Elephant in the Room: A Methodology for Case Studies Metasynthesis

Abstract

The Relationships Between Categories (RBC) technique is a qualitative methodology for the metasynthesis of psychoanalytic case studies. By analyzing repetitive bilateral, trilateral, or quadrilateral relationships of transference themes, this methodology seeks to analyze case studies with existing theoretical concepts, thereby formulating a new theory. The proposed tool attempts to explore and validate hidden connections between different psychotherapy components, thus enhancing integration of various bodies of knowledge and decreasing the gap between practice and theory. This methodology is demonstrated here by research on transference case studies that connect transference to components of cognitive behavioral therapy.

Keywords

case study metasynthesis qualitative research RBC method theoretical integration psychology method psychoanalytic research

This paper proposes a qualitative methodology for synthesizing clinical case studies, which is much needed for increasing rigor in psychoanalysis research. Even though quantitative methods are needed for validating core psychoanalytic propositions (Luborsky and Luborsky 2006; Gabbard 2006), the richness of the psychoanalytic encounter is often lost in quantitative approaches. Over the years, most psychoanalytic knowledge was developed within the framework of case observation. Case studies exert a major influence on the development of clinical practice. However, case studies are susceptible to their authors’ subjectivity (Desmet et al. 2013), requiring rigorous tools to increase the objectivity and generalizability of their findings.

Over the past two decades, an increasing trend has been evident toward the synthesizing of research conducted previously on a common subject (Cooper and Koenka 2012; Finfgeld 2003). Recently, a new enthusiasm for qualitative metasynthesis has been observed (Fishman 2001, 2004, 2013; Ludvigsen et al. 2016; Levitt, Pomerville, and Surace 2016; Noblit and Hare 1988; Netto et al. 2010; Timulak 2009; Thorne et al. 2004; Zimmer 2006).

Metasynthesis methodology is an umbrella term referring to a variety of concepts, such as qualitative meta-analysis, qualitative meta-data analysis, and metaethnography. Metasynthetic research is a type of qualitative research that is applied to a number of qualitative studies (Bondas and Hall 2007; Campbell et al. 2003; Sandelowski, Docherty, and Emden 1997; Noblit and Hare 1988). Metasynthesis does not summarize articles, nor does it produce critical literature reviews. Metasynthesis is the qualitative parallel of quantitative meta-analysis but differs from it in several fundamental respects. Qualitative metasynthesis and quantitative meta-analysis are both methods that aspire to new conclusions, through application of new research procedures to a wide range of professional articles dealing with a selected common topic. Unlike meta-analysis, however, metasynthesis uses qualitative rather than statistical procedures to assess additional points of view regarding the phenomenon in question (Bondas and Hall 2007; Noblit and Hare 1988). The central body of metasynthesis deals with qualitative research (Ludvigsen et al. 2016), and little has been written about how researchers can synthesize case studies (Easden and Kazantzis 2018; Iwakabe 2011; McLeod 2002; Willemsen et al. 2015).

Hoon (2013) provided step-by-step instructions for conducting case study metasynthesis, proposing that each case first be investigated separately for identification of variables and assessment of relationships among them. Synthesis of cases is to be performed only after this case-specific analysis is carried out. Thus, multiple causal networks, each derived from a separate case study, are combined at a later stage into a broader network. Findings of the participating studies may complement each other, leading to a broader theoretical understanding and a narrowing of the gap between theory and practice (McLeod 2002).

Case study researchers can organize the metasynthesis around cross-case similarities such as therapeutic processes, therapeutic outcomes, and therapy principles and strategies, or, alternatively, around specific concepts, themes, or categories. They can also identify how each of the cases refers to one or more of these aspects, thus articulating interpretations and conclusions that go beyond the perspective of any single case (Iwakabe and Gazzola 2009; McLeod 2013). McLeod (2013) demonstrated case study metasynthesis using three cases (Atwood 2012, two cases; Karon 2008, one case) and pointed to certain therapeutic principles that can be identified in all of them, for example “using frequent meetings at the start of therapy to develop trust,” “therapist willingness to make a commitment to long-term therapy,” and “assuming that all client statements have meanings in relation to their life experience.” Other principles, however, appeared in some cases and not in others, for instance “flexibility around location of meetings” (Karon 2008) and “explicit articulation of a therapeutic plan” (Atwood 2012). Metasynthesis of additional cases would help determine how universal the principles are, and which might be the most (or least) helpful.

Metasynthesis assesses similar and different findings in the participating studies, compiling similar aspects into common categories and investigating the relationships between them (Sandelowski, Docherty, and Emden 1997), thus striving toward new propositions based on the cumulative value of different knowledge items. Case study metasynthesis (McLeod 2013) can answer questions such as what processes are at work in the presented therapies, how these processes have been experienced by patients and therapists, which processes can be linked with therapeutic outcomes, and how these processes can be understood in terms of existing or new theoretical models. Metasynthesis can also investigate the reciprocal relations between concepts taken from different psychoanalytic schools, and can advance interdisciplinary research (Sandelowski, Docherty, and Emden 1997). Examples of this kind of research will be demonstrated below.

This paper presents the method of Relationships Between Categories (RBC) as a potential tool for rigorous metasynthesis of psychoanalytic case studies. The RBC method is a means for investigating the relationships among a text’s core components. For example: “Elinor adopts a giving up position at home and a fighting position in social situations.” The RBC method can be used to investigate links between the components “giving up,” “fighting,” “home,” and “social situations.”

The RBC method, which Lea Kacen and I first described as a method for psychological research (Rabinovich and Kacen 2010), is proposed here as a potential tool for case study metasynthesis. RBC can assist researchers in finding, presenting, and validating hidden relationships between categories, themes, and concepts in the clinical content. The method adopts an interpretive epistemological position (Bondas and Hall 2007) and promotes a critical view. It strives toward covert meanings that lie mostly at the implicit level of the data (Hill 2012; Hilliard 1993; Sandelowski 2004), so that what was previously undetected now becomes as prominent as the proverbial elephant in the room.

In this article the RBC method is presented, followed by a description of the steps in RBC-based metasynthesis of case studies.¹ Metasynthesis was performed on thirty-three transference case studies from psychodynamic papers published in peer-reviewed journals (see Appendix). The cases were analyzed for interrelationships between psychodynamic and cognitive behavioral components (Beck 1991; DeRubeis, Keefe, and Beck 2019; Weinberger and Stoycheva 2019). The present study demonstrates how the proposed tool elucidates silenced connections between the psychoanalytic concept of transference and the cognitive-behavioral concepts of classical conditioning and overgeneralization² (Ginat-Frolich et al. 2017; Sevenster et al. 2017). Transference categorization was conducted using Core Conflictual Relationship Themes (CCRT), Luborsky’s validated method for detection of transference components (Luborsky 1998; Luborsky and Luborsky 2006). The components of CCRT are wish, response from other, and response of self. The wish component refers to the person’s desired feelings in his or her relationships with others, such as to be loved, appreciated, visible. Response from other refers to the actual or imagined conflictual reaction from the others, such as rejection, indifference, or abuse. Response of self is one’s own reaction, such as anger, depression, or anxiety.

