Psychoanalytic Psychotherapy, 2015 Vol. 00, No. 0, 1–19, http://dx.doi.org/10.1080/02668734.2014.1002417
Using the Inventory of Countertransference Behavior as an observer-rated measure Jairo N. Fuertesa*, Charles J. Gelsob, Jesse J. Owenc and David Chengd a
The Derner Institute of Advanced Psychological Studies, Hy Weinberg Center, Adelphi University, Rm 319, 158 Cambridge Avenue, Garden City, NY 11530, USA; bUniversity of Maryland, College Park, MD, USA; cUniversity of Louisville, Louisville, KY, USA; d Baruch College, City University of New York, New York, NY, USA (Received 3 October 2014; accepted 20 December 2014) This study examined the use of the Inventory of Countertransference Behavior (ICB; Friedman & Gelso, 2000, The development of the inventory of countertransference behavior, Journal of Clinical Psychology, 56, 1221– 1235) as an observer-rated measure of countertransference (CT). The ICB was originally designed for use by direct psychotherapy supervisors who assess their supervisees, but this limits its use in research and with practitioners who are not in supervision. To increase the use of the ICB as an observer-rated scale, we developed clarifying statements and examples of insession therapist behaviors for each of its 21 items, creating an Inventory of Countertransference Behavior-Observer (ICB-O). Two separate teams of observers rated therapist CT using the ICB-O while listening to audiotaped recordings and reading transcripts of four psychotherapy dyads’ sessions. Our analyses indicate that the ICB-O can be used reliably as an observerrated measure of CT, and that differences emerged in the development of positive CT over time. We also obtained ratings of client insight and clients’ and therapists’ ratings of quality of sessions, and present variations in these ratings, including CT, when the treatment was classified as either more or less successful. We end the paper by presenting ways in which the ICB-O can be used in supervision, training, and research. Keywords: countertransference behavior; measurement; insight; outcome
The relationship in psychotherapy has been shown to have a significant and robust effect on the outcome of psychotherapy of every theoretical persuasion (Norcross, 2011). Originating from psychoanalytic theory (Freud, 1910/1959, 1912/1959), the concept of countertransference (CT) in recent years has been viewed as a key ingredient of the therapeutic relationship in all psychotherapies (Gelso, 2014; Gelso & Hayes, 2007). CT has been defined in a number of ways over the years, ranging from the classical view, in which CT is seen essentially as the analyst’s transference to the
*Corresponding author. Email:
[email protected] q 2015 The Association for Psychoanalytic Psychotherapy in the NHS
2
J.N. Fuertes et al.
patient’s transference (Freud, 1910/1959) to the totalistic position, where CT is conceptualized as all of the therapist’s reactions to the patient (see review by Epstein & Feiner, 1988). Our working definition of CT in the present paper seeks to integrate the varied viewpoints, defining CT as the analyst or therapist’s reactions to the patient based fundamentally on the therapist’s unresolved conflicts and vulnerabilities (see Gelso & Hayes, 2007, elaboration). These conflicts and vulnerabilities may be precipitated by the patient or the therapeutic frame, but their origin is in the therapist and his or her unresolved issues. Despite its theorized effects on the overall relationship, it is only in the past two decades that CT has begun to receive empirical attention (Gelso & Hayes, 2007). An area that has received some empirical work is countertansference management, which can be assessed via the Countertransference Factors Inventory-Revised (Latts, 1996), and which assesses five areas of CT management; therapist empathy, anxiety management, conceptualizing ability, self-insight, and self-integration. Empirical work has also been generated via the Countertransference Questionnaire (CQ; Kernhof, Obbarius, Kaufhold, Merkle, & Grabhorn, 2013; Zittel & Westen, 2003), which assesses therapists’ cognitive, affective, and behavioral countertransferential responses. Research using the CQ has demonstrated that CT is multifaceted but can be measured empirically in ways that yields clinically meaningful results and in ways that can inform the therapy process while accounting for patients’ presenting problems. A meta-analysis supports the clinically derived proposition that therapists’ enactment of CT in sessions, unless it is effectively managed, has a detrimental effect of treatment progress and outcome in diverse psychotherapies (Hayes, Gelso, & Hummel, 2011). The current investigation is one step forward in the study of CT. It builds on the work of Friedman and Gelso (2000), who developed the Inventory of Countertransference Behavior (ICB) for use with psychotherapy supervisors to assess the CT behavior of their supervisees (Fuertes, Gelso, Owen, & Cheng, 2013). It should be noted that the ICB was developed for use in nonpsychoanalytic as well as analytic forms of treatment. While use of the ICB is potentially valuable to supervisors, our aim in the present study was to examine the use of the ICB as an observer-rated scale in supervision and beyond. To do so, we developed clarifying statements and examples of in-session therapist behaviors for each of its 21 items. Despite comprising clearly written and seemingly concrete items, the ICB is nonetheless difficult to score, and the elusive nature of the phenomenon of CT makes reliable and valid use of the measure outside of direct supervision difficult. For example, the first item of the ICB, ‘The therapist colluded with the client’ can be interpreted in different ways by an observer and can represent various nuances and/or reactions of therapists to and from their clients. A thoughtful rater, supervisor, or trainee might ask: what is collusion in psychotherapy, how can it be defined, and what makes it countertransferential? Our hypothetical rater might also ask, what would be some examples of such behavior so that I can identify it when it happens? The current study is an attempt to answer these questions.
