1. Background
Depression is one of the most common mental disorders and is the fourth major cause of disability in the world (1). A variety of psychological therapies have been proposed. One of the psychoanalytic therapies is object relation therapy.
In various object relation approaches, depression is conceptualized in different ways such as reactivation of depressive position (2). In one recent approach of object relation, depression has been regarded as a kind of defect in self, which arises from the lack on necessary appropriate to create an authentic self rooted in emotions, or in other words, what self needs to be lively (3, 4).
In this approach, Summers (4-7), based on the object relation model, emphasizes on 2 critical phases in his therapy. The first one is the interpretation phase, which puts an emphasis on the client's defense mechanisms, client-analyst relation, transference, the client’s primary attachment, internalization of these relations, and insight. In the second phase, an opportunity is provided for new patterns to be created and for arrested potentials to be developed using the potential space. He believes that, in addition to interpretation, the analytic space should provide a chance for new patterns to be created and replace the current pathological ones. Potential space does not bear a meaning and any meaning in this space is potential and future-oriented. It emphasizes on self creation by client.
Understanding the nature of therapy the clients suffering from depressive disorder can play a vital role in the facilitation of therapy and boosting its effectiveness. Whilst the current theory tries to shed light on the nature of therapy for clients suffering from depressive disorder, there is still ambiguity about factors influencing this kind of therapy, which is exacerbated by the lack of evidence on how clients perceive this therapy.
2. Objectives
Reviewing recent quantitative studies (e.g. (8, 9)) regarding the effect impact of psychoanalysis on depression reveals the correlation between the quantitative approach and pre-determined mind frames. Since such positivistic paradigm lacks the capability to offer an understanding of the nature of therapy and does not consider this on the basis of client’s understanding, the present study was conducted in order to understand factors which affect this type of therapy.
3. Materials and Methods
This study is a qualitative research, which was carried out using the content analysis method proposed by Graneheim and Lundman (10).
3.1. Participants
The participants in this study included 18 clients who were purposefully selected from clients who were diagnosed with depressive disorder SCID-I/CV, had received object relation therapy based on transference and potential space on a weekly basis for at least one year, and were willing to participate in the study.
Data collection continued until it was determined that data saturation has been reached. The demographic characteristics of participants are shown in Table 1.
Table 1.Characteristics of Participants
| Code | Gender | Age | Marital Status | Education | Duration of Therapy, y |
|---|---|---|---|---|---|
| 1 | M | 40 | Single | Ph.D | 4.5 |
| 2 | F | 32 | Single | Post-doctorate | 2 |
| 3 | F | 34 | Married | Graduate | 3.5 |
| 4 | M | 32 | Married | Post-graduate | 4 |
| 5 | M | 39 | Married | Graduate | 9 |
| 6 | F | 34 | Married | Ph.D | 7 |
| 7 | F | 34 | Married | Graduate | 4 |
| 8 | F | 32 | Married | Ph.D | 2.5 |
| 9 | F | 29 | Single | Post-graduate | 3 |
| 10 | F | 32 | Single | Post-graduate | 1 |
| 11 | F | 26 | Single | Post-graduate | 2.5 |
| 12 | F | 39 | Single | Ph.D | 5 |
| 13 | M | 25 | Single | Ph.D | 3 |
| 14 | F | 35 | Married | Graduate | 3 |
| 15 | F | 38 | Married | Post-graduate | 1.5 |
| 16 | M | 28 | Single | Graduate | 3.5 |
| 17 | F | 36 | Divorced | Post-graduate | 3 |
| 18 | F | 30 | Single | Graduate | 1 |
3.2. Procedure
Data were collected through in-depth semi-structured interview. Subjects were interviewed at the clinic of the school of behavioral sciences and mental health (formerly Tehran Institute of psychiatry) and their workplace. Interviews were recorded and transcribed. Each interview session lasted from 1 to 2.5 hours in once or twice.
To adhere to ethical principles, approval of the ethics committee of Iran’s University of Medical Sciences was obtained. In addition, the participants were informed of the goals and methodology of the study, they were informed that the sessions will be audio-recorded, and were also asked to fill out and sign a written consent. They were also informed of their right to withdraw from the study at any time during the course of the study.
3.3. Data Analysis
The method consists of 4 stages: choosing a unit of analysis, detecting the meaning units and referring to a key word, the process of shortening while preserving the core, and description and interpretation on a higher logical level and creation of categories.
To prepare the data for analysis, each transcript was read several times in order to identify its meaning units. Then, they were condensed with a close description of data. After that, a list of codes was developed and reviewed from a semantic point of view. Afterwards, by specifying the differences and similarities in meanings, common codes were determined on a more abstract level using the method of reduction and induction. Data analysis was performed by the research team and all the codes and categories were approved during consecutive sessions.
For the purpose of trustworthiness, member check, peer check, and external checks were done. In order to understand the participants’ statements better, findings were presented to them so that fitness of data labeling to participants’ experience was approved (member check). In addition, some of the writings were reviewed by those faculty members who were familiar with the qualitative research method (peer check). Dependability was achieved through audit trail by 2 experts who supervised data documentation and analysis. Effort was also put in achieving data credibility through sampling people with highest variation, different demographic classes, and people who received therapy for different lengths of time.
