Randi Ulberg

Transference Interpretations in Dynamic Psychotherapy: Do They Really Yield Sustained Effects?

OBJECTIVE Transference interpretation has remained a core ingredient in the psychodynamic tradition, despite limited empirical evidence for its effectiveness. In this study, the authors examined long-term effects of transference interpretations. METHOD This was a randomized controlled clinical trial, dismantling design, plus follow-up evaluations 1 year and 3 years after treatment termination. One hundred outpatients seeking psychotherapy for depression, anxiety, personality disorders, and interpersonal problems were referred to the study therapists. Patients were randomly assigned to receive weekly sessions of dynamic psychotherapy for 1 year with or without transference interpretations. Five full sessions from each therapy were rated in order to document treatment fidelity. Outcome variables were the Psychodynamic Functioning Scales (clinician rated) and the Inventory of Interpersonal Problems (self-report). Rating on the Quality of Object Relations Scale (lifelong pattern) and presence of a personality disorder were postulated moderators of treatment effects. Change over time was assessed using linear mixed models. RESULTS Despite an absence of differential treatment efficacy, both treatments demonstrated significant improvement during treatment and also after treatment termination. However, patients with a lifelong pattern of poor object relations profited more from 1 year of therapy with transference interpretations than from therapy without transference interpretations. This effect was sustained throughout the 4-year study period. CONCLUSIONS The goal of transference interpretation is sustained improvement of the patients relationships outside of therapy. Transference interpretation seems to be especially important for patients with long-standing, more severe interpersonal problems.

Effects of transference work in the context of therapeutic alliance and quality of object relations.

OBJECTIVE Transference interpretation is considered as a core active ingredient in dynamic psychotherapy. In common clinical theory, it is maintained that more mature relationships, as well as a strong therapeutic alliance, may be prerequisites for successful transference work. In this study, the interaction between quality of object relations, transference interpretation, and alliance is estimated. METHOD One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment, but without the use of transference interpretation. Quality of Object Relations (QOR)-lifelong pattern was evaluated before treatment (P. Høglend, 1994). The Working Alliance Inventory (A. O. Horvath & L. S. Greenberg, 1989; T. J. Tracey & A. M. Kokotovic, 1989) was rated in Session 7. The primary outcome variable was the Psychodynamic Functioning Scales (P. Høglend et al., 2000), measured at pretreatment, posttreatment, and 1 year after treatment termination. RESULTS A significant Treatment Group × Quality of Object Relations × Alliance interaction was present, indicating that alliance had a significantly different impact on effects of transference interpretation, depending on the level of QOR. The impact of transference interpretation on psychodynamic functioning was more positive within the context of a weak therapeutic alliance for patients with low quality of object relations. For patients with more mature object relations and high alliance, the authors observed a negative effect of transference work. CONCLUSION The specific effects of transference work was influenced by the interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory.

The mediating role of insight for long-term improvements in psychodynamic therapy.

OBJECTIVE According to psychoanalytic theory, interpretation of transference leads to increased insight that again leads to improved interpersonal functioning over time. In this study, we performed a full mediational analysis to test whether insight gained during treatment mediates the long-term effects of transference interpretation in dynamic psychotherapy. METHOD This study is a randomized clinical trial with a dismantling design. One hundred outpatients seeking psychotherapy for depression, anxiety, personality disorders, and interpersonal problems were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment with the same therapists but without the use of transference interpretation. Interpersonal functioning and insight were measured pretreatment, posttreatment, and 1 year and 3 years after treatment termination. RESULTS Contrary to common expectation, patients with a life-long pattern of low quality of object relations and personality disorder pathology profited more from therapy with transference interpretation than from therapy with no transference interpretation. This long-term effect was mediated by an increase in the level of insight during treatment. CONCLUSIONS Insight seems to be a key mechanism of change in dynamic psychotherapy. Our results bridge the gap between clinical theory and empirical research.

