Journal of Rational-Emotive & Cognitive-Behavior Therapy
https://doi.org/10.1007/s10942-022-00443-5
Therapists’ Emotional Reactions to Patients
with Obsessive–Compulsive Disorder: The Role
of Therapists’ Orientation and Perfectionism
Andrea Pozza1
· Silvia Casale2 · Davide Dèttore2
Accepted: 2 February 2022
© The Author(s) 2022
Abstract
Therapist’s emotional response towards patients with obsessive–compulsive disorder (OCD) is under-investigated. This aspect might provide valuable information
about therapists’ difficulties during sessions and support supervisory practice, since
a proportion of OCD patients drop out due to issues related to the therapeutic relationship. In a sample of therapists, we explored the effects of therapists’ orientation (cognitive behavioural versus psychodynamic) and perfectionistic traits on their
emotional responses towards patients with OCD, controlling for other variables
potentially related to emotional response towards patients (i.e., therapists’ gender/
age and patient’s comorbid personality disorders). Ninety-four therapists (74 women
and 20 men; mean age = 42.07 ± 10.17 years), of which 47 (50%) had a cognitive
behavioural therapy (CBT) and 47 (50%) a psychodynamic orientation matched on
gender and age, completed the Therapist Response Questionnaire and Frost Multidimensional Perfectionism Scale. Therapists with a CBT orientation reported less
negative emotional responses, i.e., lower overwhelmed/disorganized, hostile/angry,
criticised/devalued, parental/protective and special/over-involved emotions towards
patients than therapists with a psychodynamic orientation. Therapists with higher
perfectionistic traits (i.e., parents’ expectations/evaluation) had higher hostile/angry
reactions, those with higher concerns over mistakes and doubts about actions had
more intense criticised/devalued emotions, while those with stronger concerns with
precision, order and organization had lower disengagement responses. The present
study is the first investigation which sheds some light on the emotional responses
of therapists towards OCD patients. Therapists’ CBT orientation and lower perfectionistic traits might be associated with better emotions. Therapists’ emotional
responses, their psychotherapeutic orientation and levels of perfectionism should be
considered during supervisory practice.
Keywords Obsessive–compulsive disorder · Psychotherapy · Perfectionism ·
Therapist · Therapeutic relationship
Extended author information available on the last page of the article
13
Vol.:(0123456789)
A. Pozza et al.
Introduction
Therapists’ Emotions Towards Patients: A Key Ingredient of the Therapeutic
Relationship
In a therapeutic relationship, the feelings and attitudes that therapists and clients
have toward one another and how these are expressed can predict positive outcomes
across a range of conditions and theoretical orientations (Fluckiger et al., 2012,
2018; Horvath et al., 2011; Norcross, 2010). This factor can be measured from three
distinct perspectives: that of the rater, patient and therapist (Horvath 2000). Therapists’ emotions towards patients can be used as a source of valuable information
about a patient’s intrapsychic and interpersonal functioning for diagnostic and therapeutic purposes (Hayes, 2004). This clinical material can also be analysed during
supervisory practice as such reactions may concern the therapist’s interpersonal/
intrapsychic world (Norcross 2005). According to the contextual model (Wampold
and Imel 2015), there are three pathways through which a therapeutic relationship works: (a) a genuine relationship, (b) the creation of expectations through the
explanation of symptoms and treatment, and (c) the enactment of health promoting
behaviours.
While the therapeutic relationship has been widely studied from the patient’s perspective, during the last decade researchers have progressively drawn their attention
to therapists’ emotional reactions to patients. Betan et al. (2005) reviewed the clinical, theoretical, and empirical literature on therapists’ emotions towards patients and
explored the feelings self-reported by a large sample of therapists through a practice network approach. Based on factor analyses, the authors identified eight emotional patterns (for a detailed overview of their model see Table 1). The researchers
focused on emotions towards patients with personality disorders aggregated at DSM
cluster level (Betan et al., 2005). Cluster A was related to criticized feelings, cluster
B was associated with overwhelmed, helpless, hostile, and disengaged feelings and
sexual attraction, and cluster C was associated with protective feelings (Betan et al.,
Table 1 Classification of therapist’s emotional responses to patient (Betan et al., 2005)
Overwhelmed/Disorganized A desire to avoid or flee the patient and strong negative feelings, including
dread, repulsion, and resentment
Helpless/Inadequate
Feelings of inadequacy, incompetence, hopelessness, and anxiety
Positive/Satisfactory
Experience of a positive working alliance and close connection with the
patient
Special/Over-involved
A sense of the patient as special relative to other patients and includes
“soft signs” of problems in maintaining boundaries, including selfdisclosure, ending sessions on time, and feeling guilty, responsible, or
overly concerned about the patient
Sexualized
Sexual feelings toward the patient or experiences of sexual tension
Disengaged
Feeling distracted, withdrawn, annoyed, or bored in sessions
Parental/Protective
Wish to protect and nurture the patient in a parental way, above and
beyond normal positive feelings toward the patient
Criticised/Devalued
Being unappreciated, dismissed, or devalued by the patient
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
2005). This approach led to the development of the Therapist Response Questionnaire (TRQ; Betan et al., 2005), a therapist self-report tool aimed to assess emotional response to a specific patient.
By asking large samples of therapists to express their emotions towards one of
their patients currently in treatment for a personality disorder, other authors provided further empirical support for the model of Betan et al. (2005) and through
confirmatory factor analyses, they demonstrated the discriminant validity of these
emotional patterns, showing that some of them were common and others specific
to personality disorders (Gazzillo et al., 2015; Tanzilli et al. 2016). However, little
is known about therapists’ self-reported reactions to patients with conditions other
than personality disorders.
The Therapeutic Relationship: A Neglected Dimension in Psychotherapy for OCD
Obsessive–compulsive disorder (OCD) is a disabling condition which affects up
2–3% of the general population (Coluccia et al., 2015; Pozza et al., 2016b, 2020,
2021; Ruscio et al., 2010). It is characterized by intrusive thoughts, mental images,
or impulses (i.e., obsessions) and repetitive behaviours (i.e., compulsions) performed to neutralise distress related to obsessions (American Psychiatric Association, 2013; Cervin et al., 2020; Pozza et al., 2017). Cognitive behavioural therapy
(CBT) is the first-line psychological treatment recommended in practice guidelines
(NICE, 2013; Pozza & Dèttore, 2017). The CBT model assumes that symptoms are
reinforced at long-term by the temporary relief provided by compulsions and dysfunctional cognitive styles (e.g., perfectionism and uncertainty intolerance) (Clark,
2003; Obsessive Compulsive Cognitions Working Group, 2005). CBT case formulation assumes that psychotherapy works by exposing the patient to doubts and related
distress, helping him/her to accept uncertainty and learn a new thinking style (Clark,
2003). However, among patients completing a standard CBT course, only 40–50%
achieve remission while the others show only partial improvement or even nonresponse (e.g., Farris et al., 2013; Fisher & Wells, 2005; Öst et al., 2015). According
to a meta-analysis, 15–30% of the those starting CBT drop out (Ong et al., 2016).
CBT components, i.e. exposure with response prevention (ERP) and cognitive
restructuring, have comparable effects when either is used as monotherapy (e.g.,
Olatunji et al., 2013). Trials comparing CBT with other therapies, such as thirdwave approaches, failed to demonstrate the superiority of one treatment over another
(e.g., Marsden et al., 2018; Twohig et al., 2018).
Recently, other theoretical orientations, including psychodynamic therapy, have
received some attention in this field and manualized protocols have been developed
and empirically assessed in preliminary research (Chlebowski and Gregory, 2009;
King, 2017; Reichsenring and Steinert, 2016, 2017). However, further evidence
about the efficacy of psychodynamic therapy is still needed.
In an attempt to better understand the processes involved in psychotherapy for
OCD, some authors (Maher et al., 2012; Simpson et al., 2011; Strauss et al. 2018;
Vogel et al., 2006; Wheaton et al., 2016) studied common factors such as the therapeutic alliance as it is perceived by the patient (Bordin, 1979). The assessment of
13
A. Pozza et al.
the emotions experienced by the therapist during treatment of patients with OCD
might shed some light on the therapeutic relationship and therefore might improve
the existing treatment protocols by orienting supervisory practice.
