Countertransference Responses Research Articles

Rethinking treatment failures. Research on a group of Italian psychotherapists.

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

Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the Psychodynamic Diagnostic Manual - third edition.

Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians' emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician's subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.

“Being affected by the other”: psychodynamic supervisors’ experiences of supervisory countertransference

This qualitative study investigated how psychodynamically-oriented supervisors experienced supervisory countertransference towards their supervisees and their understandings of this phenomenon. Seven supervisors located in the United Kingdom (UK) were recruited. Individual audio-recorded, semi-structured interviews were used to gather the participants’ subjective accounts of this phenomenon. Data was analysed using Interpretative Phenomenological Analysis (IPA). Most of the participants described experiencing supervisory countertransference towards supervisees who were not of the same gender as them. Although definitions of supervisory countertransference have linked this phenomenon to unresolved supervisor issues and blind spots, only one supervisor specifically referred to past experiences that shaped her supervisory countertransference response. Notably, some of the supervisors continued to be affected by their experiences many years after the supervision ended. The study’s findings underscored the importance of attending to and processing perturbing supervisory countertransference. Future research could explore the ways in which supervisory countertransference is shaped by gender dynamics and its contribution to supervisory discord.

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.

Empirical support for the use and further study of the countertransference construct in the clinical care of patients with bipolar disorder.

We thank Andrew Shaw and colleagues for their recent paper1 inBipolar Disorders, highlightingthat theeffectivetreatment of patients with bipolar disorder requires a good therapeutic alliance,which is related to the clinicians' countertransference reactions and their management. The authorssuggestthat the integration of a psychodynamic approach into the biological paradigm in psychiatry might be helpful to increase countertransference awareness in clinicians, andpotentially improvingdyadic communication,resolution ofalliance ruptures, and treatment adherence. Theyalsomention that although the theoretical literature on countertransference is well developed, no good empirical studies exist that investigate the countertransferential responses experienced by mental health clinicians involved in the care of individualsduring acute phases of bipolar disorder. We would, however, like to add some examples of empirical evidence for the use (and further study) of the countertransference in the clinical care of these patients.

Trauma and abuse

In this paper I reflect on my work with adult patients and the Tavistock based sexually abused girls study. I discuss two young women who came for help with their relationships, but subsequently disclosed having been sexually abused as children. I was particularly interested since contrary to what one might expect, the young woman who seemed to enjoy better relationship with her mother did less well in treatment. These two patients are contrasting and this underlines the importance of focussing on specific aspects of the primary maternal object relationship that are unique to each individual in understanding the ability to benefit from therapy. Important features shared across the two patients such as PTSD, the distortion of time, and the role of the father are considered. The timing of the disclosure is also an issue. Both patients elicit strong countertransference responses that were difficult to manage and the value of supervision was stressed. The author tries to address two questions, why the patient who had a better maternal relationship did not benefit as much, secondly the point in treatment when the disclosure occurred.

In Their Own Words: The Impact of Indirect Trauma Exposure on Judges Presiding Over Cases Involving Minors Involved in Sex Trafficking

AbstractThough secondary traumatic stress has been researched extensively among professionals working with youth in diverse professions, there is limited information about judicial experiences working with trafficked youth. This qualitative study involves 82 interviews with juvenile and family court judges to understand the impact of indirect trauma exposure. Over 80% of respondents describe symptoms of secondary traumatic stress and countertransference responses. Notably, 20% with these symptoms also reported increased professional pride in their role performance with these cases. Implications for how judges can address the effects of indirect exposure are offered based on the literature and the recommendations of the respondents.

Countertransference responses mediate the relationship between patients’ overall defense functioning and therapists’ interventions

Objective: The aim of this work was to investigate the relationship between therapists’ techniques (supportive/expressive intervention level – ESIL), therapists’ countertransference (CT) and patients’ defense level of functioning (ODF). We hypothesized that CT could play a mediating role in the relationship between patients’ ODF and therapists’ ESIL. Method: 65 psychotherapy sessions were rated by two different raters each with the Psychodynamic Interventions Rating Scale and the Defense Mechanisms Rating Scale. Clinicians used the Therapist Response Questionnaire to provide information on their CT. The 65 sessions referred to 65 clinicians (25 = females, 40 = males; 38 = psychodynamic, 27 = cognitive). More than half of the patients (n = 40; 61.5%) had a diagnosis of personality disorder. Among clinical disorders the most frequent were mood (n = 12) and anxiety disorders (n = 11). Five patients had no diagnosis. Results: Four CT responses (parental; positive; criticized; overinvolved) completely mediated the relationship between patients’ ODF and therapists’ ESIL, while no effect resulted in relation to overwhelmed, helpless, sexualized and disengaged CTs. No effect of theoretical orientations on mediation pathways was found. Conclusion: Both positive and negative CT feelings seemed to play a crucial role in the relationship between therapists’ interventions and patients’ ODF.