Psychoanalytic Psychotherapy
3
Purpose and research aims As we have indicated, research on CT has been very sparse until recent years (Hayes et al., 2011), very likely because of the difficulty in measuring the phenomenon through observers and independent raters (Gelso & Hayes, 2007). The purpose of the present study was to expand the use of the ICB in clinical practice and supervision and to make it more accessible to researchers interested in assessing CT from different vantage points. To make the ICB more descriptive so that it could be rated by observers, we developed clarifying statements and examples of possible in-session therapist behaviors for each of the 21 items of the ICB that would be clear and meaningful to therapists of all orientations. (For purposes of clarification, we called the Inventory of Countertransference Behavior-Observer (ICB-O) the measure that includes these statements and examples.) The primary research aim was to examine the level of reliability obtained by a team of three observers who used the ICB-O to rate therapist CT from audio-recorded therapy sessions of four clinical dyads. Our second aim was to examine the development of therapist CT, ratings of client insight, and ratings of quality of sessions over time and to note where appreciable changes occurred when the dyads were classified as either more or less successful. It should be noted that our research was conducted with non-analytic psychotherapists in a short-term therapy context. This is in keeping with the belief that the concept of CT, although rooted in psychoanalysis, is meaningful and operative in all psychotherapies and manifests itself of therapies of all durations. Such a view has been consistently supported by existing research on CT (see Hayes et al., 2011, review). Method Participants Participants in the study were four psychotherapy dyads; therapists completed a measure of clients’ intellectual and emotional insight after each session; and therapists and clients completed a measure of quality of session after each session, as well as a measure of outcome at the last session. CT was rated by independent observers after therapy had been completed, using audio-recordings and transcripts of the sessions. The therapists in the two therapy dyads were two advanced doctoral students in clinical psychology, both were Asian-American women 26 and 28 years of age. Their theoretical orientation was self-reported and rated from 1 (low) to 5 (high) in response to the following question: ‘Please rate the extent to which you believe in and adhere to the theory and techniques of the following therapies.’ Therapists’ mean ratings [and standard deviations (SDs)] were: psychoanalytic/ dynamic: M ¼ 3.00 (SD ¼ 0); humanistic/existential: M ¼ 3.50 (SD ¼ 0.50); and cognitive/behavioral: M ¼ 4.0 (SD ¼ 1.0). Thus, the therapists might be viewed as integrative theoretically, with a lean toward cognitive-behavioral therapy.
4
J.N. Fuertes et al.
The clients in the study were three women and one man (mean age ¼ 25, SD ¼ 7.56), two Asian-Americans, one African-American, and one Latino/ Hispanic. The dyads completed varying number of sessions. Two dyads completed 12 sessions, 1 dyad completed 5, and the remaining dyad completed 10 (37 of these sessions were taped). The number of sessions completed by these dyads is typical for the setting in which psychotherapy took place, which is a university counseling center, where the average number of sessions completed is usually between 10 and 12. Participants were also six doctoral students who listened to the audiorecorded sessions and rated therapist CT after each session. They worked as two separate teams about 2 years apart, and comprised three doctoral students in counseling psychology in an eastern university in one team and of three doctoral students in clinical psychology at another eastern university. The three raters in the first team were two women and one man (mean age ¼ 25, SD ¼ 1), one of the women was White Hispanic and the other two raters were White non-Hispanic. The three raters in the second team were also two women in one man, one woman was Black Hispanic and the other two raters were White non-Hispanic (mean age 23, SD ¼ 1). Measures The Inventory of Countertransference Behavior-Observer The ICB-O was developed for the current study and includes a clarifying statement for each item, as well as examples of possible therapist in-session behaviors, however, the ICB-O remains otherwise exactly as developed by Friedman and Gelso (2000). It contains two factors: positive and negative CT behaviors, and both were used in the current study. Some of the items include ‘The therapist rejected the client in the session,’ ‘The therapist used humor inappropriately in the session,’ and ‘The therapist talked too much during the session.’ Friedman and Gelso (2000) found an alpha coefficient of 0.79 for each subscale. The ICB-O was used by the two teams of raters and the reliability data from these ratings are presented below. Insight scale The insight scale (IS) consists of three dimensions of insight: insight amount, intellectual insight, and emotional insight (Graff & Luborsky, 1977), and in the current study we used the intellectual and emotional insight items. Each construct is rated on a five-point Likert scale in terms of amount of insight exhibited during the session, from none or slight (1) to very much (5). Definitions of the constructs to be rated by the psychotherapists were provided on the questionnaire and can be found in Gelso, Kiviglian, Wine, Jones, and Friedman (1997). Kivlighan (1995) found support for the construct validity of the two insight items in the tendency of psychotherapists and supervisors to agree on their ratings of client’s intellectual
Psychoanalytic Psychotherapy
5
(r ¼ 0.71) and emotional (r ¼ 0.75) insight. Gelso et al. (2005) found these items to be modestly correlated (r ¼ 0.41) indicating some level of overlap, but also to be considerably distinct. Quality of session questionnaire Clients and therapists were asked to complete after every session a one-item scale that asked ‘Using the scale above, please rate the overall quality of today’s session.’ The scale ranges from 1 to 5, with 1 being ‘very poor,’ 3 being ‘neutral,’ and 5 ‘very good.’ Session items such as this have been frequently used in process research (e.g., Bhatia & Gelso, 2013; Gelso, Hill, & Kiviglian, 1991; work on the Therapy Session Report, Orlinsky & Howard, 1986; and research reported by Elliot, 1986). Recently, in their sample of 249 experienced psychotherapists, Bhatia and Gelso (2013) found that the correlation of this type of item with multiitem measures of session quality (e.g., Session Evaluation Questionnaire – Depth, Stiles, & Snow, 1984) was in the vicinity of 0.90. Counseling outcome measure Therapists and clients completed the counseling outcome measure (COM; Gelso & Johnson, 1983) at the end of the last session to evaluate clients’ progress since the beginning of therapy in terms of feelings, behaviors, and self-understanding and in general. Ratings are made on a seven-point scale ranging from 1 ¼ much worse, to 4 ¼ about the same, and to 7 ¼ much improved. Given the range of the anchors used for ratings, both therapist and client ratings are generally quite high, for example, well above 5 (e.g., Gelso & Johnson, 1983; Gelso et al., 1997), and a recent study by Gelso et al. (2012) found the mean ratings from clients and therapists to be above 6. Still, reliability and validity evidence have been consistently strong (see Gelso et al., 2012). Internal consistency and retest reliability of the COM have been found to be satisfactory (Gelso & Johnson, 1983). We used the scores on the COM to rate the relative success of each dyad. Dyads 1 and 4 were classified as more successful because their combined outcome ratings were in the ‘moderately improved’ to ‘much improved’ range (i.e., 6 – 7). Dyads 2 and 3 were classified as ‘less successful’ because their combined outcome ratings were in the ‘about the same’ to ‘slight improvement’ range (i.e., 4– 5). Procedure There were three planned steps in the procedure: (1) the creation of the ICB-O involving the development of clarifying statements for each item, along with examples of in-session behavior; (2) examination of the reliability of the ICB-O in the rating of 37 sessions of psychotherapy; and (3) the re-examination of the reliability of the ICB-O with a separate team of raters. A fourth step was added
6
J.N. Fuertes et al.
