Core transference themes in depression

Journal of Affective Disorders 91 (2006) 71 – 75 www.elsevier.com/locate/jad

Brief report

Core transference themes in depression Stijn Vanheule a,⁎, Mattias Desmet a , Yves Rosseel b , Reitske Meganck a a

Ghent University, Department of Psychoanalysis and Clinical Consulting, H. Dunantlaan 2, B-9000 Ghent, Belgium b Department of Data-analysis, Ghent University, Belgium Received 18 April 2005; received in revised form 7 December 2005; accepted 9 December 2005 Available online 19 January 2006

Abstract Background: Psychodynamic and psychoanalytic theories assume that depression is concomitant with typical transference patterns. We tested whether depression can indeed be understood in these terms, and determined a parsimonious set of transference themes that are most typical of depression. Method: Transference patterns were assessed with the Core Conflictual Relationship Theme (CCRT) method, which examines transference patterns (wishes, responses of the other, and responses of the self), and which was applied to clinical interview data from mental health outpatients. Depression was assessed with the Beck Depression Inventory-II. Data were analyzed by means of the leaps and bounds regression algorithm and bootstrapping. Results: Depression can significantly be explained by typical wishes, typical subjective perceptions of how the other responds, and typical responses of the self to the other. We mapped a set of four transference themes that are most representative of depression: (1) a strong wish to feel happy guides interactions, (2) the perception that others dislike one is typical, (3) one's own reactions of disliking others are apparent, and (4) one experiences feelings of helplessness. Limitations: No control group was used. The limited amount of research in the field and the various methodological approaches in different studies make it difficult to compare our findings. Conclusion: Linking depression to transference patterns is valid. The set of transference themes that were selected cohere in a meaningful way. These themes can be expected when clinically treating depressed patients. © 2005 Elsevier B.V. All rights reserved. Keywords: Depression; Psychodynamic; Transference; Psychopathology

1. Introduction A general assumption underlying psychodynamic and psychoanalytic approaches to psychopathology is that disorders like depression are concomitant with a typical way of relating to and handling conflict with others. This idea is reflected in the transference concept, which refers to a whole pattern of expectations and reactions that is actualized the moment people interact ⁎ Corresponding author. Tel.: +32 9 264 91 01; fax: +32 9 264 64 88. E-mail address: [email protected] (S. Vanheule). 0165-0327/$ - see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2005.12.012

(Blatt, 2004; Busch et al., 2004; Verhaeghe, 2004). Although many authors have reflected on the issue of transference in depression, systematic research into this topic is thus far limited (Saketopoulou, 1999). In this article we empirically examine transference patterns that are typical for depression. In mapping these patterns we use the Core Conflictual Relationships Theme (CCRT) method (Luborsky and Crits-Christoph, 1998). This method was designed to measure the psychoanalytic transference construct in its modern interpersonal interpretation, and provides an operational, clinically valid, and reliable measure of the central

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relationship patterns that pervade self–other interactions. It provides a detailed map of the wishes and intentions that are prevalent in people's interactions (Ws), their subjective perceptions of how the other responds in relation to them (ROs), and their own typical responses to the other (RSs). CCRT research is not only relevant for either validating or falsifying the psychoanalytic transference construct, but is more broadly applicable for the field of affective disorders, as it can contribute to our understanding of the interpersonal aspect of these disorders. The advantages of the method are its comprehensive assessment and its unique stress on Ws, ROs, and RSs. We consider the CCRT method complementary to other methods for assessing interpersonal functioning. The CCRT method has previously been applied to depression, but this did not yield coherent results. At the level of the Ws, both negative and destructive wishes (e.g., being oppositional) and more positive wishes (e.g., wanting to feel trusting) have been observed (Demorest et al., 1999). Other typical wishes that have been observed are: wanting to be open to others, to be close to others, and to be understood (Deserno et al., 1998). At the level of the ROs, perceiving others as ignoring and neglecting (Demorest et al., 1999), controlling and dominating (Deserno et al., 1998), but also as understanding (Demorest et al., 1999), have been found. At the level of the RSs, helplessness (Deserno et al., 1998), positioning oneself as unreceptive (Wilczek et al., 2000), and feeling trusted have been observed to be common to depression. These disparate results might be due to different methodological approaches (coding systems, data-analytic strategies, research designs) in the various studies, and we conclude that further evaluation is needed. In this paper we first describe our study of whether statistically significant sets of Ws, ROs, and RSs are linked to depression and we hypothesize that this is the case. Second, we determine through exploration a parsimonious set of core indicators and discuss the coherence among these indicators. 2. Method 2.1. Subjects The subjects for this study were 31 mental health outpatients, randomly selected from the sample of a broader research project (n = 404). Of the participants, 19 were female, 25 were married or living with a partner, 17 used psychoactive drugs, and the mean age was 42.7 (SD = 7.5). The participants had DSM diagnoses of