Patient Sex as Moderator of Effects of Transference Interpretation in a Randomized Controlled Study of Dynamic Psychotherapy

Objective: To examine whether men and women respond differentially to brief dynamic psychotherapy, with or without transference interpretations. Method: Data from the First Experimental Study of Transference Interpretation were used. Patients (n = 100) were randomized to receive 2 different dynamic psychotherapies during 1 year, with either a moderate level of transference interpretations or no transference interpretations. We used the following outcome measures: the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems-Circumplex Version, Global Assessment of Functioning (GAF), and total mean score of Symptom Checklist-90-Revised (Global Severity Index [GSI]). Change was assessed using linear-mixed models. Results: On average, men and women responded equally across treatments. The moderator analyses, using the 2 secondary outcome measures, GAF and GSI, demonstrated that women responded better to therapy with transference interpretations, compared with men, whereas men responded better to therapy without transference interpretations, compared with women. When the moderator sex was combined with the moderator quality of object relations (QOR), a strong effect emerged: men with high QOR showed a large negative effect of transference interpretations, and women with low QOR showed a large positive effect. Conclusions: In terms of symptom change, women responded better to therapy with transference interpretations, while men responded better to therapy without transference interpretations. Patient sex showed moderator effects over and above the moderator effects of QOR.

Transference interventions and the process between therapist and patient.

Interpreting the transference has been considered a core ingredient in psychodynamic psychotherapy. The effects of analyzing the transference are probably dependent on certain characteristics of the interventions themselves and the context in which transference interventions are given. The present study describes the development and use of a therapy process rating scale (Transference Work Scale; TWS) constructed to identify, categorize, and explore work with the transference. TWS has subscales that rate timing, content, and valence of the transference interventions, as well as response from the patient. Transcribed segments (10 min) from 51 different patients were scored with TWS by 2 independent raters. The interrater agreement on the TWS items was good to excellent. Clinical examples of transference work were also rated using the Structural Analysis of Social Behavior (SASB). TWS and SASB supplement each other. TWS might be a potentially useful tool to explore the interaction of timing, category, and valence of transference work in predicting in-session patient response as well as treatment outcome.

Change in self-protect ion and symptoms after dynamic psychotherapy: the influence of pretreatment motivation.

The First Experimental Study of Transference-interpretations (FEST) is a dismantling, randomized clinical trial of the long-term effects of transference interpretation. This article looks at the influence of motivation on the ability to self-protect and symptoms. Patients were randomized to receive a moderate level of transference interpretations or no transference interpretation. Assessments were made at pretreatment, midtreatment, posttreatment, and at two follow-ups. The outcome measure, change in ability to self-protect, was cluster 4 of the Structural Analysis of Social Behavior (SASB) Long Form Intrex Introject Questionnaire, a measure close to the SASB-coded treatment process. Symptom change (SCL-90) was also analyzed. Pretreatment motivation was a significant moderator of change in the ability to self-protect and in symptom distress. Those with low motivation had a significant, positive, and long-term treatment effect of transference interpretation. Patients with low motivation showed a significant, negative effect of transference interpretation.

Women respond more favorably to transference intervention than men: a randomized study of long-term effects.

Abstract The present study focuses on whether there is a sustained difference in treatment response to transference interventions between women and men. Data from the First Experimental Study of Transference Interpretations were used. One hundred patients were randomized to receive dynamic psychotherapy in 1 year with either a moderate level of transference intervention or no transference intervention. Follow-ups were 1 year and 3 years after treatment termination. The two primary outcome measures were the Psychodynamic Functioning Scales (PFS) and Inventory of Interpersonal Problems–Circumplex Version. Change was assessed using linear mixed models. In the moderator analyses, using the primary outcome measure (PFS) and controlling for the effect of the level of relational functioning (Quality of Object Relations Scale), women and men differed significantly in their response to transference intervention. The average relational functioning female patients showed a significant positive long-term effect of transference intervention.

