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. Author manuscript; available in PMC: 2025 Jul 9.
Published in final edited form as: Psychol Trauma. 2025 Jan 9;17(6):1175–1182. doi: 10.1037/tra0001834

My Playbook: Psychotherapy Role Expectations, Relational Trauma, and Trauma-Spectrum Mental Dysfunctions in Community Mental Health Service Users in Hong Kong

Chui-De Chiu 1,2, Josephine Sheron Au 3,4, Nerissa Hoi Yan Pau 5, Harris Chi Wai Chung 1, Lois W Choi-Kain 2,6
PMCID: PMC12238290  NIHMSID: NIHMS2049726  PMID: 39786855

Abstract

Objective:

Clients with relational trauma often face challenges in forming a therapeutic alliance, a primary predictor of psychotherapy outcomes. Unresolved traumatic stress can lead to a passive stance in therapy, manifested as a tendency to seek advice and approval from therapists in order to establish more predictable relational dynamics. This comes at the cost of adequately addressing their own therapeutic needs, which often leads to stagnation, treatment dropout, and frustration with the therapist. We postulated that neither relational nor nonrelational traumas could fully account for passive and maladaptive therapy role expectations, such as advice- and approval-seeking. Instead, we hypothesized that lingering effects of trauma, evident in trauma-related pathologies like dissociation, somatization, and borderline personality disorder, contribute more significantly to the tendency to adopt a passive interpersonal stance that can impede therapeutic progress.

Method:

Using a sample of 259 community mental health service users, we examined the link between histories of relational trauma (both in childhood and adulthood), trauma-related pathologies, and role expectations in the psychotherapeutic interaction.

Results:

Bivariate correlations revealed that history of relational trauma correlated with relationship-seeking expectation—an active way of approaching therapy. However, trauma-related pathologies were invariably related to maladaptive and passive role expectations. In subsequent hierarchical regressions, when multiple factors were entered into the model, dissociation emerged as the key factor that explains maladaptive role expectations.

Conclusions:

These findings suggest the importance of establishing clear role expectations and ensuring alignment with clients at the outset of therapy, particularly when indications of trauma-related pathologies are present.

Keywords: borderline personality disorder, child abuse, dissociation, somatization, therapeutic relationship

Therapeutic alliance—the agreement on treatment goals and the tasks needed to achieve them, along with the emotional bond between a client and therapist—is a robust predictor of positive psychotherapy outcome (Zilcha-Mano & Fisher, 2022). While some clients come with psychosocial capacities facilitative to the establishment of therapeutic alliance, others come with difficulties that destabilize the therapeutic relationship. Clients who experience trauma can develop a variety of mental dysfunctions, including dissociation and borderline personality disorder (BPD), and present challenges in clinical settings due to difficulties in trusting others and interpersonal hypersensitivity (Chu, 2011; Gunderson & Lyons-Ruth, 2008). In addition to experiencing anxiety of being abandoned by and negative transference toward therapists, they are more likely to exhibit behaviors that challenge the structure and stability of therapy, such as no-showing, shutting down, avoiding and denying difficult emotions, and dropping out. In such cases, therapists’ recognition of their expectations toward psychotherapy is vital to prevent therapeutic relationship rupture and enhance therapeutic alliance (Al-Darmaki & Kivlighan, 1993; Aubuchon-Endsley et al., 2014).

Psychological trauma, particularly incidents in early developmental stages, threatens one’s physical or mental integrity, creating stress that surpasses their capacity to tolerate and effectively cope (Van der Kolk & van der Hart, 1989). Although traumatic stress can arise from various incidents, such as natural disasters and violence that involve an unfamiliar individual, relational trauma inflicted by people close to the victim is unique such that it occurs repeatedly and often involves trusted individuals to whom the victim is affectively attached (Terr, 1991). In addition to fear, childhood relational trauma causes complex emotions, including betrayal and shame (Freyd, 1994), thus hindering the individual’s socioemotional development and mental well-being.

While some individuals are resilient against traumatic experiences, others can have mental dysfunctions and exhibit difficulties in relationships. For instance, individuals with a high tendency to dissociate, a feature commonly observed among those with a history of childhood relational trauma (Chiu, Li, et al., 2024), are prone to misreading other’s emotions (Chiu, Paesen, et al., 2016; Pick et al., 2016) and showing a schematic association of being rejected (Chiu et al., 2022). Similarly, people with BPD, which often finds root in early relational trauma (Luyten et al., 2020), are less able to feel other people’s emotions (Dziobek et al., 2011; Niedtfeld, 2017) and tend to feel worse after receiving negative social feedback (van Schie et al., 2020). In conflict situations, BPD features in females have been found to be related to perception of romantic partners being less responsive, warm, supportive, and caring (Zhang, 2023). As such, clients with unresolved childhood relational trauma may be susceptible to biased social perception within therapeutic relationships.

Client Expectations in Therapy

Clients have various expectations when walking into a clinical session, from the activities they may engage in, to whether they could successfully make a change, to what they should do with their therapists. A study found that those who have higher-than-normal expectations for therapy run a risk of premature termination (Aubuchon-Endsley & Callahan, 2009). As congruence in therapeutic expectancy between client and therapist is related to affective bond and task agreement (Al-Darmaki & Kivlighan, 1993), clarifying therapeutic expectations with clients who have a history of relational trauma, and thus possible biases in social perception, is critical.

