Gender differences in response to transference interpretations Randi Ulberg October 2009 UNIVERSITY OF OSLO, NORWAY

Gender differences in Gender differences in response to transference response to transference

interpretations interpretations

Randi Ulberg

October 2009

UNIVERSITY OF OSLO, NORWAY

Per Høglend, research directorPer Høglend, research directorSvein Amlo, clinical directorSvein Amlo, clinical directorAlice MarbleAlice MarbleKjell-Petter BøgwaldKjell-Petter BøgwaldØystein SørbyeØystein SørbyeMary Cosgrove SjaastadMary Cosgrove SjaastadOscar HeyerdahlOscar HeyerdahlPaul JohanssonPaul JohanssonRandi UlbergRandi Ulberg Martin M. NilsenMartin M. NilsenMartin FuranMartin FuranKnut HagtvetKnut HagtvetJan Ivar RøssbergJan Ivar Røssberg

FEST - First Experimental Study of Transference-interpretations

Department of PsychiatryDiakonhjemmet Hospital, OsloBlakstad Hospital, Akershus

Ullevål University Hospital, Division of PsychiatryUllevål University Hospital,

Centre for Child and Adolescent PsychiatryDepartment of Psychology, University of Oslo

Dep. of Child and Adolecent Psychiatry, Vestfold

Per Høglend, research directorPer Høglend, research directorSvein Amlo, clinical directorSvein Amlo, clinical directorAlice MarbleAlice MarbleKjell-Petter BøgwaldKjell-Petter BøgwaldØystein SørbyeØystein SørbyeMary Cosgrove SjaastadMary Cosgrove SjaastadOscar HeyerdahlOscar HeyerdahlPaul JohanssonPaul JohanssonRandi UlbergRandi Ulberg Martin M. NilsenMartin M. NilsenMartin FuranMartin FuranKnut HagtvetKnut HagtvetJan Ivar RøssbergJan Ivar RøssbergHanne –Sofie DahlHanne –Sofie Dahl

FEST - First Experimental Study of Transference-interpretations

D Department of Psychiatry

Gender differences in response to Gender differences in response to transference interpretationstransference interpretations

Høglend, P., Bøgwald, K.P., Amlo, S., Marble, A., Ulberg, R., Sjaastad, M.C., Sørbye, Ø., Heyerdahl, O. & Johansson, P. (2008). Transference interpretations in dynamic psychotherapy: do they really yield sustained effects? Am. J. Psychiatry, 165: 763-771.

Ulberg, R., Johansson, P., Marble. A. & Høglend, P. (2009). Patient sex as moderator of effects of transference interpretation in a randomized controlled study of dynamic psychotherapy. Can. J. Psychiatry, 54: 78-86.

Ulberg, R., Høglend, P., Marble, A. & Johansson, P. (Submitted). Women respond favourably to transference interpretation, men do not: a randomized controlled study of long-term effects of dynamic psychotherapy

Ulberg, R., Marble. A. & Høglend. P. (2009). Do gender and level of relational functioning influence the long-term treatment response in dynamic psychotherapy? Nordic. J. Psychiatry, 63: 412-419.

Ulberg, R., Høglend, P., Marble, A., & Sørbye, Ø. (2009).From submission to autonomy; approaching independent decision making; A single case study in a randomized controlled study of long-term effects of dynamic psychotherapy American Journal of Psychotherapy, 63: 227-243.

FESTFEST

Patients referred from general Patients referred from general practitioners, outpatient departments and practitioners, outpatient departments and private practice (N =100)private practice (N =100)

Randomisation: Transference/not Randomisation: Transference/not transferencetransference

Dynamic Psychotherapy (1 weekly Dynamic Psychotherapy (1 weekly session;max 40 sessions) session;max 40 sessions)

7 therapists (5 men and 2 women)7 therapists (5 men and 2 women) Same gender therapist – patient 56 %Same gender therapist – patient 56 % Different gender therapist – patient 44 %Different gender therapist – patient 44 %


Outcome measuresOutcome measures Psychodynamic Functioning Scales (PFS) Psychodynamic Functioning Scales (PFS) Inventory of Interpersonal Problems (IIP-C) Inventory of Interpersonal Problems (IIP-C)

(Dynamic Change)(Dynamic Change)

Global Assessment of Functioning (GAF) Global Assessment of Functioning (GAF) Global Severity Index - SCL-90 (GSI)Global Severity Index - SCL-90 (GSI)