The Therapeutic Relationship and Therapists’ Perfectionism
Recent evidence suggests that therapists’ perfectionism, i.e. excessively high standards, is associated with clients’ retention in treatment and efficacy (Presley et al.,
2017). Perfectionism is common among clinical psychologists and is negatively
related to both tolerance of ambiguity and satisfaction in conducting psychotherapy
(Wittenberg & Norcross, 2001).
Theoretical models and empirical data by factor analyses indicate that perfectionism is a multidimensional construct including Perfectionistic Strivings and Evaluative Concerns (Flett & Hewitt, 2002; Frost et al., 1990). Perfectionistic strivings
refer to those facets of perfectionism that relate to perfectionistic personal standards
and a self-oriented striving for perfection. They include self-oriented perfectionism
(i.e. demanding perfection of oneself) and personal standards (i.e. setting unreasonably high personal standards and goals) (Frost et al., 1990; Hewitt & Flett, 1991).
This dimension was found to be related to both negative and positive processes (i.e.
adaptive coping) and outcomes (i.e. psychological adjustment) (e.g., Stoeber &
Otto, 2006). Conversely, perfectionistic concerns were found to be related to negative outcomes as well as socially prescribed perfectionism (i.e. perceiving others as
demanding perfection of oneself), concern over mistakes (i.e. adverse reactions to
failures), doubts about actions (i.e. doubts about performance abilities), and selfcriticism (the tendency to assume blame and feel self-critical towards the self) (Frost
et al., 1990; Hewitt & Flett, 1991).
Rationale and Hypotheses of the Study
While the therapeutic relationship has been investigated according to OCD patients’
perceptions, there is no study on the therapist’s perspective. This unexplored aspect
may provide important information about therapists’ difficulties during sessions and
OCD patients’ interpersonal functioning. This may support supervisory practice and
future improvement of psychotherapeutic intervention given the relatively high rates
of drop-out. Therapists who are aware of their emotions towards patients may manage the therapeutic relationship more effectively. In addition, knowledge of therapists’ characteristics related to negative emotions may suggest matching therapists to
patients in the most effective way.
The advancement in the development of different theoretical approaches to
psychotherapy for OCD (i.e. psychodynamic approaches) suggests the importance of assessing whether the therapeutic relationship is perceived differently
by therapists with different theoretical orientations. In the CBT literature, the
emphasis has been traditionally on implementing empirically supported interventions, whilst the importance of therapists reflecting upon their own emotional
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
reactions and/or traits has featured little until recently (Haarhoff, 2006). Indeed,
the focus of CBT interventions is traditionally directed at reducing symptoms
and it is based upon therapeutic techniques which work by directing targeting
symptoms instead of using the therapeutic relationship (including the emotional
reactions experienced by the therapists towards the patients) (Pozza & Dèttore,
2020). At the opposite end, the psychodynamic approach emphasizes not only
that the psychotherapist’s emotional reaction is an inescapable aspect of every
psychotherapy session, but also that these reactions should be used to help the
patient and promote change (Jones & Pulos, 1993).
Hypothesis A Therapists’ orientation (CBT versus psychodynamic) might be associated with different emotions towards patients. According to the contextual model
(Wampold 2015), one of the ingredients of a good therapeutic relationship is the
creation of expectations through explanation of disorder and treatment. Currently,
CBT is the most effective approach for OCD, and CBT case formulation shared by
the therapist and patient through a collaborative approach may help therapists manage the relationship better (Clark, 2003). Therapists with CBT skills may have a
comprehensive understanding of the vicious cycles maintaining symptoms and can
more effectively manage patient behaviours interfering with the therapeutic relationship (i.e. reassurance seeking). CBT formulation and skills may allow therapists to
be aware of behaviours which can negatively impact the relationship. Considering
all these points, we compared therapists’ emotional reactions to OCD patients across
two theoretical orientations, hypothesizing that CBT orientation is related to less
negative emotional reactions than the psychodynamic one.
Hypothesis B Previous evidence shows that therapist perfectionism is associated
with a negative therapeutic relationship. Higher therapist perfectionism, including high standards and expectations, might create high expectations in the therapist
regarding patient improvement/progress. Perfectionism and intolerance of uncertainty are a vulnerability/maintenance factor of OCD (Egan et al. 2011; Gentes
and Ruscio, 2011; Pozza et al. 2019). During sessions, patient’s perfectionism may
entrap a therapist with high perfectionism. Considering all these points, we hypothesized that high therapist’s perfectionism dimensions may be related to negative emotions towards patients regardless of theoretical orientation.
Role of Therapists’ Socio‑Demographics and Patients’ Comorbid Personality
Disorders
We checked for other variables potentially related to emotional response, including the therapist’s gender and age and the patient’s comorbid personality disorders. Since there is no univocal evidence suggesting the role of such variables
in the emotional reactions of therapists towards patients with OCD, we had no
specific hypotheses regarding their role.
13
A. Pozza et al.
Method
Participants and Procedure
A sample of therapists identified through the Italian regional rosters of licensed
psychotherapists and public or private mental health centres was recruited through
e-mail messages providing a detailed overview of the study’s rationale, aims and
instruments. Therapists were included if they were licensed psychotherapists
with CBT or psychodynamic training and orientation and if they provided written
informed consent to participate. Therapists were directed to select a patient among
their list of patients currently in treatment. To minimize selection biases, therapists
were asked to check their calendars to identify the last patient they had met during
the previous week who met the study criteria. Each therapist provided data about
only one patient. Patient had to meet the following criteria: (1) primary current diagnosis of OCD, (2) aged at least 16, (3) currently in CBT or psychodynamic therapy
for OCD after at least five individual sessions, (4) absence of lifetime psychosis/
bipolar disorders, (5) absence of alcohol/substance/drug addiction, (6) absence
of current suicidal ideation, (7) absence of neurological disorders, (8) absence of
mental retardation. Psychotherapeutic treatment had to consist of weekly individual
outpatient sessions according to a CBT or psychodynamic manual. Comorbid personality disorders or other psychological conditions and concurrent psychopharmacotherapy were not considered exclusion criteria since comorbid personality disorders are quite common in this clinical population (e.g., Dèttore & Pozza, 2014) and
concurrent psychopharmacological treatment is relatively frequent in clinical practice for OCD patients (Brakoulias et al., 2016).
Participation was voluntary and uncompensated. The study was approved by the
Institutional Ethics Committee. The study used a cross-sectional design where each
therapist completed the measures at only one time-point. Two groups were created:
CBT therapists and psychodynamic therapists were included according to a matching design where each CBT therapist was matched by age and gender to a psychodynamic therapist.
Measures
Therapists completed the following self-report questionnaires. To minimize their
recognizing the questionnaires, the acronyms of the measures were omitted.
Therapists’ Emotional Response to Patients
The Therapist Response Questionnaire (TRQ; Betan et al., 2005) is a clinician
report of 79 items that assess a wide spectrum of thoughts, feelings, and behaviours expressed by the therapist toward one specific patient (e.g. “I feel bored in sessions with him/her”). Items are written in a straightforward manner, without jargon
and near to clinical experience, so that the instrument can be used comparably by
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
therapists of any orientation. Therapists assess each item on a 5-point Likert scale
(“Not true” = 1, “Very true” = 5). The factor structure consists of eight emotional
dimensions: (1) Overwhelmed/Disorganized refers to a desire to avoid or flee the
patient and strong negative feelings, including dread, repulsion, and resentment; (b)
Helpless/Inadequate indicates feelings of inadequacy, incompetence, hopelessness,
and anxiety; (c) Positive/Satisfactory covers the experience of a positive working
alliance and close connection with the patient; (d) Special/Overinvolved describes a
sense of the patient as special, relative to other patients, and includes ‘soft signs’ of
problems in maintaining boundaries, including self-disclosure, ending sessions on
time, and feeling guilty about, responsible for, or overly concerned about the patient;
(e) Sexualized includes sexual feelings toward the patient or experiences of sexual
tension; (f) Disengaged describes feeling distracted, withdrawn, annoyed, or bored
in sessions; (g) Parental/Protective is characterized by a wish to protect and nurture the patient in a parental way, above and beyond normal positive feelings toward
the patient; (h) Criticized/Mistreated describes feelings of being unappreciated, dismissed, or devalued by the patient. Scores on each of the subscales are yielded by
computing the average score of the items that make up each emotional reaction. The
Italian version (Tanzilli et al. 2016) showed acceptable to good internal consistency
values across the subscales.
