Document 1946226

Exploring therapeutic action in
psychoanalytic psychotherapy
Attachment to therapist and change
Peter Lilliengren
© Peter Lilliengren, Stockholm, 2014
ISBN 978-91-7447-988-1
Printed in Sweden by US-AB, Stockholm 2014
Distributor: Department of Psychology, Stockholm University
“It has been a permissive and respectful atmosphere here and I
have dared to open up. I have dared to talk about things that I
have not talked about with many others before, even though I’m
usually an open person.” (Patient, study I)
“It’s about daring to connect, to begin trusting someone. To begin
to feel that she can come here and open up about something that
feels frightening and threatening to her. It’s about daring to be
dependent and to permit closeness, of which she has had little
positive experience.” (Therapist, study II)
“[The therapist] is an attachment figure who provides the security
needed for insecurity to be explored.” (Holmes, 2010, p. 6)
ABSTRACT
There are several theoretical notions of how psychoanalytic psychotherapy work, but only
limited empirical evidence to support any of them. The overall aim of this thesis was to
explore therapeutic action in psychoanalytic psychotherapy from different perspectives
(patient, therapist, and observer), using different methodological approaches (qualitative and
quantitative). Study I explores 22 young adult patients’ views of therapeutic action with
qualitative, grounded theory methodology. The analysis resulted in a conceptual model
indicating that talking openly in the context of a safe therapeutic relationship led to new
relational experiences and expanding self-awareness. Hindering factors included difficulties
“opening up”, experiencing the therapist as too passive and that something was missing in
therapy, leading to an experience of mismatch. Study II investigates 16 experienced
therapists’ views of therapeutic action. The results indicated that the development of a close,
safe and trusting relationship was perceived as the core curative factor. This interacted with
the patient making positive experiences outside the therapy setting and the therapist
challenging the patients’ thinking about the self. Patients’ fears about close relationships
emerged as the sole hindering factor from the therapists’ perspective, perceived as creating
distance in the therapeutic relationship and leading to maintenance of patients’ problems.
The results of study I and II suggest that the quality of patients’ attachment to their
therapist may be important for treatment process and outcome. In order to examine
attachment to therapist using quantitative methodology, a new observer-rating scale (Patient
Attachment to Therapist Rating Scale; PAT-RS) was developed. Study III involves an initial
examination of the psychometric properties of PAT-RS. Three raters rated a total of 70
interviews. The results indicated good inter-rater reliability for three of the subscales
(Security, ICC = .74; Deactivation, ICC = .62; Disorganization, ICC = .74), while one had
poor (Hyperactivation, ICC = .34). Correlations with measures of the therapeutic alliance,
mental representations, and symptom distress were moderate and in the in the expected
directions, suggesting construct validity for the reliable subscales. Study IV investigates the
relationships between secure attachment to therapist, patient-rated alliance and outcome. A
series of linear mixed-effects models, controlling for between-therapist variability and length
of therapy, indicated that secure attachment to therapist at termination was related to
improvements in symptoms, global functioning and interpersonal problems. The relationships
with symptom change and increased functioning was maintained after the therapeutic alliance
was accounted for. Further, a suppression effect was found, indicating that secure attachment
to therapist at termination predicted continued improvement in functioning during follow-up,
whereas the alliance predicted deterioration when both variables were modeled together.
The overall result of this thesis indicates that the development of a secure attachment
to the therapist may be an important mechanism of change in psychoanalytic psychotherapy.
This is discussed in relation to common and specific factors in psychotherapy, as well as in
established theoretical notions of therapeutic action in the psychoanalytic discourse.
Implications for the measurement of secure attachment to therapist and its differentiation from
the therapeutic alliance are considered. Based on the results, two tentative process models that
may be useful for clinical practice and future research are proposed: a broaden-and-built cycle
of attachment security development and change and a react-and-disconnect cycle of
attachment insecurity maintenance. Future research should investigate the temporal
development of attachment to therapist and its relation to the therapeutic alliance and outcome
more closely. Specific strategies that foster a secure attachment to therapist, as well as
interventions for dissolving insecure strategies, should be identified and integrated in the
theory and practice of psychoanalytic psychotherapy.
Keywords: Therapeutic action, mechanisms of change, psychoanalytic, psychodynamic,
psychotherapy, young adults, attachment to therapist, therapeutic alliance, process, outcome,
grounded theory, linear mixed models
LIST OF PUBLICATIONS
This thesis is based on the following studies, which are referred to in the text by their Roman
numerals.
I.
Lilliengren, P., & Werbart, A. (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(3), 324–339.
doi:10.1037/0033-3204.42.3.324
II.
Lilliengren, P., & Werbart, A. (2010). Therapists’ view of therapeutic action in
psychoanalytic psychotherapy with young adults. Psychotherapy, 47(4), 570–585.
doi:10.1037/a0021179
III.
Lilliengren, P., Werbart, A., Mothander, P. R., Ekström, A., Sjögren, S., & Ögren, ML. (2014). Patient Attachment to Therapist Rating Scale: Development and
psychometric properties. Psychotherapy Research, 24(2), 184–281.
doi:10.1080/10503307.2013.867462
IV.
Lilliengren, P., Falkenström, F., Sandell, R., Mothander, P. R., & Werbart, A. (2014).
Secure attachment to therapist, alliance, and outcome in psychoanalytic psychotherapy
with young adults. Journal of Counseling Psychology. Advance online publication.
doi:10.1037/cou0000044
The original papers are reproduced with permission from the publishers.
Papers I, II and IV: © American Psychological Association (www.apa.org).
Paper III: © Taylor & Francis (www.tandfonline.com).
LIST OF ABBREVIATIONS
AAI
Adult Attachment Interview
CATS
Client Attachment to Therapist Scale
CAQ-T
Components of Attachment Questionnaire – Therapist
DIP-Q
DSM-IV and ICD-10 Personality Questionnaire
DRS
Differentiation-Relatedness Scale
DSM-IV
Diagnostic and Statistical Manual of Mental Disorders
GAF
Global Assessment of Functioning Scale
GSI
Global Severity Index of the SCL-90
GT
Grounded Theory
HAq-II
Helping Alliance Questionnaire
ICD-10
International Statistical Classification of Diseases
ICC
Intraclass correlation coefficient
IIP
Inventory of Interpersonal Problems
ORI
Object Relations Inventory
PACS
Patient Attachment Coding System
PAT-RS
Patient Attachment to Therapist Rating Scale
PT-AAI
Patient-Therapist Adult Attachment Interview
PTI
Private Theories Interview
REML
Restricted maximum likelihood
SASB
Structural Analysis of Social Behavior
SEM
Structural Equation Modeling
SCL-90
Symptom Checklist – 90
SPSS
Statistical Package for the Social Sciences
WAI
Working Alliance Inventory
YAPP
Young Adult Psychotherapy Project
CONTENTS
INTRODUCTION ...................................................................................................................... 1 Common and specific factors .......................................................................................................................... 1 Perspectives on therapeutic action .......................................................................................... 3 The patient’s perspective ................................................................................................................................. 3 The therapist’s perspective .............................................................................................................................. 4 Methodological perspectives ........................................................................................................................... 5 Therapeutic action in psychoanalytic psychotherapy ............................................................. 6 Insight .............................................................................................................................................................. 6 Relational impact ............................................................................................................................................. 8 Alliance and attachment ....................................................................................................... 10 The therapeutic alliance ................................................................................................................................. 11 Attachment to therapist ................................................................................................................................. 12 Assessing attachment to therapist.................................................................................................................. 13 The impact of patient-therapist attachment on psychotherapy process ......................................................... 14 Differentiating secure attachment to therapist from the therapeutic alliance ................................................ 15 Young adults in psychoanalytic psychotherapy ................................................................... 16 AIM OF THE THESIS ............................................................................................................. 19 METHOD ................................................................................................................................. 21 Participants and procedures .................................................................................................. 21 Research context ............................................................................................................................................ 21 Study samples ................................................................................................................................................ 22 Ethical considerations .................................................................................................................................... 23 Measures and methods.......................................................................................................... 23 Interviews ...................................................................................................................................................... 23 Qualitative methodology ............................................................................................................................... 24 Self-report measures ...................................................................................................................................... 25 Expert-rated measures ................................................................................................................................... 26 Statistical analyses ......................................................................................................................................... 27 Development of the Patient Attachment to Therapist Rating Scale (PAT-RS) .................... 28 Basic assumptions ......................................................................................................................................... 28 Theoretical structure and subscales ............................................................................................................... 29 Item construction ........................................................................................................................................... 31 Rating procedure and scoring ........................................................................................................................ 32 RESULTS................................................................................................................................. 35 Study I: A model of therapeutic action grounded in the patients’ view of curative and
hindering factors in psychoanalytic psychotherapy.............................................................. 35 Study II: Therapists’ view of therapeutic action in psychoanalytic psychotherapy with
young adults .......................................................................................................................... 37
Study III: Patient Attachment to Therapist Rating Scale: Development and psychometric
properties .............................................................................................................................. 38
Study IV: Secure attachment to therapist, alliance, and outcome in psychoanalytic
psychotherapy with young adults ......................................................................................... 40 DISCUSSION .......................................................................................................................... 43 Reflections on main findings ................................................................................................ 43 Patients’ and therapists’ views of curative factors ........................................................................................ 43 Patients’ and therapists’ views of hindering factors ...................................................................................... 44 Assessing attachment to therapist with PAT-RS ........................................................................................... 46 Secure attachment to therapist and change .................................................................................................... 47 Secure attachment to therapist and the alliance constructs revisited ............................................................. 48 Psychoanalytic psychotherapy with young adults ......................................................................................... 49 Methodological considerations ............................................................................................. 51 Strengths ........................................................................................................................................................ 51 Limitations ..................................................................................................................................................... 52 Concluding thoughts ............................................................................................................. 53 Two tentative process models ....................................................................................................................... 53 Implications for practice ................................................................................................................................ 55 Suggestions for future research ..................................................................................................................... 56 ACKNOWLEDGEMENTS IN SWEDISH ............................................................................. 59 REFERENCES ......................................................................................................................... 61 APPENDIX: Patient Attachment to Therapist Rating Scale (PAT-RS)
ORIGINAL PAPERS I-IV
INTRODUCTION
Modern-day psychotherapy research has firmly established that “psychotherapy works”
(Lambert, 2013a). Since the 1970-ties, several hundred randomized controlled trials and
numerous meta-analyses have repeatedly shown that systematically applied psychotherapy
leads to better outcomes than no treatment or usual care for a wide range of conditions (e.g.,
Budge et al., 2013; Cuijpers, Andersson, Donker, & van Straten, 2011; Koelen et al., 2013;
Lipsey & Wilson, 1993; Smith, Glass, & Miller, 1980; Stoffers et al., 2013; Wampold, 2001).
In general, there seems to be no or only small differences between various forms of bona-fide
psychotherapy for the average patient (e.g., Baardseth et al., 2013; Benish, Imel, & Wampold,
2008; Lambert, 2013a; Leichsenring, 2001; Leichsenring & Leibing, 2003; Wampold et al.,
2002). However, establishing that psychotherapy works in general does not tell us much about
how it works. Further, psychotherapy does not produce the same outcomes in all patients.
Research indicates that approximately 20% of patients drop out before experiencing any
benefits (McMurran, Huband, & Overton, 2010; Roos & Werbart, 2013; Swift & Greenberg,
2012) and about 5-10% may actually deteriorate while in therapy (Gold & Stricker, 2011;
Lambert, 2011, 2013a; Mohr, 1995). Thus, although the general outcome for the average
patient is typically good, psychotherapy involves a complex set of interacting factors that
might lead toward improvement, dropout or deterioration for any given patient.
The question of what promotes or hinders change in psychotherapy has been the
central concern for over 60 years of process-outcome research (Orlinsky, Rønnerstad &
Wilutzki, 2004). This area of research is vast and multifaceted, both in terms of its methods
and findings. Yet, despite long-term attention from process researchers, we still know quite
little about the fundamental “mechanisms of change” in different forms of psychotherapy
(Johansson & Høglend, 2007; Kazdin, 2007, 2009; Kraemer, Wilson, Fairburn, & Agras,
2002). For example, Kazdin (2007) concludes that: “…it is remarkable that after decades of
psychotherapy research, we cannot provide an evidence-based explanation for how or why
even our most well studied interventions produce change” (p. 23). Thus, more research
investigating the therapeutic action of psychotherapy is needed. A greater understanding of
the underlying change mechanisms could aid in the development of new treatments and/or
increase the effectiveness of the models currently practiced. Further, identifying the
fundamental mechanisms and processes that lead to change might potentially also reduce the
gap between different schools of psychotherapy, as well as bring researchers and clinicians
closer to each other (Kazdin, 2008).
Common and specific factors
The repeated finding that there are no or only small differences in outcome between bona-fide
psychotherapy models has sparked a long-standing debate in the field regarding the relative
importance of common and specific factors for treatment outcome. Common factors are
1 thought to be present to some degree in all forms of psychotherapy. These include the
therapeutic alliance, patient expectations and therapist qualities such as empathy, positive
regard, and genuineness, all of which have been shown to be significant predictors of outcome
(Norcross, 2011). Since different forms of psychotherapy tend to produce similar results,
some scholars have argued that the treatment effects are probably largely due to such common
factors (Messer & Wampold, 2002).
However, it is also possible that specific factors drive the outcome in different forms
of psychotherapy, generating similar results on average (DeRubeis, Brotman, & Gibbons,
2005). Specific factors may refer to specific techniques or procedures predominantly used in a
particular form of treatment (e.g., exposure in behavior therapy or transference interpretations
in psychoanalytic psychotherapy). Specific factors may also refer to the underlying processes
through which change is proposed to occur based on a particular theoretical perspective (e.g.,
provision of insight in psychoanalytic psychotherapy or change in negative automatic
thoughts in cognitive therapy). Although there is little evidence to suggest that certain specific
factors are absolutely crucial for outcome with any given patient population, process-outcome
studies do suggest that several specific factors are linked to change (Crits-Christoph, Connolly
Gibbons, & Mukherjee, 2013). Further, some research even suggests that factors thought to be
specific to one particular school of psychotherapy may unwittingly contribute to outcome in
another form of psychotherapy (Ablon & Jones, 1998; Castonguay, Goldfried, Wiser, Raue, &
Hayes, 1996; DeFife, Hilsenroth, & Gold, 2008; Hilsenroth, Blagys, Ackerman, Bonge, &
Blais, 2005; Jones & Pulos, 1993).