Engaging the Whitewashed Countertransference: Race Unexpectedly Appears for Therapy

ABSTRACT This paper explores into racial presence in psychotherapy when a White therapist works with a White patient, focusing on countertransference responses. I consider ways the sociocultural and political world shape the subjectivities of both partners in psychotherapy and how Whiteness is especially difficult to see and make use of. The need for broader analyses of interactions between inner and outer worlds becomes clear when we hold this focus.

Challenges to making use of countertransference responses during the Covid-19 pandemic – some preliminary thoughts

ABSTRACT Some challenges to clinicians’ use of their countertransference responses during the pandemic are explored, in relation to direct clinical work and supervision. Changes to the setting, shared existential anxieties, as well as a sense that authority figures may be compromised, affect the structure of the clinical encounter. It can be harder in this context to differentiate the anxieties and defences of patient, clinician and supervisor, making it more difficult to be guided reliably by countertransference feelings.

Even though our bodies cannot be in the same place, focussing on body process is helpful in video mediated psychotherapy

ABSTRACT This article is concerned with embodied process and the need to attend to evoked emotion in order to support the transference relationship. I look briefly at Lakoff and Johnson’s work on linguistic metaphor and the way, through embodied cognition, it shapes our conceptual world. Through the use of clinical vignettes, I illustrate how some of my clients use a combination of technology and embodied process to evoke strong emotional and physiological countertransference responses in me. One of the advantages of working online is that, given the chance, our clients use their whole environment to communicate. They access software and use hardware, including furniture, to let us know about their embodied experience. Some of what they use might not be so accessible during face-to-face sessions. I have found that paying attention to what they bring and the emotions aroused enhances our communication and the transference relationship.

상담자의 사회계층 편향성과 내담자 사회계층 배경에 따른 내담자 평가와 역전이 반응

본 연구는 다문화 상담의 관점에서 상담자의 사회계층 편향성 수준과 내담자의 사회계층 배경에 따라 상담자의 내담자에 대한 평가와 역전이 반응에 차이가 있는지를 살펴보았다. 이를 위해 상담자 382명에게 사회계층을 두 가지로 조작한 가상의 내담자의 접수면접지를 제시하여 내담자 평가와 역전이 반응을 측정하였다. 그리고 상담자의 사회계층 편향성 수준에 따라 집단을 구분하여 이원분산분석과 다변량분산분석을 실시하였다. 분석 결과, 첫째 상담자의 사회계층 편향성에 따라 내담자 평가와 역전이 반응의 차이가 유의미하였다. 사회계층 편향성이 높은 상담자 집단은 사회계층 편향성이 낮은 상담자 집단에 비해 내담자를 덜 호의적으로 평가하였으며, 내담자에게 지배 및 적대 역전이 감정을 더 많이 경험하였다. 둘째, 내담자의 사회계층 배경에 따라 상담자의 내담자 평가는 의미 있는 차이가 나타나지 않았다. 셋째, 내담자 평가에 있어서 상담자의 사회계층 편향성과 내담자의 사회계층 배경 사이의 상호작용 효과는 유의하지 않았지만, ‘지배’ 역전이 반응에 있어서는 상호작용 효과가 확인되었다. 사회계층 편향성이 높은 상담자는 사회계층 편향성이 낮은 상담자에 비해서 중산층 내담자가 하류층 내담자보다 지배적이라고 느끼는 것이 밝혀졌다. 마지막으로 이러한 연구결과를 바탕으로 본 연구의 제한점 및 의의에 대해 논의하였다.