mood disorder (n = 12), depressive disorder (n = 9), dysthymic disorder (n = 3), anxiety disorder (n = 8), somatoform disorder (n = 2), eating disorder (n = 1), adjustment disorder (n = 2), impulse-control disorder (n = 1), and relational problems (n = 3). Diagnosis was deferred for 3 patients. All DSM-IV diagnoses were given by the psychiatrists. 2.2. Instruments and methods Depression was measured by means of the Dutch version of the Beck Depression Inventory-II (M = 26.6; SD = 15.0). Relationship patterns were assessed by means of the CCRT method (Luborsky and Crits-Christoph, 1998). The raw materials were narratives collected during semi-structured interviews (average duration: 2 h). Whenever participants started talking about interpersonal events during the interview, we implemented the technique used in the Relationship Anecdotes Paradigm Interview (Luborsky and Crits-Christoph, 1998; Waldinger et al., 2003). Within the narratives, relationship episodes (REs) were selected. These are relatively discrete episodes in which a person talks about himself and his relationships with others. In each episode, Ws, ROs, and RSs were coded. Two CCRT-trained researchers were engaged in extracting and coding the REs. First they coded REs separately, and then met to obtain consensus codes. Weighted Kappa coefficients of agreement indicated acceptable correspondence for the initial codes (Ws: .67, ROs: .69, RSs: .69) (Altman, 1991). CCRT coding started from the CCRT expanded categories system (Luborsky and Crits-Christoph, 1998). Within this standardized coding system, 35 Ws, 30 ROs, and 31 RSs are coded. Four tailor-made categories were added: the Ws “to be believed” and “to be treated fairly” and the RSs “passivity” and “selfdestruction.” 2.3. Data analysis In analyzing the data we made use of the leaps and bounds regression algorithm for selecting optimal subsets of indicators (Furnival and Wilson, 1974; Volinsky et al., 1997), and of bootstrapping. The algorithm evaluates all possible subsets of a predefined magnitude from a set of indicators, and it selects the best subsets in terms of their power to explain variance (adjusted R2). Each time we asked for 12 models: the 4 most powerful with 1, 2, and 3 indicators, respectively. A model was judged significant if all individual indicators were significant. The significance of the

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individual indicators was checked by means of 95% confidence intervals (95% CI) that were estimated based on 10,000 bootstrap samples from our data (DiCiccio and Efron, 1996). All analyses started from a mean REscore for each subject. 3. Results The first question can be answered positively. Statistically significant sets of Ws, ROs, and RSs could be discerned: 5 sets of Ws, 7 sets of ROs, and 7 sets of RSs. Depending on the number of indicators, the adjusted R2 values of these sets ranged between .21 and .48 (see Tables 1–3). Second, we determined a parsimonious set of core indicators for our dependent variable. At the level of the Ws, W32 (“to feel happy”) returned most consistently (5 times), each time as a significant and positive indicator. The second most prevailing wish, W1 (“to be understood”), returned 3 times (significant negative indicator). RO10 (“dislike me”) was the most prevalent RO. It returned 5 times (significant positive indicator). The next most prevailing ROs were RO25 (“are bad”), returned 4 times (significant positive indicator); RO8 (“are not trustworthy”), returned 3 times (significant positive indicator); and RO4 (“are rejecting”), returned 2 times (significant positive indicator). At the level of the RSs, 2 indicators prevailed: RS6 (“dislike others”) and RS17 (“am helpless”). RS6 returned 8 times (significant positive indicator) and RS17 6 times (significant positive indicator). We concluded that depression can meaningfully be understood in the light of 4 core indicators (all positively associated to depression): W32, RO10, RS6, and RS17.

