The Accuracy of Therapists' Interpretations and the Development of the Therapeutic Alliance

Deutungen: eine qualitative Studie unmittelbarer Patientenreaktionen

Klassische psychoanalytische Deutungen stießen in den letzten Jahren vermehrt auf Kritik: Demnach würden diese Deutungen der therapeutischen Beziehung schaden, Blockaden auslösen und mit einer problematischen therapeutischen Haltung einhergehen. Anhand der Tonbandaufnahmen von 35 psychoanalytischen Sitzungen im mittleren Behandlungsverlauf, die im Rahmen der Münchner Psychotherapiestudie aufgezeichnet wurden, wurden 23 klassische Deutungen in 16 Sitzungen identifiziert und die Reaktionen der Patientinnen und Patienten darauf mittels der Grounded-Theory-Methode analysiert. Die Reaktionen wurden in sieben Kategorien zusammengefasst, von denen zwei als unerwünscht gelten können (z. B. „Rückzug“ oder „Konfrontation“). Die Mehrzahl der Reaktionen der Patientinnen und Patienten auf klassische Deutungen fiel allerdings in Kategorien, die als fruchtbar angesehen werden, z. B. „kognitive Erkenntnis“ oder „emotionale Resonanz“. Demnach kann die teils heftige Kritik an klassischen Deutungen in unserer Studie nicht bestätigt werden.

Children Witnessing Domestic Violence in the Voice of Health and Social Professionals Dealing with Contrasting Gender Violence

Witnessing domestic violence (WDV) is recognized by the Istanbul Convention as psychological abuse that has dramatic consequences on the psychophysical health of children. Therefore, professionals who form the support network for WDV victims play a very fundamental role. In order to draw up useful guidelines for services dealing with WDV, and to give children more awareness of supportive settings, this study analyzes WDV in the perception of health and welfare professionals to enhance their skills and strategies for contrasting gender violence. Sixteen Neapolitan specialists dealing with WDV children were interviewed. A theoretical intentional sampling was used. Narrative focused interviews were carried out, transcribed verbatim and analyzed through the grounded theory methodology, using the ATLAS.ti 8 software (Scientific Software Development GmbH, Berlin, Germany). We assigned 319 codes and grouped these into 10 categories and 4 macro-categories. The analysis of the texts led to the definition of the core category as "The Crystal Fortress". It summarizes the image of the WDV children as described by the professionals working in contrasting domestic violence. In this structure the parental roles of protection and care (fortress) are suspended and everything is extremely rigid, fragile and always at risk of a catastrophe. It also symbolizes the difficult role of health professionals in dealing with such children and their families. For WDV children, protective factors guarantee solid development and supportive settings help them to learn proper emotional responsiveness and expressiveness and to develop their skills in talking with adults while avoiding negative consequences.

Helping Skills, Working Alliance, and Session Depth in China: A Multilevel Analysis

Ninety-five first-year master’s-level students in China conducted three helping sessions with two volunteer clients. After every session, clients completed measures assessing trainees’ use of helping skills, working alliance, and session depth. Results of a multilevel analysis indicated that: (a) between-trainee and between-client exploration skill use was related to better working alliance reported by the client, and between-session exploration skill use was related to greater session depth; (b) between-trainee, between-client, and between-session insight skill use was related to better working alliance, but none of these components were related to session depth; and (c) between-trainee action skill use was negatively related to client report of working alliance. We discuss theoretical and practical implications from the multilevel framework, considering the Chinese cultural context.

Are psychodynamic and psychoanalytic therapies effective? A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence-based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identified by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty-two RCTs were identified of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identified: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post-traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance-related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi-experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.

The relationship between therapeutic alliance and patient's suicidal thoughts, self-harming behaviours and suicide attempts: A systematic review

BACKGROUND

Suicidality is a common concern for people with mental health problems. The interpersonal nature of suicidality suggests that therapeutic alliance may be important when working clinically with suicidal patients. This paper is a systematic review of studies investigating the association between alliance and treatment outcome relating to suicidal ideation and behaviours.

