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. 2025 Jul 10;32(4):e70118. doi: 10.1002/cpp.70118

Transference Assessment in Psychotherapy: A Systematic Review

Francesca Marazzi 1, Alberto Stefana 1, Arianna Vecchio 2,✉, Martina Maria Mensi 1,2
PMCID: PMC12245497  PMID: 40639788

ABSTRACT

Transference, initially introduced by Sigmund Freud, represents a crucial concept in psychoanalysis, referring to the displacement of feelings, fantasies, and desires from past relationships onto the therapist. Though central to psychoanalytic therapies, transference is acknowledged across many psychotherapeutic approaches, albeit with differing views on its clinical relevance. Empirical research has shown that transference phenomena occur in all close relationships, including therapeutic settings, and are influenced by factors like the patient's attachment style. While the relationship between transference and therapy outcomes remains ambiguous, insights gained from transference work—particularly through its interpretation—are seen as beneficial to therapeutic progress, enhancing patient's awareness and improving treatment results. This systematic review examines the development and validation of 15 assessment tools for measuring transference, offering a comprehensive overview of instruments used across various psychotherapies. The tools vary in their method of data collection, including observational ratings, clinician reports, and patient self‐reports. The review highlights the need for further studies comparing these instruments, exploring their effectiveness across different patient populations, and addressing the relationship between transference and therapeutic alliance to improve clinical practice.

Summary

  • Transference, conceptualized as any affective, cognitive and/or behavioural responses of the patient toward their therapist, is a key phenomenon within psychotherapy.

  • Fifteen measures are available that assess transference: eight observer‐rated scales, four clinician‐report measures, and three self‐report measures.

  • Transference assessment measures can be used in different psychotherapeutic approaches to support clinical practice.

1. Introduction

The concept of transference, as originally articulated by Sigmund Freud, refers to the displacement onto the analyst of feelings, fantasies, desires or entire relational scenarios that reproduce psychological experiences from significant and formative past relationships (Breuer and Freud 1895; Freud 1888, 1905). Within Freud's theoretical framework, the interpretation of transference represents an essential and primary component of the analytic technique, serving as a critical means of facilitating insight (Freud 1912). Through the process of transference interpretation, patients gain awareness of their relational patterns and have the opportunity to engage in a qualitatively different relationship with the therapist, thereby accessing and translating unconscious material in new ways (Heimann 1956).

While the exploration and interpretation of transference remain hallmark techniques of psychoanalytic and psychodynamic therapies (Kernberg 2016; Levy and Scala 2012), the phenomenon itself is recognized across most major psychotherapy approaches. A growing body of empirical research has demonstrated that transference phenomena—albeit varying in type and intensity—emerge in all close interpersonal relationships (Andersen and Przybylinski 2012) and across different psychotherapeutic modalities (Gelso and Bhatia 2012). Notably, several studies have found that the therapist's theoretical orientation does not significantly influence their perceptions of transference. For instance, Gelso et al. (2005) reported no association between the therapist's adoption of a humanistic/experiential or cognitive‐behavioural approach and their perception of transference. Consistent with these findings, Bradley et al. (2005) demonstrated that psychodynamic, cognitive and eclectic clinicians produced comparable factor structures when rating transference items for randomly selected patients. Similarly, Connolly et al. (1996) found no significant differences in the frequency or content of transference as reported by patients undergoing psychodynamic versus cognitive‐behavioural therapy. Collectively, these findings suggest that therapists' theoretical orientation exerts minimal influence on their perceptions, awareness, and evaluation of transference phenomena.

Emerging research also highlights the association between transference and other key constructs in psychotherapy, such as patients' attachment styles and the quality of the therapeutic alliance. For instance, studies have shown that patients with higher levels of attachment‐related anxiety tend to evoke stronger perceptions of transference, particularly of negative valence, in their therapists (Marmarosh et al. 2009; Woodhouse et al. 2003). Moreover, specific types of transference have been linked to particular personality disorders (Bradley et al. 2005; Tanzilli et al. 2018; Colli et al. 2016). In relation to the therapeutic alliance, evidence suggests that transference significantly predicts alliance quality during psychotherapy (Zilcha‐Mano et al. 2014). Alliance ruptures—known to predict poorer treatment outcomes when left unaddressed (McLaughlin et al. 2014)—may arise from conflictual emotional processes manifesting in patients' in‐session relational patterns (Safran et al. 2011; Zilcha‐Mano et al. 2014). A nuanced exploration of transference and alliance ruptures may therefore enable therapists to effectively manage the alliance by addressing maladaptive interpersonal expectations as they emerge. However, the relationship between transference and session‐ or treatment‐level outcomes remains inconclusive, as studies have yielded mixed results (Bhatia and Gelso 2018; Gelso et al. 2005; Marmarosh et al. 2009).

Given these findings, further empirical investigation into the nature, assessment and clinical implications of transference in psychotherapy is warranted. Although several instruments have been developed to assess transference phenomena from an analytic perspective, there is currently no comprehensive, up‐to‐date synthesis of the available tools designed to evaluate patients' perceptions and affective reactions toward their therapist following a psychotherapy session.

The present study aims to address this gap by conducting a systematic review of existing instruments designed to assess transference, broadly conceptualized as any affective, cognitive, and/or behavioural responses of the patient toward their therapist. Specifically, the present review examines the main characteristics of these tools—including their theoretical underpinnings, methods of administration, and psychometric properties—as well as their areas of application across different psychotherapeutic approaches.

2. Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA 2020) guidelines (Page et al. 2021).

2.1. Search Strategy and Selection Criteria

A systematic search was performed using PubMed, PsycINFO, Scopus and CINAHL, covering each database from inception to May 2025. The search was adapted to the specific requirements of each database and employed the following keywords: Transference OR ‘Psychotherapeutic Processes’ OR ‘emotional response*’ OR ‘emotional reaction*’ OR ‘affective response*’ OR ‘affective reaction*’ OR ‘subjective experience*’) AND (‘Psychological Tests’ OR ‘validation’ OR ‘questionnaire development’) AND (‘Psychotherapy’).

2.2. Eligibility Criteria

Studies were included if they (1) reported the development or validation of a measure of transference (here defined broadly as any affective, cognitive or behavioural reactions of a patient toward their therapist); (2) were conducted in English; and (3) presented original data. Studies were excluded if they (1) were case reports or reviews and (2) were published in languages other than English. We therefore applied the filter ‘limit results to English language’ in the search.

2.3. Study Selection

An initial search identified 3652 records, which we analysed to exclude duplicates using the online tool Deduplicator (see https://sr‐accelerator.com). Abstracts were then examined with the support of the Rayyan platform (http://rayyan.qcri.org) to assess their suitability to our work. Two researchers (FM and AV) independently screened the records identified during the search. Disagreements were resolved through mutual discussion.

We independently screened 3514 papers by title and abstract, adhering to the eligibility criteria. After resolving disagreements, we analysed 66 full‐text records based on the inclusion criteria.

Figure 1 presents the study selection process in a PRISMA flowchart (Haddaway et al. 2022). The review screening yielded 16 articles for inclusion in the present study, and we assessed additional 31 articles identified via other methods. In total, the present study describes 15 instruments, whose development and validation are detailed in 47 articles.

FIGURE 1.

FIGURE 1

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PRISMA flowchart of the study selection process.

2.4. Data Extraction

From each article, the following data were extracted: (1) study characteristics (e.g., author(s), year of publication, country and study design), (2) population characteristics (e.g., sample size, age), (3) psychotherapeutic approach, (4) key psychometric properties of the measures (e.g., internal consistency coefficients) and (5) a description of the tools.

3. Results

Among the instruments, eight were observer‐rated scales, in which trained raters evaluated transcripts, audiotapes or videotapes of psychotherapy sessions to assess the patient's emotional reactions toward the therapist. Four instruments were clinician‐report measures, and three were self‐report measures. Table 1 presents the instruments included in the review.

TABLE 1.

Instruments included in the review.