Techniques of RBC Analysis

The qualitative literature offers various means for researchers working on integration among categories (Charmaz 2006; Tutty, Rothery, and Grinnell 1996), which is a core strategy for enhancing grounded theory findings (Glaser and Strauss 1967) and is found to be helpful in psychoanalytic research (Lilliengren and Werbart 2005, 2010). Strauss and Corbin (1998, pp. 148–156) recommend analyzing the interrelationships of categories by the use of tools such as writing story lines and sketching diagrams that bridge key concepts through which the researchers can distance themselves from the data and thus identify the logic connecting the different categories. According to Strauss and Corbin, the researchers can step back by sketching quasi-intuitive diagrams that take an inherent part in the interpretive process. They also recommend mapping categories of conditions, actions or interactions, and consequences (Strauss and Corbin 1998). Tutty, Rothery, and Grinnell (1996) define three key relationships between categories: “contained” (where one category is contained in another); “temporal” (where one category precedes another chronologically); and “causal” (where one category is the reason for another). These tools can help researchers examine relationships between categories in psychoanalytic material.

Continuing the work of Tutty, Rothery, and Grinnell, the RBC method takes another step forward, identifying additional types of relationships. Here, with the aim of examining how various categories in the text are structured within their different contexts (i.e., exploring the text’s contextual structure), the method attempts to increase precision by using close-to-text codes, while putting off their interpretation to a later stage. The RBC method points to three contextual links: bilateral, trilateral, and quadrilateral (see Table 1). Second-order RBC analysis, a procedure in which links found at the previous stage are linked with one another, will also be described.

Table 1.

RBC Classification

Type of Relationship	Nature of Relationship	Example
Bilateral	One category (A) appears repeatedly in the context of another category (B).	Overgeneralization cognitive distortion appears repeatedly in the context of transference.
Trilateral	One or more categories (P1,2,3 . . .) ¹ connect other disparate categories (A, B) such that it is in a bilateral relationship with each.	CCRT components connect the categories of transference and overgeneralization.
Quadrilateral	A pair of opposite categories (P, ~P) ² connects two disparate categories (A, B) such that Category A relates to Category P and Category B relates to Category ~P.	The opposite categories of close and not close connect the categories of wish and overgeneralization such that the wish relates to the category of closeness and the overgeneralization relates to the category not close (e.g., “I never felt closeness”).

Note: This table summarizes and exemplifies the characteristics of each of the three types of relationships described in the Relationships Between Categories (RBC) methodology.

P1,2,3 represent different themes, each of which connects to the same separate categories (A, B).

Categories P, ~P (Not P) are opposite categories, themes, codes, CCRTs, etc.

Bilateral Relationships

Bilateral relationships evince a pattern according to which one category (A) appears in the text time and again in the context of another category (B). In the Elinor example the category “giving up” stands in bilateral relationship with the category “home situations,” and the category “fighting” stands in bilateral relationship with the category “social situations.” Following are examples from case studies, with emphases and bracketed labeling supplied by me.

Example 1: It was so heartbreaking after I left that other session [transference], when I got so cold, I felt like all the warmth in the world was gone [overgeneralization], like those days when my mother withdrew to her bed and it felt like the sun would never come out [overgeneralization]. That’s why I had to call you afterwards! [Kavaler-Adler 2003, p. 142].

Each category in this segment connects with each of the others, yet only after analyzing the complete data of the case studies might the researcher find the repeating categories and links relevant to the research question. The relationship between the categories transference and overgeneralization can be demonstrated in the above segment. Transference occurs when patients transfer to the therapist an aspect of an early experience with significant figures that they had felt as children, while overgeneralization is demonstrated in the use of all-or-nothing words like “all,” “never,” “only,” and “everybody” (“all the warmth in the world was gone . . . the sun never would come out”). A repeated bilateral RBC shows that the categories of transference and overgeneralization are associated with one another through a common CCRT theme, though this does not necessarily indicate a direct causal connection. Several categories in the same segment might point to this meaning. However, for the time being, only the actual connections are sought, while the uncovering of the meaning linking them is postponed to a later stage.

The bilateral relationship of transference and overgeneralization is also manifest in the next example.

Example 2: When you don’t help me [transference] I feel all by myself. No one cares [overgeneralization] or knows I’m alive. Nothing feels real [overgeneralization]. [Frosch 2002, p. 61].

This sentence links the categories of transference (“you don’t help me”) and overgeneralization (“all by myself; no one cares; no one knows I’m alive; nothing feels real”). As in the previous example, these categories are connected to one another across the cases (bilateral relationships). However, such links are not always direct. To assess their recurrence throughout the research data, additional relationship patterns should be identified.

Close and Loose Bilateral Relations

Bilateral relationships between categories may be close or loose. Close RBCs describe categories connected through an explicit statement, whereas loose RBCs appear in separate parts of the same case without any direct citation linking them explicitly. Examples 1 and 2 show a close RBC between transference and overgeneralization, as they appear in the same paragraph. Loose RBCs tend to be more pervasive, but they bear only an implied connection, while close RBCs are stronger and might reduce study bias. Thus, a valuable finding might be based on loose RBCs in numerous cases and on close RBCs in only a few. Such links support each other and reinforce the credibility of the relevant finding. The accumulation of several RBCs pointing to the same finding supports and intensifies its validity and trustworthiness (Lincoln and Guba 1985).

Trilateral Relationships

The building blocks of trilateral relationships are bilateral RBCs. Trilateral relationships are seen when researchers find a specific category in several dyads of bilateral RBCs across the case studies, essentially serving as a common category that connects others. Trilateral relationships thus evince a pattern in which one category (P) connects with two other categories (A, B) such that it stands in a bilateral relationship with each, linking them with one another (see Figure 1). For example, if the patient uses the word emptiness (category P) regarding herself (category B) in one part of the session and regarding her daughter (category C) in another part of the session, we might say that something related to emptiness connects her and her daughter.

Returning to the transference and overgeneralization analysis, it can be seen that in examples 1 and 2, transference (category A) and overgeneralization (category B) are connected trilaterally by a CCRT component (category P), which is the common category of response of self (“I got so cold” in Kavaler-Adler’s case) or response from other (“no one cares” in Frosch’s), which connects with both transference and overgeneralization. In these segments, transference and overgeneralization connect with one another both bilaterally and trilaterally. When these connections appear in the same paragraph, they are considered close RBCs.