4. Results
Data analysis showed that influential factors are 2 main categories of “formation of analytic dyad” and “development of self-expression and self-awareness” as well as 4 subcategories (Table 2).
Table 2.Emerged Categories and Subcategories Related to Content Analysis of Therapeutic Process
| Main Categories | Subcategories |
|---|---|
| Formation of analytic dyad | 1. Gradual formation of therapeutic alliance |
| 2. Use of non-interpretive techniques | |
| Development of self-awareness and self-expression | 1. In-depth examination of client’s experience |
| 2. Client’s emotional expression |
4.1. Formation of Analytic Dyad
This category refers to the creation of therapeutic relationship. The subcategories are “gradual formation of therapeutic alliance” and “use of non-interpretive techniques”.
4.1.1. Gradual Formation of Therapeutic Alliance
Formation of analytic dyad is one of the influential factors. Providing a safe space by the therapist, holding and containing the client, optimal responsiveness of the therapist towards the client’s emotional needs, and managing the time of sessions by the therapist affect the formation of analytic dyad.
The safe space, in turn, is created by several actions of the therapist, which are confidentiality and non-judgmental behavior of the therapist, careful listening and remembering by the therapist, paying attention to the client’s readiness for presenting crucial topics, and considering the client’s mental capacity.
For clients, containing and holding the client by the therapist when are needed, helped to stay away from unnecessary confrontation with intense and unbearable emotions until the time was ripe.
This optimal responsiveness was based on the client’s frustration and satisfaction and put the therapist in a situation where he or she would be good enough for the client, however it never ended in satisfaction.
The clients’ psychological needs include the need to be accepted and respected, acceptance of all of his or her painful feelings and emotions and their talks, the therapist’s empathy with the client and viewing the world from the his or her point of view, the therapist’s availability, and attunement with the client’s needs and conditions.
Managing the time included starting and finishing sessions on time, integrating appropriate time intervals between clients, and not bringing up critical issues near the end of the sessions, which conveyed the sense of respect and punctuality of the therapist and provided a stable and safe model, which in turn increased predictability and gave the client a sense of security.
4.1.2. Use of Non-Interpretive Techniques
These techniques included the therapist’s supportive interventions, emphatic confrontation by gradual presentation of questions related to conflicting words, thoughts, or feelings without causing guilt feelings in the client or attacking him or her, and avoiding sudden confrontation; direct intervention of the therapist in necessary conditions in the sense of inhibiting the client from acting out their feelings; the therapist’s reflective functioning in the sense of returning what the client has brought to the session, especially reflecting the therapist’s vision of the client’s potentials and capacities.
The therapist’s supportive interventions included joining with the client, reassurance, normalization of thoughts, feelings, and fantasies.
4.2. Development of Self-Awareness and Self-Expression
For clients, the prominent factor in therapy is the development of self-awareness and self-expression. In-depth exploration of the clients’ experiences and expression of feelings falls under this category.
4.2.1. In-Depth Exploration of the Client’s Experiences
In this subcategory, all feelings, thoughts, behaviors, and fantasies of the client in the analytic dyad are examined. This subcategory includes the therapist’s neutral stance, in-depth and insightful inquiries, interpretations, and addressing client’s free associations.
Having no family relation with the therapist, not taking sides in the client’s conflicts, and taking an unbiased stance, from which they can examine the client’s experiences and conflicts accurately, constitute the neutral stance. The therapist’s silence and avoiding countertransference provides a noise-free condition, which facilitates the development of self-awareness.
In-depth examination of all the client’s thoughts, feelings and behaviors from now to the past, from the surface to the depth, and here and now, and in transference relation and its ups and downs, too extra-transference relations and relation with important people from the past, sorting out and discovering the relations between them, and recognizing the constant patterns constitute the in-depth and insightful inquiry.
Interpretation of the client’s experiences, which sheds light on patterns, was done considering several factors: timing of the interpretation, the dose of interpretations, which started by connecting small topics and continued to deep and general pattern, and interpretation tact, which was accurately based on the client’s mental experiences.
4.2.2. Client’s Emotional Expression
This includes catharsis by the client, verbalization of the deepest parts of self, and expression of feelings at the time of regression.
Expression of deep, repressed, and painful feelings at the time of inquiry and regression can comfort the client and lead to connection to the deepest parts of self, which had never been reached before. Verbalizing these feelings not only makes the clients hear themselves for the first time, but also helps the development of self-awareness.
5. Discussion
Analyzing the experiences of clients suffering from depressive disorder about object relation therapy based on transference and potential space resulted in 2 categories. From the patient’s viewpoint, the formation of analytic dyad creates a safe space for the development of self-awareness and self-expression, which in turn through creating a safe space filled with trust facilitates self-inquiry, helps to consolidate the analytic dyad and advances the therapy.