after the quantitative analyses were completed, and involved a qualitative content analysis of the sessions. The first team reviewed the ICB with the first author (a tenured faculty member who is a Hispanic male with 15 years of clinical and teaching experience) over an academic semester. The team discussed each of the 21 items and arrived at clarifying statements about what each item meant and what therapist behavior might be reflected by each item. This process was necessary because the items in the ICB are difficult to interpret; for example, the first item, ‘The therapist colluded with the client in the session’ could be interpreted in different ways. As a team we did not know what collusion meant or to what it referred in terms of actual therapist behavior. The group worked individually a few items at a time between weekly meetings and noted ideas, reactions, or behaviors about what each item meant and how such behavior would be manifested in a therapy session. At the next meeting, the group members presented their ideas, discussed them and arrived at a clarifying statement about each of the items. After discussing all of the team members’ various inputs and perspectives on what the item in question meant, the team worked collaboratively to derive a clarifying statement. The team followed this procedure in deriving clarifying statements and sample in-session behaviors for the remaining 20 items. The result is the ICB-O, shown in Appendix 1. In the ICB-O, the rater/observer is also asked to provide actual examples of CT from the session being rated. The first team of observers, working independently and using the ICB-O then rated 37 audiotaped psychotherapy sessions involving four clinical dyads. Ratings were provided at the end of each session for the whole session. To examine how ratings using the ICB-O would compare using raters who had not been involved in the study and development of the measure, a second team of raters used the ICB-O to rate CT in 14 randomly selected sessions from the original 37 sessions rated by the first team. Both teams used a written transcript of the tapes to help them follow the audio-taped sessions. In addition to the ratings of CT from the two teams of observers, the therapists and clients from the four therapy dyads observed provided their own ratings after each session of psychotherapy. Therapists rated their clients’ level of intellectual and emotional insight and therapists and clients rated the quality of their therapy sessions after every session. After the last session was completed, therapists and clients rated the outcome of treatment. Score conversions Scores for all measures were converted so that they could be on the same scale. Following recommendations by Dawes (2008), scores were converted to intervals between 20 and 80. For example, if the rating scale was originally anchored by 1 to 5, it was then converted to: 1 ¼ 20, 2 ¼ 35, 3 ¼ 50, 4 ¼ 65, and 5 ¼ 80. Previous studies have found that data conversion, as done here, does not significantly skew the data (e.g., Dawes, 2008; Moore & Owen, 2014).
Psychoanalytic Psychotherapy
7
To compute stages of treatment, we collapsed individual sessions into four quarters/stages of psychotherapy, and averaged the converted scores per stage. This is consistent with how models of short term treatment have been conceived of, for example Mann’s (1973) model of time-limited psychoanalytic psychotherapy, and allows for the examination of differences across time in treatment. Because the total number of sessions differed among dyads, we followed the lead first implemented by Hartley and Strupp (1983) and later refined by Gelso et al. (1997) to compute a quarterly breakdown for each dyad. To examine differences across the four stages of therapy, we computed reliable change indexes (RCIs) for each scale. Reliable change indicates the degree of change that exceeds what would be expected based on the measurement error of the scale (Jacobson & Truax, 1991). In the calculation of the RCI for each scale we utilized the SD of the current sample at session 1 and the internal consistency of the measure from the source article for each measure. Given that Intellectual and Emotional Insight and Quality of Sessions are one-item measures we utilized the average test – retest correlations. An RCI calculator in the form of an excel utility made available for free by the A Collaborative Outcomes Resource Network (https://psychoutcomes.org/OutcomesMeasurement/ReliableChangeIndex) was used. The formula is the square root of the standard error of measurement squared and multiplied by 2. The RCIs are presented in Table 3. The following anchors are provided as a way to describing the levels or strength of the converted scores: between 70 and 80 are ‘very strong,’ between 61 and 69 are ‘strong,’ between 50 and 60 are ‘moderate,’ between 41 and 49 are ‘mild,’ between 30 and 40 are ‘weak,’ and between 20 and 29 are ‘very weak.’ Results Reliability correlations for the two rating teams were computed. For the first team, which rated 37 sessions, ratings of positive CT (comprised of 10 items) yielded an average measures intraclass correlation coefficient of 0.84, 95% CI 0.76– 0.91, p , 0.001. Rating of negative CT (comprised of 11 items) yielded an average measures intraclass correlation coefficient of 0.83, 95% CI 0.75– 0.90, p , 0.001. For the second team, which rated 14 sessions, ratings of positive CT yielded an average measures intraclass correlation coefficient of 0.75, 95% CI 0.51– 0.90, p , 0.001. Rating of negative CT yielded an average measures intraclass correlation coefficient of 0.72, 95% CI 0.43 –0.89, p , 0.001. The means and SDs are presented in Tables 1 and 2, separately for more successful dyads (i.e., dyads 1 and 4,), and then less successful dyads (i.e., dyads 2 and 3). Figures 1 and 2 present graphs of the data found in Tables 1 and 2, visually demonstrating the pattern of development over the four quarters of treatment. Table 3 includes the RCI for each measure in the study and delineates where differences that exceeded the RCI were evident by quarter and per measure. Using the anchors presented above, the levels of CT for all dyads can be considered weak to very weak, with the average rating of positive CT being 35
8
J.N. Fuertes et al.
