https://doi.org/10.4081/ripppo.2024.736
Development and preliminary validation of the Clinician Affective REsponse (CARE) scale
Submitted: November 12, 2023
Accepted: February 19, 2024
Published: March 21, 2024
Accepted: February 19, 2024
Abstract Views: 940
PDF: 434
APPENDIX: 146
SUPPLEMENTARY MATERIALS: 144
HTML: 33
APPENDIX: 146
SUPPLEMENTARY MATERIALS: 144
HTML: 33
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
The present study reports on the development and validation of the clinician affective response (CARE) scale. The CARE scale was designed as a self-report measure of therapists’ patterns of thoughts, feelings, and behaviors toward the patient during an individual psychotherapy session. An initial pool of 116 items was generated, and its quality was evaluated by subject matter experts. Validation data were gathered from licensed psychotherapists (n=554). We used exploratory factor analysis and item response theory-graded response modeling to select items, confirmatory factor analysis to test how well the factor structure fit the data, and k-fold cross-validation to ascertain the robustness of the model. Criterion validity was evaluated by correlating the scores of the scale with the characteristics of therapists, patients, and treatment. The selected model consists of 15 items and a 3-factor structure, which showed excellent model fit, good internal consistency, and evidence of criterion validity. The CARE scale, short and quick to complete, enables therapists to reflect on and recognize their inner experiences and quantify these experiences in ways conducive to statistical analysis and research. Furthermore, the monitoring of these affective reactions toward their patients can guide therapeutic interventions and inform clinical supervisors.
Abargil, M., & Tishby, O. (2022). Countertransference awareness and treatment outcome. Journal of Counseling Psychology, 69(5), 667-677. doi: 10.1037/cou0000620.
DOI: https://doi.org/10.1037/cou0000620
Atzil-Slonim, D., Bar-Kalifa, E., Fisher, H., Peri, T., Lutz, W., Rubel, J., & Rafaeli, E. (2018). Emotional congruence between clients and therapists and its effect on treatment outcome. Journal of Counseling Psychology, 65(1), 51-64. doi: 10.1037/cou0000250.
DOI: https://doi.org/10.1037/cou0000250
Berg, J., Lundh, L. G., & Falkenstrom, F. (2019). Countertransference in Swedish psychotherapists: Testing the factor structure of the Therapist response questionnaire. Research in Psychotherapy : Psychopathology, Process, and Outcome, 22(1), 331. doi: 10.4081/ripppo.2019.331.
DOI: https://doi.org/10.4081/ripppo.2019.331
Betan, E. J., Heim, A. K., Zittel Conklin, C., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: an empirical investigation. American Journal of Psychiatry, 162(5), 890-898. doi: 10.1176/appi.ajp.162.5.890.
DOI: https://doi.org/10.1176/appi.ajp.162.5.890
Bhatia, A., & Gelso, C. J. (2018). Therapists’ perspective on the therapeutic relationship: examining a tripartite model. Counselling Psychology Quarterly, 31(3), 271-293. doi: 10.1080/09515070.2017.1302409.
DOI: https://doi.org/10.1080/09515070.2017.1302409
Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar-Quiñonez, H. R., & Young, S. L. (2018). Best practices for developing and validating scales for health, social, and behavioral research: a primer. Frontiers in Public Health, 6, 149. doi: 10.3389/fpubh.2018.00149.
DOI: https://doi.org/10.3389/fpubh.2018.00149
Brody, E. M., & Farber, B. A. (1996). The effects of therapist experience and patient diagnosis on countertransference. Psychotherapy: Theory, Research, Practice, Training, 33(3), 372-380. doi: 10.1037/0033-3204.33.3.372.
DOI: https://doi.org/10.1037/0033-3204.33.3.372
Chui, H., Li, X., & Luk, S. (2022). Therapist emotion and emotional change with clients: effects on perceived empathy and session quality. Psychotherapy, 59(4), 594-605. doi: 10.1037/pst0000442.
DOI: https://doi.org/10.1037/pst0000442
Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist response: an empirical investigation. American Journal of Psychiatry, 171(1), 102-108. doi: 10.1176/appi.ajp.2013.13020224.
DOI: https://doi.org/10.1176/appi.ajp.2013.13020224
Del Re, A. C., Flückiger, C., Horvath, A. O., & Wampold, B. E. (2021). Examining therapist effects in the alliance–outcome relationship: a multilevel meta-analysis. Journal of Consulting and Clinical Psychology, 89(5), 371-378. doi: 10.1037/ccp0000637.