(Symptom Change)(Symptom Change)

))

Global Severity Index - SCL-90 (GSI)Global Severity Index - SCL-90 (GSI)


Gender in Psychotherapy

In clinical theory it is recognized that patient gender contributes to the transference

Search: “gender OR sex AND psychotherapy” PubMed –result; 118 209 International Journal of Psychoanalysis

– result: 2008; 41 Erotic transference


Erotic transferenceErotic transference

John William Waterhouse 1849 - 1917

Erotic transference - in Erotic transference - in treatmenttreatment

Opdal LC: Erotization of the analytic Opdal LC: Erotization of the analytic situation. situation. Scandinavian PsychoanalyticScandinavian Psychoanalytic Review. Review. 2007;30:2-12.2007;30:2-12.

Gabbard G: Gabbard G: Boundaries, technique, and self-deception: a discussion (2008)Boundaries, technique, and self-deception: a discussion (2008)

Lessons to be learned from the study of sexual boundary Lessons to be learned from the study of sexual boundary violation (1996)violation (1996)

Sexual excitement and countertransference love in the analyst Sexual excitement and countertransference love in the analyst (1994)(1994)

Joy Scaverien : Gender, Joy Scaverien : Gender, Countertransference and the Erotic Countertransference and the Erotic Transference. (2006) Transference. (2006)

GENDER VS SEXGENDER VS SEX

Distinction: Distinction: GENDER (determined by GENDER (determined by

psychological and cultural conditions) psychological and cultural conditions) SEX (determined by physical SEX (determined by physical

conditions) conditions) Stoller (1968) Stoller (1968) . .

GENDER is used because it is obvious GENDER is used because it is obvious that the gender-variable not only that the gender-variable not only encloses the patient’s biological sex.encloses the patient’s biological sex.

Quality of Object Relations Quality of Object Relations (QOR)(QOR)

Lifelong pattern of relationships from Lifelong pattern of relationships from primitive to matureprimitive to mature

7-8: Mature equitable relationships7-8: Mature equitable relationships 5-6: Recent relationships may be difficult, 5-6: Recent relationships may be difficult,

but there is evidence of at least one but there is evidence of at least one mature relationship in the patient’s historymature relationship in the patient’s history

3-4:Need of dependency or overcontrol in 3-4:Need of dependency or overcontrol in most relationshipsmost relationships

1-2: Unstable, less gratifying relationships1-2: Unstable, less gratifying relationships


Pretreatment characteristics of patients who Pretreatment characteristics of patients who received dynamic psycho-therapy of one year received dynamic psycho-therapy of one year

duration with duration with (N=52) (N=52) and without and without (N=48) (N=48)

transference interpretations.transference interpretations.

AgeAge Global optimism **Global optimism ** ExpectancyExpectancy Motivation Motivation Quality of Object Quality of Object

relationsrelations Female sexFemale sex SingleSingle Depressive disordersDepressive disorders Anxiety disordersAnxiety disorders OtherOther No diagnosisNo diagnosis Personality disordersPersonality disorders More than one More than one

pers.dis.pers.dis.

Transference ComparisonTransference Comparison

38 (9) 36 (10) 38 (9) 36 (10)

61 (14) 69 (13) 61 (14) 69 (13)

8 (2) 8 (2)8 (2) 8 (2)

5.4 (0.6) 5.4 (0.6) 5.4 (0.6) 5.4 (0.6)

5.1 (0.8) 5.1 5.1 (0.8) 5.1 (0.8) (0.8)

50 % 63 %50 % 63 %

38 % 54 %38 % 54 %

50 % 52 %50 % 52 %

26 % 23 %26 % 23 %

14 % 17 %14 % 17 %

17 % 19 %17 % 19 %

44 % 46 %44 % 46 %

19 % 19 %19 % 19 %

101 pre-treatment characteristics

Women and Men

GSI

PSYCHOFARMAKA

SELF ATTACKHOSTILE

MOTHER CARING

INTRUSIVEDIVORCED

AGE

GAF

EDUCATION

CARING

DOMINATING

PAID WORK

LIFE QUALITY

PFS

LOVE SELF

DEPRESSION

SED.MED.

QOR

INSIGHT

ANTIDEPR.MED

IIP

BLAME SELF

SENSITIVITY

ANXIETY

EXPECT MUTUALITY

PREVIOUS TREATMENT

FATHER CARING

EXPECT.TREATMENT

MARRIED

DEAD PARENTS

PARENTS PSYCH. ILL

PROTECTSELF

FRIENDSHIP

SOMATIC D.

