Countertransference and the Patient's Experience: Exploring How Engagement with Affect is Related to Short-Term Psychotherapy Outcomes
Date of Degree
short-term psychotherapy, countertransference, affect, outcome, therapeutic relationship, alliance-focused therapy
Background: Therapist focus on affect in the here-and-now can facilitate a patient’s emotional experience as well as expression of affect, both of which are associated with better outcome over the course of treatment (Diener et al., 2007). A therapist’s use of her own experience of the patient can serve as a signal to intervene in the here-and-now. While “countertransference” was historically seen as an obstacle to a therapist’s neutrality and therefore efficacy (Freud, 1910), shifts in the field toward a two-person psychology model led some to reconsider it as a potential source of clinical data (Winnicott, 1947; Heimann, 1950; Racker, 1957). Empirical studies have shown that therapist awareness of countertransference is critical in order to manage internal reactions and use it as a clinical tool, as well as prevent contributions to negative therapeutic processes by withdrawing or avoiding content (Hayes et al., 2018; Westerling et al., 2019; Fauth & Hayes, 2006). Experientially grounded reflection requires an individual to become aware of their internal reactions in a nonjudgmental fashion (Experiencing, Gendlin, 1969). Therapists with higher levels of Experiencing are more likely to 1) articulate and process aspects of their internal experience, and 2) repair more ruptures over the course of treatment as compared to therapists with lower levels of Experiencing (Boutwell et al., 2015; Safran et al., 2014; Kazariants, 2011).
Objective: The present study aimed to better understand the relationships among therapist countertransference, therapist capacity for experientially grounded reflection, therapist engagement with patient affect, and patient change in short-term alliance focused psychotherapy.
Method: Approved by the International Review Board at The City College of New York on August 6, 2019, the present study examined five short-term alliance focused psychotherapy treatments using both quantitative and qualitative assessment methods. Therapists completed quantitative self-report measures pertaining to countertransferential experiences. Patients completed quantitative self-report measures regarding level of emotional, psychological, and interpersonal functioning. Third-party observers coded two sources of clinical data: 1) video-recorded therapy sessions to assess for the therapist’s level of observable engagement with the patient’s emotional experience during sessions, and 2) audio-recorded and transcribed termination interviews with therapists to assess for the therapist’s capacity for experientially grounded reflection. An additional source of qualitative data included patient responses to treatment feedback questions at termination.
Results: Five sets of key findings emerged. First, a positive association was found between a therapist’s capacity for experientially grounded reflection and that therapist’s engagement with patient affect. Second, countertransference is related to the frequency of therapist engagement with patient affect. While there are trends in how negative and positive types of countertransference might influence therapist behavior during sessions, results indicate that every therapist responds uniquely to countertransference in each unique dyadic relationship. Results suggest that countertransference is not inherently problematic, but a therapist’s lack of awareness of its occurrence can be. Third, therapist countertransference is sometimes associated with patient presentation, namely the severity of the patient’s symptomatology. Fourth, results suggest that patients achieve better outcomes in alliance-focused psychotherapy when working with therapists who: 1) more actively engage with their affect in the here-and-now across treatment, and 2) have a greater capacity for experiential reflection. The fifth finding points to the importance of supervision. Supervision can be helpful in promoting a therapist’s capacity for experientially grounded reflection and instrumental in the identification of negative countertransference. The present study found that supervision might contribute to the quality of therapist engagement with patient affect during subsequent sessions. Two unanticipated discoveries suggest the necessity for further investigation given that all patients in the sample attained clinically significant improvement. First, group-level data revealed a distinct trend in the frequency of therapist engagement with patient affect over the course of treatment. Second, four categories of therapist engagement of patient affect were revealed: 1) Use of Patient Experience, 2) Use of Therapist Experience, 3) Use of Observed Shift, and 4) Use of Therapeutic Process or Relationship.
Conclusion: Findings have the potential to inform training and supervision of therapists providing short-term psychotherapy treatments. The incorporation of experientially based learning might help therapists to cultivate a capacity for self-reflection. This may facilitate a therapeutic stance characterized by curiosity, appreciation of the complexity of the patient’s emotional experience, and empathic engagement.
Westerman, Ariel R., "Countertransference and the Patient's Experience: Exploring How Engagement with Affect is Related to Short-Term Psychotherapy Outcomes" (2022). CUNY Academic Works.