advent of objective measures of the transference concept

Jounial of Consulting and Clinical Psychology1986, Vol. 54, No. 1, 39-47

Copyright 1986 by the American Psychological Association, Inc.0022-006X/86/J00.75

Advent of Objective Measures of the Transference Concept

Lester Luborsky, Paul Crits-Christoph, and James MellonDepartment of Psychiatry, University of Pennsylvania

This is the first comprehensive review of research on measures of the transference since the concept

was first put forward at the turn of the century. Such research is of two kinds: Q-sort questionnaire

measures and psychotherapy process measures. The first type of measure, although reliable, has lacked

validity information. The newer psychotherapy process measures of the last decade, for example, the

core conflictual relationship theme method (CCRT), provide evidence for their reliability and validity.

Considerable comparability was found between data from the CCRT method and operationalized

propositions from nine of Freud's observations about transference. For example, the CCRT in rela-

tionship to the therapist was found to be highly similar to the CCRT in relationship to other people.

Methodological issues and proposals that could further advance research on transference are examined.

For more than three quarters of a century there has been con-

siderable consensus by psychoanalytic clinicians that transference

is Freud's grandest clinical concept (Breuer & Freud, 1893-1895/

1966; Freud, 1912/1966). During this period the concept has

been continually used in everyday practice in psychoanalysis and

in all of the psychodynamically oriented psychotherapies. In these

therapies the nature of transference, consistent with Freud's def-

inition (Freud, 1912/1966), refers to the patient's expression of

attitudes and behavior derived from early conflictual relationships

with significant parental figures in the current relationship with

the therapist. In each session in such therapies, the therapists

make inferences about the state of the transference as a basis for

understanding the patient and for guiding their interventions

(Luborsky, 1984).

Despite this heavy clinical reliance on the concept, there has

been until recently an impoverishment in clinically useful and

even research-useful clinical quantitative methods. These research

methods fall into two categories: (a) questionnaire measures

and (b) psychotherapy process measures. The questionnaire ap-

proach began about 35 years ago but never got very far; the

process measure approach, although new, already shows clinical

and research value.

Questionnaire Measures of Transference

To achieve an operational version of the concept, transference

was purposely denned by Chance (1952) in terms of the similarity

This work was supported in part by United States Public Health ServiceResearch Scientist Award MH 40710 to Lester Luborsky. It was firstspecifically supported in part by a grant from the Fund for PsychoanalyticResearch of the American Psychoanalytic Association. More recentlysome of the research has been supported in part by National Institute ofMental Health Grants MH40472 and MH39673.

Among those who played a vital role in the research were Arthur Auer-bach, Stephanie Ming, Keith Alexander, Frederic J. Levine, Anna RoseChildress, Kenneth D. Cohen, Paul van Ravenswaay, Leslie Alexander,Laura Dahl, Fu-Chin Lee, Lynn Tomko, KatherineCrits-Christoph, andAnita V. Hole.

Correspondence concerning this article should be addressed to LesterLuborsky, Department of Psychiatry, 207 Piersol Building, Gl, Hospitalof the University of Pennsylvania, Philadelphia, Pennsylvania 19104.

between the patient's description of a significant parent and the

patient's description of the psychotherapist. In Fiedler's studies

(e.g., Fiedler & Senior, 1952), transference was denned in terms

of a comparison of the patient's description of the ideal person

with the patient's prediction of the therapist's self-description

and by both of these with similar measures completed by the

therapist. In Apfelbaum's (1958) method, transference was in-

tended to be tapped by a questionnaire (Q-sort) on the patient's

expectations about the qualities of the therapist who would later

be assigned to the patient. The patients were grouped in terms

of three types of expectations reported in their initial (preas-

signment) Q-sort: Cluster A (therapist will give nurturance);

Cluster B (therapist will be a model); and Cluster C (therapist

will be a critic). Each of these types tended to be maintained to

the end of treatment, as indicated by high test-retest reliability.

Such stability was listed by Freud (1912/1966)asa characteristic

of transference.

Rawn (1958,1981) developed Q-sort-based scales and applied

them to four sessions of one patient's analysis. He took the un-

usual further step of comparing these results with those from

clinical observations and noted signs of convergence. Crisp

(1964a, 1964b, 1966) continued this line of research with Q-

sorts of questionnaire items. The items rated were about father

and therapist figures; the estimate of transference was based on

a comparison of these ratings. One finding indicated that attitudes

toward the therapist tend to change with or to precede changes

in symptoms, Subotnick (1966a, 1966b) developed the method

further. He used two separate sets of Q-sorts: attitudes toward

parents and attitudes toward the therapist at various points in

therapy. Similarity was found between the attitudes toward par-

ents and therapist (by high loadings on the factors common

among the Q-sorts).

All of these six sets of studies are based on the questionnaire

approach, usually in the form of the Q-sort method. They suffer

from the use of a method with questionable validity. These mea-

sures need to be compared with measures of transference based

on psychotherapy sessions of the kind described in the next sec-

tion. Furthermore, as Fisher and Greenberg (1977) pointed out,

the studies do not distinguish appropriate from inappropriate

attitudes toward the therapist, a distinction usually considered

to be required by the concept of transference.