Table 1. Means and SDs for all measures by outcome and stage of therapy more successful dyads (dyads 1 and 4). IntIns
EmotIns
Q1 27.5 (0) 37.5 (8.66) Q2 31.25 (10.61) 36.25 (9.63) Q3 42.50 (0) 35.00 (0) Q4 38.75 (8.66) 27.50 (0)
CQSess
TQSess
PosCT
NegCT
68.75 (10.61) 65.00 (0) 71.25 (9.63) 72.50 (0)
58.75 (9.63) 58.75 (9.63) 50.00 (0) 63.12 (7.5)
34.25 (2.49) 35.18 (6.38) 35.50 (9.36) 37.33 (7.85)
29.15 (6.09) 26.58 (1.90) 28.48 (3.58) 29.37 (.71)
Notes: IntIns: intellectual insight; EmotIns: emotional insight; CQSess: client-rated quality of sessions; TQSess: therapist-rated quality of sessions; PosCT: observer-rated positive countertransference; NegCT: observer-rated negative countertransference.
and negative CT 28, on a scale from 20 to 80. These results are consistent with other research on this the ICB (Friedman & Gelso, 2000; Ligiero & Gelso, 2002; Palma & Gelso, 2012). For example, Friedman and Gelso found that 126 supervisors provided mean ratings of 1.66 (or 29.9 on our metric) for positive CT, and 1.28 (or 24.2) for negative CT. These scores are also consistent with those obtained by the second team of raters in the current study, whose mean scores were 26.6 for positive CT and 24 for negative CT. As mentioned in the ‘Introduction’ section, the second aim of our study was to examine the development of therapist CT, ratings of client insight, and ratings of quality of sessions over time and to note where appreciable changes occurred when the dyads were classified as either more or less successful. A more nuanced analysis of the CT scores indicated that in more successful dyads, ratings of positive CT were about the same throughout the four stages (near the average, i.e., 35), and about the same in the total amount of positive CT in comparison to the less successful dyads. In the less successful dyads, however, positive CT started very weak, was weak to mild in quarters 2 and 3 (the difference between the first and third quarters exceeded the RCI, as shown on Table 2) and then weak again in the last quarter. Negative CT was very weak and followed a very similar pattern in both more successful and less successful dyads, and their overall levels were slightly higher in less successful dyads. While there are no differences in the total amount of CT between more successful and less successful dyads, there is a difference in the pattern of positive CT across quarters for the less successful Table 2. Means and SDs for all measures by outcome and stage of therapy less successful dyads (dyads 2 and 3).
Q1 Q2 Q3 Q4
IntIns
EmotIns
CQSess
TQSess
PosCT
NegCT
42.50 (0) 50.00 (0) 45.00 (8.66) 42.50 (0)
37.50 (8.66) 47.50 (8.66) 38.75 (10.61) 35.00 (0.00)
67.50 (8.66) 75.00 (8.66) 70.00 (8.66) 70.00 (8.66)
65.00 (0.00) 65.00 (0.00) 61.25 (10.61) 57.50 (0.00)
30.17 (5.60) 34.33 (8.11) 39.67 (4.25) 34.67 (4.07)
28.10 (4.68) 31.23 (1.45) 28.80 (5.41) 28.63 (4.37)
Notes: IntIns: intellectual insight; EmotIns: emotional insight; CQSess: client-rated quality of sessions; TQSess: therapist-rated quality of sessions; PosCT: observer-rated positive countertransference; NegCT: observer-rated negative countertransference.
Psychoanalytic Psychotherapy
9
80 70 60 50 40 30 20 10
Int Insight
TQSess
Emt Insight
PosCT
CQSess
NegCt
0 Q1
Q2
Q3
Q4
Figure 1. Means and SDs for all measures by outcome and stage of therapy more successful dyads (dyads 1 and 4). Notes: Q1, average ratings from the first stage of therapy; Q2, average ratings from the second stage of therapy; Q3, average ratings from the third stage of therapy; Q4, average ratings from the fourth stage of therapy; IntIns, therapistrated intellectual insight; EmotIns, therapist-rated intellectual insight; CQSess, clientrated quality of session; TQSess, therapist-rated quality of session; PosCT, observer-rated positive CT; NegCT, observer-rated negative CT.
80 70 60 50 40 30 20 10
Int Insight
TQSess
Emt Insight
PosCT
CQSess
NegCT
0 Q1
Q2
Q3
Q4
Figure 2. Means and SDs for all measures by outcome and stage of therapy less successful dyads (dyads 2 and 3). Notes: Q1, average ratings from the first stage of therapy; Q2, average ratings from the second stage of therapy; Q3, average ratings from the third stage of therapy; Q4, average ratings from the fourth stage of therapy; IntIns, therapistrated intellectual insight; EmotIns, therapist-rated intellectual insight; CQSess, clientrated quality of session; TQSess, therapist-rated quality of session; PosCT, observer-rated positive CT; NegCT, observer-rated negative CT.
10 Table 3. Measure
J.N. Fuertes et al. Differences exceeding the RCI by stage of therapy (Q1, Q2, Q3, and Q4).
a
SD
In more successful dyads (1 and 4) PosCT 0.79 5.07 NegCT 0.79 6.26 IntIns 0.93 15.73 EmotIns 0.92 8.22 CQSession 0.53 6.12 TQSession 0.58 8.22 In less successful dyads (2 and 3) PosCT 0.79 5.07 NegCT 0.79 6.26 IntIns 0.93 15.73 EmotIns 0.92 8.22 CQSession 0.53 6.12 TQSession 0.58 8.22
RCI 6.44 7.95 11.48 12.51 7.85 5.73 6.44 7.95 11.48 12.51 7.85 5.73
Q3 . Q1 Q1, Q2 . Q3, and Q4 . Q3 Q3 . Q1 Q2 . Q4 Q1 and Q2 . Q4
Notes: a, Internal consistency estimate from the original published measure; SD, standard deviation from session 1; RCI, reliable change index; Q1, average ratings from the first stage of therapy; Q2, average ratings from the second stage of therapy; Q3, average ratings from the third stage of therapy; Q4, average ratings from the fourth stage of therapy; PosCT, observer-rated positive CT; NegCT, observer-rated negative CT; IntIns, therapist-rated intellectual insight; EmotIns, therapist-rated intellectual insight; CQSess, client-rated quality of session; TQSess, therapist-rated quality of session.
