A avaliação de criminosos sexuais por psiquiatras e psicólogos forenses consiste em atividade específica que envolve desafios intelectuais e emocionais aos peritos. Esses profissionais trabalham diretamente com indivíduos que cometeram atos graves, que violaram o corpo e as emoções de suas vítimas, de modo profundo, estando expostos ao risco de trauma vicário, um subtipo de trauma psicológico indireto. Pouco se sabe, entretanto, sobre as repercussões desse tipo de avaliação na vida pessoal e profissional dos peritos. Assim, a tese aqui apresentada tem o objetivo de examinar as associações entre sentimentos contratransferenciais desencadeados por criminosos sexuais, mecanismos de defesa e manifestações do trauma vicário em psiquiatras e psicólogos forenses. A primeira etapa desse trabalho consistiu na revisão da literatura acerca de contratransferência e sua expressão no setting pericial, mecanismos de defesa e trauma vicário, tendo sido realizado um estudo exploratório com peritos psiquiatras. Ao se verificar que a versão brasileira da escala de avaliação de trauma vicário - a Trauma and Attachment Belief Scale (TABS) – ainda não se encontrava disponível, um estudo foi realizado para sua tradução, adaptação transcultural e validação aparente. Em seguida, o estudo principal, com delineamento transversal e utilizando métodos mistos, foi conduzido com 56 psiquiatras e psicólogos forenses brasileiros, entre outubro de 2016 e maio de 2017. Reações contratransferenciais, mecanismos de defesa e trauma vicário foram avaliados usando a Escala de Avaliação de Contratransferência (ACS), o Defensive Style Questionnaire (DSQ-40) e a TABS, respectivamente. A grounded theory (GT) foi utilizada na análise qualitativa, através de um questionário auto-aplicado, a fim de compreender a influência da avaliação de agressores sexuais na vida profissional e pessoal dos peritos. Correlações positivas foram identificadas entre sentimentos de indiferença e trauma vicário e entre mecanismos de defesa imaturos e trauma vicário. Essas correlações foram muitos fortes no subgrupo de peritos sem história de psicoterapia pessoal. A investigação qualitativa demonstrou que ocorreram mudanças na identidade profissional dos peritos, na visão de mundo e nas crenças relacionadas à segurança e confiança. Concluiu-se que estratégias específicas maladaptativas de enfrentamento, tais como sentimentos de indiferença e defesas imaturas, durante a avaliação de criminosos sexuais, estiveram associadas com manifestações de trauma vicário em psiquiatras e psicólogos forenses. / The assessment of sex offenders by forensic psychiatrists and psychologists consists in a specific activity that involves intelectual and emotional challenges to experts. These professionals work directly with individuals who have committed serious acts that violated the body and emotions from their victms, in a profound way, being exposed to the risk of vicarious trauma (VT), a subtype of indirect psychological trauma. Little is known, however, about the implications of this type of assessment in personal and professional lives of experts. Thus, the thesis presented here aims to examine the associations between countertransference reactions aroused by sex offenders, defense mechanisms and manifestations of vicarious trauma in forensic psychiatrists and psychologists. The first step of this work consisted in a review of literature about countertransference and it’s expression in a forensic setting, defense mechanisms and vicarious trauma, and we have conducted an exploratory study with forensic psychiatrists. Since it was verified that a Brazilian version of the assessment scale of vicarious trauma - the Trauma and Attachment Belief Scale (TABS) - was not yet available, a study was performed for its translation, cross-cultural adaptation, and apparent validation. Then, the main study, using a cross-sectional design and mixed methods, was conducted with 56 Brazilian forensic psychiatrists and psychologists, between October 2016 and May 2017. Countertransference reactions, defense mechanisms and vicarious trauma were assessed using the Assessment of Countertransference Scale (ACS), the Defensive Style Questionnaire (DSQ- 40) and the TABS, respectively. The grounded theory (GT) was used in qualitative analysis, by means of a self-report questionnaire, in order to understand the influence of the assessment of sexual aggressors in professional and personal life of experts. Positive correlations were found between feelings of indifference and vicarious trauma and between immature defense mechanisms and vicarious trauma. These correlations were very strong in a subgroup of experts without a history of personal psychotherapy. Qualitative data showed changes in the professionals’ identity, worldview and beliefs related to safety and trust. It was concluded that specific maladaptive coping strategies such as feelings of indifference and immature defenses during the assessment of sex offenders were associated with manifestations of vicarious trauma in forensic psychiatrists and psychologists.

Background. The reported link between psychological trauma and onset of psychosis remains controversial. Aims. To examine associations between self-reported psychological trauma and psychotic symptoms as a function of prior evidence of vulnerability to psychosis (psychosis proneness). Method. At baseline, 2524 adolescents aged 14-24 years provided self-reports on psychological trauma and psychosis proneness, and at follow-up (on average 42 months later) participants were interviewed for presence of psychotic symptoms. Results. Self-reported trauma was associated with psychotic symptoms, in particular at more severe levels (adjusted OR1.89,95% CI1.16-3.08) and following trauma associated with intense fear, helplessness or horror. The risk difference between those with and without self-reported trauma at baseline was 7% in the group with baseline psychosis proneness, but only 1.8% in those without (adjusted test for difference between these two effect sizes: χ2=4.6, P=0.032). Conclusions. Exposure to psychological trauma may increase the risk of psychotic symptoms in people vulnerable to psychosis.