39

40 L. LUBORSKY, P. CRITS-CHRISTOPH, AND J. MELLON

Psychotherapy Process Measures of Transference

Clearly a more direct approach to the concept of transference

was necessary. Because the concept was originally derived from

psychotherapy, measures might more appropriately be con-

structed from sessions, such as the following three types of meth-

ods: systematic clinical formulation, rating, and content coding.

Systematic Clinical Formulation Methods

A formulation, as used here, means a description of a patient's

main relationship patterns. Formulations were routinely made

in the Menninger Foundation Psychotherapy Project (Wallerstein,

1985; Walleistein & Robbins, 1956) by a termination research

team from an evaluation of the therapist's process notes and

from interviews with the patient, the therapist, and the patient's

relatives.

The Chicago Consensus Group (Seitz, 1966) performed the

best known study of free discursive formulations of transference

by independent groups of clinicians. They reported a lack of

consensus, but in fact, any conclusion was difficult to justify

because their method was not capable of coping objectively with

the comparison of different judges' formulations.

The Mayman and Fans (1960) formulation system was based

on clinical recognition of common elements across several early

memories. Although their system is an important precursor to

present day methods, it lacks explicit principles for guiding clin-

ical judgments and making estimates of reliability.

The basic observation that an enduring set of relationship

patterns are repeated throughout a person's life has also been

included in script theory. Carlson's (1981, p. 502) account of

Tomkins's (1979) script theory described the script as "the in-

dividual's rules for predicting, interpreting, responding to, and

controlling experiences governed by a 'family' of related scenes."

Tomkins's (1979, p. 228) theory also identifies one "nuclear

scene," or sometimes several, that manifest these rules. Carlson

(1981) provided an example of a person's nuclear scene that

recurs after 30 years. Her interpretation of this scene is the usual

psychodynamic clinical one, that is, that the scene is a pattern

setter for later relationship episodes. A more precise comparison

of Tomkins's script theory with the core conflictual relationship

theme (CCRT) and other similar methods would be facilitated

by a scoring system for the script theory.

Rating Methods

In the clinical formulation methods just described, agreement

is harder to estimate than it is in the studies using rating methods.

However, the first rating method studies were limited to ratings

of the amount but not the type of transference. One of these

(Strupp, Chassan, & Ewing, 1966) reported only slight agreement

among five independent judges in their ratings of amount of

transference in whole sessions.

In the first study of the Analytic Research Group of the In-

stitute of the Pennsylvania Hospital (Luborsky, Graff, Pulver, &

Curtis, 1973) of one psychoanalytic patient, clinicians judged

the amount of transference and related variables in 30 five-min

segments. Several findings are noteworthy: (a) The agreement

was low (r - .26) when simply the amount of overall transference

in a segment was rated, (b) The agreement was higher (for trans-

ference likely, r - .46, p < .01) when the judgment was based

on the amount of transference expressed in relation to each per-

son referred to in the segment, (c) The segments with high trans-

ference showed much more affect than did the segments with

low transference (Lower, Escoll, Little, & Ottenberg, 1973). (d)

The concept space used by each of eight psychoanalyst judges

could be reliably identified (Luborsky, Crabtree, Curtis, Ruff, &

Mintz, 1975) by a factor analysis of their ratings of 23 transfer-

ence-related concepts on the same segments, (e) Consistency over

time was found for ratings of transference and resistance made

on a postsession checksheet (Graff & Luborsky, 1977) for four

psychoanalytic patients, two more improved and two less im-

proved. The two more improved patients showed a pattern of

increasing amount of transference. These results imply that a

revision is needed in the common theory that in successful psy-

choanalysis, transference is eradicated.

Content Coding Methods

Two recently developed measures of transference are closer to

representing the clinical concept than any described so far. Both

of these use guided clinical judgment: Clinicians must follow a

set procedure and are not free to make formulations in whatever

categories they find most compatible. The method by Gill and

Hoffman (1982b) estimates the frequency of the patient's ex-

perience of the relationship with the therapist; the method by

Luborsky (1976, 1977) estimates the frequency and the content

of the CCRT.

Patient's Experience of the Relationship With the

Therapist Method (PERT)1

This guided clinical judgment method using transcripts of

psychotherapy (Gill & Hoffman, 1982a, 1982b) provides guide-

lines for a tally of the frequency of communications regarding

the patient's manifest experience of the relationship with the

therapist as well as presumed implicit references to the experi-

ence. It has two main divisions: (a) experiences of the relationship

that are manifestly about the relationship with the therapist (r)

and (b) experiences of the relationship that are not manifestly

about the relationship with the therapist or have no specific de-

signation (x). Further divisions include communications that ex-

press awareness of the presumed parallel between experiences

outside and experiences inside the session (e.g., xr). Another cat-

egory is derived from the inference of a judge rather than from

what is directly expressed by the patient (e.g., Jxr). The PERT

system also estimates the degree to which the therapist's inter-

ventions deal with the main aspects of the PERT (e.g., XR). For

both the PERT and the therapist's interventions, the judge also

indicates the basis for the inferences. One kind of reliability has

been reported so far: the agreement between two judges on the

total for each code within the entire session. The correlation for

the r code was .89 and for the xr code, .63.

