As a construct, the elaboration of countertransference experience (ECE) is intended to depict the implicit and explicit psychological work to which therapists submit their experiences with clients. Through ECE, defined as a mentalizing process of a particular kind, therapists' experiences are presumed to acquire and increase in mental quality and become available for meaning-making and judicious clinical use. In this paper, we claim that such an ongoing process facilitates engagement with common therapeutic factors, such as the therapeutic alliance and countertransference management, enhancing therapist responsiveness in psychotherapy. We synthesize relevant literature on countertransference, mentalization, and, in particular, therapists' mentalization, informed by a systematic literature review. As a result, we propose a model for assessing ECE in psychotherapy, comprising 6 diversely mentalized countertransference positions (factual-concrete, abstract-rational, projective-impulsive, argumentative, contemplative-mindful, and mentalizing), 2 underlying primary dimensions (experiencing, reflective elaboration), and 5 complementary dimensions of elaboration. Strengths and limitations of the model are discussed.

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Alliance may impact psychotherapy outcomes both as a precondition that enables therapeutic work and an evolving process that is therapeutic in itself. This study examined the participation of the elaboration of countertransference experience (ECE) in alliance variation between therapist-client dyads early in therapy and within dyads over time. A total of 44 session assessments nested within 12 dyads were modeled through longitudinal multilevel analyses and utilized to examine the associations between the ECE dimensions of Immersion and Reflection and alliance components across 4 time points within the first 10 sessions of psychotherapy. Results supported the importance of initial ECE to explain differences in alliance between dyads, the particular relevance of ECE with clients presenting lower levels of personality organization, and the effect of personality difficulties on alliance change. Unexpected results were found concerning the correlations between ECE and alliance and their covariation over time. In conclusion, ECE dimensions appear to be involved in alliance formation, both in initial differences between dyads and in changes over time within the same case. ECE seems particularly important with more personality-disturbed clients. Future research should disentangle therapist and client contributions and examine the participation of ECE in the resolution of alliance ruptures. Clinical Impact StatementQuestion: Is alliance formation associated with the psychological processes that therapists use in making sense of their experiences with clients, defined as the elaboration of countertransference experience (ECE)? Findings: Therapists' engagement in their subjective experience (Immersion) in the beginning of psychotherapy is higher in dyads with a better emotional bond. With clients with personality difficulties, therapists' explicit meaning-making (Reflection) may benefit clients' sense of collaboration and goal consensus. Meaning: In practice and in training, therapists should be helped to understand how to make use of what they experience in and between sessions in ways that improve psychotherapeutic processes and outcomes. Next Steps: Future research should disentangle therapist and client contributions to ECE and examine its participation in the resolution of alliance ruptures.

The working alliance has been recognized as a predictor of psychotherapy outcome across therapeutic orientations. Despite mixed findings regarding the effect of problem severity on the alliance formation, there is evidence suggesting that therapist factors may interfere in this association. This study examined how clients' baseline clinical features affected the early alliance and the possible role of therapists' countertransference management as a mediator. Thirteen therapeutic dyads were assessed at 2 different time points. Clients' clinical dimensions were assessed prior to the 2nd session, and therapists' countertransference management and clients' ratings of the alliance were measured after the 2nd session. Positive associations were found between clients' subjective wellbeing, social functioning, risk, and global psychological distress and countertransference management dimensions and total score. Empathy-based countertransference management suppressed the negative impact of clinical risk on alliance. Our findings suggest that clinical problems activate countertransference management, which in turn may buffer their negative effect on alliance.