Therapist Challenges and Client Responses in Psychodynamic Psychotherapy: An Empirically Supported Case Study

Clinical Impact Statement Question: How did one defended client respond to different types of challenges delivered by an advanced doctoral student therapist across the course of psychodynamic psychotherapy? Findings: Challenges that were deep, clear, empathic, moderately helpful, used when there was a strong therapeutic relationship and the client was somewhat reflective were associated with the client becoming more open and reflective. Meaning: Therapists should attend to the therapeutic relationship and client level of defensiveness when deciding whether to use challenges, monitor the type and manner in which they deliver challenges, and observe client reactions to challenges. Next Steps: This qualitative method can be used to study challenges in other cases with different types of therapists and clients. In this case study of an adult female client working with a doctoral student female therapist in 85 sessions of individual psychodynamic psychotherapy, we analyzed the antecedents, challenges, and consequences for 53 challenges in the intake and first five sessions, the middle three sessions, and the final three sessions. Within the context of a strong therapeutic relationship and when the client was balanced in being defended as well as open/reflective, the therapist's challenges that were of high quality (deep, clear, empathic, and moderately forceful) were associated with the client becoming more open/reflective. In contrast, when the client was defended (but not open/reflective), the therapist's challenges were of lower quality and were associated with the client becoming more defended and closed off. Thus, both the antecedent client state and the quality of the therapist challenges were associated with the consequences of challenges in terms of the client's response.