Name Description Construct Factors/subscales Population Scale validation steps
AD CH ADO EFA CFA IR IRR
Observer‐rated scales
Core Conflictual Relationship Theme (CCRT) Luborsky 1977

Judges examine the transcripts of psychotherapy sessions

Judges make a tailored theme formulation according to the CCRT standard structure

 Recurrent interpersonal patterns CCRT focuses on three main aspects of patients' relationship narrative:

  1. Wishes, needs or intentions expressed by the patient (Ws)

  2. Expected or actual responses of the object (ROs)

  3. Response of the self (RSs, such as emotional, behavioural reactions of the client to other's response)

 ✓ ✓
Core conflictual relationship theme: conflictual patterns of interactions with other people and the therapist, focused on the clients' core desire, the response to it they typically elicited from other people (RO), and their reaction in turn to that response (RS). A minimum of 10 relationship episodes are usually used as a basis for scoring the CCRT.

Vanderbilt Psychotherapy Process Scale (VPPS)

Gomes‐Schwartz and Schwartz (1978)

84 items at the beginning

Clinical judges rate either the actual therapy session, or audio‐ or video‐recordings of the sessions

5‐point Likert‐scale from 1 (not at all) to 5 (a great deal)

Each subscale is scored independently.

Process of psychotherapy: the quality of interaction between patients and therapists; both positive and negative aspects of patients and therapists' behaviours and attitudes that are expected to facilitate or impede progress in therapy.

 Therapeutic process
Items are divided into 8 subscales (Gomes‐Schwartz and Schwartz 1978):
  1. Patient participation (k = 8)
  2. Patient hostility (k = 6)
  3. Patient psychic distress (k = 9)
  4. Patient exploration (k = 7)
  5. Patient dependency (k = 6)
  6. Therapist exploration (k = 13)
  7. Therapist warmth and friendliness (k = 9)
  8. Negative therapist attitude (k = 6)
Gomes‐Schwartz (1978) included 45 items divided into 7 scales:
  • 1
    Patient Exploration (k = 7)
  • 2
    Therapist
Exploration (k = 7)
  • 3
    Patient Participation (k = 7)
  • 4
    Patient Hostility (k = 6)
  • 5
    Therapist Warmth and friendliness (k = 10)
  • 6
    Negative Therapist Attitude (k = 3)
  • 7
    Therapist

Directiveness (k = 5)

 ✓ ✓ ✓ ✓

Patient's Experience of the Relationship Scale (PER)

Gill and Hoffman 1982

Judges code the transcripts of single audio‐ recorded sessions of psychotherapy

Judges code communications when applicable to categories in the PER coding scheme.

Patient's experience of relationship: indications of resisted aspects of the patient's experience of the relationship with the therapist; the preconscious points of attachment of the transference in the analytic situation.

 Subjective experience of the patient in the therapeutic relationship Jurich and Richardson (2001) better explore the PER scale, individuating two patient variables and two therapist variables. These included indirectly expressed themes by patients about their experience of the therapeutic relationship (Jxr); points during the session where the therapist and patient directly address the relationship (R and r, respectively); and interventions made by the therapist to encourage the patient to talk about the therapeutic relationship (ER). ✓ ✓

Quantitative Assessment of Interpersonal Themes (QUAINT)

Crits‐Christoph et al. 1990

It is based on the CCRT. Raters examine the transcripts of psychotherapy sessions.

91 items

5‐point Likert‐scale from 1 (not present) to 5 (strongly present) to evaluate each item.

Interpersonal themes: the components of relationship themes as they are repeated in narratives about episodes of interactions between a patient and others in his life.

 Interpersonal themes and relational patterns QUAINT employs three standard categories:

  1. Wishes, needs and intentions of the patient toward the other person (k = 32)

  2. Responses of the main other person (k = 30)

  3. Responses of the self (k = 29).

 ✓ ✓

Transference Work Scale (TWS)

Ulberg, Amlo, Critchfield, et al. 2014

26 items

Raters value transcripts of the psychotherapy sessions.

Yes/no responses (8 items)

5‐point Likert‐scale from 0 (not at all) to 4 (very much) (16 items).

It is initially decided whether timing, valence, content, response are present in the transcribed segment. Each subscale, if present, is evaluated independently.

Transference work: the patient–therapist relationship, including timing, content and valence of the therapist's transference interventions as well as the response from the patient.

 Transference interventions Items are divided into 4 subscales concerning the transference work:

  1. Timing (k = 4)

  2. Valence (k = 2)

  3. Content (k = 7)

  4. Response (k = 3)

 ✓ ✓ ✓ ✓

Psychotherapy Process Q‐Set (PQS)

Jones 1985

100 items

It employs the Q‐sort methodology to a single recorded session. Each item is rated on a 9‐point scale, ranging from 1 (least characteristic) to 9 (most characteristic).

 Therapeutic process
Items describe three specific aspect of the patient–therapist interaction:
  • 1
    Therapist behaviours
(k = 41)
  • 2
    Patient behaviours
(k = 40)
  • 3
    Dyadic interactions

(k = 19)

 ✓ ✓ ✓

Adolescent Psychotherapy Q‐ Set (APQ)

Calderon et al. 2017

100 items

It uses a Q‐sort methodology applied to a single recorded session. Clinical judges sort items into 9 categories, ranging from 1 (least characteristic) to 9 (most characteristic), evaluating what is more unique to the psychotherapy process of an adolescent.

Psychotherapy process in three aspects: (1) the young person's feelings, experience, behaviour, and attitudes; (2) the therapist's attitudes and actions; and (3) the nature of the interaction of the dyad.

 Therapeutic process Items describe three specific aspects of the psychotherapy process:

  1. Adolescent's feelings, experience, behaviour and attitudes (k = 40)

  2. Therapist's attitudes and actions (k = 30)

  3. Nature of the interaction of the dyad or the emotional atmosphere of the encounter (k = 30)

 ✓ ✓
Child Psychotherapy Q‐Set (CPQ; Schneider 2004)

100 items

It employs the Q‐sort methodology to a single recorded session. Each item is rated on a 9‐point scale, ranging from 1 (least characteristic) to 9 (most characteristic).

 Therapeutic process
Items are divided into three categories:
  1. Items describing child emotion states and behaviour or experience (k = 48)
  2. Items reflecting the therapist actions and attitudes (k = 30)
  3. Items attempting to capture the nature of the interaction of the dyad, the climate or atmosphere of the encounter (k = 22)
 ✓
Therapist‐rated scale

Transference Items of the Therapy Session Check Sheet (TSCS‐TI)

Graff and Luborsky (1977)

3 items

5‐point Likert‐scale from 1 (none or slight) to 5 (very much)

Transference: the degree to which the client deals with material that is overtly or covertly related to the counsellor and is a manifestation or displacement of earlier relationships. The earlier person need not be mentioned but may be inferred (e.g., because of distortion, strong and/or inappropriate affect).

 TT The TSCS‐TI contains the three items of TSCS concerning the transference:

  1. Overall amount of transference

  2. Positive transference

  3. Negative transference

 ✓ ✓
Missouri Identifying Transference Scale (MITS) Multon et al. 1996

37 items

5‐point Likert‐scale from 1 (not evident) to 5 (very evident)

Two subscales: negative transference reactions (NTR) and positive transference reactions (PTR). The NTR score ranges from 25 to 125, while the PTR score variables from 12 to 60.

Manifestations of transference: a displacement of some of what a client has learned about human relationship in contacts with significant figures (e.g., mother, father, and siblings) during his or her formative years.

