To what extent is alliance affected by transference? An empirical exploration
Dinger, U., Zilcha-Mano, S., McCarthy, K. S., Barrett, M. S., & Barber, J. P. (2013). Interpersonal problems as predictors of alliance, symptomatic improvement and premature termination in treatment of depression. Journal of Affective Disorders, 151, 800–803.
Zilcha-Mano, S., McCarthy, K. S., Dinger, U., & Barber, J. P. (2014, May 26). To what extent Is alliance affected by transference? An empirical exploration. Psychotherapy, 51(3), 424-433. http://dx.doi.org/10.1037/a0036566
Will patients project their representations of significant others onto the therapist in a way that influences the formation of the therapeutic alliance? To address this issue, the current study explored the following questions: (1) To what extent are pretreatment representations of others projected onto the therapist and thereby predict the development of alliance throughout the course of treatment? (2) To what extent are these projections affected by the real relationship? (3) Are there specific representations of others that are more prone to be projected onto the alliance? To this end, data on 134 patients from a randomized controlled trial for depression comparing dynamic supportive–expressive therapy with supportive clin- ical management combined with pharmacotherapy or placebo were used. Findings demonstrated that the patients’ pretreatment representations of significant others predicted a substantial part of the alliance with the therapist throughout the course of treatment. However, the representations of others were not automatically projected onto the alliance but rather the projections were also influenced by the real relationship with the therapist. Throughout this process, the alliance evolves into a collage of significant others. A process of assimilation seemed to emerge during treatment, in which the most relevant representations of significant others were projected onto the alliance with the therapist.
The alliance is considered an essential aspect of psychotherapy by many theorists and researchers (e.g., Muran & Barber, 2010). In the current study we delved into one of the possible origins of the alliance by examining the extent to which it could be explained by the atient’s representations of significant others. Our findings showed that representations of significant others, as examined before treatment begins, predicted a substantial part of the alliance with the real therapist: benevolent representations of others at intake were positively related to the alliance subsequently developed with the therapist, while malevolent representations of others were negatively related to the alliance subsequently developed with the therapist. The current findings constitute fertile ground for further examination of a variety of clinically important questions. While the current study focused on describing general phenomena, future research could examine the effect of individual differences between patients (such as patient’s interpersonal problems, Dinger, Zilcha-Mano, McCarthy, Barrett, & Barber, 2013, or attachment orientation) as well as the effects of specific characteristics of the real therapist (such as the therapist’s attachment orientation, or the therapist’s personal therapy experience, Gold & Hilsenroth, 2009), and the characteristics of the specific interactions between the patient and the therapist on the phenomena described in this study. Additionally, as the current study is not ideal for evaluating therapist effects, future large-scale studies with appropriate designs for investigating therapist’s effect (e.g., appropriate patients–therapist ratio and number of therapists, see Baldwin & Imel, 2013 for comprehensive description), should further examine the influence of the therapist’s effect on the findings. Moreover, our interpretations of the findings (e.g., our “incubation process” suggestion) should be examined in clinical practice and research to learn about their potential utility.
Prof. Dr. Sigal Zilcha-Mano
Associate Professor and Licensed Clinical Psychologist, Department of Psychology, University of Haifa
Visiting Associate Professor of Clinical Psychology (in Psychiatry), Columbia University College of Physicians and Surgeons
Psychotherapy Research Lab
Experimental study of transference work (FEST)
Høglend, P., Bøgwald, K., Amlo, S., Marble, A., Ulberg, R., Sjaastad, M. C., . . . Johannson, P. (2008). Transference interpretations in dynamic psychotherapy: Do they really yield sustained effects? American Journal of Psychiatry, 65, 763-771.
Høglend, P., Perry, J. C., Dahl, H.-S., Lorentzen, S., & Hersoug, A. G. (2011). Long-term effects of transference interpretation in dynamic psychotherapy of personality disorders. European Psychiatry, 26, 419-424.
Johansson, P., Høglend, P., Ulberg, R., Amlo, S., Marble, A., Bøgwald, K.-P., & Sørbye, Ø. (2010). The mediating role of insight for long-term improvements in psychodynamic therapy. Journal of Consulting and Clinical Psychology, 78, 438-448.
Høglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171(10), 1056-1966.