MOTHER CONTROL

PD

SICK LEAVE

SOLVEPROBLEM

QORQOR

Men: Men: N = 44 QOR N = 44 QOR 5.05.0

Women: Women: N = 56 QOR N = 56 QOR 5.15.1


Patient Gender as Patient Gender as General General Predictor Predictor

in Individual Psychotherapyin Individual Psychotherapy The majority of studies have found that The majority of studies have found that

improvement in therapy is independent improvement in therapy is independent of patient gender, but a small number of patient gender, but a small number of studies found women more of studies found women more responsive to psychotherapy than men. responsive to psychotherapy than men.

Sue and Lam (2001,2002),Bergin and Garfield Sue and Lam (2001,2002),Bergin and Garfield (2004), Zlotnic et al (1996), Ogrodniczuk et al (2004)(2004), Zlotnic et al (1996), Ogrodniczuk et al (2004)


Patient Gender as Patient Gender as Moderator Moderator in Individual Psychotherapy :in Individual Psychotherapy : Male patients had better outcome in interpretive therapy than in Male patients had better outcome in interpretive therapy than in

supportive therapysupportive therapy Female patients had better outcome in supportive therapy than Female patients had better outcome in supportive therapy than

in interpretive therapy in interpretive therapy Moderator effect during therapy. No significant long-term Moderator effect during therapy. No significant long-term

moderator effect of gendermoderator effect of gender Ogrodniczuk & al 2001Ogrodniczuk & al 2001

Patients with Bipolar I Disorder after treatment with Patients with Bipolar I Disorder after treatment with interpersonal and social rhythm therapy and/or intensive clinical interpersonal and social rhythm therapy and/or intensive clinical management: management:

Women who received interpersonal and social rhythm therapy Women who received interpersonal and social rhythm therapy showed more marked and rapid improvement than menshowed more marked and rapid improvement than men

Frank et al Am J Psychiatry December 2008Frank et al Am J Psychiatry December 2008


Research questions; Research questions; during therapy

Will patient gender predict outcome Will patient gender predict outcome across treatments (No)?across treatments (No)?

Will there be an interaction effect ; Will there be an interaction effect ;

gender /treatment with or without gender /treatment with or without transference interpretations ?transference interpretations ?

Is patient gender a moderator over Is patient gender a moderator over and above QOR ? and above QOR ?


Gender in FEST at post-Gender in FEST at post-treatmenttreatment

No predictor effect of gender No predictor effect of gender


Recovered cases post-treatment

Gender as moderator

N = 18 25a 30 26a One outlier deleted from the transference group

Pro

po

rtio

n o

f re

co

ve

red

ca

se

s

0

10

20

30

40

50

60

70

80

90

100

Men Women

comparisontransferenceGAF


Recovered cases post-treatment

Combined QOR and gender

0

10

20

30

40

50

60

70

80

90

100

High QOR Mena Low QOR Womenb

comparison

transference

GAF

Pro

po

rtio

n o

f re

co

ve

red

ca

se

s

N = 10 11 11 11a Significant difference between treatments (x2=3.9, df=1, p=0.05)b Significant difference between treatments (x2=4.7, df=1, p=0.03)


PFS

0

10

20

30

40

50

60

70

80

90

100

High QOR Men Low QOR Womena

Pro

po

rtio

n o

f R

ec

ov

ere

d C

as

es

comparison

transference

Combined QOR and gender

N = 10 11 11 11a Significant difference between treatments ( Fisher exact test: p < 0.032)


a

Gender in FEST at post-Gender in FEST at post-treatmenttreatment

Significant gender differences in symptom Significant gender differences in symptom change GAF and GSI at post-treatment (linear change GAF and GSI at post-treatment (linear mixed model).Gender was a moderator of the mixed model).Gender was a moderator of the effects of transference interpretations:effects of transference interpretations: WWomen improve more with transference omen improve more with transference

interpretations than men interpretations than men Men improve more withoutMen improve more without transference transference

interpretations than womeninterpretations than women Pre-treatment variations between women and Pre-treatment variations between women and

men (hostile and dominant) could not explain men (hostile and dominant) could not explain the outcome differences. the outcome differences.

