My playbook: Psychotherapy role expectations, relational trauma, and trauma-spectrum mental dysfunctions in community mental health service users in Hong Kong.

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. (PsycInfo Database Record (c) 2025 APA, all rights reserved).