaluating behaviors as an underlying expression of separation anxiety and need for attachment and dependency. By addressing the patient’s self-destructive relational patterns and pointing out how the patient allowed himself to be dominated by others, the therapist seems to have paved the way for emotional insight and self-understanding that reduced anxiety and facilitated emotional growth. In this work, we have indications to believe that the supervision contributed to her way of handling his challenging feelings and actions.

The patient also demonstrated a psychological capability to make use of and internalize the therapist as a benevolent object with a helping function (Fonagy & Allison, 2014; Stänicke & Killingmo, 2013) to change the significant object relation of one behaving in a humiliating fashion and one being humiliated. He also seemed able to introject the feelings of being understood and cared for, which also played an important role of the fruitful therapeutic outcome. The result of this therapy process seems to involve a new capacity to engage in mutual relationships characterized by love, consideration, and respect. There was also an interpretation that some of the motivation to engage in destructive behaviors for Christian was to confirm himself as a shameful individual, and this insight might have enabled his breaking free from this way of dealing with his pain.

It should be noted that the fact that the patient responded so well to the interventions of the therapist is suggestive of some capacities in him that were present before the start of treatment, for example that he likely had a fairly secure attachment pattern as a child. Despite this, our hypothesis is that this early attachment may have been disturbed by the subsequent and repeated losses of his paternal attachment figures in his childhood, in addition to compromising his mother’s ability to take care of him.

Although resting on a single-case study within the context of clinical training, the results provide support to existing research on the therapist effect and which therapeutic attributes that are relevant for therapy outcome. In line with the findings of the FIS studies (Anderson, Crowley, Himawan, Holmberg, & Uhlin, 2016; Anderson, Finkelstein, & Horvath, 2020; Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009) and Heinonen and Nissen-Lie (2020), our results indicate that the trainee’s interpersonal qualities, in particular her capacity for emotional containment, seem to be of crucial importance for a productive outcome. More than that, we have seen how she is attentively present, tolerates criticism, manages to maintain an empathic stance, validates, explores, reflects, sorts out, and is capable of representing/giving meaning to the patient’s often shameful experiences, seemed to have contributed to this fruitful process. These qualities are consistent with existing research on beneficial therapist attributes indicating that the ability to listen, show genuine interest, and handle stressful situations with a focus on the patient and his or her unmet needs, are characteristics of skilled therapists (Jennings & Skovholt, 1999; Jennings et al., 2008; Moltu & Binder, 2011; Rønnestad & Skovholt, 2013; Skovholt & Jennings, 2004; Sullivan, Skovholt, & Jennings, 2005).

Importantly, the results also show that the trainee is able to refrain from responding in a retaliating manner or becoming defensive when she is put to test. These findings are in line with research indicating that therapists with good outcomes are less aggressive and dismissive of their patients compared with less effective therapists (Binder & Strupp, 1997; Najavits & Strupp, 1994; Strupp, 1980, 1993).

What may be of particular interest is that the findings exemplify how the trainee avoids acting out when she is faced with these challenges. The concept of transference-countertransference configurations in psychoanalytic literature (Bion, 1962; Freud, 1912; Gullestad & Killingmo, 2013; Heimann, 1950; Klein, 1949) is vital in this context. In recent years, the term “enactment” has increasingly become a matter of interest (Ivey, 2008), which could be conceptualized as a response-sensitive therapist aware of whatever unconscious transference-countertransference constellations that take place in the mutual psychotherapeutic relationship (Stänicke, Kristiansen, Strømme, & Stänicke, 2019). Ivey (2008) points out that certain enactments may have a negative impact on the therapeutic process. For example, if therapists become too afraid of “doing something wrong” or feel a persistent irritation towards the patient. In this case, the therapist repeatedly contacted her supervisor (i.e. the last author) outside of the ordinary supervision sessions to help to understand and meet these challenges and as a result of this intensive supervision for the most managed to stand against the enactment dynamic. Typically, the skepticism and subtle criticism of the patient did not hit her personally, as she did not have the opinions and feelings he openly or more indirectly presumed that she had. There was one exception, when she felt the client found her “superficial, without the necessary ability to approach his in-depth dynamics”; this was an accusation she could torment herself with, but still managed (through the support of the supervisor) not to act out.

The results might be worth of reflection on whether parts of Bion’s term “container- contained” (Bion, 1962) and the FIS terms constitute “two sides of the same coin”. The strength of the FIS studies is that this research is quantifiable and transparent. The strength of naturalistic studies is that clinical phenomena that unfold across therapies can be studied in their natural context, without trying to keep any variables constant. New knowledge can be generated in single-case studies and one can better understand which “micro-mechanisms” work and how they affect the therapy, of which this study is an example.

The results of this study may be generalizable to similar training cases by case-by-case analogy (Smaling, 2003), a research question which has to be further explored. Hopefully, future research will generate more in-depth knowledge about how therapists can respond and behave when facing clinically challenging situations across different psychotherapy approaches. Potentially, our findings contribute to a better understanding of how to actively meet disturbing affects and make sense of them, which eventually might enhance psychological maturity in both patient and therapist, rather than avoid them or smooth things over. Inspired by the FIS paradigm, a potential use of the current findings could be to develop instruments and methodology which can more specifically observe and measure phenomena that are relevant to psychodynamic psychotherapy. Furthermore, therapists with a different theoretical perspective, could get access to psychoanalytically oriented therapies to observe if some of the same relational qualities of therapists are recognizable across different schools of thought and as such constitute components to a more common therapeutic change model.

Strengths and limitations

In this study, the data analysis has stayed close to the verbatim transcripts of the therapy sessions. Thus, the findings are arguably closer to the subjective experience of the participants than many quantitative studies, which is one of the potential strengths of in-depth case studies (see McLeod, 2013). Additionally, Flyvbjerg (2006) and Levitt (2015) point out that the practical knowledge studied and generated by case studies is a kind of “intimate knowledge” about complex and underlying interpersonal phenomena. Furthermore, we have worked toward an a-theoretical dissemination of results, which hopefully may enhance the relevance and utility for psychotherapists across varying theoretical approaches. Despite this, due to the first author’s interest in therapists’ relational qualities in psychotherapy, and the interest in psychoanalytic thinking of all of us, our results may be unduly skewed to observations that fit with psychoanalytic concepts.

A common critique of qualitative studies is their lack of generalizability due to small sample sizes. In this particular case, the therapist’s ability to “detoxify” destructive clinical material for this specific patient seems to facilitate a good outcome, but we know little about whether this psychotherapy reflected a particular “good fit” between the skills of the therapist and the needs of the patient, and as such might not generalize to all her patients. Despite this, the skills we observed seem to appear as productive in other studies which examine therapist characteristics across settings, patients, and therapeutic methods (see Heinonen & Nissen-Lie, 2020). Finally, we lacked standardized outcome measures of the patient’s report on outcome data. Nonetheless, the therapeutic outcome was judged as highly favorable (indeed “life changing”, to quote the patient) based on the patient’s self-report during the psychotherapy and in post-therapy interviews, and in line with our philosophy of science, such a subjective report should be given emphasis.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The project is funded by internal grants from the Department of Psychology, UiO.