Example 3. Everything [overgeneralization] I do is pushed towards other people and it’s always [overgeneralization] getting rejections [response from other] back or negatives back [Church 1993, p. 198].

This example shows a bilateral RBC of overgeneralization and response from other (rejection), categories that also connect with transference in the given case. Thus, one can say that the category response from other trilaterally links the categories of transference and overgeneralization. These categories stand in a loose bilateral RBC in this case, because they do not appear side by side in the same paragraph. As researchers identify multiple close and loose bilateral RBCs, they can construct trilateral ones around CCRT components as common categories. Linking many RBCs to the same categories throughout the research data strengthens and validates the findings.

Figure 1.

Trilateral relationship

Quadrilateral Relationships

Quadrilateral relationships are obtained when a pair of opposite categories – P and ~P (not P) – links other categories (A and B) with one another such that P is bilaterally linked with A and ~P with B (see Figure 2). In the Elinor example mentioned above, the opposite categories giving up and fighting (P, ~P) link the categories of home situations (Category A) and social situations (Category B) by means of a quadrilateral relationship. This pattern may indicate a dependency between the behavior at home and the behavior in social situations, and it is possible that a change in one of them will also prompt a change in the other.

Example 4: I want to make love with you [transference]. There’s a difference between sex and making love. Sex is a dime a dozen, right? Making love is like . . . is kind of like a symbolic, uh, culmination of everything. And it makes two people closer. Brings ’em closer together [wish, transference component]. That’s what I would think because I never [overgeneralization] had that [Buiriski and Monroe 2000, p. 78].

In example 4, the wish category (“Brings ’em closer together”), a transference component and the overgeneralization (“I never had that”) are linked by the categories of close (P) and not close (~P). In this paragraph, as in numerous case studies throughout the research, the dyad of opposite categories (close / not close), quadrilaterally connects the categories of wish (A) and overgeneralization (B). These categories were connected through various opposing themes of response of self and response from other (love/rejection, attention/indifference, belonging/outsider, etc.). The specific themes of P and ~P differ from case to case, but the same pattern was found to be largely preserved.

Figure 2.

Quadrilateral relationship¹

Close bilateral RBCs with trilateral or quadrilateral patterns connecting them prove to be a winning combination. Loose RBCs without trilateral or quadrilateral relationships are a weak finding. Trilateral or quadrilateral patterns may strengthen loose bilateral RBCs when a repeating category/dyad links the same bilateral categories across an entire case. The more numerous the analytical procedures and the cases from which the findings are derived, the greater their significance. Different analytical procedures, each pointing separately to the same finding, confirm a triangulation test (Lincoln and Guba 1985), adhere to rigorous quality standards and reinforce the credibility of the findings (Tracy 2010). The cumulative weight of consistent findings strengthens the conclusion, serving as a stable basis for interpretation.

Second-Order RBCs

Although additional patterns may be discerned, bilateral, trilateral, and quadrilateral relationships are the basic RBC patterns, serving as basic units for more complex structures. Second-order analysis goes a step further and examines interrelationships among previous patterns, shifting the focus from simple RBC analysis to analysis of links among RBCs discovered earlier in the study. This process resembles interlocking brick construction, with different RBC patterns connected by common categories. Thus, bilateral, trilateral, and quadrilateral RBCs that contain a common category (or common set of categories) can be linked to each other like Lego blocks. At this stage, the researchers develop a full diagram, linking repetitive RBCs of bilateral, trilateral, and quadrilateral patterns to a complex network that is found to be consistent throughout the participating case studies.

Lea Kacen and I (Rabinovich and Kacen 2009, 2011) have found that RBCs of transference, overgeneralization, and additional categories were linked by “wish,” “response from other.” and “response of self,” which are Luborsky’s transferential components (1998; Luborsky and Luborsky 2006). Moreover, the above-noted quadrilateral relationship (transferential wish and overgeneralization connected by opposing themes) was linked with another dominant category: intense emotional reaction. Patients who wished to be loved but felt largely rejected, who wished to belong but felt like absolute outsiders (and so on), reacted with intense and unregulated emotions. The result is a network of categories associated with one another throughout the cases, serving as a foundation for the development of a new theory.

A Model for Case Study Metasynthesis

Although RBC has already been used for case studies (Rabinovich and Kacen 2009, 2012, 2016), extension of the RBC method for case study metasynthesis has to date not been undertaken. Individual case study reading can inform practice in a manner that cannot be achieved through other scientific publication methods. It has even been claimed that clinical practice could not have developed at all without case studies (Dattilio, Edwards, and Fishman 2010). Moreover, published cases possess utilitarian clinical value for a generation of research-based knowledge (Iwakabe and Gazzola 2009). Case studies enable communication of clinical knowledge, demonstration of how a theory is expressed in practice, how different patients respond to the same type of treatment (Iwakabe and Gazzola 2009), and which therapeutic concepts are common throughout cases from different cultures and countries. Although case studies are limited in scope, they provide an abundant source of evidence to demonstrate authors’ overt and covert theories (Dattilio, Edwards, and Fishman 2010).

Reports, emotional expressions, interpersonal knowledge, and quotations (Dattilio, Edwards, and Fishman 2010) transmit messages that embody far more than authors’ conscious ideas. Although case studies are ostensibly intended to illustrate the theories espoused by their authors, one can sometimes find other meanings in them that would appear alien to the relevant traditional school of thought. This feature invites comparison between the theoretical aspects of the participating articles and those of the case studies, identifying where the case studies took a step beyond the declared theory and locating not only overt insights but also covert patterns that appear repeatedly throughout the given database (Hilliard 1993). Metasynthesis of case studies strives for production of new knowledge and insights regarding both theory and clinical practice and can uncover silenced outlooks, thereby breaking new ground in psychology and psychoanalytic research.

The Course of Metasynthesis Research

In the course of a study, the researchers define the research topic, locate relevant articles, code and categorize case studies, analyze recurring RBC patterns, and formulate proposed interpretations.

Research question and inclusion criteria

The process begins with delineating a central research topic, followed by formulating a research question, setting criteria for inclusion and exclusion of case studies, and locating electronic databases of peer-reviewed articles that deal with the topic under investigation. The research topic and the research question that define the core theme of the study can be free of prior assumptions, as in the question “What characterizes transference case studies?” or it can be based on previous assumptions, as in the question “What are the connections between the concept of transference and cognitive-behavioral components?” The basic assumption of the latter would be that cognitive and behavioral components might appear not only in CBT, but also in psychoanalytic therapy.