DOI: https://doi.org/10.1037/ccp0000637
DeVellis, R. F., & Thorpe, C. T. (2022). Scale Development: theory and applications (5th. Ed.). Sage.
Dimmick, A. A., Callahan, J. L., & Cox, R. J. (2023). Further validation of competency assessment: the practicum evaluation form. Training and Education in Professional Psychology, 17(3), 269-276. doi: 10.1037/tep0000416.
DOI: https://doi.org/10.1037/tep0000416
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy, 55(4), 316-340. doi: 10.1037/pst0000172.
DOI: https://doi.org/10.1037/pst0000172
Friedman, S. M., & Gelso, C. J. (2000). The development of the inventory of countertransference behavior. Journal of Clinical Psychology, 56(9), 1221-1235. doi: 10.1002/1097-4679(200009)56:9<1221::AID-JCLP8>3.0.CO;2-W.
DOI: https://doi.org/10.1002/1097-4679(200009)56:9<1221::AID-JCLP8>3.0.CO;2-W
Gelso, C. (2014). A tripartite model of the therapeutic relationship: theory, research, and practice. Psychotherapy Research, 24(2), 2. doi: 10.1080/10503307.2013.845920.
DOI: https://doi.org/10.1080/10503307.2013.845920
Gelso, C. J., & Hayes, J. A. (2007). Countertransference and the therapist’s inner experience: perils and possibilities. Lawrence Erlbaum Associates Publishers.
DOI: https://doi.org/10.4324/9780203936979
Gelso, C. J., Kelley, F. A., Fuertes, J. N., Marmarosh, C., Holmes, S. E., Costa, C., & Hancock, G. R. (2005). Measuring the real relationship in psychotherapy: initial validation of the therapist form. Journal of Counseling Psychology, 52(4), 640-649. doi: 10.1037/0022-0167.52.4.640.
DOI: https://doi.org/10.1037/0022-0167.52.4.640
Gonsalvez, C. J., Deane, F. P., Terry, J., & Hoong Gooi, C. (2020). Anatomy of psychology practitioner competence: clustering approach reveals the hierarchical organization of competencies. Clinical Psychology: Science and Practice, 27(4), e12347. doi: 10.1037/h0101779.
DOI: https://doi.org/10.1037/h0101779
Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: meta-analytic findings. Psychotherapy, 55(4), 496-507. doi: 10.1037/pst0000189.
DOI: https://doi.org/10.1037/pst0000189
Hayes, J. A., & Vinca, M. (2017). Therapist presence, absence, and extraordinary presence. In L. G. Castonguay & C. E. Hill (Eds.), How and why are some therapists better than others?: Understanding therapist effects. (pp. 85-99). American Psychological Association. doi: 10.1037/0000034-006.
DOI: https://doi.org/10.1037/0000034-006
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the working alliance inventory. Journal of Counseling Psychology, 36(2), 223-233. doi: 10.1037/0022-0167.36.2.223.
DOI: https://doi.org/10.1037//0022-0167.36.2.223
Izard, C. E., Libero, D. Z., Putnam, P., & Haynes, O. M. (1993). Stability of emotion experiences and their relations to traits of personality. Journal of Personality and Social Psychology, 64(5), 847-860. doi: 10.1037/0022-3514.64.5.847.
DOI: https://doi.org/10.1037//0022-3514.64.5.847
Johnson, S. L., Leedom, L. J., & Muhtadie, L. (2012). The dominance behavioral system and psychopathology: evidence from self-report, observational, and biological studies. Psychological Bulletin, 138(4), 692-743. doi: 10.1037/a0027503.
DOI: https://doi.org/10.1037/a0027503
Jones, E. E. (2000). Therapeutic action: a guide to psychoanalytic therapy. Rowman & Littlefield.
Kimerling, R. E., Zeiss, A. M., & Zeiss, R. A. (2000). Therapist emotional responses to patients: Building a learning-based language. Cognitive and Behavioral Practice, 7(3), 312-321. doi: 10.1016/S1077-7229(00)80089-9.
