Development and validation of a revised short version of the working alliance inventory

Abstract

Although countertransference phenomena have been given much attention within psychotherapy theory, single-case studies and clinical anecdotes, empirical research is still conspicuous by its absence. To assess the therapists’ emotional reactions, which are understood to be part of the countertransference (CT), we used the Feeling Word Checklist 58 (Røssberg, Hoffart, &; Friis, 2003); a self-report questionnaire, comprising 58 feeling words. The aims of the present study were to examine the underlying factor structure and psychometric properties of these factors, and to validate the factors by exploring the relationships between countertransference feelings and the following variables: therapeutic alliance, patient personality pathology, suitability for psychodynamic therapy, interpersonal problems, level of general functioning, and symptoms. Six therapists, who treated 75 patients, with weekly, psychodynamic therapy, over 1 year, completed the checklist after each session. To establish the number of subscales in the checklist, a principal component analysis with promax rotation was conducted. The analysis revealed four clinically meaningful factors named Confident, Inadequate, Parental and Disengaged. The psychometric properties of all subscales proved to be acceptable. Alliance as reported by both patient and therapist showed differential correlations with the subscales. The patients’ relational functioning showed stronger correlations with the CT feelings than the patients’ symptoms and level of functioning. The four subscales found in the Feeling Word Checklist-58 seem to capture clinically meaningful aspects of the therapeutic dyad, and countertransference feelings are systematically related to different relational variables.     

Specific personality traits evoke different countertransference reactions: an empirical study

The main aim of this study was to examine the relationship between patients' self-reported personality characteristics, treatment outcome and therapists' countertransference reactions. Eleven therapists filled in the Feeling Word Checklist 58 (FWC-58) for each patient admitted to a day treatment program. The patients completed the Circumplex of Interpersonal Problems (CIP) at admission and discharge. Outcome measures were assessed at the end of treatment. At the start of treatment, therapists reported fewer feelings of rejection and being on guard in response to patients who reported high avoidant, exploitable, overly nurturing and intrusive CIP subscale traits. At the end of the treatment, the CIP subscales of being domineering, vindictive and cold correlated with fewer positive and more negative countertransference feelings. The study revealed a strong relationship between improvement and countertransference feelings. This study confirms clinical narratives on relationships between the therapists' countertransference reactions and patients' reported interpersonal problems and outcome.     

Psychiatric staff members' emotional reactions toward patients. A psychometric evaluation of an extended version of the Feeling Word Checklist (FWC-58)

The study evaluated the psychometric properties of an extended version of the Feeling Word Checklist (FWC-58), which measure the therapists' emotional reactions toward patients. Doctors, psychologists, nurses and aides from 23 wards in seven widely different psychiatric departments completed a total of 3012 forms. The original Feeling Word Checklist (Whyte CR, Constantopoulos C, Bevans HG. Br J Med Psychol 1982;55:187-201) was expanded with 28 feeling words covering more feelings of being invaded, idealized, devalued and of being secure. The rating scale was changed from a two-point (yes/no) scale to a five-point scale ranging from not at all (=0) to very much (=4). The factor analysis revealed ten factors with an eigenvalue equal or greater than 1.0. The two first factors were clearly the strongest but a two-factor solution did not satisfactorily reflect the data. The scree test indicated four to seven factors. We chose a seven-factor solution, as this seemed clinically most meaningful. Based on the factors we developed seven indices which were named: Important, Rejected, Confident, Bored, On guard, Overwhelmed and Inadequate. The subscales had satisfactory internal consistency and described meaningful emotional profiles of the different psychiatric wards and the individual patients. The seven subscales seem well worth to use in further research and in a clinical context.     