Other researchers have argued that the distinction between common and specific
factors is a false dichotomy (Wampold & Budge, 2012). According to a contextual view of
psychotherapy (Frank & Frank, 1991; Wampold, 2001), specific factors are essential for
outcome since without any specific activities (i.e., “healing rituals” promoting healthy
actions) associated with a particular form of psychotherapy there would simply be no
treatment for the patient to respond to. At the same time, specific factors can only be
delivered in the context of common factors (including relationship factors, as well as patient
expectations and cultural influences) and arguably derive much of their power from that
context. Several attempts have been made to theoretically integrate both common and specific
factors into generic, “meta-models” of psychotherapy (e.g., Anderson, Lunnen, & Ogles,
2010; Wampold & Budge, 2012).
However, there is probably still a long way to go before a generic meta-model of
psychotherapy will receive wide acceptance in the field. All schools of psychotherapy have
their own preferred theories and hypotheses regarding the therapeutic action of their particular
form of treatment, and many of these notions have still not been empirically tested. Further,
different theories of psychotherapy are based on different epistemological assumptions and
“visions of reality” (Messer & Winokur, 1984; Safran & Messer, 1997), which makes it
difficult to fully integrate or substitute them with a universal model. Still, one possible future
prospect is that the major schools of psychotherapy (e.g., psychoanalytic, humanistic,
cognitive, behavioral) will continue to assimilate findings from psychotherapy research,
gradually leading to greater integration of the field as a whole (Lampropoulos, 2001; Messer,
2001). A starting point for this thesis project is that this process will likely be aided by the
identification of both common and specific mechanisms of change in different forms of
psychotherapy.
2 Perspectives on therapeutic action
The study of therapeutic action may be approached from the perspective of the patient, the
therapist or independent observers (Mintz, Auerbach, Luborsky, & Johnson, 1973; Strupp,
Fox, & Lesser, 1969), as well as using different research methodologies (Lutz & Knox, 2014).
As a background for the studies included in this thesis, some current issues and findings
regarding the study of therapeutic action from these perspectives are introduced and
summarized below.
The patient’s perspective
Although it may seem obvious that asking the patient what he or she experienced as helpful or
hindering in treatment would be a valid approach to study therapeutic action, such efforts
have been questioned historically (McLeod, 1990). In the psychoanalytic tradition, the
patient’s conscious accounts of the therapy process have typically been interpreted as skewed
by forces outside the patient’s awareness and therefore regarded with some suspicion.
Similarly, behavioral researchers have tended to dismiss the patients’ subjective experiences
as unreliable, preferring the use of objective measures of overt behaviors or psychophysical
reactions. Scholars predominantly associated with the humanistic tradition, however, have
long argued that patients’ perspective on their own process of change is a fundamental source
of information (Howe, 1993; McLeod, 1990; Rogers, 1951; Strupp, Fox, & Lesser, 1969).
Ultimately, it is the patient that implements change and therefore research should be directed
towards what the patients find curative or hindering for them (Bohart, 2000; Bohart &
Tallman, 1999).
The patients’ perspective on what is helpful or curative in psychotherapy (and, to a
lesser extent, what is perceived as non-helpful or hindering) has been explored in a number of
studies since the 1960-ties. Several reviews of this literature have also been published (see
Bohart & Greaves Wade, 2013; Elliot & James, 1989; Rennie, 2002; Timulak, 2007, 2010).
Overall, the findings suggest that patients typically experience factors that are common to
different forms of psychotherapy as most helpful. For example, Elliott and James (1989)
found that the most frequently reported helpful factors across therapies were (a) facilitative
therapist characteristics, (b) self-expression permitted, (c) experiencing a supportive
relationship, (d) gaining self-understanding, and (e) therapist encouraging extra-therapy
practice. Similar findings were reported in a more recent review of 41 studies focusing on
patient identified significant events in psychotherapy (Timulak, 2010).
Research further suggests that the patient’s view of what is curative or hindering in
therapy may diverge considerably from their therapist’s view (Castonguay, et al., 2010;
Hunsley, Aubry, Verstervelt, & Vito, 1999; Leuzinger-Bohleber, 2002; Timulak, 2010;
Werbart & Levander, 2006, 2011) and that therapists often are unaware of such discrepancies
(Hill, Nutt-Williams, Heaton, Thompson, & Rhodes, 1996; Rennie, 1994; Regan & Hill,
1992). Hindering factors reported by patients typically involve misunderstandings or negative
reactions from the therapists, stressing the importance of actively inquiring into patients’
perspective of the process (Henkelman & Paulson, 2006; Hill & Knox, 2009).
Some studies also indicate that while certain patients may experience the specific
factors in a particular form of treatment as helpful, others may experience the same factors as
3 hindering (Gershefski, Arnkoff, Glass, & Elkin, 1996; Nilsson, Svensson, Sandell, & Clinton,
2007; Levy, Glass, Arnkoff, & Gershefski, 1996). For example, Nilsson and colleagues
(2007) compared satisfied and dissatisfied patients’ views of process and outcome in
psychoanalytic psychotherapy and cognitive-behavioral therapy, respectively. Patients who
were satisfied with psychoanalytic psychotherapy typically valued the reflective nature of the
psychotherapy process and described having gained self-understanding. In contrast, the
satisfied patients in cognitive-behavioral therapy described that they had learned to manage
anxiety and cope in difficult situations and appreciated the therapist activity in structuring the
treatment process. Dissatisfied patients in psychoanalytic psychotherapy typically described
experiencing the therapist as withdrawn, disengaged, not providing enough support or
guidance, whereas dissatisfied patients in cognitive-behavioral therapy typically considered
the therapist to be intrusive and oppressive, applying a rigid predetermined therapy scheme.
Hence, what patients experience as curative or hindering in treatment may also be moderated
by particular patient factors (Bohart & Greaves Wade, 2013).
Although previous research suggests that patients report common factors as most
helpful in therapy, we know very little about how such factors may interact with each other or
with specific treatment factors from the view of the patient. We know even less about how
perceived curative factors might interact with the patient’s experience of negative or
hindering aspects in treatment. Study I of the present thesis explores patients’ own views of
therapeutic action in psychoanalytic psychotherapy with particular attention to how curative
and hindering factors may interrelate.
The therapist’s perspective
Historically, the therapist perspective has had a privileged position when it comes to the
development of theories of therapeutic action (Bohart, 2000; Bohart & Tallman, 1999). In the
psychoanalytic tradition, new ideas have typically grown out of clinical observations and
experiences of practicing therapists rather than through formal research. Still, even in
traditions that emphasize experimental research, theoretical and technical advancements have
often been developed by clinicians in order to accommodate the problems they faced in
clinical practice (e.g., Beck, 1976; Ellis, 1962; Linehan, 1993). Indeed, in any field as
complex as psychotherapy, theoretical and methodological progress is not likely to be driven
by research alone.
Few would probably question the idea that experienced therapists’ views of what
works and what does not work in therapy may contain valuable information. For example,
several authors have argued that experienced therapists develop “implicit theories” regarding
how to conduct therapy that are based on a mixture of personal experiences, formal training
and professional reflections (Kottler, 1986; Najavits, 1997; Schön, 1983). These private
notions may include the therapist’s personal strategies of what to do during sessions or views
about what processes are occurring in therapy, which may more or less overlap with the
therapist’s official theoretical orientation (Sandler, 1983). Thus, experienced therapists’
implicit theorizing may contain novel ideas that, if elucidated and systematized, could
improve our formal theories and practices.
Yet, surprisingly little research has been directed at exploring what practicing
therapists view as curative and hindering in their everyday work (McLeod, 1990, 2013). One
possible explanation for the lack of research in this area may be that, traditionally, therapists’
4 subjective experiences have been reserved for supervision and personal psychotherapy
(McLeod, 1990). Therapists may also experience resistance against openly discussing private
notions when these clash with their official theoretical orientation (Sandler, 1983). Further,
the emphasis on adherence to treatment manuals in randomized controlled trials (which
arguably limits the impact of therapists’ implicit theorizing) may also have reduced research
interest in therapists’ everyday clinical thinking.
In recent years, however, the qualities of the therapist have come more into focus
following the repeated finding that therapists differ in effectiveness (Baldwin & Imel, 2013).
Further, in current definitions of evidence-based practice (American Psychological
Association, 2005), clinical expertise is considered essential for the integration of research
findings and clinical data in the context of patient characteristics, culture, and preferences.
Given that experienced therapists develop private theories that may contain valuable
information, one important area for further research concerns how practicing therapists
conceptualize and implement notions of therapeutic action in different forms of
psychotherapy and with different patient populations. Study II of this thesis explores
experienced psychotherapists’ views of therapeutic action in psychoanalytic psychotherapy
with young adults.
Methodological perspectives
How to best approach the study of therapeutic action in psychotherapy has been discussed and
debated among researchers since the dawning of modern process-outcome research (Orlinsky,
Rønnerstad & Wilutzki, 2004). This touches on some fundamental epistemological and
methodological issues involved in generating and testing clinical theories, such as the
distinction between inductive or deductive reasoning and the use of qualitative or quantitative
methods for analyzing data.
In the psychoanalytic tradition, theories of therapeutic action have historically been
generated primarily through inductive reasoning based on clinical case studies. This approach
has been heavily criticized by philosophical scholars such as Popper (1959) and Grünbaum
(1984), but also by contemporary psychoanalytic researchers (Fonagy, 2003; Luyten, Blatt, &
Corveleyn, 2006). For example, alluding to the epistemological distinction between “the
context of discovery” and “the context of justification,” Fonagy (2003) argues that the
psychoanalytic tradition may be rich in its “discoveries”, but has lagged far behind when it
comes to the “justification” of these ideas.
While the traditional psychoanalytic case study may no longer be acceptable as a
research method in and of it self, several more formal qualitative, inductive methods have
been developed and applied in psychotherapy research (McLeod, 2013; Lutz & Knox, 2014).
Typically, such methods involve the careful following of formalized steps and procedures for
categorizing and interpreting data, as well as “bracketing” the researchers theoretical
preconceptions. Some of these methods also include a second set of procedures based on
deductive reasoning, which involve “testing hypotheses” within a qualitative dataset,
presumably providing more robust and generalizable results (Strauss & Corbin, 1996). Kazdin
(2007, 2009) points out that the strengths of inductive, qualitative research is that it can
evaluate the richness and details of the psychotherapeutic process, including how and why
change unfolds or why it does not unfold, from the particular perspective of the targeted
respondents. Qualitative studies may be particularly fruitful in areas where there is a relative
5 lack of previous research or theory, illuminating novel ideas directly applicable in clinical
practice, as well as providing grounded hypotheses for further research.
However, most research on curative and hindering factors in psychotherapy has been
based on deductive reasoning and carried out with quantitative methods. Typically, such
studies have correlated some variable of interest with outcome, sometimes statistically
controlling for a particular confounding variable or variables (Crits-Christoph et al., 2013).
Although the result of process-outcome research is sometimes discussed in terms of “cause
and effect”, correlational designs do not allow causal inferences. While there exist methods
and procedures that provide more thorough tests of causal relationships between process
variables, very few psychotherapy studies have yet utilized them fully (Kazdin, 2007, 2009;
Johansson et al., 2010). Consequently, most studies in this area can only be regarded as
exploratory.
Several psychotherapy researchers have argued that, given the current state of the
field, process-outcome research should move firmly in the direction of testing specific
theoretical assumptions (Johansson & Høglend, 2007; Kraemer et al., 2002). However, others
have pointed out that the field is still searching for potential mechanisms that may underlie the
effects of different forms of psychotherapy (Kazdin, 2007). In this effort, both qualitative and
quantitative studies may enhance our understanding of processes that promote or hinder
change. Further, the establishment of any mechanism of change is likely to be reached only
through the integration of several lines of research over time. Adopting a stance of
methodological pluralism is probably still wise and such efforts could also help bridging the
gap between academic research and clinical practice (Luyten et al., 2006; Kazdin, 2008). In
the present thesis, qualitative methodology is employed in study I and II whereas study III and
IV utilize quantitative methods in order to explore the main research questions.
Therapeutic action in psychoanalytic psychotherapy
Turning to the tradition in focus for this thesis, a number of theoretical propositions regarding
how psychoanalytic1 therapies work has been suggested since Joseph Breuer’s and Sigmund
Freud’s first notion of the “cathartic cure” (Breuer & Freud, 1895/1955). Yet, almost 120
years after Breuer and Freud’s seminal work, there still exist no generally accepted theory of
therapeutic action in the psychoanalytic discourse. Comparing psychoanalytic theories of
change, Kernberg (2007) recognizes two fundamental mechanisms that are inherent (although
differentially emphasized and conceptualized) in all contemporary psychoanalytic approaches
– provision of insight and relational impact. These two notions are elaborated below in
relation to empirical findings.
Insight
The idea that increasing the patient’s insight into his or her own unconscious psychological
processes leads to change may be regarded the kernel of the psychoanalytic tradition. The
1
Throughout this thesis, the term “psychoanalytic” is used to refer to all therapeutic approaches that are theoretically
grounded in the psychoanalytic tradition and is considered equivalent in meaning to “psychodynamic”.
6 notion can be traced back to Freud’s classic formulation “…where id was, there ego shall be”
(Freud, 1933/1964, p. 80). From a psychoanalytic perspective, insight might be defined as the
self-understanding of internal conflicts, intentions, anxieties, defenses and internalized
expectations that underlie overt behaviors and symptoms (Fonagy & Kächele, 2009; Messer
& McWilliams, 2007). In particular, increased understanding of recurrent patterns of
maladaptive relating to self and others is often stressed. These patterns are assumed to occur
in the therapeutic relationship (i.e., in the “transference”) and to reflect early learning
experiences. Further, insight is typically thought to be achieved through the therapist’s skillful
use of interpretations (Kernberg, 2007), particularly interpretations of the transference, linking
the patients’ past and present experiences in the here and now. This may lead to the
development of a new explanation or narrative regarding how and why symptoms occur,
which makes them feel more manageable to the patient. Alternatively, insight may trigger a
reappraisal of the usefulness of certain overt behaviors and provide the patient with an
emotional release that frees him or her to act in new ways (Castonguay & Hill, 2007).
In terms of empirical support, there is some evidence indicating a positive link
between increased insight during treatment and outcome (Grande, Rudolf, Oberbracht, &
Pauli-Magnus, 2003; Grenyer & Luborsky, 1996; Høglend, Engelstad, Sørbye, Heyerdahl, &
Amlo, 1994; Johansson et al., 2010; Kivlighan, Multon, & Patton, 2000). Some studies also
suggest that increase in self-understanding precede symptom change (Grande et al, 2003;
Kivlighan et al., 2000) and that insight may be a specific curative factor in psychoanalytic
therapy compared to cognitive therapy (Connolly et al., 1999; Connolly Gibbons et al., 2009;
Kallestad et al., 2010). In a recent review of eight studies investigating the insight-outcome
correlation in psychoanalytic therapies, Crits-Christoph and colleagues (2013) found evidence
for a large mean effect (r = .52). However, the number of studies was small and other reviews
have found mixed results (Connolly Gibbons, Crits-Christoph, Barber, & Schamberger,
2007). Clearly, there is a need for more precise conceptualizations and measurements of the
concept, as well as more research regarding how, when and with which patients, increased
insight is essential for change (Barber, Muran, Crits-Christoph, McCarthy, & Keefe, 2013).