How clients expect to enact the role within a therapeutic relationship, hereon referred to as role expectancy (Rickers-Ovsiankina et al., 1971), largely falls into four categories: relationship-, audience-, advice-, and approval-seeking (Bleyen et al., 2001). On the one hand, the first two patterns, relationship- and audience-seeking, are expectations of being cooperative and being helped to help oneself. These expectations are agentic and prosocial in nature, as both turn toward the self and others. Accordingly, relationship-seeking correlated with perceived working alliance (Al-Darmaki & Kivlighan, 1993), and increased relationship- and audience-seeking predicted successful outcomes (Tracey & Dundon, 1988). On the other hand, advice- and approval-seeking are expectations of being criticized or being taken care of by the therapist. These expectations reflect dependency on the therapist and have been shown to be related to premature treatment dropout and worse treatment outcomes (Aubuchon-Endsley et al., 2014). Relatedly, individuals who have traumatic experiences, particularly those experiencing mental dysfunction, may have less agency in relationships, which may manifest in tendencies to seek advice and approval in therapeutic relationships.

Childhood relational trauma has significant psychopathogenic potential, but there remains a question of whether it is sufficient to induce biased social perception that undermines learning from psychotherapy. Contrary to popular belief, narratives of childhood relational trauma are not more incoherent than those of nontraumatic childhood stressful experiences (Fishere & Habermas, 2023). This coherence in autobiographical knowledge including traumatic memories is essential for positive social interactions, as our perception of others’ emotion is influenced by how we process self-related information in social contexts (Chiu et al., 2020; Chiu, Lo, et al., 2024). However, dispositional factors such as information processing patterns can affect such coherence. For instance, individuals with dissociation can disengage attention from unwanted materials (Chiu, 2018) and struggle with organizing emotion-charged autobiographical memories and constructing a coherent self-image (Chiu et al., 2012, 2019; Chiu, Tseng, et al., 2016). Therefore, susceptibility to therapeutic relationship rupture among clinical clients with childhood relational trauma may stem from biases in information processes that correspond with related pathologies.

The Present Study

Despite the plethora of case reports and treatment protocols highlighting the difficulties in establishing therapeutic alliance with individuals who have a history of childhood relational trauma, few studies have attempted to distill patients’ own expectations regarding interactions with a therapist. The present study addresses this gap in the literature regarding the relationship between role expectations, a history of psychological trauma, and trauma-spectrum mental dysfunctions.

We recruited a clinical sample from diverse community mental health service users spanning both outpatient and residential settings. Assessments covered their history of traumatic events and trauma-spectrum mental dysfunctions (i.e., dissociation, BPD features, and somatization) as well as role expectations. We bifurcated history of trauma into events that occurred during childhood versus adulthood. More importantly, to distinguish between relational and nonrelational trauma, we categorized traumatic events based on whether they involved close acquaintances. Depression, a nontrauma-centric psychopathology common in clinical populations, was also assessed, as dysregulated negative affect could influence perception of relationships. Our hypothesis was that trauma-spectrum mental dysfunctions, but not history of trauma, would correlate with expectations that threaten the therapeutic alliance, such as tendencies to seek advice and approval from the therapist. We did not hold specific hypotheses for the link of each trauma-spectrum mental dysfunction and role expectation for the lack of studies in the literature.

Method

Participants

The study design was approved by the research ethics review panel at the Faculty of Social Science, the Chinese University of Hong Kong. To include participants with diverse backgrounds, clients from community mental health centers of various districts in Hong Kong were recruited. The community centers varied in their service modes, offering either (a) individual psychological intervention or psychosocial rehabilitation, (b) family therapy, or (c) residential service (hostels or halfway houses).

Inclusion criteria included (a) users of community mental health service, (b) aged between 18 and 50, (c) ability to read Traditional Chinese characters, and (d) ability to complete self-report assessment. Service users diagnosed with neurological disease or at the acute phase of a psychotic disorder were excluded. Eligible clients were invited by their principal case workers (e.g., clinical psychologists, social workers, counselors). Over 80% of case workers (n = 61) participated in the study. All participants completed informed consent before participation.

A total of 259 participants were recruited, with 65% receiving individual psychotherapy, 18% receiving family work, and 17% receiving residential service. Eight dropped out from the study for various reasons (e.g., lengthy survey, concerns over sensitive information, refusal in submitting personal data), leaving 251 for formal analysis. For the final sample, 31% were male, and the mean of age was 42.82 (SD = 13.87). Fifty-four percent had been connected to mental health services for over 5 years (M = 10.26 years, SD = 9.83), while 70% were users of the current service setting for more than a year (M = 3.85 years, SD = 4.62).

Instruments

Role Expectations

The revised version of the Psychotherapy Expectancy Inventory (α = .93) was used (Bleyen et al., 2001). Of promising psychometric properties, the revised version of the Psychotherapy Expectancy Inventory has been widely used in psychotherapy research to investigate how such expectations impact treatment outcome (Aubuchon-Endsley et al., 2014; Tracey & Dundon, 1988) and attrition (Aubuchon-Endsley & Callahan, 2009). The 24 items of the revised version of the Psychotherapy Expectancy Inventory tap onto four types of psychotherapy expectations (Berzins et al., 1971; Rickers-Ovsiankina et al., 1971), ranging from the relatively adaptive ones, that is, relationship- or audience-seeking, to maladaptive ones, that is, advice- and approval-seeking (Bleyen et al., 2001; Coleman & Neimeyer, 2015). Each item is rated on a 7-point scale from 1 (not at all) to 7 (very strongly). The total score of each scale reflects a client’s anticipation of what to do during psychotherapy.

