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PRACTICE TOOLBOX: ADOLESCENT INTERVENTION
When working with adolescents, developmental consideration should always be at the forefront. Teens are dealing with the formation of self and identity. They are also experiencing biological changes that can shift moods and, at times, cause emotional outbursts.
Interventions for this group can be challenging, as adolescents might avoid asking for assistance in favor of “fitting in.” In turn, they might seek out other, riskier ways of coping, such as alcohol or substance use. Social work interventions focusing on adolescents help them navigate this stage of life and gain healthy coping skills.
In this Assignment, you survey interventions that might be appropriate for adolescents and select one to add to your Practice Toolbox.
Access the Clinical Social Work Interventions link in the Learning Resources.
On that site, explore three different interventions for use with adolescents. Select one that you can see yourself using in practice with adolescent clients. Do not use an intervention that you have chosen previously.
Consider why you have chosen this intervention and its strengths and limitations.
Submit a 1 full page paper analyzing the adolescent intervention you have chosen:
Why did you select the intervention?
Why might it be especially helpful for use with adolescents?
What challenges or limitations might there be for this intervention?
Use the Learning Resources to support your Assignment. Make sure to provide APA citations and a reference list.
Clinical Social Work Interventions (waldenu.edu)
Requirements: 1 Full Page Times New Roman Size 12 Font Double-Spaced APA Format Excluding the Title and Reference Pages
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JOURNAL OF PERSONALITY ASSESSMENT
2020, VOL. 102, NO. 5, 616–627
https://doi.org/10.1080/00223891.2019.1674318
Clinician Reactions When Working with Adolescent Patients: The Therapist
Response Questionnaire for Adolescents
Annalisa Tanzilli1
, Ivan Gualco2
, Roberto Baiocco3
, and Vittorio Lingiardi1
1
Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy;
Psicoterapy, Center for Individual and Couple Therapy, Genoa, Italy; 3Department of Developmental and Social Psychology, Faculty of
Medicine and Psychology, Sapienza University of Rome, Rome, Italy
2
ABSTRACT
ARTICLE HISTORY
This study examined the factor structure and psychometric properties of the Therapist Response
Questionnaire for Adolescents (TRQ-A), an 86-item clinician-report instrument measuring a wide
range of thoughts, feelings, and behaviors expressed by therapists toward their adolescent
patients. A sample of psychodynamic and cognitive-behavioral clinicians (N ¼ 192) filled in the
TRQ-A and the latest version of the Shedler-Westen Assessment Procedure for Adolescents (SWAPII-A) in order to assess the personality styles/disorders of a randomly selected adolescent patient
in their care. Factor analysis identified six conceptually coherent and internally consistent countertransference patterns: warm/attuned, angry/criticized, disorganized/frightened, overinvolved/worried, disengaged/hopeless, and sexualized. These patterns were significantly related to patients’
personality styles/disorders in a clinically meaningful and systematically predictable manner. The
results support the TRQ-A’s validity and internal reliability in evaluating the complex portrait of
multifaceted reactions that clinicians typically experience toward adolescent patients, and its
potential to improve diagnostic accuracy and guide clinicians in planning effective therapeutic
interventions. The TRQ-A promises to significantly contribute to this less explored research area
and encourage systematic studies of youth treatment, promoting best practice for successful
therapeutic outcomes.
Received 5 January 2019
Accepted 28 July 2019
Introduction
Countertransference—or, in this context, therapists’
responses or reactions to their patients—is a critical dimension of the therapeutic relationship related to psychotherapy
outcome, independent of the type of treatment administered
(Norcross & Lambert, 2018). Over recent years, it has
become increasingly clear to clinicians of diverse theoretical
persuasions that recognizing and working through their
complex reactions to patients may lead them to generate
more accurate and clinically meaningful case formulations,
as well as individualized and effective therapeutic
interventions (Bateman & Fonagy, 2006; Beck, Davis, &
Freeman, 2004; Gabbard, 2009; Lingiardi, McWilliams,
Bornstein, Gazzillo, & Gordon, 2015; Yeomans, Clarkin, &
Kernberg, 2015).