Psychiatric staff members' emotional reactions toward patients. A psychometric evaluation of an extended version of the Feeling Word Checklist (FWC-58)

The study evaluated the psychometric properties of an extended version of the Feeling Word Checklist (FWC-58), which measure the therapists' emotional reactions toward patients. Doctors, psychologists, nurses and aides from 23 wards in seven widely different psychiatric departments completed a total of 3012 forms. The original Feeling Word Checklist (Whyte CR, Constantopoulos C, Bevans HG. Br J Med Psychol 1982;55:187-201) was expanded with 28 feeling words covering more feelings of being invaded, idealized, devalued and of being secure. The rating scale was changed from a two-point (yes/no) scale to a five-point scale ranging from not at all (=0) to very much (=4). The factor analysis revealed ten factors with an eigenvalue equal or greater than 1.0. The two first factors were clearly the strongest but a two-factor solution did not satisfactorily reflect the data. The scree test indicated four to seven factors. We chose a seven-factor solution, as this seemed clinically most meaningful. Based on the factors we developed seven indices which were named: Important, Rejected, Confident, Bored, On guard, Overwhelmed and Inadequate. The subscales had satisfactory internal consistency and described meaningful emotional profiles of the different psychiatric wards and the individual patients. The seven subscales seem well worth to use in further research and in a clinical context.     

An empirical study of countertransference reactions toward patients with personality disorders

OBJECTIVE: The study examined to what extent patients with cluster A + B personality disorders (PDs) evoked other countertransference reactions among psychotherapists compared with patients with cluster C PDs as well as the relationship between the different countertransference reactions and outcome. METHODS: A total of 11 therapists at the Department for Personality Psychiatry, Ullevaal University Hospital, Oslo, Norway, filled out the Feeling Word Checklist-58 (FWC-58), 2 weeks after admission and 2 weeks before discharge, for 71 patients admitted to the day treatment program. The patients were diagnosed with the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). RESULTS: The study revealed that patients with cluster A + B PDs evoked more negative and less positive countertransference reactions than those with cluster C PDs. The psychotherapists varied significantly more in their reported countertransference reactions toward patients with cluster A + B PDs than toward those with cluster C PDs. Patients who dropped out of treatment evoked significantly more negative countertransference reactions after 2 weeks than patients who completed the treatment. In addition, the study revealed strong correlations between countertransference feelings and change during the treatment. CONCLUSIONS: This empirical study confirms clinical narratives on specified relationships between countertransference reactions, different PDs, and treatment course.     

Interaction between alliance and technique in predicting patient outcome during psychodynamic psychotherapy

The current study examined whether alliance interacted with psychodynamic interventions to predict patients' psychotherapy outcomes. A prospective study of psychodynamic psychotherapy with 68 outpatients who were treated by 23 therapists was used. The patients rated the alliance with their therapist early in treatment. Therapist use of psychodynamic techniques was reliably rated by independent clinicians for the same sessions. The therapy outcomes were measured at the end of treatment based on the patients' global symptomatology as well as estimate of improvement across a broad range of functioning. In all models, we controlled for the patients' pretherapy psychiatric severity. Analyses were conducted using multilevel modeling to account for therapist effects. Results revealed that patient rated alliance was significantly related to improvement on a measure of broad band functioning. In addition, alliance and psychodynamic interventions interacted to predict this scale of multidimensional therapy outcome. Further, results showed that several individual psychodynamic techniques interacted with alliance that were meaningfully related to this measure of broad band outcome including (1) linking current feelings or perceptions to the past; (2) focusing attention on similarities among patient's relationships repeated over time, settings, or people; and (3) identifying recurrent patterns in patient's actions, feelings, and experiences. In this sample of outpatient psychodynamic treatments, the dynamic techniques were most effective when provided in the context of strong alliances.     

Countertransference to psychiatric patients in a clinical setting: development of the Feeling Checklist-Japanese version