Relational and Nonrelational Trauma

The psychometrically sound Brief Betrayal Trauma Survey (Goldberg & Freyd, 2006), which has demonstrated convergent validity with a structured interview (Chiu et al., 2015; Chiu, Tseng, et al., 2017), was used to measure clients’ trauma experiences in childhood and adulthood. The 12 items cover various potentially traumatizing events ranging from natural disasters and traffic accidents to interpersonal maltreatment. Importantly, for interpersonal maltreatment, the Brief Betrayal Trauma Survey differentiates those that involved close others (e.g., a witness to domestic violence, being attacked by a family member) from those that do not (e.g., being attacked by a stranger or an emotionally nonclose person). On a 3-point scale from 0 (never), 1 (1 or 2 times), to 2 (more than that), participants score how frequent each incident is in childhood and adulthood, respectively. Scores of each scale are summed up, reflecting the frequency of either relational or nonrelational trauma during either childhood or adulthood.

Trauma-Spectrum Mental Dysfunctions and Depression

All the following measures focused on symptoms in the past week. They all have sound psychometric properties. Dissociation was measured by the Dissociative Symptoms Scale (α = .93; Carlson et al., 2018; Chiu et al., 2015). The 21-item Dissociative Symptoms Scale asked about moderately severe and functionally disruptive symptoms of dissociation (i.e., pathological dissociation), including depersonalization/derealization, gaps in awareness and memory, sensory misperceptions, and cognitive and behavioral reexperiencing. The frequency of each symptom is rated on a 5-point scale from 0 (not at all) to 4 (more than 10 times). Somatization was measured by the Somatic Symptoms Scale–8 (α = .87; Gierk et al., 2014). The eight items cover gastrointestinal and cardiopulmonary symptoms, pain, and fatigue. Each is rated on a 5-point scale from 0 (not at all) to 4 (very much). BPD features were measured by the Borderline Symptom List–23 (α = .97; Kleindienst et al., 2020). The 23 items cover instability across affect, relationships, self-image, and cognition. Each item is scored on a 5-point scale from 0 (not at all) to 4 (very strong). Depression was measured by the Patient Health Questionnaire–9 (α = .89; Kroenke et al., 2001). The nine items of the Patient Health Questionnaire–9 are rated on a 4-point Likert scale from 0 (not at all) to 4 (nearly every day). Total scores of all four scales were calculated, with higher scores indicating more severe levels of pathology.

Results

Preliminary Analysis

Table 1 reports the descriptive statistics of the major variables of the study. Potentially traumatizing events were prevalent in this sample. Fifty-seven percent of the participants (n = 142) endorsed at least one incident of childhood trauma. The majority of those with childhood trauma, 87% (n = 124), had at least one incident involving a close other (i.e., relational). For those reporting trauma in adulthood (58%, n = 146; for at least one relational, n = 122), three quarters reported at least one incident of childhood relational trauma. Consistent with the literature, those with childhood trauma reported more symptoms than those without childhood trauma on dissociation, BPD features, and somatization.

Table 1.

Differences Between Participants With and Without Childhood Trauma in Demographic, Clinical Utilization, and Psychopathological Variables

Variable Endorsed CT
(n = 142)		 Denied CT
(n = 107)		 Group
difference
M SD M SD F p
Demographic and clinical variables
 Age 41.98 13.80 43.60 13.75 0.84 .36
 Gender 0.30 0.46 0.33 0.47 0.28 .60
 Years of education 12.32 2.89 12.44 3.24 0.10 .75
 Years of MHS 11.11 10.22 9.21 9.23 2.28 .13
Depression and trauma-spectrum mental dysfunctions
 Dissociation 15.44 13.85 8.00 9.53 22.73 <.01
 BPD features 1.49 1.02 0.97 0.78 19.50 <.01
 Somatization 14.01 7.13 10.11 6.82 18.92 <.01
 Depression 11.07 6.31 7.81 5.94 17.11 <.01
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Note. For gender, 0 = female and 1 = male. Endorsed CT = participants who endorsed at least one childhood trauma; Denied CT = those who denied any childhood trauma; MHS = mental health service; BPD = borderline personality disorder.

To get a picture of the prevalence rates of trauma-spectrum mental dysfunctions in this sample, we used the established cutoff of each scale to identify those reaching clinically significant levels of distress warranting a probable diagnosis.1 Somatization (51%) and BPD (38%) were common in this sample, with prevalence rates that were similar to or even above that of depression (43%).

Role Expectancy: Correlation With Trauma and Trauma-Spectrum Mental Dysfunctions

Correlation analysis was performed with Pearson’s product-moment coefficient. Table 2 summarizes the result. A differential pattern was observed between relational trauma and trauma-spectrum mental dysfunctions. Relationship-seeking expectation correlated positively with relational trauma of both childhood and adulthood (ds = 0.275 and .464), but not with most trauma-spectrum mental dysfunctions, with the exception of BPD features (d = 0.285). By contrast, trauma-spectrum mental dysfunctions correlated with approval- (ds = 0.289–0.543) and advice-seeking expectancies (ds = 0.205–0.398). Despite the link between adulthood relational trauma and advice-seeking (d = 0.423), the two maladaptive expectations were only marginally correlated with relational trauma. Of note, depression had similar correlations with approval- and advice-seeking (ds = 0.368 and 0.516).