 TT MITS is composed of two subscales:

  1. Negative transference reactions (k = 25)

  2. Positive transference reactions (k = 12)

 ✓ ✓ ✓

Psychotherapy Relationship Questionnaire (PRQ)

Westen et al., 2000

64 items

5‐point Likert scale from 1 (not true) to 5 (very true)

Transference patterns: the patient's relational patterns in psychotherapy or the patient's responses to the clinician (including thoughts, feelings, affect regulation strategies, behaviours, motives and conflicts)

 Operational transference
PRQ is composed by 5 transference patterns:
  1. Angry/entitled (k = 25)
  2. Anxious/preoccupied (k = 13)
  3. Secure/engaged (k = 12)
  4. Avoidant/counterdependent (k = 9)
  5. Sexualized (k = 5)
Tanzilli et al. (2018) have divided the original angry/entitled dimension into two new factors (hostile and special/entitled) and they identified 6 transference patterns:
  1. Hostile (k = 13)
  2. Positive/working alliance (k = 12)
  3. Special/entitled (k = 9)
  4. Anxious/preoccupied (k = 9)
  5. Avoidant/dismissing attachment (k = 7)
  6. Sexualized (k = 5)
 ✓ ✓ ✓ ✓
In‐Session Patient Affective Reactions Questionnaire–Clinician form (SPARQ‐C; Stefana et al., 2025)

8‐item clinician‐report questionnaire

It assesses therapist's perception of their patient's positive and negative affective reactions toward them during the most recent individual psychotherapy session. Each statement is rated on a 5‐point Likert scale, ranging from 0 (not at all) to 4 (very much).

 TT

  1. Positive affect scale (k = 4)represents therapist's perception of the patient as feeling being cared for, appreciated, respected and guided by them.

  2. Negative affect scale (k = 4) represents therapist's perception of the patient as feeling shyne and shame with them, fear of speaking openly, worry of not being helped, and a sense of personal failure due to his/her need for help from the therapist.

 ✓ ✓ ✓ ✓
Patient‐rated scales
Client Reactions System (Hill et al. 1988)

21 items

It measures the feelings and experiences that clients have in response to therapist interventions. Reactions during the therapy session are identified by clients during a review of the audio or videotape conducted immediately after the session. The tape is stopped after each therapist speaking turn, and the client identifies up to three reactions he or she had to that statement.

 Phenomenological reactions of the patient in response to the therapist The 21 nominal, nonmutually exclusive clients reactions are organized into 5 clusters:

  1. Supported (k = 4):

  2. Therapeutic work (k = 9)

  3. Challenged (k = 1)

  4. Negative reactions (k = 6)

  5. No reaction (k = 1)

 ✓
In‐Session Patient Affective Reactions Questionnaire (SPARQ; Stefana et al. 2023, Stefana et al. 2024)

8‐item self‐report questionnaire

It asks patients to rate their positive and negative affective reactions toward their therapist during their most recent individual psychotherapy session. Each statement is rated on a 5‐point Likert scale, ranging from 0 (not at all) to 4 (very much).

 TT

  1. Positive affect scale (k = 4) represents patient's perception of being cared for, appreciated, respected and guided by the therapist.

  2. Negative affect scale (k = 4) represents patient's feelings of shyness and shame with the therapist, fear of speaking openly, worry of not being helped, and a sense of personal failure due to their need for help from the therapist.

 ✓ ✓ ✓ ✓
Rift In‐Session Questionnaire (RISQ; Stefana et al. 2023)

4‐item self‐report questionnaire

It measures the patient's tendency to feel demeaned by their therapist during their most recent individual psychotherapy session. Each item is rated ‘Yes’ or ‘No’ to indicate whether they have experienced those feelings.

 TT (1) Rift factor (k = 4) describes the patient's tendency to feel disparaged, belittled, rejected and attacked by their therapist. ✓ ✓ ✓ ✓
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3.1. Observer‐Rated Measures

The observer‐rated measures identified include the Core Conflictual Relationship Theme (CCRT), Vanderbilt Psychotherapy Process Scale (VPPS), Patient's Experience of the Relationship (PER), Quantitative Assessment of Interpersonal Themes (QUAINT), Transference Work Scale (TWS), Psychotherapy Process Q‐Set (PQS), Adolescent Psychotherapy Q‐Set (APQ) and Child Psychotherapy Q‐Set (CPQ).

3.1.1. Core Conflictual Relationship Theme

The CCRT is an analytic method developed by Luborsky (1977) to measure a patient's recurring central relationship pattern within talking therapy and guide its exploration. In the first phase, raters review therapy session transcripts to identify relevant narrative sections, termed ‘relationship episodes’ (REs). In the second step, another group of raters evaluates these REs and identifies three key aspects of interactions. Thus, the CCRT serves as a system to guide clinical judgement regarding the relational patterns central to psychotherapy sessions (Luborsky et al. 1986). Raters use their own words to define the wishes and responses that best represent each narrative, focusing on three core elements: the patient's wishes, needs, or intentions expressed (Ws); the expected or actual responses of the other (ROs); and the patient's emotional or behavioural reactions (RSs).

To examine the CCRT's usefulness as a measure of transference, Luborsky et al. (1986) compared its results with nine of Freud's (1912) observations on transference, based on an earlier study of eight patients (Luborsky et al. 1985). These studies re‐examined Freud's observations regarding transference and demonstrated that each person has a specific transference model derived from primary relationships, which is applied consistently across relationships and includes both conscious and unconscious components. Furthermore, the therapeutic relationship reflects this transference model while also extending to relationships outside psychotherapy (Luborsky et al. 1985, 1986). Although not specifically designed to assess transference, the CCRT has been effectively used for this purpose in adult psychotherapy research. In a medium‐sized sample of 35 patients, Crits‐Christoph (1988) showed that the CCRT can reliably assess relational patterns in psychotherapy. In their work, Luborsky and Crits‐Christoph (1990) collected and described numerous clinical cases and provided guidance for identifying each patient's central recurrent relationship and formulating CCRT‐based interventions. This line of research showed how the more the therapist focuses on central relational conflicts, the more the patient benefits from therapy. Vanheule et al. correlated depression themes that emerged in sessions with CCRT categories and found that more severe depression in 31 outpatients was associated with specific transferential themes (Vanheule et al. 2006). Beretta et al. observed that in 40 adult patients paired with nine psychodynamic therapists, transference reactions appear early in psychotherapy and reflect internalized objects reactions (Beretta et al. 2007).

Regarding the reliability of the CCRT, the pooled intraclass correlation was 0.68, with a per‐judge intraclass correlation of 0.51 (Crits‐Christoph 1988).

3.1.2. Vanderbilt Psychotherapy Process Scale

The VPPS was developed by the Vanderbilt group, based on the Therapy Session Report (TSR) (Orlinsky and Howard 1967), to assess positive and negative aspects of the psychotherapy interaction that influence therapeutic progress (Strupp et al. 1974). The VPPS is designed for evaluation by an external clinical observer, either at the end of a session or via audio or video recordings (Suh et al. 1989). Its items were intentionally selected to remain neutral regarding any specific psychotherapy orientation; each item is rated on a Likert scale from 1 (not at all) to 5 (a great deal). Two versions of the scale exist and differ in the allocation of the 84 items into either eight (Gomes‐Schwartz and Schwartz 1978) or seven (Gomes‐Schwartz 1978) subscales. These subscales capture patient characteristics such as the level of exploration, engagement in therapy, emotional stance and negativism during the session.

The eight‐subscale version demonstrates strong internal consistency (average Cronbach's α = 0.82) and high interrater reliability (average r = 0.82) (Strupp et al. 1974). In this version, Cronbach's α coefficients ranged from 0.83 to 0.91 for seven subscales, with negative therapist attitude (k = 3) showing α = 0.65 (Gomes‐Schwartz 1978). Interrater reliability ranged from 0.82 to 0.93, except for patient participation (r = 0.76) and therapist warmth and friendliness (r = 0.60). These reliability estimates were confirmed in a subsequent study (O'Malley et al. 1983).

3.1.3. Patient's Experience of the Relationship

The PER scale, developed by Gill and Hoffman (1982), identifies activities occurring during psychotherapy through the analysis of therapy session transcripts. This method focuses on the therapeutic relationship in psychoanalytic settings and identifies both directly and symbolically expressed transferential themes and therapeutic responses. The scale assesses several variables: patient communications unrelated to (x) or directly referring to (r) their experience of the relationship; communications expressing awareness of a parallel between experiences outside and inside the analytic situation, emphasizing clarification of those inside (xr) or outside (rx); and inferences made by the raters about implicit references to the patient's relational experience, whether manifestly (Jrr) or not (Jxr). Jurich and Richardson (2001) further refined the PER scale by focusing on two patient variables and two therapist variables. These included indirectly expressed patient themes regarding the therapeutic relationship (Jxr), moments when the therapist and patient directly address the relationship (R and r, respectively) and therapist interventions aimed at encouraging the patient to discuss the therapeutic relationship (ER). The PER has also been applied to adolescent patients and showed that experienced therapists' interventions were better received than those of novice therapists (Church 1993).

