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Elaboration of Countertransference Experience and the Workings of the Working Alliance

Authors:
João Francisco Barreto at University of Porto
João Francisco Barreto
Gil Nata at University of Trás-os-Montes and Alto Douro
Gil Nata
Paula Mena Matos
Paula Mena Matos
Paula Mena Matos
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Abstract

Alliance may impact psychotherapy outcomes both as a precondition that enables therapeutic work and an evolving process that is therapeutic in itself. This study examined the participation of the elaboration of countertransference experience (ECE) in alliance variation between therapist–client dyads early in therapy and within dyads over time. A total of 44 session assessments nested within 12 dyads were modeled through longitudinal multilevel analyses and utilized to examine the associations between the ECE dimensions of Immersion and Reflection and alliance components across 4 time points within the first 10 sessions of psychotherapy. Results supported the importance of initial ECE to explain differences in alliance between dyads, the particular relevance of ECE with clients presenting lower levels of personality organization, and the effect of personality difficulties on alliance change. Unexpected results were found concerning the correlations between ECE and alliance and their covariation over time. In conclusion, ECE dimensions appear to be involved in alliance formation, both in initial differences between dyads and in changes over time within the same case. ECE seems particularly important with more personality-disturbed clients. Future research should disentangle therapist and client contributions and examine the participation of ECE in the resolution of alliance ruptures. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Elaboration of Countertransference Experience and the Workings of the
Working Alliance
João F. Barreto
University of Porto and Polytechnic Institute of Porto
Gil Nata and Paula Mena Matos
University of Porto
Alliance may impact psychotherapy outcomes both as a precondition that enables therapeutic work and
an evolving process that is therapeutic in itself. This study examined the participation of the elaboration
of countertransference experience (ECE) in alliance variation between therapist– client dyads early in
therapy and within dyads over time. A total of 44 session assessments nested within 12 dyads were
modeled through longitudinal multilevel analyses and utilized to examine the associations between the
ECE dimensions of Immersion and Reflection and alliance components across 4 time points within the
first 10 sessions of psychotherapy. Results supported the importance of initial ECE to explain differences
in alliance between dyads, the particular relevance of ECE with clients presenting lower levels of
personality organization, and the effect of personality difficulties on alliance change. Unexpected results
were found concerning the correlations between ECE and alliance and their covariation over time. In
conclusion, ECE dimensions appear to be involved in alliance formation, both in initial differences
between dyads and in changes over time within the same case. ECE seems particularly important with
more personality-disturbed clients. Future research should disentangle therapist and client contributions
and examine the participation of ECE in the resolution of alliance ruptures.
Clinical Impact Statement
Question: Is alliance formation associated with the psychological processes that therapists use in
making sense of their experiences with clients, defined as the elaboration of countertransference
experience (ECE)? Findings: Therapists’ engagement in their subjective experience (Immersion) in
the beginning of psychotherapy is higher in dyads with a better emotional bond. With clients with
personality difficulties, therapists’ explicit meaning-making (Reflection) may benefit clients’ sense
of collaboration and goal consensus. Meaning: In practice and in training, therapists should be
helped to understand how to make use of what they experience in and between sessions in ways that
improve psychotherapeutic processes and outcomes. Next Steps: Future research should disentangle
therapist and client contributions to ECE and examine its participation in the resolution of alliance
ruptures.
Keywords: countertransference, alliance, therapist factors, mentalization, longitudinal multilevel analysis
Although the association between alliance and outcome is
among the most robust findings in psychotherapy research (Flück-
iger, Del Re, Wampold, & Horvath, 2018), there is still room for
different understandings of the mechanisms underlying this asso-
ciation. Recently, Zilcha-Mano (2017) distinguished between a
trait-like component of alliance, the client’s general ability to form
satisfactory relationships with others, manifested in a strong alli-
ance and simultaneously influencing the capacity to benefit from
treatment, and a state-like component of alliance, referring to
changes in alliance that bring about therapeutic change. As the
author observed, although the former component may work as a
precondition that enables therapy to be effective, the latter estab-
lishes alliance, especially its bond component, as a therapeutic
ingredient in itself, capable of producing changes.
This article was published Online First August 29, 2019.
João F. Barreto, Center for Psychology at University of Porto, Faculty of
Psychology and Education Science, University of Porto, and School of Health,
Polytechnic Institute of Porto; Gil Nata, Center for Research and Intervention
in Education and Center for Psychology at University of Porto, University of
Porto; Paula Mena Matos, Center for Psychology at University of Porto,
Faculty of Psychology and Education Science, University of Porto.