Countertransference responses of one music therapist to autistic echolalia

ABSTRACTIntroduction: In this article, the continuation of a previous study, we explored the phenomenon of echolalia in children with Autism Spectrum Disorder (ASD) from the perspective of one music therapist.Method: We micro-analyzed the music therapist’s responses to the echoing of three clients in 40 interaction segments that occurred during music therapy, focusing on their musical and interactive characteristics. We interpreted these responses as stemming from countertransference reactions to the phenomenon of echolalia.Results: The music therapist’s responses were interpreted and classified into six categories, according to their interpersonal and musical attributes: (a) ignoring the client’s echolalia, (b) exhibiting boredom, hyper-activity, and/or despair, (c) attempting to control the situation, (d) attempting to teach the client, (e) using the echolalia to communicate with the client, and (f) showing empathy.Discussion: In the discussion, we attempted to interpret the findings as processes of countertransference and addressed the importance of mapping and understanding the therapist’s reactions to the phenomenon of echolalia. Practical implications for caregivers working with children with ASD were suggested.

Reflections on Offering a Therapeutic Creative Arts Intervention With Cult Survivors: A Collective Biography

A new, evidence-based, multimodal, and creative psychological therapy, Arts for the Blues, was piloted with survivors of cultic abuse in a workshop within a conference setting. The five facilitators, who occupied diverse roles and perspectives within the workshop and research project, reflected on their experiences of introducing this novel intervention to the cult-survivor population. In this underreported territory of using structured, arts-based, psychological therapy with those who have survived cultic abuse, the authors used a process of collective biography to compile a firstperson, combined narrative based on those reflections. This approach allows for a visceral insight into the dynamics and obstacles encountered, and the countertransference responses of the facilitators. This reflexive process shined a light into aspects of research and practice that were not all visible to the individual researchers previously, with implications for research ethics, psychological therapy, and creative arts within the cult-survivor field.

The Imp in the iPhone

ABSTRACTA case vignette involving contemporary communications technology—an iPhone, a computer, digital photos, and Skype—suggests that unconscious communications are not only repetitions of the patient’s ongoing experience and dynamics, but may also be prospective, expressing emerging emotional and psychological potentials that were previously unavailable to the patient. These communications may also provide direction for the treatment via the analyst’s countertransference fantasies and responses. It is also suggested that these bidirectional communications are shared between patient and analyst through an unconscious field akin to what Jung posited as a collective unconscious.

Enhancing the Dyad: The Benefits of Combining Group Therapy with Psychoanalytic Treatment

ABSTRACTIn this article, I consider the benefits of adding group therapy to psychoanalytic treatment. I describe the evolution of combined treatment, advantages of the group modality, and some of the reasons for therapists’ resistance to it. Through clinical example, I describe developmental blocks that became clear during a patient’s analysis, countertransference responses I became aware of during the analysis, and my assessment of the potential risks and benefits of adding group therapy. I then describe how some of the patient’s developmental blocks were engaged after the addition of group therapy, particularly highlighting the to-and-fro between modalities during working-through. Subsequent discussion addresses the indications for the addition of group therapy, specific therapeutic elements gained through combined treatment, and technical challenges confronting the combined therapist.

Countertransference when working with narcissistic personality disorder: An empirical investigation.

Narcissistic personality disorder (NPD) is one of the most challenging clinical syndromes to treat in psychotherapy, especially due to the difficulties of establishing a good enough therapist-patient relationship. Countertransference responses to NPD can be particularly intense, frustrating, and difficult to manage, as is often reported in the clinical literature though not clearly supported empirically. The aims of this study were to (a) investigate the relationship between patients' NPD and therapists' responses; (b) examine the associations between patient, clinician, therapy variables and clinicians' reactions during treatment of NPD patients; and (c) provide an empirically derived portrait of countertransference with NPD. A sample of psychiatrists and clinical psychologists (N = 67) completed the Therapist Response Questionnaire to identify patterns of countertransference, the Shedler-Westen Assessment Procedure-200, and the Global Assessment of Functioning Scale to assess the personality pathology and psychosocial functioning of a patient in their care. The results showed that NPD was positively associated with hostile/angry, criticized/devalued, helpless/inadequate, and disengaged countertransference and negatively associated with therapists' positive response, regardless of patients' personality and psychosocial functioning. NPD patients with stronger traits of cluster B personality pathology tended to elicit more negative and heterogeneous countertransference reactions than NPD patients without these features. The countertransference patterns with NPD patients were not strongly influenced by the variables of clinicians and therapy, with the exception of clinical experience. Overall, the portrait of therapists' reactions to NPD provided a clinically nuanced and empirically founded description strongly resembling theoretical-clinical accounts. The therapeutic implications of these findings were discussed. (PsycINFO Database Record

Factor structure, reliability, and validity of the Therapist Response Questionnaire.