Historically, countertransference has its roots in Freudian
psychoanalysis. The classical and overly narrow conceptualization of this phenomenon as a manifestation of unresolved
conflict within the analyst and an obstacle to the therapeutic
process (Freud, 1910, 1912) predominated psychoanalytic
thought and practice until the 1950s. Gradually, it broadened to encompass all feelings, thoughts, and behaviors
experienced by clinicians toward patients in therapy
(Heimann, 1950). Consistent with this totalistic approach
(see Kernberg, 1965), countertransference became a precious
therapeutic tool, providing insight into patients’ dysfunctional interpersonal and intrapsychic dynamics in their significant relationships. Along with this view, a
complementary conception was developed, which claimed
that countertransference reactions essentially represent a
complement to the patient’s style of relating (Racker, 1957).
More recently, some perspectives on transference–countertransference configurations from intersubjective and relational psychoanalysis have emphasized the reciprocal
interactions between patients and therapists, supporting the
assumption that meaning and insight are co-constructed
within the therapeutic relationship (Gabbard, 2001; cfr.,
Eagle, 2000). In an effort to integrate these heterogeneous
positions, some authors have proposed a definition of countertransference that is classically linked to unresolved conflicts in the therapist but also refers to the interplay between
the therapist and peculiar aspects of the patient and his/her
functioning (e.g. Gelso & Hayes, 2007). Moreover, like the
totalistic view, countertransference is understood as a ubiquitous and potentially useful phenomenon for practitioners
of various backgrounds and experiences, in all therapeutic
CONTACT Annalisa Tanzilli
[email protected]
Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza
University of Rome, via dei Marsi 78, 00185 Rome, Italy.
Supplemental data for this article is available online at on the publisher’s website http:10.1080/00223891.2019.1674318.
ß 2019 Taylor & Francis Group, LLC
CLINICIAN REACTIONS WHEN WORKING WITH ADOLESCENT PATIENTS
situations and settings. If appropriately explored and managed, it is considered not a hindrance to the patient’s treatment, but a precious resource for improving clinical work
across a wide array of treatments, reducing ineffective or
detrimental interventions, and bridging impasses in the psychotherapy process (Hayes, Gelso, Goldberg, & Kivlighan,
2018). In this study, we focused on the self-reported
responses of therapists toward their patients in the context
of adolescent psychotherapy in a predominantly totalistic
perspective.
While the corpus of knowledge and clinical observations
of countertransference dynamics with adolescent patients is
rich, the empirical literature is far more limited. According
to the clinical contributions in youth psychotherapy, adolescents tend to evoke reactions in their therapists that are
unique in terms of their affective quality and intensity and
their difficulty to manage (e.g. Brandell, 1992; Tsiantis,
Sandler, Anastasopoulos, & Martindale, 1996). Overall, these
reactions may vary on the basis of: (a) the adolescent
patient’s psychological functioning and emerging personality
patterns (Malone & Malberg, 2017); (b) the adolescent’s
developmental stage, which may provoke personal conflicts
in clinicians related to their own adolescent experiences
(Anastasopoulos & Tsiantis, 1996; Brandell, 1992); (c) the
patient’s parents (and related family dynamics) who are
directly involved in the treatment process, requiring therapists to experience and deal with multiple and emotionally
charged countertransference configurations (Tsiantis et al.,
1996); and (d) the therapists’ own characteristics (e.g. Gelso
& Hayes, 2007; Tsiantis et al., 1996).