An example of a session as scored by the PERT system is the

best way to further explicate the method (later we will refer back

to the same example to illustrate the CCRT scoring). This ex-

ample is from the treatment of a young man in psychoanalysis

1 This is our acronym for the Gill and Hoffman (1982b) system.

OBJECTIVE MEASURES OF TRANSFERENCE 41

(from GUI & Hoffman, 1982b, p. 151 ff). Judges chose these

segments from the transcript as relevant to the PERT. Each of

the following segments is a narrative episode about a relationship

with a different person. In order to facilitate the comparison with

the CCRT method, the person with whom the patient is inter-

acting in each episode is named after the relationship episode

(RE) number, as would be done for the CCRT system.

RE no. 1: A guy (man friend).

He came over to drink beer, and to have this conversation which was alittle difficult. I pretended to be enjoying it, enjoying him, you know, inthe spirit of good fellowship and shit and stuff, but I really wanted to

be—well, I didn't want to be reading, but you know, I felt that this wasthe thing that, that was keeping me from reading and that hassled me. Ireally nicking resented it a lot. You know among my friends, they'rerespecting and always have really respected my wanting to do my ownthing. . . But you know, with a guy like this (clears throat), he's just inanother world totally from that. And, you know, he wouldn't understandif I said that, you know, he would be insulted and that kind of shit Youknow it was kind of a hassle.

This would be provisionally scored an x because it is a com-

munication about matters manifestly other than the patient's

experience of the relationship with the therapist. According to

Gill and Hoffman (1982b), the episode may allude to resentment

of the involvement that the patient feels that the analyst demands

of him. However, such an inference based on a single episode is

not regarded as supported until more direct evidence for it

emerges.

RE no. 2: Therapist.

This morning I, like didn't particularly feel like coming here, you know.Because like, I don't know, I felt some kind of, you know, I felt like Ididn't need it. I guess I was just, you know, my spirits were a little raised.If only now I could get out of the bag of feeling that I have t o . . . .

A coding of Jxr for RE no. 1 can now be justified on the basis

of the episode about the therapist, and that would be the final

score. The previous x episode can be thought of retrospectively

as including implicit elaborations of the present issue about the

experience of the relationship with the therapist, elaborations

that the patient resists making because he feels that he may insult

the therapist.

RE no. 3: Woman (a potential date).

This woman bag is real bad for me. The woman that I'm going ape shitover now is a woman I've never even seen. I think I told you about thetelephone operator who I made a date with. And 1 keep calling her back,

but she's never home and I talk to her roommate. That's been a big hasslebecause I keep, you know, hoping she'll be there, that she'll talk to me.I've never even seen this girl, I mean, I don't know anything about her,you know.

Again a coding of Jxr appears to be warranted, and a similar

theme appears to be further exemplified. Again the basis for the

Jxr coding is the explicit statement by the patient about the ther-

apist (RE no. 2).

A bit later, more about the same episode with the woman (a

potential date) is presented:

When I finally got through to her roommate yesterday and found outthat she wasn't going to be in, like all the woman obligations just wentoff me. I knew that there was nothing I could do to find a woman and,you know, there was kind of a relief.

Another Jxr coding would be given for the following example.

RE no. 4: Some girl (fantasy).

The fantasy that really turned me on was this, you know, heterosexualsadistic fantasy. I mean just really fucking the shit out of some girl andher being, you know, prostrate before my, you know, my massive oigan.

And uh, I described to you before how, you know, the idea of girls doingthings that are really, had a lot of indignity about them.

RE no. 5: Therapist.

Well, now I'm getting that same feeling that, you know, I'm sort of talking

about worthless shit. Because, and you know, my basis for thinking thatis the fact that you haven't said anything. Jeez, we go through this samenonsense every session, it's just amazing to me. I'm sort of ashamed thatmy mind isn't a little more creative, to think of different hassles. Youknow, it's sort of boring going through the same hassle four times a week,for what at this point seems like a timeless period.

For each example, possible responses by the therapist are in-

dicated by Gill and Hoffman (1982b) that illustrate the types of

inferences that their judges make, for example, after RE no. 5,

the therapist might have said, "Maybe you feel that I'm sitting

here enjoying my power over you while you are forced to go

through all kinds of contortions to gratify me."

These examples, although brief, do illustrate the PERT system.

This system does not provide a quantitative method for scoring

the inferences about the types of content of the PERT, although

the judge does write out inferences about the content and, at the

end, a summary account of the transference and of the therapist's

contribution to its explication.

Core Conjlictual Relationship Theme Method (CCRT)

Description of the method. This method (Luborsky, 1976) is

also a system to guide clinical judgment of the content of the

central relationship patterns in psychotherapy sessions. Although

the CCRT judges read the entire session, the primary data to be

scored are narrative episodes about relationships that patients

commonly tell during psychotherapy sessions. These are parts

of sessions in which the patient explicitly narrates experiences

in relationships. Typical narratives are about father, mother,

brothers, sisters, friends, bosses, and the therapist. These rela-

tionship episodes are identified by a separate set of independent

judges before the transcripts are given to the CCRT judges. A

minimum of 10 relationship episodes are usually used as a basis

for scoring the CCRT. The use of narratives as well as some of

the scoring categories bear a resemblance to the Thematic Ap-

perception Test (Murray, 1938).

