Per Høglend, research director Svein Amlo, clinical director Alice Marble Kjell-Petter Bøgwald

1. 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, research director Svein Amlo, clinical director Alice Marble Kjell-Petter Bøgwald Øystein Sørbye Mary Cosgrove Sjaastad Oscar Heyerdahl Paul Johansson Randi UlbergMartin M. Nilsen Martin Furan Knut Hagtvet Jan Ivar Røssberg Hanne-Sofie Dahl Anne Grethe Hersoug John Christopher Perry 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 Department of Psychiatry Department ofPsychiatry

2. Dora Case Høglend et al. 2006 American Journal of Psychiatry Høglend et al. 2008 American Journal of Psychiatry Ulberg et al. 2009 Canadian journal of Psychiatry

3. 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

4. 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

6. 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

7. So we see that you avoid talking about this DEFENCE Psychodynamicinterpretation because you feel anxious and uncomfortable ANXIETY discussing your sadness and anger over IMPULSE your fathers death. PARENTS You did the same after your divorce OTHERS and again now that we are ending therapy THERAPIST Defence Anxiety Parents Others Impulse Therapist

8. Outcome measures specific to psychodynamic psychotherapy

9. Psychodynamic Functioning Scales ( PFS) • Quality of Family relationships 1 - 100 • Quality of Friendships 1 - 100 • Quality of Romantic Relations 1 - 100 • Tolerance for Affects 1 - 100 • Insight 1 - 100 • Problem solving Capacity 1 - 100 • Overal Psychodynamic Functioning is the simple weighted average of the six scales. • Reliability for average scores of three expert raters: • status scores = 0.91 • change scores( relative interpretation) = 0.82 • change scores (absolute interpretation) = 0.94

10. 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

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

12. Trans. interpretations ( 4 items)*** Extra-transference interpr. (5 items)*** Supportive ( 7 items) General skill (8 items) Transference Comparison 1.7 (0.7) 0.1 (0.2) 2.4 (0.5) 2.7 (0.6) 0.7 (0.3) 0.7 (0.3) 3.6 (.0.2) 3.6 (0.3) Treatment integrity (Sessions rated = 452) Scale format: No emphasis Minor Moderate Considerable Major emph. 0 1 2 3 4 C T

13. 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

14. The proportion of patients recovered at posttreatmentPFS outcome GAF>61 GAF< 61** N = 24 27 24 24

15. The proportion of patients recovered on both the primary outcome measures (PFS, IIP) at three year follow-up High QOR Low QOR N = 29 26 19 25

16. 3. Mediatoranalysis:What is the mechanism linking transference interpretation to long-term improvement of interpersonnal function? ? Resultat Mediator Psykoterapi

17. FEST Mediated moderation Insight pre – 3 year follow-up Time x Treat (low QOR) 1,2 (p=0,04) Insight 0,6 (p=0,000) Insight x QOR 0,1 (p=0,06) Time x Treat (low QOR) 1,2 (p=0,03) Time x Treat (low QOR) 0,3 (non-significant) Transference/ Non-transference Interpersonal pre- 3 year follow-up Linear mixed models, log time

24. Follow-up period 3 yearsPD subsample (N=45) • Transference Comparison • N=22 N=23 • General practitioners • Any 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%

25. 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

26. Treatment • Initial phase • Patient: 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 know • Therapist. No, but may be you get disappointed, withdraws, overeats instead of feeling that you are angry with me for not helping out.

27. 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 75 • Became 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)

28. 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.