Introduction: This thesis evaluated the effectiveness of an educational intervention for Toronto Transit Commission (TTC) employees exposed to a traumatic event at work. Methods: This study used a sequential mixed methods design. The primary outcome was the proportion seeking mental health treatment after an educational intervention (BPI) compared to a group not receiving an educational intervention (TAU). Qualitative interviews aimed to understand what compelled participants to seek help and perceptions of the educational intervention. Results: 60 TAU and 50 BPI participants were recruited. A larger proportion of BPI participants sought specialty mental health treatment compared to the TAU (p=0.034). Reasons for seeking treatment were varied and we found overall positive responses to the educational intervention, particularly normalization of reactions. Conclusions: A greater proportion of those receiving the educational intervention sought help. However, the interviews showed that although the educational intervention was helpful, it was not central to this decision.

Introduction: This thesis evaluated the effectiveness of an educational intervention for Toronto Transit Commission (TTC) employees exposed to a traumatic event at work. Methods: This study used a sequential mixed methods design. The primary outcome was the proportion seeking mental health treatment after an educational intervention (BPI) compared to a group not receiving an educational intervention (TAU). Qualitative interviews aimed to understand what compelled participants to seek help and perceptions of the educational intervention. Results: 60 TAU and 50 BPI participants were recruited. A larger proportion of BPI participants sought specialty mental health treatment compared to the TAU (p=0.034). Reasons for seeking treatment were varied and we found overall positive responses to the educational intervention, particularly normalization of reactions. Conclusions: A greater proportion of those receiving the educational intervention sought help. However, the interviews showed that although the educational intervention was helpful, it was not central to this decision.

No description available.

O conceito de contratransferência foi introduzido por Freud e ampliado por outros autores, sendo compreendido como as reações emocionais despertadas pelo paciente no terapeuta. Tem papel central na teoria e na técnica psicanalíticas atuais por ser uma importante ferramenta para o entendimento do mundo interno e das comunicações do paciente, com influência no desenvolvimento da relação terapêutica e no desfecho do tratamento. A partir do reconhecimento da importância da mente do terapeuta e do campo terapêutico, tem sido discutida a associação entre características da pessoa real do terapeuta e a forma como é estabelecida a relação com o paciente. Do mesmo modo, características específicas dos pacientes, como ter sido vítima de trauma psíquico, são consideradas potenciais desencadeadoras de padrões contratransferenciais similares. A relevância do estudo dos sentimentos contratransferenciais despertados no atendimento de vítimas de trauma psíquico se justifica pela grande intensidade destes e pelo potencial destas reações emocionais se tornarem barreiras para o sucesso do tratamento quando não compreendidas pelo terapeuta.Avaliar o padrão de expressão da contratransferência dos terapeutas durante o atendimento inicial de pacientes mulheres vítimas de trauma psíquico e a sua associação com características dos terapeutas e das pacientes, tais como o momento da consulta, o gênero do terapeuta, a natureza do trauma (violência sexual ou violência urbana) e o momento da violência sexual na vida das pacientes. Também foi investigada a associação entre o padrão contratransferencial e a presença de sintomas de Transtorno de Estresse Pós-Traumático e de sintomas depressivos atuais nas pacientes, escores em rastreamento para transtornos de personalidade e em escala de percepção da gravidade da doença nas pacientes e estilo defensivo utilizado pelas mesmas. Os estudos foram realizados no Núcleo de Estudos e Tratamento do Trauma Psíquico (NETTRAUMA), do Hospital de Clínicas de Porto Alegre (HCPA), Brasil. Os terapeutas eram médicos residentes do segundo ano de Psiquiatria do HCPA. No primeiro estudo, foi conduzidauma avaliação qualitativa, a análise de conteúdo, associada a uma análise estatística, de 36 relatos de sentimentos contratransferenciais despertados no primeiro atendimento de pacientes mulheres, sendo13 vítimas de violência sexual na infância, 15 vítimas de violência sexual atual, e 8 vítimas de violência urbana. Os relatos foram classificados em 6 grupos, conforme o gênero do terapeuta e a natureza do trauma. O segundo estudo teve a participação de 26 terapeutas, 11 homens e 15 mulheres. Foram incluídas nesta amostra todas as pacientes mulheres vítimas de violência sexual, tanto na infância quanto na idade adulta, atendidas no NET-TRAUMA durante dois anos consecutivos, totalizando 40 pacientes. Após a primeira consulta com a paciente, era solicitado ao terapeuta que preenchesse a Escala para Avaliação da Contratransferência (EACT). Neste mesmo momento, era solicitado à paciente que preenchesse os instrumentos referentes aos fatores em estudo: a Escala Davidson de Trauma (EDT), a Standardized Assessment of Personality - Abbreviated Scale (SAPAS), o Inventário de Depressão de Beck (BDI), e a versão em português do Defense Style Questionaire (DSQ-40). A Escala de Impressão Clínica Global (CGI) era preenchida após a consulta de triagem. Na análise dos relatos redigidos pelos terapeutas, observou-se predomínio de sentimentos de aproximação nos terapeutas de ambos os gêneros no atendimento de vítimas de violência sexual. Entre terapeutas mulheres, a natureza do trauma (sexual ou urbano) não influenciou os padrões contratransferenciais. Entre os terapeutas homens, a natureza do trauma influenciou