Table 2.

Simple Correlations of Potential Traumatizing Events, Depression, and Trauma-Spectrum Mental Dysfunctions With Each Role Expectation

Variable Approval-seeking Advice-seeking Audience-seeking Relationship-seeking
r p r p r p r p
Potentially traumatizing events
 CRT .10 .13 .12 .06 .03 .65 .14 .03
 ART .11 .07 .21 <.01 .07 .30 .23 <.01
 CNT .03 .63 .06 .38 .05 .47 .01 .87
 ANT .13 .04 .07 .26 .05 .43 .09 .17
Depression and trauma-spectrum mental dysfunctions
 Dissociation .29 <.01 .11 .07 <.01 .97 .09 .15
 BPD features .26 <.01 .20 <.01 −.05 .41 .14 .03
 Somatization .17 <.01 .14 .03 −.08 .21 .11 .09
 Depression .25 <.01 .18 <.01 −.04 .51 .12 .05
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Note. CRT = childhood relational trauma; ART = adulthood relational trauma; CNT = childhood nonrelational trauma; ANT = adulthood nonrelational trauma; BPD = borderline personality disorder.

Role Expectancy and the Clinical Variables: Hierarchical Regression Analysis

To identify the specific associations of the trauma-related mental dysfunctions and role expectations, hierarchical regression analysis was conducted. Models were constructed step by step to examine whether trauma and trauma-spectrum mental dysfunctions had effects on role expectations beyond variables that are not trauma-specific. Baseline models included years of being connected to mental health services as well as demographic variables. In Step 1, the four types of traumas (relational vs. nonrelational, childhood vs. adulthood) and their interactions were entered into the models. Depression and trauma-spectrum mental dysfunctions were added in Step 2. The results are summarized in Table 3.

Table 3.

Associations of Demographics, Potentially Traumatizing Events, and Trauma-Spectrum Mental Dysfunctions With Role Expectations in Hierarchical Regression Analyses

Variable Approval-seeking Advice-seeking Audience-seeking Relationship-seeking
β t p β t p β t p β t p
Baseline Demographics and years of mental health service history
 Age .00 0.00 >.99 .16 2.30 .02 .13 1.88 .06 .16 2.40 .02
 Gender −.09 −1.44 .15 −.12 −1.89 .06 .03 0.45 .65 −.16 −2.51 .01
 Years of education .11 1.70 .09 .10 1.48 .14 .06 0.86 .39 .14 2.20 .03
 Years of MHS .04 0.57 .57 −.05 −0.73 .47 .06 0.94 .35 −.04 −0.60 .55
Step 1 Potentially traumatizing events
 CRT .09 0.90 .37 .03 0.27 .79 .04 0.42 .67 .12 1.30 .20
 ART .03 0.29 .77 .20 2.04 .05 .09 0.92 .36 .28 2.93 <.01
 CRT × ART −.04 −0.79 .43 −.01 −0.24 .81 −.05 −0.95 .34 −.11 −2.27 .02
 CNT −.15 −1.65 .10 −.01 −0.08 .94 −.05 −0.55 .58 −.15 −1.74 .08
 ANT .04 0.43 .66 −.06 −0.67 .50 −.07 −0.67 .50 −.05 −0.51 .61
 CNT × ANT .09 2.17 .03 .01 0.22 .82 .06 1.41 .16 .05 1.23 .22
Step 2 Depression and trauma-spectrum mental dysfunctions
 Dissociation .20 2.17 .03 −.08 −0.82 .41 .09 0.88 .38 −.04 −0.42 .67
 BPD features .12 0.93 .36 .23 1.70 .09 −.05 −0.35 .72 .12 0.94 .35
 Somatization −.09 −0.91 .36 −.04 −0.45 .65 −.12 −1.23 .22 −.03 −0.37 .71
 Depression .09 0.79 .43 .07 0.59 .56 .03 0.26 .79 .02 0.15 .88
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Note. For gender, 0 = female and 1 = male. MHS = mental health service; CRT = childhood relational trauma; ART = adulthood relational trauma; CNT = childhood nonrelational trauma; ANT = adulthood nonrelational trauma; BPD = borderline personality disorder.

For relationship-seeking, Step 1 model showed that its correlation with adulthood relational trauma remained significant; there was an additional interaction effect between childhood and adult relational trauma. Figure 1 illustrates the interaction effect. Put differently, participants with relational trauma, either in childhood or adulthood, held an expectation of having a quality relationship with their therapists. Such an association was not observed for nonrelational trauma. However, the aforementioned simple correlations between adult relational trauma and advice-seeking expectation, and between adult nonrelational trauma and approval-seeking expectation, disappeared when controlling for other variables.

Figure 1. The Effect of Childhood Relational Trauma (CRT) and Adulthood Relational Trauma (ART) on Relationship-Seeking Expectation.

Figure 1

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Note. The figure shows that patients who endorsed a history of relational trauma, especially in adulthood, reported an expectation of a genuine and open therapeutic relationship.