Long -Term ResponsesLong -Term Responses

We wanted to explore We wanted to explore whether the whether the average QOR women and men average QOR women and men responded differently to responded differently to transference interpretationtransference interpretation

Outcome Measures: PFS and IIP-C Outcome Measures: PFS and IIP-C (dynamic, interpersonal change)(dynamic, interpersonal change)


Model predicted “true” trajectories of the PFS for the transference group and comparison group within the subsamples of female patients. Controlled for the effects of QOR.

Effect size 0.49 0.59 0.69 Effect size 0.49 0.59 0.69 0.77 0.77

p=0.08 p=0.03 p=0.01 p=0.08 p=0.03 p=0.01 p=0.01p=0.01

Model predicted “true” trajectories of the PFS for the transference group and comparison group within the subsamples of male patients. Controlled for the effects of QOR.

Model predicted “true” trajectories of the PFS for the transference group and comparison group within the subsamples of male and female patients. Controlled for the effects of QOR.

Between groups effect sizes (Cohen’s d) for Women : 0.59 0.69 0.77 p=0.03 p=0.01 p=0.01

Match and mismatch Match and mismatch therapist-patient gendertherapist-patient gender

There were 56 matched and 43 There were 56 matched and 43 mismatched therapy dyads. mismatched therapy dyads.

For women treated by women the For women treated by women the treatment effect of transference treatment effect of transference interpretations became stronger interpretations became stronger than for women in general. (The than for women in general. (The estimate increased from 1.16 to estimate increased from 1.16 to 1.56) 1.56)

Gender as moderator of long-term Gender as moderator of long-term treatment effects, controlled for treatment effects, controlled for Quality Quality

of Object Relations Scaleof Object Relations Scale (QOR); Low (QOR); Low QOR womenQOR women

Dependent variable and parameter

Estimate 90% CI t df p

Psychodynamic Functioning Scales:

Women coded 0 and men coded 1 Intercept

60.47 59.48 to 61.45 101.9 120,520 0.000

Time (log) 3.75 3.18 to 4.32 11.0 117,001 0.000

Time x Treatment 1.87 0.79 to 2.94 2.9 99,712 0.005

QOR( - 4.41) 4.37 3.60 to 5.13 9.5 113,545 0.000

Gender 1.36 0.18 to 2.53 1.9 112,507 0.059

Time x Treatment x (QOR - 4.41)

-1.20 -1.94 to -0.47 -2.7 109,465 0.008

Time x Treatment x Gender

-1.28 -2.39 to –0.17 -1.9 110,446 0.059

Trajectories of the Psychodynamic Functioning Scales (PFS) for the transference group and comparison group within the sub samples of female patients with low scores and male patients with high scores

on the Quality of Object Relations Scale (QOR)

Summary gender-Summary gender-findings FESTfindings FEST

Women respond significantly better than men to transference Women respond significantly better than men to transference interpretation during therapy and during long-term follow-up. interpretation during therapy and during long-term follow-up.

Poor relational functioning women benefit much more from Poor relational functioning women benefit much more from transference interpretations than good relational functioning transference interpretations than good relational functioning men.men.

During therapy: Gender differences measured with GAF and GSI During therapy: Gender differences measured with GAF and GSI (symptomatic change)(symptomatic change)

During follow-up: Gender differences measured with GSI During follow-up: Gender differences measured with GSI (symptomatic change) and PFS (dynamic change)(symptomatic change) and PFS (dynamic change)

When including the two pre-treatment differences (dominant and When including the two pre-treatment differences (dominant and hostile) between men and women as covariates in the model, the hostile) between men and women as covariates in the model, the moderator findings became stronger for both outcome measures. moderator findings became stronger for both outcome measures.

Match and mismatch therapist-patient gender; women treated by Match and mismatch therapist-patient gender; women treated by women profited even more from transference interpretationswomen profited even more from transference interpretations

Poor relational functioning women is Poor relational functioning women is the sub group of patients in FEST the sub group of patients in FEST which improve most from dynamic which improve most from dynamic psychotherapy with transference psychotherapy with transference interpretationsinterpretations

A Single Case Study:A Single Case Study:From Submission to Autonomy:From Submission to Autonomy:

Approaching Independent Decision Approaching Independent Decision Making. Making.

Explore one single case to shed light on Explore one single case to shed light on and illustrate a good outcome therapy and illustrate a good outcome therapy process in one woman with poor relational process in one woman with poor relational functioningfunctioning. .