Countertransference is an important dimension of the therapeutic alliance between care providers and patients. The Feeling Checklist (FC) is a self-report questionnaire for the assessment of countertransference by hospital staff toward patients. The FC was translated from English into Japanese and its factor structure, reliability, and validity in the Japanese version (FC-J) were examined. A total of 281 Japanese psychiatric nurses were tested with the FC-J. All nurses were primarily involved in provision of psychiatric care. Principal-component factor analysis with varimax rotation was performed to identify the potential components of the FC-J. In a factor analysis of the FC-J, seven factors were extracted. The five subscales that were determined and labeled included Reject, Distance, Helpfulness, Closeness, and Involvement, which collectively accounted for 56.0% of the variance. Cronbach's alpha, a measure of internal consistency, for individual subscales was 0.833 for Reject, 0.763 for Distance, 0.768 for Helpfulness, 0.617 for Closeness, and 0.663 for Involvement. Notably, there was a significant correlation between the FC-J and the Nurse Attitude Scale (P < 0.0001). Moreover, one-way anova was performed with each FC-J subscale to examine differences among psychiatric diagnoses in the study sample. A significant difference was found for Involvement (P < 0.001), with the total score on Involvement being the highest in the personality disorder group. These results are considered to verify the reliability and validity of the FC-J as a scale to measure countertransference among Japanese care providers. The use of this scale allows individual care providers to recognize and be cognizant of their own countertransference objectively and thereby contributes to improve the relationship between patients and care providers.     

Therapeutic interventions related to outcome in psychodynamic psychotherapy for anxiety disorder patients

This is the first study with acceptable inter-rater reliability to examine specific therapeutic techniques related to change in anxiety disorder patients during short-term psychodynamic psychotherapy. The study first examined the effectiveness of short-term psychodynamic psychotherapy and results showed significant and positive pre-/post-treatment changes on both patient and independent clinical ratings for anxiety, global symptomatology, relational, social, and occupational functioning. Likewise, the majority of patients (76%) reported anxiety symptoms within a normal distribution at termination. Importantly, psychodynamic interventions rated early in treatment (third/fourth session) were positively related to changes in anxiety symptoms. Further, results showed that several individual psychodynamic techniques were meaningfully related to outcome including (1) focusing on wishes, fantasies, dreams, and early memories; (2) linking current feelings or perceptions to the past; (3) highlighting patients' typical relational patterns; and (4) helping patients to understand their experiences in new ways. Clinical applications are discussed.     

Staff members' emotional reactions to aggressive and suicidal behavior of inpatients

OBJECTIVE: This study examined the relationship between the characteristics of inpatients and staff members' emotional reactions to the patients, particularly the extent to which the reactions were related to patients' aggressive or suicidal behavior. METHODS: The Feeling Word Checklist-58 was used to measure staff members' feelings. Two positive and five negative feeling dimensions were examined: important, confident, rejected, on guard, bored, overwhelmed, and inadequate. A total of 253 staff members from a wide variety of psychiatric wards at a university-affiliated hospital in Oslo, Norway, completed a total of 2473 checklists about their emotional reactions to 207 patients. For each patient, a member of the research team used information from ward staff who knew the patient to complete a Social Dysfunction and Aggression Scale measuring whether the patient had been aggressive (outward aggression) or suicidal (inward aggression). RESULTS: Staff reported positive feelings about patients much more frequently than negative feelings. Multiple regression analysis revealed that patient characteristics explained much more of the variance in negative feelings than in positive feelings. Outward aggression explained an average of 22 percent of the variance in scores on the five negative dimensions. Inward aggression explained an average of 12 percent more of the variance in scores on the five negative dimensions. Gender, age, amount of medication, and diagnosis (psychotic or not psychotic) explained only a small proportion of the variance in feeling scores. CONCLUSIONS: Even though the level of negative feelings toward patients was low, patients' aggressive and suicidal behavior explained a large proportion of the variance in negative feelings.     

The Karolinska Psychodynamic Profile. II. Interdisciplinary and cross-cultural reliability

The Karolinska Psychodynamic Profile (KAPP) is a rating instrument based on psychoanalytical theory, that is intended to assess relatively stable modes of mental functioning, as they appear in self-perception and in interpersonal relations. The 18 subscales of the KAPP and their scale steps are described in detail and kept close to clinically observable phenomena. The information needed for assessment is obtained through a structural interview procedure. The interrater reliability was tested with different Swedish raters with varying psychodynamic training and experience. It was also tested with a non-Swedish rater with psychoanalytic training. The interrater correlations were generally high, suggesting that the KAPP has interdisciplinary and cross-cultural reliability.     

