Genderdifferences in response to transferenceinterpretations Randi Ulberg October 2009 UNIVERSITY OF OSLO, NORWAY
FEST - First Experimental Study of Transference-interpretations FEST - First Experimental Study of Transference-interpretations Per Høglend, research director Svein Amlo, clinical director Alice Marble Kjell-Petter Bøgwald Øystein Sørbye Mary Cosgrove Sjaastad Oscar Heyerdahl Paul Johansson Randi Ulberg Martin M. Nilsen Martin Furan Knut Hagtvet Jan Ivar Røssberg Per Høglend, researchdirector Svein Amlo, clinicaldirector Alice Marble Kjell-Petter Bøgwald Øystein Sørbye Mary CosgroveSjaastad Oscar Heyerdahl Paul Johansson Randi UlbergMartin M. Nilsen Martin Furan Knut Hagtvet Jan IvarRøssberg Hanne –Sofie Dahl Diakonhjemmet Hospital, Oslo Blakstad Hospital, Akershus Ullevål University Hospital, Division of Psychiatry Ullevål University Hospital, Centre for Child and Adolescent Psychiatry Department of Psychology, University of Oslo Dep. of Child and Adolecent Psychiatry, Vestfold Department of Psychiatry D Department of Psychiatry
Genderdifferences in response to transferenceinterpretations 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.
FEST • Patientsreferred from general practitioners, outpatientdepartments and private practice (N =100) • Randomisation: Transference/nottransference • DynamicPsychotherapy(1 weeklysession;max 40 sessions) • 7 therapists (5 men and 2 women) • Same gendertherapist – patient 56 % • Differentgendertherapist – patient 44 % UNIVERSITY OF OSLO, NORWAY
PsychodynamicFunctioningScales (PFS) Inventory of Interpersonal Problems (IIP-C) (DynamicChange) Global Assessment of Functioning (GAF) Global SeverityIndex - SCL-90 (GSI) (Symptom Change) ) Global SeverityIndex - SCL-90 (GSI) Outcomemeasures UNIVERSITY OF OSLO, NORWAY
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 UNIVERSITY OF OSLO, NORWAY
Erotictransference John William Waterhouse 1849 - 1917
Erotictransference - in treatment • Opdal LC: Erotization of the analytic situation. Scandinavian PsychoanalyticReview. 2007;30:2-12. • Gabbard G: Boundaries, technique, and self-deception: a discussion (2008) Lessons to be learned from the study of sexual boundary violation (1996) Sexual excitement and countertransference love in the analyst (1994) • JoyScaverien : Gender, Countertransference and theEroticTransference. (2006)
GENDER VS SEX • Distinction: • GENDER (determined by psychological and cultural conditions) • SEX (determined by physical conditions) Stoller (1968) . • GENDER is used because it is obvious that the gender-variable not only encloses the patient’s biological sex.
Quality of ObjectRelations (QOR) • Lifelongpattern of relationships from primitive to mature • 7-8: Matureequitablerelationships • 5-6: Recentrelationshipsmay be difficult, butthere is evidence of at leastonematurerelationship in thepatient’shistory • 3-4:Need of dependency or overcontrol in most relationships • 1-2: Unstable, less gratifyingrelationships UNIVERSITY OF OSLO, NORWAY
Age Global optimism ** Expectancy Motivation Quality of Objectrelations Female sex Single Depressive disorders Anxietydisorders Other No diagnosis Personalitydisorders More thanonepers.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 % Pretreatmentcharacteristics of patientswhoreceiveddynamicpsycho-therapy of oneyeardurationwith(N=52) and without(N=48) transferenceinterpretations.
HOSTILE PARENTS PSYCH. ILL QOR SELF ATTACK DEAD PARENTS PAID WORK FRIENDSHIP CARING ANTIDEPR.MED SED.MED. EXPECT MUTUALITY GAF SENSITIVITY 101 pre-treatment characteristics Women and Men MOTHER CARING SOMATIC D. GSI AGE INSIGHT PFS IIP PROTECT SELF SOLVE PROBLEM LOVE SELF BLAME SELF PSYCHOFARMAKA FATHER CARING INTRUSIVE SICK LEAVE DIVORCED DOMINATING LIFE QUALITY EDUCATION DEPRESSION PREVIOUS TREATMENT PD MARRIED EXPECT. TREATMENT ANXIETY MOTHER CONTROL
QOR • Men: N = 44 QOR 5.0 • Women: N = 56 QOR 5.1 UNIVERSITY OF OSLO, NORWAY
PatientGender as General Predictorin IndividualPsychotherapy The majority of studies have foundthatimprovement in therapy is independent of patientgender, but a smallnumber of studies foundwomen more responsive to psychotherapythan men. Sue and Lam (2001,2002),Bergin and Garfield (2004), Zlotnic et al (1996), Ogrodniczuk et al (2004) UNIVERSITY OF OSLO, NORWAY
PatientGender as Moderator in IndividualPsychotherapy : Male patientshadbetteroutcome in interpretivetherapythan in supportivetherapy Femalepatientshadbetteroutcome in supportivetherapythan in interpretivetherapy Moderator effect during therapy. No significantlong-term moderator effectofgender Ogrodniczuk & al 2001 Patientswith Bipolar I Disorderaftertreatmentwith interpersonal and socialrhythmtherapy and/or intensive clinicalmanagement: Womenwhoreceived interpersonal and socialrhythmtherapyshowed more marked and rapid improvementthan men Frank et al Am J PsychiatryDecember 2008 UNIVERSITY OF OSLO, NORWAY
Research questions; during therapy • Willpatientgenderpredictoutcomeacrosstreatments (No)? • Willthere be an interactioneffect ; gender /treatmentwith or withouttransferenceinterpretations ? • Is patient gender a moderator over and above QOR ? UNIVERSITY OF OSLO, NORWAY
Gender in FEST at post-treatment No predictoreffect of gender UNIVERSITY OF OSLO, NORWAY