de forma significativa a contratransferência, havendo um número elevado de sentimentos de distanciamento nos relatos de atendimentos de vítimas de violência urbana em relação àqueles atendimentos a vítimas de violência sexual na infância (p=0,02). No segundo estudo, os terapeutas apresentaram, da mesma forma, mais sentimentos de proximidade em relação às pacientes, que foram maiores no meio e no final das consultas (p<0,001), sem influência do gênero do terapeuta. Em uma sub-amostra estratificada para pacientes atendidas por terapeutas mulheres, identificou-se associação significativa entre maiores escores obtidos pelas pacientes na SAPAS e menos sentimentos de proximidade das terapeutas (p=0,038).Estes estudos evidenciaram um predomínio de respostas contratransferenciais de proximidade em terapeutas jovens, no início da vida profissional, ao longo das primeiras consultas compacientes mulheres vítimas de violência sexual. Destaca-se a importância da utilização da contratransferência para a melhor compreensão dos pacientes, o que pode trazer benefícios ao tratamento e ao prognóstico destes, ressaltando-se a necessidade de que investigações continuadas sobre o tema sigam sendo desenvolvidas. / The concept of countertransference was introduced by Freud and expanded by other authors. It is understood as the emotional reactions triggered by the patient in the therapist. It is pivotal in the current psychoanalytic theory and technique since it is an important tool in understanding the patient’s internal world and reportings, influencing the therapeutic relationship and the outcome of the treatment. From the acknowledgement of the importance of the therapist’s mind and the therapeutic field, there has been a growing debate on the association between characteristics of the real person of the therapist and the way that the relationship with the patient is established. Likewise, specific characteristics of the patients, such as having been victim of a psychological trauma, have been considered potential triggers of similar patterns of countertransferential responses. The relevance of studying the countertransferential feelings triggered when seeing victims of psychological trauma is justified by their high intensity and by the possibility of such emotional reactions becoming barriers for a successful treatment when they are not understood by the therapist.To evaluate the therapists’ countertransference during the first visit of women victims of psychological trauma, and its association with therapists’ and patients’ characteristics, such as the moment within the visit, the gender of the therapist, the nature of the trauma (sexual violence or urban violence) and the time when sexual violence occurred in the patient’s life. The association between countertransference pattern and the presence of Post-Traumatic Stress Disorder symptoms and of depressive symptoms in the patients, scores in a screening of personality disorders and in a scale of perception of disease severity in the patients and the defensive style utilized by them were also investigated. The studies were conducted at the Center for the Study and Treatment of Psychological Trauma (NET-TRAUMA), of Hospital de Clínicas de Porto Alegre (HCPA), Brazil. The therapists were second-year Psychiatry residents of HCPA. On the first study, a qualitative evaluation, thecontent analysis, was performed, associated to a statistical analysis, of 36 reports of the countertransferential feelings aroused in the first visit of female patients. Thirteen patients were victims of sexual violence during childhood, 15 were victims of current sexual violence, and 8 were victims of urban violence. The reports were categorized into 6 groups according to the gender of the therapist and the nature of the trauma. Twenty-six therapists (11 males and 15 females) participated in the second study. All women victims of sexual violence, both during childhood and adulthood, seen at the NET-TRAUMA during two consecutive years were included in this sample, which totaled 40. After the patient’s first visit, the therapist was asked to complete the Assessment of Countertransference Scale (ACTS). On the same visit, the patient was asked to complete the instruments regarding the factors in study: the Davidson Trauma Scale (DTS), the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), the Beck Depression Inventory (BDI), and the Brazilian Portuguese version of the Defense Style Questionnaire (DSQ-40). The Clinical Global Impressions Scale (CGI) was completed after the screening visit. In the analysis of the therapists’ reports, a predominance of feelings of closeness was observed in therapists of both genders when caring for victims of sexual violence. Among female therapists, the nature of the trauma (sexual or urban) did not influence the countertransferential pattern. Among male therapists, the nature of the trauma significantly influenced countertransference, with increased number of feelings of distance toward victims of urban violence compared to victims of sexual violence during childhood (p=0.02). On the second study, the therapists showed, likewise, more feelings of closeness toward the patients, which were higher in the midpoint and in the end of the visits (p<0.001), without influence of the therapists' gender. In a stratified sample of patients seen by female therapists, there was a significant association between higher patients’ SAPAS scores and less therapists’ feelings of closeness (p=0.038).These studies have showed a predominance of countertransferential reactions of closeness in young therapists, at the beginning of their professional lives, during the first visit of women victims of sexual violence. The importance of the use of countertransference for theunderstanding of the patients is emphasized, as it can be beneficial for their treatment and prognosis; further investigation on the matter is of interest.