The CCRT judge reads the relationship episodes in the tran-

script and identifies the types of each of the three components

within each episode: (a) the patient's main wishes, needs, or in-

tentions toward the other person in the narrative; (b) the responses

of the other person; and (c) the responses of the self. Within each

component the types with the highest frequency across all rela-

tionship episodes are identified; their combination constitutes

the CCRT.

The steps in the CCRT method represent a formalization of

the usual inference process of clinicians in formulating trans-

ference patterns. The clinician-judge first identifies the wishes

and responses to the wishes in each of the REs and from these

makes a preliminary CCRT formulation (Steps 1 and 2), and


then the same judge reidentifies and reformulates (Steps 1'

and!1):

Step 1. Identify the types of wishes (W) and responses (RO,

response from other; RS, response from self) in each relationship

episode (RE).

Step 2. Formulate a preliminary CCRT based on the frequency

of each of the types of each component.

Step 1'. Reidentify, where needed, the types of W, RO, and

RS based on the Step 2 preliminary CCRT.

Step 2'. Reformulate, where needed, based on the recount of

all Ws, ROs, and RSs in Step 1'.

It should be noted that the CCRT judges work independently

of each other. Judges are trained by first reading the CCRT man-

ual (Luborsky, 1983) and trying several standard practice cases,

receiving feedback from the research team about their perfor-

mance after each one. Although we have preferred to use ex-

perienced clinicians with a psychoanalytic orientation as judges,

some graduate students have also performed well as judges be-

cause the task does not require that the judge be committed to

a particular school of therapy. In fact, the CCRT may belong in

a family of related conceptualizations of relationship patterns,

which includes Tomkins's (1979) concept of a nuclear script,

Meichenbaum and Gilmore's (1984) concept of core organizing

principles, and other concepts reviewed by Singer (1984).

The simplest way to illustrate the CCRT scoring system as

well as its similarity and contrast with the PERT system is to

briefly apply the CCRT system in abbreviated form to the five

narratives from Gill and Hoffman (1982b) reproduced earlier

(see Table 1). As can be seen in the CCRT formulation at the

bottom of Table 1, the most frequent form of the wish component

in these five REs is to be free of obligations imposed by others

(in Step 2' each judge identified this wish in four of the five REs).

The most frequent RO is that the other person does not respond

to the wish. The most frequent RS is to feel hassled and to feel

compelled to give in.

Reliability of the CCRT (agreement among judges). Even in

the first trials of the CCRT method (Luborsky, 1977), consid-

erable agreement among judges was found. In Levine and Lu-

borsky (1981), 16 graduate psychology student judges individually

scored the CCRT for one patient (Mr. B.N.). When the scoring

of each of these judges was compared with composite scoring of

4 research judges (who also individually scored the CCRT), good

agreement was found (average correlation of .88). Furthermore,

agreement was shown by the method of mismatched cases:

Agreement was greater when the components to be compared

were drawn from the Mr. B.N. case itself rather than from two

other purposely mismatched cases.

A larger reliability study was carried out on eight patients

each scored by three independent judges (Luborsky, Crits-Chris-

toph, et al., 1985). Determining agreement involved the use of

Table 1

Comparison of Core Conjlictual Relationship Theme (CCRT) Components Selected by Two Judges

Component Judge I Judge 2

Relationship episode no. 1: GuyWishResponse from other

Response from self

Relationship episode no. 2: TherapistWishResponse from self

Relationship episode no. 3: WomanWish

Response from other

Response from self

Relationship episode 4: Some girl (fantasy)Wish

Response from other

Response from self

Relationship episode no. 5: TherapistWishResponse from otherResponse from self

CCRT formulation'Wish

Response from otherResponse from self

To be free of the unwanted visitor

He wouldn't understand; he would beinsulted

1 feel hassled, resentful, compelled to sufferhis presence

To be free of having to come to the sessionI didn't feel like coming but come anyway

To be free of the obligation to have toreach this woman

She can't be reachedI feel hassled

To have the girl under my sexualdomination

She is forced to submitSelf-blame

To be free of having to come for so longHe gives no response1 feel hassled and blame myself

To be free of being obligated and imposedon/4

Does not respond/3Feel hassled/3; compliance/3

To be respected for wanting to do my own thing

He interfered; he didn't respect me; he wouldn'tunderstand; he would be insulted

I feel hassled, resentful; I submitted to him

To not feel that I have to come to the sessionI feel compelled to come

To get in touch with her yet not to feel I have to

She doesn't respondI feel hassled; I feel relieved

To be sexually dominant

She submitsI am strong and overpowering

To not go through the "hassle" in therapyHe does not respondI feel worthless and ashamed

To feel free from obligations and the control ofothers/4

Does not respond/2Feel hassled/2; feel compelled to submit/2

1 Number after slash refers to the number of relationship episodes, within these five relationship episodes, that contain the theme component.


a second set of two judges who compared the CCRT formulations

of each of the three CCRT judges and were asked to indicate

whether the formulations were basically similar or different. For-

mulations were judged to be similar if the identical words or

words with similar meanings (e.g., anxious and afraid) were used

by the different CCRT judges. This task showed good interjudge

agreement (96%). We then calculated how often the three CCRT

judges came up with similar formulations across the eight cases.