FEST is designed to investigate long-term effects of transference work in dynamic psychotherapy.
We randomly assigned 100 patients to 1 year of dynamic psychotherapy with a low to moderate level of transference work or to the same type of therapy without transference work. The same therapists administered both treatments after extensive training. Treatment integrity was documented with ratings ofmore than 450 full sessions. The only component that differed between the two treatments was use of a low to moderate frequency of transference work interventions. Thus, the design makes it possible to study causal effects of transference work.
There was no overall effect of transference work. However, patients with a low quality of object relations benefited significantly more from therapy with transference work compared to therapy without transference work (1). This effect was sustained during a 3-year followup period (2). Patients with mature relationships and greater psychological resources benefited equally well from both treatments. Furthermore, female patients responded significantly better than men to therapy with work (3). Among the 46 patients with one or more personality disorders, 17 of 23 patients (74%) no longer met diagnostic criteria for any personality disorder in the transference group, versus 10 of 23 patients (43%) in the comparison group. The dropout rate was 0% in the transference group and 22% in the comparison group. Patients who did not receive transference work had about four times more additional mental health specialist treatment during the 3-year follow-up period, compared with patients who received transference work (4). All the therapists in this study had extensive experience and were specifically trained to deliver the two treatments, which limits generalizability to ordinary clinical practice.
The long-term effect of transference work among patients with low-quality object relations was mediated (explained) by increased gain of insight during therapy (5). Several studies suggest that changes in insight or self-understanding are specific to dynamic psychotherapy and are not associated with other treatments, such as cognitive-behavioral therapy or antidepressant medication. FEST extended this work by linking theuse of specific techniques to gains in insight and subsequent improvement in interpersonal functioning (6).
These findings are consistent with the clinical theory that insight may be a specific mechanism of change in dynamic therapy. It should be noted, however, that the association between insight and outcome cannot be experimentally controlled. The true causal mechanism of change could be some unknown variable correlated with insight. This is an inevitable limitation, to date, in mediator studies.
Prof. Per Høglend
Division of Mental Health and Addiction, University of Oslo
An experimental study of transference interpretations
Høglend, P., Amlo, S., Marble, A., Bögwald, K.-P., Sörbye, Ö., Sjaastad, M. C., & Heyerdahl, O. (2006). Analysis of the patient-therapist relationship in dynamic psychotherapy: An experimental study of transference interpretations. American Journal of Psychiatry, 163, 1739-1746.
Høglend, P., Bogwald, K. P., Amlo, S., Marble, A., Ulberg, R. S., M.C., & Johansson, P. (2008). Transference interpretations in dynamic psychotherapy: Do they really yield sustained effects? . American Journal of Psychiatry, 165, 763-771.
Høglend, P., & Gabbard, G. (2012). When is transference work useful in psychodynamic psychotherapy? A review of empirical research. In R. Levy, J. S. Ablon & H. Kächele (Eds.), Psychodynamic Psychotherapy Research (pp. 449-467). Totowa,NJ: Humana Press.
Transference interpretation has remained a core ingredient in the psychodynamic tradition, despite limited empirical evidence for its effectiveness. The purpose of this study was to measure the effects of transference interpretations (the assumed core active ingredient) in dynamic psychotherapy, using an experimental design.
This was a randomized controlled clinical trial, dismantling design, plus follow-up evaluations 1 year and 3 years after treatment termination. One hundred outpatients seeking psychotherapy for depression, anxiety, personality disorders, and interpersonal problems were referred to the study therapists. One group received dynamic psychotherapy over 1 year, with a moderate level of transference interpretations, while the other group received dynamic psychotherapy with no transference interpretations. Patients were randomly assigned to receive weekly sessions of dynamic psychotherapy for 1 year with or without transference interpretations. Five full sessions from each therapy were rated in order to document treatment fidelity.
Outcome variables were the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems Scale-Circumplex version, Global Assessment of Functioning Scale, and Symptom Checklist-90-R. Quality of Object Relations Scale (lifelong pattern) and personality disorders were preselected as possible moderators of treatment effects. Change was assessed using linear-mixed Outcome variables were the Psychodynamic Functioning Scales (clinician rated) and the Inventory of Interpersonal Problems (selfreport). Rating on the Quality of Object
Clinically significant results
Despite an absence of differential treatment efficacy, both treatments demonstrated significant improvement during treatment and also after treatment termination. However, patients with a lifelong pattern of poor object relations profited more from 1 year of therapy with transference interpretations than from therapy without transference interpretations. This effect was sustained throughout the 4-year study period.
