Critical incidents in psychotherapy

The critical-incident technique was used to obtain a list of patient behaviors that create special difficulties for the psychotherapist. The list was prepared by a group of seven clinicians during a series of meetings. Included in the list were such items as: insulting the therapist; coming late to the session; threatening suicide; and offering gifts. The list was given to 21 experienced psychiatrists who were asked to rate both the importance and the frequency of occurrence of each incident in their experience. The critical incidents could be divided into five major categories: threat of harm from the patient; criticism of the therapist or the therapy; occurrence of a major life crisis; attempts by the patient to seek friendship or seduction, and miscellaneous incidents, such as being consistently late. When ratings by the experienced psychiatrists were compared with those of 10 third-year psychiatric residents, it was found that the inexperienced psychiatrists in almost every case rated the incident as less important and more frequent than did the experienced clinicians. In terms of implications, knowledge of critical incidents in psychotherapy may provide a source of material for training purposes, may enable the development of modeling procedures for training in communication skills, and may encourage supervisors to focus attention on important therapeutic issues.