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Saturday, February 11, 2023

Countertransference awareness and treatment outcome

Abargil, M., & Tishby, O. (2022). 
Journal of counseling psychology,
69(5), 667–677.


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.

From the Discussion section

Increased therapist awareness of CT facilitate improvement in patient symptoms, emotion regulation and affiliation in relationships. Since awareness is an integral part of CT management, these findings are consistent with Hayes’ results from 2018 regarding the importance of CT management and its contribution to treatment outcome. Moreover, therapist’s self-awareness was found to be important in treating minorities (Baker, 1999). This study expands the ecological validity of therapist awareness and shows that the therapists’ awareness of their own wishes in therapy, as well as his perception of himself and the patient, is relevant to the general population as well. Thus, therapists of all theoretical orientations are encouraged to attend to their personal conflicts and to monitor their reactions to patients as a routine part of effective clinical practice. Moreover, therapist awareness has been found in the past to lead to less therapist self-confidence, but to better treatment outcomes (Williams, 2008). Our clinical examples illustrate these findings (the therapist who had high awareness showed much more self- doubt) and the results of multilevel regression analysis demonstrate better improvement for patients whose therapists were highly aware. Interestingly, the IIP control dimension was not found to be related to the therapist’s awareness of CT. It may be that since this dimension relates to the patient’s control need, the awareness of transference is more important. Another possibility is that the patient’s experience of the therapist as “knowing” may actually increase his control needs. Moreover, regarding patient main TC, we only found a trend and not a significant interaction. One reason may be the sample size. Another explanation is that patients do not necessarily link the changes in their lives to the relationship with the therapist and the insights associated with it. Thus, although awareness of CT helps to improve other outcome measures, it is not related to the way patients feel about the reason they sought out treatment.

A recent study of CT found that negative types of CT were correlated with more ruptures and less repair in the alliance. For positive CT the picture is more complex; Positive patterns predicted resolution when the therapists repeated positive patterns with par- ents but predicted ruptures when they tried to “repair” negative patterns with the parents (Tishby & Wiseman, 2020). The authors suggest that awareness of CT will help the therapist pay more attention to ruptures during treatment so they can address it and initiate resolutions processes. Our findings support the authors’ suggestion. The clinical example demonstrates that when the therapist was aware of negative CT and was able to talk about it in the awareness interview, he was also able to address the difficult feelings that arose during a session with the patient. Moreover, the treatment outcomes in these treatments were better which characterizes treatments with proper repair processes.