Transference, countertransference, emotional expression, and session quality over the course of supportive expressive therapy: The raters' perspective

Abstract

Independent judges rated transference, countertransference, therapist emotional expression, and session quality, in videotaped sessions of Supportive Expressive Psychotherapy for Depression over time. Based on 44 patients and four therapists, HLM analyses suggested that negative transference predicted therapist expression of negative affect. While negative transference predicted a rough session, positive transference predicted a deep session. Positive countertransference and positive affect predicted a smooth but superficial session, with positive transference sometimes acting as a moderator. Sessions became less deep and smoother over time, with therapist emotional expression moderating the relationship between treatment phase and depth. The results suggest that positive countertransference behaviors and feelings have a particularly negative impact on a session and that transference contributes to a deep and rough session.

Unabhängige Rater beurteilten die Übertragung, Gegenübertragung, den emotionalen Ausdruck des Therapeuten und die Sitzungsqualität von Sitzungen einer Supportiven Psychotherapie bei Depressionen, welche auf Video aufgenommen wurden. Basierend auf 44 Patienten und 4 Therapeuten indizierten die Ergebnisse von HLM Analysen, dass negative Übertragungen den Ausdruck von negativem Affekt durch den Therapeuten vorhersagten. Während negative Übertragungen herausfordernde Sitzungen vorhersagten, prädizierten positive Übertragungen intensiv-tiefgründige Sitzungen. Positive Gegenübertragungen und positiver Affekt prädizierten ruhige aber oberflächliche Sitzungen, wobei positive Übertragung hier in einigen Fällen als Moderator fungierte. Sitzungen wurden oberflächlicher und ruhiger im Zeitverlauf, wobei der emotionale Ausdruck des Therapeuten den Zusammenhang zwischen Behandlungsphase und Oberflächlichkeit moderierte. Die Ergebnisse legen nah, dass positives Gegenübertragungsverhalten und –gefühle einen wesentlichen negativen Einfluss auf eine Sitzung haben und dass Übertragung zu einer tiefgreifenden und herausfordernden Sitzung beiträgt.

Giudici indipendenti hanno valutato nel tempo transfert, controtransfert, espressione emotiva del terapeuta e qualità delle sedute, in session videoregistrate di Psicoterapia Supportivo-Espressiva per la depressione. Analisi HLM, basate su 44 pazienti e quattro terapeuti, hanno suggerito che il transfert negativo prediceva l'espressione di emozioni negative nel terapeuta. Mentre il transfert negativo era predittore di una session spigolosa, il transfert positivo prediceva una session profonda. Il controtransfert positivo e un sentimento positivo erano predittori di una session calma ma superficiale, con il transfert positivo che a volte agiva in qualità di moderatore. Le sessioni sono diventate meno profonde e più calme nel tempo, con l'espressione emotiva del terapeuta che mediava la relazione tra la fase del trattamento e la profondità. I risultati suggeriscono che comportamenti e sentimenti controtransferali positivi hanno un impatto particolarmente negativo sulla session e che il transfert contribuisce ad una session profonda e turbolenta.

Juízes independentes classificaram transferência, contratransferência, expressão emocional do terapeuta, e a qualidade de sessão, através de sessões gravadas em vídeo da Psicoterapia Expressiva de Suporte para a Depressão ao longo do tempo. Baseada em 44 pacientes e quatro terapeutas, as análises HLM sugeriram que a transferência negativa pressupõe uma terapia expressiva de efeito negativo. Enquanto a transferência negativa pressupõe uma sessão intensa, a transferência positiva pressupõe uma sessão profunda. Contratransferência positiva e afeto positivo pressupõem uma sessão suave, mas superficial, com a transferência positiva, por vezes atuando como um moderador. As sessões tornaram-se menos profundas e suaves ao longo do tempo, com uma terapia de expressão emocional moderando a relação entre a fase de tratamento e a profundidade. Os resultados sugerem que os comportamentos e sentimentos de contratransferência positiva têm um impacto particularmente negativo na sessão, e que a transferência contribui para uma sessão profunda e intensa.

Jueces independientes evaluaron la transferencia, contratransferencia, expresión de los afectos por parte de los terapeutas y calidad de las sesiones a lo largo del tiempo en sesiones video-grabadas de Terapia Soportativo-Expresiva para la depresión. El análisis del material de 44 pacientes y 4 terapeutas sugirió que la emergencia de transferencia negativa por parte del paciente predice la expresión de afectos negativos por parte del terapeuta. Mientras que la transferencia negativa predijo una sesión dura, la transferencia positiva predecía una sesión profunda. La contratransferencia positiva y la expresión de afectos positivos predecían una sesión fluida pero superficial, en la cual la transferencia positiva funcionaba a veces como un moderador. Las sesiones tendían a volverse más suaves y menos profundas a medida que pasaba el tiempo, mientras que las expresiones en relación a los afectos por parte del terapeuta moderaban la relación entre la fase en que se encontraba el tratamiento y su profundidad. Los resultados sugieren que los sentimientos y las conductas por parte del terapeuta basados en la contratransferencia positiva tienen un impacto particularmente negativo sobre el desarrollo de la sesión y que la transferencia contribuye a la profundidad y dureza de la sesión.

Keywords:

• process research
• psychoanalytic/psychodynamic therapy

Acknowledgements

The original study was funded by NIMH grant R01 MH 061410 to Jacques P. Barber.

Notes

1. Judges rated every process measure for each session, which may create an artificial dependency between scores used as criterion and predictor in our subsequent analyses (e.g., a judge feels particularly positive toward a therapist in a given session and therefore gives high ratings on both positive countertransference and session depth). The following steps were taken to reduce the impact of any artificial dependency. We averaged scores for each measure across the five judges, which is likely to reduce the influence of any one judge's scores on the relation to scores on other measures. In addition, we tested whether a given judge's score on a predictor variable is more related to his or her own score on a criterion variable for a given session compared to the relation of the other judges' predictor scores to that same judge's criterion score for that session. We conducted HLMs for each pairing of criterion and predictor (positive countertransference and positive transference, positive countertransference and therapist emotional expression, and so on) that we used in subsequent analyses (HLM was used to control for the nested nature of the data). Every judge's criterion score for a given session was regressed on the scores of a predictor variable from each of the five judges, a dummy-coded variable for whether the predictor score came from the original judge or one of the other four judges, and the interaction of the predictor and dummy-coded variable. In essence, each criterion score from a judge for a given session was paired off with his or her predictor score for that session and every other judge's predictor scores, and each judge's criterion score for that same session was similarly treated. If the interaction were significant, it would indicate bias, or that the relation of criterion and predictor scores was stronger (or potential weaker) when they came from the same judge than when scores came from different judges. Of the 16 analyses, only three had a significant interaction. Ratings of negative countertransference were more related to session smoothness (r _own (569) = −.09 vs. r _different (2294)=.01), as were ratings of therapist emotional expression (r _own (569)=.37 vs. r _different (2294)=.17). Positive countertransference scores were more associated with depth scores when taken from the same judge (r (569) = −.29) than from different judges (r (2294) = −.02). When interpreting any relations involving these predictors and criteria, we make note of the potential for bias.

2. Four patients provided only one data point so modeling change over their therapy was not possible.