The formation of analytic dyad created a safe space for the patient through an intimate, safe and trustful relation, optimal responsiveness toward the client’s emotional needs, and use of non-interpretive techniques in order to create therapeutic alliance. This helped the patient to gradually talk about feelings, events or fantasies, which were unpleasant, dangerous or even forbidden. The therapist could facilitate the acceptance of such feelings and open the space to talk about such topics through keeping and tolerating them. This was in accordance with previous experimental research of importance of therapeutic relation (11, 12). The emphasis of the present study on analytic dyad conforms to psychoanalytic writings about the significance of new relational experiences in therapy (13, 14), especially in interpersonal viewpoint of psychoanalysis (15-17). Therapeutic relationship is considered as the re-creation of child-parent relationship, which aims to mend deficits (18). According to Wallin (19), “psychotherapy is a kind of self-transformation through relationship in which the attachment of the client to the therapist is a fundamental issue because it provides a secure base for inquiry, development and change”. In this study, patients had the opportunity to discover, test, and revise the internal representation of themselves and others with the therapist in a trustful space. The client’s roots of patterns were discovered with active participation of the therapist. As a result of this, the patient found the therapeutic space safer, which facilitated self-awareness and self-expression.
In addition, the clients described the category of development of self-awareness and self-expression as a process in which they made a joint inquiry with the therapist. Here, the therapist was considered as an active participant who intervened with asking questions, relating topics, examining feelings, behaviors and fantasies, and interpreting. The results of this study are in line with the findings of the studies (11, 12, 20), which emphasize the development of self-awareness and inquiry into patterns. The significance of discovering patterns in a person’s behavior and relating them to the past, as well as, addressing transference and countertransference conforms to the psychoanalytic literature, which considers the development of self-expression as a principle in therapy (21, 22). Moreover, the emphasis of the current study on the patient’s ability for self-expression and free association agrees with the strategies of psychoanalysis in therapeutic action (23, 24).
There has long been a gap between 2 approaches: the ones that emphasize interpretation, unconscious conflicts, memories of early experiences, unconscious fantasies, defense mechanisms, resistance, transference, and insight in therapeutic action, as well as the ones that emphasize on therapeutic relationship in therapeutic action and, as an example, gaining insight by the client was related to the gaining insight in the relationship. This gap has had an effect on the therapist’s listening and intervention. A number of studies have addressed both approaches (for example, (25-30), however, in none of them, have these concepts studied as interactive concepts with mutual effect. In other words, each study has focused on one aspect of the psychoanalytic therapy and has either ignored the other essential aspect or considered it as less important. Since the present study emphasizes the importance of both therapeutic relationship and insight and unconscious interpretation, and conceptualizes them in an integrated and uniform manner, it offers a new perspective on the therapeutic process. This new prospect is achieved in the context of transitional space and is derived from the mental experiences of the clients and, more than the merely theoretical approaches, benefits from clients’ metaphors and words in understanding the therapeutic action. From the clients’ point of view, the therapeutic process, in object relation therapy based on transference and potential space uses therapeutic relation and expansion of self-consciousness and discovering patterns in the therapeutic action, both of which interact with each other. Contrary to the articles mentioned above, in which some theorists emphasize on the relational experience in therapy and consider the interpretation as a form of relational experience, and others highlight client’s intrapsychic experiences and interpretation of subconscious conflicts, the results of the present study show that this approach, from clients’ point of view, integrates these 2 important aspects of therapy. The findings showed that formation of analytical dyad and creation of a safe therapeutic space provide a space for exploring habitual and pathological patterns and emotional impulses that have never found the opportunity to be expressed. Moreover, investigation of such patterns and developing insight into them lead to an increase in clients’ trust in the presence of the therapist and the safe therapeutic space and facilitate the positive self-inquiry cycle. Both of these approaches can lead to new ways of being and relating to others.
The study has some limitations. Since the object relation therapy based on transference and potential space has been newly introduced in Iran, not many therapists are trained in it and use it in their work. This limited the selection of participants for the study. In addition, because the majority of the clients are from the socially and economically upper-class, there was a limitation in choosing people from the lower-class.
Future researches can address facilitating and hindering factors of therapy in this model. Conducting a research based on grounded theory and developing a theory, which originates from clients’ mental experience of therapeutic process, can play a significant role in gaining insight into various aspects of this model of therapy. In addition, in future studies, integrating a qualitative and quantitative approach can lead to a better understanding of therapeutic action in object relation therapy based on transference and potential space. Investigating therapeutic action from therapists’ point of view can play a significant role in making this model more applicable.
5.1. Conclusion
The present study confirmed that the formation of safe therapeutic space can result in a sense of security due to the trustworthiness of the other individuals presence. This space creates the appropriate context for exploring habitual and pathological patterns in transference and extra-transference space and provides space for expression of repressed emotions. The importance of safe therapeutic space becomes more evident when insight is gained into pathological patterns and is challenged in the therapeutic process. In this circumstance, clients need another person who can feel and contain their sense of threat so that they can explore new ways of being and relating.