Since insight in the psychoanalytic sense of the term typically involves
understanding of recurrent, maladaptive relationship patterns, it may be linked to the use of
transference interpretations. The impact of transference work has been investigated in several
studies (e.g., Connolly, Crits-Christoph, Shappel, Barber, Luborsky, & Shaffer, 1999; CritsChristoph & Connolly Gibbons, 2001; Høglend, 1993, 2003; Ogrodniczuk, Piper, Joyce, &
McCallum, 1999; Piper, Azim, Joyce, & McCallum, 1991; Ryum, Stiles, Svartberg, &
McCullough, 2010; Schut et al., 2005). However, the results have been somewhat
inconclusive, with some studies indicating a positive effect on treatment process and outcome
whereas other studies suggest that the use of transference interpretations may have a negative
impact, especially if used excessively (for a recent review see Høglend, 2014).
In a randomized controlled trial comparing psychoanalytic psychotherapy with or
without transference work, Høglend and colleagues (2006, 2008) found that the effect of
transference interpretations was moderated by the quality of patients’ object relations. Patients
with lower quality of object relations, indicating more long-standing and severe interpersonal
difficulties, made larger gains in the treatment format that included transference work.
Further, this was particularly true in the context of weaker alliances (Høglend et al., 2011).
Conversely, for patients with more mature object relations and high alliance, a negative
7 impact of transference work was observed. Thus, the inconsistent findings of previous studies
might be explained by the moderation of particular patient variables. Further, a mediational
analysis from the same trial showed that the positive effect of transference interpretations on
long-term outcome was mediated by increased insight during therapy (Johansson et al., 2010).
Thus, the moderate use of transference interpretations, leading to increased insight with
patients who have poorer quality of object relations, may be the first evidenced-based
mechanism of change established in psychoanalytic psychotherapy.
According to psychoanalytic theory, insight does not only refer to increased
cognitive self-understanding but also involves a crucial emotional component (Fonagy &
Kächele, 2009). The importance of so-called ”emotional insight” was recognized early by
Freud (1914/1958) and Strachey (1934) as the most potent form of self-understanding.
Emotional insight might be defined as the process by which the patient gains access to and
integrates conflicted internal emotional states that were previously warded off through the use
of maladaptive defense mechanisms (Davanloo, 1990; A. Freud, 1937; Malan, 1979). In line
with this notion, exploration of affect has consistently been linked to more positive outcomes
in psychoanalytic psychotherapy (for a meta-analysis, see Diener, Hilsenroth, & Weinberger,
2007). Although emotional processing is typically regarded as central change agent in several
contemporary models of psychotherapy (Greenberg & Pascual-Leone, 2006, Whelton, 2004),
some preliminary findings suggest that focusing on affect may have particular benefits in
psychoanalytically oriented psychotherapy compared to cognitive therapy (Ulvenes et al.,
2012).
Relational impact
The second fundamental change mechanism in psychoanalytic discourse involves the impact
of the therapeutic relationship. The idea that the experiential and transactional aspects of the
relationship contain curative elements dates back to early psychoanalytic theorists such as
Sandor Ferenczi and Otto Rank (Ferenczi & Rank, 1925). Typically, the underlying notion is
that the interaction with the therapist can repair deficits, or correct skewed development, that
originate in the patients’ experiences with family members and/or other important caregivers
early in life. A developmental metaphor is often used (Mayes & Spencer, 1994) were the
therapeutic relationship is seen as symbolically representing a parent-child relationship. As
eloquently described by Loewald (1960), this position suggests that the process of change is:
“…set in motion, not simply by the technical skill of the [therapist] but by the fact that the
[therapist] makes himself available for the development of a new ‘object-relationship’
between the patient and the [therapist]” (p. 16). Typically, the acquisition of insight is
regarded as an outcome of the therapeutic interaction rather than as a requisite for change in
psychoanalytic models that stress the role of relational impact (Messer & McWilliams, 2007).
While there is ample evidence that the quality of the therapeutic relationship is linked
with outcome across therapeutic modalities (Norcross, 2011), few studies have specifically
tested psychoanalytically derived hypotheses regarding how the relationship leads to change.
One psychoanalytic notion, which has influenced other schools of psychotherapy as well (see
Castonguay & Hill, 2012), is the concept of corrective emotional experience (Alexander &
French, 1946). This was originally defined as the patient “…re-experiencing the old, unsettled
conflict but with a new ending” (p. 338), meaning that change occurs when the therapists act
in ways that contradict the patients’ prior relational learning. Although the study of corrective
8 emotional experiences has been hampered by problems with definition and precision in
measurement (Castonguay & Hill, 2012), some support for the notion might be inferred from
different lines of research.
One such line of research concerns the processes involved when repairing ruptures in
the therapeutic alliance (Christian, Safran, & Muran, 2012). Safran and Muran (2000)
conceptualize the therapeutic alliance as a process of ongoing negotiation between patient and
therapist. When ruptures in this negotiation occur, it is hypothesized that the mutual working
through of the event towards re-establishing the alliance will typically involve corrective
emotional experiences. In a small meta-analysis, Safran, Muran, and Eubanks-Carter (2011)
found that the aggregated correlation of rupture-repair episodes to treatment outcome
indicated a statistically significant medium effect (r = .24).
Another line of research is qualitative research focusing on patient perceived helpful
events in treatment. For example, in a single-case study of a successful short-term dynamic
treatment of panic disorder, Friedlander and colleagues (2012) found evidence for corrective
emotional experiences in the patient’s own description of the psychotherapy process and the
relationship with the therapist. Further, the patient narratives indicated that both specific (e.g.,
confrontation of defenses) and common factors (e.g., a positive alliance) interacted in
producing corrective experiences. In another qualitative study involving 12 patients,
corrective emotional experiences were typically related to repairing ruptures in the alliance as
well as the therapist actively reaching out or normalizing patients’ concerns (Knox, Hess,
Hill, Burkard, & Crook-Lyon, 2012).
An additional psychoanalytic notion of how the relationship contributes to change is
through internalization (Gabbard & Westen, 2003). Internalization refers to the process by
which the patient develops some attribute that originally belongs to the therapists. It may
involve the patient developing a specific function, such as the ability to self-sooth through
repeated experiences of being soothed by the therapists. The patient may also internalize the
therapist’s affective attitudes toward him or her self or develop the ability to self-reflect by
internalizing the therapists’ analytic capabilities (Gray, 1986; Kernberg, 1997; Kohut, 1984;
Loewald, 1962). Specifically, the underlying idea of internalization is that the interaction with
the therapist will gradually lead to changes in the patients’ implicit cognitive-affective
schemas, or internal representations of self and others (Blatt & Behrends, 1987; Blatt,
Auerbach, & Behrends, 2008; Blatt & Luyten, 2009).
Changes in internal representations during treatment have also been associated with
long-term improvements in psychoanalytic therapies (Blatt, Zuroff, Hawley & Auerbach,
2010; Barber et al., 2013). There are also some studies supporting the idea that internalization
might be involved in this process. For example, Quintana and Meara (1990) found that
patients, over the course of therapy, tended to adopt attitudes towards themselves that were in
line with the attitudes the therapists had towards them. Further, in contrast to merely
“remembering” information about the therapists, the concept of internalization suggests that
patients will bring forth representations of their therapists to regulate painful affects, moderate
feelings of loneliness, and facilitate problem-solving and conflict resolution. Geller and
Farber (1993) investigated the recall of internalized representation of the therapist in a sample
of 206 patients in psychoanalytic psychotherapy or psychoanalysis. Supporting the notion of
internalization, they found that representations of the therapist were most likely to be evoked
when painful affects were experienced. Further, the ability to engage in internal dialogues
9 with one’s therapist, both during therapy and after termination, was significantly correlated
with positive outcome. That the internal representation of the therapist might be used as a
self-supportive strategy in the post-treatment process has been reported in other studies as
well (Kantrowitz, Katz, & Paolitto, 1990; Falkenström, Grant, Broberg, & Sandell, 2007).
Lastly, one recent theoretical development that integrates the impact of the
therapeutic relationship with both cognitive and emotional aspects of insight is the notion of
mentalization (Allen, Fonagy & Bateman, 2008). This concept refers to the process through
which an individual comes to understand self and others in terms of mental states and to use
that information flexibly to explain and guide relationship behavior. Mentalization develops
optimally in the context of secure attachment relationships where the caregiver uses marked
mirroring to represent the child’s internal emotional states (Fonagy, Gergely, Jurist, & Target,
2002). Transferred to psychotherapy, development of patients’ capacity for mentalization is
thought to be contingent on the therapist’s ability to represent and adequately mirror the
patient’s shifting mental states in the therapeutic process (Allen & Fonagy, 2006; Allen et al.,
2008). A few studies indicate that the capacity for mentalization may increase over the course
of psychoanalytic psychotherapy and it has been found to relate to change in personality
functioning (Levy et al., 2006), as well as to change in anxiety symptoms (Rudden, Milrod,
Target, Ackerman, & Graf, 2006). However, other studies have not found mentalization to be
clearly related to change (Karlsson & Kermott, 2006; Vermote et al., 2010) and more studies
are needed before any conclusions can be drawn regarding its importance for different patient
populations or in different treatment models (Barber et al., 2013).
In summary, there is some empirical support for the fundamental mechanisms of
change proposed by contemporary psychoanalytic theories (i.e., increased insight, relational
impact, improved mentalization). However, the available evidence is limited, sometimes
contradictory, and the research is hampered by difficulties in defining and measuring the
concepts. Few studies go beyond a basic correlational design and there is very limited
empirical data linking specific interventions and strategies to any of these mechanisms. We
also know very little about how insight and the relational impacts may interact with each other
and with particular patient and therapist factors, or with hindering aspects in treatment. It is
quite likely that the impact of both insight and relationship are moderated by several unknown
variables. Although the evidence-base for psychoanalytic therapies is growing for a range of
psychiatric conditions (Abbass et al., 2014; Barber et al., 2013; Leichsenring & Klein, 2014),
we need to know more about the factors responsible for change.
Alliance and attachment
As stated above, there is a large amount of research indicating that the quality of the
therapeutic relationship is related to treatment outcome across therapeutic modalities
(Norcross, 2011). This body of research suggests that several components (such as therapist
empathy, congruence, positive regard and the therapeutic alliance) are linked to change. Two
aspects of the therapeutic relationship that are central to this thesis are introduced and
elaborated below – the therapeutic alliance and attachment to therapist.
10 The therapeutic alliance
The concept of the therapeutic alliance has evolved from of the psychoanalytic tradition
(Freud, 1912/1966; Sterba, 1934; Zetzel, 1956; Greenson, 1967) into its present-day pantheoretical definition (Bordin, 1979; Muran & Barber, 2010). Bordin’s well-known
conceptualization separates the alliance into three main components: agreement on goals;
consensus on the therapeutic task; and the emotional bond between the patient and the
therapist. In contrast to the original psychoanalytic formulation that emphasized unconscious
distortions in the relationship between therapist and patient (i.e., Freud, 1912/1966), this
definition highlights the conscious, collaborative aspects of the therapeutic relationship
(Horvath, 2006).
The therapeutic alliance is beyond comparison the most studied process variable in
psychotherapy research and the strength of the alliance has repeatedly been associated with
good outcome. In a recent large-scale meta-analysis (involving 190 studies and over 14.000
treatments) the aggregated alliance-outcome correlation was found to be r = .275, indicating
that the alliance accounts for about 7–8% of the variance in in outcome (Horvath, Del Re,
Fückinger, & Symonds, 2011). The therapeutic alliance proved to be a robust predictor of
outcome regardless of which particular alliance measure was used or if patients, therapists, or
observers rated it. Further, the alliance-outcome relationship was consistent regardless of
when it was measured in the treatment process (e.g., early, mid-treatment, late in therapy),
which kind of problem the patient sought treatment for (e.g., depression, anxiety) or which
therapeutic modality the patient received (e.g., cognitive-behavioral therapy, interpersonal
therapy, psychoanalytic psychotherapy). No other currently known variable has been found to
account for more of the variance in outcome across different forms of psychotherapy (Muran
& Barber, 2010; Norcross, 2011).
However, although the alliance is associated with change, this does not imply that the
relationship is causal. The idea that alliance leads to change has been questioned repeatedly
(e.g., DeRubeis, Brotman, & Gibbons, 2005). Critics have pointed to studies showing that
early symptom improvement predicts later alliances (e.g., Barber et al., 1999; Strunk,
Brotman, & DeRubeis, 2010; Strunk, Cooper, Ryan, DeRubeis, & Hollon, 2012), suggesting
that a strong alliance may be the result of specific treatment factors employed early in
treatment. Recent research that address this issue indicates that although symptomatic
improvement early in treatment predicts the alliance, the alliance also predicts subsequent
change, pointing towards a reciprocal relationship between therapeutic gains and the alliance
(Falkenström, Granström, & Holmqvist, 2013, 2014; Tasca & Lampard, 2012; Zilcha-Mano,
Dinger, McCarthy, & Barber, 2013). Consequently, the alliance seems to be an essential
ingredient in the change process and not merely a result of early improvement.
Still, the fundamental question regarding precisely how the alliance leads to change
remains unanswered. Some researchers have raised concerns that this question will continue
to be difficult to address since the concept is not distinctly defined (Horvath, 2006), nor is it
anchored in any particular theory of therapeutic change (Castonguay, 2006). Some have even
proposed that the alliance may have outlived its usefulness and that the field should move on
to other constructs (Safran & Muran, 2006). Clearly, testing specific theoretical explanations
of the alliance-outcome linkage is an important task for future research.
11 Attachment to therapist
John Bowlby’s (1969, 1973, 1980, 1988) attachment theory has become one of the most
influential theoretical frameworks in clinical practice, as well as psychotherapy research, in
the last two decades (Obegi & Berant, 2009). In the clinical literature, several authors have
elaborated on how attachment theory may inform individual psychotherapy (e.g., Eagle, 2013;
Holmes, 2001, 2010; Fosha, 2000; Muller, 2010, Pearl, 2008; Wallin, 2007). A number of
studies have also investigated how patients’ (as well as therapists’) global attachment
orientations, or “attachment styles”, may influence treatment processes and outcome (for
reviews, see Bernecker, Levy, & Ellison, 2014; Daniel, 2006; Diener & Monroe, 2011; Levy,
Ellison, Scott, & Bernecker, 2011; Slade, 2008; Smith, Msetfi, & Golding, 2010). Based this
body of research, it has been proposed that the therapy process may benefit if therapist use
knowledge of their patients’ attachment style as a guide for understanding patient responses
and attuning their interventions (Levy et al., 2011).
