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

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 DahlAnne Grethe HersougAnne Grethe HersougJohn Christopher PerryJohn Christopher Perry

FEST - First Experimental Study of Transference-interpretations

Department of Psychiatry

Dora Case

Høglend et al. 2006 American Journal of PsychiatryHøglend et al. 2008 American Journal of PsychiatryUlberg et al. 2009 Canadian journal of Psychiatry

Positive studies

Gabbard et al. 1994: ”Transference interpretation is is high gain high risk” Malan: 1976 Marziali: Positive association on 1 of 7 variables

Negative studies:

8 on outcome: 4 neg.correlations trans. Int. outcome 4 non.sign. association

10 on in-session effects: alliance, defensiveness, involvement, opposition, silence, drop-out

Within-group correlations

High QOR Transference group (N=26)

PFS IIP GAF GSI

Early transference

interpretations 0.30 0.12 0.18 0.35

Low QOR Transference goup (N=24)

Early transference

interpretations -0.40* -0.17 -0.29 -0.03

FEST 1994 -2004

Randomized Clinical Trial with Dismantling design

100 patients randomized to one year psychodynamic psychotherapy with and without transference interpretation

All therapists did both treatments

They were trained for up to 4 years

So we see that you avoid talking about thisSo we see that you avoid talking about this DEFENCEDEFENCE

Psychodynamic interpretation

Defence Anxiety

Impulse

Parents Others

Therapist

ANXIETY

IMPULSE

PARENTS

OTHERS

THERAPIST

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

Outcome measures specific to psychodynamic psychotherapy

Psychodynamic Functioning Scales ( PFS)Psychodynamic Functioning Scales ( PFS)

Quality of Family relationships Quality of Family relationships 1 - 1001 - 100Quality of Friendships Quality of Friendships 1 - 1001 - 100Quality of Romantic Relations Quality of Romantic Relations 1 - 1001 - 100Tolerance for Affects Tolerance for Affects 1 - 1001 - 100Insight Insight 1 - 1001 - 100Problem solving Capacity Problem solving Capacity 1 - 1001 - 100

Overal Psychodynamic Functioning is the simple weighted average Overal Psychodynamic Functioning is the simple weighted average of the six scales.of the six scales.

Reliability for average scores of three expert raters: Reliability for average scores of three expert raters: – status scores = 0.91 status scores = 0.91 – change scores( relative interpretation) = 0.82 change scores( relative interpretation) = 0.82 – change scores (absolute interpretation) = 0.94change scores (absolute interpretation) = 0.94

Specific Techniques

1.Therapist addresses transactions in the patient-therapist relationship

2. Therapist encourages exploration of thoughts and feelings about the therapy and the therapist and repercussions on transference by high therapist activity

3 .The therapist encourages the patient to discuss how the therapist might feel or think about the patient

4. The therapist explicitely includes himself in interpretive linking of dynamic elements (conflicts), direct manifestations of transference, allusions to the transference,

5. The therapist interprets repetitive interpersonal patterns, including genetic interpretations, and links to transference

Pretreatment characteristics of patients who received dynamic psycho-therapy of one year duration with (N=52) and without (N=48) transference interpretations.

Age

Global optimism **

Expectancy

Motivation

Quality of Object relations

Female sex

Single

Depressive disorders

Anxiety disorders

Other

No diagnosis

Personality disorders

More than one pers.dis.

Transference Comparison

38 (9) 36 (10)

61 (14) 69 (13)

8 (2) 8 (2)

5.4 (0.6) 5.4 (0.6)

5.1 (0.8) 5.1 (0.8)

50 % 63 %

38 % 54 %

50 % 52 %

26 % 23 %

14 % 17 %

17 % 19 %

44 % 46 %

19 % 19 %

Treatment integrity (Sessions rated = 452)Treatment integrity (Sessions rated = 452)

Trans. interpretations ( 4 items)*** Trans. interpretations ( 4 items)***

Extra-transference interpr. (5 items)***Extra-transference interpr. (5 items)***

Supportive ( 7 items)Supportive ( 7 items)

General skill (8 items) General skill (8 items)

Transference ComparisonTransference Comparison

1.7 (0.7) 0.1 (0.2)1.7 (0.7) 0.1 (0.2)