The result of Step 2 model showed trauma-spectrum mental dysfunctions had a significant effect, in addition to trauma, on approval-seeking. Dissociation stood out solely among the other trauma-spectrum mental dysfunctions in its association with approval-seeking, even when controlling for depression. No significant associations were found between advice-seeking and other trauma-spectrum symptoms. BPD features had a numerically higher effect, though its statistical significance was marginal due to the elevated standard error of the regression coefficient. The elevation of standard error suggested a large overlap between BPD and other trauma-spectrum mental dysfunctions on predicting advice-seeking.

Discussion

Unresolved traumatic stress from important relationships in childhood has been commonly identified as a key factor for the development of unhealthy relationships later in life, influencing in particular the capacity to generate a productive and durable therapeutic alliance. The present study examined the relationship of trauma history and trauma-spectrum mental dysfunctions with mental health users’ expectations about how they position themselves within a therapeutic context, that is, their role expectations. Our results showed two patterns of associations attributable to trauma-centric factors. On the one hand, relational trauma, either in childhood or adulthood, was associated with an expectation that typically facilitates therapeutic alliance—relationship-seeking. On the other hand, trauma-spectrum mental dysfunctions, particularly dissociation, were related to expectations that can undermine therapeutic alliance—approval- and advice-seeking.

The distinct associations of trauma and trauma-spectrum mental dysfunctions with role expectations highlight the difference between traumatic experiences and related pathologies. Our results align with the large body of literature on the diverse trajectories of traumatic experiences. While trauma inevitably leads to distress and stress reactions, long-term negative impact does not manifest in some, or even the majority, of survivors (Bonanno, 2004; Masten, 2001). Despite the prevalence of adverse childhood experiences in patients with complex mental disturbances (Chiu, Li, et al., 2024; Chiu, Tseng, et al., 2017) or with chronic somatic issues (Chiu, Lee, et al., 2017), a direct link between early traumatic experiences and late-life mental issues is not invariantly established (Dutra et al., 2009; Ogawa et al., 1997). Additional factors can come into play in the maintenance of initial stress reactions or the development of complex stress pathologies, such as the chronicity of traumatic stress (Chiu et al., 2015) or individuals’ neurocognitive propensity (Chiu et al., 2019; also see Lebois et al., 2022).

The link between relational trauma and relationship-seeking expectation was interesting given the socioemotional nature of the wound. As it relates to the violation of one’s fundamental needs for intimacy and attachment, relational trauma has been theorized to be distinct from other types of traumas and cause pain that goes beyond fear. Such pain may be elicited when these clients reflect upon interpersonal issues and inner experiences. The role expectation of relationship-seeking in therapy, which calls for relatively equal status with genuine and respectful engagements, may indicate their sensitivity or preference to working through complex emotions, including betrayal and shame, in a new therapeutic relationship. A client’s relationship-seeking expectation contributes to the success of therapy and the formation of therapeutic alliance, particularly when their therapist shares such expectations (Al-Darmaki & Kivlighan, 1993; Tracey & Dundon, 1988). This may motivate and prepare them to benefit from psychotherapy.

On the contrary, trauma-spectrum mental dysfunctions were associated with approval- and advice-seeking tendencies. Rather than focusing on how a therapeutic relationship should be developed, individuals with such expectations look to the interacting partner, that is, the therapist, for acceptance and guidance. Although being dependent can be pragmatic in abusive or authoritarian relationships, expectations of approval and advice correlate negatively with ratings on autonomy (Coleman & Neimeyer, 2015). Such expectations can hinder the practice of being agentic in presumably healthier, therapeutic relationships. Within the context of therapy, these clients may avoid acknowledging their needs and thereby passively or indirectly expressing their frustration through anger, burnout, reluctance to continue treatment, and therapy-interfering behaviors, such as being late or no-showing. As such, clients with trauma-spectrum mental dysfunctions may have difficulties voicing their needs and thus would require greater guidance in therapy, at least when related symptoms are still present.

Intriguingly, despite a numerically larger correlation coefficient of BPD features, the link between trauma-spectrum symptoms and advice-seeking expectation was only marginally significant when controlling for trauma history and other variables. In contrast, the link of approval-seeking expectation and dissociation reached significance. At first glance, this difference might seem surprising considering the salience of attachment anxiety in BPD. However, a closer look at the data revealed that sensitivity to therapists’ perception and evaluation can be explained by dissociation—a clinical presentation common among BPD patients—which involves the fragmentation of a person’s sense of self (Lynn et al., 2022). Dissociative individuals exhibit tendencies to follow the instructions and suggestions from a therapist (Wieder et al., 2022). Similarly, a recent experiment using the implicit association test showed that dissociative individuals tend to pair self-pronouns with rejection words as opposed to acceptance words (Chiu et al., 2022). This schematic self-association was found to predispose shame, as well as the feelings of being small and powerless (Chiu et al., 2021). Clients who are prone to dissociation may therefore comply in a therapeutic room, staying passive in expressing feelings and thoughts that may in turn lead to ruptures in a therapeutic relationship.