DOI: https://doi.org/10.1016/S1077-7229(00)80089-9
Kyriazos, T. A. (2018). Applied psychometrics: sample size and sample power considerations in factor analysis (EFA, CFA) and SEM in general. Psychology, 09(08), 08. doi: 10.4236/psych.2018.98126.
DOI: https://doi.org/10.4236/psych.2018.98126
Latts, M. G. (1997). A revision and validation of the countertransference factors inventory. Dissertation Abstracts International: Section B: the Sciences and Engineering, 58(1-B), 0455.
Lindy, J. D., & Lindy, D. C. (2004). Countertransference and disaster psychiatry: from Buffalo Creek to 9/11. Psychiatric Clinics of North America, 27(3), 571-587. doi: 10.1016/j.psc.2004.03.009.
DOI: https://doi.org/10.1016/j.psc.2004.03.009
Meehan, K. B., Levy, K. N., & Clarkin, J. F. (2012). Construct validity of a measure of affective communication in psychotherapy. Psychoanalytic Psychology, 29(2), 145-165. doi: 10.1037/a0027450.
DOI: https://doi.org/10.1037/a0027450
Messina, I., Solina, C., Arduin, A., Frangioni, V., Sambin, M., & Gelso, C. (2018). Origins of countertransference and core conflictual relationship theme of a psychotherapist in training as emerging in clinical supervision. Psychotherapy, 55(3), 222-230. doi: 10.1037/pst0000148.
DOI: https://doi.org/10.1037/pst0000148
Moltu, C., Binder, P.-E., & Nielsen, G. H. (2010). Commitment under pressure: experienced therapists’ inner work during difficult therapeutic impasses. Psychotherapy Research: Journal of the Society for Psychotherapy Research, 20(3), 309-320. doi: 10.1080/10503300903470610.
DOI: https://doi.org/10.1080/10503300903470610
Najavits, L. M., Griffin, M. L., Frank, A., Weiss, R. D., Liese, B. S., Thompson, H., Nakayama, E., Siqueland, L., Daley, D., & Onken, L. S. (1995). Therapists’ emotional reactions to substance abusers: A new questionnaire and initial findings. Psychotherapy: Theory, Research, Practice, Training, 32(4), 669-677. doi: 10.1037/0033-3204.32.4.669.
DOI: https://doi.org/10.1037/0033-3204.32.4.669
Pallagrosi, M., Fonzi, L., Picardi, A., & Biondi, M. (2014). Assessing clinician’s subjective experience during interaction with patients. Psychopathology, 47(2), 111-118. doi: 10.1159/000351589.
DOI: https://doi.org/10.1159/000351589
Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461-472. doi: 10.1037/pst0000165.
DOI: https://doi.org/10.1037/pst0000165
Pérez-Rojas, A. E., Palma, B., Bhatia, A., Jackson, J., Norwood, E., Hayes, J. A., & Gelso, C. J. (2017). The development and initial validation of the countertransference management scale. Psychotherapy, 54(3), 307-319. doi: 10.1037/pst0000126.
DOI: https://doi.org/10.1037/pst0000126
Pope, K. S., & Tabachnick, B. G. (1993). Therapists’ anger, hate, fear, and sexual feelings: national survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research and Practice, 24(2), 142-152. doi: 10.1037/0735-7028.24.2.142.
DOI: https://doi.org/10.1037//0735-7028.24.2.142
Pope, K. S., & Vasquez, M. J. T. (2016). Ethics in Psychotherapy and counseling: a practical guide. John Wiley & Sons.
Prasko, J., Ociskova, M., Vanek, J., Burkauskas, J., Slepecky, M., Bite, I., Krone, I., Sollar, T., & Juskiene, A. (2022). Managing transference and countertransference in cognitive behavioral supervision: theoretical framework and clinical application. Psychology Research and Behavior Management, 15, 2129-2155. doi: 10.2147/PRBM.S369294.
DOI: https://doi.org/10.2147/PRBM.S369294
Price, S. D., Callahan, J. L., & Cox, R. J. (2017). Psychometric investigation of competency benchmarks. Training and Education in Professional Psychology, 11(3), 128-139. doi: 10.1037/tep0000133.
DOI: https://doi.org/10.1037/tep0000133
Revelle, W., & Condon, D. M. (2019). Reliability from α to ω: a tutorial. Psychological Assessment, 31(12), 1395-1411. doi: 10.1037/pas0000754.