2.4 (0.5) 2.7 (0.6)2.4 (0.5) 2.7 (0.6)

0.7 (0.3) 0.7 (0.3)0.7 (0.3) 0.7 (0.3)

3.6 (.0.2) 3.6 (0.3) 3.6 (.0.2) 3.6 (0.3)

Scale format: No emphasis Minor Moderate Considerable Major emph. 0 1 2 3 4

TC

Quality of Object Relations

Lifelong pattern of relationships from primitive to mature

7-8: Mature equitable relationships

5-6: Recent relationships may be difficult, but there are evidence of at least one mature relationship in the patients history

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

1-2: Unstable, less gratifying relationships

The proportion of patients recovered at posttreatmentPFS outcome

GAF>61 GAF< 61**

N = 24 27 24 24

0

10

20

30

40

50

60

ComparisonTransference

The proportion of patients recovered on both the The proportion of patients recovered on both the primary outcome measures (PFS, IIP) at three year primary outcome measures (PFS, IIP) at three year

follow-upfollow-up

0

5

10

15

20

25

30

35

40

ComparisonTransference

High QOR Low QOR

N = 29 26 19 25

Psykoterapi

Mediator

Resultat

3. Mediatoranalysis:What is the mechanism linking transference interpretation

to long-term improvement of interpersonnal function?

?

FEST

Mediated moderation

Transference/Non-transference

Insight pre – 3 year follow-up

Interpersonal pre- 3 year follow-up

Insight 0,6 (p=0,000)Insight x QOR 0,1 (p=0,06)

Linear mixed models, log time

Time x Treat (low QOR)1,2 (p=0,04)

Time x Treat (low QOR)1,2 (p=0,03)

Time x Treat (low QOR)0,3 (non-significant)

Follow-up period 3 yearsPD subsample (N=45)

Transference Comparison N=22 N=23 General practitionersAny treatment 60%** 90%Antidepressant medication 30%* 57%Hospitalized 0% 13%Sick leave 10%* 38% Specialist treatment

Any treatment 20%** 52%Additional psychother. 20%** 48%Antidepressive medication 20%** 48%

40 year old female

Depression and bulimia

Living with her fouth partner, contemplating leaving him

Verbally aggressive father, mother alcoholic

Talent in sport provided self esteem

Difficulties expressing her feelings and opinions, rather asks for help

After disagreements binge eating and purging alternating with very strict diet

TreatmentInitial phasePatient: I’m not sure what to takk about. Whhat can I ask from oothers, like with my childern, and wonder what other people would do.Therapist: Can you imagine me having an opinion on this ?Patient: If I can think of what you would do ? I don’t get answers here.Therapist: How doo you feel about that ?Patient: Don’t knowTherapist. No, but may be you get disappointed, withdraws, overeats instead of feeling that you are angry with me for not helping out.

As therapy progressed, the patient more often expressed her own points of view

Therapist: Hoow do you feel about me, leading you on to thin ice so to speak, pointing out that you don’t say what you mean or how you feel ?

Patient: I’m not sure how I feel. I see that i suddenly changed and became a bit more opinionated. So why not try somthing in between ?

At posttreatment: Insight increased from 63 to 75Became aware of how much she automatically disawoved her own feelings, especiallly negative ones. She now saw the connection between specific stressors, negative emotions, binge eating and how it interfered with her daily life. She had become aware of how she repeated her feeling towards her parents, her partners, friends and also the therapist.

At 3-years follow up: Recovered on all outcome variables. GAF, GSI, IIP, and The Psychodynamic Functioning Scales (PFS)

Patients increase insight from 62 to 74

62: tendency to blame self or other to much too much in disputes. Unclear, ”learned ” or somewhat stereotyped awareness of connections between past and present experiences. In some areas attitudes, needs, behaviours and coping seem unrecognized,automatic, and stress reactions comme as a surprise. Understands that symptoms is a sign of disturbance.

74: Can account for the most important inner conflicts and motives, related problems and repetitive behavior interpersonal patterns. May blame self or others too much after disputes, but observes own reactions and learn froom it (integration). Generally curious and tolerant, realistic expectations about the future.