Changes in countertransference and changes in patient working alliance and outcome: An empirical study.

The American Psychological Association task force on empirically supported therapy relationships defined countertransference (CT) management (i.e., awareness of CT) as a "promising" element in psychotherapy research. The present study aimed to examine how changes in therapist CT and awareness of CT relate to therapy process and outcome. The data analysis was based on 41 treatments and used the core conflictual relationship theme to measure CT. We found that changes in therapists' Wishes from the relationship with the patient at the beginning of therapy were related to patients' working alliance and symptom changes at the end of treatment. Changes in therapist awareness of CT moderated the relationship between therapists' wishes from the therapy and patients' symptom changes during therapy. Last, we present a case study and discuss how awareness of CT can help the therapist handle the challenges that arise from it. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Should we feel the same? Mutual recognition and congruence between therapist and client regarding ruptures and repairs.

The pattern of rupture and repair within therapeutic alliances has been associated with improved outcome. The present study adds to this body of research by examining rupture and repair from a dyadic perspective. First, we examined the relationship between mutual recognition of ruptures, rupture intensity, and client ratings of session helpfulness. We then examined client-therapist congruence regarding rupture and repair characteristics and their relation to client ratings of session helpfulness. Data were collected from 90 client-therapist dyads (providing two subsamples of 61 and 45 dyads) during 16 sessions of short-term psychodynamic therapy. Clients and therapists rated the occurrence of ruptures, rupture characteristics, and rupture repair following each session. Clients also rated session helpfulness following each session. We found a significant negative interaction effect, indicating that when clients rated ruptures as more intense, therapist rupture recognition was related to lower client ratings of session helpfulness. Client-therapist congruence in the perception of rupture intensity was positively related to client perceptions of the extent to which ruptures were discussed. Finally, we found a significant positive relationship between client-therapist congruence in their perception of rupture repair and client ratings of session helpfulness. This study demonstrates the significance of the dyadic view of the rupture/repair process. Therapist recognition of ruptures may not be enough to facilitate repair, specifically in ruptures with a high level of intensity. Nevertheless, congruence in intensity is valuable for addressing the rupture within the session, and congruence in repair is valuable for session helpfulness. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Therapists' responsiveness in the process of ruptures and resolution: Are patients and therapists on the same page?

OBJECTIVE: This study examined the association between the rupture-repair process and patients' and therapists' perceptions of the therapist's responsiveness. METHOD: We used the Rupture Resolution Rating System to rate early sessions (3-5) in 35 short-term psychodynamic psychotherapy cases. The patients and therapists rated their perceptions of the therapist's responsiveness after each session using the Patient's Experience of Attunement and Responsiveness (PEAR) Scale. RESULTS: Therapists' contribution to ruptures was negatively associated with both patients' and therapists' PEAR ratings. Confrontation ruptures were negatively associated with patients' PEAR ratings, whereas there was no significant association with withdrawal ruptures. Resolution was positively associated with both patients' and therapists' PEAR ratings. In addition, resolution moderated the negative association between ruptures and patients' PEAR ratings. CONCLUSION: The findings emphasize the link between therapists' responsiveness and the rupture-repair process. They also highlight the significance of providing therapists with the necessary training to recognize these dynamics and engage in discussions about them with their patients when appropriate.

Therapy matchmaking: Patient-therapist match in personality traits and attachment style.

OBJECTIVE: This study examined the relationships between patient-therapist similarity and therapy outcome. We aimed to explore whether patient-therapist match in personality and attachment styles leads to a better therapy outcome. METHOD: We collected data from 77 patient-therapist dyads in short-term dynamic therapy. Patients' and therapists' personality traits (Big-5 Inventory) and attachment styles (ECR) were assessed prior to beginning therapy. Outcome was measured on the OQ-45. RESULTS: When patients and therapists scored either high or low on neuroticism and conscientiousness we found a decrease in symptoms from beginning to end of therapy. When patients' and therapists' combined scores were either high or low on attachment anxiety, we found an increase in symptoms. CONCLUSION: Match or mismatch on personality and attachment style in therapy dyads contributes to therapy outcome.