Therapists’ Perfectionism
The Frost Multidimensional Perfectionism Scale (MPS; Frost et al., 1990) is a
35-item questionnaire which includes four subscales: Concern over Mistakes and
Doubts about Actions (i.e. negative reactions to mistakes, perception of even minor
errors as failure, and repeatedly doubting the quality of one’s performance), Concern with Precision, Order and Organization (i.e. usually not referring to pathological functioning, the tendency to organize behaviour and be neat), Excessively High
Personal Standards (i.e. the tendency to set excessively high standards), Parents’
Expectations and Evaluation (i.e. perceiving one’s parents as having high expectations or being excessively critical). The questionnaire showed good reliability (Frost
et al., 1990). The Italian version (Lombardo, 2008) showed acceptable to good internal consistency values across the subscales.
Statistical Analysis
Between-group comparisons were performed through one-way ANOVAs or nonparametric tests to explore differences in emotional responses, perfectionism and
demographic features between CBT and psychodynamic therapists. Pearson’s
bivariate correlation coefficients were calculated separately for the two therapist groups. Values were interpreted according to the following criteria (Cohen
et al., 1998): 0 < r <|.30|= weak; |.30|< r <|.50|= moderate; |.50|< r <|.70|= strong;
|.70|< r <|1|= very strong. A series of generalised linear models (GLMs) was calculated with maximum likelihood estimation by entering main effects of therapist
characteristics (theoretical orientation, perfectionism, gender and age) and patient
characteristics (presence of a comorbid personality disorder) and therapists’
13
A. Pozza et al.
emotional responses to patients as outcomes. The statistical significance was set
at p < 0.05 with a Bonferroni correction for multiple hypotheses. The statistical
analyses were conducted using SPSS software, version 21.00.
Results
Sample’s Characteristics
Ninety-four therapists were included (74 women and 20 men; overall mean
age = 42.07 ± 10.17 years). Of these, 47 therapists (50%) had a CBT and 47 (50%)
a psychodynamic orientation (Table 2).
Table 2 Descriptive characteristics of the total sample of therapists (n = 94)
Therapists’ characteristics
n (%)
Mean (SD)
Gender
Female
74 (78.70)
Male
20 (21.30)
Age (years)
42.07 (10.17)
Marital status
Single
44 (46.80)
Cohabitant/married
44 (46.80)
Separated/divorced
4 (4.30)
Psychotherapeutic orientation
CBT
47 (50)
Psychodynamic therapy
47 (50)
Patients’ demographic and clinical characteristics
n (%)
Mean (SD)
Gender
Female
41 (43.60)
Male
53 (56.40)
Age
34.67 (11.19)
Presence of a comorbid personality disorder
No
79 (84)
Yes
15 (16)
Presence of a comorbid Axis disorder
No
77 (81.90)
Yes
17 (18.10)
13
2
1.MPS Concern over Mistakes and Doubts about Actions
2. MPS Concern with Precision, Order and Organization
3. MPS Excessively High Personal Standards
4. MPS Excessive Concern with Parents’ Expectations and Evaluation
5.TRQ Helpless/Inadequate
3
4
5
.084 .489** .429** .217*
**
.327
.144
6
7
.284** .070
− .161 − .117 .049
.436** .045
.148
.027
.124
.119
− .005
8
9
10
11
.295** .323** .248*
12
.267** .093
7.TRQ Positive/Satisfactory
8.TRQ Hostile/Angry
9.TRQ Criticised/Devalued
10.TRQ Special/Over-involved
11.TRQ Parental/Protective
.079
.174
− .067 − .117 − .183 − .148 − .087 − .192
.128
.211
*
− .054 .161
.207*
− .142 − .020
.124
.112
− .056 .063
.188
.670** − .236* .553** .665** .378** .220*
6.TRQ Overwhelmed/Disorganised
13
.617
**
**
.631
**
.615
*
− .166 − .138 .248
**
.617
**
.441
.406
**
.169
.299
.369**
**
.079
− .243*
.581
.572
**
.279
*
.249
**
.612
**
.623**
**
**
.496**
**
.406**
.343
**
.204*
.240*
− .016
.280
.367
12.TRQ Sexualised
.093
13.TRQ Disengaged
1
MPS, Multidimensional Perfectionism Scale; TRQ, Therapist Response Questionnaire. *p < 0.05, ** p < 0.001
Therapists’ Emotional Reactions to Patients with Obsessive–…
Table 3 Pearson’s bivariate correlations for the whole sample of therapists (n = 94)
13
A. Pozza et al.
Bivariate Associations Between Therapists’ Perfectionism and Emotional
Responses in the Whole Sample
Correlation coefficients are shown separately for the whole sample of therapists in
Table 3.
Concern over Mistakes and Doubts about Actions correlated positively and
weakly to moderately with all the emotional reactions except for positive/satisfactory, sexualized, and disengaged feelings. 2. MPS Concern with Precision. Order
and Organization did not have significant correlations with any of the feelings.
Excessively High Personal Standards correlated positively and weakly only with
parental protective feelings. Excessive Concern with Parents’ Expectations and
Evaluation correlated positively and weakly only with hostile and angry feelings.
Bivariate Associations Between Therapists’ Perfectionism and Emotional
Responses in the Separate Groups
Correlation coefficients are displayed separately for the two therapist groups in
Table 4.
Therapists’ and patients’ age and number of sessions were not related to any emotional responses and perfectionism dimensions in the CBT group. In the psychodynamic group, these variables were not related to emotional responses and perfectionism, but the number of sessions was positively and moderately related to hostile/
angry responses (more sessions were associated with more hostile/angry responses).
In the CBT group, concern over mistakes and doubts about actions correlated
positively and moderately with hostile/angry and criticised/devalued, while in the
psychodynamic group this perfectionism dimension was associated positively and
moderately with hostile/angry, overwhelmed/disorganised and special/over-involved
feelings.
In the CBT group, concern with precision, order and organization was not related
to any emotional responses while, interestingly, in the psychodynamic group, it correlated negatively with parental/protective and disengaged feelings.
In the CBT group, excessively high personal standards and excessive concern
with parents’ expectations were positively and moderately associated respectively
with parental/protective and hostile/angry emotions. In the psychodynamic group,
these two perfectionism dimensions were not related to any emotional responses.
Comparisons Between Therapist Groups on Emotional Responses
CBT therapists reported significantly lower overwhelmed/disorganized, hostile/
angry and criticised/devalued emotional responses towards their OCD patients than
psychodynamic therapists. No significant differences emerged between the two
groups regarding the other emotional responses measured by the TRQ. The results
of the comparison are presented in Table 5.
