Gender differences in response to transference interpretations

Randi Ulberg October 2009

UNIVERSITY OF OSLO, NORWAY

Per Høglend, research director Svein Amlo, clinical director Alice Marble Kjell Per Petter Bøgwald Høglend, research director Oscar Heyerdahl Alice Marble Randi Ulberg Martin M. Nilsen Martin Furan Bøgwald Mary Cosgrove Sjaastad Oscar Heyerdahl Paul Johansson Randi Ulberg Martin M. Nilsen Martin Furan Knut Hagtvet Department of Psychiatry Hanne –Sofie Dahl D Department of Psychiatry 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

Gender differences in response to transference 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.

FEST

 Patients referred from general practitioners, outpatient departments and private practice (N =100)  Randomisation: Transference/not transference  Dynamic Psychotherapy (1 weekly session;max 40 sessions)  7 therapists (5 men and 2 women)  Same gender therapist – patient 56 %  Different gender therapist – patient 44 %

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Outcome measures

 Psychodynamic Functioning Scales (PFS)  Inventory of Interpersonal Problems (IIP-C) (Dynamic Change)  Global Assessment of Functioning (GAF)  Global Severity Index - SCL-90 (GSI) (Symptom Change)

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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

Erotic transference

John William Waterhouse 1849 - 1917

Erotic transference - in treatment

  Opdal LC: Erotization of the analytic situation. Scandinavian Psychoanalytic Review. 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)  Joy Scaverien : Gender, Countertransference and the Erotic Transference. (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 Object Relations (QOR)

     Lifelong pattern of relationships from primitive to mature 7-8: Mature equitable relationships 5-6: Recent relationships may be difficult, but there is evidence of at least one mature relationship in the patient’s history 3-4:Need of dependency or overcontrol in most relationships 1-2: Unstable, less gratifying relationships

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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 %

HOSTILE PARENTS QOR SELF ATTACK PD PSYCH. ILL DEAD PARENTS CARING ANTIDEPR.

SED.

EXPECT MUTUALITY MED MED.

GAF MOTHER CARING 101 pre-treatment GSI SENSITIVITY SOMATIC D.

AGE SOLVE PROBLEM IIP characteristics PFS Women and Men PSYCHOFARMAKA INTRUSIVE SICK EDUCATION DIVORCED LEAVE LOVE FATHER CARING SELF SELF BLAME SELF LIFE QUALITY INSIGHT PROTECT DOMINATING PREVIOUS PAID WORK FRIENDSHIP DEPRESSION ANXIETY TREATMENT MOTHER EXPECT.

MARRIED CONTROL TREATMENT

QOR



Men:



Women: N = 44 QOR 5.0

N = 56 QOR 5.1

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Patient Gender as General Predictor in Individual Psychotherapy

 The majority of studies have found that improvement in therapy is independent of patient gender, but a small number of studies found women more responsive to psychotherapy than men. Sue and Lam (2001,2002),Bergin and Garfield (2004), Zlotnic et al (1996), Ogrodniczuk et al (2004)

UNIVERSITY OF OSLO, NORWAY

Patient Gender as Moderator in Individual Psychotherapy :

   Male patients had better outcome in interpretive therapy than in supportive therapy Female patients had better outcome in supportive therapy than in interpretive therapy Moderator effect during therapy. No significant long-term moderator effect of gender Ogrodniczuk & al 2001   Patients with Bipolar I Disorder after treatment with interpersonal and social rhythm therapy and/or intensive clinical management: Women who received interpersonal and social rhythm therapy showed more marked and rapid improvement than men Frank et al Am J Psychiatry December 2008

UNIVERSITY OF OSLO, NORWAY

Research questions; during therapy

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

Will there be an interaction effect ;  gender /treatment with or without transference interpretations ?

Is patient gender a moderator over and above QOR ?

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Gender in FEST at post-treatment



No predictor effect of gender

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Recovered cases post-treatment Gender as moderator

100 90 80 70 60 50 40 30 20 10

GAF

comparison transference 0

Men Women

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

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Recovered cases post-treatment Combined QOR and gender

100 90 80 70 60

GAF

comparison transference 50 40 30 20 10 0

High QOR Men

a

Low QOR Women

b N = 10 11 11 11

a

Significant difference between treatments (x 2 =3.9, df=1, p=0.05)

b

Significant difference between treatments (x 2 =4.7, df=1, p=0.03)

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70 60 50 40 100 90 80

Combined QOR and gender PFS

comparison transference 30 20 10 0

High QOR Men Low QOR Women a

N = 10 11 11 11

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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 without transference interpretations than women Pre-treatment variations between women and men (hostile and dominant) could not explain the outcome differences.

Long -Term Responses

 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)

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69 67 65 73 71 75 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.

Women Comparison (N=30) Women Transference (N=26) 63 pre-treatment mid-treatment post-treatment Effect size 1-year follow-up

Time

0.49 0.59 0.69 p=0.08 p=0.03 p=0.01 3-year follow-up 0.77

p=0.01

75 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.