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.

Changes in clients' relational patterns with parents and therapist during psychodynamic psychotherapy: Their association and relation to treatment outcome.

OBJECTIVE: The study aimed to explore how changes in clients' relational patterns during psychodynamic psychotherapy relate to treatment outcomes and therapy effectiveness. METHOD: Seventy clients receiving psychodynamic psychotherapy in a university counseling center were interviewed three times and filled out the OQ-45 questionnaire five times during therapy. We used the Core Conflictual Relationship Theme (CCRT) to study clients' relational patterns. Mixed models were used to assess the interaction between clients' CCRT intensity toward their parents and toward their therapists, treatment effectiveness, and treatment outcome. RESULTS: First, we found that clients' relational patterns with their parents correlated with relational patterns with their therapists across several time points in therapy. Then, we found significant interactions, indicating that treatment effectiveness moderates the relationship between clients' CCRT intensity and treatment outcomes. CONCLUSIONS: The findings suggest that the transference phenomenon is related to therapy outcomes differently in effective and less-effective therapies, depending on the transference intensity. Further research is needed to expand knowledge about the intensity of transference and its possible impact on treatment choice and management.

Countertransference awareness and treatment outcome.

Countertransference (CT) is considered a central component in the therapy process. Research has shown that CT management does not reduce the number of CT manifestations in therapy, but it leads to better therapy outcomes. In this study, we examined therapists' awareness of their CT using a structured interview. Our hypotheses were (a) treatments in which therapists were more aware of their CT would have a better outcome and (b) different definitions of CT would be related to different therapy outcomes. Twenty-nine patients were treated by 19 therapists in 16 sessions of short-term psychodynamic therapy. We used the core conflictual relationship theme to measure CT, a special interview was developed to study CT awareness. Results show that awareness of CT defined as the relationship with the patient moderated 10 outcome measures and awareness of CT defined as the relationship with the patient that repeats therapist conflicts with significant others moderated three outcome measures We present examples from dyads in this study and discuss how awareness can help the therapist talk to and handle patient challenges. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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

Background Ruptures in the alliance are co-constructed by clients and therapists, reflecting an interaction between their respective personality configurations [Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press]. In order to work effectively with ruptures, therapists should be aware of their own feeling states, acknowledging the subjectivity of their perceptions [Safran, J. D. (2002). Brief relational psychoanalytic treatment. Psychoanalytic Dialogues, 12(2), 171-195. https://doi.org/10.1080/10481881209348661]. Lack of such awareness may be a product of countertransference (CT), which has been shown to be inversely related to outcome. However, when effectively managed, CT contributes to positive outcome [Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507. https://doi.org/10.1037/pst0000189]. Objectives: The present study examined the associations between types of CT and therapists' reports of ruptures and resolutions. Method: Data were collected from 27 therapists, who treated 67 clients in yearlong psychodynamic psychotherapy. CT patterns were assessed based on therapists' Core Conflictual Relationship Themes with their parents, which were repeated in narratives about their clients [Tishby, O., & Wiseman, H. (2014). Types of countertransference dynamics and their impact on the client-therapist relationship. Psychotherapy Research, 24(3), 360-375. https://doi.org/10.1080/10503307.2014.893068]. Results: Negative CT patterns were associated with more ruptures and less resolution. Positive patterns predicted resolution when the therapists repeated positive patterns with parents, but predicted ruptures when they tried to "repair" negative patterns with the parents. These results point to the importance of therapists' awareness of their CT in order to deal effectively with ruptures and facilitate resolution.

How therapists' emotion recognition relates to therapy process and outcome.