13
2
3
4
5
6
7
8
9
10
.126
− .148 − .047
1. Therapist’s age (years)
.273
.391** − .052 − .058
− .041 .101
2. Number of sessions
1
.205
− .003 .126
− .012 − .031 − .058 .108
3. Patient’s age (years)
.019
1
.000
− .209 − .070 − .048 − .230 − .213
4. MPS Concern over Mistakes and
Doubts about Actions
− .061 .098
1
5. MPS Concern with Precision. Order
and Organization
− .081 .155
6. MPS Excessively High Personal
Standards
.123
− .191
**
*
.548
.431
.280
− .043 1
.348*
.089
− .141 .106
.017
.433** .232
1
.477** .233
7. MPS Excessive Concern with Parents’
Expectations and Evaluation
− .105 .146
.522** .126
.496** 1
8. TRQ Helpless/Inadequate
.123
.242
− .033 − .035 1
9. TRQ Overwhelmed/Disorganised
10. TRQ Positive/Satisfactory
11. TRQ Hostile/Angry
12. TRQ Criticised/Devalued
.116
.056
**
.409
.191
.201
.166
**
*
.288
− .085 .093
.274
− .005 .148
*
.336
.258
**
− .153
− .242
− .146
− .096
.012
− .059 .074
.080
.094
.197
.136
− .132 .028
.250
.349
.106
11
12
13
14
.056
.146
.038
− .188 − .041 − .031
.037
.098
.019
.185
.213
− .031
− .104
.065
− .030 − .173 .083
− .141
*
**
.355
.450
.298
.067
− .174 − .103 .146
.214
.160
.288
.100
.255
.344*
− .156 .038
.192
− .125
.390**
.268
.227
.186
− .128 .081
.135
− .033 .649**
.742
1
.041
− .061 .219
**
.631
**
.637
**
**
.652
**
.517
.570
*
1
− .359
.133
**
− .052
**
**
.615
.696** .303*
**
.695
**
.274
*
1
.368
**
**
.055
.337*
.479
.012
− .40**
.083
.022
.588**
.205
.120
.379*
.142
.148
**
.210
− .034 .377
− .189
.173
.268
.415
.730
.522
.381
.705
.182
− .098 .260
− .298* .141
.134
.304*
.616** .699**
.397**
.221
.462** 1
15. TRQ Sexualised
− .057 − .226 .231
− .073
.415** .172
.461**
.508** .276
16. TRQ Disengaged
.035
− .309* − .043 − .092 .639** .436** − .096
.558**
.479** .705** .088
.279
− .080 − .252
**
.534
14. TRQ Parental/Protective
.150
− .094 .114
**
13. TRQ Special/Over-involved
− .163 − .035 .353*
.497
.514
**
.414
− .204 .094
**
1
**
.283
16
− .027
.575** − .336* .493**
**
.175
15
.491
− .032 − .060
.408** 1
.153
− .029
1
13
CBT, Cognitive Behavioural Therapy; CI, Confidence Interval; MPS, Multidimensional Perfectionism Scale; TRQ, Therapist Response Questionnaire. *p < 0.05, **
p < 0.001
Therapists’ Emotional Reactions to Patients with Obsessive–…
Table 4 Pearson’s bivariate correlations for CBT (above the diagonal) and psychodynamic group (under the diagonal)
13
Table 5 Comparisons between CBT (n = 47) and psychodynamic therapists (n = 47)
Perfectionism (MPS scales)
Concern over Mistakes and Doubts about Actions
Therapist’s orientation
Mean
SD
95% CI
Lower
Upper
CBT
31.89
10.793
28.72
35.06
Psychodynamic
30.53
7.843
28.23
32.83
CBT
22.45
4.889
21.01
23.88
Psychodynamic
20.57
4.481
19.26
21.89
CBT
22.26
5.507
20.64
23.87
Psychodynamic
20.85
3.873
19.71
21.99
Excessive Concern with Parents’ Expectations and
Evaluation
CBT
17.87
7.444
15.69
20.06
Psychodynamic
17.60
6.364
15.73
19.46
Emotional response to the patient (TRQ scales)
Therapist’s orientation
Mean
Concern with Precision. Order and Organization
Excessively High Personal Standards
Helpless/Inadequate
Overwhelmed/Disorganised
Positive/Satisfactory
Hostile/Angry
Criticised/Devalued
95% CI
Lower
Upper
16.02
6.825
14.02
18.03
Psychodynamic
19.09
6.114
17.29
20.88
CBT
16.91
5.633
15.26
18.57
Psychodynamic
20.45
7.274
18.31
22.58
CBT
22.70
6.175
20.89
24.52
Psychodynamic
21.00
5.846
19.28
22.72
CBT
11.05
4.799
9.65
12.46
Psychodynamic
14.23
5.984
12.45
16.01
9.51
3.296
8.54
10.48
12.97
CBT
11.77
4.108
10.56
CBT
8.74
2.907
7.89
9.59
Psychodynamic
9.60
3.375
8.60
10.61
p-value
0.490
0.486
3.746
0.056
2.045
0.156
0.037
0.847
F(1. 93)
p-value
5.254
0.024
6.927
0.010
1.883
0.173
7.980
0.006
8.617
0.004
1.754
0.189
A. Pozza et al.
CBT
Psychodynamic
Special/Over-involved
SD
F(1. 93)
Emotional response to the patient (TRQ scales)
Parental/Protective
Sexualised
Disengaged
Therapist’s orientation
Mean
SD
95% CI
Lower
Upper
CBT
12.15
3.816
11.03
13.27
Psychodynamic
13.30
4.587
11.95
14.64
CBT
4.69
1.078
4.38
5.01
Psychodynamic
4.90
1.503
4.46
5.35
CBT
9.23
3.919
8.08
10.38
Psychodynamic
9.38
4.240
8.14
10.63
F(1. 93)
p-value
1.743
0.190
0.596
0.442
0.031
0.860
CBT, Cognitive Behavioural Therapy; CI, Confidence Interval; MPS, Multidimensional Perfectionism Scale; TRQ, Therapist Response Questionnaire
Therapists’ Emotional Reactions to Patients with Obsessive–…
Table 5 (continued)
13
A. Pozza et al.
Table 6 Comparison between CBT and psychodynamic therapists on demographics, session number and
patients’ characteristics (n = 94)
Therapist’/patient’s characteristics
Therapist’s orientation Mean SD
95% CI
Age of the therapist
(years)
CBT
42.62
10.584 39.51
Psychodynamic
41.53
9.835 38.64
F(1. 93) p-value
Lower Upper
45.72 0.265
Number of sessions with
the patient
CBT
69.25 127.311 30.54
107.96 0.108
Psychodynamic
76.88
82.002 51.33
102.43
Age of the patient (years)
CBT
33.24
11.729 29.76
36.72 1.530
Psychodynamic
36.13
10.546 32.97
39.30
Therapist’s gender
Patient’s gender
Patient with a comorbid
personality disorder
0.608
44.42
0.743
0.219
CBT (n)
Psychodynamic (n)
Total
χ2(1)
p-value
Male
10
10
20
0
1.000
Female
37
37
74
Male
29
24
53
1.081
0.298
Female
18
23
41
No
40
39
79
0.079
0.778
Yes
7
8
15
CBT, Cognitive Behavioural Therapy
Comparison Between Theoretical Orientation and Therapists’ Demographics
and Patients’ Characteristics
The therapists’ groups were matched by age and gender and were not significantly
different regarding therapists’ and patients’ demographic characteristics. The comparisons between CBT and psychodynamic therapists are shown in Table 6.
Multivariate Effects of Therapists’ Orientation and Perfectionism on Emotions
Towards Patients
The results of the GLMs are presented in Table 7. With regard to therapist’s variables, theoretical orientation, perfectionism and gender had specific effects on specific emotional reactions to patients. CBT orientation was associated with lower
overwhelmed/disorganized, hostile/angry, criticised/devalued, parental/protective
and special/over-involved emotional responses to patients.
Specific therapist perfectionistic traits were associated with some of the emotional reactions. In particular, higher parents’ expectations and evaluation correlated
with higher hostile/angry reactions. Higher concerns over mistakes and doubts about
actions were associated with more intense criticised/devalued emotions. Stronger
concerns with precision, order and organization were related to lower disengagement responses.