Regarding reliability, intraclass correlations between raters were 0.92 for directly referenced relationship experiences (r) and 0.84 for indirectly expressed themes (Jxr) when calculated for entire sessions. Exact agreement on individual transcript lines was 96% for r and 88% for Jxr (Jurich and Richardson 2001).

3.1.4. Quantitative Assessment of Interpersonal Themes

The QUAINT was developed by Crits‐Christoph et al. (1990) to quantitatively analyse relational themes by evaluating standard categories derived from the CCRT (Luborsky 1977). Unlike the CCRT, QUAINT employs standardized language to rate patient wishes and responses using three sets of predefined categories: 32 for patient wishes, needs and intentions toward another person; 30 for responses of the other person; and 29 for self‐responses. With the QUAINT method, each item is rated on a Likert scale from 1 (not present) to 5 (strongly present). Connolly et al. (1996) further investigated the QUAINT in a study of 35 patients in cognitive therapy and 25 patients in supportive‐expressive treatment. Their findings suggest that the QUAINT method allows for a more precise evaluation of interpersonal patterns (Connolly et al. 1996).

Item reliabilities varied from 0.00 to 0.92. The lower reliabilities were mostly associated with items that occurred infrequently for this particular patient. Only items with reliabilities of 0.50 or higher were retained, resulting in a final dataset comprising 20 wishes, 23 responses from others and 19 self‐responses, with median interjudge reliabilities of 0.69, 0.68 and 0.67, respectively (Crits‐Christoph et al. 1990).

3.1.5. Transference Work Scale

The TWS is a microanalytic tool developed by the First Experimental Study of Transference‐Interpretation (FEST) research group (Høglend et al. 2006, 2008) to assess the immediate impact of transference interventions (TIs), as well as patient cooperation or withdrawal and emotional responses (Ulberg, Amlo, Critchfield, et al. 2014; Ulberg, Amlo, and Høglend 2014). The TWS comprises 26 items divided into four subscales concerning the transference work: Timing; Valence; Content; Response. Sixteen items are rated on a 5‐point Likert scale from 0 (not at all) to 4 (very much). As part of FEST, the TWS was applied in a study involving 51 adult patients undergoing psychodynamic treatment. In this study, two independent raters evaluated the transcription of 10‐min session segments. Results indicate that raters need not be experts to use the TWS effectively (Ulberg, Amlo, Critchfield, et al. 2014; Ulberg, Amlo, Hersoug, et al. 2014).

The TWS demonstrated strong inter‐rater reliability across most items. TIs were identified in 31 of 51 segments, with excellent agreement on identification (Cohen's κ = 1.00, ICC = 0.87) and high consistency in categorization (κ = 0.77). The timing of the initial intervention showed good reliability (κ = 0.60, ICC = 0.75), with ICCs reaching 0.95 for natural connection and 0.93 for precision in the highest category. However, reliability was lower for the item assessing therapist supportiveness (item 22, κ = 0.31, ICC = 0.37). Items assessing the patient's relationship to parents (items 17 and 18) frequently scored 0 (44–48% and 40%, respectively), while other items had normally distributed ratings.

3.1.6. Psychotherapy Process Q‐Set, Adolescent Psychotherapy Q‐Set and Child Psychotherapy Q‐Set

The PQS, developed by Jones (1985) based on Q‐methodology, was designed to quantitatively assess various dimensions of the psychotherapeutic process. Conceptualized as a theoretically neutral instrument, the PQS enables the characterization of a broad spectrum of patient–therapist interactions. The instrument comprises 100 items that describe therapist behaviours (k = 41), patient behaviours (k = 40) and dyadic interactions (k = 19). It can be applied to video or audio recordings, as well as transcripts of entire psychotherapy sessions. One of its primary strengths is its pantheoretical applicability. Each item is rated on a 9‐point scale, ranging from 1 (least characteristic) to 9 (most characteristic) of the session being evaluated.

Validation studies have confirmed the PQS's reliability across various psychotherapeutic approaches (Ablon and Jones 1999, 2002; Jones et al. 1988, 1991; Jones and Pulos 1993). Inter‐rater reliability for the full set of 100 items has been reported to range between 0.83 and 0.89 per rater pair (Jones et al. 1988, 1991).

Subsequent adaptations of the Q‐sort methodology extended its application to younger populations, resulting in the development of the Child Psychotherapy Q‐Set (children aged 3–13) (CPQ; Schneider 2004) and the Adolescent Psychotherapy Q‐Set (aged 12–18) (Calderon et al. 2017). These instruments, each comprising 100 items, describe salient aspects of the therapeutic process, including (a) the child's or adolescent's attitudes, emotions, behaviours or internal experiences; (b) the therapist's actions and attitudes; and (c) the dyadic interaction, including the emotional tone and overall atmosphere of the therapeutic encounter. The number of items within each category varies slightly depending on whether the instrument is designed for children or for adolescents.

Validation studies demonstrated that the APQ effectively represents a wide range of events, interventions and processes in psychotherapy and is applicable to both psychodynamic psychotherapy and CBTs (Calderon et al. 2017). The APQ demonstrated a good interrater reliability: the mean ICC ranged from 0.72 (range = 0.44–0.88) for short‐term psychoanalytic psychotherapy sessions to 0.73 (range = 0.65–0.81) for cognitive‐behavioural therapy sessions.

Regarding the CPQ, although it has been applied in empirical investigations and has shown potential as a descriptive measure of child psychotherapy processes, its psychometric validation remains limited, with no large‐scale studies currently available.

3.2. Therapist‐Rated Scales

The clinician‐rated measures identified include the Therapy Session Check Sheet—Transference Items (TSCS‐TI), Missouri Identifying Transference Scale (MITS), Psychotherapy Relationship Questionnaire (PRQ) and the In‐Session Patient Affective Reactions Questionnaire–Clinician (SPARQ‐C).

3.2.1. Therapy Session Check Sheet—Transference Items

The TSCS‐TI (Arachtingi and Lichtenberg 1999) is an adaptation of the Therapy Session Check Sheet (TSCS) originally developed by Graff and Luborsky (1977). The TSCS requires therapists to evaluate their patients and sessions across seven categories, including transference. In their study, Graff and Luborsky found a significant correlation between therapists' clinical impressions and the increase of transference.

The TSCS‐TI uses only three TSCS items related to transference: overall amount of transference, positive transference, and negative transference. Each item is scored on a 5‐point Likert scale from 1 (none or slight) to 5 (very much). Arachtingi and Lichtenberg's validation study involved 29 therapists from various psychotherapy approaches (psychodynamic, eclectic and cognitive‐behavioural) and 62 patients aged 19 to 63 years, each of whom participated in at least three therapy sessions. The results indicated that patients' self‐esteem and ego identity can impact therapists' perception of transference. Recently, Kline et al. (2023) employed the TSCS‐TI with 23 therapists paired with 49 adult patients. While the therapists trained in various approaches (psychodynamic, humanistic and cognitive‐behavioural), they agreed to work within a psychodynamic framework for this study. However, the study did not replicate the original TSCS findings (Graff and Luborsky 1977), as no significant correlations were found between positive or negative transference across the psychotherapy process based on therapist ratings.

The TSCS‐TI demonstrated moderate inter‐rater reliability, with mean correlations of 0.40 (Gelso et al. 1991; Graff and Luborsky 1977). Furthermore, the transference evaluations followed a theoretically sensible pathway for distinguishing successful and unsuccessful psychoanalysis, reflecting the analysts' process notes and supporting the instrument's validity (Gelso et al. 1991).