Empathy is an essential characteristic for therapists that explained 9% of the variance in treatment outcomes. Many measures of empathy are based on self-report questionnaires. Therefore, they reflect how a person perceives his empathic abilities, which can be biased from his true abilities. The ability to recognize emotions has been found to be related to empathy and serves as a measure for the use of empathic abilities. In this study, we examined therapists' empathic abilities, using a novel task for recognizing emotions, and looked at how they related to the therapy process and outcomes. The study included 33 patient-therapist dyads. Therapist empathy was assessed with an emotion detection task, the JeFEE. Clients filled questionnaires after each session regarding therapy progress and their symptoms. We found that emotion recognition moderated the change in (a) client secure attachment to therapist, (b) client avoidant attachment to therapist, (c) client working alliance, (d) client rate of tense or upset they felt during the session, (e) client lack of emotional clarity of emotions, (f) client non-acceptance of emotional responses, (g) client overall emotion regulation and (h) client main target complaint. Implication for therapy and therapists' selection and training are discussed.

Therapeutic distance in client-therapist narratives: client attachment, therapist attachment, and dyadic effects.

Based on the attachment framework, therapeutic distance conceptualization focuses on closeness-distance dynamics in the therapeutic relationship. We aimed to evaluate the psychometric properties of the Therapeutic-Distance-Scale, Observer-version (TDS-O) and apply a dyadic approach to examine associations between attachment characteristics and therapeutic distance experiences of clients, therapists, and mutual effects. Sixty-six clients and their 29 therapists completed the ECR and relational narratives collected in RAP interviews at early, mid, and late psychodynamic-therapy were rated on TDS-O scales: too close, too distant, autonomy, and engagement. The TDS-O showed good IRR, internal reliability and content validity. Client anxiety was not associated with therapeutic distance but associated with autonomy. Client avoidance associated with clients' experiencing therapist as too close, and lower engagement only at early therapy, but was not associated with therapists' experience. Therapist anxiety was not related to closeness-distance at early therapy but related to gaps between client and therapist experiences at mid and late therapy. Therapist avoidance related to clients experiencing therapists as too close and granting less autonomy at early and mid-therapy, and to therapist experience of distance at late therapy. The findings underscore the importance of therapists' regulating therapeutic distance through attunement to client's interpersonal needs and therapy phase.

Changes in clients and therapists experiences of therapeutic distance during psychodynamic therapy.

Attachment theory provides a framework for examining closeness-distance experiences in the development of the therapeutic relationship. OBJECTIVE: To examine changes in clients' and therapists' experiences of therapeutic distance along with psychodynamic therapy. HYPOTHESES: Clients' and therapists' comfort with closeness and distance will increase, and the client's autonomy and engagement will increase with time. METHOD: A total of 67 clients and their 27 therapists underwent Relationship Paradigm interviews in which they told narratives about their experience with each other, three times during therapy. The narratives were rated on the Therapeutic Distance Scale-Observer (TDS-O) version. RESULTS: Growth curve analysis of the TDS-O ratings showed that clients decrease in perceiving therapists as too distant and increase in engagement. Therapists showed a decrease in perceiving clients as too close and an increase in granting autonomy and engagement. A clinical illustration depicts these experiences in a client-therapist dyad. CONCLUSIONS: Therapists' awareness of clients' changing needs of closeness and autonomy may enhance attunement.

Reevaluating ruptures and repairs in alliance: Between- and within-session processes in cognitive-behavioral therapy and short-term psychodynamic psychotherapy.

OBJECTIVE: Ruptures and repairs in alliance and their association with treatment outcome have been studied widely. Many of these studies have used indirect methods, focused on decreases in alliance across sessions while measuring alliance at postsession. However, this approach does not establish whether observed decreases occur within (as insinuated by most theories) or between sessions. In the current study, we examined decreases of alliance measured both pre- and postsession in 3 clinical trials and explored the phenomenology and interpretation of these decreases. Additionally, we investigated the effects of rupture magnitude and the interpretation of repairs on treatment outcome, examining whether the "repairs benefit" or the "unrepaired ruptures damage" theories were supported by the data. METHOD: Presession and postsession therapeutic alliance and outcome measures were examined from patients who participated in 1 of 3 studies: cognitive-behavioral therapy (CBT) for social anxiety disorder (N = 29), CBT for panic disorder (N = 31), or short-term psychodynamic psychotherapy for depression (N = 44). Patterns of change in alliance are described. Ruptures and repairs are examined according to several criteria and are used to predict outcome using longitudinal multilevel modeling. RESULTS: In all samples, alliance systematically decreased between sessions and increased within them. Decreases in alliance as measured by traditional postsession to postsession were unreliable predictors of within-session decreases in alliance and of outcomes. CONCLUSIONS: Decreases in alliance across sessions are not valid measures of ruptures as defined by most theories. Instead, we suggest that they are indicative of an ebb-and-flow model for the development of alliance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Do positive features of mental health change together with symptoms and do they predict each other?