On the empirical side, research has paid little attention to
clinicians’ responses to adolescents in treatment. One issue
that has hindered the development of systematic investigations in this field is the paucity of measures and assessment
procedures capable of evaluating this complex and multifaceted construct in adolescent psychotherapy. Overall, only a
few studies have tried to examine this important topic taking into account the specific features of therapists’ subjective
experiences toward young patients (e.g. Knaus et al., 2016;
Satir, Thompson-Brenner, Boisseau, & Crisafulli, 2009;
Ulberg et al., 2013). Satir et al. (2009) asked 120 clinicians
of different theoretical orientations to evaluate their emotional reactions to female young patients with an eating disorder (ED) using the Therapist Response Questionnaire
(Countertransference) for Adolescents (TRQ-A). The clinicians also filled out the Shedler-Westen Assessment
Procedure for Adolescents (SWAP-200-A; Westen, Shedler,
Durrett, Glass, & Martens, 2003), in order to identify specific personality subtypes in ED patients. The TRQ-A is the
adolescent version of the Therapist Response Questionnaire
for adults (TRQ; Betan, Heim, Zittel Conklin, & Westen,
2005), which is a 79-item clinician-report questionnaire
designed to capture common countertransference patterns in
clinical practice. Betan et al. (2005) developed the TRQ to
evaluate a wide range of thoughts, feelings, and behaviors
expressed by therapists toward their adult patients, and
identified eight countertransference dimensions: (a) overwhelmed/disorganized, (b) helpless/inadequate, (c) positive,
617
(d) special/overinvolved, (e) sexualized, (f) disengaged,
(g) parental/protective, and (h) criticized/mistreated. They
showed significant relationships between the Diagnostic and
Statistical Manual of Mental Disorders (4th ed. [DSM–IV];
American Psychiatric Association, 1994) Cluster A and the
criticized/mistreated pattern; Cluster B and overwhelmed/
disorganized feelings, helplessness, hostility, disengagement,
and sexual attraction; and Cluster C and nurturing and
warm feelings, regardless of therapists’ orientations.
Replicating this study in a new and larger sample, Tanzilli
et al. (2016) found similar results, with the exception that
the original criticized/mistreated pattern was split into hostile/angry and criticized/devaluated factors. These countertransference dimensions were significantly related to distinct
patient personality disorders and traits (e.g. Gazzillo et al.,
2015; Tanzilli, Muzi, Ronningstam, & Lingiardi, 2017;
Tanzilli, Lingiardi, & Hilsenroth, 2018).
The TRQ-A is an 86-item measure that is very useful in
the context of psychotherapy with young patients (Satir
et al., 2009). The measure retains all of the original 79 items
of the TRQ and includes additional items. The new statements were formulated from a review of the general psychotherapy and psychoanalytic literature on adolescent
treatment and countertransference reactions (e.g. Tsiantis
et al., 1996). They describe specific experiences that clinicians may have when working with adolescent patients, and
refer to three specific domains: identification with childhood
experiences, identification with parental figures, and reactions to specific family members. The TRQ-A factor structure consists of six countertransference dimensions that
significantly differ from those originally identified by Betan
et al. (2005) on the TRQ: (a) angry/frustrated, (b) warm/
competent, (c) aggressive/sexual, (d) failing/incompetent, (e)
bored/angry at parents, and (f) overinvested/worried. These
distinct patterns of therapist reactions significantly and consistently related to four diagnostically valid personality prototypes––high-functioning/perfectionistic,
dysregulated,
depressed/inadequate, and constricted/obsessional––derived
by Satir et al. (2009) from the sample of young ED patients.
Personality pathology styles reflecting dysregulation and
constriction were associated with intense feelings of anger
and frustration and a weaker sense of warmth, nurturance,
and competence in therapists. Moreover, specific therapist
reactions demonstrated meaningful relationships with the
severity of ED symptoms, some clinician variables (e.g. gender and profession, but not degree of clinical experience),
and treatment length and improvement.