The goal of transference interpretation is sustained improvement of the patient’s relationships outside of therapy. Transference interpretation seems to be especially important for patients with long-standing, more severe interpersonal problems.
Prof. Per Høglend
Division of Mental Health and Addiction, University of Oslo
Countertransference as object of empirical research?
Kächele, H., Erhardt, I., Seybert, C., & Buchholz, M. B. (2015). Countertransference as object of empirical research? International Forum of Psychoanalysis, 24, 96-108 .
Buchholz, M.B. (2015). Growth - What reconciliation of conflicts could mean. A lesson from the history of psychoanalysis. International Forum of Psychoanalysis, 24, (2), 88-95.
The concept of countertransference as a robust cornerstone of psychoanalytic work has gained in momentum over the last five decades. It is a prime example for elastic concepts covering the range from microprocess to global clinical phenomena. Empirical research on treatment process has for a long time - for good reasons - avoided to even try to measure countertransference. Today we encounter various efforts for a methodology to measuring countertransference. The paper organizes the various approaches in terms of stages of research.
Clinical Case Studies
Using the PEP-database searching for the term countertransference in the titles of papers one learns about 730 articles which use the term countertransference from 1952 til 2012; since 2000 the information provided (193 papers and books) underlines that countertransference indeed enjoys a high degree of attention.
Descriptive studies as a formal research activities fulfill the task to systematically describe the phenomena under scrutiny. Singer and Luborsky (1977) point out that most psychotherapy researchers feel „that a scientific orientation requires controlling certain variables even if doing so means that the phenomena studied are not in their most natural form. Consequently much psychotherapy research deals only with approximations of the actual clinical experience“ (p.438).
Experimental Analogue Studies
A fairly ecologically valid experimental study on the issue of countertransference propensities was performed by Beckmann (1974). Applying a psychoanalytically informed, but psychometrically sound questionaire, the Giessen-Test (Beckmann & Richter 1972) he studied a group of psychoanalytic candidates who observed many patients in a psychoanalytic initial interview through a one-way-window. Candidates who qualified with higher levels of depressive features overrated the degree of hysterical features in the patients; vice versa candidates who qualified with higher levels of hysterical features overrated the degree of depressive features in the patients; and candidates with higher levels of obsessiveness overrated the degree of obsessiveness in the patients.
A recent review on the state of the art concerning countertransference was provided by Hayes, Gelso, & Hummel (2011). They review three metaanalyses; the first focuses on the impact of countertransference on the outcome of treatment, the second focuses on the issue whether the capacity to manage countertransference reduces the actualization of countertransference feelings and the third asks whether managing the countertransference improves the outcome.
Conversational studies on countertransference are becoming more and more popular as only the detailed microanalysis of what goes on in the session allows to identify hidden dimensions. Countertransference-aspects are addressed here in an important, but very indirect way. The “third-position”-utterance seems to come from a “resonating alignment” (Buchholz 2013) which produces a feeling in the analyst that something is still missing and that a further utterance should follow. “Something more” refers to what Stern et al. (1998) had termed “non-interpretative mechanisms”. So it seems that modern audio- and video technique, used by conversation analysts and “baby-watchers” since the 1960s in a similar way, really opens new horizons for the detailed analysis of what is really said and done in a psychoanalytic session. In a personal comment Peräyklä (2011a) debates how the (alleged) “anti-mentalism” of conversation analysis and the more introspective approach of psychoanalysis can be brought together on the basis of detailed observation. It seems that we might expect for the future a clarification of what the “clinical facts” (Tuckett 1994) of psychoanalysis are and how the future role of countertransference will be.
Prof. Dr. Dr, H,. Kächele
International Psychoanalytic University Berlin
Prof. Dr. Dr, M. B. Buchholz
International Psychoanalytic University Berlin
Countertransference phenomena and personality pathology in clinical practice: An empirical investigation
Betan, E. J., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162(5), 890-898.