dyads, with more fluctuation in the first three quarters and a considerable drop in the last quarter (versus a steady pattern of positive CT in more successful dyads). With respect to client insight, overall mean scores were mild to moderate, and less successful dyads reported higher overall levels of both intellectual and emotional insight. In terms of intellectual insight, there was a considerable difference in means between more successful and less successful dyads (35 vs. 45, respectively), and a difference in emotional insight between more successful versus less successful dyads (34 vs. 39.6, respectively). Table 3 shows differences that exceed the RCI, namely that intellectual insight increased from the first quarter to the third for more successful dyads and that emotional insight decreased from the second to the fourth quarter among the less successful dyads. These findings point to something counterintuitive, which is that higher levels of insight are not necessarily an indicator of the success of psychotherapy. What appears to be associated with success is a pattern where there are increases in insight as therapy progresses. What appears to be detrimental to success is a pattern where there are appreciable decreases in emotional insight in the latter quarters of treatment. Scores on quality of sessions are very strong for clients (70) and moderately strong for therapists (60), on the scale from 20 to 80; total ratings on quality of sessions were about the same between more successful and less successful dyads. However, differences in the patterns of therapist ratings are evident. In more successful dyads, therapists’ ratings of quality of sessions increase throughout the four quarters of therapy, and Table 3 shows that these ratings
Psychoanalytic Psychotherapy
11
exceed the RCI between quarters one and two (lower) in comparison to quarter 3 (higher), and between quarter 4 (higher) and quarter 3 (lower). In contrast, in less successful dyads, therapists’ ratings decreased, and Table 3 shows that the ratings in quarters one and two were higher than in quarter 4. Our finding indicate that it is not the total amount of quality of sessions that is associated with more successful treatment but instead a pattern of increasing ratings (vs. decreasing ratings) over the course of treatment. The results with respect to therapists’ ratings of quality of sessions raise several questions: What drives therapists’ ratings of quality of sessions, what factors are associated with their increase or decrease in treatment, and to what extent does CT dictate whether these ratings fluctuate in treatment? Content analyses After conducting our planned analyses, the first author and two members of the second rating team listened to the session tapes again without using the ICB-O in order to ‘flesh out’ and describe the ratings obtained with the ICB-O and the possible links between CT behavior, client insight, and quality of the sessions. Since each therapist had one more successful and one less successful case, we examined if differences in therapists’ CT behavior, or differences in therapist – client interactions/dynamics could be discerned as a function of the relative success of the case. Several observations or patterns were discernable from listening to the tapes. In one of the more successful dyads, a strong therapeutic relationship was present between the therapist and the client from the beginning of therapy; there was an immediate level of comfort or liking between the participants. The therapist appeared confident in her role and conveyed a therapeutic presence that appropriately probed, empathized, and directed the client toward more comprehensive and deeper explorations and analyses of her associations and feelings. In the other more successful dyad, the therapist and the client also established good rapport from the beginning of treatment and it remained strong throughout. While the client spoke rapidly and for long periods of time without interruption, the therapist was nevertheless able to interject interventions that guided the client to an analysis of her feelings and conflicts. In contrast, in one of the less successful dyads, the therapy relationship did not seem to evolve to a point where effective client engagement or exploration could take place. In many of the sessions, it appeared that the focus of the work was on external events in the life of the client, and the therapist made a few and futile attempts to deepen their discussion or to engage the client in analyzing her views or associations. The therapist offered some interpretations but they did not seem to resonate with the client, and when the therapist made an attempt to probe there seemed to be well-established resistance on the part of the client (e.g., the client would not associate to the intervention). In the other less successful dyad, the therapist’s attempts to build rapport with the client came across more like
12
J.N. Fuertes et al.
befriending behaviors, and lacked a sense of either therapeutic purpose or direction. Many of the sessions in this dyad sounded like venting sessions for the client with some level of collusion from the therapist, and these exchanges seemed excessive and not constructive or therapeutic. Discussion Overall, our observations from listening to the tapes are that in the less successful dyads there was a form of collusion that took place on the part of the therapists with clients who were very well defended against the tasks and rigors of the therapeutic work. In the less successful dyads, the therapists were less likely to participate in probing or to intervene in a way that might promote depth or breadth of exploration or analysis from their clients – consequently the discussions lacked depth. This observation coincides with the quantitative findings for less successful dyads, which show that therapists’ ratings of quality of session and clients’ level of emotional insight decreased over time. Their sessions seemed more like ‘chit chat’ conversations with a ‘best friend’ rather than therapeutic work. To describe this behavior in terms of ICB-O items while keeping in mind that overall CT levels were low, the therapists were more likely to agree too often, to oversupport, to take on an inappropriate advising tone, to engage in too much selfdisclosure, to befriend, and to let the client go on and on in a matter that seemed on the surface friendly and supportive but masked apathy and an abdication of the proper role of the psychotherapist. While unresolved personal issues from the therapists’ past might account for their CT behavior in these sessions, it is apparent that the clients played a very influential role in regulating the lead of the therapist and in limiting the depth and flow of psychotherapy. While there were signs of CT behavior in the more successful dyads, particularly positive CT such befriending-type behaviors, the therapist seemed to know when the client was open or ready for therapeutic interventions or seemed to find the moments when she could weigh in clinically. The quantitative analyses show that therapists’ ratings of client intellectual insight increased as the sessions progressed, as did their ratings of the quality of sessions. While the skill of CT management (see Gelso & Hayes, 2007) can be called to explain differences in the effects of CT behavior between the dyads, the fact that each therapist had a more successful and a less successful case indicates that CT management was affected in a deleterious way by interactional dynamics in the less successful dyads. In summary of this section, the ICB-O yielded acceptable levels of reliability with the two teams of raters, higher with the first team that rated a larger number of sessions. We deem these levels acceptable in light of the abstract and elusive nature of construct rated, and conclude that the ICB-O can be used reliably in research by raters to assess CT or in rating CT behavior of therapists who are not supervisees. Our quantitative results also show that with respect to the relative success or outcome of treatment, it is not the total amount of positive or negative CT, or of emotional or intellectual insight, or of quality of sessions that is