Several limitations should be noted. First, most participants were middle-aged adults who were known to mental health services for over a year. As role expectation may be shaped by previous therapeutic encounters and other interpersonal experiences, it is important to note that the findings may not generalize to younger adults and those with little to no experience with psychotherapy. Second, although we capitalized on hierarchical regression analysis to control for potential bias based on the use of simple correlations, the positive association between dissociation and approval-seeking was small, suggesting that there are factors beyond trauma and trauma-spectrum mental dysfunctions that contribute to approval-seeking expectation. Dissociation in different psychiatric conditions (e.g., posttraumatic stress disorder, dissociative disorders) may also differ. Third, the report of traumatic experiences was retrospective and they may be subjected to memory or interpretation bias. For instance, clients with resolved traumatic stress may generate alternative meaning to the event and find the event less traumatic. Finally, the result from a single geographic area might not apply generally. More studies are needed to replicate the findings.

The results of this study highlight the importance of considering role expectations among clients who experience unresolved trauma-related distress, who are prone to dropout and poor treatment outcomes. In such cases, alignment in role expectations between clients and therapists may foster therapeutic alliance. Clinicians’ assessment of clients’ anticipation and preference toward a therapeutic relationship can facilitate the monitoring of potential maladaptive engagement styles that may interrupt the process of therapy. Addressing the gap between therapists’ and clients’ perception of the current relationship may provide an opportunity to review what is happening in the here and now, thereby stimulating clients’ reflection on their assumption about relationships.

The way people relate is oftentimes fluid, with rules neither clear nor universal. Our results showed a natural and adaptive yet unmet attachment need for bonding and intimacy for those with a history of relational trauma. The experience of betrayal might lead them to yearn for an egalitarian relationship in therapy. However, for individuals experiencing trauma-spectrum mental dysfunctions, especially in relation to dissociation, an internal conflict of approach avoidance emerges in a therapeutic context. They may come with expectations of being advised or approved, as being passive, obedient, or submissive may have been adaptive in previous dysfunctional relationships.

Clinical Impact Statement.

Cultivating therapeutic alliance poses a challenge for clinicians working with clients with a history of psychological trauma. Our results highlight that clinicians’ competence in managing issues regarding therapeutic relationship is at the core of trauma work. Clients with a history of trauma, particularly incidents involving close others early in development, usually enter therapy with an expectation of fostering an adaptive relationship with their therapists. However, if trauma-related symptoms remain active, particularly for dissociation, this expectation may threaten the therapeutic relationship. Assessing and managing dissociation appears to be vital for the development of adaptive therapeutic relationship.

Acknowledgments

The authors have no known conflicts of interest to disclose. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research and the preparation of the article were supported by grants from the Research Grant Council, Hong Kong SAR (Grants GRF 14614722 and RMG 6904861) and from the Social Science Panel from the Chinese University of Hong Kong (Grants 4052284 and 4052340) to Chui-De Chiu.

The authors thank the participants for their kind involvement in the study, as well as the clinical psychologists, social workers, and counselors at Baptist Oi Kwan Social Service for their assistance in participant recruitment.

Footnotes

1

The cutoffs used were 10 for depression (Kroenke et al., 2001), 12 for somatization (Gierk et al., 2014), and 1.5 for BPD features (Kleindienst et al., 2020). There is no cutoff available for the Dissociative Symptoms Scale.