The data revealed that on the wish component, the three CCRT

judges had similar formulations 75% of the time (6 out of 8);

two of the three judges had similar formulations 100% of the

time. For the negative RO, 63% of the time the three judges arrived

at similar formulations, whereas two out of three judges arrived

at similar formulations 88% of the time. For the negative RS,

the three judges reached similar formulations 38% of the time,

whereas two of the three reached similar formulations 88% of

the time. We should emphasize that for good reliability to be

achieved, judges should be well-trained in the use of the method

(by following the manual and comparing their work with our set

of practice cases).

Correspondence of the CCRT with Freud's observations of

transference. One way to examine the usefulness of the CCRT

as a measure of transference is to compare its results with nine

observations Freud (1912/1966) made about transference. The

basis for much of this novel comparison is a study (Luborsky,

Crits-Christoph, et al., 1985; Luborsky, Mellon, et al., 1985) of

eight patients' psychotherapy sessions. Each patient's CCRT was

scored independently twice: by three judges on a minimum of

10 REs drawn from two sessions early in treatment and by three

different judges on 10 REs from two sessions late in treatment

(about 1 year later). Each of the following sections takes up one

of Freud's nine observations in terms of the relevant CCRT re-

sults.

1. Number of transference patterns. Freud (1912/1966) stated

that each patient has one transference pattern, "(or several such)"

(p. 100). Thus he thought there was one main pattern, but his

parenthetical addition shows he was not sure. The CCRT results

for the early sessions of the eight patients correspond with his

initial impression: There is one main theme, but often a lesser

frequency theme is apparent as well. Averaging across the eight

patients, the main wish was judged to be present in 80% of each

patient's REs, whereas a secondary wish was present, on the

average, in only 16% of each patient's REs (Luborsky, Crits-

Christoph, et al., 1985).

2. Uniqueness of transference patterns. Another observation

of Freud (1912/1966, p. 99) was that each patient has a special

form of transference pattern. The CCRT results are consistent

with this observation. Some of the main wishes from our sample

include to be strong, free, and independent; to be close to and

open to others; to be responsible and in control; to be seen and

treated as a special person; and to be assertive and not acquiesce

to authority. Although some degree of similarity was observed

among the wish component of different patients, examination

of the response components as well reveals a relatively distinct

pattern for each patient (Luborsky, Mellon, et al., 1985).

3. Erotic basis of transference pattern. Freud (1912/1966, p.

99) stated that the pattern applies to the "conduct of his [or her]

erotic life"—the pattern that becomes the transference pattern

begins in the child's early years, governs the conduct of the erotic

life and then generalizes to every new person. One implication

of these views (from Luborsky, Crits-Christoph, et al., 1985) will

be examined here as an illustration.

Independent judges rated the degree to which each of the REs

dealt with explicitly erotic versus explicitly nonerotic interactions.

The CCRT was derived for each group of REs. We then had a

second set of judges rate paired comparisons of the two categories

of the CCRTs to establish their degree of similarity. The results

indicated a fair degree of similarity (mean similarity of 4.78 on

a 7-point scale where 1 = completely different and 7 = completely

identical). This finding implies that the erotic relationships do

express a version of the CCRT that is similar to the CCRT from

the nonerotic relationships.

4. Awareness of the transference pattern. Freud (1912/1966,

p. 100) observed that the transference pattern is composed of a

portion that is kept out of awareness and a portion that is in

awareness. Our initial attempt at the development of a measure

(Crits-Christoph & Luborsky, 1984) relied on guided clinical

judgments of the extent to which the patient was aware of the

CCRT pattern that was derived from a given session. Results

indicated (Crits-Christoph & Luborsky, 1984) that a patient's

level of awareness of the CCRT varied considerably from session

to session and that there was usually at least one part of the

CCRT that was judged to be not in awareness.

5. Consistency of transference pattern aver time. Freud

(1912/1966, p. 100) believed that the pattern "is constantly re-

peated—constantly reprinted afresh—in the course of the per-

son's life." Luborsky, Crits-Christoph, et al. (1985) compared

CCRTs scored from sessions early in treatment with the same

patient's CCRTs scored from sessions late in treatment, approx-

imately 1 year later. Considerable consistency over time was

found: The average similarity on a 1 to 7 scale (1 = not similar,

1 = completely identical) of early and late CCRTs for each patient

was 5.7. This is in comparison to a mean similarity of 4.0 for

early CCRTs of each patient paired with late CCRTs of different

patients.