3.2.2. Missouri Identifying Transference Scale

The MITS was developed by Multon et al. (1996) to measure transference reactions and to examine the process and outcome of short‐term psychoanalytic counselling. Drawing on Greenson's work distinguishing unrealistic from realistic patient reactions to the therapist (Greenson 1967), the MITS includes 37 items, divided into two subscales: negative transference reactions (NTR) and positive transference reactions (PTR); each item is rated on a 5‐point Likert scale from 1 (not evident) to 5 (very evident). Clinicians complete the scale after each session (Blanck and Blanck 1974). Exploratory findings by Multon et al. (1996) demonstrated a significant progressive decrease in negative transference reactions over the course of psychotherapy sessions.

Regarding reliability, both MITS subscales showed high internal consistency, with Cronbach's α of 0.96 for NTR and 0.88 for the PTR all item‐total correlations exceeded 0.40.

3.2.3. Psychotherapy Relationship Questionnaire

The PRQ, developed by Westen and colleagues (Bradley et al. 2005; Westen 2000), is designed to assess transference patterns for both clinical and research purposes. The PRQ assesses a wide spectrum of patients' thoughts, feelings, motivations, conflicts, and behaviours toward the therapist over the last eight psychotherapy sessions. It is divided into five transference patterns: angry/entitled (k = 25); anxious/preoccupied (k = 13); secure/engaged (k = 12); avoidant/counterdependent (k = 9); sexualized (k = 5); each item is rated on a 5‐point Likert scale from 1 (not true) to 5 (very much). Bradley et al. (2005) administered the PRQ to 181 clinicians (psychologists and psychiatrists) from various therapeutic orientations to evaluate relational patterns in adult patients with personality disorders. Their findings suggest that the way patients interact with their therapists provides valuable insight into their personalities, attachment styles, and interpersonal functioning. Tanzilli et al. (2018) subsequently applied the PRQ to an Italian sample of 314 clinicians from psychodynamic and cognitive‐behavioural approaches, with each clinician completing the scale for one patient. They identified six different patterns: hostile (k = 13), positive/working alliance (k = 12), special/entitled (k = 9), anxious/preoccupied (k = 9), avoidant/dismissing attachment (k = 7) and sexualized (k = 5). This study confirmed the PRQ as a valid and reliable tool for assessing patients' relational patterns during therapy and replicated Bradley et al.'s (2005) findings regarding the systematic relationship between patients' responses and their personality traits (see also Stefana et al. 2020).

Regarding reliability, all five subscales demonstrated high internal consistency: α = 0.94 for angry/entitled, 0.85 for anxious/preoccupied, 0.86 for secure/engaged, 0.84 for avoidant/counterdependent and 0.86 for sexualized (Bradley et al. 2005). These results were confirmed by the psychometric evaluation of the Italian version of the questionnaire (Tanzilli et al. 2018), which also reported good fit indices in a confirmatory factor analysis (CFA) (χ2 [1415] = 6529.43, CFI = 0.96; NNFI = 0.96; RMSEA = 0.06; SRMR = 0.08).

3.2.4. In‐Session Patient Affective Reactions Questionnaire–Clinician

The SPARQ‐C (Stefana et al. Forthcoming) is the clinician‐report adaptation of the SPARQ (Stefana et al. 2023), originally developed as a self‐report measure for patient perceptions and affective reactions (Stefana et al. 2023). Each item was rephrased from the clinician's perspective. The SPARQ‐C consists of two scales, each with four items: positive affect (k = 4) and negative affect (k = 4). The positive affect scale evaluates the patient's feelings of security and comfort within the therapeutic relationship, while the negative affect scale assesses feelings of shame, shyness, fear of speaking openly, worry about receiving inadequate help from the therapist, and a sense of failure. Each item is rated on a 5‐point Likert scale from 0 (not at all true) to 4 (very true). CFA combining the two scales demonstrated an excellent fit to the data (χ2 [19] = 26.01, CFI = 0.98; TLI = 0.97, RMSEA = 0.05; SRMR = 0.05). Both scales exhibited excellent internal reliability, with McDonald's ωt of 0.84 for positive affect and 0.77 for negative affect.

3.3. Patient‐Rated Scales

The patient‐rated measures identified include the Client Reactions System (CRS), the In‐Session Patient Affective Reactions Questionnaire (SPARQ) and the Rift In‐Session Questionnaire (RISQ).

3.3.1. Client Reactions System

The CRS, developed by Hill et al. (1988), is designed to assess patients' immediate reactions following a psychotherapy session. This tool comprises 21 nominal, non‐mutually exclusive reaction categories, which are organized into five clusters: supported (k = 4; understood, supported, hopeful, relief), therapeutic work (k = 9; negative thoughts and behaviours, unstuck, new perspective, educated, new ways to behave), challenged, negative reactions (k = 6; scared, worse, stuck, lack direction, confused, misunderstood), and no reaction. During the procedure, patients review the audio or video recording of the session immediately afterward. The recording is paused after each therapist's intervention, allowing the clients to identify and describe how they felt at that specific moment in the session. The CRS has been validated primarily in terms of content and apparent validity, with practical use in psychotherapeutic research (Hill 1992). However, specific data on the reliability of the instrument are lacking.

3.3.2. In‐Session Patient Affective Reactions Questionnaire

The SPARQ was developed by Stefana et al. (2023, 2024) to explore patients' perception and affective reactions to their therapist as experienced during the most recent individual psychotherapy session. The authors aimed to build and validate a brief, clinically sophisticated, pantheoretical self‐report measure that is feasible for use in a real‐world psychotherapy setting. The SPARQ does not yield a total score and comprises two scales: positive affect (k = 4) and negative affect (k = 4). The inventory was developed using two large, independent clinical samples (development: N = 701; validation: N = 700). CFA of the two‐factor model showed a good fit to the data (χ2 [19] = 5.62, CFI = 0.96, TLI = 0.94, RMSEA = 0.08, SRMR = 0.05). Multigroup CFA models confirmed measurement invariance between patients attending in‐person (face‐to‐face or on the couch) and remote (via video or telephone) sessions, as well as between patients with or without a psychiatric diagnosis. The positive affect and negative affect scales demonstrated adequate internal consistency, with McDonald ωt of 0.87 and 0.75, respectively. The Positive and Negative Affect scales demonstrated adequate internal consistency, with McDonald's ωt of 0.87 and 0.75, respectively (Stefana et al. 2024).

3.3.3. Rift In‐Session Questionnaire

The RISQ was also developed by Stefana et al. (2023) to assess patients' experiences of feeling disparaged, belittled, rejected, and attacked during a session. The RISQ consists of four statements with dichotomous responses (yes/no) that indicate whether they accurately capture the patient's experience during the session. Its development and validation occurred in parallel with those of the SPARQ, and although the two measures can be used independently, they complement each other. The CFA model for the RISQ demonstrated good fit indices (χ2 [2] = 2.431, CFI = 1.00, TLI = 1.00, RMSEA = 0.01, SRMR = 0.03), and internal reliability of the RISQ was demonstrated by McDonald's ωt of 0.70.

4. Discussion

Transference, originally conceptualized within psychoanalysis, has since been recognized as a trans‐theoretical construct. Over time, it has attracted considerable interest from empirical researchers, leading to the development of various assessment instruments. To the best of our knowledge, this is the first systematic review to examine all validated measures of transference specifically designed for use in psychotherapy and counselling sessions.

Our review identified 15 instruments for the assessment of transference. Five of these tools (i.e., TSCS, CCRT, PER, QUAINT, TWS) were originally developed within psychodynamic frameworks, while the remaining 10 (i.e., VPPS, MITS, PRQ, SPARQ‐C, PQS, APQ, CPQ, SPARQ, CRS, RISQ) were designed from a trans‐theoretical perspective. Although five of these instruments are rooted in psychoanalytic or psychodynamic models, empirical research has demonstrated their applicability across different psychotherapeutic approaches.

Most available measures are designed for use with adult populations, with only one (APQ) specifically developed for adolescents and another (TWS) applicable to both adolescents and adults. This reflects the predominant focus of psychotherapy process research on adult patients, with adolescent populations remaining understudied—likely due to the unique clinical challenges posed by this group (Pfeiffer et al. 2022; Radez et al. 2021). For this reason, instruments such as the TWS offer a particularly valuable resource for investigating transference phenomena in adolescents and for comparing these patterns across developmental stages.