Psychometric Properties of the Norwegian Aberrant Behavior Checklist and Diagnostic Relationships in a Neuro-Pediatric Sample

ABSTRACT

Introduction: Although the Aberrant Behavior Checklist (ABC) is one of the most widely used behavioral rating scales among people with developmental disabilities, very few studies have examined the factor structure of the non-English versions.Methods: The construct validity of the Norwegian ABC was examined in a clinical sample of children and adolescents with neurological and neurodevelopmental disorders (N = 339). Diagnoses were obtained from direct interdisciplinary assessments in our neuro-pediatric clinics. Results: In an exploratory factor analysis, 46 of the 58 items (79%) loaded most heavily on four of the five original factors in the English version. Confirmatory factor analysis revealed less-than-optimal fit indices for the five-factor solution. Internal consistency was adequate to excellent for all subscales (α range = .76–.95). The ABC showed meaningful overlap and differentiation with the Strengths and Difficulties Questionnaire, the Behavior Rating Inventory of Executive Function, the Vineland Adaptive Behavior Scales, and full scale IQ. There were positive correlations between several of the ABC subscales and diagnoses of attention deficit/hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, and emotional disorder Conclusion: Satisfactory psychometric properties were found for the ABC, with the exception of the Inappropriate Speech factor, in a mixed sample of higher functioning children and adolescents with neurodevelopmental and neurological disorders.     

Therapists' relationships with their patients in the intake interview: an empirical comparison of psychodynamically and cognitive-behaviorally oriented psychotherapists

This study was conducted in a real-life clinical practice setting and assessed the working alliances, countertransference feelings, diagnostic ratings, and prognostic judgments among psychotherapists at a university outpatient clinic. The study was based on the intake judgments of 9 psychodynamically and 4 cognitive-behaviorally oriented therapists, who had been assessed after having completed their diagnostic interviews with 144 and 89 patients, respectively. Cognitive-behaviorally oriented therapists perceived the quality of the working alliance to be better and their feelings of sympathy to be stronger than did psychodynamically oriented therapists. In addition, they perceived patients' motivation, the amount of shared understanding of the illness as well as several prognostical factors to be more favorable. The results may reflect different therapeutic philosophies and value systems inherent to the cognitive-behavioral and psychoanalytic orientations.     

Toward more (and better) countertransference research

This article addresses the definitional and measurement barriers currently inhibiting countertransference research and indicates new pathways toward meaningful and clinically relevant countertransference research. First, I review the countertransference definitional debate and advocate for the adoption of a moderate countertransference definition. Second, I review the extant countertransference research, with primary emphasis on measurement issues, and recommend new methods and instruments for assessing the construct. Finally, I conclude with a few remarks about clinical implications and directions for future CT research. (PsycINFO Database Record (c) 2011 APA, all rights reserved).     

Psychological climate and countertransference in psychiatric treatment homes

Holmqvist R, Fogelstam H. Psychological climate and countertransference in psychiatric treatment homes. Scand 1996: 93: 288–295. © Munksgaard 1996. The associations between milieu therapists' feelings towards patients and the unit's psychological climate were studied at 21 small treatment homes for severely disturbed psychiatric patients. The milieu therapists filled out self-report instruments where they rated their feelings towards patients on a feeling-word checklist and their opinion about the psychological climate on a Bion-based scale. Scores on the climate scale were used as independent variables in a series of regression analyses, with scores on the feelings as the dependent variables. It was found that a substantial component of the average differences between units with regard to feelings towards patients could be attributed to the unit's climate. Correlations showed that units characterized by ‘Work’ and ‘Pairing’ had high scores for helpful and autonomous feelings, while unhelpful feelings were evoked in units characterized by ‘Dependency’ and ‘Fight’. Close feelings were evoked in units characterized by ‘Dependency’.     