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
Table 7 General linear models: effects of therapist and patient characteristics on therapists’ emotions
towards patients (n = 94)
Outcome: TRQ Helpless/Inadequate
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
16.185
6.559
25.812
10.860
.001
Therapist’s male gender
1.760
− .757
4.276
1.878
.171
Therapist’s female gender
0a
− .126
.121
Therapist’s age (years)
− .002
CBT orientation
− 3.118 − 5.642 − .595
Psychodynamic orientation
0a
.001
.971
5.867
.015
3.254
.071
Absence of a comorbid personality disorder
− 3.121 − 6.511 .270
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
.078
− .091
.247
.821
.365
MPS Concern with Precision. Order and Organization
− .217
− .500
.066
2.264
.132
MPS Excessively High Personal Standards
.175
− .154
.503
1.087
.297
MPS Parents’ Expectations and Evaluation
.079
− .137
.295
.516
.473
Patients’ age (years)
.040
− .074
.155
.476
.490
Outcome: TRQ Overwhelmed/Disorganized
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
18.516
8.846
28.187
14.083
.000
Therapists’ male gender
1.781
− .747
4.309
1.907
.167
Therapists’ female gender
0a
− .194
.054
Therapists’ age (years)
− .070
1.238
.266
CBT orientation
− 3.856 − 6.392 − 1.321 8.890
.003
Psychodynamic orientation
0a
Absence of a comorbid personality disorder
− 1.278 − 4.684 2.129
Presence of a comorbid personality disorder
0a
.540
.462
MPS Concern over Mistakes and Doubts about
Actions
.147
− .023
.317
2.890
.089
MPS Concern with Precision. Order and Organization
− .055
− .339
.229
.145
.704
MPS Excessively High Personal Standards
− .022
− .352
.308
.017
.897
MPS Parents’ Expectations and Evaluation
.091
− .125
.308
.685
.408
Patients’ age (years)
.017
− .099
.132
.081
.776
Outcome: TRQ Positive/Satisfactory
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
13.551
4.370
22.732
8.368
.004
Therapists’ male gender
1.224
− 1.176 3.625
.999
.317
Therapists’ female gender
0a
Therapists’ age (years)
.027
− .090
CBT orientation
.558
− 1.849 2.964
.145
.210
.647
.206
.650
13
A. Pozza et al.
Table 7 (continued)
Outcome: TRQ Positive/Satisfactory
95% CI
β
Psychodynamic orientation
Lower
Upper
Wald’s χ2(1) p-value
− .882
5.586
2.033
.154
0a
Absence of a comorbid personality disorder
2.352
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
− .023
− .184
.138
.078
.779
MPS Concern with Precision. Order and Organization
.133
− .136
.403
.937
.333
MPS Excessively High Personal Standards
.182
− .132
.495
1.288
.256
MPS Parents’ Expectations and Evaluation
.035
− .170
.241
.114
.736
Patients’ age (years)
− .039
− .149
.070
.493
.483
Outcome: Hostile/Angry
95% CI
Lower
Upper
Wald’s χ2(1) p-value
β
Intercept
4.688
− 3.081 12.457
1.399
.237
Therapists’ male gender
1.790
− .247
3.826
2.966
.085
Therapists’ female gender
0a
− .100
.099
.000
Therapists’ age (years)
− .001
CBT orientation
− 3.243 − 5.289 − 1.198 9.655
Psychodynamic orientation
0a
Absence of a comorbid personality disorder
− .445
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
MPS Concern with Precision. Order and Organization
.990
.002
− 3.187 2.297
.101
.751
.064
− .072
.200
.846
.358
− .035
− .265
.194
.091
.763
.458
MPS Excessively High Personal Standards
.101
− .165
.367
.550
MPS Parents’ Expectations and Evaluation
.189
.013
.365
4.419
.036
Patients’ age (years)
.061
− .032
.155
1.643
.200
Outcome: TRQ Criticised/Devalued
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
8.112
3.199
13.026
10.473
.001
Therapists’ male gender
1.517
.232
2.801
5.358
.021
Therapists’ female gender
0a
− .019
.106
Therapists’ age (years)
.043
CBT orientation
− 1.833 − 3.121 − .545
Psychodynamic orientation
0a
Absence of a comorbid personality disorder
− 1.404 − 3.135 .326
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
.116
13
.029
.202
1.833
.176
7.782
.005
2.530
.112
6.902
.009
Therapists’ Emotional Reactions to Patients with Obsessive–…
Table 7 (continued)
Outcome: TRQ Criticised/Devalued
MPS Concern with Precision. Order and Organization
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
− .057
− .201
.087
.603
.437
MPS Excessively High Personal Standards
− .124
− .292
.044
2.094
.148
MPS Parents’ Expectations and Evaluation
.092
− .018
.202
2.674
.102
Patients’ age (years)
.008
− .051
.066
.065
.799
Outcome: TRQ Special/Over-Involved
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
5.406
.798
10.015
5.288
.021
Therapists’ male gender
.664
− .545
1.872
1.159
.282
Therapists’ female gender
0a
− .058
.060
Therapists’ age (years)
.001
CBT orientation
− 1.226 − 2.439 − .012
Psychodynamic orientation
0a
Absence of a comorbid personality disorder
1.655
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
MPS Concern with Precision. Order and Organization
.002
.969
3.919
.048
.029
3.282
3.980
.046
.012
− .069
.093
.085
.770
− .131
− .268
.005
3.571
.059
MPS Excessively High Personal Standards
.140
− .018
.298
3.029
.082
MPS Parents’ Expectations and Evaluation
.099
− .005
.204
3.479
.062
Patients’ age (years)
.005
− .051
.060
.026
.871
Outcome: TRQ Parental/Protective
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
9.323
2.977
15.669
8.292
.004
Therapists’ male gender
.797
− .862
2.456
.886
.347
Therapists’ female gender
0a
− .104
.058
Therapists’ age (years)
− .023
CBT orientation
− 1.737 − 3.400 − .073
.307
.580
4.188
.041
Psychodynamic orientation
0a
− 1.541 2.929
.371
.543
Absence of a comorbid personality disorder
.694
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
.062
− .050
.173
1.173
.279
MPS Concern with Precision. Order and Organization
− .072
− .258
.115
.570
.450
MPS Excessively High Personal Standards
.186
− .031
.402
2.824
.093
MPS Parents’ Expectations and Evaluation
.053
− .089
.195
.536
.464
Patients’ age (years)
− .019
− .095
.057
.246
.620
13
A. Pozza et al.
Table 7 (continued)
Outcome: TRQ Sexualised
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
5.371
3.348
7.394
27.083
.000
Therapists’ male gender
.122
− .413
.657
.200
.655
Therapists’ female gender
0a
Intercept
Therapists’ age (years)
− .007
− .033
.019
.272
.602
CBT orientation
− .186
− .718
.345
.471
.492
Psychodynamic orientation
0a
− .394
1.031
.766
.381
Absence of a comorbid personality disorder
.318
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
.009
− .026
.045
.271
.603
MPS Concern with Precision. Order and Organization
.004
− .056
.063
.014
.907
MPS Excessively High Personal Standards
− .043
− .112
.026
1.507
.220
MPS Parents’ Expectations and Evaluation
.010
− .036
.055
.168
.682
Patients’ age (years)
− .004
− .028
.020
.109
.742
Outcome: TRQ Disengaged
95% CI
β
Lower
Upper
Wald’s χ2(1) p-value
Intercept
12.846
6.736
18.956
16.979
.000
Therapists’ male gender
.411
− 1.186 2.009
.254
.614
Therapists’ female gender
0a
Therapists’ age (years)
− .040
− .118
1.004
.316
CBT orientation
.002
− 1.600 1.604
.038
.000
.998
Psychodynamic orientation
0a
− 2.718 1.586
.266
.606
Absence of a comorbid personality disorder
− .566
Presence of a comorbid personality disorder
0a
MPS Concern over Mistakes and Doubts about
Actions
.053
− .054
.160
.930
.335
MPS Concern with Precision. Order and Organization
− .224
− .404
− .045
5.995
.014
MPS Excessively High Personal Standards
.047
− .162
.256
.194
.659
MPS Parents’ Expectations and Evaluation
− .016
− .153
.121
.052
.820
Patients’ age (years)
.016
− .057
.089
.187
.665
CBT, Cognitive Behavioural Therapy; CI, Confidence Interval; MPS, Multidimensional Perfectionism
Scale; TRQ, Therapist Response Questionnaire
a
Parameters are set at zero because they are redundant in the statistical model
Therapist’s male gender was associated with higher criticised/devalued feelings. Absence of a comorbid personality disorder in the patient was related to
higher special/over-involved reactions.
