The purpose of this study was to explore how personal therapy influences experienced psychodynamic psychotherapists’ ways of being clinicians, and, by implication, their professional development. A hermeneutic research method, which also drew upon aspects of grounded theory methodology, was therefore devised to explore and examine how personal therapy and professional practice relate to each other and to the therapist’s development, and to deepen this descriptive account into a more differentiated and theoretically viable understanding. In-depth, semi-structured interviews were conducted with eight psychodynamic psychotherapists who were working as clinicians and who were concurrently in therapy. Keeping the research objective in mind, a list of questions was developed from the interview material through which the data was re-read and edited. In accordance with the aims of the study, and as suggested by the results of the initial phase of the textual analysis, intersubjective theory, mainly that of Jessica Benjamin, was used to generate a conceptual framework through which the interview material was further interpreted. This foregrounded the shifting power distributions and the varying processes of identification between the treating therapists and the participants. The Jungian notion of the wounded healer was intersubjectively reconfigured as indicating a therapist whose (often unacknowledged) needs and vulnerabilities engender a proclivity to relate to patients as objects rather than subjects. The participants could all be described as having started out their professional lives as wounded healers. The effects of personal therapy on their clinical work were conceptualised in terms of increased abilities for subject-to-subject relating. These were linked to augmented capacities for reflective and symbolic thinking and an enhanced openness to the implicit, unformulated and opaque aspects of experiences in the therapeutic space. Finally an intersubjective model of personal therapy and development as a therapist was generated. It was concluded that because of the focus on the therapeutic relationship as the vehicle for change in psychodynamic psychotherapy, as well as the current increasing emphasis on the use of the therapist’s subjectivity, the therapist’s capacity to engage in and sustain subject-tosubject relating and, by implication, the therapist’s personal therapy, are of pivotal importance for all therapists doing the work of psychodynamic psychotherapy.

Abstract: Aim: There is limited understanding of therapeutic relationships in community occupational therapy from a psychodynamic perspective. I explored community occupational therapists’ lived experiences of therapeutic relationships with special attention to countertransference. Methods: Interpretive and descriptive phenomenology was used. Eight occupational therapists with experience providing occupational therapy to people in their homes completed two qualitative interviews. Epoche and reduction analysis methods were applied during the thematic analysis and phenomenological writing phases of the study. Findings: Themes related to the therapeutic relationship illuminated tensions therapists experienced between 1) the need to obtain “buy-in” from clients and insecurity regarding their expertise and the potential effectiveness of occupational therapy; 2) self-disclosure and self-protection, and 3) “planting the seed” and feeling responsible for immediate therapeutic outcomes. Therapists voiced difficulty understanding the concept of countertransference but were able to provide powerful examples. They experienced objective, subjective, positive, and negative countertransference. Themes included: 1) fear: experiencing physical vulnerability; 2) sadness: experiencing emotional vulnerability; and 3) frustration: experiencing social vulnerability, all of which impacted therapists’ conscious and unconscious behaviours. Discussion: When reflected upon, countertransference appeared to be a powerful source of information during therapeutic clinical reasoning. It informed the therapists’ use of therapeutic skills including boundary setting, self-disclosure, compassion, empathy, and containment in a diverse array of therapeutic relationships. Significance: Occupational therapy may benefit from a more transparent discussion and acceptance of the emotional dimensions of practice. Integrating a greater awareness and understanding of the intersubjective dynamics of the therapeutic relationship in practice may be beneficial for community occupational therapists.