Hypothesize that changes in symptoms, Hypothesize that changes in symptoms, self-image, and changes in insight and self-image, and changes in insight and interpersonal functioning would coincide interpersonal functioning would coincide well with the changes in the process well with the changes in the process between therapist and patient and the between therapist and patient and the therapist’s countertransference feelings. therapist’s countertransference feelings.

Anonymous patient and therapist

Miklós Ligeti1871-1944

From Submission to From Submission to AutonomyAutonomyMethodMethod

Case formulationsCase formulations Repeated applications of self–reports Repeated applications of self–reports

and observer–rated measures, and observer–rated measures, (during and after therapy)(during and after therapy)

Transcription of sessions; detailed Transcription of sessions; detailed observer ratings of the therapist–observer ratings of the therapist–patient interaction, using Structural patient interaction, using Structural Analysis of Social Behaviour (SASB)Analysis of Social Behaviour (SASB)

Egon Schiele 1890-1918

Munch 1863-1944

Munch 1863-1944

Munch 1863-1944

Munch 1863-1944

Munch 1863-1944

Patient’s ExpectationsPatient’s Expectations

Example transference interpretation:Example transference interpretation:

Therapist: You experienced that you became attracted to Therapist: You experienced that you became attracted to that handyman because he seemed to be somehow that handyman because he seemed to be somehow attentive and caring towards you. You fell in love very attentive and caring towards you. You fell in love very fast like you have done since you were a teen-ager fast like you have done since you were a teen-ager

Patient: Yes, ehmPatient: Yes, ehm

Therapist: I don’t know, but when I was attentive towards Therapist: I don’t know, but when I was attentive towards you and linked your relation to me to your relation to you and linked your relation to me to your relation to other people, you didn’t fall in love with me, but it other people, you didn’t fall in love with me, but it seems you became more attentive towards yourself seems you became more attentive towards yourself

Patient: Yes, that is absolutely right. I really wondered Patient: Yes, that is absolutely right. I really wondered what happened with me when I met that guy. I find it what happened with me when I met that guy. I find it easier to reflect here with you…….I’m not hiding ….my easier to reflect here with you…….I’m not hiding ….my feelings…I don’t fall in love to escape….feelings…I don’t fall in love to escape….

Egon Schiele 1890-1918

Marc Chagall 1887-1985

Low QOR woman; Low QOR woman; transference therapy transference therapy

session 07 (SASB)session 07 (SASB)





Changes in process and outcome measures in a good Changes in process and outcome measures in a good outcome therapy during 1 year dynamic psychotherapy outcome therapy during 1 year dynamic psychotherapy

and up to 3 year follow-upand up to 3 year follow-up

ProcessWeighted autonomya

Therapist

Weightedautonomya

Patient

Counter transference;Positiveb

Counter transference;Negativeb

Counter Transference;Paternalisticb

Pre - treatment -16.25 -4.3 2.7 0.2 3.0

Mid-treatment 9.27 18.1 2.8 0.0 2.3

Late in treatment 9.97 15.4 3.2 0.0 2.3

1 year post-treatment

- - - -


- - - -

OutcomeDepressionc Insightd Internal dialogue

with therapiste

Interpersonal functioningd

Exploitablef

Pre - treatment 1.9 65.7 - 65.0 2.00

Mid-treatment 0.3 - - - 0.69

Treatmenttermination

0.0 80.0 7.2 73.7 0.79


0.0 81.0 2.0 81.1 0.50


0.0 80.3 2.0 79.8 0.50

At 3-year follow-up:At 3-year follow-up:

““I am more in contact with I am more in contact with myself and take myself more myself and take myself more seriously and see my own worth. seriously and see my own worth. I can forgive myself and ask for I can forgive myself and ask for help if I need it”.help if I need it”.

Summary single- caseSummary single- case The process between the therapist and the The process between the therapist and the

patient showed patient showed friendly complementarity friendly complementarity The The autonomy–encouraging interaction autonomy–encouraging interaction coincided coincided

with the positive changes in with the positive changes in depressive feelings depressive feelings insight insight self–imageself–image interpersonal functioning. interpersonal functioning.

The patient became The patient became less exploitable less exploitable and more and more autonomous, independentautonomous, independent, and capable of , and capable of choosing what was best for herchoosing what was best for her

Discussion; Findings in brain function

1. Gender differences in brain activation-pattern (fMRI) between men and women during processing of negatively valenced words versus non-words Women showed greater activation in areas participating in understanding

and expressing language and processing emotions and memories. Men showed greater activation in areas important for executive functions

and behavior. Transference interpretations often spot difficult conflict areas. Gender-

related neural responses to emotional stimuli might be connected to different response between men and women to transference interpretations.