The reviewed instruments conceptualize transference broadly, as comprising affective, cognitive, and behavioural responses directed toward the therapist. While many measures share a similar overarching definition of transference, the specific dimensions they assess vary. For instance, the MITS and SPARQ focus on the valence of affect (positive vs. negative), while the TWS additionally examines the timing, content and nature of the patient's response.

These instruments can be categorized into three groups based on their method of data collection. First, observational rating measures (e.g., CCRT, VPPS, PER, QUAINT, TWS, PQS, APQ) rely on the coding of session recordings or transcripts. These methods enable the identification of transference ‘in vivo’ by pinpointing specific interactional sequences and reducing recall biases, thereby enhancing objectivity. However, they are time‐intensive, require specialized training, and may not be feasible for routine clinical use. Moreover, they infer transference based on observable behaviours, verbal content and non‐verbal cues, rather than on patients' explicit reports.

Second, therapist‐report measures (e.g., TSCS, MITS, PRQ) ask clinicians to rate the patient's transference reactions based on their impressions and recollections of a session. While these tools are practical for clinical use, they are susceptible to recall biases and may be influenced by the therapist's own countertransference reactions.

Third, patient self‐report measures (e.g., SPARQ, RISQ) assess the patient's perceptions of their affective and relational experiences toward the therapist. These instruments are generally brief and easy to administer, but they rely on retrospective recall, which may capture general impressions rather than specific episodes of transference. Additionally, they primarily measure conscious responses, limiting their ability to assess unconscious relational dynamics.

To date, there is a notable lack of studies directly comparing these different methods of transference assessment. As such, the degree of convergence between instruments remains largely unknown. This gap in the literature underscores the need for future research comparing the validity, reliability, and clinical utility of these measures across different patient populations and therapeutic modalities.

Despite these methodological limitations, the literature consistently highlights the centrality of transference in psychotherapy. Transference reflects patients' internalized relational patterns and plays a pivotal role in shaping the therapeutic process (Bradley et al. 2005; Tanzilli et al. 2018). Its careful assessment and interpretation can inform interventions that enhance therapeutic effectiveness (Clarkin et al. 2023) and help identify potential alliance ruptures, which, if left unresolved, may compromise treatment outcomes (McLaughlin et al. 2014; Safran et al. 2011).

Lastly, although several of the reviewed instruments are widely used in research, only a few adhere to best practices in psychometric scale development and validation (DeVellis and Thorpe 2022; Stefana et al. 2025). For example, confirmatory factor analyses have been conducted for only four instruments (i.e., PRQ, RISQ, SPARQ, SPARQ‐C). It is also important to note that for measures assessing broad constructs such as transference, especially those designed to be brief, internal consistency coefficients are not expected to be excessively high. Overly high reliability may, in fact, indicate a narrow construct coverage and a loss of conceptual validity. In some cases, Cronbach's alpha values in the range of 0.55 to 0.65 may be considered acceptable for measures capturing multifaceted phenomena such as transference.

5. Conclusions

Transference processes play a central role in psychotherapy, regardless of theoretical orientation. The present systematic review provided an overview of existing assessment instruments that capture patients' transference, broadly defined as perceptions and affective reactions to their therapist during a session. Although several instruments have been validated over the years, most are primarily suited for research purposes, with only four demonstrating sufficient clinical feasibility. Moreover, only a few of these tools followed best practices in scale development and validation. Future research should extend the investigation of transference to include patients of developmental age and assess the convergence among different measures. Additional studies are also needed to examine the relationship between transference and other important constructs, such as the therapeutic alliance, to further elucidate the mechanisms underlying therapeutic change.

Conflicts of Interest

The authors declare no conflicts of interest.

Marazzi, F. , Stefana A., Vecchio A., and Mensi M.. 2025. “Transference Assessment in Psychotherapy: A Systematic Review.” Clinical Psychology & Psychotherapy 32, no. 4: e70118. 10.1002/cpp.70118.

Funding: This work was supported by Ministero della Salute Ricerca Corrente 2024.

Francesca Marazzi and Alberto Stefana equally contributed to the present work.

Footnotes

1

Abbreviations: AD, adults; ADO, adolescents (12–18 years old); CFA, confirmatory factor analysis; CH, children (3–13 years old); EFA, exploratory factor analysis; IR, internal reliability; IRR, inter‐rater reliability; TT, total transference.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

