Countertransference types and their relation to rupture and repair in the alliance

Rethinking treatment failures. Research on a group of Italian psychotherapists

Introduction

Psychotherapeutic failures involve situational, relational, and personal factors. Dropout refers to a patient's unilateral termination of treatment without the therapist's knowledge or approval. Premature termination occurs when therapy is discontinued before achieving a sufficient reduction in initial problems.

Objective

This study explores the role of therapist's emotional response (countertransference), gender, psychotherapeutic orientation, and patient diagnosis in the context of psychotherapeutic failures.

Method

A mixed-method approach was used. Fifty-nine Italian psychotherapists, practicing mostly privately with at least 5 years of experience, were recruited through Italian professional internet websites. The Therapist Response Questionnaire and the Impasse Interview were administered to each psychotherapist. Each therapist was asked to reflect on their last dropout patient. Quantitative (MANOVA) and qualitative analyses (textual content analysis) were conducted with SPSS and T-LAB, respectively.

Results

The quantitative analyses revealed that the most frequent countertransference response was Helpless/Inadequate, with female therapists experiencing this more frequently than male therapists. The qualitative analyses identified two main factors explaining most of the variance in countertransference responses: Parental/Protective versus Hostile/Angry, and Positive/Satisfying versus Helpless/Inadequate, with Helpless/Inadequate central. Additionally, the qualitative analysis of treatment interruption methods revealed two factors explaining over 50% of the variance. Lack of communication was linked to negative themes, while mediated and direct communication were associated with positive terms. Direct communication was characterized as useful, while mediated communication was linked to dropout and attachment figures.

Conclusion

Under pressure, psychotherapists' anxiety levels increase, often managed ambivalently or avoidantly. These results suggest that awareness of psychotherapist emotional responses is important to limit psychotherapeutic failures. These findings offer valuable insights for clinical practice.

Development and preliminary validation of the Clinician Affective REsponse (CARE) scale

The present study reports on the development and validation of the clinician affective response (CARE) scale. The CARE scale was designed as a self-report measure of therapists' patterns of thoughts, feelings, and behaviors toward the patient during an individual psychotherapy session. An initial pool of 116 items was generated, and its quality was evaluated by subject matter experts. Validation data were gathered from licensed psychotherapists (n=554). We used exploratory factor analysis and item response theory-graded response modeling to select items, confirmatory factor analysis to test how well the factor structure fit the data, and k-fold cross-validation to ascertain the robustness of the model. Criterion validity was evaluated by correlating the scores of the scale with the characteristics of therapists, patients, and treatment. The selected model consists of 15 items and a 3-factor structure, which showed excellent model fit, good internal consistency, and evidence of criterion validity. The CARE scale, short and quick to complete, enables therapists to reflect on and recognize their inner experiences and quantify these experiences in ways conducive to statistical analysis and research. Furthermore, the monitoring of these affective reactions toward their patients can guide therapeutic interventions and inform clinical supervisors.

Identifying the origins of countertransference using the Core Conflictual Relationship Theme method: A multiple case study approach

OBJECTIVE

Measurement of countertransference (CT) has proven challenging throughout the history of studying this construct. We sought to determine the potential value of using a common measure of transference, the Core Conflictual Relationship Theme (CCRT) method, as a means of studying CT.

METHOD

The Relationship Anecdote Paradigm and the CCRT method were used to examine CT in two studies. In Study 1, we examined the correspondence between a therapist's wishes with significant people in her life (i.e., her parents and husband) and three long-term patients. In Study 2, we identified the interpersonal wishes of a different therapist and examined 14 of her sessions with 3 patients for evidence of how these wishes and needs were displayed in her clinical work.

RESULTS

Analyses revealed that specific wishes in therapists' personal lives could be detected from projective interviews and these wishes were similar, but not necessarily identical, to wishes in therapists' descriptions of, and actual work with, their patients. Evidence of both chronic wishes and patient-specific wishes was revealed.

CONCLUSIONS

These findings support the idea that the origins of CT reside in therapists' interpersonal wishes and that the CCRT may be a promising means of identifying CT in research, practice, and supervision.

Countertransference in the treatment of patients with personality disorders: A longitudinal study

OBJECTIVE

This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT.

METHOD

A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists' emotional response was repeatedly assessed by the Feeling Word Checklist-Brief Version (FWC-BV) with three subscales-Inadequate, Confident, and Idealized.

RESULTS

Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate.

CONCLUSION

Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

Psychotherapy process research: Identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness

This paper provides an overview of my research programme for the past 37 years. The focus of my work has been on identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness. Two foci will be reviewed, first, my research on client and therapist interpersonal process and second, productive processing in psychotherapy in three different therapeutic approaches including EFT, CBT and CCT. Given that many competing theoretical perspectives are effective, I was curious about change processes that are common and unique to each. In my work, I employed a variety of research methodologies drawing on frameworks with alternative epistemological and ontological assumptions to capture specific in-session change processes in an attempt to reveal the richness and complexity of the phenomena being studied and illuminate the process of change.