Hofer et al; Sex differences in brain activation patterns during processing of positively and negatively valenced emotional words. Psychological Medicine 2007 (pp109-119)

2. Oxytocine (higher in women than in men) partly determines interpersonal affiliation during loss of social contact. Mechanisms distinctly different in women and men.

Taylor SE and Gonzaga GC; Affiliative responses to stress. In Harmon-Jones E, Winkielman P (Eds.)

Social Neuroscience. NY Guilford Press. 2007 (pp 454-473)


SummarySummary

Women responded significantly better Women responded significantly better than men to transference than men to transference interpretation: interpretation: Post-treatment; a difference in symptom change Post-treatment; a difference in symptom change

between women and men between women and men Long-term; different symptom and dynamic Long-term; different symptom and dynamic

change between women and menchange between women and men Female patients, who have difficult Female patients, who have difficult

relationships to other people (low QOR) was the relationships to other people (low QOR) was the sub group of patients in FEST showing the best sub group of patients in FEST showing the best treatment effects from dynamic psychotherapy treatment effects from dynamic psychotherapy with transference interpretations. with transference interpretations.



Methode

• Psychodynamic Functioning Scales (PFS) • Inventory of Interpersonal Problems -

Circumplex version (IIP-C) • Global Assessment of Functioning (GAF) • Symptom Checklist-90 (SCL-90)• Feeling Word Checklist (FWC–58)

Countertransference• Therapist Representation Inventory (TRI) • Structural Analysis of Social Behaviour (SASB)

Hypotheses – during therapy (short-term resposes)

• Patient gender will not predict outcome across treatments

• Men and women may respond differently to dynamic psychotherapy with and without transference interpretation at post-treatment, but we make no prediction with regard to the direction of an interaction effect


Gender as a Moderator of Treatment EffectsGAF dependent variable

Parameter Estimate Df t-value p-value 90%CI

Intercept 59,44 104,7 70,56 0,001 58,04 to 60,84

Time 5,00 102,1 9,79 0,001 4,16 to5,86

Time x Treatment 0,90 93,6 1,15 0,25 -0,40to2,21

Gender 3,44 109,0 2,79 0,01 1,40to5,49

Time x Treatment x Gender -2,78 102,1 2,97 0,01 -4,33to-1,23


Gender as Moderator of Treatment Effects over and above QOR

GAF dependent variable

Parameter Estimate 90% CI t df p

Intercept 57.45 55,84 – 59,05 59,46 105,8 0,001

Time 4.93 4,09 – 5,77 9,71 99,7 0,001

Time x treatment 2.11 0,56 – 3,67 2,25 95,4 0,03

QOR – 4,41 2.80 1,54 – 4,407 3,69 106,6 0,001

Gender 3.67 1,73 – 5,62 3,14 106,6 0,001

Time x Treatment x QOR(-4,41)

-1.49 -2,53 - -0,45 2,37 99,6 0,02

Time x treatment x Gender -3,07 -4,63 – 1,50 3,24 99,6 0,001


Munch 1863-1944

• So we see that you avoid talking about this

• because you feel anxious and uncomfortable

• discussing your sadness and anger over

• your fathers death.

• You did the same after your divorce

• and again now that we are ending therapy.

Psychodynamic interpretation

Defence Anxiety

Impulse

Parents Others

Therapist

DEFENCE

ANXIETY

IMPULSE

PARENTS

OTHERS

THERAPIST

Level of transference interventions Degrees of comprehension from superficial to

profoundanalysis of the emotions and behavioral patterns• Level 1: the therapist addressed transactions in the patient–

therapist relationship.

• Level 2: the therapist encouraged exploration of thoughts and feelings about the therapy and the therapist.

• Level 3: the therapist was to encourage the patient to discuss how the patient believed the therapist might feel or think about the patient.

• Level 4: the therapist includes himself explicitly in interpretive linking of dynamic elements (conflicts), direct manifestations of transference, and allusions to the transference.

• Level 5: the therapist interprets repetitive interpersonal patterns and links these patterns to transaction between the patient and the therapist.

Gabriel Byrne; In Treatment

Anonymous therapist

Documents

Gender differences in response to transference interpretations Randi Ulberg October 2009 UNIVERSITY OF OSLO, NORWAY