References

  1. Ablon, J. S. , and Jones E. E.. 1999. “Psychotherapy Process in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.” Journal of Consulting and Clinical Psychology 67, no. 1: 64–75. [DOI] [PubMed] [Google Scholar]
  2. Ablon, J. S. , and Jones E. E.. 2002. “Validity of Controlled Clinical Trials of Psychotherapy: Findings From the NIMH Collaborative Study.” American Journal of Psychiatry 159, no. 5: 775–783. [DOI] [PubMed] [Google Scholar]
  3. Andersen, S. M. , and Przybylinski E.. 2012. “Experiments on Transference in Interpersonal Relations: Implications for Treatment.” Psychotherapy (Chicago, ill.) 49, no. 3: 370–383. 10.1037/a0029116. [DOI] [PubMed] [Google Scholar]
  4. Arachtingi, B. M. , and Lichtenberg J. W.. 1999. “Self‐Concept and Self‐Esteem as Moderators of Client Transference.” Psychotherapy (Chic) 36, no. 4: 369–379. 10.1037/h0087749. [DOI] [Google Scholar]
  5. Beretta, V. , Despland J.‐N., Drapeau M., et al. 2007. “Are Relationship Patterns With Significant Others Reenacted With the Therapist?: A Study of Early Transference Reactions.” Journal of Nervous and Mental Disease 195, no. 5: 443–450. 10.1097/01.nmd.0000253766.35132.30. [DOI] [PubMed] [Google Scholar]
  6. Bhatia, A. , and Gelso C. J.. 2018. “Therapists' Perspective on the Therapeutic Relationship: Examining a Tripartite Model.” Counselling Psychology Quarterly 31, no. 3: 271–293. 10.1080/09515070.2017.1302409. [DOI] [Google Scholar]
  7. Blanck, G. , and Blanck R.. 1974. Ego Psychology Theory and Practice. Columbia University Press. [Google Scholar]
  8. Bradley, R. , Heim A. K., and Westen D.. 2005. “Transference Patterns in the Psychotherapy of Personality Disorders: Empirical Investigation.” British Journal of Psychiatry: The Journal of Mental Science 186: 342–349. 10.1192/bjp.186.4.342. [DOI] [PubMed] [Google Scholar]
  9. Breuer, J. , and Freud S.. 1895. “Studies on Hysteria.” In In the Standard Edition of the Complete Psychological Works of Sigmund Freud, edited by Strachey J., vol. 2. [Google Scholar]
  10. Calderon, A. , Schneider C., Target M., and Midgley N.. 2017. “The Adolescent Psychotherapy Q‐Set (APQ): A Validation Study.” Journal of Infant, Child & Adolescent Psychotherapy 16, no. 1: 106–120. 10.1080/15289168.2016.1255499. [DOI] [Google Scholar]
  11. Church, E. 1993. “Reading the Transference in Adolescent Psychotherapy: A Comparison of Novice and Experienced Therapists.” Psychoanalytic Psychology 10, no. 2: 187–205. 10.1037/h0079462. [DOI] [Google Scholar]
  12. Clarkin, J. F. , Calligor E., and Sowislo J.. 2023. “Transference‐Focused Psychotherapy for Levels of Personality Pathology Severity.” In Gabbard's Textbook of Psychotherapeutic Treatments. [Google Scholar]
  13. Colli, A. , Tanzilli A., Gualco I., and Lingiardi V.. 2016. “Empirically Derived Relational Pattern Prototypes in the Treatment of Personality Disorders.” Psychopathology 49, no. 5: 364–373. 10.1159/000448623. [DOI] [PubMed] [Google Scholar]
  14. Connolly, M. B. , Crits‐Christoph P., Demorest A., Azarian K., Muenz L., and Chittams J.. 1996. “Varieties of Transference Patterns in Psychotherapy.” Journal of Consulting and Clinical Psychology 64, no. 6: 1213–1221. 10.1037//0022-006x.64.6.1213. [DOI] [PubMed] [Google Scholar]
  15. Crits‐Christoph, P. 1988. “Clinicians Can Agree in Assessing Relationship Patterns in Psychotherapy: The Core Conflictual Relationship Theme Method.” Archives of General Psychiatry 45, no. 11: 1001–1004. 10.1001/archpsyc.1988.01800350035005. [DOI] [PubMed] [Google Scholar]
  16. Crits‐Christoph, P. , Demorest A., and Connolly M. B.. 1990. “Quantitative Assessment of Interpersonal Themes Over the Course of Psychotherapy.” Psychotherapy: Theory, Research, Practice, Training 27, no. 4: 513–521. 10.1037/0033-3204.27.4.513. [DOI] [Google Scholar]
  17. DeVellis, R. F. , and Thorpe C. T.. 2022. Scale Development: Theory and Applications. Fifth ed. SAGE. [Google Scholar]
  18. Freud, S. 1888. “Hysteria.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, edited by Strachey J., 41–57. [Google Scholar]
  19. Freud, S. 1905. Dora: An Analysis of a Case of Hysteria. Simon & Schuster, Inc. [Google Scholar]
  20. Freud, S. 1912. “The Dynamics of Transference.” In Freud's Technique Papers: A Contemporary Perspective, edited by Ellman S. J., 35–50. Jason Aronson Inc. [Google Scholar]
  21. Gelso, C. J. , and Bhatia A.. 2012. “Crossing Theoretical Lines: The Role and Effect of Transference in Nonanalytic Psychotherapies.” Psychotherapy 49, no. 3: 384–390. 10.1037/a0028802. [DOI] [PubMed] [Google Scholar]
  22. Gelso, C. J. , Hill C. E., and Kivlighan D. M.. 1991. “Transference, Insight, and the Counselor's Intentions During a Counseling Hour.” Journal of Counseling & Development 69, no. 5: 428–433. 10.1002/j.1556-6676.1991.tb01539.x. [DOI] [Google Scholar]
  23. Gelso, C. J. , Kelley F. A., Fuertes J. N., et al. 2005. “Measuring the Real Relationship in Psychotherapy: Initial Validation of the Therapist Form.” Journal of Counseling Psychology 52, no. 4: 640–649. 10.1037/0022-0167.52.4.640. [DOI] [Google Scholar]
  24. Gill, M. M. , and Hoffman I. Z.. 1982. “A Method for Studying the Analysis of Aspects of the Patient's Experience of the Relationship in Psychoanalysis and Psychotherapy.” 137–167. [DOI] [PubMed]
  25. Gomes‐Schwartz, B. 1978. “Effective Ingredients in Psychotherapy: Prediction of Outcome From Process Variables.” Journal of Consulting and Clinical Psychology 46, no. 5: 1023–1035. 10.1037/0022-006X.46.5.1023. [DOI] [PubMed] [Google Scholar]
  26. Gomes‐Schwartz, B. , and Schwartz J. M.. 1978. “Psychotherapy Process Variables Distinguishing the Inherently Helpful Person From the Professional Psychotherapist.” Journal of Consulting and Clinical Psychology 46, no. 1: 196–197. 10.1037/0022-006X.46.1.196. [DOI] [PubMed] [Google Scholar]
  27. Graff, H. , and Luborsky L.. 1977. “Long‐Term Trends in Transference and Resistance: A Report on a Quantitative‐Analytic Method Applied to Four Psychoanalyses.” Journal of the American Psychoanalytic Association 25, no. 2: 471–490. 10.1177/000306517702500210. [DOI] [PubMed] [Google Scholar]
  28. Greenson, R. R. 1967. The Technique and Practice of Psychoanalysis. Vol. 1. International Universities Press. [Google Scholar]
  29. Haddaway, N. R. , Page M. J., Pritchard C. C., and McGuinness L. A.. 2022. “PRISMA2020: An R Package and Shiny app for Producing PRISMA 2020‐Compliant Flow Diagrams, With Interactivity for Optimised Digital Transparency and Open Synthesis.” Campbell Systematic Reviews 18, no. 2: e1230. 10.1002/cl2.1230. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Heimann, P. 1956. “Dynamics of Transference Interpretations.” International Journal of Psycho‐Analysis 37, no. 4–5: 303–310. [PubMed] [Google Scholar]
  31. Hill, C. E. 1992. “An Overview of Four Measures Developed to Test the Hill Process Model: Therapist Intentions, Therapist Response Modes, Client Reactions, and Client Behaviors.” Journal of Counseling & Development 70, no. 4: 728–733. [Google Scholar]
  32. Hill, C. E. , Helms J. E., Spiegel S. B., and Tichenor V.. 1988. “Development of a System for Categorizing Client Reactions to Therapist Interventions.” Journal of Counseling Psychology 35, no. 3: 222–233. [Google Scholar]
  33. Høglend, P. , Amlo S., Marble A., et al. 2006. “Analysis of the Patient‐Therapist Relationship in Dynamic Psychotherapy: An Experimental Study of Transference Interpretations.” American Journal of Psychiatry 163, no. 10: 1739–1746. 10.1176/ajp.2006.163.10.1739. [DOI] [PubMed] [Google Scholar]
  34. Høglend, P. , Bøgwald K.‐P., Amlo S., et al. 2008. “Transference Interpretations in Dynamic Psychotherapy: Do They Really Yield Sustained Effects?” American Journal of Psychiatry 165, no. 6: 763–771. 10.1176/appi.ajp.2008.07061028. [DOI] [PubMed] [Google Scholar]
  35. Jones, E. E. 1985. “Psychotherapy Process Q‐Set Coding Manual.”
  36. Jones, E. E. , Cumming J. D., and Horowitz M. J.. 1988. “Another Look at the Nonspecific Hypothesis of Therapeutic Effectiveness.” Journal of Consulting and Clinical Psychology 56, no. 1: 48–55. 10.1037/0022-006X.56.1.48. [DOI] [PubMed] [Google Scholar]
  37. Jones, E. E. , Hall S. A., and Parke L. A.. 1991. “The Process of Change: The Berkeley Psychotherapy Research Group.” In Psychotherapy Research: An International Review of Programmatic Studies, edited by Beutler L. E. and Crago M., 99–106. American Psychological Association. [Google Scholar]