Treatment of adolescents with depression: the effect of transference interventions in a randomized controlled study of dynamic psychotherapy

BackgroundDepression in adolescents seems to be a growing problem that causes mental suffering and prevents young people from joining the workforce. There is also a high risk of relapse during adult life. There is emerging evidence for the effect of psychodynamic psychotherapy in adolescents. In-session relational intervention (that is, transference intervention) is a key component of psychodynamic psychotherapy. However, whether depressed adolescents profit most from psychodynamic psychotherapy with or without transference interventions has not been stated.ObjectThe effect of transference interventions in depressed adolescents and the moderator moderating effect of quality of object relations, personality disorder and gender will be explored.Methods and study designThe First Experimental Study of Transference Work–In Teenagers (FEST–IT) will be a randomized clinical trial with a dismantling design. The study is aimed to explore the effects of transference work in psychodynamic psychotherapy for adolescents with depression. One hundred patients ages 16 to 18 years old will be randomized to one of two treatment groups, in both of which general psychodynamic techniques will be used. The patients will be treated over 28 weeks with either a moderate level of transference intervention or no transference intervention. Follow-up will be at 1 year after treatment termination. The outcome measures will be the Psychodynamic Functioning Scales (PFS), Inventory of Interpersonal Problems–Circumplex Version (IIP-C), Global Assessment of Functioning (GAF), and the total mean score of Symptom Checklist–90 (Global Severity Index; GSI), Beck Depression Inventory (BDI), and Montgomery Åsberg Rating Scale (MADRS). The quality of adolescents’ relationships will be a central focus of the study, and the Adolescent Relationship Scales (ARS) and Differentiation–Relatedness Scale (DRS) will also be used. Change will be assessed using linear-mixed models. Gender personality disorder (PD) and quality of object relations (QOR) will be the preselected putative moderators.DiscussionThe object of this clinical trial is to explore the effect of transference interventions in psychodynamic psychotherapy in adolescents with a major depressive disorder. Using a randomized and dismantling design, we hope that the study will add more specific knowledge to the evidence base.Trial registrationClinicalTrials.gov Identifier: NCT01531101First Experimental Study of Transference work Work–In Teenagers (FEST-IT)

Do gender and level of relational functioning influence the long-term treatment response in dynamic psychotherapy?

Background: Gender as a moderator of long-term treatment effects has to a very little extent been explored in individual psychotherapy. We have previously reported a short-term difference in treatment-response to transference interpretations between women with poor relational functioning (low Quality of Object Relations Scale; low QOR) and men with good relational functioning (high QOR). The present study focuses on whether there also is a sustained difference in treatment-response between those two subgroups. Material and method: In the First Experimental Study of Transference-interpretations (FEST), patients (n=100) were randomized to receive dynamic psychotherapy over 1 year with either a moderate level of transference interpretations or no transference interpretations. Assessments were made at pre-treatment, mid-treatment, post-treatment, and at 1- and 3-year follow-ups. The outcome measures used were the Psychodynamic Functioning Scales (PFS), Inventory of Interpersonal Problems (IIP-C), Global Assessment of Functioning (GAF) and Symptom Checklist-90 (GSI). Change was assessed using linear–mixed models. Results: In the moderator analyses, women with low QOR showed a significant positive long-term treatment effect of transference interpretation (P=0.005), while men with high QOR responded equally well to both therapies. Conclusion: Women with poor relational functioning and men with good relational functioning showed sustained different treatment-response to transference interpretations.

The Effects of the Therapist's Disengaged Feelings on the In‐Session Process in Psychodynamic Psychotherapy

The primary aim of this article was to explore the effects of the therapists disengaged feelings (i.e., bored, tired of, sleepy, indifferent, aloof) in psychodynamic therapy. The Transference Work Scale was used in combination with the Defense Mechanism Rating Scales and Structural Analyses of Social Behavior to explore the in-session process in 2 therapies with female patients with interpersonal problems. Analyses showed differences in in-session processes (i.e., defense mechanisms; transference work; degree of affiliation and interdependence in the dialogue) and treatment outcome between therapies characterized by a low versus a higher degree of disengaged feelings. Compared to the case with the engaged therapist, the disengaged therapist showed poorer interaction and less response to transference and defense interpretation. When aware of their disengaged feelings, therapists are advised to encourage their patients to discuss the patient-therapist interaction.