METHODS

Systematic searches of PsychINFO, MEDLINE, AMED, EMBASE, Web of Science and CINAHL were completed using words that captured the concepts of alliance and suicidality. Eligible studies: involved participants aged 18-years-old or over; used a validated measure of therapeutic alliance; and reported associations between alliance and suicidality. Abstracts, qualitative studies and articles not written in English were excluded.

RESULTS

Twelve studies were included. Findings indicated that alliance is associated with suicidality. Alliance was related to suicidality in eleven of the papers. Self-harming behaviours had the strongest association with patient-rated alliance. Suicide attempts had the weakest association, possibly due to the infrequency of suicide attempts in the studies reviewed.

LIMITATIONS

The twelve studies were heterogeneous in terms of the measure of alliance used, method of assessing suicidality, clinical setting and professional-type. This variability limited the degree to which findings could be synthesised.

CONCLUSION

Therapists, care-coordinators and mental health teams should recognise the importance of building a strong therapeutic alliance with suicidal patients. Researchers should use consistent methods of measuring alliance and assessing suicidality in future studies. Clinicians and researchers should note that suicidal thoughts, self-harm and suicide attempts may be related to alliance in different ways and therefore should be assessed as separate constructs.

Fluctuations in alliance and use of techniques over time: A bidirectional relation between use of "common factors" techniques and the development of the working alliance

OBJECTIVE

The aim of this study was twofold: (a) Investigate whether therapists are consistent in their use of therapeutic techniques throughout supportive-expressive therapy (SET) and (b) Examine the bi-directional relation between therapists' use of therapeutic techniques and the working alliance over the course of SET.

METHOD

Thirty-seven depressed patients were assigned to 16 weeks of SET as part of a larger randomized clinical trial (Barber, Barrett, Gallop, Rynn, & Rickels, ). Working Alliance Inventory-Short Form (WAI-SF) was collected at Weeks 2, 4, and 8. Use of therapeutic interventions was rated by independent observers using the Multitheoretical List of Therapeutic Interventions (MULTI). Intraclass correlation coefficients assessed therapists' consistency in use of techniques. A cross-lagged path analysis estimated the working alliance inventory- Multitheoretical List of Therapeutic Interventions bidirectional relation across time.

RESULTS

Therapists were moderately consistent in their use of prescribed techniques (psychodynamic, process-experiential, and person-centred). However, they were inconsistent, or more flexible, in their use of "common factors" techniques (e.g., empathy, active listening, hope, and encouragements). A positive bidirectional relation was found between use of common factors techniques and the working alliance, such that initial high levels of common factors (but not prescribed) techniques predicted higher alliance later on and vice versa.

CONCLUSION

Therapists tend to modulate their use of common factors techniques across treatment. Additionally, when a strong working alliance is developed early in treatment, therapists tend to use more common factors later on. Moreover, high use of common factors techniques is predictive of later improvement in the alliance.

Simulation modeling analysis of sequential relations among therapeutic alliance, symptoms, and adherence to child-centered play therapy between a child with autism spectrum disorder and two therapists

This study examined the sequential relations among three pertinent variables in child psychotherapy: therapeutic alliance (TA) (including ruptures and repairs), autism symptoms, and adherence to child-centered play therapy (CCPT) process. A 2-year CCPT of a 6-year-old Caucasian boy diagnosed with autism spectrum disorder was conducted weekly with two doctoral-student therapists, working consecutively for 1 year each, in a university-based community mental-health clinic. Sessions were video-recorded and coded using the Child Psychotherapy Process Q-Set (CPQ), a measure of the TA, and an autism symptom measure. Sequential relations among these variables were examined using simulation modeling analysis (SMA). In Therapist 1's treatment, unexpectedly, autism symptoms decreased three sessions after a rupture occurred in the therapeutic dyad. In Therapist 2's treatment, adherence to CCPT process increased 2 weeks after a repair occurred in the therapeutic dyad. The TA decreased 1 week after autism symptoms increased. Finally, adherence to CCPT process decreased 1 week after autism symptoms increased. The authors concluded that (1) sequential relations differ by therapist even though the child remains constant, (2) therapeutic ruptures can have an unexpected effect on autism symptoms, and (3) changes in autism symptoms can precede as well as follow changes in process variables.