6. Change in the transference pattern. On this topic Freud

(1912/1966, p. 100) stated, "It is certainly not entirely insus-

ceptible to change." The wording of the observation implies that

Freud (1912/1966) considered the pattern to have considerable

stability as well as some latitude for change. The CCRT results

correspond with this observation (Luborsky, Crits-Christoph, et

al., 1985). For the eight patients, we examined the change from

early sessions to late-in-treatment sessions of the percentage of

REs in which the CCRT was present. For example, for early

sessions, the average percentage of REs that contained the main

positive response from others category was 10.0%. This increased

to an average of 17.3% in later sessions. The amount of change

in the CCRT, however, varied depending on whether the patient

improved in treatment (see the Validity: CCRT improvement

versus standard improvement measures section).

7. Transference pattern in relation to the therapist. Freud

(1912/1966, p. 100) observed that the therapist becomes "at-

tached to" one of the "stereotype plates." His words mean that

the relationship with the therapist in the course of the treatment

becomes like the general transference pattern, that is, the stereo-

type plate. This hypothesis was tested (Luborsky, Crits-Christoph,

et al., 1985) by deriving CCRT formulations separately for REs

involving the therapist and for those involving other people (i.e.,


not the therapist). Judges blindly rated the similarity of the ther-

apist CCRT to the other people CCRT for each patient and, for

comparison purposes, also rated the similarity of the therapist

CCRT of each patient to the other people CCRTs of the seven

other patients in the study. The correct pairings of therapist

CCRTs with other people CCRTs were given an average similarity

rating of 6.5 on a 7-point scale (7 = completely identical) whereas

the incorrect pairs (i.e., therapist CCRT for one patient matched

with an other people CCRT of another patient) were given a

lower average similarity rating (4.6). These results constitute the

first quantitative confirmation of the existence of a parallel, based

on psychotherapy sessions, of the patient's experience of the re-

lationship with the therapist and the patient's experience of re-

lationships with other people.

S. Early origins of the transference pattern. In Freud's (1912/

1966, p. 99) view, the transference pattern derives from the

"combined operation of his [or her] innate disposition with the

influences brought to bear on him [or her] during his [or her]

early years." This observation implies that there should be a

parallel between the relationship pattern with the therapist and

the one with the early parental figures. The term transference

seemed fitting to Freud (1912/1966) because it was a central part

of his concept that attitudes and behavior developed in the re-

lationships to the early parental figures were transferred to other

relationships.

Luborsky, Crits-Christoph, et al. (1985) compared CCRTs

scored from REs involving a memory of an interaction with

early parental figures versus the overall CCRT scored from all

other REs. A high degree of similarity was evident (mean rating

on a 7-point scale = 6.4) for early memory of parent CCRTs

paired with the same patient's overall CCRT. When the early

memory of parent CCRT for each patient was matched with

overall CCRTs from other patients, less similarity was evident

(mean similarity = 3.6).

The accuracy of recall by the patient of the early parental

relationships, however, presents potential problems for data de-

rived from psychotherapy alone. One way to deal with this lim-

itation is to examine those rare patients in psychotherapy for

whom early observational data are also available.

9. Transference inside versus outside of the treatment setting.

Freud (1912/1966, p. 101) stated, "It is not a fact that transference

emerges with greater intensity and lack of restraint during psy-

choanalysis than outside it" Through this statement Freud af-

firmed that transference is evident both inside and outside of the

analysis. Using the CCRT method, the first study of this obser-

vation is under way (van Ravenswaay, Luborsky, & Childress,

1983). To evaluate the transference pattern from data obtained

outside of the psychotherapy, a method was constructed called

the Relationship Anecdotes Paradigm (RAP) Test (Luborsky,

1978). It is a specially designed interview in which the person is

asked to tell relationship anecdotes about specific other people.

We have found so far on six patients that there is considerable

consistency in the CCRT derived from narratives within treat-

ment sessions with the CCRT derived from outside-of-treatment

narratives, a finding consistent with Freud's observation about

the generality of transference. The inside and the outside sources

both reveal virtually the same wish as well as many of the same

responses from the other person and responses from the self. The

parallel implies that the transference pattern is expressed in

treatment but exists outside of therapy as well.

In summary, there is much concordance between Freud's nine

observations about transference and data from the CCRT mea-

sure. For each of Freud's observations for which an operational

proposition was readily derivable—six out of nine by conservative

count—the CCRT data provided results consistent with the ob-

servations. This implies some usefulness for the CCRT measure

as a measure of the transference concept.

Validity: CCRT improvement versus standard improvement

measures. One way to assess the validity of the CCRT is to

relate it to other measures. Using data from the study of eight

patients (Luborsky, Mellon, et al., 1985), we hypothesized that

change in the CCRT from early to late in treatment should be

related to independent measures of the outcome of treatment.