References

  1. Al-Darmaki F, & Kivlighan DM (1993). Congruence in client-counselor expectations for relationship and the working alliance. Journal of Counseling Psychology, 40(4), 379–384. 10.1037/0022-0167.40.4.379 [DOI] [Google Scholar]
  2. Aubuchon-Endsley NL, & Callahan JL (2009). The hour of departure: Predicting attrition in the training clinic from role expectancies. Training and Education in Professional Psychology, 3(2), 120–126. 10.1037/a0014455 [DOI] [Google Scholar]
  3. Aubuchon-Endsley NL, Callahan JL, & Scott S. (2014). Role expectancies, race, and treatment outcome in rural mental health. American Journal of Psychotherapy, 68(3), 339–354. 10.1176/appi.psychotherapy.2014.68.3.339 [DOI] [Google Scholar]
  4. Berzins JI, Herron EW, & Seidman E. (1971). Patients’ role behaviors as seen by therapists: A factor-analytic study. Psychotherapy, 8(2), 127–130. 10.1037/h0086638 [DOI] [Google Scholar]
  5. Bleyen K, Vertommen H, Vander Steene G, & van Audenhove C. (2001). Psychometric properties of the Psychotherapy Expectancy Inventory-Revised (PEI-R). Psychotherapy Research, 11(1), 69–83. 10.1080/713663853 [DOI] [PubMed] [Google Scholar]
  6. Bonanno GA (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20–28. 10.1037/0003-066X.59.1.20 [DOI] [PubMed] [Google Scholar]
  7. Carlson EB, Waelde LC, Palmieri PA, Macia KS, Smith SR, & McDade-Montez E. (2018). Development and Validation of the Dissociative Symptoms Scale. Assessment, 25(1), 84–98. 10.1177/1073191116645904 [DOI] [PubMed] [Google Scholar]
  8. Chiu C-D (2018). Enhanced accessibility of ignored neutral and negative items in nonclinical dissociative individuals. Consciousness and Cognition, 57, 74–83. 10.1016/j.concog.2017.11.009 [DOI] [PubMed] [Google Scholar]
  9. Chiu C-D, Ho HL, & Tollenaar MS (2022). Relational self-evaluations in dissociation: Implicit self-rejection? Psychological Trauma: Theory, Research, Practice, and Policy, 14(1), 99–106. 10.1037/tra0001017 [DOI] [PubMed] [Google Scholar]
  10. Chiu C-D, Lee M-H, Chen W-C, Ho HL, & Wu H-C (2017). Childhood trauma perpetrated by close others, psychiatric dysfunction, and urological symptoms in patients with interstitial cystitis/bladder pain syndrome. Journal of Psychosomatic Research, 93, 90–95. 10.1016/j.jpsychores.2016.12.014 [DOI] [PubMed] [Google Scholar]
  11. Chiu C-D, Li D-J, Hsieh Y-C, Chou L-S, Au JS, Chen Y-L, & Lin C-H (2024). Linking childhood trauma and dissociation to psychotic symptoms in major depressive disorder, bipolar disorders, and schizophrenia: A transdiagnostic examination using patient and clinician ratings. Psychological Trauma: Theory, Research, Practice, and Policy, 16(Suppl. 1), S242–S249. 10.1037/tra0001584 [DOI] [PubMed] [Google Scholar]
  12. Chiu C-D, Lin C-C, Yeh Y-Y, & Hwu H-G (2012). Forgetting the unforgotten affective autobiographical memories in nonclinical dissociators. Emotion, 12(5), 1102–1110. 10.1037/a0025900 [DOI] [PubMed] [Google Scholar]
  13. Chiu C-D, Lo AP-K, Mak FK-L, Hui K-H, Lynn SJ,& Cheng S-K (2024). Remember walking in their shoes? The relation of self-referential source memory and emotion recognition. Cognition and Emotion, 38(1), 120–130. 10.1080/02699931.2023.2274040 [DOI] [PubMed] [Google Scholar]
  14. Chiu C-D, Ng HC, Kwok WK, & Tollenaar MS (2020). Feeling empathically toward other people and the self: The role of perspective shifting in emotion sharing and self-reassurance. Clinical Psychological Science, 8(1), 169–183. 10.1177/2167702619863058 [DOI] [Google Scholar]
  15. Chiu C-D, Paesen L, Dziobek I, & Tollenaar MS (2016). Weakened cognitive empathy in nonclinical individuals with dissociation proneness. Journal of Social and Clinical Psychology, 35(5), 425–436. 10.1521/jscp.2016.35.5.425 [DOI] [Google Scholar]
  16. Chiu C-D, Siu CY, Ng HC, & Baldwin MW (2021). Visuospatial perspective shifting and relational self-association in dispositional shame and guilt. Consciousness and Cognition, 92, Article 103140. 10.1016/j.concog.2021.103140 [DOI] [PubMed] [Google Scholar]
  17. Chiu C-D, Tollenaar MS, Yang C-T, Elzinga BM, Zhang T-Y, & Ho HL (2019). The loss of the self in memory: Self-referential memory, childhood relational trauma, and dissociation. Clinical Psychological Science, 7(2), 265–282. 10.1177/2167702618804794 [DOI] [Google Scholar]
  18. Chiu C-D, Tseng M-C, Chien Y-L, Liao S-C, Liu C-M, Yeh Y-Y, & Hwu H-G (2015). Cumulative traumatization associated with pathological dissociation in acute psychiatric inpatients. Psychiatry Research, 230(2), 406–412. 10.1016/j.psychres.2015.09.028 [DOI] [PubMed] [Google Scholar]
  19. Chiu C-D, Tseng M-C, Chien Y-L, Liao S-C, Liu C-M, Yeh Y-Y, & Hwu H-G (2016). Misattribution of the source of self-generated representations underlies dissociative and psychotic symptoms. Frontiers in Psychology, 7, Article 541. 10.3389/fpsyg.2016.00541 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Chiu C-D, Tseng M-CM, Chien Y-L, Liao S-C, Liu C-M, Yeh Y-Y, Hwu H-G, & Ross CA (2017). Dissociative disorders in acute psychiatric inpatients in Taiwan. Psychiatry Research, 250, 285–290. 10.1016/j.psychres.2017.01.082 [DOI] [PubMed] [Google Scholar]
  21. Chu JA (2011). Rebuilding shattered lives: Treating complex posttraumatic and dissociative disorders (2nd ed.). Wiley. 10.1002/9781118093146 [DOI] [Google Scholar]
  22. Coleman RA, & Neimeyer RA (2015). Assessment of subjective client agency in psychotherapy: A review. Journal of Constructivist Psychology, 28(1), 1–23. 10.1080/10720537.2014.939791 [DOI] [Google Scholar]