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
Discussion
The present study is the first investigation of the therapeutic relationship with
OCD patients from the therapist’s perspective. The model proposed by Betan
et al. (2005) identifies specific patterns of emotional responses experienced by
therapists towards patients. However, little is known about the role of therapists’
orientation and perfectionism. Therapists’ emotional reactions to patients represent clinically informative material about patients’ interpersonal functioning
and might support supervisory practice. We compared the emotional reactions
to OCD patients of therapists with a CBT orientation to those with a psychodynamic one. We also explored the role of therapists’ perfectionism on emotional
reactions.
Overall, in the whole sample of therapists, in line with previous data regarding the maladaptive effects of perfectionism on the therapeutic alliance (Ganske et al., 2015; Zuroff et al., 2010) we found that those therapists with higher
concern over mistakes and doubts about actions were more likely to report more
intense emotional reactions including helpless/inadequate, overwhelmed/disorganised, hostile/angry, criticised/devalued, special/over-involved, and parental/
protective feelings except for positive feelings related to a satisfactory relationship, sexualised, and disengaged feelings towards their patients. Excessively High
Personal Standards correlated positively and weakly only with parental protective
feelings. Therapists with excessive concern with parents’ expectations and evaluation reported more hostile and angry feelings. Finally, therapists with higher
concern with precision, order and organization did not report any emotional feelings towards patients.
We found that compared to psychodynamic therapists, CBT therapists had
less negative feelings on some specific emotional patterns, particularly helpless/
inadequate, overwhelmed/disorganized, hostile/angry and criticised/devalued
emotional responses to patients. An interpretation of this result may be related
to one of the key processes usually occurring during psychotherapy for OCD, i.e.
patients’ tendency to seek more and more reassurance from therapists about the
validity of their obsessional doubts (e.g., Kobori and Salkovskis 2013). CBT therapists may have more skills to manage this difficult aspect of the therapeutic relationship. Generally, OCD patients expect therapists to be able to offer immediate
reassurance about their doubts and neutralize their discomfort. A therapist who
is not aware of this interpersonal cycle may provide reassurance to each request
with the aim of immediately reducing the patient’s discomfort; in turn, this can
reactivate the patient’s doubts in the long-term thus reinforcing discomfort again.
A therapist who offers reassurance may get entrapped in special and over-involved
feelings (when the patient’s distress is initially reduced) but also in angry and
criticised emotions because reassurance becomes more and more ineffective. We
can speculate that compared to psychodynamic therapists, CBT therapists might
be more aware of these interpersonal vicious cycles and more prepared to manage reassurance-seeking. These skills in CBT therapists may prevent or attenuate some interpersonal scripts which OCD patients manifest during sessions,
13
A. Pozza et al.
particularly feelings of abandonment, dependence, vulnerability, and insufficient
self-control (e.g., Voderholzer et al. 2014). In addition, one of the key elements
of CBT which may help these therapists more effectively manage the relationship
is case formulation, a therapist and patient shared goal-oriented process of understanding how OCD and therapy work (e.g., Natrass et al. 2015). CBT case formulation of OCD assumes that therapy works by exposing the patient to doubts and
helping him/her to accept uncertainty (e.g., Clark, 2003). We can speculate that
this element might help CBT therapists to tolerate and more effectively manage
overwhelming feelings deriving from the client’s reassurance requests in the therapeutic relationship. Regarding the psychodynamic approach, there is not consensus about the most effective attitude to adopt toward OCD patients’ reassuring
requests, the reason why we hypothesized that psychodynamic therapists experienced more overwhelming feelings towards patients (King, 2017). The techniques
used in CBT involve exposure and response prevention. As reassurance may often
be inappropriately used to counter anxiety generated by obsessive thinking, reassurance seeking may be a compulsive action that a CBT therapist would not reinforce as he/she tends to be aware of the role of providing reassurance as a reinforcing factor of OCD symptoms. CBT therapists would not become angered by
reassurance-seeking, but would see that action as part of the condition and an
area for treatment targeting, not something that would cause emotional distress.
Therapists’ responses to patients’ reassurance requests are central for treating
psychopathology also within a psychodynamic perspective. In psychodynamic
psychotherapies, there is an emphasis on the evocation of affect, on bringing
unconscious into awareness, and on integrating current difficulties with previous
life experience, using the therapist–patient relationship as a change agent (Jones
& Pulos, 1993). An explanation why CBT therapists reported less overwhelming feelings than the psychodynamic ones might be that the latter do not directly
focus on symptoms (i.e., the content of obsessional doubts, the vicious cycle of
reassurance seeking) and perhaps are not skilled in managing symptoms in the
short term (i.e., when obsessions and compulsions arise) (McKay, 2011).
Interestingly, the two therapist groups were not different on any perfectionism
dimensions, indicating that perfectionism might be a transtheoretical characteristic and therefore independent of therapists’ theoretical orientations.
Bivariate associations showed that in both the orientations, concerns over mistakes and doubts about actions were associated with angry feelings. In addition,
this perfectionism dimension was related, respectively, to criticised emotions in
the CBT group and to overwhelmed and over-involved reactions in the psychodynamic one. While in the CBT group a higher concern with precision, order
and organization was not associated with any emotional patterns, it was related
to lower parental/protective and disengaged feelings among the psychodynamic
therapists. Interestingly, high personal standards and excessive concern with
parents’ expectations were associated with parental and angry emotions in CBT
therapists, while this perfectionism dimension was not related to any emotional
pattern in the psychodynamic group.
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
The results of the GLMs further supported the effects found through direct comparisons of therapists’ orientations. This result suggests that some negative emotional reactions are related to the therapist’s theoretical orientation and skills.
In addition, we found some therapists’ perfectionistic traits had a role regardless
of orientation. Specifically, concern over mistakes and doubts about actions was
associated with criticised feelings, and parents’ expectations and evaluation were
related to hostile feelings. This result suggests that supervisory practice should consider these perfectionism features as interpersonal therapist characteristics potentially interfering with the therapeutic relationship with OCD patients. The role of
excessively high standards was not significant, in contrast with previous research on
psychotherapy processes (Presley et al., 2017).
Interestingly, therapists more concerned with precision, order and organization
experienced lower disengagement reactions. This result may be in line with the bidimensional model of perfectionism where this dimension may have a positive effect
on the resources of the individual, i.e. coping and resiliency (Enns et al. 2005; Stoeber & Otto, 2006).
Surprisingly, none of the variables examined were associated with a positive
therapeutic relationship. This suggests the importance of deeply understanding what
factors determine a better relationship between therapist and patient. An interpretation may be that this emotional dimension is a transtheoretical element related
to alliance and common factors rather than specific techniques. Alternatively, it
may be that some variables not considered in the present study have an effect: for
example, patient’s adherence to therapy and symptom improvement may facilitate
self-efficacy feelings in the therapist which make him/her perceive the relationship
more positively. The fact that the absence of a comorbid personality disorder was
associated with a better therapeutic relationship may be attributable to the fact that
the presence of a comorbid personality disorder in OCD has been found to be not
related to drop-out or less symptom improvement by some studies (Dèttore et al.,
2013; Olatunji et al., 2013). Another interpretation may be that if the therapist is
aware of a patient’s personality comorbidity, he/she may have lower expectations
regarding the patient’s interpersonal functioning or may be more careful about collusion with interpersonal vicious cycles.
Implications for Clinical and Supervisory Practice
Since we found that some perfectionism dimensions were associated with some negative emotional reactions to patients with OCD, it is clear that reducing perfectionistic
strivings and concerns might be essential to prevent their potential destructive impact
on the clients’ well-being, independently of the theoretical model. Supervisory practice
of therapists working with OCD clients should be focused on therapists’ perfectionism
and their emotional experience towards this type of patients. Not embracing methods to
reduce perfectionism might imply conveying pressure to clients, who may be deprived
of learning that mistakes are inevitable and should be accepted. As Wittenberg and
Norcross suggested (2001), both the CBT and the psychodynamic approach embrace
methods or techniques to reducing perfectionism: restructuring of the self-destructive
13
A. Pozza et al.
“shoulds,” and selective abstraction, the former; therapy’s incorporation of a less punitive superego, the latter. Cognitive restructuring, which revealed to be an effective intervention for perfectionism (DiBartolo et al., 2001; Rozental, 2020), might be introduced
in supervisory sessions of therapists to target perfectionistic cognitions related to their
clients with OCD. Another type of intervention that might be integrated in supervisory
practice might include self-compassion exercises which may be useful for therapists
with high perfectionistic tendencies and negative emotional responses towards their
OCD patients, as suggested by the promising use of this intervention with psychotherapy trainees (Richardson et al., 2020).