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Introdução: O conceito de contratransferência evoluiu de “um obstáculo ao tratamento” à ferramenta útil à compreensão do paciente dentro de uma relação bi-pessoal. Atualmente, buscam-se evidências da sua especificidade, correlacionando padrões específicos de contratransferência com características do paciente e terapeuta, classes diagnósticas e desfechos do tratamento. Acredita-se que, devido à intensidade das reações emocionais despertadas nos terapeutas que atendem vítimas de trauma, o estudo da contratransferência nesta população auxilie no autoconhecimento dos terapeutas, amplie a compreensão sobre o fenômeno e contribua para um melhor atendimento dos pacientes. O desenvolvimento de pesquisas nesta área esbarra no reduzido número de escalas validadas para acessar a contratransferência. No Brasil, estão disponíveis a escala para Avaliação da Contratransferência e as versões traduzidas do Inventory of Countertransference Behavior e Mental States Rating System, mas nenhuma validada.A Escala para a Avaliação da Contratransferência (EACT) foi criada em nosso meio, com elevada validade de face, construída em torno de três dimensões conceituais de sentimentos. Entretanto, suas propriedades psicométricas ainda não foram avaliadas. Objetivos: Investigara validade de construto da EACT, respondida por terapeutas de vítimas de trauma psíquico (Artigo 1). Secundariamente, analisar a correlação entre a contratransferência inicial com vítimas de trauma psíquico e os dados demográficos e clínicos de terapeutas e pacientes e o tipo de trauma, e investigar a associação entre a contratransferência inicial e a adesão dos pacientes ao tratamento e o seu desfecho, operacionalizado como alta ou abandono (Artigo 2). Método: Delineamento transversal (Artigo 1) e análises secundárias com dados longitudinais (Artigo 2). A amostra foi composta por 50 psiquiatras no segundo ano de formação durante estágio no Núcleo de Estudos e Tratamento de Trauma Psíquico do Hospital de Clínicas de Porto Alegre, Brasil. Esses terapeutas atenderam 131 pacientes recrutados consecutivamente durante 4 anos, que incluiu a primeira ou segunda consulta de vítimas de abuso sexual, seqüestro, assalto, agressão física, tentativa de homicídio, tortura e trauma indireto, independentemente do tempo decorrido entre a consulta atual e o evento traumático. Foram excluídos atendimentos de pacientes que chegaram à primeira consulta com ideação suicida grave, sintomas psicóticos e/ou com indicação de internação psiquiátrica. Os pacientes foram selecionados após triagem, que avaliou as variáveis clínicas e o diagnóstico segundo os critérios do DSM-IV-TR. Na primeira consulta, foram coletados os dados demográficos e clínicos e avaliada a contratransferência identificada pelo terapeuta através da EACT. Os pacientes foram acompanhados ao longo do tratamento psiquiátrico para determinar o número de consultas, faltas e o desfecho: alta ou abandono. A EACT é uma escala auto-aplicável, composta por 23 itens pontuados para 3 momentos da sessão (início, durante e final) em escala tipo Likert (0=ausência a 3=muito), e distribuídos em 3 domínios: aproximação (10 itens), afastamento (10 itens) e indiferença (3 itens). A validade de constructo da EACT no atendimento desta população foi avaliada através da análise fatorial exploratória (EFA) e consistência interna (α de Cronbach). O tamanho amostral foi calculado a partir de pelo menos 5 aplicações da EACT para cada item da escala (mínimo N = 115). E a análise fatorial confirmatória foi usada para determinar os parâmetros de adequação (goodness-of-fit) da versão da EACT no atendimento de vítimas de trauma obtida na EFA em comparação com a versão original. Resultados: A EFA mostrou 3 fatores com homogeneidade consistente, sendo distinta da versão original da EACT a correlação entre os itens e o terceiro fator: afastamento (9 itens com 24% da variância; α = 0,88), aproximação (7 itens com 15% da variância; α=0,82) e tristeza (6 itens com 9% da variância; α = 0,72). O item alegria, com carga fatorial baixa, foi retirado da análise por ser considerado irrelevante neste contexto. A análise fatorial confirmatória evidenciou melhores critérios de goodness-of-fit em todos os parâmetros testados para a presente versão da EACT do que a original. Secundariamente, as características demográficas e clínicas dos terapeutas e dos pacientes dos grupos alta e abandono foram similares. Os terapeutas com idade ≤ 27 anos pontuaram maior afastamento que os mais velhos (0,14 ± 1 vs. -0,21 ± 0,9; P=0,019). Os pacientes casados induziram nos terapeutas mais sentimentos de afastamento (0,20 ±1 vs. -0,19 ± 0,9; P = 0,016) e tristeza (0,18 ±1 vs. -0,17 ± 1; P = 0,049) que os que vivem sozinhos. Nas variáveis clínicas, as vítimas de trauma indireto e de múltiplos traumas despertaram mais tristeza (0,38 ± 1 e 0,76 ± 0,4, respectivamente), comparadas às vítimas de violência sexual (0,03 ± 0,9) e urbana (-0,3 ± 1) (P = 0,039). A mediana de consultas realizadas foi 5 [4; 8], faltas 1 [0; 1] e a taxa de abandono foi de 34,4%. Na análise multivariada, identificou-se que os pacientes com relato de história de trauma na infância abandonaram menos o tratamento (OR = 0,39; P = 0,039; CI 95% 0,16- 0,95). Não foi detectada associação entre sentimentos contratransferenciais iniciais com os desfechos do tratamento. Conclusões: A EACT apresentou propriedades psicométricas consistentes, demonstrando ser um instrumento confiável para acessara contratransferência inicial de terapeutas de vítimas de trauma psíquico. Os sentimentos contratransferenciais no atendimento inicial destes pacientes associaram-se a parâmetros demográficos e clínicos, mas não se associaram ao abandono do tratamento. Estudos futuros devem avaliar a modificação