A avaliação de criminosos sexuais por psiquiatras e psicólogos forenses consiste em atividade específica que envolve desafios intelectuais e emocionais aos peritos. Esses profissionais trabalham diretamente com indivíduos que cometeram atos graves, que violaram o corpo e as emoções de suas vítimas, de modo profundo, estando expostos ao risco de trauma vicário, um subtipo de trauma psicológico indireto. Pouco se sabe, entretanto, sobre as repercussões desse tipo de avaliação na vida pessoal e profissional dos peritos. Assim, a tese aqui apresentada tem o objetivo de examinar as associações entre sentimentos contratransferenciais desencadeados por criminosos sexuais, mecanismos de defesa e manifestações do trauma vicário em psiquiatras e psicólogos forenses. A primeira etapa desse trabalho consistiu na revisão da literatura acerca de contratransferência e sua expressão no setting pericial, mecanismos de defesa e trauma vicário, tendo sido realizado um estudo exploratório com peritos psiquiatras. Ao se verificar que a versão brasileira da escala de avaliação de trauma vicário - a Trauma and Attachment Belief Scale (TABS) – ainda não se encontrava disponível, um estudo foi realizado para sua tradução, adaptação transcultural e validação aparente. Em seguida, o estudo principal, com delineamento transversal e utilizando métodos mistos, foi conduzido com 56 psiquiatras e psicólogos forenses brasileiros, entre outubro de 2016 e maio de 2017. Reações contratransferenciais, mecanismos de defesa e trauma vicário foram avaliados usando a Escala de Avaliação de Contratransferência (ACS), o Defensive Style Questionnaire (DSQ-40) e a TABS, respectivamente. A grounded theory (GT) foi utilizada na análise qualitativa, através de um questionário auto-aplicado, a fim de compreender a influência da avaliação de agressores sexuais na vida profissional e pessoal dos peritos. Correlações positivas foram identificadas entre sentimentos de indiferença e trauma vicário e entre mecanismos de defesa imaturos e trauma vicário. Essas correlações foram muitos fortes no subgrupo de peritos sem história de psicoterapia pessoal. A investigação qualitativa demonstrou que ocorreram mudanças na identidade profissional dos peritos, na visão de mundo e nas crenças relacionadas à segurança e confiança. Concluiu-se que estratégias específicas maladaptativas de enfrentamento, tais como sentimentos de indiferença e defesas imaturas, durante a avaliação de criminosos sexuais, estiveram associadas com manifestações de trauma vicário em psiquiatras e psicólogos forenses. / The assessment of sex offenders by forensic psychiatrists and psychologists consists in a specific activity that involves intelectual and emotional challenges to experts. These professionals work directly with individuals who have committed serious acts that violated the body and emotions from their victms, in a profound way, being exposed to the risk of vicarious trauma (VT), a subtype of indirect psychological trauma. Little is known, however, about the implications of this type of assessment in personal and professional lives of experts. Thus, the thesis presented here aims to examine the associations between countertransference reactions aroused by sex offenders, defense mechanisms and manifestations of vicarious trauma in forensic psychiatrists and psychologists. The first step of this work consisted in a review of literature about countertransference and it’s expression in a forensic setting, defense mechanisms and vicarious trauma, and we have conducted an exploratory study with forensic psychiatrists. Since it was verified that a Brazilian version of the assessment scale of vicarious trauma - the Trauma and Attachment Belief Scale (TABS) - was not yet available, a study was performed for its translation, cross-cultural adaptation, and apparent validation. Then, the main study, using a cross-sectional design and mixed methods, was conducted with 56 Brazilian forensic psychiatrists and psychologists, between October 2016 and May 2017. Countertransference reactions, defense mechanisms and vicarious trauma were assessed using the Assessment of Countertransference Scale (ACS), the Defensive Style Questionnaire (DSQ- 40) and the TABS, respectively. The grounded theory (GT) was used in qualitative analysis, by means of a self-report questionnaire, in order to understand the influence of the assessment of sexual aggressors in professional and personal life of experts. Positive correlations were found between feelings of indifference and vicarious trauma and between immature defense mechanisms and vicarious trauma. These correlations were very strong in a subgroup of experts without a history of personal psychotherapy. Qualitative data showed changes in the professionals’ identity, worldview and beliefs related to safety and trust. It was concluded that specific maladaptive coping strategies such as feelings of indifference and immature defenses during the assessment of sex offenders were associated with manifestations of vicarious trauma in forensic psychiatrists and psychologists.