Tailoring common treatment principles to fit individual personalities

The American Psychological Association Task Force headed by Castonguay and Beutler (2006) distilled general treatment principles common to all therapies from the empirical literature. As part of this work, Critchifield and Benjamin (2006a, 2006b) summarized principles for treatment of personality disorder. The principles are pragmatic in the sense that they are based on evidence of what works, and clinicians are encouraged to apply them in ways that fit the unique presentation and needs of a given patient. An important element of the recommended approach is that it be coherent, well-coordinated, and agreed upon by the patient. Additional principles emphasize the importance of an individual's attachment and trauma history. A complex case example is presented to illustrate one way in which emphasis on an individual's relational learning history can be used to further refine and extend wisdom inherent in the cross-cutting principles and move in the direction of an integrative treatment that is closely tailored to specific case features. A research approach is also outlined for how to test the validity of principles that prescribe differential use of technique to address diverse patient presentations.

Therapeutic alliance and change in suicidal ideation during treatment in integrated primary care settings

A strong therapeutic alliance is considered to be an essential factor for the effective assessment and management of suicidal patients; however, to date this has received little empirical attention. The current study evaluated the association of future change in suicidal ideation with therapeutic alliance during first appointments with primary care behavioral health consultants. The Behavioral Health Measure (BHM; Kopta & Lowery, 2002 ) and Therapeutic Bond Scale (TBS; CelestHealth Solutions, 2006) were completed by 497 primary care patients who kept 2 to 8 appointments with the integrated behavioral health consultant. Results indicated that suicidal ideation generally improved over the course of several behavioral health appointments and that therapeutic alliance was rated very high by patients. Therapeutic alliance during the first appointment was not associated with eventual change in suicidal ideation.

Interaction between alliance and technique in predicting patient outcome during psychodynamic psychotherapy

The current study examined whether alliance interacted with psychodynamic interventions to predict patients' psychotherapy outcomes. A prospective study of psychodynamic psychotherapy with 68 outpatients who were treated by 23 therapists was used. The patients rated the alliance with their therapist early in treatment. Therapist use of psychodynamic techniques was reliably rated by independent clinicians for the same sessions. The therapy outcomes were measured at the end of treatment based on the patients' global symptomatology as well as estimate of improvement across a broad range of functioning. In all models, we controlled for the patients' pretherapy psychiatric severity. Analyses were conducted using multilevel modeling to account for therapist effects. Results revealed that patient rated alliance was significantly related to improvement on a measure of broad band functioning. In addition, alliance and psychodynamic interventions interacted to predict this scale of multidimensional therapy outcome. Further, results showed that several individual psychodynamic techniques interacted with alliance that were meaningfully related to this measure of broad band outcome including (1) linking current feelings or perceptions to the past; (2) focusing attention on similarities among patient's relationships repeated over time, settings, or people; and (3) identifying recurrent patterns in patient's actions, feelings, and experiences. In this sample of outpatient psychodynamic treatments, the dynamic techniques were most effective when provided in the context of strong alliances.

Program, counselor, and patient variability in the alliance: a multilevel study of the alliance in relation to substance use outcomes

We explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N = 1,613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale. Using multilevel modeling, we found that alliance was related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance-outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient-counselor alliance.