Bowlby (1988) also suggested that the therapeutic relationship is a form of
attachment relationship in itself. Specifically, he proposed that: “…in providing his patient
with a secure base from which to explore and express his thoughts and feelings, the therapist’s
role is analogous to that of a mother who provides her child with a secure base from which to
explore the world.” (p. 140). In recent years, several scholars have elaborated on the idea that
the therapist is an “attachment figure” who optimally functions as a secure base for the patient
(e.g., Farber, Lippert, & Nevas, 1995; Farber & Metzger, 2009; Obegi, 2008; Mallinckrodt,
2010). Clearly, Bowlby’s analogy does not imply that the therapist should strive to become a
“new parent” to the patient. Rather, it suggests that the same psychobiological systems
underlying human attachment are likely to be involved when establishing and maintaining a
trustful and collaborate therapeutic relationship. Obegi (2008) points out that there are several
structural similarities between therapeutic relationships and attachment relationships: both
endure over time and involve seeking out a specific, non-interchangeable individual for help
and support in a time of distress. Thus, besides the influence of patients’ (and therapists’)
global attachment styles, the development and quality of the specific attachment formed
between patient and therapist may be important for psychotherapy process and outcome.
Shaver and Mikulincer (2009; see also Mikulincer, Shaver, & Pereg, 2003) have
integrated findings from attachment research into a model of adult attachment system
functioning that may be useful for understanding the development of patient-therapist
attachment and its impact in the psychotherapeutic process. According to this model, when a
sufficiently intense threat is perceived (consciously or unconsciously), the attachment system
is activated and prompts the individual to seek proximity to external or internalized
attachment figures. Based on their developmental experiences, however, individuals will vary
in their expectations regarding how attachment figures are likely to respond to their physical
and emotional needs. If attachment figures are expected to be available and responsive,
security-based strategies to seek comfort, emotional proximity, and support will typically be
employed. In contrast, individuals who do not expect attachment figures to be responsive will
experience a heightened sense of distress and use secondary attachment strategies. If it is
anticipated that intensified proximity-seeking behaviors may result in some measure of
responsiveness from others, hyperactivating strategies will likely be used. In contrast, if
proximity seeking is expected to be useless or even lead to further emotional injury,
deactivating strategies are more likely evoked. The model may also be extended to
12 individuals whom, due to developmental deficits and/or disruptive attachment experiences
such as trauma or repeated physical or emotional abuse/neglect, have not developed an
organized secondary strategy and may resort to disorganized strategies.
Since the attachment system will naturally activate when stressful emotional material
is approached in the psychotherapy process, the patient’s internal working models of self and
others (and the associated secondary attachment strategies) will start to color the relationship
with the therapist at some point. The interaction with the therapist will then determine
whether the relationship formed over time will have the basic qualities of a secure attachment
relationship or if insecure strategies will dominate (Daly & Mallinckrodt, 2006; Mallinckrodt,
2010; Romano, Fitzpatrick, & Janzen, 2008). From an attachment perspective, the
development of a sufficiently secure therapeutic relationship is fundamental for change since
it enables the patient to explore, access, process and integrate distressing material (Bowlby,
1988; Eagle, 2013; Holmes, 2001, 2010; Fosha, 2000; Muller, 2010, Pearl, 2008; Wallin,
2007). In contrast, an insecure attachment to the therapist will inhibit the exploratory system,
making integration and change less likely to occur. In line with the clinical literature, Shaver
and Mikulincer’s (2009) model suggests that a sufficiently responsive therapist will promote a
broaden-and-build cycle of attachment security which will lead to reduced distress and, over
time, change the patients’ internal working models of self and others.
Assessing attachment to therapist
The study of patient-therapist attachment is a new and still developing area in psychotherapy
research. One important methodological advance has been the construction of specific
measures for assessing the quality of patient attachment to therapist. Today, two self-report
instruments exist. Mallinckrodt and colleagues (1995) developed the Client Attachment to
Therapist Scale (CATS), which is a 36-item self-report questionnaire including three
subscales: Secure, Preoccupied/Merger, and Avoidant/Fearful attachment to the therapist.
CATS has good internal consistency and test-retest reliability, and the subscales correlate in
expected ways with measures of adult attachment, working alliance, and object relations
(Mallinckrodt et al., 1995, 2005). The Components of Attachment Questionnaire-Therapist
(CAQ-T), developed by Parish and Eagle (Parish & Eagle, 2003a, 2003b), is a 34-item selfreport measure that was designed to assess the impact of specific aspects of attachment in the
therapeutic relationship: proximity seeking, separation protest, safe haven, particularity,
secure base, and stronger/wiser. The mean of all 34 items in the scale is understood as a
measure of the intensity of the patient’s overall attachment to the therapist. Psychometric data
for CAQ-T suggest satisfying internally consistency and some support for its construct
validity has also been reported (Parish & Eagle, 2003a, 2003b; Saypol & Farber, 2010).
Although the available data indicate that both CATS and CAQ-T are reliable and
valid measures, the use of self-report to assess the patients’ attachment to their therapists may
have specific limitations. For example, self-assessment might be problematic since attachment
involves unconscious, implicit-procedural processes (Maier, Bernier, Pekrun, Zimmermann,
& Grossmann, 2004). Observer ratings of interview material may be an appropriate
alternative (de Haas, Bakermans-Kranenburg, & van Ijzendoorn, 1994; Jacobvits, Curran, &
Moller, 2002). In one study, Diamond and colleagues (2003) adapted the interview protocol
of the Adult Attachment Interview (AAI), forming the Patient–Therapist Adult Attachment
Interview (PT-AAI), which was used to evaluate patients’ attachment states of mind in
13 relation to the therapist in a small sample of borderline patients (n = 10). The results indicated
that therapist-specific attachment early in therapy was in high concordance with patients’ AAI
classifications, indicating preliminary validity of the approach. Although promising, the use
of the AAI coding scheme may require extensive training and the reliability of the coding
procedure has not been evaluated in the context of the therapeutic relationship. Further, since
the PT-AAI approach assesses attachment to therapist categorically rather than dimensionally,
it might have limited utility for research purposes (Ravitz, Maunder, Hunter, Sthankiya, &
Lancee, 2010). Other measures that aim to assess the quality of patient attachment to therapist
from an observer perspective have recently been developed (Lilliengren et al., 2014; Talia et
al., 2014). Study III of the present thesis involves an initial evaluation of one such approach
(Patient Attachment to Therapist Rating Scale, PAT-RS; see below).
The impact of patient-therapist attachment on psychotherapy process
A small but growing body of research indicates that the quality of patients’ attachment to their
therapist relate to specific in-session processes in theoretically consistent ways. For example,
patients who develop a more secure attachment to their therapist, as measured with the secure
subscale of CATS, have been found to engage in deeper and smoother exploration in therapy
(Mallinckrodt et al., 2005; Romano et al., 2008). Additionally, in a study applying CAQ-T,
Saypol and Farber (2010) found that secure attachment to the therapist was associated with
higher levels of patient self-disclosure in treatment. In a study investigating relationshipbuilding episodes, Janzen and colleagues (2008) found that when patients disclosed
distressing thoughts or feelings in therapy, the level of secure attachment to the therapist
increased. Further, as the level of security increased so did the level of exploration, relief, and
perceived therapist support, and the patients perceived their sessions as more impactful. Thus,
the results indicate a reciprocal relationship between patient disclosure, increased secure
attachment to therapist and session impact, which is consistent with the broaden-and-build
cycle of attachment security (Shaver & Mikulincer, 2009).
Taken together, these studies support the idea that a secure attachment to the
therapist will facilitate deeper emotional exploration in therapy, as hypothesized by Bowlby
(1988). Further, insecure attachment to therapist (avoidant-fearful in particular) has
consistently been associated with less exploration, depth, disclosure, and readiness for change
in treatment, as well as a weaker alliance (Bachelor, Menunier, Laverdiére, & Gamache,
2010; Fuertes et al., 2007; Lunsford, 2010; Mallinckrodt et al., 2005; Romano et al., 2008).
Hence, insecure attachment strategies that are evoked in the therapeutic relationship may form
important obstacles to the therapeutic process.
However, a crucial question is whether the quality of patients’ attachment to their
therapist is related to treatment outcome, as suggested by attachment theory. This question has
only been addressed in a couple of studies so far and the results have been somewhat
inconsistent. Sauer and colleagues (2010) found that higher levels of secure attachment to the
therapists (measured at session three) predicted reductions in psychological distress over time
in a sample of 95 moderately distressed patients treated with brief therapy at a university
clinic. In contrast, Wiseman and Tishby (2014) recently found that secure attachment to
therapist (measured at session five) was unrelated to change in a sample of young adults
undergoing one year of psychodynamic psychotherapy. Nevertheless, lower attachment
avoidance in relation to the therapist early in treatment predicted improvements, perhaps
14 indicating that the absence of insecure-avoidant attachment strategies (i.e., deactivation),
which may block the treatment process (Muller, 2010), was more important than the presence
of secure attachment to therapist. Clearly, more studies are needed to investigate the influence
of both secure and insecure forms of attachment to therapist on therapy process and outcome.
The association between secure attachment to therapist at termination and outcome is
explored in study IV of this thesis.
Differentiating secure attachment to therapist from the therapeutic alliance
There is a notable conceptual overlap between secure attachment to therapist and the
therapeutic alliance, particularly regarding the bond-aspect of the alliance (Obegi, 2008).
Bordin (1979) defined the alliance bond as the sense of mutual liking, trust and respect
between patient and therapist. He also suggested that the strength of the alliance bond may
become increasingly important as the patient approaches more threatening material in the
treatment process: “…some basic level of trust surely marks all varieties of therapeutic
relationships, but when attention is directed toward the more protected recesses of inner
experience, deeper bonds of trust and attachment are required and developed” (p. 254).
Hence, Bordin’s conceptualization of the bond part of the alliance seems to mirror the
development of a secure attachment to the therapist to a large degree.
In line with this, studies using the CATS typically report strong correlations (.60 .80) between secure attachment to therapist and patients’ self-rating of the alliance (Bachelor
et al., 2010; Lunsford, 2010; Mallinckrodt et al., 1995, 2005; Romano et al., 2008; Sauer et
al., 2010). Addressing this overlap, Mallinckrodt and colleagues (2005) concluded that: “…a
high quality working alliance and a secure attachment to one’s therapist appear to have many
features in common and are probably perceived relatively similarly by clients” (p. 97).
However, although the constructs overlap to some extent, there are also important
conceptual differences (Mallinckrodt, Coble, & Gantt, 1995; Mallinckrodt, Porter, &
Kivlighan, 2005; Obegi, 2008). For example, whereas the alliance is primarily concerned with
the patient’s conscious perception of the collaboration with the therapist (Horvath, 2006),
attachment to therapist reflects the function of the relationship, i.e., how the patient uses the
bond and relates to the therapist on both conscious and unconscious emotional levels. Put
differently, attachment to therapist specifies the quality of the bond (i.e., secure or insecure)
the patient develops to his or her therapist.
Further, attachment theory suggests that the therapeutic attachment will contain
several specific relational components (Mallinckrodt, 2010; Mallinckrodt et al., 1995, 2005;
Obegi, 2008; Parish & Eagle, 2003a; see also Table 2 below). For example, attachment to
therapist involves a “secure base”-component, indicating that the safety of the relationship
enables the patient to approach and explore novel or frightening experiences. Other
components include feeling comforted by the therapist (“safe haven”), turning to the therapist
for knowledge and guidance (“stronger and wiser”), having a desire to seek out and maintain
closeness to the therapist in times of distress (“proximity seeking”), viewing the therapist as a
unique and non-interchangeable person (“particularity”), experiencing the therapist as
sufficiently responsive (“responsiveness”), viewing the relationship as affectively charged
(“strong emotions”), reacting with distress when separated (“separation anxiety”), and
forming a representation of the therapist that may be evoked in times of distress (“mental
representation”).
15 Although different measures of the alliance may capture some of these components,
the alliance concept itself does not include any of them specifically (Obegi, 2008).
Accordingly, a strong therapeutic alliance may not necessarily indicate that the patient and
therapist have also developed a secure attachment relationship. Some patients may report a
strong alliance even though they do not use the therapeutic relationship as a “secure base” or
experience it as a “safe haven.” For example, Lunsford (2010) found a positive correlation
between the Avoidant/Fearful subscale of the CATS and the Tasks subscale of the Working
Alliance Inventory (WAI), suggesting that some patients may agree on and even carry out
particular therapeutic tasks although they may not establish a trustful, emotional bond with
the therapist. In the same study, the Preoccupied/Merger subscale of the CATS was unrelated
to Goals and Tasks, but positively associated with the Bond subscale of the WAI, indicating
that patients who formed an insecure-anxious attachment to their therapist also tended to
report a strong alliance bond. Consequently, a strong alliance bond may sometimes reflect an
insecure attachment strategy rather than a constructive use of the therapeutic relationship.
It is also possible that some patients who have developed a secure attachment to the
therapist may report a temporary weak alliance, for example in connection with an alliance
rupture (Safran & Muran, 2000) or when exploring negative transference reactions
(Woodhouse, Schlosser, Crook, Ligiéro, & Gelso, 2003). Thus, one might hypothesize that
the therapeutic alliance may vary during therapy while a secure attachment to the therapist
probably develops more progressively throughout the psychotherapeutic process and is likely
to stay relatively stable once established.
However, in order to investigate such hypotheses the alliance and secure attachment
to therapist needs to be assessed distinctly; hence, the large overlap found between measures
of these constructs is problematic. For example, Sauer and colleagues (2010) could not
differentiate the impact of secure attachment to therapist from the alliance due to the strong
co-variation between the measures. It is possible that observer-rated measures of secure
attachment to therapist may be useful in this regard, which is considered in study IV of this
thesis.
Young adults in psychoanalytic psychotherapy
All four studies in this thesis were conducted on data from patients that were between the ages
of 18-24 when entering treatment. This period in life is often referred to as young adulthood
or emerging adulthood (Arnett, 2000, 2007; Jacobsson, 2005; Szajnberg & Massie, 2003;
Tanner & Arnett, 2009). For most people in industrialized Western countries, this is typically
a phase of profound external and internal change as various possibilities in life are explored,
elaborated and consolidated. During this time, many move away from their family of origin,
finish their education, become financially independent, move in with someone, perhaps also
marry or become a parent. It is a time when society expects the individual to begin to make
independent decisions and accept responsibility for them. By the end of this period most
people will have made life choices that will have and enduring effect for the remainder of
their adult lives. When later asked to consider the most important events in their lives, many
adults name events that took place during this period (Martin & Smyer, 1990).
