The self-critical patient in clinical supervision: a qualitative study of therapists’ alliance struggles and emotional reactions in short-term psychodynamic psychotherapy for depression

ABSTRACT Self-critical perfectionism has been linked to alliance impairments due to patients’ distancing attitudes. However, systematic research on therapists’ emotional experiencing when working with self-critical patients is scarce. This qualitative study explores how therapists perceive, emotionally experience, and react to self-critical patients’ interpersonal dynamics. We studied narrative data from clinical supervisions where psychodynamic psychotherapists discussed self-critical patients (N = 7) within the context of an RCT on Major Depressive Disorder. Consensual Qualitative Research was applied to identify recurrent patterns in the data. As a global impediment to treatment, therapists observed a pattern of non-engagement. Patients’ superficial and avoidant way of communicating, hostility or aggressiveness in the alliance, and low or inaccurate treatment expectations emerged as main obstacles to the therapeutic process, evoking negative affect in therapists. More vulnerable aspects of the patient and case formulation emerged as having a mitigating effect on unfavorable therapist reactions. Our findings confirm longstanding clinical and theoretical accounts associating therapeutic work with self-critical patients with negative affect in therapists. Our study suggests that negative responses may be enacted in therapy which can reinforce poor alliance. We discuss the role of supervision in helping therapists to become aware of and manage negative responses, engage in case conceptualization, and advance clinical work.