Inclusion criteria include keywords, year of publication, accessibility (e.g., English language, available electronic versions). Inclusion of all relevant articles published during a selected period ensures representation of a broad spectrum of approaches to the research topic. Researchers should also scrutinize case studies for exclusions based on the limited availability of verbal exchanges between therapist and patient, because verbally rich case studies are essential in applying RBC and CCRT analyses. In fact, the richer the cases, the more the RBC repetitive patterns can be identified, and therefore the more extensive the basis for metasynthetic interpretations.

University databases are searched for relevant cases. The Single Case Archive (www.singlecasearchive.com), for example, is a good peer-reviewed database of psychotherapy case studies. This database enables searching by case-specific descriptors and gathering cases on a specific topic for metasynthesis goals (Desmet et al. 2013). In our study, transference case studies published in peer-reviewed journals were included. All of the included articles take a noticeably dynamic point of view, focusing on transference as a main issue, and include at least one case study aimed at illustrating the article’s topic (Rabinovich and Kacen 2009, 2012).

Holistic reading

This method does not examine the patients themselves, but rather the core topic and the different authors’ points of view. Case studies and their various authors are the key participants in the study (Desmet et al. 2013). The subject matter under investigation comprises the language and text structures adopted by those authors. The researchers launch the analysis by performing a holistic reading of the different articles in full, while examining the case studies in their theoretical contexts, that is, by comparing the theories with the case study content. At this stage the researchers identify the declared agendas of the authors by looking for disparities between theoretical and case study information, comparing overt insights and covert patterns, and paying particular attention to repeating aspects and categories relevant to the research question.

Coding and categorizing

Researchers initiate the key stage of the analysis only after becoming familiar with each of the articles as a whole. Having formulated a general impression of the participating articles, the researchers carefully assess the codes, as embodied in the language, concepts, metaphors, sentences, and words of each of the case studies. The analysis begins with open coding of these meaning units and proceeds to classification of the codes into broader categories, assessing similarities and differences among them. Categorization looks for recurring (or opposing) meanings that appear in the cases regardless of variance in wording.

Dominant categories are those that meet two key criteria: (1) they are common in the participating case studies and (2) they are repeatedly linked with the study’s core theme and with one another. Core findings that arise from one case study will be examined in the other cases. Repeated patterns of reciprocity among a series of categories support their centrality to the topic at hand.

To find dominant categories, the researchers locate all case study segments that include the research keywords, as derived from the research question. The categories appearing in these segments are assessed carefully to identify the dominant ones that recur throughout the database. After identifying the dominant categories, the researchers locate all text segments addressing them, thus uncovering an additional line of recurring categories. These “subcategories” also appear throughout the case studies and relate to the dominant categories and to one another. This process may be repeated until no more recurring categories emerge. In this manner the analysis explores a contextual associative network of categories linked to one another throughout the case studies.

Categories at the margins of an individual case study could be considered of secondary importance. As the analysis proceeds, however, they may well emerge as important categories because of their repetition across the full set of case studies. Thus, careful analysis of an individual case study, together with horizontal analysis across the full database, indicates the dominance of specific categories within the given topic. Categories that maintain systematic reciprocal relations throughout most of the cases will then be analyzed, presented, and validated using the RBC method.

Subjectivity of categorizing

Each text segment may incorporate numerous codes that researchers can ascribe to higher categories. Coding and categorization constitute a kind of interpretive process in which researchers choose the categories with which case study components will be associated. Researchers might associate a specific component with different categories or select one category for it. This decision is affected both by the research question and by the researchers’ subjective points of view.

One of the patterns that recurred in our numerous case studies is illustrated in the following: “My Mom rejected me, you are rejecting me, everybody rejects me’ (transference, overgeneralization, response of other; trilateral RBC). Each of these case studies involves a different CCRT theme of response from other (e.g., rejection, indifference, abuse). Depending on the research question, one could associate the components of this sentence with different categories (e.g., past, present, emotional figure, myself; quadrilateral RBC). However, since the researchers in our study are seeking the connection between transference and CBT components, they would associate the components of this pattern with the categories of transference and cognitive overgeneralization.

Use of validated tools

Researchers may enhance categorization objectivity by using validated tools relevant to the research topic. Such credibility may be enhanced, for example, by the use of a validated and reliable method such as Luborsky’s CCRT method, which has been published among a line of leading studies in the field (Crits-Christoph et al. 1988; Luborsky, Crits-Christoph, and Mellon 1986; Luborsky 1998; Luborsky and Luborsky 2006). Throughout analyses of bilateral, trilateral, and quadrilateral relationships, CCRT components have been found to be a linking factor between transference and CBT concepts. Such findings, when consistent with other studies and theories, have strong validity (Lincoln and Guba 1985).

Relationships Between Categories (RBC) Analysis

The analysis of relationships between categories previously discussed in grounded theory (Glaser and Strauss 1967; Glaser 1978; Strauss and Corbin 1998) is a critical phase in case study metasynthesis, as it looks for recurring connections between categories that are relevant to the core topic of the research (Walsh and Downe 2005). Researchers find RBCs by mapping series of bilateral links, some of which appear to have the same (or opposite) categories in common. These categories can be regarded as connections to trilateral and quadrilateral RBCs, validating the bilateral links and indicating, to some extent, the meanings connecting them.

Rabinovich and Kacen (2009, 2012), after coding CCRT components, analyzed their relationships with CBT components in sentences, in paragraphs, and in entire cases, striving to find categories related to the research question and to each other. Categories found to have consistent connections throughout the case studies served for development of a new theory. In the present research, segments that included Luborsky’s transferential CCRT components (wish, response from other, and response of self) were closely examined in the texts to discern relationships between transference and CBT components detected by open coding. The analysis showed that RBCs of transference, overgeneralization, and classical conditioning were linked by CCRTs in 90 percent of the thirty-three cases participating in this study (Rabinovich and Kacen 2009, 2012). One of the core conclusions was that classical conditioning mechanisms play a role in creating a frequent linkage of the RBC category of significant figure and CCRT components (Rabinovich and Kacen 2012). In this way, the researchers strive to identify systematic connections and validate them by assessing their prevalence and structure in the language of the case studies.

Theme Network Sketching and Interpretations

This stage of the analysis is the crux of the metasynthesis among the cases. Through second-order analysis, a thematic network is found to be consistent over all the case studies, becoming a springboard for the attainment of new interpretations. Repetitive connections of the core theme, dominant categories, subcategories, and other elements will provide the researchers an infrastructure for the formulation of new conceptualizations, buttressed by the relevant professional literature (Strauss and Corbin 1998). A summative research report is then composed.