Limitations
The cross-sectional design and the lack of a random assignment of therapists to patients
did not allow us to ascertain a causal effect and exclude the possibility that the observed
relations were spurious. In addition, another relevant issue concerns the fact that each
therapist rated his/her emotions towards only one patient, as in previous studies using
the TRQ (e.g., Gazzillo et al., 2015; Tanzilli et al., 2016). It could be argued that the
emotions reported by the therapist in this study were related to the characteristics of a
specific patient and not just to the clinical features of OCD. Therefore, further studies
should assign each therapist to multiple patients with OCD and use multilevel analyses
to distinguish the effects of therapist’ and patient’s features, and the effects of OCD.
Future studies should also investigate whether therapists’ emotional responses predict
treatment outcome and/or drop-out by a longitudinal design. It may be interesting to
assess whether therapists’ emotions are associated with other patient characteristics and
processes, such as interpersonal maladaptive schemas which may have an impact on
the therapeutic relationship.
A key issue regards the fact that novelty in working with OCD patients was not
assessed, since the experience of therapists was only detected by a generic variable,
i.e., therapists’ age. Therefore, future research should examine the role of this variable
that could impact on the emotional reactions of therapists, for example by assessing
the number of OCD patients treated in the therapists past working experience and/or
the number/type of clinical trainings about OCD psychotherapy. Another point which
needs investigation is the association between therapists’ emotional responses and the
therapeutic alliance as perceived by patients. Our protocol may also be improved by
adding other measures of therapists’ emotional responses such as observer-based or
psychophysiological measures. Finally, further research may use other therapist orientations and other patient’s psychological conditions as further comparison groups such
as other OCD spectrum conditions (Pozza et al., 2016a).
Conclusions
The present study is the first empirical investigation on the emotional responses of
therapists towards patients with OCD. Therapists’ CBT orientation and lower perfectionistic traits might be associated with better emotions towards the patients suggesting
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
a better therapeutic relationship, at least from the therapist’s perspective. Supervisory
practice should take into account the emotional responses experienced by the therapist
and therapist’s orientation and perfectionism with the aim to monitor and improve the
therapeutic relationship and potentially the effectiveness of treatment.
Authors’ contributions AP designed the study, conducted the literature searchers, collected the data, analysed the data, wrote the first draft of the paper; SC designed the study, conducted the literature searches,
wrote the first draft of the paper and checked the final version; DD designed the study, conducted the
literature searches, collected the data, wrote the first draft of the paper and checked the final version.
Funding The study did not receive any funding.
Availability of data and materials Data will be made available upon request.
Declarations
Conflict of interest The authors have no conflicts of interest to declare.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is
not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licen
ses/by/4.0/.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders-fifth
edition (DSM 5). VA American Psychiatric Publishing.
Betan, E., Heim, A. K., Zittel Conklin, C., & Westen, D. (2005). Countertransference phenomena and
personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162, 890–898.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252.
Brakoulias, V., Starcevic, V., Belloch, A., Dell’Osso, L., Ferrão, Y. A., Fontenelle, L. F., Lochner, C.,
Marazziti, D., Martin, A., Matsunaga, H., & Miguel, E. C. (2016). International prescribing practices in obsessive–compulsive disorder (OCD). Human Psychopharmacology: Clinical and Experimental, 31, 319–324.
Cervin, M., Perrin, S., Olsson, E., Aspvall, K., Geller, D. A., Wilhelm, S., McGuire, J., Lázaro, L., Martínez-González, A. E., Barcaccia, B., Pozza, A., Goodman, W. K., Murphy, T. K., Seçer, I., Piqueras,
J. A., Rodríguez-Jiménez, T., Godoy, A., Rosa-Alcázar, A. I., Rosa-Alcázar, A., … Mataix-Cols, D.
(2020). The centrality of doubting and checking in the network structure of obsessive-compulsive
symptom dimensions in youth. Journal of the American Academy of Child & Adolescent Psychiatry,
59, 880–889.
Chlebowski, S., & Gregory, R. J. (2009). Is a psychodynamic perspective relevant to the clinical management of obsessive-compulsive disorder? American Journal of Psychotherapy, 63, 245–256.
Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (1998). Applied multiple regression/correlation analysis
for the behavioral sciences. Routledge.
13
A. Pozza et al.
Coluccia, A., Fagiolini, A., Ferretti, F., Pozza, A., & Goracci, A. (2015). Obsessive-Compulsive Disorder
and quality of life outcomes: protocol for a systematic review and meta-analysis of cross-sectional
case-control studies. Epidemiology, Biostatistics and Public Health, 12, e11037.
Clark, D. A. (2003). Cognitive-behavioural therapy for OCD. The Guilford Press.
Dèttore, D., & Pozza, A. (2014). Obsessive Compulsive Disorder and comorbid personality disorders.
In E. M. Crowe & A. R. O’Dell (Eds.), Obsessive compulsive disorder: Symptoms, prevalence and
psychological treatments (pp. 1–46). Nova Science Publishers.
Dèttore, D., Pozza, A., & Coradeschi, D. (2013). Does time-intensive ERP attenuate the negative impact
of comorbid personality disorders on the outcome of treatment-resistant OCD? Journal of Behavior
Therapy and Experimental Psychiatry, 44, 411–417.
DiBartolo, P. M., Frost, R. O., Dixon, A., & Almodovar, S. (2001). Can cognitive restructuring reduce the
disruption associated with perfectionistic concerns? Behavior Therapy, 32, 167–184.
Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review.
Clinical Psychology Review, 31, 203–212.
Enns, M. W., Cox, B. J., & Clara, I. P. (2005). Perfectionism and neuroticism: A longitudinal study of specific
vulnerability and diathesis-stress models. Cognitive Therapy and Research, 29, 463–478.
Farris, S. G., McLean, C. P., Van Meter, P. E., Simpson, H. B., & Foa, E. B. (2013). Treatment response,
symptom remission and wellness in obsessive-compulsive disorder. The Journal of Clinical Psychiatry,
74, 685–690.
Fisher, P. L., & Wells, A. (2005). How effective are cognitive and behavioral treatments for obsessive–compulsive disorder? A clinical significance analysis. Behaviour Research and Therapy, 43, 1543–1558.
Flett, G. L., & Hewitt, P. L. (2002). Perfectionism: Theory, research, and treatment. American Psychological
Association.
Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance
in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59, 10–17.
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy:
A meta-analytic synthesis. Psychotherapy, 55, 316–340.
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive
Therapy and Research, 14, 449–468.
Ganske, K. H., Gnilka, P. B., Ashby, J. S., & Rice, K. G. (2015). The relationship between counseling trainee
perfectionism and the working alliance with supervisor and client. Journal of Counseling & Development, 93, 14–24.
Gazzillo, F., Lingiardi, V., Del Corno, F., Genova, F., Bornstein, R. F., Gordon, R. M., & McWilliams, N.
(2015). Clinicians’ emotional responses and Psychodynamic Diagnostic Manual adult personality disorders: A clinically relevant empirical investigation. Psychotherapy, 52, 238–246.
Gentes, E. L., & Ruscio, A. M. (2011). A meta-analysis of the relation of intolerance of uncertainty to
symptoms of generalized anxiety disorder, major depressive disorder, and obsessive compulsive disorder. Clinical Psychology Review, 31(6), 923–933.
Haarhoff, B. A. (2006). The importance of identifying and understanding therapist schema in cognitive therapy training and supervision. New Zealand Journal of Psychology, 35, 126–131.
Hayes, J. A. (2004). The inner world of the psychotherapist: A program of research on countertransference.
Psychotherapy Research, 14, 21–36.
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60,
456–470.