Triadic nonverbal communication in mother-infant consultations: Two contrasted cases

The aim of the present case study was to present and discuss the analysis of triadic nonverbal communication between mother, infant, and therapist in two early consultations as an indicator of the therapeutic alliance. The analysis explored nonverbal triadic interactions (body positions and facial orientations of the mother, infant, and therapist, and expressive behaviors of the infant) and triadic affective sharing (via a microanalytic interview of the therapist). The quality of the therapeutic alliance and clinical outcome for each case are described. The description of the two cases illustrates the importance of the progressive development of nonverbal "engagement" by the three people (triadic alliance) and of moments with triadic emotional sharing. The contribution of the therapist appears to be crucial, in particular via his or her body and affective engagement with the infant. The triadic alliance appears to be both an indicator of the therapeutic alliance and an element that can foster it.

Therapist technique and patient defensive functioning in ultra-brief psychodynamic psychotherapy: a Lag sequential analysis

This study examined the association between therapist interventions, including interpretations, and patient defensive functioning. The first session of 32 (n = 32) Brief Psychodynamic Interventions were rated for therapist interventions and patient defensive functioning. Lag sequential analysis was used to determine if (a) there are organized sequences of therapist interventions; (b) there are predictable sequences in the patients' level of defensive functioning; (c) there are sequences of therapist interventions leading to change in the patients' defensive functioning; and (d) there are levels of patient defensive functioning leading to organized therapist response. Results suggested that there are organized sequences in the therapists' interventions and that patient in-session defensive functioning is relatively stable. However, no chain of therapist interventions led to a predictable response in the patients' defensive functioning or vice versa.

Subject and interviewer determinants of the adequacy of the dynamic interview

The dynamic interview is widely used in clinical and research settings, but factors associated with an adequate dynamic interview have not been systematically studied. Twenty-six subjects had a median of 3 dynamic interviews at least 6 months apart, conducted by 13 clinician interviewers. We examined the resulting 72 videotaped interviews for predictors of dynamic interview adequacy. Overall Dynamic Interview Adequacy was not explained by subject, occasion, or interviewer, per se, although significant negative effects were found for personality disorder and borderline personality scores and diagnoses of major depression and dysthymia, and positive effects for interviewer experience. Dynamic adequacy was related to overall breadth and depth of topic coverage (R2 = 0.424). However, in stepwise multiple linear regression, 5 therapeutic alliance factors together contributed an R2 = 0.768, diminishing the effect of topic coverage. Adequate dynamic interviews established a positive subject-interviewer interaction, facilitated subject exploration, and minimized technical interviewing errors, thereby yielding sufficient topic coverage.

Are relationship patterns with significant others reenacted with the therapist?: a study of early transference reactions

This study examines how patients' relationship patterns are reenacted with the therapist during the first sessions of psychotherapy. Forty (N = 40) outpatients treated with a Brief Psychodynamic Intervention were included in the study. Their narratives of relationship episodes with significant others (e.g., mother, father, romantic partner, colleagues) were compared with relationship episodes with their therapist using the Core Conflictual Relationship Theme method. The Core Conflictual Relationship Theme focuses on 3 aspects of patients' relationship narratives: what the patient wants from others or from self; how others react to his/her wish; and how the patient consequently reacts. Results showed that 60% of patients display similar relationship patterns with their therapist and with significant others. The patterns that were reenacted with the therapist were not the most pervasive ones but were similar to those found in relationship episodes involving parents or romantic partners. These findings provide some support for the clinical concept of repetition of internalized relational patterns with the therapist very early in psychotherapy. Clinical implications are discussed.

Teaching evidence-based psychotherapies

Currently our field is actively involved in developing new ways to characterize and treat children and adolescents with psychiatric disorders and in evaluating the effects of our therapies. We also are beginning to examine the effectiveness of our teaching methods. This article presents evidence for, ideas about, and a philosophy to guide individuals who are privileged to train child psychiatrists in psychotherapies. Specifically, it discusses the issues of the evidence base for diagnosis and for nonspecific and specific active elements of child psychotherapy. Evidence for methods of training is presented. The article addressed the need for supervising psychiatrists to keep abreast of developments in teaching methods so that we can best train competent, curious, and compassionate child psychiatrists.