16 In the last couple of decades, young adulthood has also been associated with
increased psychological distress in several Western countries (Evans, 2009; Grant & Potenza,
2009; McGorry, Purcell, Goldstone, & Amminger, 2011; Socialstyrelsen, 2013a; 2013b). This
trend seems to be typical for societies where young people are given an extended time to
explore their future possibilities (Arnett, 2000, 2007). When Erikson (1959, 1968) formulated
his theory of psychosocial development he described adolescence as a time of identity crisis
and inner turmoil, while the crisis in young adulthood was one of intimacy versus isolation.
Nowadays, when young people have more time to explore their possibilities, this identity
crisis seems to be delayed (Arnett, 2000, 2007; Côté, 2000; Robbins & Wilner, 2001).
Accordingly, the increase in distress among young adults may indicate that the transition from
adolescence to adulthood has become more complicated and conflicted in our time
(Jacobsson, 2005).
From a psychoanalytic perspective, the developmental task of young adulthood
concerns the consolidation of ego-capacities required for the life and career decisions at hand.
When this consolidation is only partially or unevenly achieved, for example due to the
activation of inner conflicts or deficits related to early developmental experiences,
maladaptive coping strategies may be triggered, leading to increased symptoms and
interpersonal distress (Adatto, 1980; Emde, 1985; Escoll, 1987). Although there are no
randomized controlled trials of psychoanalytically oriented psychotherapy that specifically
target young adults, several naturalistic studies indicate that such treatments are effective in
this population (Baruch & Fearon, 2002; Blatt, Steyner, Auerbach, & Behrends, 1998;
Falkenström, 2009; Harpaz-Rotem & Blatt, 2005; Jeanneau & Winzer, 2007; Philips,
Wennberg, Werbart & Schubert, 2006; Werbart, Forsström, & Jeanneau, 2012). The effect
sizes of psychoanalytic psychotherapy for young adults in routine care are comparable to the
effects commonly reported in randomized controlled trials (Falkenström, 2009). Further, the
effects tend to increase after treatment termination (Lindgren, Werbart & Philips, 2010;
Werbart et al., 2012).
Yet, according to the clinical literature (e.g., Barnett, 1971; Escoll, 1987; Jacobs,
1988; Pearl, 2008; Perelberg, 1993), the developmental tasks of young adults may sometimes
collide with the process of psychoanalytic psychotherapy. Jacobs (1988) suggests that, since
young adults are in a transient life situation, they may be more focused on “real-world issues”
and therefore lack motivation for reflecting upon themselves and their past. Further, young
adults are typically still in the process of separating from internal representations of parents
and occupied by conflicts regarding dependency and intimacy. Engaging in an intimate
therapeutic relationship may evoke particular stress since young adult patients may not want
to be caught up in transference feelings that pull them backwards in threatening ways (Jacobs,
1988). From an attachment perspective, providing a secure base for the young adult patient
may also involve particular challenges for the therapist due to the conflict between patients’
attachment to their parents and their efforts to become autonomous (Pearl, 2008). In line with
these clinical observations, research suggests that establishing a working alliance with young
adults may pose particular difficulties and young adults have a higher risk of dropping out
from treatment (Swift & Greenberg, 2012).
On the other hand, young adulthood has also been identified as a period in life where
there is a strong potential for personality change and emotional growth (Tanner & Arnett,
2009). Change in personality may be considered a natural outcome related to young adults
17 activities in establishing careers, find their personal identity and committing to close
relationships. The culture of Western societies typically promotes such activities during this
period, which may act as a catalyst for change. Thus, young adulthood may be regarded both
a “sensitive period” and as a “window of opportunity” when it comes to the risk for
developing of psychological distress, as well as engaging in psychotherapy.
18 AIM OF THE THESIS
The overall aim of this thesis is to explore therapeutic action in psychoanalytic psychotherapy
from multiple perspectives (patient, therapist, and observer) using different methodological
approaches (qualitative and quantitative). The primary objective is to contribute to the
empirical literature regarding curative and hindering factors in psychotherapy in general, and
therapeutic action in psychoanalytic psychotherapy in particular. Further, since the research
project that provided the data for this thesis targeted young adults (aged 18-24), implications
for psychoanalytic psychotherapy with this population have particular attention.
The thesis includes four separate studies that were carried out consecutively during
the study period (2002–2013). Each study was designed in relation to the specific research
questions that emerged from the findings of the previous study. An overview of the specific
aim, sample size, material, data analytic strategy and main methodological approach of each
study is presented in Table 1.
Table 1. Overview of the included studies
Aim
n
Material
Data analytic strategy
Methodology
Study I
To explore patients’ view of
therapeutic action in
psychoanalytic psychotherapy
22
Patient
interviews
Grounded theory
Qualitative
Study II
To explore experienced
therapists’ view of therapeutic
action in psychoanalytic
psychotherapy
16
Therapist
interviews
Grounded theory
Qualitative
Study III
To investigate the psychometric
properties of a new rating scale
for patient-therapist attachment
70
Self-report and
expert-rated
measures
Standard statistical
methods
Quantitative
Study IV
To investigate the relationships
between secure attachment to
therapist, alliance, and outcome
70
Self-report and
expert-rated
measures
Linear mixed-effects
models
Quantitative
Study I and II were specifically aimed at exploring the patients’ and therapists’
subjective views of therapeutic action. Some of the research questions were: what do patients
and therapists perceive as curative in psychoanalytic psychotherapy? What hinders change,
according to patients’ and therapists’ views? How are these factors interrelated? Using an
experience-near, inductive methodological approach, the objective was to construct tentative
models of how curative and hindering factors interact from the view of the respective
respondents.
19 Based on the main findings of study I and II, our attention was directed towards the
quality of patient-therapist attachment for psychotherapy process and outcome. In order to
study patient attachment to therapist using deductive reasoning and quantitative methods, a
new instrument called the Patient Attachment to Therapist Rating Scale (PAT-RS) was
developed. The specific aim of study III was to investigate the psychometric properties of this
rating scale using standard statistical methods.
The aim of study IV was to explore the relationships between secure attachment to
therapist, alliance and outcome. Specifically, we sought to investigate whether secure
attachment to therapist was associated with changes during therapy and could predict any
changes during the 1.5 year follow-up period, independent of patient-rated alliance. The study
used deductive reasoning and quantitative, statistical methods to address these questions.
20 METHOD
Participants and procedures
Research context
The included studies are all based on data from the Young Adult Psychotherapy Project
(YAPP). YAPP was a naturalistic, prospective, and longitudinal study of young adults (aged
18–25) in psychoanalytic psychotherapy conducted in Stockholm, Sweden. The overall aim of
the project was to evaluate the effectiveness of psychoanalytic psychotherapy for young
adults as routinely practiced at the Institute of Psychotherapy, where subsidized
psychotherapy was provided for people with various psychological problems.
Inclusion of patients took place between 1998 and 2002. The patients applied
through the Institute’s telephone service and were admitted as openings became available. A
few patients were also referred to the project from psychiatric outpatient clinics in the greater
Stockholm area. On the basis of clinical judgment of suitability and patient motivation,
accepted patients were offered either individual or group therapy. A total of 134 patients were
included (73% female; mean age = 22, SD = 2.2) of which 92 were allocated to individual
psychotherapy and 42 to group therapy. No formal psychiatric diagnoses were assessed, but
the main problem areas were identified and categorized from intake interviews (Wiman &
Werbart, 2002). The most common complaints were low self-esteem (97%), depressed mood
(66%), anxiety (55%), and conflicts in close relationships (66%). Further, about one-third had
self-reported personality disturbance according to the DSM-IV and ICD-10 Personality
Questionnaire (DIP-Q; Ottosson et al., 1995, 1998). All patients were assessed with
standardized self-report measures and interview instruments administered at intake, at
termination, and at two follow-up assessments: 1.5 and 3 years after termination, respectively.
The psychotherapies in YAPP were aimed at overcoming developmental arrests in
young adulthood and improving the patients’ adaptive capacity. The goals, duration, and
frequency of therapy were adjusted to each patient’s needs with the possibility of
renegotiating during treatment. The project involved a total of 37 therapists who all shared a
psychoanalytical frame of reference, even if they were working quite autonomously and had
varying preferences regarding theory and technique. During the project, the therapists met
weekly in clinical teams to discuss clinical experiences and treatment problems. However, no
manual or treatment fidelity checks were used, rather the therapies were carried out in
accordance with the naturalistic setting of the project.
The overall result of the project indicated that the patients made moderate (Cohen’s d
> 0.50) to large (d > 0.80) improvements on primary outcome measures between intake and
termination on average (Philips et al., 2006). These benefits were maintained at follow-up
(Lindgren et al., 2010). The specific selection procedures and subsamples for each study are
described below.
21 Study samples
Study I. The subsample for the first study was selected on the basis of availability. At the start
of the study (July 2002) 26 patients had terminated their individual psychotherapy in YAPP.
However, interview data was missing in four of cases and, consequently, a total of 22 patients
were included. Three were male (14%) and 19 female (86%) and their average age was 22.5
years (SD = 2.2, range 19–25) at the beginning of therapy. In terms of their demographic data,
eight (36%) lived alone, 5 (23%) lived with parents, and 9 (41%) lived with a partner. None
was married or had children. Many of the patients were working full time (n = 10, 45%),
followed by full-time studies (n = 8, 36%) and working in combination with studies (n = 4,
18%). Sixteen of the patients (73%) were born in Sweden and had both parents of Swedish
origin. In all, 17 patients (77%) had at least one parent with a university degree. Nine of the
patients (41%) reported having had previous outpatient or inpatient psychiatric treatment. The
average length of psychotherapy for this subsample was 18.6 months (range 7–32 months)
with a frequency of one (12 cases) or two (10 cases) sessions weekly. The reported problems
areas that brought the patient to therapy, as well as mean pre- and post levels of self-reported
and expert rated symptoms and functioning, were very similar to the YAPP sample as a
whole.
Study II. The subsample of the second study consisted of the 16 therapists who had treated the
22 patients included in study I. Four therapists were male and 12 were female, all of
Scandinavian origin. As to their profession, two were physicians, seven were psychologists,
and seven were social workers. The therapists were all highly educated, middle-aged
specialists in psychoanalysis (n = 7) or psychoanalytic psychotherapy (n = 9) with extensive
clinical experience. Besides their work as psychotherapists, they were all engaged as
instructors and supervisors in the Advanced Psychotherapy Training Program at the Institute
of Psychotherapy. The mean time in clinical practice after attaining their psychotherapy
license was 11 years (range 3–16, SD = 3.97). Eleven therapists treated one patient (of the 22
included in study I) each, four had two patients, and one had three patients.
Study III and IV. All patients who received individual psychotherapy in YAPP and
participated in the interview at termination (thereby enabling the assessment of attachment to
therapist) were of interest for study III and IV. Of the 92 patients allocated to individual
psychotherapy, nine never started treatment, one dropped out during the project, and 12 did
not show up for the assessments at termination. Consequently, the available sample consisted
of 70 patients. Fourteen of these (20%) were male and 56 (80%) female and the average age
was 22 years (SD = 2.1, range 18–26) at start of therapy. Most (n = 23, 32.8%) lived alone, 17
(24.2%) with a partner, eight (11.4%) with a friend or in a student dormitory; 17 (24.2%)
reported still living with one or both of their parents, and five (7.1%) with another close
relative (i.e., sibling, cousin or grandparent). At intake, none of the patients was married or
had children. Twenty-three (32.8%) were fulltime students, 16 (22.8%) worked full-time, and
14 (20%) reported combining part-time work with part-time studies. Nine (12.8%) studied
part-time and four (5.7%) worked part-time without any other occupation. Three (4.2%) were
unemployed or on longer-term sick leave; however, 18 (25.7%) reported being unable to work
or study at the beginning of therapy due to poor mental and/or physical health. In terms of
cultural and socioeconomic background, 65 (92.8%) of the patients were born in Sweden, 18
22 (25.7%) had at least one parent of foreign origin. Most came from highly educated families
where at least one parent had an academic degree (n = 51, 72.8%). Half of the sample (n = 35,
50%) had experienced parental divorce during childhood.
A total of 32 therapists (21 female and 11 male) treated the 70 patients in this
subsample. Fourteen of the therapists were psychoanalysts, 16 were licensed psychotherapists
and two had basic psychotherapy training. Their professional background varied: six
physicians/psychiatrists, 12 psychologists, 13 social workers, and one hand another academic
degree. On average, the therapists had about 10 years of experience practicing psychotherapy.
Twelve of the therapist treated one patient, 13 had two patients, and seven had three or more
patients in the sample. The average length of treatment was 23 months (SD = 13.0, range 2–
55) with a frequency of sessions equally distributed between once or twice weekly. The
outcome for this sample was very similar to the reported results for the whole YAPP
population (Lindgren et al., 2010) and indicated large (Cohen’s d > 0.80) to moderate (d >
0.50) within-group effects between intake and termination, but no or only small gains during
follow-up (d < 0.20).
Ethical considerations
YAPP was approved by the Regional Ethical Review Board at Karolinska Institute in
Stockholm, Sweden. All patients were informed about the overall aims and procedures of the
project before treatment started and gave their written consent to participate. Interviews and
self-report measures were coded and all personal data was kept apart from the research
databases throughout the project. In study I and II, particular efforts were made to preserve
patient and therapist confidentiality when selecting and presenting quotations from the
interviews in the results sections of the papers.
Measures and methods
Interviews
All four studies in this thesis utilize interview data that was collected shortly after treatment
termination with two semi-structured interview protocols: The Private Theories Interview
(PTI; manual published in Werbart & Levander, 2006, 2011) and the Object Relation
Inventory (ORI; Auerbach & Blatt, 1996). The PTI is an in-depth interview that aims at
collecting each patient’s subjective meaning making concerning his or her presenting
problems, the background to those problems and his or her own ideas of cure, as well as descriptions of changes during and after psychotherapy. In line with a basic
phenomenological approach, the interviewer starts with open-ended questions and then asks
the patient to elaborate their answers in these main areas as well as give concrete examples
and illustrative episodes when applicable.
In the ORI, the patient is requested to give a description of his/her mother, his/her
father, him/ herself, and of the therapist. The spontaneous response was followed by an
“inquiry” in which the interviewer enquiringly repeated adjectives or descriptive words
mentioned by the patient, for example, “You said understanding?” The information obtained
23 with the ORI is used for rating the level of complexity and differentiation in mental
representations of self- and others (see the Differentiation-Relatedness Scale below).
The therapists were interviewed with the same protocols shortly after termination
with each patient they treated in YAPP. The protocols were adjusted so that the therapists
were asked to elaborate their own views of the patients’ difficulties, as well as what
contributed to, or hindered treatment, in each particular case.
Nineteen experienced psychotherapists and psychologists were trained in the specific
techniques of each protocol and carried out the interviews in YAPP. The interviews lasted
about 60 minutes together and were audio-recorded and transcribed verbatim.