Horvath, A. O. (2000). The therapeutic relationship: From transference to alliance. Journal of Clinical Psychology, 56, 1631–73.
Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy.
Psychotherapy, 48, 9–16.
Jones, E. E., & Pulos, S. M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of Consulting and Clinical Psychology, 61, 306–316.
King, R. (2017). Psychodynamic Perspectives on OCD. In C. Pittenger (Ed.), Obsessive-compulsive disorder: Phenomenology, pathophysiology, and treatment (pp. 65–74). Oxford University Press.
Lombardo, C. (2008). Adattamento italiano della Multidimensional Perfectionism Scale (MPS). Psicoterapia
Cognitiva e Comportamentale, 14, 31–46.
Maher, M. J., Wang, Y., Zuckoff, A., Wall, M. M., Franklin, M., Foa, E. B., & Simpson, H. B. (2012). Predictors of patient adherence to cognitive-behavioral therapy for obsessive-compulsive disorder. Psychotherapy and Psychosomatics, 81, 124–126.
13
Therapists’ Emotional Reactions to Patients with Obsessive–…
Marsden, Z., Lovell, K., Blore, D., Ali, S., & Delgadillo, J. (2018). A randomized controlled trial comparing EMDR and CBT for obsessive-compulsive disorder. Clinical Psychology and Psychotherapy, 25,
e10–e18.
McKay, D. (2011). Methods and mechanisms in the efficacy of psychodynamic psychotherapy. American
Psychologist, 66, 147–148.
Natrass, A., Kellett, S., Hardy, G. E., & Ricketts, T. (2015). The content, quality and impact of cognitive
behavioural case formulation during treatment of obsessive compulsive disorder. Behavioural and Cognitive Psychotherapy, 43, 590–601.
NICE. (2013). Obsessive-compulsive disorder: Evidence update september 2013. In NICE clinical guideline,
31. Available at: https://www.nice.org.uk/guidance/cg31/evidence/evidence-update-194847085
Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A.
Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (pp. 113–141). American Psychological Association.
Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief
questionnaire and interpretation of intrusions inventory-Part 2: Factor analyses and testing of a brief
version. Behaviour Research and Therapy, 43, 1527–1542.
Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47, 33–41.
Ong, C. W., Clyde, J. W., Bluett, E. J., Levin, M. E., & Twohig, M. P. (2016). Dropout rates in exposure with
response prevention for obsessive-compulsive disorder: What do the data really say? Journal of Anxiety
Disorders, 40, 8–17.
Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156–169.
Pozza, A., Albert, U., & Dèttore, D. (2019). Perfectionism and intolerance of uncertainty are predictors of
OCD symptoms in children and early adolescents: A prospective, cohort, one-year, follow-up study.
Clinical Neuropsychiatry, 16, 53–61.
Pozza, A., Barcaccia, B., & Dèttore, D. (2017). The Obsessive Compulsive Inventory-Child Version (OCICV): Further evidence on confirmatory factor analytic structure, incremental and criterion validity in
italian community children and adolescents. Archives of Psychiatric Nursing, 31, 291–295.
Pozza, A., & Dettore, D. (2017). Drop-out and efficacy of group versus individual cognitive behavioural
therapy: What works best for Obsessive-Compulsive Disorder? A systematic review and meta-analysis
of direct comparisons. Psychiatry Research, 258, 24–36.
Pozza, A., & Dèttore, D. (2020). Modular cognitive-behavioral therapy for affective symptoms in young individuals at ultra-high risk of first episode of psychosis: Randomized controlled trial. Journal of Clinical
Psychology, 76, 392–405.
Pozza, A., Giaquinta, & Dèttore, D. (2016a). Borderline, avoidant, sadistic personality traits and emotion
dysregulation predict different pathological skin picking subtypes in a community sample. Neuropsychiatric Disease and Treatment, 12, 1861–1867.
Pozza, A., Mazzoni, G. P., Berardi, D., & Dèttore, D. (2016b). Studio preliminare sulle proprietà psicometriche della versione italiana della Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) in campioni non-clinici e campioni clinici con Disturbo Ossessivo-Compulsivo e Disturbi d’Ansia. Psicoterapia
Cognitiva e Comportamentale, 22, 271–296.
Pozza, A., Starcevic, V., Ferretti, F., Pedani, C., Crispino, R., Governi, G., Luchi, S., Gallorini, A., Lochner,
C., & Coluccia, A. (2021). Obsessive-compulsive personality disorder co-occurring in individuals with
obsessive-compulsive disorder: a systematic review and meta-analysis. Harvard Review of Psychiatry,
29, 95–107.
Pozza, A., Veale, D., Marazziti, D., Delgadillo, J., Albert, U., Grassi, G., Prestia, D., & Dèttore, D. (2020).
Sexual dysfunction and satisfaction in obsessive compulsive disorder: Protocol for a systematic review
and meta-analysis. Systematic Reviews, 9, 1–13.
Presley, V. L., Jones, C. A., & Newton, E. K. (2017). Are perfectionist therapists perfect? The relationship
between therapist perfectionism and client outcomes in cognitive behavioural therapy. Behavioural and
Cognitive Psychotherapy, 45, 225–237.
Richardson, C. M., Trusty, W. T., & George, K. A. (2020). Trainee wellness: Self-critical perfectionism, selfcompassion, depression, and burnout among doctoral trainees in psychology. Counselling Psychology
Quarterly, 33, 187–198.
13
A. Pozza et al.
Rozental, A. (2020). Beyond perfect? A case illustration of working with perfectionism using cognitive
behavior therapy. Journal of Clinical Psychology, 76, 2041–2054.
Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive
disorder in the national comorbidity survey replication. Molecular Psychiatry, 15, 53–63.
Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence
predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder. Journal of
Consulting and Clinical Psychology, 79, 247–252.
Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence, challenges.
Personality and Social Psychology Review, 10, 295–319.
Strauss, A. Y., Huppert, J. D., Simpson, H. B., & Foa, E. B. (2018). What matters more? Common or
specific factors in cognitive behavioral therapy for OCD: Therapeutic alliance and expectations as
predictors of treatment outcome. Behaviour Research and Therapy, 105, 43–51.
Tanzilli, A., Colli, A., Del Corno, F., & Lingiardi, V. (2016). Factor structure, reliability, and validity of the
Therapist Response Questionnaire. Personality Disorders: Theory, Research, and Treatment, 7, 147–158.
Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., et al.
(2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.
Voderholzer, U., Scwartz, C., Thiel, N., Kuelz, A. K., Hartmann, A., Scheidt, C. E., et al. (2014). A
comparison of schemas, schema modes and childhood traumas in obsessive-compulsive disorder,
chronic pain disorder and eating disorders. Psychopathology, 47, 24–31.
Vogel, P. A., Hansen, B., Stiles, T. C., & Götestam, K. G. (2006). Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD.
Journal of Behavior Therapy and Experimental Psychiatry, 37, 247–255.
Wampold, B. E. (2015). How are important the common factors in psychotherapy? An update. World
Psychiatry, 14, 270–277.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes
psychotherapy work. New York: Routledge.
Wheaton, M. G., Huppert, J. D., Foa, E. B., & Simpson, H. B. (2016). How important is the therapeutic alliance in treating obsessive-compulsive disorder with exposure and response prevention? An
empirical report. Clinical Neuropsychiatry, 6, 88–93.
Wittenberg, K. J., & Norcross, J. C. (2001). Practitioner perfectionism: Relationship to ambiguity tolerance and work satisfaction. Journal of Clinical Psychology, 57, 1543–1550.
Zuroff, D. C., Kelly, A. C., Leybman, M. J., Blatt, S. J., & Wampold, B. E. (2010). Between-therapist and
within-therapist differences in the quality of the therapeutic relationship: Effects on maladjustment
and self-critical perfectionism. Journal of Clinical Psychology, 66, 681–697.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Authors and Affiliations
Andrea Pozza1
· Silvia Casale2 · Davide Dèttore2
* Andrea Pozza
andrea.pozza@unisi.it
1
Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Mario
Bracci 16, 53100 Siena, Italy
2
Department of Health Sciences, University of Florence, Florence, Italy
13