The measure of change in CCRT was the difference score between

the early treatment pervasiveness of each CCRT component (i.e.,

the percentages of relationship episodes that contained each main

wish, negative RS, negative RO, positive RS, and positive RO)

and the late-in-treatment pervasiveness of the same CCRT com-

ponents. Two independent outcome measures were selected as

criteria, one from the perspective of the patient, the Hopkins

Symptom Checklist total score, and one from the perspective of

an external clinical judge, the Health-Sickness Rating Scale (Lu-

borsky, 1975). Both measures were obtained at the beginning of

treatment and at termination in the Penn Psychotherapy Project

(Luborsky et al., 1980). Change in the pervasiveness of the main

negative RS was significantly correlated with change in Health-

Sickness Rating Scale, r(6) = -.81, p < .05, as was change on

the main wish, r(6) = -.73, p < .05. Change in the main positive

RO was significantly correlated with change on the Hopkins

Symptom Checklist, r(6) = -.79, p < .05. The direction of all

of these correlations was as expected, that is, increase in the

frequency of positive components or decrease in negative com-

ponents of the CCRT was associated with more favorable out-

comes. A study by Baguet, Gerin, Sali, and Marie-Cardine (1984)

has also shown a relation of change on the CCRT to change on

the Health-Sickness Rating Scale.

Another kind of validity also has been explored: validity de-

fined as meaningful relation of the CCRT to other phenomena.

The core content of what is forgotten during momentary for-

getting in psychotherapy is similar to the CCRT content (Lu-

borsky, in press).

Comparison of the CCRT method with other methods. The

PERT measure (Gill & Hoffman, 1982b) is the best known similar

measure; the actual consistency of the PERT and CCRT methods

is under investigation (Kaechele, Thomae, & Luborsky, 1983).

The Plan Diagnosis Method (Weiss & Sampson, in press) may

also be a similar measure, although its authors do not explicitly

describe it as a measure of transference. It involves a clinical

description of four components: the patient's goals for therapy,

the inner obstacles (pathogenic beliefs) preventing the patient

from reaching the goals, the tests in the treatment through which

the patient confirms or disconfirms the obstacles, and the insights

that will be helpful. The clinical description of each component

is reduced to a list of brief statements. In a reliability study

(Rosenberg, Silberschatz, Curtis, Sampson, & Weiss, 1983), the

list was expanded to include statements that were not relevant

to the particular patient, just as was done in the method of mis-

matched cases (Levine & Luborsky, 1981). An independent team

was able to reliably differentiate case-relevant versus case-irrel-

evant statements.


The Dynamic Focus Method (Schacht & Binder, 1982) pro-

vides guidelines for formulating the treatment focus of the ther-

apist's interventions. This system has four components called

(a) acts of self, (b) expectations of others, (c) consequent acts of

others toward self, and (d) consequent acts of self toward self.

These four components appear to be similar to the three com-

ponents in the CCRT. Acts of self, for example, include the wishes.

The expectations of others and consequent acts of others toward

self are both included in the RO in the CCRT system. Consequent

acts of self toward self are essentially the same as the RS in the

CCRT system.

Teller and Dan! (1981) are developing a language-based (and

eventually computer-assisted) data analysis system for psycho-

therapy sessions. They demonstrated the principle that even

within a single session with only a few frames, that is, recurrent

structures within relationship episodes, one can tap into basic

underlying relationship schemata.

Another promising method that may capture transference

phenomena is configurational analysis (M. Horowitz, 1979). In

this method, the data from process notes and transcripts of ses-

sions are examined from three points of view: state, relationship,

and information. Of the three, the system for the analysis of the

relationship is most like that of the CCRT. Evidence for reliability

for the state analysis is provided (M. Horowitz, 1979).

Benefits of Transference Interpretations

Much of the research interest in fashioning measures of the

transference arose because the theory of the curative action of

psychoanalytic psychotherapy stresses that the therapist's inter-

ventions should deal with the transference. Nevertheless, only a

few studies, noted next, have tried to measure the beneficial im-

pact of therapist's interpretations.

The Menninger Foundation Psychotherapy Project (Kernberg

et al., 1972) suggested that when the focus on transference is

high, patients diagnosed as borderline psychotic and treated by

skillful therapists improve significantly more. Malan's study

(1976) found a trend for the more successfully treated patients

to be those for whom an emphasis was placed on interpretations

dealing with transference in relation to parents and therapists.

Because Malan's data consisted of only the therapists' process

notes, Marziali (1984) replicated his work by using recordings

of 26 patients. The frequency of interpretations with therapist-

parent links and therapist-parent-other links correlated signif-

icantly with several of the outcome scales as well as with the sum

of five psychodynamic scales (e.g., the therapist-parent and ther-

apist-parent-other measures both correlated .57, p < .01, with

the sum score).

In Crisp's work (1964a, 1964b, 1966) it was found that atti-

tudes toward the therapist often change along with or before

changes in the patient's symptoms. The implication is that the

understanding (probably aided by the therapist's interventions)

precedes symptom change.

The earliest precise analysis of the immediate effects of trans-

ference interpretations within psychodynamic psychotherapy

sessions was by Garduk and Haggard (1972). They compared

the immediate effects during the 5 min after transference inter-

pretations versus after noninterpretations for four cases. Inter-

pretations were shown to elicit more defensive associations, more

transference-related material, more understanding, and more af-

fect than were noninterpretations.

Individual differences among patients in response to transfer-

ence interpretations are impressive. In a study (Luborsky, Bach-

rach, Graff, Pulver, & Christoph, 1979) of three patients selected

to represent a range of outcomes, 16 interpretations were chosen

for each patient. These were reliably rated by independent judges

for 250 word units before and after each interpretation. For each

patient there was a clear parallel among positivity of the im-

mediate response to interpretations, the helping alliance, and the

outcome of treatment.