Qualitative methodology
In study I and II, interview material obtained with the PTI was analyzed with qualitative
methodology. The specific data analytic strategy followed Grounded Theory (GT; Strauss &
Corbin, 1998; Hartman, 2001). GT was originally developed within sociology (Glaser &
Straus, 1967) but has increasingly been applied in other research areas (e.g., economics,
education, health sciences and psychology). The aim of GT is to generate theory regarding
social phenomena in a substantive area, based on the systematic analysis of qualitative data
(although quantitative data may also be included in a GT-analysis). The method is based on
the principles of constant comparative analysis and saturation of data, which involves
examining the raw data closely to derive and organize categories from it until all data is
accounted for. Thus, GT is an inductive and interpretative, “bottom-up” approach, and
philosophically it has been regarded as a form of methodological hermeneutics (Rennie,
2006). The finished GT-analysis is typically presented as a conceptual model that centers on a
core concept that, to mix methodological metaphors, “explains” as much of the “variance” in
the qualitative data as possible (Hartman, 2001).
There are no universally agreed upon rules regarding how to conduct a “proper” GTanalysis and even the originators of the method debate its basic procedures (see Rennie,
1998). Following Strauss and Corbin (1998), a set of common steps and procedures that
typically characterizes GT were employed in study I and II. The analyses started with open
coding which involved reading the selected interview material in detail, line by line, and
provide an open code describing the main content of the narratives. Codes that seemed closely
related in meaning, theme, or content were grouped into categories. As more and more
categories emerged in open coding, a process of axial coding was initiated, which involved
comparing and revising categories and identifying subthemes and relationships between
categories. Finally, the categories and relationships were integrated into a conceptual model in
selective coding. Figure 1 provides a graphical illustration of the coding process as
implemented in study II.
Throughout the coding process, memos were written describing the properties and
dimensions of the categories, as well as notes on the coder’s associations to established
theoretical constructs. These memos were also used in efforts to “bracket” prior knowledge of
the theoretical and empirical literature (Elliott, Fischer, & Rennie, 1999; Malterud, 2001).
Further, in the later stages of the coding process, categories and memos were reviewed and
discussed among the first and second author of study I and II. Questions raised were taken
back to data in the original transcripts and differences in opinion between the researchers
were discussed until agreement was reached. Also, in study II, the preliminary results were
24 presented to four of the respondents in the study (i.e., two male and two female therapists)
who were asked to reflect if anything seemed odd or missing. Field notes from this 1.5-hour
long meeting were then integrated into the coding process.
Figure 1. An illustration of the coding process in study II.
A specialized computer program for qualitative data analysis, known as ATALS.ti
(2000), was used in the coding process of studies I and II. ATLAS.ti retains the links between
transcripts, codes, categories, and memos throughout the analysis, making it possible to move
back and forth between coding, elaborating the categories, writing memos, and building the
conceptual model. The networking function of ATLAS.ti was used to sort codes and to
visually connect categories into diagrams that outlined their relations.
Self-report measures
Symptom Checklist – 90 (SCL-90; Derogatis, 1994; Derogatis, Lipman, & Covi, 1973) is a
self-report questionnaire that consists of 90 items referring to symptoms experienced over the
last 7 days. The items are rated on 5-point Likert scales ranging from 0 (not at all) to 4 (very
much). The Global Severity Index (GSI) of the SCL-90 was used as an indicator of total
symptom load. The Swedish version of the measure has demonstrated adequate reliability and
validity (Fridell, Zvonomir, Johansson, & Malling Thorsen, 2002). In study IV, excellent
internal consistency (α > .90) was observed across all measurement points.
The Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, &
Villasenor, 1988; Horowitz, Alden, Wiggins, & Pincus, 2002) is a 64-item self-report measure
that assesses interpersonal problems in eight circumplex subscales. Each item is rated on 5 25 point Likert scales ranging from 0 (not at all) to 4 (very much) and the sum of all items
constitutes a measure of overall interpersonal distress. The Swedish translation of IIP has
shown adequate psychometric properties (Weinryb et al., 1996). The internal consistency for
the total score ranged between .93–.95 across the measurement points in study IV.
The Structural Analysis of Social Behavior Intrex Questionnaire (SASB; Benjamin, 2000) is a
self-report measure aimed at assessing the patients’ internalized self-concept. The instrument
consists of 36 items rated on 11-point Likert scales ranging from 0 (not true) to 100 (true).
The test–retest reliability for the SASB has been shown to be high (r = .87) for both the
American (Benjamin, 1984; Benjamin, Rothweiler, & Critchfield, 2006) and the Swedish
version (Armelius, 2001). The items may also be grouped into eight clusters: Self-Autonomy,
Self-Affirm, Self-Love, Self-Protect, Self-Control, Self-Ignore, Self-Hate, and Self-Blame
with four or five items in each cluster. In study III, we followed Adamson and Lyxell (1996)
and combined clusters 2, 3, and 4 to indicate a positive self-concept, while the combination of
clusters 6, 7, and 8 indicated a negative self-concept. The internal consistency proved to be
good for both the combined positive (α = .86) and negative (α = .85) clusters in our sample.
The Helping Alliance Questionnaire (HAq-II; Luborsky et al., 1996) is a well-established
measure of the therapeutic alliance based on Luborsky’s (1976) and Bordin’s (1979)
formulations of the alliance. The measure consists of 19 items that are rated on 6-point Likert
scales ranging from 1 (I strongly feel it is not true) to 6 (I strongly feel it is true). Both
patients and therapists rated the alliance every third month during treatment in YAPP. The
HAq-II has demonstrated excellent reliability and good convergent validity with other
measures of the alliance (Luborsky et al., 1996). Based on data from YAPP, the Swedish
version of the HAq-II has been shown to have excellent internal consistency (Cronbach’s α =
.91) for the patient questionnaire and good (α = .88) for the therapist questionnaire (Lindgren
et al., 2010).
Expert-rated measures
The Global Assessment of Functioning Scale (GAF; American Psychiatric Association, 2000)
is an expert-rated measure of overall symptomatic and social functioning. The scale ranges
from 1 to 100 with 10-point intervals describing discrete levels of functioning. The ratings in
YAPP were based on the interview material obtained with the PTI. A group of trained raters
did all assessments and, to increase reliability, ratings were obtained through group discussion
until consensus was reached. The therapists were not involved in the rating of their own
patients.
The Differentiation-Relatedness Scale (DRS; Blatt & Auerbach, 2001; Diamond, Blatt,
Stayner, & Kaslow, 1995) is a 10-point expert-rating scale used to evaluate the degree of
complexity and differentiation in cognitive-affective schemas of self and significant others.
The ratings are based on information obtained with the Object Relation Inventory (ORI;
Auerbach & Blatt, 1996) and higher ratings indicate more mature and integrated mental
representations. In the present studies, each patient’s representations of mother, father,
him/herself, and the therapist were assessed by a group of trained raters. Inter-rater reliability
was found to be in the good range (ICC = .71) for a subsample of patients in YAPP
(Hjälmdahl, Claesson, Werbart, & Levander, 2001).
26 The Patient Attachment to Therapist Rating Scale (PAT-RS; Lilliengren, 2011; Lilliengren et
al., 2014) is an observer-rating scale that aims at assessing the quality of patient-therapist
attachment from patients’ description of the therapist as a person, their experience of the
therapeutic process, and their reactions to attachment related issues in the therapeutic
relationship (closeness, separation, etc.). PAT-RS was developed as a part of this thesis (see
below) and the instrument includes four subscales: Security, Hyperactivation, Deactivation,
and Disorganization. In study III and IV, PAT-RS was applied to interview material obtained
with both PTI and ORI at termination of therapy. Three raters rated the material; the main
developer of PAT-RS and two master-level students who received training in PAT-RS.
Twelve of the 70 interviews were rated with consensus discussion among the raters during
training and calibration and 37 interviews were rated independently for the assessment of
inter-rater reliability (average scores was used in the final variable). A single rater (author and
main developer of PAT-RS) rated the remaining 21 interviews. During the rating procedure,
all raters were kept blind with regards to outcome measures in YAPP. The psychometric
properties of the PAT-RS subscales were investigated in study III and are reported in the
results section below.
Statistical analyses
Study III. We used standard statistical procedures to examine the psychometric properties of
the PAT-RS subscales. Internal consistency was estimated with Cronbach’s α and inter-rater
reliability with the intraclass correlation, two-way random effects model with absolute
agreement (ICC [2, 1]; Shrout & Fleiss, 1979). In this context, the ICC estimate reflects rater
similarity. According to criteria proposed by Cicchetti (1994), an ICC below .40 may be
considered poor; between .40–.59 fair; between .60–.74 good, and above .75 excellent. The
construct validity of the PAT-RS subscales was explored using bivariate Pearson r
correlations with other measures. Missing data were handled with pairwise deletion. Finally,
an exploratory factor analysis was performed to examine the underlying factor structure of all
subscale ratings. Since we expected that data would not meet all criteria for normality we
used the principal axis factoring extraction method (Fabrigar, Wegener, MacCallum, &
Strahan, 1999). We also expected factors to be correlated and applied oblique rotation (direct
oblinim with Keiser normalization) as suggested by Costello and Osborne (2005).
Study IV. Linear mixed-effects models procedures (Heck, Thomas, & Tabata, 2014) were
used to investigate the relationships between secure attachment to therapist, patient-rated
alliance and outcome. Because a considerable amount of the data was nested within therapists,
we first examined the possible presence of therapist effects using the intraclass correlation
estimate (ICC; see Wampold & Serlin, 2000). In this context, the ICC estimate may be
interpreted as the percentage of the total variability in a given variable that may be attributable
to between-therapists differences. No significant between-therapist variability was observed
in either our independent variables or in terms of outcome. Still, since even small amounts of
therapist variability may lead to biased estimates (Crits-Christoph & Mintz, 1991; Wampold
& Serlin, 2000), we decided to include a random intercept at the therapist level in all analyses
in order to provide a more conservative test of our final regression models.
The data was analyzed separately for two time periods: intake to termination and
termination to 1.5 years follow-up. Because we were only able to assess secure attachment to
27 therapist at termination, the results for the first period are referred to as “associations”,
whereas the results for the second period are regarded as “predictions”. We first modeled
change between intake and termination using outcome at termination as dependent variable
while controlling for score at intake, constituting our baseline model. To address the specific
hypotheses in study IV, Security was then entered together with length of therapy as a
covariate since, arguably, longer therapy may both lead to better outcomes and a more secure
attachment to the therapist (Model 1). Next, the alliance was entered together with the other
variables (Model 2) and, lastly, the procedures were repeated for the termination to follow-up
time period.
Since we did not aim to examine the fit between different models, restricted
maximum likelihood (REML) estimation was applied and since only one parameter was
included at level 2 (i.e., the random intercept), a scaled identity matrix covariance structure
(variance components) was assumed. In order to obtain more interpretable outputs we
calculated the standardized β-coefficients for each independent variable in our final models,
using the standard formula: β = B (SDx / SDy).
All statistical calculations in study III and IV were performed with the SPSS (v. 19)
software package. Before the analyses, data was inspected following the recommendations of
Tabachnick and Fidell (2013). A univariate outlier in IIP total score at termination was
corrected to the next score within three standard deviations from the mean. Significantly
skewed variables were either square root or log10 transformed. Primary significance level was
set to p < .05 and, due to the primarily exploratory aims of the studies (Bender & Lange,
2001), all tests were performed without any correction for family-wise error rate (e.g.,
Bonferroni).
Development of the Patient Attachment to Therapist
Rating Scale (PAT-RS)
A new rating scale for patient-therapist attachment, called the Patient Attachment to Therapist
Rating Scale (PAT-RS), was developed as part of this thesis. The background for this effort
was the results of study I and II, which directed our attention towards the possible influence of
patient-therapist attachment quality on psychotherapy process and outcome. Given the rich
interview material available in YAPP, the idea of using a rating scale to assess attachment to
therapist from the patients’ narratives emerged. However, we could not find any available
measure in the literature that fitted our needs and, consequently, we decided to construct our
own instrument. The basic assumptions, theoretical structure, subscales, item construction and
rating procedure of PAT-RS are described in detail below. This section may be regarded as a
general introductory manual to the use of PAT-RS. The current English version of the rating
sheet is provided in the Appendix of this thesis.
Basic assumptions
In line with an attachment-based view of the therapeutic relationship (Bowlby, 1988; Farber
& Metzger, 2009, Obegi, 2008; Mallinckrodt, 2010; Shaver & Mikulincer, 2009), PAT-RS is
based on the assumption that engaging in a helping relationship with a therapist will
28 unavoidably activate the patient’s attachment system. This, in turn, will bring the patient’s
internal working models and attachment strategies to the fore. The interaction with the
therapist will then determine whether the relationship they form will have the basic qualities
of a secure attachment relationship or if insecure strategies will dominate. Accordingly, PATRS is constructed as a relationship specific measure (Mikulincer & Shaver, 2007) and aims at
assessing the quality of the relationship with the therapist rather than the patient’s “attachment
style”. Of course, the patient’s global attachment orientation will likely influence the
interaction with the therapist, but the particular quality of their attachment is regarded as the
result of a complex interaction between the patient’s and the therapist’s personal
characteristics (e.g., their respective attachment styles, as well as other factors), specific
therapeutic technique (e.g., how the therapists responds to the patient’s attachment needs as
well as the timing and focus of specific interventions) and contextual factors (e.g., how the
relationship is structured over time in terms of frequency of meetings, etc.).
A second assumption underlying PAT-RS is that it is possible to assess the
attachment quality of the therapeutic relationship from narratives of how patients view the
therapist as a person, how they experience the therapeutic process, as well as their reactions to
attachment related issues in the therapeutic relationship (i.e., closeness, separation, etc.).
Since attachment involves unconscious processes and strategies, it is assumed that the quality
of the attachment will be indicated by how the patient’s (explicitly or implicitly) describes the
function of the therapeutic relationship. In contrast to attachment measures that assess the
discourse quality in the interview (such as the AAI), the focus of PAT-RS is primarily on the
content of the patient’s narratives and descriptions of how he or she experiences the therapist
and uses the therapeutic relationship for exploration of anxiety-provoking inner experiences.
Lastly, PAT-RS is designed as a dimensional measure. Thus, it is assumed that it is
both possible and meaningful to assess attachment quality in terms of levels on particular
subscales (see below). These levels may vary between particular patient-therapist dyads, as
well as within the same dyad at different assessment points. Consequently, the PAT-RS
subscales are assumed to provide a nuanced picture of the quality of patient-therapist
attachment at a particular point in time.