Table 1 Regression models with 1, 2, or 3 wishes that are most strongly linked to depression Model

Adjusted R2

Indicators (95% CI)

1: W32⁎

.27

2: W7⁎

.21

3: W13

.14

4: W8

.12

5: W1 W32⁎

.36

6: W32 W37

.36

7: W26 W37

.32

8: W11 W32

.31

9: W7 W26 W37

.45

10: W13 W1 W26⁎

.45

11: W13 W1 W32

.44

12: W11 W33 W26⁎

.43

+W32⁎ (9.25/28.11) +W7⁎ (3.80/14.61) +W13 (−.94/15.85) +W8 (−3.11/20.83) −W1⁎ (−13.92/−1.66) +W32⁎ (10.89/28.59) +W32⁎ (8.64/29.19) +W37 (−.45/8.65) +W26 (−1.84/20.93) +W37⁎ (1.14/12.03) −W11 (−9.19/.21) +W32⁎ (12.99/31.28) +W7⁎ (4.09/13.64) +W26 (−1.06/19.03) +W37⁎ (.93/10.89) +W13⁎ (2.00/17.69) −W1⁎ (−17.75/−2.57) +W26⁎ (3.39/16.36) +W13 (−.22/16.05) −W1⁎ (−16.22/−3.06) +W32⁎ (5.36/26.21) −W11⁎ (−15.83/−5.02) +W33⁎ (7.51/19.66) +W26⁎ (2.06/18.00)

4. Discussion We hypothesized that depression can meaningfully be explained by CCRT categories. By examining transference patterns that are typical for depression we observed that this was the case. The more severe a patient's depression, the more probable it is that specific transference themes effectively emerge. Our next step was to map themes that could be considered core indicators. Four indicators were selected: the wish to feel happy, the perception that others dislike one, the self's reactions of disliking others, and feelings of helplessness. The wish to feel happy (the longing to be self-sufficient and satisfied) is the desire that guides the interaction. Theoretically, it makes sense that this desire emerges as distinctive – it is narcissistic – but in previous CCRT studies it was never selected. The

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⁎P b.05. W1: “to be understood.” W7: “to be liked.” W8: “to be opened up to.” W11: “to be close to others.” W13: “to be helped.” W26: “to be good.” W32: “to feel happy.” W33: “to be loved.” W37: “to be treated fairly.”

perception of others as disliking one is at odds with this core wish. Demorest and colleagues (1999) and Deserno and associates (1998) observed similar perceptions of

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Table 2 Regression models with 1, 2, or 3 responses of the other that are most strongly linked to depression

Table 3 Regression models with 1, 2, or 3 responses of the self that are most strongly linked to depression

Model

Adjusted R2

Indicators (95% CI)

Model

Adjusted R2

Indicators (95% CI)