DOI: https://doi.org/10.1037/pas0000754
Robinson, L., Delgadillo, J., & Kellett, S. (2020). The dose-response effect in routinely delivered psychological therapies: a systematic review. Psychotherapy Research, 30(1), 79-96. doi: 10.1080/10503307.2019.1566676.
DOI: https://doi.org/10.1080/10503307.2019.1566676
Russell, J. A., & Carroll, J. M. (1999). On the bipolarity of positive and negative affect. Psychological Bulletin, 125(1), 3-30. doi: 10.1037/0033-2909.125.1.3.
DOI: https://doi.org/10.1037//0033-2909.125.1.3
San, L., & Arranz, B. (2023). Effective patient-physician communication in the era of neuropsychopharmacology. European Neuropsychopharmacology, 71, 1-2. doi: 10.1016/j.euroneuro.2023.02.007.
DOI: https://doi.org/10.1016/j.euroneuro.2023.02.007
Shafranske, E. P., & Falender, C. A. (2008). Supervision addressing personal factors and countertransference. In C. A. Falender & E. P. Shafranske (Eds.), Casebook for clinical supervision: a competency-based approach. (pp. 97-120). American Psychological Association. doi: 10.1037/11792-005.
DOI: https://doi.org/10.1037/11792-005
Stefana, A. (2017). History of countertransference: From Freud to the British object relations school. Routledge. doi: 10.4324/9781315445601.
DOI: https://doi.org/10.4324/9781315445601
Stefana, A., Bulgari, V., Youngstrom, E. A., Dakanalis, A., Bordin, C., & Hopwood, C. J. (2020). Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review. Clinical Psychology & Psychotherapy, 27(5), 697-713. doi: 10.1002/cpp.2455.
DOI: https://doi.org/10.1002/cpp.2455
Stefana, A., Fusar-Poli, P., Gnisci, C., Vieta, E., & Youngstrom, E. A. (2022). Clinicians’ emotional reactions toward patients with depressive symptoms in mood disorders: a narrative scoping review of empirical research. International Journal of Environmental Research and Public Health, 19(22), 22. doi: 10.3390/ijerph192215403.
DOI: https://doi.org/10.3390/ijerph192215403
Stefana, A., Langfus, J. A., Vieta, E., Fusar-Poli, P., & Youngstrom, E. A. (2023). Development and initial validation of the in-Session Patient Affective Reactions Questionnaire (SPARQ) and the Rift In-Session Questionnaire (RISQ). Journal of Clinical Medicine, 12(15), 5156. https://doi.org/10.3390/jcm12155156.
DOI: https://doi.org/10.3390/jcm12155156
Stefana, A., Youngstrom, E. A., & Vieta, E. (2022). Empirical support for the use and further study of the countertransference construct in the clinical care of patients with bipolar disorder. Bipolar Disorders, 24(1), 84-85. doi: 10.1111/bdi.13153.
DOI: https://doi.org/10.1111/bdi.13153
Streiner, D. L., Norman, G. R., & Cairney, J. (2015). Health measurement scales: a practical guide to their development and use (5th Ed.). Oxford University Press.
DOI: https://doi.org/10.1093/med/9780199685219.001.0001
Tanzilli, A., Colli, A., Del Corno, F., & Lingiardi, V. (2016). Factor structure, reliability, and validity of the therapist response questionnaire. Personality Disorders: Theory, Research, and Treatment, 7(2), 147-158. doi: 10.1037/per0000146.
DOI: https://doi.org/10.1037/per0000146
Tanzilli, A., Majorana, M., Fonzi, L., Pallagrosi, M., Picardi, A., Fornari, M. A. C. de’, Biondi, M., & Lingiardi, V. (2018). Relational variables in short-term psychodynamic psychotherapy: an effectiveness study. Research in Psychotherapy : Psychopathology, Process, and Outcome, 21(3), 327. doi: 10.4081/ripppo.2018.327.
DOI: https://doi.org/10.4081/ripppo.2018.327
Tanzilli, A., Trentini, C., Grecucci, A., Carone, N., Ciacchella, C., Lai, C., Sabogal-Rueda, M. D., & Lingiardi, V. (2022). Therapist reactions to patient personality: a pilot study of clinicians’ emotional and neural responses using three clinical vignettes from in treatment series. Frontiers in Human Neuroscience, 16, 1037486. doi: 10.3389/fnhum.2022.1037486.
