Practice-Based Psychotherapy Research
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PPRNet Blog: November 2014

Giorgio A. TascaAt the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.

About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.

Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.

At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.

If you have ideas for an article to review or a topic you would like to see covered, please send me an email at

Giorgio A. Tasca

blogTransference in Psychotherapy: A Review of the Research

Hoglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171, 1056-1066.

In this overview of patient-therapist relationship factors, Per Hoglend reviews research on transference in psychotherapy. He argues that transference and transference work is a specific technique that focuses on exploring the patient-therapist relationship. Hoglend takes a broad definition of transference as: the patient’s pattern of feelings, thoughts, perceptions, and behaviors that emerge in the therapeutic relationship and reflect the patient’s personality functioning. Hoglend also defines transference work as any therapist intervention that refers to or explains the patient’s experience of the therapist and their interaction. These interventions include the therapist: (1) addressing transactions in the patient-therapist relationship; (2) encouraging exploration of feelings and thoughts about the therapy or therapist; (3) encouraging the patient to discuss how he or she believes the therapist might feel or think about the patient; (4) including him or herself in interpreting the patient’s dynamics; and (5) interpreting repetitive interpersonal dynamics and linking these to the therapy relationship. More than 30 studies have been published on providing empirical evidence for the relationship between transference work in psychotherapy and positive patient interpersonal outcomes. Effect sizes of the association between transference work and patient outcomes tend to be large. Some of the research indicates that low frequency of transference interventions is useful, but that a higher frequency may lead to negative effects on the patient. Research on transference-focused psychotherapy indicates that it is as effective as dialectical behavior therapy and supportive psychotherapy for borderline personality disorder, but that transference-focused therapy produced better outcomes for attachment related functioning like mentalizing. In the First Experimental Study of Transference Work (FEST), Hoglend found that patients with low quality of object relations (i.e. a poorer ability to maintain close relationships and to regulate affect) benefitted most from transference focused therapy. However, those with high quality of object relations did not require the transference work to get better. Also, women responded better to transference work than men. There are some studies of therapeutic approaches like cognitive behavior therapy, in which patients with depression had better outcomes when the patient-therapist relationship was explicitly discussed.

Practice Implications

Hoglend argues that transference work in psychotherapy is an active ingredient that can lead to specific change in some patients. Most studies that Hoglend reviewed showed significant and large associations between transference work and interpersonal changes in patients. Exploring the patient-therapist relationship appears to be most useful for female patients, those with difficult interpersonal relationships, and those with more severe personality pathology. Patients with more mature relationships may not benefit as much from transference work. Although generally effective, if transference work is used too frequently in a session it can also lead to negative patient outcomes.

View the Transference in Psychotherapy: A Review of the Research article.
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blogManaging Countertransference: Meta-analytic Evidence

Hayes, J.A., Gelso, C.J., & Hummel, A.M. (2011). Managing countertransference. Psychotherapy, 48, 88-97.

This is another in a series of meta-analyses on relationship factors that work in psychotherapy that appeared also in John Norcross’ book Psychotherapy Relationships That Work. As I mentioned in previous blogs, meta-analyses represent the state of the art in systematically reviewing a research literature. In meta-analyses, the effect sizes from many studies are aggregated into an estimate of an overall effect that is much more reliable than any single study. In these meta-analyses, Hayes and colleagues assessed whether therapist countertransference had a negative effect on patient outcomes, and whether successful management of countertransference is related to better therapy outcomes. Traditionally, countertransference was seen as solely related to therapist unconscious conflicts, and countertransference was to be avoided. Broader conceptualizations view countertransference as representing all of the therapist’s reactions to the client. More interpersonal or relational models view countertransference as therapist reactions that complement a patient’s ways of relating, or see countertransference as mutually constructed by therapist and patient, so that the needs and conflicts of both patient and therapist contribute to the manifestation of countertransference in therapy. Hayes and colleagues argue that countertransference must include some aspect of therapist unresolved conflicts, and that countertransference in the therapist is potentially useful to understanding patient dynamics and personality style. Countertransference may be reflected in therapist anger, boredom, anxiety, despair, arousal, etc. These feelings range in intensity as well. According to Hayes and colleagues, successful management of countertransference might involve: self-insight (therapist being aware of their own feelings, attitudes, personality, etc.); self integration (therapist’s healthy character structure); anxiety management (therapist’s ability to control and understand own anxiety); empathy (the ability to put one’s self in the other’s shoes in order to focus on the client’s needs); and conceptualizing ability (therapist’s ability to draw on theory to understand the patient’s role in the therapeutic relationship). Hayes’ and colleagues meta analyses included between 7 to 11 studies of 478 to 1065 participants. The findings showed that countertransference in the therapist was associated with negative patient outcomes, though the effect was small. Successful management of countertransference was associated with better therapy outcomes, and the effect was large.

