‘Transference patterns in the psychotherapy of personality disorders: empirical investigation REBEKAH BRADLEY, AMY KEGLEY HEIM and DREW WESTEN. Background Theconceptof ‘transference has broadenedtoa recogrtion that patients ofen express enduring relational pattern inthe ‘therapeutic relationship. Aims Toerarine the structureof patient relational paternsin psychotherapy and their relation with DSM-IV personality disorder symptoms Method Arandomsample of poychologists and psychiatrists (18!) completed battery of instruments ona randomly selected patient intheir care. Results Exploratory factor analysis identified five transerence dimensions angry entitled, anxéousjpreoccupied svoidant/courterdependent, secure) engaged and sexualsed These were assocatedin predictable ways with Axi I pathology; four mappedonto aduit attachment styles. An aggregated portrait oftransference patterns in narcisstic patients provideda clsialy rch, empirically based description of transference processes that strongly resembled circa theories, Conclusions The wayspatients interact wit ther therapists can provide important data about thee personality, attachment patterns and interpersonal functioning, These processes canbe measured cliically sophisticated and psychometrcally sound ways, Such processes are relatively independent of clinicians theoretical orientation Declaration of interest None. Funding detaiedin Acknowledgements, Since Freud's inital secopnition chat patents may enact interpersonal patterns in the therapy relationship (Freud, 1912, 41917), the concept of transference has evolved considerably (Sandler, 1976; ‘Wachtel, 1997). In contemporary tems, wansference refers broadly to patterns of thoupht, feeling, motivation and behaviour that emerge in the therapeutic elationship and reflec enduring aspect ofthe patient's personality and interpersonal functioning (Westen & Gabbard, 2002). Although & small body of reseatch exists oa tanser- ence processes (eg. Laborsky 8 Crit Christoph, 1990; Cuts eal, 1994), mach Of our understanding of transference is derived from clini! observation, inthis study we apie a clinician report measure of tansfereace phenomena to a sample of patents in psychotherapy, with two goals fet, to identify ehestracte of patient’ relational patterns as observed in psycho- therapy; and second, to test hypotheses bout the ration between teansference patterns and peesonaliy pathology. The ‘broader goal ofthis esearch was to develop clinically sophisticated, paychometially Sound measce of patient’ interaction patterns ia psychotherapy including thoughts, flings, affect regulation strate es, motives, behaviours and conflicts) that could be uefa in research and practice. METHOD. We used a practice neewock approach, in ‘which andomly selected clinicians peovide ata on patients that can be aggrenated across large samples (Westen & Sheer, 1999; Margzon etal 2000; Audin etal 2001; Shlder 8 Westen, 2004) Elsewhere we have addessed in detail the cational for clinician-eport dat, including advan. tages and limitations (see Westen ‘Weinberger, 2004) The peimary advantage is that clinicians are experienced observers, with skills and a normative basis with hich to make inferences and recognise vances in psychopathology. The primacy ‘objection is the possibilty of bias incinicl Judgement. Recent research suggests, how fever, that clinicians tend to make highly reliable and valid judgements if thei observations are quantifed using psycho- ‘metic instruments. Cocelations between treating clinicians! and independent inter- viewer? assessments of a range of clinical ‘ratables on instruments designed for ose by experienced clinicians tend to be large, typically over 0.50 (Eikesroth et al, 2000, Westen & Muderisola, 2003), and clinician-eported personality data pre dict measuees of adaptive functioning, atachmeat pateens, and family and developmental history suggestive of validity (NakaslHskovies ta, 2002; Westen ta, 2003). Clinician theoretical orientation pe dicts ide variance in descriptions of clini- ‘al phenomena when clinicians are asked to describe a specific patient rather than ‘thir beliefs oc theories (Sheer Be Westen, 2004). Participants Participants were 181 expeienced tii cans randomly selected from the member Ship registers ofthe American Pryhiaric and American Psychological Asocatons. ‘We requested mailing ste ofdnicians with at least 3 year post icensire or post: residency experience, who indicated that they performed a least 10 hours per week of diac patient care. Approximately 10% of solicited clinicians retened postcards cating their imterest in participating in @ project requiring approximately 4h of their time for an honorarium of USSBS. Validity checks comparing psychologists with