The measurement and impact of childhood teasing in a sample of young adults

This study examined the psychometric properties of the Teasing Questionnaire-Revised (TQ-R) and the relationships among recalled childhood teasing and current psychosocial distress in 414 undergraduate students. Participants were administered the TQ-R, Beck Depression Inventory-II, State-Trait Anxiety Inventory-Trait Version, Brief Fear of Negative Evaluation Scale, and UCLA Loneliness Scale. Confirmatory factor analysis supported a five-factor model assessing teasing related to performance, academic issues, social behavior, family background, and appearance. Internal consistency of the TQ-R and its factors was acceptable, and intercorrelations among subscales were moderate, suggesting that the factors measure related but conceptually distinct teasing experiences. Defining Pearson product-moment correlations with a magnitude of greater than.25 as conceptually meaningful, we found that the TQ-R Total score was meaningfully related to depressive symptoms, anxiety, fear of negative evaluation, and loneliness. Being teased in the Performance and Social domains as a child was moderately related to current psychopathology. Implications of these findings for clinical practice and future research are discussed.     

Psychodynamic group treatment of young adult bulimic women: preliminary positive results

This paper presents preliminary results of symptomatic and behavioral changes and psychodynamic observations for 9 young adult bulimic women treated with psychodynamic group psychotherapy. Pre/post group test results showed significant improvement on all measures of eating pathology, on the EDI ineffectiveness item and the Janis-Field feelings of inadequacy scale as well as on the total score of the Hopkins Symptom checklist. These results were consistent with independent clinical conclusions and with verbal reports of improvements in binging and purging behaviour. Clinical content shed light on the role of the parents, especially the father, in the development of body-image, sense of adequacy and self-esteem, life goals and feminine identification. The authors conclude that clinical observations to date have yielded interesting psychodynamic hypotheses and the initial symptomatic improvements warrant cautious therapeutic optimism.     

Premature termination--a multifactoral phenomenon

Twelve drop out cases in psychodynamic short term therapies according to the focus of cyclic maladaptive pattern by Strupp and Binder (CMP 1984) are reviewed regarding initial diagnostics, tape-recorded therapy sessions, and supervision records. Predictors of premature termination of therapy such as initially rated patients' therapy motivation, narcissistic personality traits, but also characteristics of interpersonal behavior of both patient and therapist are examined and discussed. Particularly important are the therapeutic alliance and narcissistic patients' difficulties to relate personally to their therapists instead of enacting projective dynamics of idealization and devaluation. Therapists frequently tend to respond to them by subconscious display of hostile countertransference. Four patterns of dynamics of therapy drop outs are described.     

The value of a psychodynamic approach in the managed care setting

The managed care setting presents significant challenges to all psychotherapists. Psychodynamic therapists, however, experience specific difficulties in this environment. Despite managed care's general hostility toward psychodynamic theory and practice, psychodynamic therapists provide unique and significant opportunities for patients. Psychodynamic training, with its emphasis on careful evaluation, exploration of unconscious conflict, transference and countertransference, and other therapeutic phenomena, enables clinicians to provide an invaluable service to managed care organizations. The case of K., a 45-year-old man, is used to illustrate the ways in which psychodynamic elements of a brief treatment contributed to a successful outcome. The importance of including psychodynamic treatment in managed care settings is discussed.     

Psychometric properties of an instrument for measuring threat/control-override symptoms

Threat/control-override symptoms refer to delusional persecutory thoughts and feelings of losing control over mind and body. The Threat/Control-Override Questionnaire (TCOQ) was developed to assess such symptoms, and the purpose of the present study was to examine the psychometric properties of this measure in nonclinical students (n = 759) and acute and stabilized psychotic patients (n = 111 and 33, respectively). Factor analysis of TCOQ data in students and acute psychotic patients yielded a two-factor solution, with components referring to "threat" and "control-override" symptoms. Internal consistency and test-retest reliability were satisfactory and concurrent and discriminant validity were shown by a meaningful pattern of correlations with other self-report and interview measures. Group comparisons showed that patients displayed significantly higher scores on the TCOQ than did the nonclinical students. Altogether, it can be concluded that the TCOQ is a reliable and valid index for assessing feelings of persecution and losing control.