Practice Implications

Successful management of countertransference is a characteristic of effective therapists. Therapists can work on a number of issues to reduce the negative impact of countertransference and to increase its utility in helping to understand certain patients. Therapists can work to gain self-understanding and their or her own psychological health. The research suggests the importance of therapists resolving their own major conflicts through personal therapy and clinical supervision. Having a good grasp of psychological theory and theories of therapy can also help with using countertransference effectively, as long as the theory is not used defensively by the therapist. Further, there is value in therapists admitting mistakes and acknowledging that their own conflict was the source of the error. Although countertransference theory and research focuses on the therapist, Hayes and colleagues acknowledge that some clients evoke greater and more intense countertransference reactions that others.

View the Managing Countertransference: Meta-analytic Evidence article abstract.

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blogChild Abuse and Mental Disorders in Canada: A Population Survey

Afifi, T. O., MacMillan, H. L., Boyle, M., Taillieu, T., Cheung, K., & Sareen, J. (2014). Child abuse and mental disorders in Canada. Canadian Medical Association Journal, cmaj-131792.

Childhood adversity, including physical abuse, sexual abuse, neglect, witnessing violence, and loss of an attachment figure early in life is well known to result in a number of health and mental health problems later in life. Afifi and colleagues refer to child abuse at a significant public health problem worldwide. Despite the well known effects of child abuse, until recently there has been little research on the estimates of abuse and its outcomes in Canada. In their study, Afifi and colleagues looked at three types of child abuse (physical abuse, sexual abuse, and intimate partner violence) and its effects on 14 mental conditions including suicide and substance abuse. The authors used data from the 2012 Canadian Community Health Survey that included a representative sample of respondents aged 15 years and older living in the 10 provinces representing over 25,000 Canadians. The household survey response rate was close to 80%, and those over the age of 18 (N = 23,395) were asked about child abuse that occurred before the age of 16. Physical abuse was defined as any instances of being slapped, punched, kicked, burned etc. Sexual abuse was defined as being forced into any unwanted sexual activity by being threatened. Exposure to partner violence was classified as having seen or heard parents, step-parents, or guardians hitting each other. The prevalence of any of these 3 types of child abuse was 32.1%, with physical abuse being most common (26.1%), followed by sexual abuse (10.1%) and exposure to intimate partner violence (7.9%). Women were more likely than men to have experienced childhood sexual abuse (14.4% versus 5.8%) and exposure to intimate partner violence (8.9% versus 6.9%) as children. Men were more likely than women to have experienced child physical abuse (31.0% versus 21.3%). All forms of child abuse were associated with an increase in later mental illness, such that those who experienced any form of child abuse were over 3 times more likely to have a later mental illness. Obsessive–compulsive disorder was associated specifically with sexual abuse, eating disorders were specifically associated with physical abuse, post traumatic stress disorder was specifically associated with sexual abuse and certain types of physical abuse. All 3 types of abuse were associated with drug abuse/dependence, suicidal ideation, and suicide attempts. Exposure to a higher number of abuse types (i.e., sexual abuse, physical abuse, intimate partner violence) was associated with more mental illnesses, and the effect was worse for women.

Practice Implications

Child abuse is an important public health problem in Canada and is associated with a number of mental health problems in adulthood. Health care providers should be aware of the relation between specific types of child abuse and certain mental conditions. Clinicians working in the mental health field should acquire skills in assessing patients for exposure to abuse, and should understand the implications for treatment.

View the Child Abuse and Mental Disorders in Canada: A Population Survey article.
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