1: RO25⁎

.36

RS6⁎

.39

2: RO10⁎

.30

RS17⁎

.28

3: RO4⁎

.25

RS23⁎

.27

4: RO8⁎

.21

RS25⁎

.22

5: RO25 RO17⁎

.41

RS6 RS17⁎

.48

6: RO29 RO10

.41

RS6 RS27⁎

.45

7: RO25 RO14

.39

RS6 RS23⁎

.43

8: RO25 RO18

.39

RS6 RS25

.42

9: RO29 RO10 RO18

.51

RS6 RS12 RS17

.58

10: RO20 RO8 RO10⁎

.48

RS6 RS18 RS17

.55

11: RO20 RO8 RO4⁎

.48

RS5 RS14 RS17

.52

12: RO24 RO29 RO10

.48

+RO25⁎ (5.05/12.20) +RO10⁎ (6.22/14.72) +RO4⁎ (3.64/11.33) +RO8⁎ (2.69/1.78) +RO25⁎ (4.69/12.71) +RO17⁎ (.48/12.94) +RO29 (NA) +RO10⁎ (7.45/15.62) +RO25⁎ (3.65/12.03) +RO14 (− .57/9.37) +RO25⁎ (4.24/11.38) +RO18 (NA) +RO29 (NA) +RO10⁎ (6.02/14.46) −RO18 (NA) +RO20⁎ (.80/9.99) +RO8⁎ (1.45/14.48) +RO10⁎ (3.50/12.12) +RO20⁎ (.58/9.06) +RO8⁎ (2.29/14.81) +RO4⁎ (2.72/8.41) −RO24 (− 37.85/2.80) +RO29 (NA) +RO10⁎ (7.00/15.87)

RS6 RS14 RS17

.52

+RS6⁎ (5.67/13.77) +RS17⁎ (2.54/10.27) +RS23⁎ (3.19/10.93) +RS25⁎ (3.96/16.47) +RS6⁎ (3.58/11.15) +RS17⁎ (.44/6.72) +RS6⁎ (5.17/13.93) +RS27⁎ (.91/7.58) +RS6⁎ (3.33/12.48) +RS23⁎ (.06/7.36) +RS6⁎ (2.42/12.49) +RS25 (− 2.76/12.21) +RS6⁎ (4.23/11.91) +RS12 (− .46/17.83) +RS17⁎ (3.71/8.97) +RS6⁎ (3.92/11.68) +RS18 (− 1.37/12.39) +RS17⁎ (2.88/9.82) −RS5 (NA) +RS14 (NA) +RS17⁎ (3.34/9.66) +RS6⁎ (3.19/11.18) +RS14 (− 6.52/45.06) +RS17⁎ (2.73/7.46)

⁎P b. 05. “NA”: confidence intervals could not be reliably determined. RO4: “are rejecting.” RO8: “are not trustworthy.” RO10: “dislike me.” RO14: “are unhelpful.” RO17: “oppose me.” RO18: “are cooperative.” RO20: “are controlling.” RO24: “are strong.” RO25: “are bad.” RO29: “are happy.”

⁎P b.05. “NA”: confidence intervals could not be reliably determined. RS5: “like others.” RS6: “dislike others.” RS12: “am controlling.” RS14: “am self-controlled.” RS17: “am helpless.” RS18: “feel selfconfident.” RS23: “feel unloved.” RS25: “feel guilty.” RS27: “feel anxious.”

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others. The subsequent reactions of the self to the situation thus created are twofold, and consist of both disliking the other and of feeling helpless, attitudes that have previously been observed in other studies (Deserno et al., 1998; Wilczek et al., 2000). We concluded that helplessness and disliking others constitute a basic strategy in depression for dealing with situations in which the other is experienced as hostile in relation to one's own narcissistic wishes. This is a typical transference dynamic that can be expected when clinically treating patients with depression. Although a significant and meaningful result was obtained in this study, further exploration of the topic is necessary. Subsequent studies should evaluate whether distinctive transference themes consistently return in different types of populations (e.g., inpatients vs. outpatients), and should compare these results to control groups. We also suggest that future CCRT studies attentively reflect on methodological issues. Whether a single standard coding scheme can be developed and whether a univocal data-analytic strategy can be selected are subjects that require more study. The technique we applied is promising, as it is especially well suited for analyzing data in which a large number of independent variables are taken into account for a limited number of subjects, and in which the dependent variable is continuous. References Altman, D.G., 1991. Practical Statistics for Medical Research. Chapman and Hall, London. Blatt, S.J., 2004. Experiences of Depression. American Psychological Association, Washington, DC.

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