O conceito de contratransferência foi introduzido por Freud e ampliado por outros autores, sendo compreendido como as reações emocionais despertadas pelo paciente no terapeuta. Tem papel central na teoria e na técnica psicanalíticas atuais por ser uma importante ferramenta para o entendimento do mundo interno e das comunicações do paciente, com influência no desenvolvimento da relação terapêutica e no desfecho do tratamento. A partir do reconhecimento da importância da mente do terapeuta e do campo terapêutico, tem sido discutida a associação entre características da pessoa real do terapeuta e a forma como é estabelecida a relação com o paciente. Do mesmo modo, características específicas dos pacientes, como ter sido vítima de trauma psíquico, são consideradas potenciais desencadeadoras de padrões contratransferenciais similares. A relevância do estudo dos sentimentos contratransferenciais despertados no atendimento de vítimas de trauma psíquico se justifica pela grande intensidade destes e pelo potencial destas reações emocionais se tornarem barreiras para o sucesso do tratamento quando não compreendidas pelo terapeuta.Avaliar o padrão de expressão da contratransferência dos terapeutas durante o atendimento inicial de pacientes mulheres vítimas de trauma psíquico e a sua associação com características dos terapeutas e das pacientes, tais como o momento da consulta, o gênero do terapeuta, a natureza do trauma (violência sexual ou violência urbana) e o momento da violência sexual na vida das pacientes. Também foi investigada a associação entre o padrão contratransferencial e a presença de sintomas de Transtorno de Estresse Pós-Traumático e de sintomas depressivos atuais nas pacientes, escores em rastreamento para transtornos de personalidade e em escala de percepção da gravidade da doença nas pacientes e estilo defensivo utilizado pelas mesmas. Os estudos foram realizados no Núcleo de Estudos e Tratamento do Trauma Psíquico (NETTRAUMA), do Hospital de Clínicas de Porto Alegre (HCPA), Brasil. Os terapeutas eram médicos residentes do segundo ano de Psiquiatria do HCPA. No primeiro estudo, foi conduzidauma avaliação qualitativa, a análise de conteúdo, associada a uma análise estatística, de 36 relatos de sentimentos contratransferenciais despertados no primeiro atendimento de pacientes mulheres, sendo13 vítimas de violência sexual na infância, 15 vítimas de violência sexual atual, e 8 vítimas de violência urbana. Os relatos foram classificados em 6 grupos, conforme o gênero do terapeuta e a natureza do trauma. O segundo estudo teve a participação de 26 terapeutas, 11 homens e 15 mulheres. Foram incluídas nesta amostra todas as pacientes mulheres vítimas de violência sexual, tanto na infância quanto na idade adulta, atendidas no NET-TRAUMA durante dois anos consecutivos, totalizando 40 pacientes. Após a primeira consulta com a paciente, era solicitado ao terapeuta que preenchesse a Escala para Avaliação da Contratransferência (EACT). Neste mesmo momento, era solicitado à paciente que preenchesse os instrumentos referentes aos fatores em estudo: a Escala Davidson de Trauma (EDT), a Standardized Assessment of Personality - Abbreviated Scale (SAPAS), o Inventário de Depressão de Beck (BDI), e a versão em português do Defense Style Questionaire (DSQ-40). A Escala de Impressão Clínica Global (CGI) era preenchida após a consulta de triagem. Na análise dos relatos redigidos pelos terapeutas, observou-se predomínio de sentimentos de aproximação nos terapeutas de ambos os gêneros no atendimento de vítimas de violência sexual. Entre terapeutas mulheres, a natureza do trauma (sexual ou urbano) não influenciou os padrões contratransferenciais. Entre os terapeutas homens, a natureza do trauma influenciou de forma significativa a contratransferência, havendo um número elevado de sentimentos de distanciamento nos relatos de atendimentos de vítimas de violência urbana em relação àqueles atendimentos a vítimas de violência sexual na infância (p=0,02). No segundo estudo, os terapeutas apresentaram, da mesma forma, mais sentimentos de proximidade em relação às pacientes, que foram maiores no meio e no final das consultas (p<0,001), sem influência do gênero do terapeuta. Em uma sub-amostra estratificada para pacientes atendidas por terapeutas mulheres, identificou-se associação significativa entre maiores escores obtidos pelas pacientes na SAPAS e menos sentimentos de proximidade das terapeutas (p=0,038).Estes estudos evidenciaram um predomínio de respostas contratransferenciais de proximidade em terapeutas jovens, no início da vida profissional, ao longo das primeiras consultas compacientes mulheres vítimas de violência sexual. Destaca-se a importância da utilização da contratransferência para a melhor compreensão dos pacientes, o que pode trazer benefícios ao tratamento e ao prognóstico destes, ressaltando-se a necessidade de que investigações continuadas sobre o tema sigam sendo desenvolvidas. / The concept of countertransference was introduced by Freud and expanded by other authors. It is understood as the emotional reactions triggered by the patient in the therapist. It is pivotal in the current psychoanalytic theory and technique since it is an important tool in understanding the patient’s internal world and reportings, influencing the therapeutic relationship and the outcome of the treatment. From the acknowledgement of the importance of the therapist’s mind and the therapeutic field, there has been a growing debate on the association between characteristics of the real person of the therapist and the way that the relationship with the patient is established. Likewise, specific characteristics of the patients, such as having been victim of a psychological trauma, have been considered potential triggers of similar patterns of countertransferential responses. The relevance of studying the countertransferential feelings triggered when seeing victims of psychological trauma is justified by their high intensity and by the possibility of such emotional reactions becoming barriers for a successful treatment when they are not understood