Based on the presented findings, Kacen and I propose that pervasive transference themes are channeled through classical conditioning mechanisms, established early in life, that have been transformed into a cognitive overgeneralization that colors the person’s relationships with emotional figures (Rabinovich and Kacen 2011). Overgeneralization is actually an instance of Freud’s stereotype plates (1912) or Bowlby’s internal working models (1969), binding new therapy situations to previous attachment schemes, producing the unregulated transferential reaction identified in our analysis (see Figure 3).

Rabinovich and Kacen (2012) use the term thematic conditioning to designate the process of connecting early parental figures and transferential CCRTs such as rejection, indifference, judgment, and criticism. However, classical conditioning is considered today to be a more complicated process than Pavlov thought, and overgeneralization is a process more complicated than classical conditioning. Moreover, the understanding of overgeneralization and other cognitive misperceptions has changed since Beck’s initial formulations in the 1970s; they are now understood as a part of unconscious information processing (Weinberger and Stoycheva 2019).

Current research on modern learning theory (Mineka and Zinbarg 2006) indicates that the human psyche and interpersonal reactions are influenced by multi-component classical conditioning involving a set of self-representations (sensations, emotions, cognitions, perceptions, memories, etc.). While several self-representations are repeatedly activated together and connected with one another (classical conditioning), each self-representation may activate more internal stimuli in a domino effect, progressing to a full reaction in seconds. This reaction might be mistakenly generalized to new inter- and intrapersonal events (transference), resembling the generalization of Pavlov’s dogs salivating on hearing a new, unrelated sound (Pavlov 1927).

Recent literature on neuropsychology offers a model that may deepen our understanding of transference (Gabbard 2006; Pally 2007), by suggesting that self-representations are expressed within neural circuits that are simultaneously activated in the brain. These circuits may join together into a larger network that represents a set of aspects of a particular event. Such neural networks can become weightier through the impact of past experience and may be reactivated as a full pattern in a new event, even if it includes only a few of the aspects of the previous event. Our tendency to reactivate these dominant neural networks has been described as a “neuroscience interpretation” (Pally 2007) or, in the language of the presented findings, as an overgeneralization.

This perspective can explain why therapy relationships are found to be a high-ranking therapeutic factor (Lambert and Barley 2001; Tschuschke et al. 2015). The corrective emotional experience in therapy (Alexander and French 1946; Lane et al. 2015) can be an opportunity for new interpersonal thematic conditioning. This process enables both a mental and a neural change in which self-representations become more dominant, competing with the old transferential ones (Rabinovich and Kacen 2012; Sayin and Ceylan 2013; Westen and Gabbard 2002).

During this stage of analysis, the researchers should choose the specific categories that are to serve as key themes for interpretational propositions. In making these choices, researchers should consider the research question, other studies relating to the dominant categories, and unsolved issues in the field. One metasynthetic study could yield several foci of meanings regarding the core category, and these could ultimately combine into a broader understanding. Metasynthesis research reveals a categorization network, which gives rise to a broader thematic picture of the phenomenon studied. To interpret the significance of the network, researchers should consider it in view of existing knowledge and possibly formulate a new theoretical interpretation. By connecting concepts from different bodies of knowledge, the method challenges the prevailing theory and may also pave the way toward narrowing the gaps between theory, research, and practice (Rabinovich and Kacen 2013; Rabinovich 2020).

Figure 3.

Case studies metasynthesis

Discussion

This paper introduces a rigorous methodology of RBC metasynthesis for peer-reviewed case studies with the aim of building new theories, and can assist researchers who are interested in investigating psychoanalytic treatment. Such case studies serve as an abundant source for derivation of new information, based on repetitive thematic connections found to be common to a set of different case studies in a given field of interest. The RBC method is applied to the clinical discourse to examine bilateral, trilateral, and quadrilateral interrelationships found to be a common pattern, thus providing a core around which researchers can synthesize the case studies. Once such patterns are detected, researchers may be able to identify an extensive network of themes as a platform for a new conceptual and clinical interpretation. The present article demonstrates how the RBC method is applied to metasynthesis of transference case studies, thus also clarifying the nature of transference. The findings connect the phenomenon of transference to behavioral classical conditioning and to cognitive overgeneralization, demonstrating these connections throughout the language of the case studies and raising interpretive propositions that resonate with current studies and other theoretical and psychoanalytic concepts.

Freud (1937) was the first to suggest that themes that are mentioned alongside each other as an associative system imply unconscious content. Recent studies have found these associations to be created by simultaneous brain activity, strongly supporting Freud’s notion of the unconscious (Pally 2007). RBC metasynthesis strives to reveal covert connections that persist throughout the cases under scrutiny, thereby elucidating a deeper layer of information on which to develop new evidence-based knowledge. Just as Freud’s free associations are a key to the human unconscious mind, RBC patterns are a key to a hidden layer of the text. Connections among categories imply the unconscious relationship between them, essentially revealed by their appearance together in the same paragraph, segment, or case. In this way, RBC analysis can elucidate the text’s associative connections that hold the hidden structures of the cases.

The analysis of RBC-based metasynthesis is based on an epistemological point of view (Bondas and Hall 2007), identifies solid evidence of reciprocal relationships, and strives to validate elusive connections in the text and in the human psyche. RBC methodology provides tools for exposing covert patterns embodied in the context of cases, transforming covert into overt knowledge and intuitive impressions into clear findings. Although each of the case studies focuses on a different aspect of the relevant topic, the method helps researchers recognize hidden knowledge, as it maintains an extensive foothold across the data. The links among transference, overgeneralization, and classical conditioning were not prominent when focusing on each individual case separately, but are clearly evident when viewed against the full database. Repetition throughout the different cases confers validity and trustworthiness (Lincoln and Guba 1985) to seemingly marginal findings.

RBC analysis may reveal silenced patterns representing views common to several authors, together comprising a series of arguments for a new theoretical and clinical understanding. Key findings are often based on systematic covert patterns that do not necessarily constitute a significant part of the author’s declared theory, which is grounded in evidence from case descriptions (Eisenhardt 1989), but go beyond the authors’ conceptualization (Sandelowski 2004). In the above-described transference research, the participating case studies were psychodynamic by definition and were not theoretically oriented toward CBT. Although expressions of overgeneralization and classical conditioning were found systematically throughout the cases, the authors did not mention those concepts at all. The above findings were deemed dominant not because of their considerable prominence in any individual case study, but rather by virtue of their consistency in the case study narratives throughout the entire database. Although these findings were not conspicuous, they cannot be ignored.