Theoretical structure and subscales
PAT-RS is theoretically grounded in the two-dimensional model of adult attachment
(Bartholomew, 1990; Bartholomew & Horowitz, 1991; Hazan & Shaver, 1987). This wellestablished model relates adult attachment-system function and interpersonal dynamics to the
underlying dimensions of anxiety and avoidance (Mikulincer & Shaver, 2007). The anxiety
dimension refers to the level of preoccupation with attachment-related issues such as
separation and autonomy. High values in this dimension indicate the presence of
hyperactivating attachment strategies, which are typically associated with high emotionality,
strong reactions to separation, fear of abandonment, overdependence, and worry about not
being accepted or loved. The avoidance dimension reflects strivings for independence,
autonomy, and self-regulation and high values in this dimension indicates the presence of
deactivating attachment strategies to avoid closeness, intimacy, vulnerability, dependence,
and emotional openness in relationships. Following the two-dimensional model, the PAT- RS
is designed to assess the quadrants of attachment relatedness in four subscales: Security,
Hyperactivation, Deactivation, and Disorganization (see Figure 2).
29 HIGH AVOIDANCE Subscale 3: Deactivation Subscale 4: Disorganization HIGH ANXIETY LOW ANXIETY Subscale 1: Security Subscale 2: Hyperactivation LOW AVOIDANCE Figure 2. The subscales of PAT-RS represented in the two-dimensional model of adult attachment.
Subscale 1: Security. This subscale reflects the patient’s level of secure attachment to the
therapist. High scores indicate low degree of anxiety and low degree of avoidance. This is
theoretically desirable since a sufficient sense of security and trust is necessary for activation
of the exploratory system, enabling the patient to be emotionally open and approach
potentially threatening and painful material in the therapy process. The Security subscale also
reflects to what extent there is a balance between autonomy and dependence in the
relationship. Optimally, the patient can experience a certain degree of dependence without
losing agency or the ability for mature self-regulation when appropriate. The therapeutic
relationship thus functions as “a secure base,” enabling the patient to explore and make
changes in his or her life outside sessions.
Subscale 2: Hyperactivation. This subscale reflects to what extent the patient relates to the
therapist using hyperactivating strategies. High scores indicate a low degree of avoidance but
a high degree of attachment anxiety. The patient might typically be preoccupied with worry
about abandonment and lack of understanding and care from the therapist, which leads to
increased emotional arousal to ensure attention and support. Theoretically, this is a
suboptimal way of relating in therapy since high attachment anxiety inhibits the exploratory
system. Although the patient might be very open with emotional material, there is typically a
lack of appropriate cognitive elaboration and reflection (mentalization) necessary for
integration and change in internal working models. Further, the patient will tend to depend too
strongly on the therapist, leading to decreased agency and difficulties separating from therapy.
Typically, the patient will fear making changes on his/her own outside therapy and might long
for the perceived safety of the therapeutic relationship.
Subscale 3: Deactivation. This subscale reflects the patient’s use of deactivating strategies in
relation to the therapist. High scores indicate low anxiety but a high degree of avoidance,
30 leading the patient to keep an emotional distance in the therapeutic relationship. Patients
yielding a high score on this subscale will typically value their independence and autonomy
and have difficulties experiencing dependence and vulnerability and with receiving care. This
will also lead to suboptimal relating in therapy since the avoidance of intimacy and openness
limits the therapist’s ability to both understand and impact the patient on an emotional level.
The avoidance of emotional arousal might also lead to an intellectualized therapeutic process,
which does not have the same impact on the inner working models. The patient may be active
outside therapy, but typically there is a lack of emotional connection between the therapeutic
process and the patient’s activities.
Subscale 4: Disorganization. The last subscale reflects the patient’s level of fearfulness and
disorganization in relation to the therapist. High scores indicate both a high degree of anxiety
and a high degree of avoidance. Theoretically, this indicates that the patient is trapped in a
state of “fright without a solution” (Hesse & Main, 2000) with the therapist. Fear evoked by
the therapeutic process leads the patient to seek proximity to the therapist, but at the same
time the patient experiences an increasing need for distance because of additional fear that is
evoked by the closeness itself. Thus, the patient does not “succeed” in developing a coherent
way of relating but rather oscillates between hyperactivation and deactivation and/or develops
idiosyncratic, maladaptive ways of relating in therapy. Typically, the patient will have grave
difficulties trusting the therapist although he or she might at the same time describe a strong
need for closeness. The patient might be very reluctant to open up, fearing the therapist’s or
his/her own reaction, or both. This might lead to “a passive neediness” or the patient might be
openly hostile and demanding in an effort “to control” the therapist. The experience of the
therapeutic relationship will typically be described in contradictory statements and might also
involve “unusual” or “odd” ideas and perceptions. When it comes to the balance between
autonomy and dependence the patient typically oscillates between extremes (does not need
the therapist at all—cannot do anything without his/her therapist). This subscale is
theoretically the opposite of attachment security and is therefore hypothetically associated
with most difficulties, both within the therapeutic setting and outside therapy.
Item construction
To assess the subscales, PAT-RS is organized around nine components that have been
suggested to define an attachment relationship (Parish & Eagle, 2003a, 2003b): 1. Secure
base, 2. Stronger/wiser, 3. Safe haven, 4. Proximity seeking, 5. Particularity, 6.
Responsiveness, 7. Strong feelings, 8. Separation anxiety and, 9. Mental representation (see
Table 2).
For each of these components, the patient is expected to experience the
therapeutic relationship and relate to the therapist in theoretically consistent ways,
corresponding with the four quadrants in the two-dimensional model. Adopting a “prototypematching” approach to attachment measurement (Bartholomew & Horowitz, 1991; Maunder
& Hunter, 2012; Pilkonis, 1988; Strauss, Lobo-Drost, & Pilkonis, 1999), we constructed four
prototypical descriptions (one for each subscale/quadrant) for each of the nine components
listed above. These short descriptions may be considered “ideal examples” of what patients
may typically report for each component (see the full rating sheet in the Appendix). The
prototypical descriptions were derived from items of previously constructed self-report
31 measures (CATS; Mallinckrodt et al., 1995; CAQ-T; Parish & Eagle, 2003a, 2003b), as well
as relationship-specific attachment coding schemes (PT-AAI; Diamond et al., 2003; AAI Qsort; Koback, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993). Further, the clinical
attachment literature (Bowlby, 1988; Fosha, 2000; Holmes, 2001, 2010; Muller, 2010; Pearl,
2008; Wallin, 2007) was searched for typical examples of attachment-related responses in the
therapeutic relationship. Before including the prototypical descriptions in the final rating
sheet they were discussed with one clinical and one non-clinical attachment researcher.
Table 2. Components of an Attachment Relationship
Component
Description
1. Secure base
The attachment figure provides a sense of security and confidence in exploring
new situations.
2. Stronger/wiser
The attachment figure is someone who seems capable of providing protection and
guidance.
3. Safe haven
The attachment figure is someone to turn to for comfort, support and reassurance,
especially in times of distress.
4. Proximity seeking
The tendency of individuals to seek an optimal level of proximity and closeness
with their attachment figure.
5. Particularity
The attachment figure is a particular, unique other person, who cannot be easily
replaced by another.
6. Responsiveness
The attachment figure is perceived as optimally responsive in relation to the
individual’s emotional needs.
7. Strong feelings
The attachment figure is associated with positive (i.e. joy, love), as well as
negative (i.e. anger, sadness), emotions during the formation, maintenance,
disruption and renewal of the attachment bond.
Separation from the attachment figure is associated with distress, which might
evoke attempts to resist being separated.
8. Separation anxiety
9. Mental representation
In adults, an internalized representation of the attachment figure can be evoked for
comfort or guidance in times of distress.
Note. Adapted from “A New Measure of Components of Attachment” by M. Parish and M. N. Eagle, 2003, unpublished
manuscript, Derner Institute of Advanced Psychological Studies, Adelphi University.
Rating procedure and scoring
PAT-RS is primarily constructed for the rating of transcribed interviews. The rater is
instructed to read the interview material as a whole and mark all paragraphs and sentences
that contain information about how the patient perceived the therapist and experienced the
therapeutic relationship. Since PAT-RS is a relationship-specific measure, the instruction is to
disregard descriptions of relationships other than the one with the therapist. Further, it is the
patient’s relationship with the therapist in the present that is to be rated. Descriptions of
change in the therapeutic relationship are noted, but the rater should focus on how the patient
experiences and relates to the therapist at the time of the interview.
After reading the whole interview transcript, the rater reads all four prototypical
descriptions for the first component in PAT-RS (see Appendix) and rates each description on
a 5-point Likert scale ranging from 1 (does not fit at all) to 5 (fits very well). The central idea
with the prototypical descriptions is to direct the rater’s attention toward what is typically
expected, but the rater is allowed to consider other information in the interview when it seem
32 relevant for the specific component and the underlying dimension being assessed. The
procedure is then repeated for the next component. If in doubt regarding a particular
component the rater is instructed to review marked paragraphs and try rating again. If there is
still insufficient information for rating a particular component the rater indicates this and
moves to the next component.
A mean index score for each subscale is calculated by dividing the total number of
components rated for that particular interview transcript by the sum of ratings in each
subscale. Consequently, for each subscale the final subject score ranges from 1.00 to 5.00.
33 34 RESULTS
Study I: A model of therapeutic action grounded in the
patients’ view of curative and hindering factors in
psychoanalytic psychotherapy
The aim of study I was to explore patients’ views of therapeutic action in psychoanalytic
psychotherapy. Some of the specific research questions were: what do patients perceive as
curative in treatment? What hinders change, according to patients’ views? How are these
factors interrelated? PTI-interviews conducted with 22 patients who had recently terminated
individual psychotherapy in YAPP were analyzed using grounded theory methodology.
The analysis resulted in a conceptual model consisting of 9 main categories with 16
subthemes (Figure 3). The first curative factor that emerged was Talking about oneself (1),
which involved talking in two distinct modes: (a) expressing, reflecting, and labeling one’s
own thoughts and feelings, and (b) remembering and revising one’s personal history.
However, at the same time as talking about oneself was described as curative, the patients also
expressed that talking about themselves in therapy could be anxiety provoking and energy
consuming. Hence, Talking is difficult (2) emerged as a hindering factor, possibly obstructing
the process of talking about oneself as a curative factor.
The second curative factor emerging was Having a special place and a special kind
of relationship (3), which indicated that the patients viewed the therapy setting and the
relationship with the therapist as a unique, curative experience in itself. This experience
involved (a) an atmosphere of acceptance, respect and support, (b) the therapist being an
“outside person” with no relation to the patient’s family or friends and, (c) having time and
continuity in the treatment. Talking about oneself in the context of this special kind of
relationship was associated with the therapeutic impact of New relational experiences (4). The
narratives indicated that when patients were able to overcome the difficulties associated with
talking, this was in itself experienced as an important new relational experience. Further, the
feeling of safety in therapy provided them with a platform for trying out new ways of being
and relating to other people, thus increasing the probability of new relational experiences
between sessions.
The third curative factor that emerged was Exploring together (5), indicating that
patients valued the mutual collaboration with the therapists’ and that this collaboration had a
distinct “exploring” quality to it. Several subthemes emerged, including (a) analyzing causes
to one’s problems and finding connections to one’s personal history, (b) discovering and
challenging self-defeating thoughts and negative interpretations of the self and the world, (c)
focusing on what the patient wanted to get out of life and, (d) defining problems and setting
goals for the treatment which lead to a clearer picture of the difficulties and ways of coping
35 with them. The exploratory work in therapy was further connected to an experience of
Expanding self-awareness (6). This included (a) having “sorted out” thoughts, feelings and
experiences and memories of the past as well as (b) having discovered patterns in one’s
personality and way of relating to self and others. Further, the patients described that the joint
exploratory activity with the therapist helped them (c) gain new perspectives and (d) learn
new ways of thinking, which could be implemented in their ordinary life and lead to
reductions in distress.
Figure 3. A tentative theoretical model of therapeutic action grounded in the patients’ view of curative and hindering factors
in psychoanalytic psychotherapy with young adults. Curative factors are indicated by solid line rectangles, hindering aspects
by dashed-line rectangles, therapeutic impacts by dotted ellipses, and negative impacts by dashed-line stars.
However, expanding self-awareness was also connected with a negative impact,
labeled Self-knowledge is not always enough (7). This category indicated that some patients
experienced expanding self-awareness as insufficient for change. This was further associated
with disappointment in the treatment and connected to the hindering factor Something was
missing (8). Typically, disappointed patients experienced the therapist as too passive and
wanted more feedback, guidance, and advice. Some also expressed missing more structured
and “action-oriented” interventions (such as homework assignments) linking therapy to the
problems they faced in ordinary life.
Lastly, the experience that something was missing was further associated with the
negative impact of Experiencing mismatch (9). Several disappointed patients expressed
concerns that the therapeutic modality might not have been “right” for their problems or
36 wondered how they “fitted together” with their particular therapist. Experiencing mismatch
had a negative influence on the experience of a special relationship with the therapist,
possibly undermining the curative factors in the model. There was no connection between
exploring together and the “something was missing” or “experiencing mismatch” categories,
possibly indicating that such experiences were not often addressed or resolved in treatment.
Study II: Therapists’ view of therapeutic action in
psychoanalytic psychotherapy with young adults
The aim of study II was to explore experienced therapists’ view of therapeutic action in
psychoanalytic psychotherapy. Specific research questions were: What in treatment
contributed to change and what hindered change, according to the therapists’ view? What
kind of changes do the therapists perceive in their patients? How are these factors interrelated
from the therapists’ point of view? PTI-interviews with 16 therapists (who treated the 22
patients included in study I) were analyzed using grounded theory methodology.
The analysis resulted in a conceptual model consisting of one core category with
three subcategories, seven main categories, and seven linking concepts (Figure 4).
Figure 4. A tentative theoretical model of therapeutic action grounded in the therapists’ view of curative and hindering
factors in psychoanalytic psychotherapy with young adults. Curative factors are indicated by solid line rectangles with
rounded corners, the hindering factor by a dashed-line rectangle, positive outcome categories by ellipses, and negative
outcome by a dashed-line star. The linking concepts are placed in italics directly on the lines between categories. Dashed
lines indicate a negative influence between categories and direct lines indicate a positive influence.
37 The core curative factor in treatment from the therapists view was Developing a
close, safe and trusting relationship (1). This involved the patient gradually becoming more
attached to the therapist and, consequently, being able to talk about difficult and painful
subjects, as well as express feelings more openly. When patients opened up this provided an
opportunity to revise inner conceptions of self and others, either in direct dialogue with the
therapist or implicitly through the interaction between patient and therapist. From the
therapists’ view, it was central that the patients’ negative expectations were contradicted in
the relationship.
Further, the therapists regarded the development of a trusting relationship to be
dependent on their adopting and maintaining a stance of genuine interest, acceptance,
flexibility and confidence in the therapy process. Further, the therapists also stressed the
importance of having time and continuity, as well as the patients’ resources and commitment
to the therapy process, sometimes viewed as conflicting with their “intrinsic developmental
force” as young adults.
Other curative factors that emerged were the Patient making positive experiences
outside the therapy setting (2) and the therapist Challenging and developing the patient’s
thinking about the self (3). Here, the therapeutic process was described as a joint activity of
“thinking together”, resulting in the patient Becoming a subject (4) and acquiring an
Increasing capacity to think and process problems (5).