by the therapist.To evaluate the therapists’ countertransference during the first visit of women victims of psychological trauma, and its association with therapists’ and patients’ characteristics, such as the moment within the visit, the gender of the therapist, the nature of the trauma (sexual violence or urban violence) and the time when sexual violence occurred in the patient’s life. The association between countertransference pattern and the presence of Post-Traumatic Stress Disorder symptoms and of depressive symptoms in the patients, scores in a screening of personality disorders and in a scale of perception of disease severity in the patients and the defensive style utilized by them were also investigated. The studies were conducted at the Center for the Study and Treatment of Psychological Trauma (NET-TRAUMA), of Hospital de Clínicas de Porto Alegre (HCPA), Brazil. The therapists were second-year Psychiatry residents of HCPA. On the first study, a qualitative evaluation, thecontent analysis, was performed, associated to a statistical analysis, of 36 reports of the countertransferential feelings aroused in the first visit of female patients. Thirteen patients were victims of sexual violence during childhood, 15 were victims of current sexual violence, and 8 were victims of urban violence. The reports were categorized into 6 groups according to the gender of the therapist and the nature of the trauma. Twenty-six therapists (11 males and 15 females) participated in the second study. All women victims of sexual violence, both during childhood and adulthood, seen at the NET-TRAUMA during two consecutive years were included in this sample, which totaled 40. After the patient’s first visit, the therapist was asked to complete the Assessment of Countertransference Scale (ACTS). On the same visit, the patient was asked to complete the instruments regarding the factors in study: the Davidson Trauma Scale (DTS), the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), the Beck Depression Inventory (BDI), and the Brazilian Portuguese version of the Defense Style Questionnaire (DSQ-40). The Clinical Global Impressions Scale (CGI) was completed after the screening visit. In the analysis of the therapists’ reports, a predominance of feelings of closeness was observed in therapists of both genders when caring for victims of sexual violence. Among female therapists, the nature of the trauma (sexual or urban) did not influence the countertransferential pattern. Among male therapists, the nature of the trauma significantly influenced countertransference, with increased number of feelings of distance toward victims of urban violence compared to victims of sexual violence during childhood (p=0.02). On the second study, the therapists showed, likewise, more feelings of closeness toward the patients, which were higher in the midpoint and in the end of the visits (p<0.001), without influence of the therapists' gender. In a stratified sample of patients seen by female therapists, there was a significant association between higher patients’ SAPAS scores and less therapists’ feelings of closeness (p=0.038).These studies have showed a predominance of countertransferential reactions of closeness in young therapists, at the beginning of their professional lives, during the first visit of women victims of sexual violence. The importance of the use of countertransference for theunderstanding of the patients is emphasized, as it can be beneficial for their treatment and prognosis; further investigation on the matter is of interest.

A avaliação de criminosos sexuais por psiquiatras e psicólogos forenses consiste em atividade específica que envolve desafios intelectuais e emocionais aos peritos. Esses profissionais trabalham diretamente com indivíduos que cometeram atos graves, que violaram o corpo e as emoções de suas vítimas, de modo profundo, estando expostos ao risco de trauma vicário, um subtipo de trauma psicológico indireto. Pouco se sabe, entretanto, sobre as repercussões desse tipo de avaliação na vida pessoal e profissional dos peritos. Assim, a tese aqui apresentada tem o objetivo de examinar as associações entre sentimentos contratransferenciais desencadeados por criminosos sexuais, mecanismos de defesa e manifestações do trauma vicário em psiquiatras e psicólogos forenses. A primeira etapa desse trabalho consistiu na revisão da literatura acerca de contratransferência e sua expressão no setting pericial, mecanismos de defesa e trauma vicário, tendo sido realizado um estudo exploratório com peritos psiquiatras. Ao se verificar que a versão brasileira da escala de avaliação de trauma vicário - a Trauma and Attachment Belief Scale (TABS) – ainda não se encontrava disponível, um estudo foi realizado para sua tradução, adaptação transcultural e validação aparente. Em seguida, o estudo principal, com delineamento transversal e utilizando métodos mistos, foi conduzido com 56 psiquiatras e psicólogos forenses brasileiros, entre outubro de 2016 e maio de 2017. Reações contratransferenciais, mecanismos de defesa e trauma vicário foram avaliados usando a Escala de Avaliação de Contratransferência (ACS), o Defensive Style Questionnaire (DSQ-40) e a TABS, respectivamente. A grounded theory (GT) foi utilizada na análise qualitativa, através de um questionário auto-aplicado, a fim de compreender a influência da avaliação de agressores sexuais na vida profissional e pessoal dos peritos. Correlações positivas foram identificadas entre sentimentos de indiferença e trauma vicário e entre mecanismos de defesa imaturos e trauma vicário. Essas correlações foram muitos fortes no subgrupo de peritos sem história de psicoterapia pessoal. A investigação qualitativa demonstrou que ocorreram mudanças na identidade profissional dos peritos, na visão de mundo e nas crenças relacionadas à segurança e confiança. Concluiu-se que estratégias específicas maladaptativas de enfrentamento, tais como sentimentos de indiferença e defesas imaturas, durante a avaliação de criminosos sexuais, estiveram associadas com manifestações de trauma vicário em psiquiatras