The Use of Transference in CAT: Refinement of a Proposed Model

Bennett, D., 1995. The Use of Transference in CAT: Refinement of a Proposed Model. Reformulation, ACAT News Spring, p.x.

The Use of Transference in CAT: Refinement of a Proposed Model

Dawn Bennett

This paper will outline some of the process work I have been involved in as part of the Borderline Project.

The concept of transference has been central to discourse on psychotherapeutic technique. Although the concept has been widely and loosely applied then is general agreement that the client’s maladaptive interpersonal patterns of relating will emerge in the relationship with the therapist and that this is a useful source of information. A number of theoretical models propose that the crucial therapeutic task is to identify and describe these patterns accurately and avoid colluding with, or reciprocating them. Therapy can be effective if enactments are identified and resolved in the client-therapist relationship and if the collaborative work on these resolutions can be extended by the client to relationships outside of therapy. Indeed, all forms of therapy warn against the countertherapeutic effects of failing to recognise or of colluding with the client’s maladaptive relationship patterns when they emerge in the client-therapist relationship. Safran and colleagues (Safran, Crocker, McMain & Murray, 1990) have conceptualised the enactment of these patterns in the therapeutic relationship as potential ruptures to the therapeutic alliance. The emphasis has tended to be on the technical operations of the therapist, conveying the therapist as active in relation to a passive client. Successful identification and resolution of transference enactments may require contributions of client and therapist, to which end the therapist would need to foster the client’s engagement in a joint task.
My research is concerned with two areas:

1. Investigating the CAT therapist’s ability to identify and accurately describe maladaptive patterns - problem procedures. Is the SDR an accurate summary?

2. Examining therapist activity when these patterns occur in the therapeutic relationship.

This paper will present some findings from the second area.

CAT is explicit in understanding transference in terms of reciprocal role procedures - the patient enacts one or other pole of a reciprocal role pattern Producing pressures on the therapist to enact the other. The overall aim of the research is to construct a model of successful resolution of RRP enactments. The idea is not to develop an intervention manual that is rigidly prescriptive but to guide therapists in what may be some key ingredients for making good use of the valuable opportunity for therapeutic change which is presented by a RRP enactment

Borderline clients are ideal for such an investigation as the behaviours which disrupt their personal relationships frequently present difficulties for therapists and risk disrupting therapy.

The research is guided by the Task Analysis paradigm for psychotherapy process research (Greenberg 1984a, 1986, 1992). This paradigm identifies a ‘marker’ of the task to be resolved and proceeds through an intensive analysis of the task performance.

There are a number of stages to the research:

1. Identifying ‘markers’ of RRP enactments - How do therapists or research observers know that an in-session event is an enactment of a RRP? Can these be reliably identified?

2. Model development - What should occur at these points in therapy? This led to the development of an ‘ideal model’ of enactment resolution. It is based on theory, experience and intuition and drawn up by Tony Ryle, a psychotherapy researcher and myself.

3. Empirical analysis - What actually occurs? This involves the observation and description of actual ‘successful’ resolution performances through the intensive analysis of single cases

4. Model refinement. How accurate was the model? The model will be refined by comparison of the ideal model and the actual performances

5. Model verification - It is necessary to test the model by evaluating whether the presence of the stages described in the model distinguish between resolved and non-resolved enactments.

6. Treatment development. Interventions can-be developed and refined in response to the findings emerging from the model.
Further stages to the research would be concerned with evaluating the effectiveness of the intervention.

The research procedure will be illustrated by description of the stages of a successful resolution of a transference enactment of a reciprocal role procedure from one ‘good? outcome case in the borderline project

Those sessions showing evidence of a shift in the therapeutic relationship (scores on the Therapy Experience Questionnaire (TEQ) and the sessional grid) are selected for analysis. Within these sessions, the in-session event of interest is evidence of enactment of patterns identified in the client’s SDR, in the client-therapist interaction. A coding procedure has been developed in which sessions are divided into themes or topics and raters identify whether the content or process of each theme is an enactment or manifestation of the client’s TPPs or RRPs as outlined on the client’s SDR. The ‘ideal model’ hypothesises five stages for the resolution of enactments from acknowledgement of an in-session experience (focusing on the ‘here-and-now’); its exploration; linking (to the SDR, occurrence with others) and explanation (history/origins); negotiation of understandings and disagreements and consensus. There are an additional three stages constituting further explanation (that procedures maintain the core state); new ways of relating (exploration of exits in the therapeutic relationship) and closure. The model does not represent a fixed order of stages but assumes that there will be cycling within and between stages.