Psychoanalytic Psychotherapy
13
important, but rather their pattern of development. In more successful treatment, client insight increases, therapists’ ratings of quality of sessions increase, and positive CT remains stable throughout treatment. Our descriptive analyses of CT point to a powerful dynamic that stems from the client in defending and regulating the depth and course of treatment which leads in less successful cases to therapist collusion, apathy, and very limited efforts to intervene. These therapist behaviors seem to be adequately assessed with the ICB-O. Use of the ICB-O Overall our results indicate that the ICB-O can be used to assess CT using independent raters. The reliability estimates were replicated from one team of researchers to another and similar levels of CT were rated by our two separate ratings teams in comparison to those obtained by Friedman and Gelso (2000). The results showing different patterns in CT between more successful versus less successful dyads indicate that the measure is sensitive to different manifestations of the construct in treatment. As far as use of the measure, the ICB-O might be utilized in supervision in order to monitor CT behaviors about which the therapist/trainee is unaware, and which could derail treatment – particularly more extreme behaviors as rated by the measure. For example, it may be common for therapists in training to sympathize with some of their clients, and some of this behavior may be infrequent and even innocuous depending on the situation. However, a more persistent and debilitating stance on the part of the therapist, such as collusion or submissiveness on the part of the therapist or supervisee, as indicated by items in the ICB-O, may in fact be counter-productive or even injurious to the client. The ICB-O could highlight in supervision and in training manifestations of CT behavior, and when used with audio or videotapes of sessions, the ICB-O might help pinpoint segments in the session where CT behaviors occur, what triggers it, and its effect on the overall process of psychotherapy. Furthermore, the ICB-O could serve as a red flag for dyads that the supervisor or therapist may suspect are stagnant or experiencing difficulty. This inventory may also be used as a reference for progress and technique development in supervision and when used in research may yield data of what could have potentially aided or prevented successful therapy. The ICB-O might be useful in research examining therapist factors in psychotherapy process and outcome. For example, the ICB-O could be administered periodically in order to monitor CT behavior and to assess its relationship to other indices of process or outcome, such as therapist/trainee insight, therapists’ perceptions of the quality of their sessions, or comfort with difficult clients or in delivering more advanced interventions, such as challenges. Procedurally, the ICB-O can be introduced in training and supervision as a teaching method and aid that can highlight certain behaviors that are associated with progress of therapy. For example, while it is always important to develop an alliance and rapport with clients, the need to ‘befriend’ the client, as highlighted
14
J.N. Fuertes et al.
in the ICB-O, might be self-serving on the part of the therapist and unhelpful to the goals of treatment. Supervisors could explain that the use of the ICB-O is not necessarily as a measure of ability or worth as a therapist, but as a measure of specific phenomena that occurs in all therapy situations. The measure can serve as a teaching tool about the various aspects of CT behavior, and could be given as reading material to the supervisee or trainee along with other readings about CT. Prior to using it in supervision, the items and examples of in-session behavior might facilitate a conversation about possible biases or dispositions on the part of the trainee/therapist that could be addressed, discussed, and dealt with preventively before the start of therapy. The ICB-O could then be used from the first session as a baseline observation that the supervisor and therapist can refer to in order to monitor treatment. Any items with scores that the supervisor deems to be high could be discussed just like any other issue in supervision. Limitations While the design of the study offered the opportunity to examine in depth the complex phenomenon of CT, including the use of raters to examine several dyads from the beginning to the end of treatment, this approach to research carries many limitations when viewed from a traditional scientific perspective. As is always a concern with case studies and qualitative research, generalizations are limited, and the recommendations for practice or supervision presented here need to be taken with caution. The sample size was very small and limited to just one setting, a university counseling center; and while we were able to record four dyads and 37 sessions, the sample was one of convenience, and involved two Asian therapists, who may or may not reflect approaches to treatment in other settings or by therapists from different theoretical or cultural backgrounds. As indicated, the therapists’ self-ratings suggested that they were integrative in orientation, with a leaning toward cognitive-behavioral therapy. Given this leaning, it is likely that their attention to CT behavior was probably less central to their work than would be with more analytically minded practitioners. The clients in the study were also college age students who do not represent the broader patient populations in treatment, and so the manifestation of CT behavior for these therapists in these dyads is very likely a product of both clients’ and therapists’ demographic characteristics, as well as therapists’ theoretical perspectives. Still, as we earlier noted, CT behavior is in no way unique to any given theoretical orientation. Instead, we suggest that it is one of those general relationship ingredients that occurs and is important in all forms of therapy. Thus, the study of CT among integrative therapists ought to have considerable implications for psychoanalytic and other therapist orientations. Despite the limitations of the current study, the results point to acceptable levels of reliability for use of the ICB-O in research on CT and to assess CT with therapists who are not necessarily supervisees. By expanding the use of the measure beyond supervision, the current study has advanced the possible ways in
Psychoanalytic Psychotherapy
15
which CT can be assessed and studied. The current study has also yielded possibly important information about the use of ratings of insight and quality of sessions in psychotherapy and how these ratings may be predictive of the overall outcome of treatment. Finally, we have also provided preliminary qualitative data on the manifestation of CT in-session. We note how CT is inevitably tied to interpersonal dynamics between therapist and client, and how the client adds a crucial, and possible, if left unattended, insalubrious effect on the process and outcome of therapy. Acknowledgements We thank Claudia Perolini, Adam Joncich, Marissa Miller, Arielle Kahn, Michael Kestenbaum, and Mariela Reyes for their assistance with the ratings of countertransference. We would also like to thank Clara Hill and Mark Hilsenroth for comments provided to an earlier version of this paper.