  38. Jones, E. E. , and Pulos S. M.. 1993. “Comparing the Process in Psychodynamic and Cognitive‐Behavioral Therapies.” Journal of Consulting and Clinical Psychology 61, no. 2: 306–316. [DOI] [PubMed] [Google Scholar]
  39. Jurich, J. , and Richardson L.. 2001. “The Patient's Experience of the Relationship Scale as a Means of Studying the Inpatient Psychotherapy Relationship.” Psychotherapy Research 11, no. 4: 473–482. 10.1093/ptr/11.4.473. [DOI] [Google Scholar]
  40. Kernberg, O. F. 2016. “The Four Basic Components of Psychoanalytic Technique and Derived Psychoanalytic Psychotherapies.” World Psychiatry 15, no. 3: 287–288. 10.1002/wps.20368. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Kline, K. V. , Hill C. E., Lu Y., and Gelso C. J.. 2023. “Transference and Client Attachment to Therapist in Psychodynamic Psychotherapy.” Psychotherapy (Chicago, Ill.) 60, no. 4: 467–476. 10.1037/pst0000492. [DOI] [PubMed] [Google Scholar]
  42. Levy, K. N. , and Scala J. W.. 2012. “Transference, Transference Interpretations, and Transference‐Focused Psychotherapies.” Psychotherapy 49, no. 3: 391–403. 10.1037/a0029371. [DOI] [PubMed] [Google Scholar]
  43. Luborsky, L. 1977. Measuring a Pervasive Psychic Structure in Psychotherapy: The Core Conflictual Relationship Theme. In N. Freedman & S. Grand (A c. Di), communicative Structures and Psychic Structures: A Psychoanalytic Interpretation of Communication , 367–395. Springer US. 10.1007/978-1-4757-0492-1_16. [DOI] [Google Scholar]
  44. Luborsky, L. , and Crits‐Christoph P.. 1990. “Understanding Transference: The Core Conflictual Relationship Theme Method”.
  45. Luborsky, L. , Crits‐Christoph P., and Mellon J.. 1986. “Advent of Objective Measures of the Transference Concept.” Journal of Consulting and Clinical Psychology 54, no. 1: 39–47. 10.1037/0022-006X.54.1.39. [DOI] [PubMed] [Google Scholar]
  46. Luborsky, L. , Mellon J., Van Ravenswaay P., et al. 1985. “A Verification of Freud's Grandest Clinical Hypothesis: The Transference.” Clinical Psychology Review 5, no. 3: 231–246. 10.1016/0272-7358(85)90046-7. [DOI] [Google Scholar]
  47. Marmarosh, C. L. , Gelso C. J., Markin R. D., Majors R., Mallery C., and Choi J.. 2009. “The Real Relationship in Psychotherapy: Relationships to Adult Attachments, Working Alliance, Transference, and Therapy Outcome.” Journal of Counseling Psychology 56, no. 3: 337–350. 10.1037/a0015169. [DOI] [Google Scholar]
  48. McLaughlin, A. A. , Keller S. M., Feeny N. C., Youngstrom E. A., and Zoellner L. A.. 2014. “Patterns of Therapeutic Alliance: Rupture–Repair Episodes in Prolonged Exposure for Posttraumatic Stress Disorder.” Journal of Consulting and Clinical Psychology 82, no. 1: 112–121. 10.1037/a0034696. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Multon, K. D. , Patton M. J., and Kivlighan D. M. Jr. 1996. “Development of the Missouri Identifying Transference Scale.” Journal of Counseling Psychology 43, no. 3: 243. [Google Scholar]
  50. O'Malley, S. S. , Suh C. S., and Strupp H. H.. 1983. “The Vanderbilt Psychotherapy Process Scale: A Report on the Scale Development and a Process‐Outcome Study.” Journal of Consulting and Clinical Psychology 51, no. 4: 581–586. 10.1037/0022-006X.51.4.581. [DOI] [PubMed] [Google Scholar]
  51. Orlinsky, D. E. , and Howard K. I.. 1967. “The Good Therapy Hour. Experiential Correlates of Patients' and Therapists' Evaluations of Therapy Sessions.” Archives of General Psychiatry 16, no. 5: 621–632. 10.1001/archpsyc.1967.01730230105013. [DOI] [PubMed] [Google Scholar]
  52. Page, M. J. , McKenzie J. E., Bossuyt P. M., et al. 2021. “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews.” BMJ (Clinical research ed.) 372: n71. 10.1136/bmj.n71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Pfeiffer, S. , Huffer A., Feil A., and In‐Albon T.. 2022. “Implicit Attitudes Toward Psychotherapy and Explicit Barriers to Accessing Psychotherapy in Youths and Parent–Youth Dyads.” Clinical Psychology in Europe 4, no. 3: e7375. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Radez, J. , Reardon T., Creswell C., Lawrence P. J., Evdoka‐Burton G., and Waite P.. 2021. “Why Do Children and Adolescents (Not) Seek and Access Professional Help for Their Mental Health Problems? A Systematic Review of Quantitative and Qualitative Studies.” European Child & Adolescent Psychiatry 30, no. 2: 183–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Safran, J. D. , Muran J. C., and Eubanks‐Carter C.. 2011. “Repairing Alliance Ruptures.” Psychotherapy 48, no. 1: 80–87. 10.1037/a0022140. [DOI] [PubMed] [Google Scholar]
  56. Schneider, C. 2004. “The Development of the Child Psychotherapy Q‐Set”.
  57. Stefana, A. , Bulgari V., Youngstrom E. A., Dakanalis A., Bordin C., and Hopwood C. J.. 2020. “Patient Personality and Psychotherapist Reactions in Individual Psychotherapy Setting: A Systematic Review.” Clinical Psychology & Psychotherapy 27, no. 5: 697–713. 10.1002/cpp.2455. [DOI] [PubMed] [Google Scholar]
  58. Stefana, A. , Damiani S., Granziol U., et al. 2025. “Psychological, Psychiatric, and Behavioral Sciences Measurement Scales: Best Practice Guidelines for Their Development and Validation.” Frontiers in Psychology 15: 1494261. 10.3389/fpsyg.2024.1494261. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Stefana, A. , Fusar‐Poli P., Vieta E., and Youngstrom E. A.. 2024. “Assessing the Patient's Affective Perception of Their Psychotherapist: Validation of the In‐Session Patient Affective Reactions Questionnaire.” Frontiers in Psychiatry 15: 1346760. 10.3389/fpsyt.2024.1346760. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Stefana, A. , Langfus J. A., Vieta E., Fusar‐Poli P., and 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, no. 15: 5156. 10.3390/jcm12155156. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Stefana, A. , Ünver B., Vieta E., Fusar‐Poli P., and Youngstrom E. A.. Forthcoming. “Therapist's Assessment of Their Patient's Session‐Level Emotional Processes: Validation of the in‐Session Patient Affective Reactions Questionnaire–Clinician Form.” Journal of Clinical Psychology. [Google Scholar]
  62. Strupp, H. H. , Hartley I., and Blackwood G. L. J.. 1974. “ Vanderbilt Psychotherapy Process Scale ”.
  63. Suh, C. S. , O'Malley S. S., Strupp H. H., and Johnson M. E.. 1989. “The Vanderbilt Psychotherapy Process Scale (VPPS).” Journal of Cognitive Psychotherapy 3, no. 2: 123–154. 10.1891/0889-8391.3.2.123. [DOI] [Google Scholar]
  64. Tanzilli, A. , Colli A., Gualco I., and Lingiardi V.. 2018. “Patient Personality and Relational Patterns in Psychotherapy: Factor Structure, Reliability, and Validity of the Psychotherapy Relationship Questionnaire.” Journal of Personality Assessment 100, no. 1: 96–106. 10.1080/00223891.2016.1272050. [DOI] [PubMed] [Google Scholar]
  65. Ulberg, R. , Amlo S., Critchfield K. L., Marble A., and Høglend P.. 2014. “Transference Interventions and the Process Between Therapist and Patient.” Psychotherapy (Chicago, ill.) 51, no. 2: 258–269. 10.1037/a0034708. [DOI] [PubMed] [Google Scholar]
  66. Ulberg, R. , Amlo S., Hersoug A. G., Dahl H.‐S. J., and Høglend P.. 2014. “The Effects of the Therapist's Disengaged Feelings on the in‐Session Process in Psychodynamic Psychotherapy.” Journal of Clinical Psychology 70, no. 5: 440–451. 10.1002/jclp.22088. [DOI] [PubMed] [Google Scholar]
  67. Ulberg, R. , Amlo S., and Høglend P.. 2014. “Manual for Transference Work Scale; a micro‐Analytical Tool for Therapy Process Analyses.” BMC Psychiatry 14: 291. 10.1186/s12888-014-0291-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Vanheule, S. , Desmet M., Rosseel Y., and Meganck R.. 2006. “Core Transference Themes in Depression.” Journal of Affective Disorders 91, no. 1: 71–75. 10.1016/j.jad.2005.12.012. [DOI] [PubMed] [Google Scholar]
  69. Westen, D. 2000. “Psychotherapy Relationship Questionnaire (PRQ) Manual”.
  70. Woodhouse, S. S. , Schlosser L. Z., Crook R. E., Ligiéro D. P., and Gelso C. J.. 2003. “Client Attachment to Therapist: Relations to Transference and Client Recollections of Parental Caregiving.” Journal of Counseling Psychology 50, no. 4: 395–408. 10.1037/0022-0167.50.4.395. [DOI] [Google Scholar]
  71. Zilcha‐Mano, S. , McCarthy K. S., Dinger U., and Barber J. P.. 2014. “To What Extent Is Alliance Affected by Transference? An Empirical Exploration.” Psychotherapy 51, no. 3: 424–433. 10.1037/a0036566. [DOI] [PubMed] [Google Scholar]

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