dos sentimentos contratransferenciais ao longo do tratamento e o seu impacto sobre os desfechos do tratamento. / Introduction: The concept of countertransference (CT) evolved from an “obstacle to treatment” to "an useful tool to understand patients within a bi-personal relationship". Currently, evidences of its specificity are searched for, correlating specific CT patterns to patients and therapists’ features, diagnostic classes, and treatment outcomes. Due to the intensity of emotional reactions aroused in therapists caring for trauma victims, it is believed that the study of CT in this population will help self-knowledge of therapists and contribute for a better patient care. The development of studies in this field is hindered by the reduced number of validated scales to assess CT. In Brazil, the Assessment of Countertransference Scale and the translated versions of the Inventory of Countertransference Behavior and Mental States Rating System are available, however, none of them has been validated. The Assessment of Countertransference Scale (ACS) has been created in our department with high face validity, built around three conceptual dimensions of feelings. However, its psychometric properties have not been assessed yet. Objectives: To investigate the construct validity of the ACS answered by therapists of psychological trauma victims (Article 1). Then, to assess the correlation between initial CT with victims of psychological trauma and the clinical and demographic data of therapists and patients and the type of trauma, and to investigate the association between initial countertransference and patients’ adherence to treatment and its outcome, defined as discharge or drop-out (Article 2). Methods: A Cross-sectional study (Article 1) and secondary analysis with longitudinal data (Article 2) were carried out. The sample was formed by 50 psychiatrists in the second year of training in their internship in the Center for Study and Treatment of Traumatic Stress in Hospital de Clínicas de Porto Alegre, Brazil. These therapists cared for 131 patients consecutively recruited for 4 years, including the first and second appointment with victims of sexual abuse, kidnapping, robbery, physical assault, homicide attempt, torture and indirect trauma, regardless of the time elapsed between the current appointment and the trauma event. We have excluded patients that arrived in the first appointment with severe suicidal ideation, psychotic symptoms and/or referral for psychiatric hospitalization. Patients have been selected after screening, which assessed the clinical variables and the diagnoses according to DSM-IV-TR criteria. In the first appointment, demographic and clinical data were collected and CT, identified by therapists through the ACS, was assessed. Patients were followed-up during psychiatric treatment to determine the number of appointments, absences, and the outcome: discharge or drop-out. ACS is a self-applied scale composed by 23 items scored for 3 moments of the session (start, midpoint and end) in a Likert-type scale (0=absence to 3=very), and distributed into 3 dimensions: closeness (10 items), distance (10 items) and indifference (3 items). The construct validity of ACS in the care for this population was assessed through the Exploratory Factor Analysis (EFA) and the internal consistency (α de Cronbach). The sample size was calculated for at least 5 applications of ACS for each item of the scale (minimum N = 115). The Confirmatory Factor Analysis (CFA) was used to determine the goodness of fit parameters of the ACS version in the care for trauma victims obtained in the EFA compared to the original version. Results: EFA showed 3 factors with consistent homogeneity, but the correlation between the items and the third factor were different from the original version, in the following: rejection (9 items with 24% of variance; α = 0.88), closeness (7 items with 15% of variance; α = 0.82) and sadness (6 items with 9% of variance; α = 0.72). The item “happiness”, with low factorial load, was withdrawn from the analysis because it was considered to be irrelevant in this context. CFA showed better goodness of fit criteria in all tested parameters for the present version of ACS compared to the original version. Secondly, the demographic and clinical characteristics of therapists and patients of the discharge and drop-out groups were similar. Therapists with ages ≤ 27 years scored more rejection than older therapists (0.14 ± 1 vs. -0.21 ± 0.9; P = 0.019). Married patients induced in therapists more feelings of rejection (0.20 ± 1 vs. -0.19 ± 0.9; P = 0.016) and sadness (0.18 ± 1 vs. -0.17 ± 1; P = 0.049) than those patients living alone. In the clinical variables, the victims of indirect trauma and of several traumas aroused more feelings of sadness (0.38 ± 1 and 0.76 ± 0.4, respectively) compared to sexual violence (0.03 ± 0.9) and urban violence victims (-0.3 ± 1) (P = 0.039). Median of appointments performed was 5 [4; 8], absences 1 [0; 1] and the drop-out rate was 34.4%. In the multivariate analysis, we have identified that patients with reported history of childhood trauma were less likelihood of dropping out treatment (OR=0.39; P = 0.039; CI 95% 0.16-0.95). Association between the initial CT feelings and the treatment outcomes has not been detected. Conclusions: ACS presented sound psychometric properties, and it has been demonstrated to be a reliable instrument to access initial CT of therapists in victims of psychological trauma. Countertransference feelings in the initial care of patients were associated with clinical and demographic parameters, but it were not associated with treatment drop-out. Further studies should assess the changes in CT feelings over treatment and their impact on treatment outcomes.