In a previous study, it was found that several constructs derived from a positive definition of mental health had changed during psychotherapy. It remains unclear whether they change as part of a single process together with symptomatic change, as part of separate processes, or whether a change in one of the variables predicts change in another variable. Our objective in this study was to examine the relationship between the observed changes and to establish temporal precedence that constitutes a necessary condition for causation. Sixty-two clients who underwent psychotherapy in a naturalistic setting completed questionnaires at 5 time points throughout treatment. The change scores for each client in each of the variables were calculated. The correlations between the changes' scores were tested. To examine the time order, we used autoregressive cross-lagged modeling. A negative correlation was found between the symptoms change score and the happiness change score, r(60) = -0.53, p < .000. A positive correlation was detected between playfulness and happiness change scores, r(60) = 0.31, p = .014. Playfulness predicted subsequent levels of creativity, b = 0.66, t(121) = 2.1, p < .05. Honesty-humility levels predicted subsequent levels of creativity, b = 0.65, t(121) = 9.71, p < .001. The findings support the claim that the change in positive features of mental health is an independent process from symptomatic improvement. In addition, playfulness and honesty-humility temporally precede creativity, and thus might be part of a single change in a mental health construct that is positively defined. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Changes in playfulness, creativity and honesty as possible outcomes of psychotherapy.

Objectives: This study comprised an examination of whether clients' playfulness, creativity, honesty, humor, and happiness changed during psychotherapy. Methods: Sixty-two clients who underwent psychotherapy in a naturalistic setting completed questionnaires at five time points throughout treatment. An HLM analytic approach was applied to account for the hierarchical nature of the data. Results: Mental distress declined during treatment, while playfulness and creativity increased significantly. Honesty decreased significantly in the course of the treatment, while no significant change was found in the level of affiliative humor or the level of happiness. Conclusions: Changes in personality variables that can serve as positive constructs defining mental health, namely playfulness, creativity, and honesty, might be a possible outcome of psychotherapy.

Therapist effects in yearlong psychodynamic therapy: An exploratory study.

A large body of research indicates that therapists can have a strong impact on treatment outcome, but little is known about the relationship between therapist effects and treatment phase. Our objective was to examine the interactive effect of therapist effectiveness and treatment phase on the outcome of 1 year of dynamic therapy. Therapists' effectiveness scores were defined as the extent of change for each therapist on the OQ-45 scores across their clients at five time points. The sample included 24 therapists who conducted psychodynamic therapy with 65 clients in a naturalistic setting. A three-level hierarchical linear model was applied. In accordance with the hypotheses, a significant main effect was found for effectiveness (estimate = 1.69, p < .05), for the two-way interactions between effectiveness and time (estimate = 1.36, p < .01), and for effectiveness and initial severity of symptoms (estimate = -0.02, p < .05). Simple slope analysis was conducted showing that among the less effective therapists, no significant change in outcome was found as time progressed; among the more effective therapists, outcome improved as time progressed. In addition, therapists were more influential in the treatments of clients with low initial severity. Our findings lend some support to the notion that therapist effects become increasingly influential as therapy progresses. The findings highlight the need for further research into changes in the magnitude of therapists' effect in various phases of therapy. Furthermore, the severity level of the initial symptoms of the client should be taken into account.