References Bhatia, A., & Gelso, C. J. (2013). A test of the tripartite model of the therapy relationship from the therapist’s perspective. Paper presented at the Conference of the North American Society for Psychotherapy Research, October 17 – 19, Memphis, TN. Dawes, J. (2008). Do data characteristics change according to the number of scale points used? An experiment using 5-point, 7-point, and 10-point scales. International Journal of Market Research, 50, 61 – 77. Elliot, R. E. (1986). Interpersonal process recall (IPR) as psychotherapy process research method. In L. Greenberg & W. Pinsoff (Eds.), The psychotherapeutic process (pp. 503–528). New York, NY: Guilford Press. Epstein, L., & Feiner, A. H. (1988). Countertransference: The therapist’s contribution to the treatment. In B. Wolstein (Ed.), Essential papers on countertransference (pp. 282–303). New York, NY: New York University Press. Freud, S. (1959). Future prospects of psychoanalytic psychotherapy. In J. Strachey (Ed. & Trans.), The standard edition of the complete works of Sigmund Freud (Vol. 11, pp. 139– 151). London: Hogarth Press. (Original work published in 1910). Freud, S. (1959). Recommendations for physicians on the psycho-aalytic method of treatment. In J. Riviere (Ed. & Trans.), Collected papers of Sigmund Freud (Vol. 2, pp. 323– 341). New York, NY: Basic Books. (Original work published in 1912). Friedman, S., & Gelso, C. (2000). The development of the inventory of countertransference behavior. Journal of Clinical Psychology, 56, 1221– 1235. Fuertes, J. N., Gelso, C. J., Owen, J. J., & Cheng, D. (2013). Real relationship, working alliance, transference/countertransference and outcome in time-limited psychotherapy. Counselling Psychology Quarterly. doi:10.1080/09515070.2013.845548 Gelso, C. J. (2014). A tripartite model of the therapeutic relationship. Theory, research, and practice. Psychotherapy Research, 24, 117–131. Gelso, C. J., & Hayes, J. A. (2007). Countertransference and the therapist’s inner experience: Perils and possibilities. Mahway, NJ: Lawrence Erlbaum. Gelso, C. J., Hill, C., & Kiviglian, M. (1991). Transference, insight, and the counselor’s intentions during a counseling hour. Journal of Counseling and Development, 69, 428– 433. Gelso, C. J., & Johnson, D. H. (1983). Explorations in time-limited psychotherapy and psychotherapy. New York, NY: Columbia University, Teachers College Press.
16
J.N. Fuertes et al.
Gelso, C. J., Kelley, F. A., Fuertes, J. N., Marmarosh, C., Holmes, S. E., Costa, C., & Hancock, G. R. (2005). Measuring the real relationship in psychotherapy: Initial validation of the therapist form. Journal of Counseling Psychology, 52, 640– 649. Gelso, C. J., Kiviglian, D., Busa-Knepp, J., Spiegel, E. B., Ain, S., Hummel, A. M., . . . Markin, R. D. (2012). The unfolding of the real relationship and the outcome of brief psychotherapy. Journal of Counseling Psychology, 59, 495– 506. Gelso, C. J., Kiviglian, D., Wine, B., Jones, A., & Friedman, S. (1997). Transference, insight, and the course of time-limited therapy. Journal of Counseling Psychology, 44, 209– 217. Graff, H., & Luborsky, L. L. (1977). Long-term trends in transference and resistance. A report on a quantitative-analytic method applied to four psychoanalyses. Journal of the American Psychoanalytical Association, 25, 471– 490. Hartley, D. E. M., & Strupp, H. H. (1983). The therapeutic alliance: Its relationship to outcome in brief psychotherapy. In J. Masling (Ed.), Empirical studies in analytic theories (pp. 1 –37). Hillsdale, NJ: Erlbaum. Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. In J. C. Norcross (Ed.), Psychotherapy relationships that work; evidence-based responsiveness (2nd ed., pp. 239– 260). New York, NY: Oxford. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12 – 19. Kernhof, K. M., Obbarius, A., Kaufhold, J., Merkle, W., & Grabhorn, R. (2013). Countertransference in residential treatment setting. Psychotherapeut, 58, 152– 158. Kivlighan, D. M. (1995). Similarities and differences among counselor, supervisor and observer ratings of individual counseling process. Unpublished manuscript, University of Missouri, Columbia. Latts, M. G. (1996). A revision and validation of the Countertransference Factors Inventory (Unpublished doctoral dissertation). University of Maryland, College Park, MD. Ligiero, D., & Gelso, C.J. (2002). Countertransference, attachment, and the working alliance: The therapist’s contribution. Psychotherapy: Theory, Research, Practice, Training, 39, 3 – 11. doi:10.1037/0033-3204.39.1.3 Mann, J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard University Press. Moore, J., & Owen, J. (2014). Assessing outcomes in university and college counseling centers: Practical methods and evidence. Journal of College Counseling, 58, 175– 185. Norcross, J. C. (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York, NY: Oxford. Orlinsky, D. E., & Howard, K. I. (1986). The psychological interior of psychotherapy: Explorations with the therapy session reports. New York, NY: Guilford Press. Palma, B., & Gelso, C.J. (2012). Disentangling the therapist’s contribution to the therapeutic relationship: Attachment style, countertransference, and the real relationship (Unpublished doctoral dissertation). University of Maryland, College Park, MD. Stiles, W. B., & Snow, J. S. (1984). Counseling session impact as viewed by novice counselors and their clients. Journal of Counseling Psychology, 31, 3 – 12. Zittel, C., & Westen, D. (2003). The countertransference questionnaire. Atlanta, GA: Departments of Psychology and Psychiatry and Behavioral Sciences, Emory University. Retrieved from http://www.psychsystems.net/lab
Psychoanalytic Psychotherapy
17
Appendix 1. ICB-O: items, clarifying statements, and a sample of in-session behavior For the 21 items below, please rate the therapist’s reaction to the client during the counseling session using the scale from 1 to 5. Please refer to the clarifying statement below each item and to the examples of possible in-session therapist behaviors to help you make each rating. The therapist: 1
2
to little or no extent
3 to a moderate extent
4
5 to a great extent
1. Colluded with the client in the session _____ Clarifying Statement: Letting the client engage in unhelpful thoughts or patterns of behaviors without addressing. Example of Possible Therapist In-session Behavior: Going along with something that is bad, wrong; joining the client in helpless behavior 2. Rejected the client in the session_____ Clarifying Statement: Can be implicit or explicit- not validating the client when he/she should have been validated. Example of Possible Therapist In-session Behaviors: Rejecting the client, not validating something the client says that should have been validated, saying something hurtful to the client, therapist changing the subject inappropriately. 3. Over-supported the client in the session_____ Clarifying Statement: Providing support in such a way that blocks the client from working through his problem. Example of Possible Therapist In-session Behaviors: Therapist showing excessive sympathy for the client. Examples: ‘You tried your best,’ ‘He is a monster/evil’ 4. Befriended the client in the session_____ Clarifying Statement: Broke therapeutic boundaries, to act ‘friendly’ Example of Possible Therapist In-session Behaviors: Related to client in a friendly way more than in a therapeutic way. 5. Was apathetic towards the client in the session_____ Clarifying Statement: The therapist does not seem to care about the client or the outcome. Shows little investment in the client. Example of Possible Therapist In-session Behaviors: The therapist showed no or little reaction to the client, even when client shared material that would have warranted some reaction on the part of the therapist. 6. Behaved as if she or he were ‘somewhere else’ during the session_____ Clarifying Statement: Temporarily ‘zoned out’ Example of Possible Therapist In-session Behaviors: The therapist’s interventions seemed out of context in a way that revealed therapist was not closely following what the client was saying.