Sources of psychiatric staff members' feelings towards patients and treatment outcome

This study had two purposes. The first was to assess to what extent psychiatric staff members' feelings towards patients in small psychiatric units could be attributed to (a) the individual staff member's habitual feeling style, (b) stable and consistent feelings towards individual patients (the patient's evocative style) and (c) the interaction between these two factors. The second purpose was to analyse the associations between the proportions of these factors and the average outcome for the patients in the units. The study was based on a previously presented model for analysing sources of staff counter-transference. The model specifies contributions from the different sources by using two-way ANOVAs. In the present study, data from 21 psychiatric treatment units for patients with psychosis and personality disorder were used. The results indicated that the staff members' individual habitual feeling style and the interaction between this habitual feeling style and the patient's evocative style contributed most to the variance in staff feelings. Patients' individual evocative patterns contributed less. Positive treatment outcome was mainly negatively associated with contributions to the staff counter-transference from these sources, implying that fixed patterns in personal feeling style or fixed reaction styles to individual patients had a negative influence on outcome.

The History and Empirical Status of Key Psychoanalytic Concepts

Over the past century, the ideas set out in psychoanalytic theory have permeated the field of psychology as well as literature, art, and culture. Despite this popularity, analytic theory has only recently received empirical support. In this chapter, we seek to highlight several fundamental concepts of analytic theory (the unconscious, drives, defenses, object relations, Oedipus complex) and psychodynamic treatments (transference, countertransference, interpretations, resistance). The first section of the chapter offers a comprehensive definition and historical background for each concept. This foundation is followed by a review of the empirical evidence supporting the reliability and validity of these concepts, their impact on treatment, and their broader influence on the future of psychology.

How to address patients' defences: a pilot study of the accuracy of defence interpretations and alliance

This pilot study examined the accuracy of therapist defence interpretations (TAD) in high-alliance patients (N = 7) and low-alliance patients (N = 8). TAD accuracy was assessed in the two subgroups by comparing for each case the patient's most frequent defensive level with the most frequent defensive level addressed by the therapist when making defence interpretations. Results show that in high-alliance patient-therapist dyads, the therapists tend to address accurate or higher (more mature) defensive level than patients most frequent level. On the other hand, the therapists address lower (more immature) defensive level in low-alliance dyads. These results are discussed along with possible ways to better assess TAD accuracy.

Clinical tasks of the dynamic interview

We examined psychodynamic interview tasks and techniques to identify clinical actions that improve or impede exploration of subjects' emotional responses, conflicts, defenses, and central relationship themes. This article extends previous quantitative studies (Perry, Fowler, & Greif, unpublished; Perry, Fowler, & Semeniuk, 2005) by examining interview vignettes in 50-minute psychodynamic research interviews. We conducted qualitative analyses on 72 dynamic research interviews given by 26 subjects to delineate categories of tasks and interventions. Results indicated five broad tasks of the dynamic interview: 1) Frame Setting; 2) Offering Support; 3) Exploring Affect; 4) Offering Trial Interpretations; and 5) Providing a Formulation and Feedback of relationship themes and conflicts. We further selected two interviews each from 10 subjects, in which there was a difference of one standard deviation or greater on the Overall Dynamic Interview Adequacy scale (Perry, 1999), and interviewer errors from the Therapeutic Alliance Analogue scale (Perry, Brysk, & Cooper, 1989). We utilized excerpts from these interviews to highlight the importance of these tasks and techniques in deepening discussion of dynamically meaningful material.