Betan, E. J., & Westen, D. (2009). Countertransference and personality pathology: Development and clinical application of the Countertransference Questionaire. In R. A. Levy & J. S. Ablon (Eds.), Handbook of Evidence-Based Psychodynamic Psychotherapy. Bridging the Gap Between Science and Practice (pp. 179-198). New York: Humana Press.
This study provides initial data on the reliability and factor structure of a measure of countertransference processes in clinical practice and examines the relation between these processes and patients’ personality pathology.
A national random sample of 181 psychiatrists and clinical psychologists in North America each completed a battery of instruments on a randomly selected patient in their care, including measures of axis II symptoms and the Countertransference Questionnaire, an instrument designed to assess clinicians’ cognitive, affective, and behavioral responses in interacting with a particular patient.
Factor analysis of the Countertransference Questionnaire yielded eight clinically and conceptually coherent factors that were independent of clinicians’ theoretical orientation: 1) overwhelmed/ disorganized, 2) helpless/inadequate, 3) positive, 4) special/overinvolved, 5) sexualized, 6) disengaged, 7) parental/protective, and 8) criticized/mistreated. The eight factors were associated in predictable ways with axis II pathology. An aggregated portrait of countertransference responses with narcissistic personality disorder patients provided a clinically rich, empirically based description that strongly resembled theoretical and clinical accounts.
Countertransference phenomena can be measured in clinically sophisticated and psychometrically sound ways that tap the complexity of clinicians’ reactions toward their patients. Countertransference patterns are systematically related to patients’ personality pathology across therapeutic approaches, suggesting that clinicians, regardless of therapeutic orientation, can make diagnostic and therapeutic use of their own responses to the patient.
The results point to several conclusions.
First, eight countertransference dimensions were identified as robust across extraction methods and rotations: 1) overwhelmed/ disorganized, 2) helpless/inadequate, 3) positive, 4) special/ overinvolved, 5) sexualized, 6) disengaged, 7) parental/ protective, and 8) criticized/mistreated. These dimensions are clinically and theoretically coherent, representing diverse reactions clinicians may have toward patients that likely reflect a combination of the therapist’s own dynamics, responses evoked by the patient, and the interaction of patient and therapist. The factor structure offers a complex portrait of countertransference processes that is substantially more nuanced than global distinctions between positive and negative countertransference. What this study suggests, however, is a way of transcending some of the limitations inherent in clinical theories derived from case studies, in which a single clinician attempts to classify countertransference experiences or constellations based on his or her own experience with a limited number of patients. By using an instrument that provides a “common language” for describing a subtle clinical phenomenon, Betan and colleges can essentially pool the knowledge of dozens of clinical observers, identifying latent constructs (varieties of countertransference experience) that reflect patterns that individual observers themselves may not have recognized.
Second, although every clinician and every therapeutic dyad is distinct, the significant correlations between the countertransference factors and personality disorder symptoms suggest that countertransference responses occur in coherent and predictable patterns. The associations between countertransference patterns and personality disorder characteristics support the broad view of countertransference reactions as useful in the diagnostic understanding of the patient’s dynamics, particularly those involving repetitive interpersonal patterns. To the extent that patients sharing diagnostic features on axis II have similar ways of thinking, feeling, and behaving interpersonally, one would expect them to evoke similar reactions from others, including therapists, and this appears to be the case.
Third, data from clinicians of different theoretical orientations showed similar patterns vis-à-vis patients with particular kinds of pathology, suggesting that the results are not artifacts of clinicians’ theoretical preconceptions. What is striking about this finding is that coherent patterns of countertransference response emerge in treatments regardless of whether the clinician even “believes” in the concept of countertransference responses or has been trained to attend to them. Finally, the empirical portrait of countertransference responses toward patients with narcissistic personality disorder points to the way researchers can use this measure to create empirical prototypes of subtle countertransference constellations with patients presenting with specific types of personality disturbance. In principle, with a large enough sample, one could empirically map the terrain of countertransference patterns in response to multiple forms of personality pathology. One could also identify distinct constellations within diagnoses (e.g., different kinds of narcissistic patients) or to patients who share certain experiences (e.g., survivors of childhood sexual trauma) that may occur across treatments, at different points in therapy, or at different points in a single therapy hour. In working with survivors of childhood sexual abuse, for example, clinicians often face the opposite danger of pushing too much or too early for the patient to remember— and potentially recapitulating the patient’s subjective experience of unwanted penetration, abuse, or lack of boundaries—versus avoiding discussion of traumatic events in intimate detail for fear of traumatizing the patient— and potentially recapitulating the patient’s experience of unacknowledged but shared secrets or the inability or unwillingness of a caregiver who knew about the abuse to talk about it. Identification of such patterns as common constellations in the treatment of abuse survivors could be very useful in teaching clinicians about potential countertransference dangers inherent in working with abuse survivors in a way that is both clinically sensitive and empirically grounded.