Psychoanalytic knowledge and training rely widely on the case study method (Longhofer, Floersch, and Hartmann 2017; Mackay and Poser 2004) for yielding complex theoretical and clinical ideas. One case study is worth a thousand words of theory, because it has an essential wisdom, embodies rich elements, and reaches beyond the theories that the words aim to represent. Since case studies express the way that professionals actually operate, and how they understand patients and therapeutic situations, they can help researchers expand the integration between theories and narrow the gaps between theory and practice (McLeod 2002). Whereas a single case cannot be generalized (Flyvbjerg 2006), meta–case study is a crucial method for extracting their wealth of information and for developing new psychotherapies and psychoanalytic knowledge. However, the methodology of meta–case study is still in its infancy, and there is a critical need for researchers to develop more rigorous tools for conducting case study research (Hoon 2013; McLeod 2013). This article is an additional step in the dialogue of researchers and therapists about case study potential. Further applications for psychoanalytic metasynthesis of cases are expected.

Limitations and Further Research

This method focuses a great deal of effort on strengthening the findings of relationships between individual categories of psychoanalytic case descriptions. This approach is less suitable for a narrative analysis that strives to achieve multivariate interpretation and is not economical as a method of analysis of overt material. However, it is a useful technique for extracting hidden knowledge, translating it into near-text conclusions, and making it as prominent as the elephant in the room.

The literature describes the various shortcomings of case studies, including reliance on the therapist’s memory and choices, and lack of additional sources of information, such as the patient. It also points to a tendency toward interpreting findings in professional terms without considering alternative explanations. Moreover, case studies often lack contextual information that would enable readers to evaluate the interpretations presented by the authors (Dattilio, Edwards, and Fishman 2010).

The examples presented here show that RBC-based metasynthesis may overcome this content selectivity of the case studies, since they are based on the rich availability of process and significant dialogue for RBC analysis. Under certain circumstances, the selectivity of the case studies’ content may even reinforce the findings. In the brief selections extracted from published case studies, from which many details have necessarily been omitted, the appearance of persistent components (e.g., transference, overgeneralization, and classical conditioning) speaks for itself. The brevity of cases intensifies the significance of each component selected for inclusion, guaranteeing its relevance to the topic at hand.

Further discussion is required concerning adaptation of the presented method for metasynthesis of other types of documents, such as RBC analysis of theoretical articles (see Rabinovich 2016), that can be used with the aim of theoretical integration (Norcross and Goldfried 2005; Wood, Froh, and Geraghty 2010) of psychoanalytic literature. This method might also be considered for future case study research investigating the interrelationships and cumulative wisdom of components of different psychoanalytic schools.

Footnotes

Appendix: Case Study Database

Item No.	Patient	Source	Pages
1.	Mr. D.	Almond, R. (2004). “I can do it (all) myself”: Clinical technique with defensive narcissistic self-sufficiency. Psychoanalytic Psychology 21:371−384.	374−380
2.	Jennifer	Buirski, P., & Monroe, M. (2004). Intersubjective observations on transference love. Psychoanalytic Psychology 17:78−87.	78−87
3.	Joanne	Burch, B. (1996). Between women: The mother-daughter romance and homoerotic transference in psychotherapy. Psychoanalytic Psychology 13:475−494.	480−492
4.	Susan		487−492
5.	Ms. J.	Bienen, M. (1990). The pregnant therapist: Countertransference dilemmas and willingness to explore transference material. Psychotherapy: Theory, Research, Practice, Training 27:607−612.	608−618
6.	Ms. R.		610−611
7.	Jane	Church, E. (1993). Reading the transference in adolescent psychotherapy: A comparison of novice and experienced therapists. Psychoanalytic Psychology 10:187−205.	195−203
8.	John		199−203
9.	Laura	Diamond, D. (1992). Gender-specific transference reactions of male and female patients to the therapist’s pregnancy. Psychoanalytic Psychology 9:319−345.	330−333
10.	Fred		333−336
11.	Daniel		336−340
12.	Anna	Foster, R.P. (1992). Psychoanalysis and the bilingual patient: Some observations on the influence of language choice on the transference. Psychoanalytic Psychology 9: 61−76.	68−71
13.	Ms. B.	Frosch, A. (2002). Transference: Psychic reality and material reality. Psychoanalytic Psychology 19:603−633.	612−622
14.	Mike	Hillman, J., & Stricker, G. (2001). The management of sexualized transference and countertransference with older adult patients: Implications for practice. Professional Psychology: Research and Practice 32:272−277.	273−274
15.	Phillip		274−275
16.	Lily	Kalb, M. (2002). Does sex matter? The confluence of gender and transference in analytic space. Psychoanalytic Psychology 19:118−143.	118−140
17.	Pauline	Kavaler-Adler, S. (2003). Lesbian homoerotic transference in dialectic with developmental mourning: On the way to symbolism from the protosymbolic. Psychoanalytic Psychology 20:131−152.	133−151
18.	Edith	La Roche, M.J. (1999). Culture, transference and countertransference among Latinos. Psychotherapy: Theory, Research, Practice 36:389−397.	392−396
19.	Sandra		393−395
20.	Patty	Ogden, J.K. (1999). Love and sex in 45 minutes: Transference love as self- and mutual regulation Psychoanalytic Psychology 16:588−604.	594-603
21.	James	Russ, H. (1993). Erotic transference through countertransference: The female therapist and the male patient. Psychoanalytic Psychology 10:393−406.	397−399
22.	Dave		401−404
23.	Ms. J.	Stern, D.A. (1991). Transference as a shared (illusionary) reality: Technical implications for certain types of eroticized treatment relationships. Psychoanalytic Psychology 8:463−476.	471−475
24.	Unnamed female	Trop, J.L. (1988). Erotic and eroticized transference: A self psychology perspective. Psychoanalytic Psychology 5:269−284.	270−275
25.	Unnamed female		275−280
26.	A.	Yi, K. (1998). Transference and race: An intersubjective conceptualization. Psychoanalytic Psychology 15: 245−261.	252−256
27.	B.		253−256
28.	C.		254−256
29.	J.	Yi, K. (1995). Psychoanalytic psychotherapy with Asian clients: Transference and therapeutic considerations. Psychotherapy: Theory, Research, Practice, Training 32: 308−316.	309−310
30.	B.		313−314
31.	Ms. A.	Young, W. (1992). The emergence of the transference storm in the psychoanalytic process. Psychoanalytic Psychology 9:213−230.	219−223
32.	Mr. C.		223−225
33.	Mr. D.		225−227

Senior lecturer, Ashkelon Academic College, Sapir Academic College.

Submitted for publication February 11 2019.

ORCID iDs

Merav Rabinovich

Notes

References

Alexander

French

T.M.