The aim is to describe systematically the moment-by-moment therapist and client activities in response to the enactments. Following from the identified marker the task performances are broken down into small meaningful units of therapist and patient actions which are coded. They were then developed into descriptive accounts of the performances.

The refinement of the ideal model by comparison to the actual resolution performances of a series of ‘good outcome’ cases is currently in progress. The procedure will be repeated one case at a time until no further refinements can be added to the model.

In order to test if the processes outlined in the ideal model are related to therapeutic change, those clients with unsuccessful outcomes will be considered. It would be hypothesised that if the processes outlined in the ideal model are causal processes in therapeutic change then unsuccessful cases would be characterised by the presence of enactments of RRPs between client and therapist which were not identified by the therapist and possibly colluded with, or if identified, were poorly explained, misunderstood or rejected by the client.

Preliminary Findings

Initial observations from two ‘good outcome’ therapies axe that the therapists intervened in a fashion consistent with the proposed ‘ideal model’. Therapists did not follow all stages of the model at each marker of an enactment but there was evidence of returning to the enactment or linking it with other enactments at later points in the therapy. It is possible that, for these successful outcome cases, the therapists returned to ‘finish off’ their interventions suggesting that they had a sense of incomplete resolution. This stresses the importance of timing, sequencing and the context in which interpretations are offered in addition to accuracy. Tony Ryle also talks of not ‘hammering away’ until agreement is reached.

The present research finds support for Wachtel’s view (Gold & Wachtel, 1993) that it is not necessary or indeed possible to completely avoid falling into complementary behaviour patterns - reciprocal role procedures. He states that it is sufficient that the therapist is not an ‘accomplice’, caught up in the client’s patterns, for the most part but that the therapist acknowledges and specifically discusses with the client when it occurs to promote understanding of how patterns repeat in the client’s life. Similarly, Kiesler (1982) advocated that this form of metacommunication between therapist and client is more useful if specific about the particular client behaviours and communications that impact on the therapist. CAT is clearly a strong advocate of such a perspective.

Dawn Bennett

References

Gold, J.R. & Wachtel, P.L. (1993) Clinical Psychodynamics. IN G Stricker & J.R. Gold (eds.) Comprehensive Handbook of Psychotherapy Integration. New York, Plenum Press.
Greenberg L.S. (1984a) Task Analysis: The General Approach. In L.Rice & L.S. Greenberg (eds.) Patterns of Change: Intensive Analysis of Psychotherapy Process. (pp124-148) New York, Guilford Press.

Greenberg, L.S. (1986) Change Process Research. Journal of Consulting and Clinical Psychology, 54, 4-9.

Greenberg, L.S. (1992) Task Analysis: Identifying Components of Intrapersonal Conflict Resolution. In S.G.Toukmanian & D.L.Rennie (eds.) Psychotherapy Process Research: Paradigmatic and Narrative Approaches. (pp1-21). Newbury Park, Sage.

Kiesler, D.J. (1982) Confronting the Client-Therapist Relationship in Psychotherapy In J.C.Anchin & D.J.Kiesler (eds.) Handbook of Interpersonal Psychotherapy. New York, Plenum Press.

Safran, J.D., Crocker, P. McMain, S. & Murray, P. (1990) Therapeutic alliance rupture as a therapy event for empirical investigation. Psychotherap, 27, 154-165.

Full Reference

Bennett, D., 1995. The Use of Transference in CAT: Refinement of a Proposed Model. Reformulation, ACAT News Spring, p.x.

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The Use of Transference in CAT: Refinement of a Proposed Model