Dynamic suicide topic modelling: Deriving population-specific, psychosocial and time-sensitive suicide risk variables from Electronic Health Record psychotherapy notes

In the machine learning subfield of natural language processing, a topic model is a type of unsupervised method that is used to uncover abstract topics within a corpus of text. Dynamic topic modelling (DTM) is used for capturing change in these topics over time. The study deploys DTM on corpus of electronic health record psychotherapy notes. This retrospective study examines whether DTM helps distinguish closely matched patients that did and did not die by suicide. Cohort consists of United States Department of Veterans Affairs (VA) patients diagnosed with Posttraumatic Stress Disorder (PTSD) between 2004 and 2013. Each case (those who died by suicide during the year following diagnosis) was matched with five controls (those who remained alive) that shared psychotherapists and had similar suicide risk based on VA's suicide prediction algorithm. Cohort was restricted to patients who received psychotherapy for 9+ months after initial PTSD diagnoses (cases = 77; controls = 362). For cases, psychotherapy notes from diagnosis until death were examined. For controls, psychotherapy notes from diagnosis until matched case's death date were examined. A Python-based DTM algorithm was utilized. Derived topics identified population-specific themes, including PTSD, psychotherapy, medication, communication and relationships. Control topics changed significantly more over time than case topics. Topic differences highlighted engagement, expressivity and therapeutic alliance. This study strengthens groundwork for deriving population-specific, psychosocial and time-sensitive suicide risk variables.

The experience of closeness and distance in the therapeutic relationship of patients with different attachment classifications: an exploration of prototypical cases

Background

Individuals with different attachment classifications (Secure, Avoidant and Preoccupied) may experience emotional closeness differently, in their intimate relationships but also as clients in psychotherapy. However, evidence for this assumption almost exclusively comes from research with self-report questionnaires.

Aims

In this paper, we use observer-rated measures to explore in depth how patients with different attachment classifications experience closeness and distance from the therapist in different phases of therapy.

Method

Three patients' and their therapists' narratives about the therapeutic relationship at three time points during therapy were extracted and analyzed with two transcript-based observational measures: The Patient Attachment Coding System (PACS), which classifies patients' attachment according to their discourse behavior, and the therapeutic-Distance Scale-Observer version (TDS-O), which assesses the therapeutic relationship in terms of closeness, distance, autonomy and engagement. Cases were chosen from a larger research project due to their different prototypical attachment classification on the PACS. The narratives were obtained from Relationship Anecdote Paradigm (RAP) interviews in which the patients and their therapists narrated separately about meaningful interactions with each other, at early, middle and late phases of therapy. In addition, we followed patients self-report of the alliance and symptoms (OQ-45).

Results

Although all patients reported experiencing discomfort with feeling distant from the therapist the therapeutic distance, the secure patient was able to reflect on his feelings and, in the therapist's recollection, was able to share them with the therapist. This allowed the therapist to harness these feelings for the benefit of the therapy. The avoidant and the preoccupied patients both experienced the therapist as distant, but the avoidant patient prevented closeness by a minimal expression of feelings, and the preoccupied described strong frustration with the therapist in a one-sided manner that prevented collaborative processing and left the therapist confused.

Discussion

It appears that patient discourse is a stable (trait-like) component of attachment, while the therapeutic-distance is a process (state-like) component that may change along therapy. The discourse of insecure patients may hinder therapists' ability to adjust the therapeutic-distance to patients' needs. Therapists' knowledge about the ways patients with different attachment classifications communicate their proximity wishes may improve their attunement.

Therapists’ Emotional Responses in Individual Therapy with Depressed Adolescents: An Evaluation of the Data Structure of the Feeling-Word Checklist—28

Countertransference (CT) responses during therapy sessions can be understood as the therapist’s emotional reactions towards the patient. Within adolescents’ psychotherapy, little is known about the effects of the therapists’ feelings on treatment outcome. The Feeling-Word Checklist—28 (FWC-28) is a self-report questionnaire designed to evaluate the therapist’s in-session feelings during therapy with younger patients. The aim of the study was to evaluate the psychometric properties of the clinician-rated FWC-28 and explore the associations between the CT-subscales and therapeutic alliance. Data were collected from a randomized controlled trial in which 11 therapists specialized in child and adolescent psychotherapy treated 16- to 18-year-old patients (n = 62) with major depressive disorder in outpatient clinics. The patients received psychodynamic psychotherapy treatment over 28 sessions. Therapists rated their emotional responses towards their patients on FWC-28 after sessions 3, 12, 20, and 28. Principal component analysis (PCA) with oblique rotation was performed to find clinically meaningful subscales of the FWC-28. PCA revealed four clinically meaningful components termed as follows: inadequate, confident, motherly, and disengaged. The psychometric properties of the FWC and the reliability of the CT subscales measured with Cronbach’s alpha were acceptable. The therapist-reported alliance showed significant and clinically meaningful correlations with all CT-subscales. Our findings indicate that the checklist is adequate for clinical practice and countertransference research in adolescents’ psychotherapy.

Some directions for research and theory on countertransference

The topic of countertransference (CT) has been a controversial one over the decades, and its various, often conflicting, definitions have made it difficult to gather clear and consistent empirical evidence about the phenomenon. The growing awareness that CT occurs across theoretical orientations has fueled the need for research on CT, its effects, how it emerges in treatment, and how it can be used to enhance psychotherapy. In this paper, we reflect on three studies published in the special section on CT that we believe advance the field of CT research. We also provide future directions for CT theory and research, including attending to CT definitions and their rationale in empirical studies, striving for methodological diversity, differentiating acute and chronic CT, and continuing to investigate CT management.