Therapist Patient Relationships

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Sullivan was the first personality theorist to recognize the potential therapeutic value of the relationship between therapist and patient. He and his followers have argued that what the therapist says and does may play an important role in the patient's well-

Chapter 8 Sullivan: Interpersonal Theory 235

being and progress and that the purpose of therapy is to create a new relationship hi which the patient internalizes positive rather than negative aspects of the therapist/patient relationship.

Hans Strupp, William Henry, and colleagues have used Lorna Smith Benjamin s (1974, 1996) Structural Analysis of Social Behavior (SASB) to see how interpersonal dynamics between patient and therapist affect the success of therapy. The SASB looks at interpersonal behavior from tlnee perspectives: (1) Focus on the Other, or a person's typical behavior while relating to another person; (2) Focus on the Self, or a person's typical reactions to another person's behavior; and (3) Intro-jection, or tinning inward and reflecting on how one has been treated by significant others. The SASB allows researchers to study interpersonal relations moment by moment and to see what the therapist actually does to foster or hnpede therapeutic progress.

In an early study, William Henry, Thomas Schacht, and Hans Strupp (1990) used the SASB to hypothesize that patients would develop views of themselves that were consistent with how the therapist viewed them. In general, Henry et al. found that patients developed relatively stable behaviors that were consistent with the way their therapist treated them. More specifically, these researchers found that therapists' hostile and controlling statements were highly correlated with patients' self-derogatory statements. Also, patients whose therapists belittled, blamed, ignored, or neglected them tended to blame themselves and to show poor therapeutic outcome.

Later, Strupp, Henry, and their associates (Harrist, Quhitana, Strupp, & Henry, 1994) used the SASB to demonstrate the positive effect of therapists' behavior on patient's self-perceptions and on then therapeutic outcome. When therapists hi this study used affirming, helping, and nurturing techniques, patients tended to be more disclosing, expressive, and trusting as well as more self-accepting and self-nourishing. Further, by internalizing the more positive aspects of the relationship, patients showed less depression and anxiety and greater overall improvement in psychosocial functioning.

Later, Russell Hilliard, William Henry, and Hans Strupp (2000) examined the early developmental history of both the therapist and the patient to study therapeutic processes and outcomes. This study, which was part of the Vanderbilt Psychotherapy Research Project, examined the effects of therapists' training on the effectiveness of thne-lhnited dynamic psychotherapy. Patients were adults, mostly European Americans, responding to notices hi the media requesting volunteers. Therapists were eight licensed, experienced, psychodynamic-oriented clinical psychologists and eight psychiatrists in private practice. As hypothesized, Hilliard et al. found that early childhood experiences of patients and therapists contributed to therapeutic outcome. More interestingly, however, was the finding that therapists' developmental history was a more powerful contributor to outcome than was their expensive and extensive training. The implications of this finding are monumental— graduate schools and other institutions that tram psychotherapists could do a more effective job of selecting applicants if they considered those applicants' developmental history. This finding may also be linked to Sullivan's childhood experience with a schizophrenic mother and his later phenomenal ability to successfully treat schizophrenic patients. Nevertheless, developmental history alone was not sufficient to account for all the links Hilliard et al. found between the process of therapy and therapeutic outcomes. These authors suggested that a combination of therapists' and patients' interpersonal histories and current interpersonal relationships may offer the most reliable predictor of therapy outcomes.

Most recently, a study by Kelly Schloredt and Julia Heiman (2003) used the SASB to investigate the relationship between sexual abuse as a child, self-concept, and adult sexual behavior and satisfaction. They hypothesized that a victim of childhood sexual abuse has the problem of "reconciling her abuse with her sense of sexuality and integrating what the experience taught her about how others treat her body" (p. 276).

Schloredt and Heiman divided their participants mto tlnee groups—those who had experienced childhood sexual abuse only (CA), those who had experienced both sexual and physical abuse (SPA), and those who had experienced no abuse (NA). Based on the Sullivanian notion of introjection, they predicted that women who experienced both sexual and physical abuse, compared with those hi each of the other two groups, would be highest hi sexual dysfunction, sexual risk-taking, and viewing then sexuality hostilely than the CSA and NA groups. On these dimensions, the CSA group was predicted to be in middle between the SPA and NA groups.

Participants in the study were 148 women recruited from the community. All completed a modified version of the SASB that asked them to rate their sexuality for two different contexts, once at its best and once at its worst. Second, they rated their sexual functioning over the past year by answering questions concerning number of partners, contraception use, safe-sex practices as well as masturbation, sexual arousal, frequency of orgasm, and pahi. Finally, participants completed general measures of depression and anxiety.

Because abuse victims were higher on depression and anxiety than the nonabuse group, these two variables were held constant in the analyses. Results supported the basic predictions: The sexual-physical abuse group was highest on negative affect (fear, anger, and disgust) during sexual arousal, with the sexual abuse group behig next, and the nonabused group behig lowest in negative feelings. When reporting sexuality at its worst, the two abuse groups reported less friendliness and more hostility hi their sexual experiences. Sexual risk-taking also distinguished the groups, mostly on the number of sexual partners, with abuse groups reporting an average of 21 lifetime partners and the nonabuse groups reporting an average of 8. However, Schloredt and Heiman found no differences between the tlnee groups on general sexual interest, sexual arousal, or sexual fear.

This empirical approach is similar to Sullivan's theoretical notions that adult self-concept is at least in part formed by childhood sexual abuse.

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