(1946). The corrective emotional experience. Psychoanalytic Therapy: Principles and Application. Lincoln: University of Nebraska Press, 1980, pp. 66–70.

Atwood

G.E.

(2012). Psychotherapy as a human science: Clinical case studies exploring the abyss of madness. Pragmatic Case Studies in Psychotherapy 8:1–24.

Beck

A.T.

(1991). Cognitive therapy: A 30-year retrospective. American Psychologist 46:368–375.

Bondas

Hall

E.O.C.

(2007). Challenges in approaching metasynthesis research. Qualitative Health Research 17:113–121.

Bowlby

(1969). Attachment and Loss: Vol. 1. Attachment. New York: Basic Books.

Buiriski

Monroe

(2000). Intersubjective observations on transference love. Psychoanalytic Psychology 17:78–89.

Campbell

Pound

Pope

Britten

Pill

Morgan

(2003). Evaluating metaethnography: A synthesis of qualitative research on lay experiences of diabetes and diabetes care. Social Science & Medicine 56:671–684.

Carver

C.S.

Ganellen

R.J.

(1983). Depression and components of self-punitiveness: High standards, self-criticism, and overgeneralization. Journal of Abnormal Psychology 92:330–337.

Charmaz

(2006). Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. London: Sage Publications.

10.

Church

(1993). Reading the transference in adolescent psychotherapy: A comparison of novice and experienced therapists. Psychoanalytic Psychology 10:187–205.

11.

Cooper

Koenka

A.C.

(2012). The overview of reviews: Unique challenges and opportunities when research syntheses are the principal elements of new integrative scholarship. American Psychologist 67:446–462.

12.

Crits-Christoph

Luborsky

Dahl

Popp

Mellon

Mark

(1988). Clinicians can agree in assessing relationship patterns in psychotherapy: The Core Conflictual Relationship Theme method. Archives of General Psychiatry 45:1001–1004.

13.

Dattilio

F.M.

Edwards

D.J.

Fishman

D.B.

(2010). Case studies within a mixed methods paradigm: Toward a resolution of the alienation between researcher and practitioner in psychotherapy research. Psychotherapy: Theory, Research, Practice, Training 47:427–441.

14.

Desmet

Meganck

Seybert

Willemsen

Van Camp

Geerardyn

Declercq

Inslegers

Trenson

Vanheule

Kirshner

Schindlerm

Kächele

(2013). Psychoanalytic single cases published in ISI-ranked journals: The construction of an online archive. Psychotherapy & Psychosomatics 82:120–121.

15.

DeRubeis

R.J.

Keefe

J.R.

Beck

A.T.

(2019). Cognitive Therapy. New York: Guilford Press.

16.

Easden

M.H.

Kazantzis

(2018). Case conceptualization research in cognitive behavior therapy: A state of the science review. Journal of Clinical Psychology 74:356–384.

17.

Eisenhardt

K.M.

(1989). Building theories from case study research. Academy of Management Review 14:532–550.

18.

Finfgeld

D.L.

(2003). Metasynthesis: The state of the art—so far. Qualitative Health Research 13:893–904.

19.

Fishman

D.B.

(2001). From single case to database: A new method for enhancing psychotherapy, forensic, and other psychological practice. Applied & Preventive Psychology 10:275–304.

20.

Fishman

D.B.

(2004). Editor’s introduction to PCSP—From single case to database: A new method for enhancing psychotherapy practice. Pragmatic Case Studies in Psychotherapy 1:1–50.

21.

Fishman

D.B.

(2013). The pragmatic case study method for creating rigorous and systematic, practitioner-friendly research. Pragmatic Case Studies in Psychotherapy 9:403–425.

22.

Flyvbjerg

(2006). Five misunderstandings about case-study research. Qualitative Inquiry 12:219–245.

23.

Freud

(1912). The dynamics of transference. Standard Edition 12:99–108.

24.

Freud

(1937). Constructions in analysis. Standard Edition 23:257–269.

25.

Frosch

(2002). Transference: Psychic reality and material reality. Psychoanalytic Psychology 19:603–622.

26.

Gabbard

G. O.

(2006). A neuroscience perspective on transference. Psychiatric Annals 36:282–288.

27.

Ginat-Frolich

Klein

Katz

Shechner

(2017). A novel perceptual discrimination training task: Reducing fear overgeneralization in the context of fear learning. Behaviour Research & Therapy 93:29–37.

28.

Glaser

B.G.

(1978). Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Mill Valley, CA: Sociology Press.

29.

Glaser

B.G.

Strauss

(1967). The Discovery of Grounded Theory: Strategies for Qualitative Inquiry. Chicago: Aldine.

30.

Hill

C.E.

ed. (2012). Consensual Qualitative Research: A Practical Resource for Investigating Social Science Phenomena. Washington, DC: American Psychological Association.

31.

Hilliard

R.B.

(1993). Single-case methodology in psychotherapy process and outcome research. Journal of Consulting & Clinical Psychology 61:373–380.

32.

Höfler

Gloster

A.T.

Hoyer

(2010). Causal effects in psychotherapy: Counterfactuals counteract overgeneralization. Psychotherapy Research 20:668–679.

33.

Hoon

(2013). Meta-synthesis of qualitative case studies: An approach to theory building. Organizational Research Methods 16:552–556.

34.

Iwakabe

(2011). Extending systematic case study method: Generating and testing hypotheses about therapeutic factors through comparisons of successful and unsuccessful cases. Pragmatic Case Studies in Psychotherapy 7:339–350.

35.

Iwakabe

Gazzola

(2009). From single-case studies to practice-based knowledge: Aggregating and synthesizing case studies. Psychotherapy Research 19:601–611.

36.

Karon

B.P.

(2008). An “incurable” schizophrenic: The case of Mr. X. Pragmatic Case Studies in Psychotherapy 4:1–24.

37.

Kavaler-Adler

(2003). Lesbian homoerotic transference in dialectic with developmental mourning: On the way to symbolism from the protosymbolic. Psychoanalytic Psychology 20:131–152.

38.

Lambert

M.J.

Barley

D.E.

(2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training 38:357–361.

39.

Lane

R.D.

Ryan

Nadel

Greenberg

(2015). Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science. Behavioral & Brain Sciences 38:1–64.

40.

Levitt

H.M.

Pomerville

Surace

F.I.

(2016). A qualitative meta-analysis examining clients’ experiences of psychotherapy: A new agenda. Psychological Bulletin 142:801–830.

41.

Lilliengren

Werbart

(2005). A model of therapeutic action grounded in the patients’ view of curative and hindering factors in psychoanalytic psychotherapy. Psychotherapy: Theory, Research, Practice, Training 42:324–339.

42.