DOI: https://doi.org/10.3389/fnhum.2022.1037486
Tellegen, A., Watson, D., & Clark, L. A. (1999). On the dimensional and hierarchical structure of affect. Psychological Science, 10(4), 297-303. doi: 10.1111/1467-9280.00157.
DOI: https://doi.org/10.1111/1467-9280.00157
Tishby, O., & Wiseman, H. (2022). Countertransference types and their relation to rupture and repair in the alliance. Psychotherapy Research, 32(1), 29-44. doi: 10.1080/10503307.2020.1862934.
DOI: https://doi.org/10.1080/10503307.2020.1862934
Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277. doi: 10.1002/wps.20238.
DOI: https://doi.org/10.1002/wps.20238
Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22(1), 25-41. doi: 10.1002/wps.21035.
DOI: https://doi.org/10.1002/wps.21035
Watkins, M. W. (2018). Exploratory factor analysis: a guide to best practice. Journal of Black Psychology, 44(3), 219-246. doi: 10.1177/0095798418771807.
DOI: https://doi.org/10.1177/0095798418771807
Werbart, A., Gråke, E., & Klingborg, F. (2022). Deadlock in psychotherapy: a phenomenological study of eight psychodynamic therapists’ experiences. Counselling Psychology Quarterly, 35(4), 744-762. doi: 10.1080/09515070.2020.1863186.
DOI: https://doi.org/10.1080/09515070.2020.1863186
Wise, E. A. (2004). Methods for analyzing psychotherapy outcomes: a review of clinical significance, reliable change, and recommendations for future directions. Journal of Personality Assessment, 82(1), 50-59. doi: 10.1207/s15327752jpa8201_10.
DOI: https://doi.org/10.1207/s15327752jpa8201_10
Supporting Agencies
European Union’s Horizon 2020How to Cite
Stefana, A., Fusar-Poli, P., Langfus, J., Vieta, E., & Youngstrom, E. (2024). Development and preliminary validation of the Clinician Affective REsponse (CARE) scale. Research in Psychotherapy: Psychopathology, Process and Outcome, 27(1). https://doi.org/10.4081/ripppo.2024.736
Copyright (c) 2024 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
Similar Articles
- Lucia Nuñez, Sofía Fernández, Nicolle Alamo, Nick Midgley, Claudia Capella, Mariane Krause, The therapeutic relationship and change processes in child psychotherapy: a qualitative, longitudinal study of the views of children, parents and therapists , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 25 No. 1 (2022)
- Gaia Albano, Arianna Teti, Arianna Scrò, Rubinia Celeste Bonfanti, Lucia Fortunato, Gianluca Lo Coco, A systematic review on the role of therapist characteristics in the treatment of eating disorders , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 27 No. 2 (2024)
- Meltem Yilmaz, Kutlu Kağan Türkarslan, Ludovica Zanini, Dilara Hasdemir, Grazia Fernanda Spitoni, Vittorio Lingiardi, Transference interpretation and psychotherapy outcome: a systematic review of a no-consensus relationship , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 27 No. 1 (2024)
- Christine Koddebusch, Christiane Hermann, A proposed conceptualization of therapeutic competence: the three level model , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 21 No. 1 (2018)
- Fabienne Gutjahr, Cord Benecke, Crying in psychotherapy: an exploratory mixed-methods study on forms of emotional crying and associated therapeutic interventions , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 27 No. 1 (2024)
- Racheli Miller, Mark J. Hilsenroth, Paul L. Hewitt, Perfectionism and therapeutic alliance: a review of the clinical research , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 20 No. 1 (2017)
- Saryn R. Levy, Mark J. Hilsenroth, Francine Conway, Jesse Owen, Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 25 No. 2 (2022)
- Ana Nunes da Silva, Antònio Branco Vasco, Jeanne C. Watson, Alexithymia and emotional processing: a longitudinal mixed methods research , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 21 No. 1 (2018)
- Jordan Bate, Angelica Tsakas, Facilitative interpersonal skills are relevant in child therapy too, so why don’t we measure them? , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 25 No. 1 (2022)
- Hubert de Condé, Emmanuelle Zech, Jochem Willemsen, The person behind the therapist: a recall study on significant events that contribute to therapists’ personal and professional development , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 27 No. 2 (2024)
You may also start an advanced similarity search for this article.