e psicólogos forenses. / The assessment of sex offenders by forensic psychiatrists and psychologists consists in a specific activity that involves intelectual and emotional challenges to experts. These professionals work directly with individuals who have committed serious acts that violated the body and emotions from their victms, in a profound way, being exposed to the risk of vicarious trauma (VT), a subtype of indirect psychological trauma. Little is known, however, about the implications of this type of assessment in personal and professional lives of experts. Thus, the thesis presented here aims to examine the associations between countertransference reactions aroused by sex offenders, defense mechanisms and manifestations of vicarious trauma in forensic psychiatrists and psychologists. The first step of this work consisted in a review of literature about countertransference and it’s expression in a forensic setting, defense mechanisms and vicarious trauma, and we have conducted an exploratory study with forensic psychiatrists. Since it was verified that a Brazilian version of the assessment scale of vicarious trauma - the Trauma and Attachment Belief Scale (TABS) - was not yet available, a study was performed for its translation, cross-cultural adaptation, and apparent validation. Then, the main study, using a cross-sectional design and mixed methods, was conducted with 56 Brazilian forensic psychiatrists and psychologists, between October 2016 and May 2017. Countertransference reactions, defense mechanisms and vicarious trauma were assessed using the Assessment of Countertransference Scale (ACS), the Defensive Style Questionnaire (DSQ- 40) and the TABS, respectively. The grounded theory (GT) was used in qualitative analysis, by means of a self-report questionnaire, in order to understand the influence of the assessment of sexual aggressors in professional and personal life of experts. Positive correlations were found between feelings of indifference and vicarious trauma and between immature defense mechanisms and vicarious trauma. These correlations were very strong in a subgroup of experts without a history of personal psychotherapy. Qualitative data showed changes in the professionals’ identity, worldview and beliefs related to safety and trust. It was concluded that specific maladaptive coping strategies such as feelings of indifference and immature defenses during the assessment of sex offenders were associated with manifestations of vicarious trauma in forensic psychiatrists and psychologists.

O conceito de contratransferência foi introduzido por Freud e ampliado por outros autores, sendo compreendido como as reações emocionais despertadas pelo paciente no terapeuta. Tem papel central na teoria e na técnica psicanalíticas atuais por ser uma importante ferramenta para o entendimento do mundo interno e das comunicações do paciente, com influência no desenvolvimento da relação terapêutica e no desfecho do tratamento. A partir do reconhecimento da importância da mente do terapeuta e do campo terapêutico, tem sido discutida a associação entre características da pessoa real do terapeuta e a forma como é estabelecida a relação com o paciente. Do mesmo modo, características específicas dos pacientes, como ter sido vítima de trauma psíquico, são consideradas potenciais desencadeadoras de padrões contratransferenciais similares. A relevância do estudo dos sentimentos contratransferenciais despertados no atendimento de vítimas de trauma psíquico se justifica pela grande intensidade destes e pelo potencial destas reações emocionais se tornarem barreiras para o sucesso do tratamento quando não compreendidas pelo terapeuta.Avaliar o padrão de expressão da contratransferência dos terapeutas durante o atendimento inicial de pacientes mulheres vítimas de trauma psíquico e a sua associação com características dos terapeutas e das pacientes, tais como o momento da consulta, o gênero do terapeuta, a natureza do trauma (violência sexual ou violência urbana) e o momento da violência sexual na vida das pacientes. Também foi investigada a associação entre o padrão contratransferencial e a presença de sintomas de Transtorno de Estresse Pós-Traumático e de sintomas depressivos atuais nas pacientes, escores em rastreamento para transtornos de personalidade e em escala de percepção da gravidade da doença nas pacientes e estilo defensivo utilizado pelas mesmas. Os estudos foram realizados no Núcleo de Estudos e Tratamento do Trauma Psíquico (NETTRAUMA), do Hospital de Clínicas de Porto Alegre (HCPA), Brasil. Os terapeutas eram médicos residentes do segundo ano de Psiquiatria do HCPA. No primeiro estudo, foi conduzidauma avaliação qualitativa, a análise de conteúdo, associada a uma análise estatística, de 36 relatos de sentimentos contratransferenciais despertados no primeiro atendimento de pacientes mulheres, sendo13 vítimas de violência sexual na infância, 15 vítimas de violência sexual atual, e 8 vítimas de violência urbana. Os relatos foram classificados em 6 grupos, conforme o gênero do terapeuta e a natureza do trauma. O segundo estudo teve a participação de 26 terapeutas, 11 homens e 15 mulheres. Foram incluídas nesta amostra todas as pacientes mulheres vítimas de violência sexual, tanto na infância quanto na idade adulta, atendidas no NET-TRAUMA durante dois anos consecutivos, totalizando 40 pacientes. Após a primeira consulta com a paciente, era solicitado ao terapeuta que preenchesse a Escala para Avaliação da Contratransferência (EACT). Neste mesmo momento, era solicitado à paciente que preenchesse os instrumentos referentes aos fatores em estudo: a Escala Davidson de Trauma (EDT), a Standardized Assessment of Personality - Abbreviated Scale (SAPAS), o Inventário de Depressão de Beck (BDI), e a versão em português do Defense Style Questionaire (DSQ-40). A Escala de Impressão Clínica Global (CGI) era preenchida após a consulta de triagem. Na análise dos relatos redigidos pelos terapeutas, observou-se predomínio de sentimentos de aproximação nos terapeutas de ambos os gêneros no atendimento de vítimas de violência