  23. Dutra L, Bureau JF, Holmes B, Lyubchik A, & Lyons-Ruth K. (2009). Quality of early care and childhood trauma: A prospective study of developmental pathways to dissociation. Journal of Nervous and Mental Disease, 197(6), 383–390. 10.1097/NMD.0b013e3181a653b7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Dziobek I, Preissler S, Grozdanovic Z, Heuser I, Heekeren HR, & Roepke S. (2011). Neuronal correlates of altered empathy and social cognition in borderline personality disorder. NeuroImage, 57(2), 539–548. 10.1016/j.neuroimage.2011.05.005 [DOI] [PubMed] [Google Scholar]
  25. Fishere M, & Habermas T. (2023). Coherence of child maltreatment narratives by emerging adults: How does child maltreatment affect how we share our story? Applied Cognitive Psychology, 37(3), 531–541. 10.1002/acp.4056 [DOI] [Google Scholar]
  26. Freyd JJ (1994). Betrayal trauma: Traumatic amnesia as an adaptive response to childhood abuse. Ethics & Behavior, 4(4), 307–329. 10.1207/s15327019eb0404_1 [DOI] [Google Scholar]
  27. Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, & Löwe B. (2014). The Somatic Symptom Scale-8 (SSS-8): A brief measure of somatic symptom burden. JAMA Internal Medicine, 174(3), 399–407. 10.1001/jamainternmed.2013.12179 [DOI] [PubMed] [Google Scholar]
  28. Goldberg LR, & Freyd JJ (2006). Self-reports of potentially traumatic experiences in an adult community sample: Gender differences and test—retest stabilities of the items in a brief betrayal-trauma survey. Journal of Trauma & Dissociation, 7(3), 39–63. 10.1300/J229v07n03_04 [DOI] [PubMed] [Google Scholar]
  29. Gunderson JG, & Lyons-Ruth K. (2008). BPD’s interpersonal hypersensitivity phenotype: A gene–environment-developmental model. Journal of Personality Disorders, 22(1), 22–41. 10.1521/pedi.2008.22.1.22 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Kleindienst N, Jungkunz M, & Bohus M. (2020). A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). Borderline Personality Disorder and Emotion Dysregulation, 7(1), Article 11. 10.1186/s40479-020-00126-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Kroenke K, Spitzer RL, & Williams JBW (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Lebois LAM, Ross DA, & Kaufman ML (2022). “I am not I”: The neuroscience of dissociative identity disorder. Biological Psychiatry, 91(3), e11–e13. 10.1016/j.biopsych.2021.11.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Luyten P, Campbell C, & Fonagy P. (2020). Borderline personality disorder, complex trauma, and problems with self and identity: A social-communicative approach. Journal of Personality, 88(1), 88–105. 10.1111/jopy.12483 [DOI] [PubMed] [Google Scholar]
  34. Lynn SJ, Polizzi C, Merckelbach H, Chiu C-D, Maxwell R, van Heugten D, & Lilienfeld SO (2022). Dissociation and dissociative disorders reconsidered: Beyond sociocognitive and trauma models toward a transtheoretical framework. Annual Review of Clinical Psychology, 18(1), 259–289. 10.1146/annurev-clinpsy-081219-102424 [DOI] [PubMed] [Google Scholar]
  35. Masten AS (2001). Ordinary magic. Resilience processes in development. American Psychologist, 56(3), 227–238. 10.1037/0003-066X.56.3.227 [DOI] [PubMed] [Google Scholar]
  36. Niedtfeld I. (2017). Experimental investigation of cognitive and affective empathy in borderline personality disorder: Effects of ambiguity in multimodal social information processing. Psychiatry Research, 253, 58–63. 10.1016/j.psychres.2017.03.037 [DOI] [PubMed] [Google Scholar]
  37. Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, & Egeland B. (1997). Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Development and Psychopathology, 9(4), 855–879. 10.1017/S0954579497001478 [DOI] [PubMed] [Google Scholar]
  38. Pick S, Mellers JDC, & Goldstein LH (2016). Explicit facial emotion processing in patients with dissociative seizures. Psychosomatic Medicine, 78(7), 874–885. 10.1097/PSY.0000000000000327 [DOI] [PubMed] [Google Scholar]
  39. Rickers-Ovsiankina MA, Geller JD, Berzins JI, & Rogers GW (1971). Patient’s role-expectancies in psychotherapy: A theoretical and measurement approach. Psychotherapy, 8(2), 124–126. 10.1037/h0086637 [DOI] [Google Scholar]
  40. Terr LC (1991). Childhood traumas: An outline and overview. The American Journal of Psychiatry, 148(1), 10–20. 10.1176/ajp.148.1.10 [DOI] [PubMed] [Google Scholar]
  41. Tracey TJ, & Dundon M. (1988). Role anticipations and preferences over the course of counseling. Journal of Counseling Psychology, 35(1), 3–14. 10.1037/0022-0167.35.1.3 [DOI] [Google Scholar]
  42. Van der Kolk BA, & van der Hart O. (1989). Pierre Janet and the breakdown of adaptation in psychological trauma. The American Journal of Psychiatry, 146(12), 1530–1540. 10.1176/ajp.146.12.1530 [DOI] [PubMed] [Google Scholar]
  43. van Schie CC, Chiu C-D, Rombouts SARB, Heiser WJ, & Elzinga BM (2020). Stuck in a negative me: fMRI study on the role of disturbed self-views in social feedback processing in borderline personality disorder. Psychological Medicine, 50(4), 625–635. 10.1017/S0033291719000448 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Wieder L, Brown RJ, Thompson T, & Terhune DB (2022). Hypnotic suggestibility in dissociative and related disorders: A meta-analysis. Neuroscience and Biobehavioral Reviews, 139, Article 104751. 10.1016/j.neubiorev.2022.104751 [DOI] [PubMed] [Google Scholar]
  45. Zhang Y. (2023). Unresponsive self and romantic partner: Perception of responsiveness and borderline personality disorder features [Unpublished doctoral dissertation]. The Chinese University of Hong Kong. [Google Scholar]
  46. Zilcha-Mano S, & Fisher H. (2022). Distinct roles of state-like and trait-like patient–therapist alliance in psychotherapy. Nature Reviews Psychology, 1(4), 194–210. 10.1038/s44159-022-00029-z [DOI] [Google Scholar]

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