In another study, Knaus et al. (2016) used the TRQ
(Betan et al., 2005) to identify the main differences in the
emotional reactions of psychiatrists seeking two patient
groups composed of 19 adolescents with Cluster B personality disorders and 11 adolescents with anorexia nervosa,
respectively. The authors asked an external rater to examine
with the TRQ 30 videotaped clinician–patient sessions. The
findings showed that patients with Cluster B disorders
tended to elicit more pervasive and negative feelings of hostility, inadequacy, disorganization, and disengagement than
anorexic patients. Moreover, Ulberg and colleagues (Ulberg
618
TANZILLI ET AL.
et al., 2013) explored the countertransference of 41 clinicians
to their adolescent patients (N ¼ 410) using the Feeling
Word Checklist–24 (FWC–24; Holmqvist, Hill, & Lang,
2007), which is a questionnaire that is typically used to capture therapists’ self-reported feelings in adult psychotherapy.
The results demonstrated that confident countertransference
was positively associated with clinician’s age, more practical
experience, and more clinical supervision, as well as a higher
quality therapeutic alliance; in contrast, inadequate and disengaged dimensions showed strong relationships with a
lower quality therapeutic alliance.
In the present empirical investigation, we focused on the
TRQ-A of Satir et al. (2009). Preliminary data on the psychometric properties of this measure are very promising;
however, the high specificity of Satir et al.’s (2009) adolescent sample with EDs represents an important challenge to
the generalizability of the results. Research has highlighted
that, when treating ED patients, clinicians report specific
configurations of emotional responses, including intense
feelings of ineffectiveness and incompetence, frustration,
anger, and lack of connection with patients (e.g. ThompsonBrenner, Satir, Franko, & Herzog, 2012). The countertransference dimensions identified in Satir et al.’s (2009) study
seem to reflect specific characteristics of ED patients: (a)
personality pathology that are frequently comorbid with
EDs––most commonly DSM-IV Cluster B disorders (e.g.
borderline and histrionic personality disorders) in patients
with bulimia nervosa and Cluster C disorders (e.g. avoidant
and obsessive-compulsive personality disorders) in patients
with anorexia nervosa (e.g. Thompson-Brenner, Eddy, Satir,
Boisseau, & Westen, 2007)–– and (b) severe symptoms that
may involve medical complications and urgent hospitalization, with poor prognosis and little improvement in treatment (e.g. Gabbard, 2009; Mitchell & Crow, 2006).
To date, no research has taken an analytic approach to
exploring the TRQ-A factor structure, providing evidence
for its latent dimensions on diverse therapist–patient populations; moreover, no research has investigated the validity
and internal reliability of its scales. Our study sought to
both reexamine and extend Satir et al.’s (2009) findings, also
by examining the differential emotional responses of clinicians to adolescent patients with a broad range of personality styles/disorders. Specifically, research aimed at
investigating the following hypotheses:
Hypothesis 1: The TRQ-A factor structure would reflect a wide
and multifaceted spectrum of countertransference reactions
experienced by clinicians toward adolescent patients (without a
specific clinical diagnosis); moreover, the reliability of its scales
would be high, showing excellent levels of internal consistency.
Hypothesis 2: Therapists’ emotional reactions would differ
according to certain clinician variables (e.g. gender, theoretical
orientation, and clinical experience). Some studies in the
empirical literature cited above examined the impact of
therapists’ characteristics on countertransference reactions, but
the research findings are controversial (e.g. Satir et al., 2009;
Ulberg et al., 2013). It remains unclear whether—and to what
extent—these variables influence clinicians’ reactions in
adolescent
psychotherapy.
We
hypothesized
that
countertransference responses to young patients would not
relate to clinician gender and theoretical orientation, but to
clinical experience, as more experienced mental health
professionals would have less strong and negative
countertransference reactions.
Hypothesis 3: The TRQ-A would demonstrate good convergent
validity. Its scales would be able to measure—in a
psychometrically sound and clinically relevant way—specific
countertransference responses associated with distinct
personality disorders in a sufficiently large sample of adolescent
patients. Overall, consistent with the research cited above (e.g.