Recovered cases post-treatment Gender as moderator 100 90 comparison GAF transference 80 70 Proportion of recovered cases 60 50 40 30 20 10 0 Men Women N = 18 25a 30 26 aOne outlier deleted from the transference group UNIVERSITY OF OSLO, NORWAY
Recovered cases post-treatment Combined QOR and gender 100 90 GAF comparison 80 transference 70 Proportion of recovered cases 60 50 40 30 20 10 0 High QOR Mena Low QOR Womenb N = 10 11 11 11 aSignificant difference between treatments (x2=3.9, df=1, p=0.05) bSignificant difference between treatments (x2=4.7, df=1, p=0.03) UNIVERSITY OF OSLO, NORWAY
Combined QOR and gender 100 PFS 90 comparison transference 80 70 60 Proportion of Recovered Cases 50 40 30 20 10 0 High QOR Men Low QOR Womena N = 10 11 11 11 a Significant difference between treatments ( Fisher exact test: p < 0.032) a UNIVERSITY OF OSLO, NORWAY
Gender in FEST at post-treatment • Significant gender differences in symptom change GAF and GSI at post-treatment (linear mixed model).Gender was a moderator of the effects of transference interpretations: • Women improve more with transference interpretations than men • Men improve more withouttransferenceinterpretationsthanwomen • Pre-treatment variations between women and men (hostile and dominant) could not explain the outcome differences.
Long -TermResponses • We wanted to explore whether the average QOR women and men responded differently to transference interpretation • Outcome Measures: PFS and IIP-C (dynamic, interpersonal change) UNIVERSITY OF OSLO, NORWAY
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. Effectsize 0.49 0.59 0.69 0.77 p=0.08 p=0.03 p=0.01 p=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 therapist-patient gender There were 56 matched and 43 mismatched therapy dyads. For women treated by women the treatment effect of transference interpretations became stronger than for women in general. (The estimate increased from 1.16 to 1.56)
Gender as moderator of long-term treatment effects, controlled for Quality of Object Relations Scale (QOR); Low QOR women
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)
Summarygender-findings FEST • Women respond significantly better than men to transference interpretation during therapy and during long-term follow-up. • Poor relational functioning women benefit much more from transference interpretations than good relational functioning men. • During therapy: Gender differences measured with GAF and GSI (symptomatic change) • During follow-up: Gender differences measured with GSI (symptomatic change) and PFS (dynamic change) • When including the two pre-treatment differences (dominant and hostile) between men and women as covariates in the model, the moderator findings became stronger for both outcome measures. • Match and mismatch therapist-patient gender; women treated by women profited even more from transference interpretations
Poor relational functioning women is the sub group of patients in FEST which improve most from dynamic psychotherapy with transference interpretations
A Single Case Study:From Submission to Autonomy:Approaching Independent Decision Making. Explore one single case to shed light on and illustrate a good outcome therapy process in one woman with poor relational functioning. Hypothesize that changes in symptoms, self-image, and changes in insight and interpersonal functioning would coincide well with the changes in the process between therapist and patient and the therapist’s countertransference feelings.
Anonymouspatient and therapist Miklós Ligeti1871-1944
From Submission to AutonomyMethod Case formulations Repeated applications of self–reports and observer–rated measures, (during and after therapy) Transcription of sessions; detailed observer ratings of the therapist–patient interaction, using Structural Analysis of Social Behaviour (SASB)
Exampletransferenceinterpretation: Therapist: You experienced that you became attracted to that handyman because he seemed to be somehow attentive and caring towards you. You fell in love very fast like you have done since you were a teen-ager Patient: Yes, ehm Therapist: I don’t know, but when I was attentive towards you and linked your relation to me to your relation to other people, you didn’t fall in love with me, but it seems you became more attentive towards yourself Patient: Yes, that is absolutely right. I really wondered what happened with me when I met that guy. I find it easier to reflect here with you…….I’m not hiding ….my feelings…I don’t fall in love to escape….
Changes in process and outcome measures in a good outcome therapy during 1 year dynamic psychotherapy and up to 3 year follow-up
At 3-year follow-up: “I am more in contact with myself and take myself more seriously and see my own worth. I can forgive myself and ask for help if I need it”.
Summary single- case • The process between the therapist and the patient showed friendly complementarity • The autonomy–encouraging interaction coincided with the positive changes in • depressive feelings • insight • self–image • interpersonal functioning. • The patient became less exploitable and more autonomous, independent, and capable of choosing what was best for her