Therapist sensitivity towards emotional life-career issues and the working alliance with suicide attempters

This study investigated the usefulness of an action theoretical model of suicide in interviewing suicide attempters. Eighteen interviews were video-recorded and transcribed. The patients' narratives were reconstructed and life-career issues relevant for the patient's suicidality formulated. Skin conductance response was used to determine narrative content associated with actualized emotions. Scores of the patients' ratings of helping alliance experienced in the interview were positively associated with the therapists' sensitivity towards emotionally relevant life-career issues. Furthermore, relationship satisfaction was related to a narrative interviewing style. We conclude that working alliance in clinical interviews with suicide attempters can be improved when the interviewer uses a patient-oriented approach aimed at understanding the patient's suicidality in the context of personal life-career, or identity issues.

A review of therapist characteristics and techniques positively impacting the therapeutic alliance

The present review is a comprehensive examination of the therapist's personal attributes and in-session activities that positively influence the therapeutic alliance from a broad range of psychotherapy perspectives. Therapist's personal attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to contribute positively to the alliance. Therapist techniques such as exploration, reflection, noting past therapy success, accurate interpretation, facilitating the expression of affect, and attending to the patient's experience were also found to contribute positively to the alliance. This review reveals how these therapist personal qualities and techniques have a positive influence on the identification or repair of ruptures in the alliance.

Interaction of therapeutic process and alliance during psychological assessment

Utilizing a collaborative therapeutic assessment (TA) model proposed by Finn and Tonsager (1997), we examined the interaction between therapeutic alliance and in-session process during the assessment phase of treatment. This study compares the utility of the TA model (n = 38) versus a traditional information gathering model (n = 90) of assessment. The results of this study indicate that the use of a TA model may decrease the number of patients who terminate treatment against medical advice. The Session Evaluation Questionnaire (Stiles & Snow, 1984), Combined Alliance Short Form (Hatcher & Barends, 1996), and Penn Helping Alliance Questionnaire-Revised (Barber & Crits-Christoph, 1996) can reliably measure the patient's experience of the assessment. The psychological assessment process may impact the patient's experience of assessment feedback and aid in the development of a therapeutic alliance. The therapeutic alliance developed during the assessment was found to be related to alliance early in psychotherapy. We discuss the theoretical, clinical, and research implications of these findings.

Reliability and base rates of interpersonal themes in narratives from psychotherapy sessions

We present an analysis of the reliability and base rates of the interpersonal contents of narratives told by patients in psychotherapy. Trained judges rated two samples, including 60 opiate-dependent patients in cognitive or psychodynamic therapy and 72 depressed patients in cognitive or interpersonal therapy. Using a comprehensive system based upon a circumplex model and involving 104 separate categories, we found that most categories of interpersonal behavior could be rated reliably. Potential problem categories were identified and strategies for increasing reliability are discussed. In particular, categories related to the concept of the introject (what the self does to the self) had low reliability. An analysis of the base rates of interpersonal themes revealed that issues related to autonomy/ assertion were most prevalent, although some differences between the two samples were evident. The implications of the results for research on narratives and models of psychotherapy are discussed.

Transference in Everyday Experience: Implications of Experimental Research for Relevant Clinical Phenomena

Experimental research examining the clinical concept of transference ( S. Freud, 1912/1958 ; H. S. Sullivan, 1953 ) using a social–cognitive model has demonstrated that mental representations of significant others are stored in memory and can be activated and applied in new social encounters, with consequences for cognition, evaluation, affect, motivation, expectancies, and self-evaluations ( S. M. Andersen & N. S. Glassman, 1996 ; S. M. Andersen, I. Reznik, & S. Chen, 1997 ). These findings constitute an empirical demonstration of transference in everyday social relations and suggest that transference is a normal, nonpathological process, occurring both inside and outside of psychotherapy, following basic rules of social information processing. In this article, clinical implications of this research are discussed, including how the content versus process of transference may contribute to maladaptive transference responses and the potential value of identifying triggering cues in transference in real life and in therapy, to promote more adaptive responding.