Knaus et al., 2016) and other empirical investigations of the
TRQ in adult psychotherapy (e.g. Betan et al., 2005; Colli,
Tanzilli, Dimaggio, & Lingiardi, 2014), we conducted an
exploratory analysis to investigate whether there were significant
and systematically predictable associations of moderate
magnitude (Cohen, 1988) between: (a) paranoid, schizoid, and
schizotypal personality disorders and a warm/competent
countertransference pattern (negative direction); (b) antisocial,
borderline, histrionic, and narcissistic personality disorders and
angry/frustrated, aggressive/sexual, and failing/incompetent
countertransference patterns; (c) avoidant and dependent
personality
disorders
and
overinvested/worried
countertransference pattern, and obsessive personality disorder
and bored/angry at parents pattern.
Hypothesis 4: Overall, adolescent patients with lower levels of
personality functioning would elicit clinician emotional
responses characterized by a sense of impotence and frustration,
and greater difficulty establishing an emotional connection and
good collaboration in clinical work.
Method
Participant sampling
A national sample of psychodynamic and cognitive-behavioral therapists were recruited from the rosters of the largest
Italian associations of psychotherapy, some institutions of
the National Health System, and centers that specialized in
treating personality disorders. Therapists had at least 3 years
of post-psychotherapy licensure experience and 10 hours per
week of direct patient care. They were directed to select an
adolescent patient in their care according to the following
criteria: (a) aged between 13 and 18; (b) non-psychotic and
not in treatment with drug therapy for psychotic symptoms;
(c) no mental retardation; (d) been in therapy for a minimum of 8 sessions and a maximum of 10 months; and (e)
agreed to participate in a research protocol on psychological
assessment. To minimize selection bias, clinicians were
asked to consult their calendar to identify the last patient
they saw during the previous week who met the study criteria. In order to avoid therapist effects (i.e. confounded issues
of countertransference in the event that several patients
were nested within a single therapist), we asked each clinician to furnish data on only one patient. Our response rate
was 32%. All clinicians provided written informed consent
and were instructed to withhold any identifying information
about their patient. They received no remuneration. The
study was approved by the research ethics committee of the
Department of Dynamic and Clinical Psychology, Faculty of
Medicine and Psychology, Sapienza University of Rome
(protocol number: 14/2017; date of approval: 04/12/2017).
CLINICIAN REACTIONS WHEN WORKING WITH ADOLESCENT PATIENTS
Therapists
The therapist sample consisted of 192 Caucasian individuals,
of whom 121 were females; 143 were psychologists and 49
were psychiatrists. The mean age was approximately 45 years
(SD ¼ 7.9, range ¼ 31–66). Two main clinical-theoretical
approaches were represented: psychodynamic (n ¼ 119) and
cognitive-behavioral (n ¼ 73). The average length of clinical
experience as a therapist was 12.7 years (SD ¼ 7.8, range ¼
3–34). With respect to their patients, 135 were from private
practice and the remaining 57 were from public mental
health institutions.
Patients
The patient sample consisted of 192 Caucasian individuals,
of whom 127 were female. The mean age was 16 years
(SD ¼ 1.5, range ¼ 13–18). Among the patients with DSM-5
(APA, 2013) diagnoses (both independent and comorbid
with a personality disorder), 29 had a persistent depressive
disorder (dysthymia), 20 had a generalized anxiety disorder,
19 had a panic disorder, 19 had a feeding and eating disorder, 5 had an attention-deficit/hyperactivity disorder, 4
had a conduct disorder, 4 had a substance-related and
addictive disorder, and 3 had oppositional defiant disorder.
Among the patients with personality pathology (both independent and comorbid with a longer-held DSM-5[APA,
2013] diagnosis), 14 had a Cluster A personality disorder
diagnosis, 31 had a Cluster B personality disorder diagnosis,
and 47 had a Cluster C personality disorder diagnosis.