Ephi Betan, Ph.D. Amy Kegley Heim, Ph.D. Carolyn Zittel Conklin, Ph.D. Drew Westen, Ph.D.
Long-term effects of analysis of the patient–therapist relationship in the context of patients’ personality pathology and therapists’ parental feeling
Dahl, H.-S. J., Røssberg, J. I., Crits-Christoph, P., Gabbard, G. O., Hersoug, A. G., Perry, J. C., . . . Høglend, P. A. (2014). Long-term effects of analysis of the patient–therapist relationship in the context of patients’ personality pathology and therapists’ parental feelings. Journal of Consulting and Clinical Psychology, 82(3), 460-471.
Transference work (analysis of the patient-therapist relationship) is considered a core active ingredient in dynamic psychotherapy. However, there are contradictory findings as for whom and under what circumstances working explicitly with the therapist-patient relationship is beneficial. This study investigates long-term effects of transference work in the context of therapists’ self-reported parental countertransference (CT), and patients’ level of personality pathology. Hence, we wanted to examine whether or not parental CT are associated with the specific long-term effects of transference work, and whether these associations change as a function of different levels of patients’ personality pathology. Transference work focus on the ongoing relationship between therapist and patient. We believe that this explicit focus will make CT affect the therapeutic process more than in the non-transference work group. Based on the sparse literature in the field we expected that transference work in the context of elevated parental CT might be beneficial for patients with more severe personality pathology, but possibly harmful for patients without personality pathology. The rationale for this differential prediction is as follows: When personality pathology is high, parental CT informs the therapist’s appreciation of the patient’s needs for protective (positive parental) engagement. However, when personality pathology is low, therapists are advised to be more neutral and adopt an “analytic” neutral stance. Parental CT may not be accurately attuned to these patients’ needs, and possibly impede exploration.
One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to dynamic psychotherapy with a low to moderate level of transference work, or to the same type of therapy, but without transference work. Transference work was defined broadly, as all interventions that allude to the therapist or the therapy. The same therapists did both treatments after extensive training. Personality pathology was evaluated before treatment as the sum of fulfilled personality disorder criteria on SCID II. Countertransference feelings were assessed with the Feeling Word Checklist-58 (FWC-58), the therapists were asked to rate to what degree they had experienced 58 feeling states after each session. In this paper we study the Parental countertransference (CT) subscale which had the highest mean value of the subscales. The parental CT subscale included the words: Motherly, Affectionate, Dominating, and Important. The outcome variables were the Psychodynamic Functioning Scales and Inventory of Interpersonal Problems, measured at pre-treatment, mid-treatment, post-treatment, one year, and three years after treatment termination.
A significant treatment group (transference vs. no transference) by personality pathology by parental CT interaction was present. This indicates that parental CT had significantly different impact on the effect of transference work, depending on the level of personality pathology. In the context of low parental CT, transference work was positive for all patients. However, when parental CT increased, the specific effect of transference work was even more positive for patients with high levels of personality pathology, but negative for patients with low levels of personality pathology. These patients did not deteriorate, but the patients with little personality pathology in the non-transference group did relatively better compared to the transference group, when parental CT was high. Patients with high levels of personality pathology was relatively better off in the transference group independent of parental CT, although they did even better when parental CT was high.
The therapist’s parental countertransference and the level of patient’s personality pathology strongly influenced the specific effect of transference work as measured three years after therapy.
The study adds to an evolving body of literature suggesting that patient characteristics, technique variables, and therapist variables are all important. Examination of any one of these variables in isolation from the others may provide an incomplete understanding of their role in relation to outcome.
Hanne-Sofie J. Dahl
Department of Psychiatry, Vinderen, University of Oslo, Pb 85, 0319, Oslo, Norway
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