The aim of this study was to examine the stability of the factor structure and psychometric properties of the Therapist Response Questionnaire (Betan, Heim, Zittel Conklin, & Westen, 2005; Zittel Conklin & Westen, 2003), a clinician report instrument able to measure the clinician's emotional reactions to the patient in psychotherapy. A national sample of psychiatrists and clinical psychologists (N = 332) of psychodynamic and cognitive-behavioral orientation completed the Therapist Response Questionnaire, as well as the Shedler-Westen Assessment Procedure-200 (Westen & Shedler, 1999a, 1999b), to assess personality disorders and level of psychological functioning, regarding a patient currently in their care. They also administered the Symptom Checklist-90-Revised (Derogatis, 1994) to the patients. Exploratory and confirmatory factor analyses revealed 9 distinct countertransference factors that were similar to 8 dimensions identified in the original version of the measure: (a) helpless/inadequate, (b) overwhelmed/disorganized, (c) positive/satisfying, (d) hostile/angry, (e) criticized/devalued, (f) parental/protective, (g) special/overinvolved, (h) sexualized, and (i) disengaged. These scales showed excellent internal consistencies and good validity. They were especially able to capture the quality and intensity of emotional states that therapists experience while treating personality-disordered patients, as well as to better differentiate them; additionally, they tapped into the complexity of clinicians' reactions toward patients experiencing severe psychiatric symptomatology. Results seem to confirm that Therapist Response Questionnaire is a valid and reliable instrument that allows to evaluate patterns of countertransference responses in clinically sensitive and psychometrically robust ways, regardless of therapists' orientations. The clinical and research implications of these findings are addressed.

A developmental perspective on adolescent psychoanalytic psychotherapy. An Italian study with the Adolescent Psychotherapy Q-Set

Introduction: despite large and widely accepted research on effectiveness, most of psychotherapy research has been done with adults; few studies have been published on the process of adolescent psychotherapy, due to the complexity of the subject and the absence of instruments sensitive enough to empirically capture its nuances. Within psychoanalytic framework, a developmental approach is particu-larly helpful in the psychotherapy of adolescents. Objective: the purpose of this study was to investigate the typical features of Italian Adolescence Psychodynamic Psychotherapy and its similarities and differences with other adolescence psycho-therapeutic approaches; We also aimed at analyzing typical therapists’ responses to adolescent patients. Method: 50 italian adolescence psychotherapists filled a brief questionnaire about their clinical expertise, completed the Adolescent Psychothe-rapy Q – Set (APQ) and the Therapist Response Questionnaire (TRQ) in order to describe their “actual” practice with adolescents. Results: therapeutic process is characterized by a priority to helping adolescent make sense of his own experience, it focuses on present relationships and emotions rather than on past. Strong similar-ities with Mentalization Based Therapy, mild and no correlations with Cognitive-Behavioral Therapy and Classical Psychoanalysis respectively were found; towards adolescents therapists generaly display positive and protective countertransference responses. They less frequenlty show negative responses as overprotection, hostility or feeling of overwhelming. Conclusions: APQ and TRQ can provide meaningfull information about adolescent psychotherapy process. Instruments’ improvement (i.e. reviewd items for APQ) and future perspectives are also discussed.

Listening to My Mother's Testimony

The article opens with a discussion of the complex inter-relationship between psychoanalysis and testimony. This is followed by a close reading of the author's mother's testimony, viewed for the first time 26 years after it was originally taken by him. The multiple perspectives of this viewing are elucidated: the five-year-old boy through whom the mother tells her story; the adult who has his own memories of the shared survival experiences; the interviewer who listens to the mother and to himself; and the psychoanalyst who reflects on what he hears and what he picks up on repeated hearings of the testimony, noticing market shifts in his own countertransference responses, which enhance his comprehension. Special themes are highlighted, as well as interactions between memories which may illustrate intergenerational transmission of trauma in the making. Three transcribed video excerpts are presented with detailed commentary by the author of this article.