Finally, among the patients with two or more personality
disorders, 19 had comorbidity within the same cluster and
10 had comorbidity between clusters. The prevalence rates
of personality disorders were: 5.95% paranoid, 7.74% schizoid, 2.38% schizotypal, 7.14% antisocial, 8.93% borderline,
8.93% histrionic, 11.90% narcissistic, 14.29% avoidant,
16.67% dependent, and 16.67% obsessive-compulsive. The
average length of treatment was 6 months (SD ¼ 2.7; range
¼ 2–10).
Measures
Clinical questionnaire
We constructed a questionnaire to collect general information about the clinicians, their adolescent patient, and their
therapy. Clinicians provided their basic demographic data,
including their profession (psychiatrist or psychologist), theoretical orientation and training, and years of experience.
Moreover, they provided their patient’s demographic data
and DSM-5 diagnosis assigned at intake (selecting the disorder/s from a list of diagnoses), as well as data on the
patient’s therapy, including length of treatment.
Shedler-Westen assessment procedure for adolescents,
version II
The SWAP-II-A—the most recent version of the SWAP for
adolescents (Westen et al., 2003)—is a 200-item personality
and personality pathology Q-sort measure designed for use
619
by clinicians or clinically experienced observers (DeFife,
Malone, DiLallo, & Westen, 2013; Shedler, Westen, &
Lingiardi, 2014; Westen, DeFife, Malone, & DiLallo, 2014).
To describe a patient using the SWAP, the clinician or
observer sorts the 200 personality statements into eight categories based on their applicability to the patient, from 0 (not
descriptive of the person) to 7 (most descriptive), in order to
comply with a fixed distribution. This procedure furnishes:
(a) a personality diagnosis expressed as a matching of the
patient assessment with 10 personality disorder scales, which
are clinical prototypes of DSM-IV axis II disorders (PD
scales); and (b) a personality diagnosis based on a matching
of the patient’s SWAP description with a new taxonomy of
personality styles that are empirically derived from Q-factor
analysis (Q-factors). It also includes a dimensional measure
of psychological strengths and adaptive functioning. In this
study, we attended only to the PD scales and the high-functioning index, excluding the Q-factors. The SWAP-II-A
showed considerable evidence of reliability and validity
(DeFife et al., 2013; Westen et al., 2014).
Therapist response questionnaire for adolescents
TRQ-A (Satir et al., 2009) is a measure that identifies distinct countertransference patterns in clinical practice with
adolescent patients from the clinician perspective. Therapists
assess each item on a 7-point Likert scale ranging from 1
(not true) to 7 (very true). The six countertransference
dimensions identified by the TRQ-A factor analysis were:
(a) angry/frustrated, which indicates feelings of rage and
irritation toward the patient (e.g. “I wish I had never taken
him/her on as a patient”; “I feel used or manipulated by
him/her”); (b) warm/competent, which describes an experience of intimate closeness toward the patient and desire to
take care of him/her (e.g. “S/he is one of my favorite
patients”; “I feel nurturing toward him/her”); (c) aggressive/
sexual, which describes the presence of both sexual attraction and hostile feelings (e.g. “I feel sexual tension in the
room”; “I feel envious of, or competitive with him/her”); (d)
failing/incompetent, which indicates feelings of hopelessness
and anxiety, as well as failure to establish a good working
alliance (e.g. “I feel I am failing to help him/her or I worry
that I won’t be able to help him/her”; “I feel like my hands
have been tied or that I have been put in an impossible
bind”); (e) bored/angry at parents, which indicates feelings
of annoyance, boredom in therapy, and rage toward the
adolescent patient’s parents (e.g. “I don’t feeling fully
engaged in sessions with him/her”; “I find myself feeling
frustrated with parents of this patient more than other
patient’s parents”); and (f) overinvested/worried, which
describes feelings of overly strong involvement in the therapeutic relationship (e.g. “I do things for him/her, or go the
extra mile for him/her in ways that I don’t for other
patients”; “I call him/her between sessions more than my
other patients”). These scales showed good internal consistency, with some exceptions (Streiner, 2003): angry/frustrated
(a ¼ .81), warm/competent (a ¼ .88), aggressive/sexual (a
¼ .70), failing/incompetent (a ¼ .86), bored/angry at parents
(a ¼ .65), and overinvested/worried (a ¼ .57). The Italian
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TANZILLI ET AL.