Therapists' honesty, humor styles, playfulness, and creativity as outcome predictors: A retrospective study of the therapist effect.

OBJECTIVE: This study examined whether therapists' honesty, humor style, playfulness, and creativity would retrospectively predict the outcomes of therapies ended five years earlier. METHOD: In the Jerusalem-Haifa study, 29 therapists treated 70 clients in dynamic psychotherapy for 1 year. The Outcome Questionnaire 45 scores were collected at five time points. Five years later, the therapists were contacted via email and asked to fill out honesty, humor styles, playfulness, and creativity self-report questionnaires. Five were excluded since they had only one client in the study each. The remaining 24 therapists treated 65 clients out of whom 20 therapists with 54 clients completed the questionnaires. RESULTS: Therapists' Aggressive Humor Style (AHS) was a significant negative predictor of clients' symptom change over time. The therapists' honesty scores were positively correlated with symptom change. That is, higher AHS therapists were more effective, while higher honesty therapists were less effective. CONCLUSIONS: Therapists' inferred traits of Honesty-Humility and AHS may influence the effectiveness of their treatments.

Applying relationship anecdotes paradigm interviews to study client-therapist relationship narratives: Core conflictual relationship theme analyses.

OBJECTIVE: We describe client-therapist relational narratives collected in relationship anecdotes paradigm (RAP) interviews during psychotherapy and the application of the core conflictual relationship theme (CCRT) method. Changes in clients' and therapists' CCRT in relation to each other are examined and associations between their CCRTs and self-reported ruptures and repairs are explored. METHOD: Sixty-seven clients and 27 therapists underwent RAP interviews and completed self-report rupture and repair items at early, middle, and late psychodynamic psychotherapy. Client-therapist relationship narratives were rated on the CCRT and the relational interplay within dyads was explored qualitatively. RESULTS: CCRT changes from early to late therapy showed that with time clients perceived the therapist (RO) and the self (RS) more positively, and the therapist perceived the self (RS) less negatively. Some associations were found between tension in the session and clients' and therapists' negative RO and RS. Therapists' reports of alliance repairs were associated with positive RO and RS. CONCLUSIONS: Relational narratives that clients and therapists tell in RAP interviews about meaningful interactions between them, enhance our understanding of clients' and therapists' inner experiences during interpersonal dances in the therapeutic relationship. Limitations and directions for future research are discussed, and implications for training are suggested.

Relational Patterns and the Development of the Alliance: A Systematic Comparison of two Cases.

A systematic case study approach was taken to explore the impact of client and therapist relational patterns on the development of the therapeutic alliance and symptom reduction in two cases of psychodynamic psychotherapy treated by the same therapist. The cases were selected from a larger sample and represent two distinct trajectories of alliance development: improvement versus deterioration. The comparison was based on participants' ongoing narratives about each other and about significant others, using the Relationship Anecdote Paradigm (RAP) interview. The qualitative findings were triangulated with process and outcome measures assessed at four time points during the year of treatment. We hypothesized that different therapeutic processes, including different handling by the therapist of interpersonal difficulties as they arose in treatment, could explain the two distinct trajectories of alliance development and symptom change within the caseload of one therapist. Results indicate two linked elements that may explain a steady increase in alliance and decrease in symptoms in one case, compared with the second case that started with an increase in alliance and symptom improvement, but gradually reached an impasse and a setback in symptoms. One element was the extent to which client's and therapist's relational patterns clashed, impacting each other negatively. The second was the extent to which differences and disagreements were stated openly and negotiated so that the therapist could flexibly adapt to meet the client's relational patterns in one case versus inability to do so in the other. Implications for training and other psychotherapy orientations are discussed. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The interaction of client and therapist relational patterns may be a key factor in the development of the therapeutic alliance and might potentially impact client outcome. Therapeutic practice will likely be improved if therapists are more aware of their own relational patterns and the ways these interact with their clients' relational patterns. Striving for this awareness should probably be a main focal point for therapists throughout their careers, in their training, supervisions and personal therapies.