Each of the new measures of transference has been presented

as a guide to the therapist in formulating and responding in-

terpretively. The categories of the PERT measure are set up in

terms of Gill's (1982) and Gill and Hoflman's (1982b) belief in

the importance of therapist responding interpretively to indi-

cations of PERT. In the CCRT measure, the principles for for-

mulating the CCRT and deciding on the best response based on

this formulation are explicated in Luborsky (1984) for both the

CCRT method and a simplified clinical version that can be used

in everyday practice. Similarly, Silberschatz (1984) reported using

the Plan Diagnosis Method as a guidance system for judges. A

significant correlation was obtained between the judges' rating

of consistency of the therapist's response to the Plan Diagnosis

Method with the immediate and long-term benefits to the patient.

Methodological Issues in the Measurement of

Transference

Research on such a complex concept as transference presents

challenging methodological problems for investigators attempting

to develop a reliable and valid measure. One research issue con-

cerns the choice of the data base on which to score a transference

measure. The use of psychotherapy transcripts and recordings

is warranted not only because these are the data from which the

concept was originally generated but also because psychotherapy

provides a real-life enactment of the transference with the ther-

apist that others can observe. Disadvantages of using material

from psychotherapy sessions are the large amount of time needed

for transcription and the intricate process of reviewing the tran-

scripts to arrive at formulations or to make ratings. Although

questionnaire methods save research time, the validity of such

measures needs to be demonstrated.

Decisions about the data base do not stop with the use of

psychotherapy sessions. It is necessary to identify a scorable unit

so that judges can concentrate their efforts on relevant material.

The Schacht and Binder (1982) Dynamic Focus Method uses

patient utterances (a single, uninterrupted turn at talk) as the

unit of scoring. For the CCRT method, a procedure of delineating

relationship episodes has been adopted. The assumption is that

transference patterns will be evident in many of them. However,

it will be important to determine the extent to which a set of

such units is representative for a patient and whether there are

differences in adequacy of the units that affect the scoring. In

order to mitigate some of these problems, Schacht and Binder

(1982) developed a special interview to elicit more relevant ut-

terences to score.

Measures that involve determining a clinical formulation (e.g.,

CCRT, Plan Diagnosis, and Dynamic Focus) require a meth-

odological decision on guided versus unguided clinical judgment

In the unguided approach, the clinician is free to choose any

principle and any level of abstraction for his or her formulations.

The guided approach, in contrast, specifies some principles and


some of the levels of abstraction in advance. Holt (1978) reviewed

guided versus unguided clinical judgments and concluded that

guided approaches yield greater reliability and validity. For

transference, attempts to use unguided judgments have given

ambiguous results (e.g., Seitz. 1966). The more recent measures

all provide some degree of guidance to the judge.

Even with a guided clinical method the problem of variability

in wording and amount of detail in each judge's formulations

still exists. This variability is especially true of ideographic meth-

ods, such as the CCRT, because these allow for unique descrip-

tions of each case. The CCRT method minimizes variability in

wording across judges by encouraging the judges to stay close to

the wording used in the transcripts, by keeping the level of in-

ferences to moderately clearly inferable ones, and by extracting

only the redundant themes across many REs.

The nomothetic approach escapes the problem of variability

in wording by asking judges to fit formulations into preset cat-

egories. For example, the Schacht and Binder (1982) Dynamic

Focus Method requires judges to code formulations into the cat-

egories provided by the "Structual Analysis of Social Behavior"

(Benjamin, 1974). Although the idiographic approach is closer

to the process of making transference formulations in clinical

practice, the use of preset categories provides many clear benefits

to the researcher. These include the likely higher reliability and

ease of application and quantification compared with free-form

patient-specific categories. The noncomparable data from free-

form methods make statistical evaluation difficult. Whether the

gains of preset categories offset the loss of uniqueness in descrip-

tion of each case remains a question for future research.

Further assessment of the validity of the new measures of

transference is needed. In terms of discriminant validity, it must

be demonstrated that these measures provide information beyond

that given by general personality measures (e.g., the Inventory

of Interpersonal Problems; L. Horowitz, Weckler, & Doren, 1983)

and diagnostic assessment systems (e.g., the Schedule for Affective

Disorders and Schizophrenia; Endicott & Spitzer, 1978). Other

kinds of validity questions must also be raised: What types of

criteria should transference measures be expected to predict?

How should such relationships be assessed? How do measures

derived from narratives told in psychotherapy relate to obser-

vations of interpersonal interactions? These questions are now

being addressed, but further work is needed.

In conclusion, the oldest line of quantitative research based

on questionnaire methods did not gain much acceptance. Only

within the last 10 years have measures been based on psycho-

therapy sessions. It is time now to move ahead with further de-

velopment of these methods, as well as to examine how the earlier

questionnaire and the newer session methods are interrelated.

In the event that the two approaches agree, we will have to ac-

knowledge that the advent of objective transference measures

was much earlier than was recognized in the last review of the

field (Luborsky & Spence, 1978).

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Revision received May 13, 1985 •

advent of objective measures of the transference concept

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