version of the TRQ-A used in the study was translated by
the authors (the first and last authors) and its adequacy was
evaluated through back-translation by a professional translator.
Procedure
After we received clinicians’ agreement to participate, we
asked them to evaluate (using the TRQ-A) their emotional
responses to the adolescent patient selected on the basis of
the criteria reported above. Between 1 and 3 weeks later,
they assessed the same patient’s personality using the
SWAP-II-A. We used this interval because the TRQ-A and
SWAP-II-A require different time commitments. The first
measure is more clinician-friendly; thus, we asked clinicians
to complete it immediately after a session with the designated patient. In contrast, the SWAP-II-A is more time-consuming; thus, we asked clinicians to complete it later.
Moreover, by separating the two evaluations, we aimed at
reducing any possible timing or halo biases (i.e. whereby
clinicians’ ratings of their own emotional responses could
affect their concurrent evaluations of patients’ personalities).
Data analysis
Statistical analyses were performed with SPSS 20 for
Windows (IBM, Armonk, NY). To identify the latent factor
structure of the TRQ-A, we carried out an exploratory factor
analysis (EFA) on the full therapist sample (N ¼ 192).
Consistent with Satir et al.’s (2009) study, we used the principal axis factoring (PAF) extraction method with promax
rotation, which is more appropriate when minor to moderate correlations are expected between variables. When examining complex and multifaceted psychological constructs
(such as countertransference patterns using the TRQ-A), it
is plausible to assume that single dimensions are differentiated yet interdependent (see Fabrigar, Wegener, MacCallum,
& Strahan, 1999).
To determine the number of factors to retain and then
rotate, we considered the following criteria in EFA: Kaiser’s
criteria eigenvalues > 1, the scree plot, the parallel analysis,
the percentage of variance accounted for by the factor solution, and the interpretability of the factor solution. As suggested by B€
uhner (2010), we only included items that loaded
j.45j on one factor and j.30j on all other factors, in
order to maximize the factors’ internal reliability. We ran
bivariate correlations among all TRQ-A unit-weighted scale
scores to obtain the intercorrelations between scales, then
correlated the scale scores of the TRQ-A current version
with the six scales of the original version. Following this, we
calculated Cronbach’s alpha coefficients to measure the
internal consistencies of the TRQ-A scales. Moreover, to
evaluate the relationships of clinician (gender, theoretical
orientation, and years of experience) variables with the
TRQ-A unit-weighted scale scores, we conducted independent sample t tests and bivariate correlations (r, two-tailed).
To assess the convergent validity and clinical applicability
of the TRQ-A, we performed partial correlations (partial r,
two-tailed) between the new TRQ-A unit-weighted scale
scores and each personality disorder scale of the SWAP-IIA, controlling for the effects of the other nine personality
disorders in all analyses. Finally, we performed bivariate correlations between the unit-weighted scale scores of the TRQA current version and the SWAP-II-A high-functioning scale.