Men Comparison (N=18) Men Transference (N=25) 73 71 69 67 65 63 pre-treatment mid-treatment post-treatment 1-year follow-up

Time

3-year follow-up

75 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.

Women Comparison (N=30) Women Transference (N=26) Men Comparison (N=18) Men Transference (N=25) 73 71 69 67 65 63 pre-treatment mid-treatment post-treatment 1-year follow-up

Time

Between groups effect sizes (Cohen’s d) for Women : 0.59 0.69 p=0.03 p=0.01 3-year follow-up 0.77

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 Dependent variable and parameter Estimate 90% CI t df p

Psychodynamic Functioning Scales: Women coded 0 and men coded 1 Intercept Time (log) Time x Treatment QOR( - 4.41) Gender Time x Treatment x (QOR - 4.41) Time x Treatment x Gender 60.47

3.75

1.87

4.37

1.36

-1.20

-1.28

59.48 to 61.45

3.18 to 4.32

0.79 to 2.94

3.60 to 5.13

0.18 to 2.53

-1.94 to -0.47

-2.39 to –0.17

101.9

11.0

2.9

9.5

1.9

-2.7

-1.9

120,520 117,001 99,712 113,545 112,507 109,465 110,446 0.059

0.000

0.000

0.005

0.000

0.059

0.008

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) Women low QOR Transference (N=11) Men high QOR Transference (N=11)

68 66 64 62 60 78 76 74 72 70 pre-treatment post-treatment 1-year f ollow-up

Time Women low QOR Comparison (N=11) Men high QOR Comparison (N=10)

3-year f ollow-up

Summary gender-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.

Anonymous patient and therapist

Miklós Ligeti1871-1944

From Submission to Autonomy Method

 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)

Egon Schiele 1890-1918

Munch 1863-1944

Munch 1863-1944

Munch 1863-1944

Munch 1863-1944

Munch 1863-1944

Patient’s Expectations

Independent Insight Less exploitable TREATMENT HELPS

Example transference interpretation:

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….

Egon Schiele 1890-1918

Marc Chagall 1887-1985

Low QOR woman; transference therapy session 07 (SASB)

Low QOR woman; transference therapy session 16 (SASB)

Low QOR woman; transference therapy session 29 (SASB)

Changes in process and outcome measures in a good outcome therapy during 1 year dynamic psychotherapy and up to 3 year follow-up Process Pre - treatment Mid-treatment Late in treatment 1 year post treatment 3 year post treatment Weighted autonomy a Therapist

-16.25

9.27

9.97

Depression c Outcome Pre - treatment Mid-treatment Treatment termination 1 year post treatment 3 year post treatment

1.9

0.3

0.0

0.0

0.0

Weighted autonomy a Patient

-4.3

18.1

15.4

-

Insight d

65.7

80.0

81.0

80.3

Counter transference; Positive b

2.7

2.8

3.2

2.0

2.0

Counter transference; Negative b

0.2

0.0

0.0

-

Internal dialogue with therapist e

-

Interpersonal functioning d

65.0

7.2

73.7

81.1

79.8

Counter Transference; Paternalistic b

3.0

2.3

2.3

-

Exploitable f

2.00

0.69

0.79

0.50

0.50

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

1.

Discussion; Findings in brain function

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)

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Summary



Women responded significantly better than men to transference interpretation:

 Post-treatment; a difference in symptom change between women and men   Long-term; different symptom and dynamic change between women and men Female patients, who have difficult relationships to other people (low QOR) was the sub group of patients in FEST showing the best treatment effects from dynamic psychotherapy with transference interpretations.

UNIVERSITY OF OSLO, NORWAY

UNIVERSITY OF OSLO, NORWAY

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

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Gender as a Moderator of Treatment Effects GAF dependent variable

Parameter Intercept Estimate

59,44

Time Time x Treatment

5,00 0,90

Gender

3,44

Time x Treatment x Gender

-2,78

Df

104,7 102,1 93,6 109,0 102,1

t-value

70,56

p-value 90%CI

0,001 58,04 to 60,84 9,79 1,15 2,79 2,97 0,001 4,16 to5,86 0,25 -0,40to2,21 0,01 1,40to5,49 0,01 -4,33to-1,23

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Gender as Moderator of Treatment Effects over and above QOR GAF dependent variable

p Parameter Intercept Time Time x treatment Estimate

57.45

4.93

2.11

90% CI 55,84 – 59,05 4,09 – 5,77 0,56 – 3,67

t

59,46 9,71 2,25

df

105,8 99,7 95,4 0,001 0,001 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

Time x treatment x Gender

-3,07 -2,53 - -0,45 2,37 -4,63 – 1,50 3,24 99,6 99,6 0,02 0,001

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Munch 1863-1944

Psychodynamic interpretation DEFENCE • 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.

ANXIETY IMPULSE PARENTS OTHERS THERAPIST Defence Anxiety Parents Others Impulse 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 .

Anonymous therapist

Gabriel Byrne; In Treatment