sexual. Entre terapeutas mulheres, a natureza do trauma (sexual ou urbano) não influenciou os padrões contratransferenciais. Entre os terapeutas homens, a natureza do trauma influenciou de forma significativa a contratransferência, havendo um número elevado de sentimentos de distanciamento nos relatos de atendimentos de vítimas de violência urbana em relação àqueles atendimentos a vítimas de violência sexual na infância (p=0,02). No segundo estudo, os terapeutas apresentaram, da mesma forma, mais sentimentos de proximidade em relação às pacientes, que foram maiores no meio e no final das consultas (p<0,001), sem influência do gênero do terapeuta. Em uma sub-amostra estratificada para pacientes atendidas por terapeutas mulheres, identificou-se associação significativa entre maiores escores obtidos pelas pacientes na SAPAS e menos sentimentos de proximidade das terapeutas (p=0,038).Estes estudos evidenciaram um predomínio de respostas contratransferenciais de proximidade em terapeutas jovens, no início da vida profissional, ao longo das primeiras consultas compacientes mulheres vítimas de violência sexual. Destaca-se a importância da utilização da contratransferência para a melhor compreensão dos pacientes, o que pode trazer benefícios ao tratamento e ao prognóstico destes, ressaltando-se a necessidade de que investigações continuadas sobre o tema sigam sendo desenvolvidas. / The concept of countertransference was introduced by Freud and expanded by other authors. It is understood as the emotional reactions triggered by the patient in the therapist. It is pivotal in the current psychoanalytic theory and technique since it is an important tool in understanding the patient’s internal world and reportings, influencing the therapeutic relationship and the outcome of the treatment. From the acknowledgement of the importance of the therapist’s mind and the therapeutic field, there has been a growing debate on the association between characteristics of the real person of the therapist and the way that the relationship with the patient is established. Likewise, specific characteristics of the patients, such as having been victim of a psychological trauma, have been considered potential triggers of similar patterns of countertransferential responses. The relevance of studying the countertransferential feelings triggered when seeing victims of psychological trauma is justified by their high intensity and by the possibility of such emotional reactions becoming barriers for a successful treatment when they are not understood by the therapist.To evaluate the therapists’ countertransference during the first visit of women victims of psychological trauma, and its association with therapists’ and patients’ characteristics, such as the moment within the visit, the gender of the therapist, the nature of the trauma (sexual violence or urban violence) and the time when sexual violence occurred in the patient’s life. The association between countertransference pattern and the presence of Post-Traumatic Stress Disorder symptoms and of depressive symptoms in the patients, scores in a screening of personality disorders and in a scale of perception of disease severity in the patients and the defensive style utilized by them were also investigated. The studies were conducted at the Center for the Study and Treatment of Psychological Trauma (NET-TRAUMA), of Hospital de Clínicas de Porto Alegre (HCPA), Brazil. The therapists were second-year Psychiatry residents of HCPA. On the first study, a qualitative evaluation, thecontent analysis, was performed, associated to a statistical analysis, of 36 reports of the countertransferential feelings aroused in the first visit of female patients. Thirteen patients were victims of sexual violence during childhood, 15 were victims of current sexual violence, and 8 were victims of urban violence. The reports were categorized into 6 groups according to the gender of the therapist and the nature of the trauma. Twenty-six therapists (11 males and 15 females) participated in the second study. All women victims of sexual violence, both during childhood and adulthood, seen at the NET-TRAUMA during two consecutive years were included in this sample, which totaled 40. After the patient’s first visit, the therapist was asked to complete the Assessment of Countertransference Scale (ACTS). On the same visit, the patient was asked to complete the instruments regarding the factors in study: the Davidson Trauma Scale (DTS), the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), the Beck Depression Inventory (BDI), and the Brazilian Portuguese version of the Defense Style Questionnaire (DSQ-40). The Clinical Global Impressions Scale (CGI) was completed after the screening visit. In the analysis of the therapists’ reports, a predominance of feelings of closeness was observed in therapists of both genders when caring for victims of sexual violence. Among female therapists, the nature of the trauma (sexual or urban) did not influence the countertransferential pattern. Among male therapists, the nature of the trauma significantly influenced countertransference, with increased number of feelings of distance toward victims of urban violence compared to victims of sexual violence during childhood (p=0.02). On the second study, the therapists showed, likewise, more feelings of closeness toward the patients, which were higher in the midpoint and in the end of the visits (p<0.001), without influence of the therapists' gender. In a stratified sample of patients seen by female therapists, there was a significant association between higher patients’ SAPAS scores and less therapists’ feelings of closeness (p=0.038).These studies have showed a predominance of countertransferential reactions of closeness in young therapists, at the beginning of their professional lives, during the first visit of women victims of sexual violence. The importance of the use of countertransference for theunderstanding of the patients is emphasized, as it can be beneficial for their treatment and prognosis; further investigation on the matter is of interest.