18
J.N. Fuertes et al. 7. Talked too much in the session_____ Clarifying Statement: Your estimate is that the therapist spoke more than 50% of the time and it appeared excessive. Example of Possible Therapist In-session Behaviors: Too many interventions on the part of the therapist. Interventions that were too long Therapist speaking too frequently 8. Frequently changed the topic during the session_____ Clarifying Statement: Changed topics inappropriately, no therapeutic reason evident. Example of Possible Therapist In-session Behaviors: When therapist starts speaking about a totally new topic without resolution or appropriate transition from the previous points discussed 9. Was critical of the client during the session_____ Clarifying Statement: Harsh or hostile interventions, seeming to come from the therapist’s own issues or frustration, not therapeutic Example of Possible Therapist In-session Behaviors: Explicitly being judgmental against client/client’s views 10. Spent time complaining during the session_____ Clarifying Statement: Burdening the client with ‘personal’ complaints Example of Possible Therapist In-session Behaviors: Therapist complaining about things to the client and that reflect the therapists needs or has a self-centeredness about it. 11. Treated the client in a punitive manner in the session_____ Clarifying Statement: Punishment for a specific action, a demerit, could be subtle such as delaying the session, possibly belittling or infantilizing Example of Possible Therapist In-session Behaviors: Being judgmental against the client. Using against the client what the client is discussing or had discussed 12. Inappropriately apologized to the client during the session_____ Clarifying Statement: Clearly coming from therapist’s own needs Example of Possible Therapist In-session Behaviors: Apologized to the client for no good reason. Example: apologized about having to end the session, or after making an intervention that the client did not receive well. 13. Acted in a submissive way with the client during the session_____ Clarifying Statement: Relinquishing control and power of the session to the client in a way that seemed inappropriate and/or unprofessional. Example of Possible Therapist In-session Behaviors: There seemed to be a power differential in the room where the client adopted a more dominant role and the therapist a submissive role 14. Acted in a dependent manner during the session_____ Clarifying Statement: Acted as though the therapist needed the client’s approval Example of Possible Therapist In-session Behaviors: As if the therapist was looking for approval from the client. 15. Seemed to agree too often with the client during the session_____ Clarifying Statement: Doesn’t get the client out of a comfort zone. Therapist appears uncomfortable with confrontation, comes from therapist’s own discomfort with tension
Psychoanalytic Psychotherapy
19
Example of Possible Therapist In-session Behaviors: Never (not even slightly) conveying the possibility of a different, alternative way to look at things. When therapist interventions solely affirm/agree 100% with all what the client says. 16. Inappropriately took an advising tone with the client during the session_____ Clarifying Statement: Too directive in the face of complexity, foreclosure of exploration of problems, appears defensive and not helpful or well timed. Example of Possible Therapist In-session Behaviors: Gave advice too quickly or directly, suggested courses of action. 17. Distanced him/herself from the client in the session_____ Clarifying Statement: Active defense against the client or subject matter because of intensity, complexity, or an intimacy that was threatening. Example of Possible Therapist In-session Behaviors: Suddenly the therapist seems detached, distant, far away, not appropriately involved in the conversation with the client. 18. Engaged in too much self-disclosure during the session_____ Clarifying Statement: Therapist talked excessively about him/herself, related client’s comments or experiences inappropriately back to him/herself Example of Possible Therapist In-session Behaviors: Inappropriately sharing with the clients information about him/herself, 19. Behaved as if she or he were absent during the session_____ Clarifying Statement: Preoccupied, distracted, overall, was ‘not there’ for the duration of the session Example of Possible Therapist In-session Behaviors: Could be like 17 above [distanced him/herself] but perhaps more indicative of total session behavior, whereas 17 may be more temporary. 20. Inappropriately questioned the client’s motives during the session_____ Clarifying Statement: Conveys some suspicion or mistrust, suggests therapist can’t accept client’s views or motives Example of Possible Therapist In-session Behaviors: Therapist inappropriately asked too many questions to the client, as if therapist did not/could not believe/ understand the client. 21. Provided too much structure in the session_____ Clarifying Statement: Imposed an excessive amount of structure on the session, let structure override clinical judgment Example of Possible Therapist In-session Behaviors: Therapist seemed not spontaneous, interventions seemed rigid, excessively calculated. Positive CT items: 1, 3, 4, 7, 8, 12, 13, 14, 15, 18. Negative CT items: 2, 5, 6, 9, 10, 11, 16, 17, 19, 20, 21.