This work has been supported by the Foundation for Science and
Technology (FCT) Grant SFRH/BD/96922/2013 and partially by Polytech-
nic Institute of Porto fundings (Programa de Formação Avançada de
Docentes, Editions 2012 and 2013) earned by João F. Barreto. This work
was also funded by the Center for Psychology at University of Porto, FCT
(FCT UID/PSI/00050/2013), and EU FEDER through COMPETE 2020
program (POCI-01-0145-FEDER-007294).
Correspondence concerning this article should be addressed to João F.
Barreto, Faculdade de Psicologia e de Ciências da Educação, Universidade
do Porto, Rua Alfredo Allen, 4200-135 Porto, Portugal. E-mail: jfbarreto@
fpce.up.pt
This document is copyrighted by the American Psychological Association or one of its allied publishers.
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Psychotherapy
© 2019 American Psychological Association 2020, Vol. 57, No. 2, 141–150
ISSN: 0033-3204 http://dx.doi.org/10.1037/pst0000250
141
... as measured through self-report within Kernberg's model of personality organization. Yet, with clients presenting higher personality disturbance, therapists' reflection positively predicted clients' alliance tasks/goals component (Barreto et al., 2020). ...
... Forty-four session assessments were received (see Procedure). More information on the participants can be found in Barreto et al. (2020). ...
... Attachment and sociodemographic data were collected prior to the second session. The process variables (from ECE-RS and Working Alliance Inventory-Short Revised [WAI-SR]) were measured after sessions 2, 5, 8, and 10 (see Barreto et al., 2020, for more information on procedure and inclusion criteria). ...
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Individual and combined attachment dimensions within the dyad may affect therapists’ experiences in ways that hinder mentalizing and threaten the alliance. Previous research on a particular therapists’ mentalizing ability named the elaboration of countertransference experience (ECE) suggests that attachment may affect therapists’ mental processes, which in turn are involved in alliance variations between dyads and over time. In this study, these findings are extended by examining therapist, client, and combined attachment dimensions as moderators of the association between ECE and working alliance. Forty-four assessments from the first 10 psychotherapy sessions of 12 independent dyads were examined. The ECE dimension of reflection/conjecture was positively associated with the alliance bond and total score in therapeutic dyads that differed more in attachment. Possible in-session dynamics at stake are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
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... Research on cognitive biases may provide some common language for the key biases and problems that may occur as emotions intensify (Bowes et al., 2020), and perhaps even a range of strategies for mitigating reactivity to cognitive biases. As research progresses, it may help clinicians gain a shared language for noticing cultural discomfort as soon as possible (Abargil & Tishby, 2022) and begin to elaborate through reflection and consultation (Barreto et al., 2020). ...
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... Both of these studies provide additional proof of the therapist's attachment role when facing more self-challenging experiences in psychotherapy. Emotional arousal could be triggered by emotionally distressing moments in psychotherapy, namely the ones that seem to question the psychotherapist's competence in managing boundaries, ruptures, and dealing with uncertainty (Barreto et al., 2020;Carvalho & Matos, 202;Mikulincer et al., 2013;Miller-Bottome et al., 2018;Rubino et al., 2000;Schauenburg et al., 2010). ...
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... EEX can be said to be inherently present in empirical research that tries to address therapists' work in the here and now of the therapeutic exchange, as in the study of transference interpretations (Høglend et al., 2011), immediacy (Shafran et al., 2016), metacommunication (Safran & Muran, 2000), empathy (Elliott et al., 2018) or moments of meeting (Duarte et al., 2020). Also, research addressing therapists' mentalizing and/or reflective processes in therapy deal directly or indirectly with EEX (e.g., Barreto et al., 2020;Barreto & Matos, 2022;Bucci et al., 2012;Bucci & Maskit, 2007;Cartwright et al., 2015;De la Cerda et al., 2019;Diamond et al., 2003;Ensink et al., 2013;Kazariants, 2011;Reading et al., 2019;Safran et al., 2014;Talia et al., 2020). ...
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... Even in cases when individual ruptures, as a process, were investigated, the focus has been almost exclusively from the therapist's perspective; that is, it is generally assumed that it is the client who triggers or signals the breakdown of the relationship, and it is the therapist's role to effect repair (Cirasola et al., 2022). Also, existing research has largely focused on the possible/ probable motives and intentions of the client, as evident in the rupture episode, and the strategies and skills of the therapist that should be in place to repair the rupture (Barreto et al., 2020;Ben David-Sela et al., 2021). While these studies helped us, for example, to usefully classify these disruptions as aggressive (confrontational) or passive (withdrawal) and to link successful resolution of ruptures to positive therapy outcome, this type of research so far has revealed less on how ruptures actually unfold in practice and what role conversational resources play in the negotiations that follow the rupture event. ...
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