Results
Factor structure and internal reliability of the TRQ-A
The exploratory factor analysis (EFA) was conducted on the
data provided by 192 clinicians. The Kaiser-Meyer-Olkin
(KMO; Tabachnick & Fidell, 2013) measure of .83 and
Bartlett’s test of sphericity, v2(3655) ¼ 12405.33, p < .001,
indicated that the sample was sufficient to perform the factor analysis. Principal axis factoring (PAF) extraction with
promax rotation was carried out and six factors were
retained. This factor solution accounting for approximately
48% of the variance represented the most parsimonious and
theoretically grounded factor structure of great clinical utility. It was also confirmed by parallel analysis, because the
eigenvalue of the sixth factor was the last to exceed the
threshold of the 95th percentile of the first eigenvalue of the
randomly generated data (see supplementary materials). All
of the TRQ-A scales were well marked by at least four items,
suggesting that the stability of this solution was unlikely to
be substantially affected by sample size (Fabrigar et al.,
1999). Table 1 shows the factor structure of the TRQ-A current version, displaying items for each of the six countertransference patterns that were similar to those originally
proposed by Betan et al. (2005): (a) warm/attuned, (b)
angry/criticized, (c) disorganized/frightened, (d) overinvolved/worried, (e) disengaged/hopeless, and (f) sexualized.
The warm/attuned factor (11 items) included items indicating close connection, trust, and collaboration with the
patient, resulting from a good working alliance. The angry/
criticized factor (10 items) included items describing feelings
of anger, hostility, and irritation, but also a sense of being
criticized, dismissed, and devaluated by the adolescent
patient. The disorganized/frightened factor (10 items)
included items describing intense feelings of being overwhelmed by the patient’s emotions and needs and a strong
sense of anxiety and dread toward the patient. The overinvolved/worried factor (7 items) included items indicating
excessive engagement in the therapeutic relationship, such as
difficulty maintaining the boundaries of the setting and critical feelings toward the adolescent patient’s parents. The disengaged/hopeless factor (7 items) included items describing
a failure to establish an effective therapeutic relationship; a
strong sense of frustration, inadequacy, and impotence; feelings of boredom; and withdrawal. The sexualized factor (4
items) included items describing sexual attraction toward
the patient.
These six dimensions were not very similar to those proposed by Satir et al. (2009). The main differences between
the TRQ-A current and original versions in the factor composition of all scales were as follows: (a) items of the
CLINICIAN REACTIONS WHEN WORKING WITH ADOLESCENT PATIENTS
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Table 1. Factor structure of the therapist response questionnaire for adolescents (TRQ-A) current versiona.
k
Factors and items
b
Factor 1: Warm/attuned
I have warm, almost parental feelings toward him/her (71)
I like him/her very much (72)
If s/he were not my patient, I could imagine being friends with him/her (8)
I am very hopeful about the gains s/he is making or will likely make
in treatment (1)
S/he makes me feel good about myself (26)
I feel pleased or satisfied after sessions with him/her (59)
S/he is one of my favorite patients (81)
I look forward to sessions with him/her (22)
I feel nurturing toward him/her (53)
I feel like I understand him/her (46)
I wish I had never taken him/her on as a patient (6)
Factor 2: Angry/criticized
I lose my temper with him/her (54)
I get enraged at him/her (32)
I tell him/her I’m angry at him/her (47)
I feel used or manipulated by him/her (39)
I feel criticized by him/her (14)
I feel angry at him/her (18)
I have to stop myself from saying or doing something aggressive or critical (45)
I feel dismissed or devalued (7)
I feel annoyed in sessions with him/her (10)
I don’t trust what s/he’s telling me (13)
Factor 3: Disorganized/frightened
S/he frightens me (41)
I dread sessions with him/her (15)
I feel anxious working with him/her (35)
I feel overwhelmed by his/her strong emotions (31)
I feel I am “walking on eggshells” around him/her, afraid that if I say the
wrong thing s/he will explode, fall apart, or walk out (40)
I feel overwhelmed by his/her needs (57)
When checking my phone messages, I feel anxiety or dread that there will be
one from him/her (67)
S/he tends to stir up strong feelings in me (34)
I have trouble relating to the feelings s/he expresses (51)
I feel confused in sessions with him/her (12)
Factor 4: Overinvolved/worried
I find myself being