Lilliengren

Werbart

(2010). Therapists’ view of therapeutic action in psychoanalytic psychotherapy with young adults. Psychotherapy: Theory, Research, Practice, Training 47:570–585.

43.

Lincoln

Guba

E.G.

(1985). Naturalistic Inquiry. Thousand Oaks, CA: Sage Publications.

44.

Lissek

Kaczkurkin

A.N.

Rabin

Geraci

Pine

D.S.

Grillon

(2014). Generalized anxiety disorder is associated with overgeneralization of classically conditioned fear. Biological Psychiatry 75:909–915.

45.

Longhofer

Floersch

Hartmann

(2017). A case for the case study: How and why they matter. Clinical Social Work Journal 45:189–200.

46.

Luborsky

(1998). A guide to the CCRT method. In Understanding Transference: The Core Conflictual Relationship Theme Method, ed. Luborsky

Crits-Christoph

2nd ed. Washington, DC: American Psychological Association, pp. 15–36.

47.

Luborsky

Crits-Christoph

Mellon

(1986). Advent of objective measures of the transference concept. Journal of Consulting & Clinical Psychology 54:39–47.

48.

Luborsky

(2006). Research and Psychotherapy: The Vital Link. Lanham, MD: Aronson, pp. 31–48.

49.

Ludvigsen

M.S.

Hall

E.O.

Meyer

Fegran

Aagaard

Uhrenfeldt

(2016). Using Sandelowski and Barroso’s meta-synthesis method in advancing qualitative evidence. Qualitative Health Research 26:320–329.

50.

Mackay

Poser

(2004). The case study in psychoanalytic education. Modern Psychoanalysis 29:171–192.

51.

McLeod

(2002). Case studies and practitioner research: Building knowledge through systematic inquiry into individual cases. Counselling & Psychotherapy Research 2:264–268.

52.

McLeod

(2013). Increasing the rigor of case study evidence in therapy research. Pragmatic Case Studies in Psychotherapy 9:382–402.

53.

Mineka

Zinbarg

(2006). A contemporary learning theory perspective on the etiology of anxiety disorders: It’s not what you thought it was. American Psychologist 61:10–26.

54.

Netto

Bhopal

Lederle

Khatoon

Jackson

(2010). How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 25:248–257.

55.

Noblit

G.W.

Hare

R.D.

(1988). Meta-ethnography: Synthesizing Qualitative Studies. Vol. 11. Thousand Oaks, CA: Sage Publications.

56.

Norcross

J.C.

Goldfried

M.R.

eds. (2005). Handbook of Psychotherapy Integration. New York: Oxford University Press.

57.

Pally

(2007). The predicting brain: Unconscious repetition, conscious reflection and therapeutic change. International Journal of Psychoanalysis 88:861–881.

58.

Pavlov

I.P.

(1927). Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. London: Oxford University Press.

59.

Rabinovich

(2016). Psychodynamic emotional regulation in view of Wolpe’s desensitization model. American Journal of Psychology 129:65–79.

60.

Rabinovich

(2020). Relationships Between Categories: The context of the symptom in practice. Journal of Contemporary Psychotherapy 50:95–103.

61.

Rabinovich

Kacen

(2009). Let’s look at the elephant: Metasynthesis of transference case studies for psychodynamic and cognitive psychotherapy integration. Psychology & Psychotherapy: Theory, Research & Practice 82:427–447.

62.

Rabinovich

Kacen

(2010). Advanced relationships between categories (RBC): Analysis as a qualitative research tool. Journal of Clinical Psychology 66:698–708.

63.

Rabinovich

Kacen

(2011). Wish and overgeneralization model for psychotherapy integration. Journal of Psychotherapy Integration 21:43–69.

64.

Rabinovich

Kacen

(2012). Transference in view of a classical conditioning model. American Journal of Psychology 125:209–223.

65.

Rabinovich

Kacen

(2013). Qualitative coding methodology for interpersonal study. Psychoanalytic Psychology 30:210–231.

66.

Sandelowski

(2004). Using qualitative research. Qualitative Health Research 14:1366–1386.

67.

Sandelowski

Docherty

Emden

(1997). Focus on qualitative methods—qualitative metasynthesis: Issues and techniques. Research in Nursing & Health 20:365–372.

68.

Sayin

Ceylan

M.E.

(2013). The neurobiology of transference. Journal of Mind & Behavior 34:233–258.

69.

Sevenster

Haesen

Vervliet

Kindt

D’Hooge

(2017). Prevention and treatment strategies for contextual overgeneralization. Scientific Reports 7:1–14.

70.

Strauss

Corbin

(1998). Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage Publications.

71.

Thorne

Jensen

Kearney

M.H.

Noblit

G.W.

Sandelowski

(2004). Qualitative metasynthesis: Reflections on methodological orientation and ideological agenda. Qualitative Health Research 14:1342–1365.

72.

Timulak

(2009). Meta-analysis of qualitative studies: A tool for reviewing qualitative research findings in psychotherapy. Psychotherapy Research 19:591–600.

73.

Tracy

S.J.

(2010). Qualitative quality: Eight “big-tent” criteria for excellent qualitative research. Qualitative Inquiry 16:837–851.

74.

Tschuschke

Crameri

Koehler

Berglar

Muth

Staczan

Von Wyl

Schulthess

Koemeda-Lutz

(2015). The role of therapists’ treatment adherence, professional experience, therapeutic alliance, and clients’ severity of psychological problems: Prediction of treatment outcome in eight different psychotherapy approaches. Preliminary results of a naturalistic study. Psychotherapy Research 25:420–434.

75.

Tutty

L.M.

Rothery

M.A

Grinnell

R.M.

(1996). Qualitative Research for Social Workers. Boston: Allyn & Bacon.

76.

Walsh

Downe

(2005). Meta-synthesis method for qualitative research: A literature review. Journal of Advanced Nursing 50:204–211.

77.

Weinberger

Stoycheva

(2019). The Unconscious: Theory, Research, and Clinical Implications. New York: Guilford Press.

78.

Westen

Gabbard

G.O.

(2002). Developments in cognitive neuroscience: II. Implications for theories of transference. Journal of the American Psychoanalytic Association 50:99–134.

79.

Willemsen

Inslegers

Meganck

Geerardyn

Desmet

Vanheule

(2015). A metasynthesis of published case studies through Lacan’s L-schema: Transference in perversion. International Journal of Psychoanalysis 96:773–795.

80.

Wood

A.M.

Froh

J.J.

Geraghty

A.W.

(2010). Gratitude and well-being: A review and theoretical integration. Clinical Psychology Review 30:890–905.

81.

Zimmer

(2006). Qualitative meta-synthesis: A question of dialoguing with texts. Journal of Advanced Nursing 53:311–318.