pay- chit, who responded at substsnlly liferent aes, uncoveed no significant dif ference on any vatiable of interest (13 tests and analyses of variance, P<0.01), suggesting thatthe relatively modest ce sponse sate (reflecting substantial time commitment fora token honorarium) was unlikely to account for the findings (ee Lintations Inclusion and exclusion criteria To obtain aeros-secton of prychotherapy atiats sen in clinial practice, we asked clinicians to desribe a non-paychotic pa- tient at least 18 years old who they bad ‘ecated with pryshotherapy fora mitimum of eght sessions (to maximise the likeli hood tha they would know the patient well‘enough to provide a reaxoably accurate 1). We used the scree plot, pexcentage of variance accounted for and parallel analysis (Horn, 1965; O'Connor, 2000) to elect the numberof factors to rotate, The ste plot indicated a break between five and tx fe tors, and pacallel analysis indicated that five factors had eigenvalues larger than ‘would be expected by chance, Several fc- tors emerged across algocthms and rots tions, with the mote coherent solution emerging from a fivefactor oblique (Pro max) solution which accounted for 45% ‘ofthe variance {with factors each account ing for 2.5% to 26.4% of the vatiance) forther details ate available from the authors upon request, ‘Table 1 describes the factor. To create facrorbased (unit weighted) scores, we inluded items losding 0.50 o¢ more for factor 1 and 0.40 or moce for factors 2-5 fo maximise relibility, Intercorrelations among. the fire factors ranged from 0112 t0 0.54, witha median of 0.14, Factor! Factor 1, angeyentled (coefficient 10.94), if marked by items indicating tendeney to make excesive demands of the therapist while simultaneously being angry and dismissive, The items accord with clinical descriptions of transference process in patents with Axis It luster B disorders, nobly narcisistic and borderline pesonality disorders, Fectar2 Factor 2, anxiouspreoceupied (coefficient 0.85) includes items describing fear of the theeapists disapproval, fears of eee tion bythe eherapis, a overly compliant tnd dependent attitude toward the“Tablet Factor seu of th Pychotherpy Rosie Qustonnr Factor 23 4s Fecor Angled staves in way tat tom ected, wanes pei vers, lower fs than is warranted by sje income) 08 ‘Vacate beeween ding and dvaing the therapt oe Feel rte of hetherape, on on Repeatedly esr fils to respec the boundaries ofthe thera relitionship oe Lbargumenentve on Is provoitetends to st upsuton In whlch the therapis fkangry, atcha or provoked oe Inoppottiona tend to igre withthe heap’ pproich, commits suggestion, 069 ow Pye the therapist ff agaist another person gx arent, ote rather herp) as Ismanpuste or "Nets tobe spac tothe therapist wars tobe more import than th herapa'scher patents oer Flesng ager at the therapist. os Requires or demands excessive cont, oe ec, from the therapist. 066 Isundtic toward the thrapt eg enjoy ming the herp sur) oes Fealangry tonardte therapist on Neads exces aiiation from the therapist 00 os Imagns s/he and he thera are much moe snr than thoy rely reams to watt be tw! os withthe thera Voices concrrs thatthe therapist ie ot ding enough toby os Is dsmisivoor devaluing toward the therpit oss lecompectve withthe therapist os on Es sadam, sarcasm or oer ube ce ever sggresve respons rom the heaps, os Isp: makes the thrapit fsa waking on gee ost Expresses wih thatthe therapist ould har parent ost ‘oclates erween considerable involemesivetinet inthe therapy and thoughts of ulting 030 “resto get he harap otk hs or hr sen conf with other people 080 Fctor2:Aaiospreceuied Fal esr, doing someting wrong in therapy on Fealinferir tothe therapist 070 letra of contradicting or digreing with he therspa hs trouble asserting own ester vewpole 066 Fearsshoisulingheeherapet. oe Has trouble aking about own sucess shenerent or pride with the thera ous overly compan os lesraid of being abandoned by the harpist. ost lesralt speak hjher min for ear of provoking stack, t,t, from the terapit ost ‘Appears comfortableina childs elein therapy endeto draw paronclikeresporsestromthe therapist, «39 031 Feel dep ashamed about her ations, wishes, symptoms, ute, ee owe Hasty cxpresing ange or dsppelrement ovard the thera, een when the therapist as ade on 2 make or not been el Is uncomfortabe imagining tt the therapist cares about hha, dep obvious nds otharwie on, a9 Worle hace harap dose not inher on lls for the therapist ob deci, wars the thera total hier what odo om oa 031 ‘Worries tha the heaps eno ep ihe oat Foctor 3 Securelegsged cs warm ekings from tho therape on Inempsthiwoward the herpes oe lopli 260 lsatuned tothe vera and nner meanings fhe herp communicates adept readng os bl soci eves (nets