The sole hindering factor that emerged in the model was The patient’s fear about
close relationships (6). The therapists described several pathways through which this fear may
hinder the therapeutic process, including the patient keeping an emotional distance in sessions
or reducing the intensity or length of treatment, as well as negative countertransference
evoked in the therapist leading to difficulties maintaining a therapeutic stance. The result of
such processes was typically viewed as hindering the development of a close, trusting
relationship, leading to Core problems remaining (7). Finally, the therapists also tended to
view therapeutic work as something that the patient continued after therapy had ended,
indicated by the category The therapeutic process continues after termination (8).
Study III: Patient Attachment to Therapist Rating Scale:
Development and psychometric properties
The aim of study III was to describe the development and theoretical structure of the Patient
Attachment to Therapist Rating Scale (PAT-RS), as well as investigate its psychometric
properties. Three raters (main author and two master level students trained by the main
author) applied PAT-RS to interview material obtained from 70 patients who had terminated
their individual therapy in YAPP. Reliability was estimated on 37 of the interviews that were rated independently by
the raters (Table 3). Strong internal consistency (α >.90) was found for all four subscales
indicating that the ratings of the prototypical descriptions followed each other closely in each
subscale. The inter-rater reliability was close to excellent for Security (ICC = .74) and
Disorganization (ICC = .74), as well as in the good range for Deactivation (ICC = .62).
However, the inter-rater reliability for the Hyperactivation subscale was poor (ICC = .34).
38 Table 3. Reliability of the PAT-RS Subscales (n = 37)
PAT-RS Subscale
Security
Internal consistency
Rater 1
Rater 2
Rater 3
Inter-rater reliability
Single measures
95% CI
Average measures
95% CI
Hyperactivation
Deactivation
Disorganization
.98
.99
.97
.97
.92
.94
.97
.97
.95
.99
.97
.98
.74
[.60, .85]
.90
[.82, .94]
.34
[.14, .55]
.61
[.33, .78]
.62
[.44, .78]
.83
[.70, .91]
.74
[.60, .85]
.90
[.82, .94]
Note. PAT-RS = Patient Attachment to Therapist Rating Scale; CI = confidence interval.
Means, standard deviations and correlations are presented in Table 4. As expected,
Security was negatively correlated with all three insecure subscales. In line with the
underlying theoretical model, Disorganization was positively correlated with both
Hyperactivation and Deactivation and the association between the Hyperactivation and
Deactivation was weak. Further, Security correlated strongly and negative (r = –.92) with an
insecurity index based on the average score of the insecure subscales, suggesting that Security
captures a general secure-insecure dimension of patients’ attachment to their therapist.
Table 4. Means, standard deviations and correlations
PAT-RS Subscale
PAT-RS Subscale
Security
Hyperactivation
Deactivation
Disorganization
Insecurity indexa
Alliance
Patient rated
Therapist rated
Mental representations
Mother
Father
Self
Therapist
Self-concept
Positive
Negative
Interpersonal problems
Symptom severity
Global functioning
Length of therapy
n
M
SD
Security
Hyperactivation
Deactivation
Disorganization
70
70
70
70
70
3.3
1.9
1.9
1.4
1.7
1.1
0.8
0.9
0.8
0.6
–.43**
–.76**
–.63**
–.92**
–.15
.35**
.56**
.55**
.70**
.82**
61
66
5.0
4.7
0.5
0.4
.47**
.40**
–.43**
–.22*
–.26*
–.32**
–.33*
–.27*
70
70
70
68
7.2
7.4
7.2
7.8
1.0
0.8
1.1
1.4
.25*
.28*
.45**
.44**
–.10
–.07
–.21*
–.15
–.18
–.13
–.21*
–.34**
–.19
.00
–.20*
–.11
65
65
65
65
69
70
52.4
24.3
1.2
0.9
68.5
23.0
18.2
19.0
0.6
0.7
11.5
13.0
.28*
–.21*
–.13
–.31**
.46**
.19
–.27*
.31*
.27*
.55**
–.35**
–.08
–.12
.00
.04
.04
–.29**
–.05
–.24*
.21*
.28*
.35**
–.52**
.19
Note. PAT-RS = Patient Attachment to Therapist Rating Scale
a
The insecurity index represents the average score of all three insecure subscales
*p < .05. **p < .01.
39 The pattern of correlations with other measures supports construct validity of the
Security subscale. As expected, there was a positive association between Security and the
therapeutic alliance, more mature mental representations, a more positive and less negative
self-concept, less symptoms and higher global functioning. The correlations are of moderate
strength, suggesting that the subscale also captures something different from other measures.
Contrary to expectations, however, Security was not significantly associated with lower levels
of interpersonal problems, although the correlation found is in the predicted direction.
Overall, the pattern of correlations also supports the construct validity of the
Deactivation subscale, which was moderately associated with lower alliance and less complex
mental representations of the self and the therapist. The pattern of correlations with self-report
measures indicates that the Deactivation subscale taps the use of avoidant strategies in
comparison with the other insecure subscales.
However, the pattern of correlations for the Hyperactivation and Disorganization
subscales were very similar, making it difficult to interpret their respective validity beyond
the general conclusion that both subscales likely tap insecure attachment to therapist. Also,
the Hyperactivation subscale had poor reliability, hence; any statements regarding its validity
would be pre-mature. Notably, none of the subscales were significantly related to therapy
length.
The exploratory factor analysis yielded a three-factor solution, explaining 82% of the
variance. Security and Deactivation merged to form opposite poles in Factor 1. Factor 2 and 3
had high loadings in Hyperactivation and Disorganization, respectively, suggesting that the
subscales capture different aspects although the correlations with other measures came out
very similar.
Study IV: Secure attachment to therapist, alliance, and
outcome in psychoanalytic psychotherapy with
young adults
The aim of study IV was to explore the relationships between secure attachment to therapist
(as measured with the Security subscale of PAT-RS), patient-rated alliance and outcome in a
sample of 70 young adult patients treated with psychoanalytic psychotherapy. Specific
research questions and hypotheses were: (1) Is secure attachment to therapist at termination
associated with improvement? In line with attachment theory, we hypothesized that secure
attachment to the therapist at termination would be related to change during therapy. (2) Does
secure attachment to therapist relate to outcome once alliance is controlled for? Since secure
attachment indicates that the patient uses the relationship for emotional exploration, we
hypothesized that it would be more strongly associated with improvement. (3) Does secure
attachment to the therapist or the alliance predict any changes after treatment termination? In
line with attachment theory, we hypothesized that secure attachment to therapist would be
more closely linked with sustained or even increased improvement post-treatment compared
with the alliance. The main research questions were addressed in a series of linear mixedeffects models, controlling for length of therapy and between-therapist variability.
40 Table 5. Linear mixed-effects models for associations with outcome at termination
Note: GSI = Global Severity Index; GAF = Global Assessment of Functioning; IIP = Inventory of Interpersonal Problems; CI
= confidence interval; ICC = Intraclass correlation for therapist effect. Unstandardized estimates are based on transformed
variables.
*p < .05. **p < .01.
Table 6. Linear mixed-effects models for predictors of outcome at follow-up
Note: GSI = Global Severity Index; GAF = Global Assessment of Functioning; IIP = Inventory of Interpersonal Problems; CI
= confidence interval; ICC = Intraclass correlation for therapist effect. Unstandardized estimates are based on transformed
variables.
*p < .05. **p < .01.
The results for associations between secure attachment to therapist and outcome are
displayed in Table 5. In support of our first hypothesis, Model 1 indicated that secure
attachment to therapist was associated with pre-post improvement in symptoms (GSI, β = –
.29, p = .007), global functioning (GAF, β = .45, p < .001) and interpersonal problems (IIP, β
= –.22, p = .024). After controlling for the alliance in Model 2, the relationships were
maintained in terms of symptoms (GSI, β = –.28, p = .033) and global functioning (GAF, β =
41 .45, p = .002), but the association with reduction in IIP was no longer significant (β = –.17, p
= .160). The alliance was not significantly related to change in any outcome, supporting our
second hypothesis. Of note, length of therapy proved unrelated to pre-post treatment change
in all outcome variables.
The results for predictions of changes after treatment termination are presented in
Table 6. Unexpectedly, we found that length of therapy predicted deterioration in terms of
symptoms (GSI, β = .26, p = .002) as well as interpersonal problems (IIP, β = .21, p = .015)
during follow-up. Security was not directly associated with changes after termination in
Model 1. However, when entered together in Model 2, both secure attachment to therapist and
the alliance were significantly related to change in global functioning, but in opposite
directions (Security, β = .32, p = .030; Alliance, β = –.28, p = .035). That is, a more secure
attachment to the therapist at termination predicted increase in functioning during follow-up,
whereas a stronger alliance predicted decrease when both predictors were accounted for. No
indication of significant between-therapist variability was observed in any of the models.
42 DISCUSSION
Reflections on main findings
Patients’ and therapists’ views of curative factors
The models that emerged in studies I and II indicate that therapeutic action in psychoanalytic
psychotherapy involves a complex set of interacting factors from both patients’ and
therapists’ perspectives. The model based on the therapists’ views is somewhat more
elaborated, likely due to the therapists’ training and experience in reflecting on these issues.
Looking at the models together, there is an interesting overlap in terms of the curative factors
that emerged. From the patients’ view, therapeutic action basically involved talking openly
about themselves and exploring personal experiences in the context of a secure therapeutic
relationship. Mirroring this, the therapists stressed the development of a close, safe and
trusting relationship, which enabled them to “think together” with the patient. Thus, on a
general level, both patients and therapists had similar views of the most fundamental curative
factors, which may also be considered common factors in any exploratory model of
psychotherapy (Lambert, 2013b; Wachtel & Messer, 1997).
In terms of more specific psychoanalytic mechanisms of change, both models
include therapeutic impacts that correspond quite well with the notion of corrective emotional
experiences (Alexander & French, 1946; Castonguay & Hill, 2012). For patients,
experiencing the relationship with the therapist as “special” helped them overcome the
difficulties associated with opening up. This was described as a new relational experience,
which also encouraged them to try out new ways of relating to significant others. The
therapists explicitly stressed the therapeutic impact of patients’ negative expectations being
contradicted in the therapeutic relationship, but they also emphasized the importance of
patients’ approaching their core problems and making corrective experiences outside the
therapy setting. Although psychoanalytic psychotherapy is often focused on within-session
interactions, Alexander and French (1946) did not restrict the term corrective emotional
experiences to the therapeutic relationship: “…the actual experience of a new solution in the
transference situation or in his everyday life gives the patient a conviction that change is
possible and induces him to give up the old neurotic patterns” (p. 338, italics added). Hence,
both patients’ and therapists’ views of corrective experiences seem to be in line with the
original definition of this term.
It is also notable that both patients and therapists typically describe corrective
emotional experiences as involving shifts toward more emotional openness and trust in
relationships. This may be interpreted as reflecting change towards greater attachment
security, particularly in the context of the therapeutic relationship, and seem consistent with
the broaden-and-build cycle of security development (Shaver & Mikulincer, 2009).
Interestingly, however, both models also involve the therapist helping the patient move
43 toward greater self-definition, self-acceptance and self-care, as well as a sense of personal
agency and responsibility. Hence, the formation of a secure attachment to the therapist seems
to function as a vehicle for helping the patient develop more mature forms of both relatedness
and self-definition (Blatt, 2008; Blatt et al., 2008; Luyten & Blatt, 2013; Pearl, 2008).
Additionally, both patients’ and therapists’ views of therapeutic action involve the
acquisition of “insight”. In line with a classic psychoanalytic view of this concept, some
patients explicitly described having discovered patterns in their way of relating that were
linked to their past and that this prompted them to relate to others in new ways. However,
insight emerged as part of broader categories in both models, involving the development of
several mental capacities. These included the ability to see things from different perspectives,
as well as the capacity to contain and process problems rather than act out in destructive ways,
perhaps indicating internalization of the therapist’s ability to contain and reflect.
From a contemporary attachment-informed psychoanalytic perspective, one possible
interpretation is that these broad gains in “mental capacities” reflect improved mentalization
(Allen & Fonagy, 2006; Allen et al., 2008). In line with this view, it is interesting that the
therapists rarely mentioned using specific “insight-promoting” psychoanalytic techniques
such as defense or transference interpretations, but rather seemed to focus on helping the
patients “think about the self” in a more general sense. Hence, therapeutic action appeared to
involve the reflective process in itself rather than the specific mental content resulting from
that process (i.e., particular “deep” psychoanalytic insights). Further, it is also notable that
both patients and therapists experienced the therapeutic impact of insight as a result of their
“mutual exploration”, perhaps reflecting that the capacity for mentalization is optimally
developed in the context of secure attachment relationships involving joint attention and
“moments of meeting” (Fonagy et al., 2002; Stern et al., 1998).
Patients’ and therapists’ views of hindering factors
In contrast to curative factors, patients’ and therapists’ views of hindering factors seem more
divergent. From the patients’ view, hindering factors included difficulties “opening up” and
expressing thoughts and emotions freely in sessions. Further, some patients experienced
increased self-knowledge as insufficient for change, which was also related to experiencing
that something was missing in treatment. Typically, this included experiencing the therapist as
too passive and wanting more advice, direction and guidance, as well as more focus on
between-session activities. Disappointed patients experienced a “mismatch” which seemed to
undermine the relationship factors that were identified as curative in the model. In essence,
the hindering aspects that emerged from the patients’ view appear to represent negative
reactions to treatment elements that are quite specific to psychoanalytic psychotherapy (i.e.,
the invitation to form a close relationship and talk openly about anxiety-provoking inner
experiences, exploratory work toward greater self-understanding, the therapist’s relative
passivity, non-directiveness and non-intrusiveness). This result mirrors other studies that have
indicated that certain patients may experience specific factors in different treatment modalities
as obstructing rather than helpful (Gershefski, Arnkoff, Glass, & Elkin, 1996; Nilsson,
Svensson, Sandell, & Clinton, 2007; Levy, Glass, Arnkoff, & Gershefski, 1996). Further,
patients who reacted negatively typically had their own ideas of what could have been
different. However, it seems that that these ideas were seldom or never discussed, nor
integrated in the therapeutic process.
44 Turning to the therapists’ view, it was striking that the patients’ fear of closeness
emerged as the sole hindering factor. The therapists described several pathways through
which this fear could hinder the therapeutic process, including the patient keeping an
emotional distance in sessions or reducing the intensity or length of treatment. Some
therapists also mentioned that the patient’s distancing and disconnection from the therapeutic
work could evoke negative reactions in them (i.e., “countertransference”), which then led to
difficulties in maintaining an adequate therapeutic stance. The result of such processes was
typically viewed as hindering the development of a close, trusting relationship, leading to a
treatment that lacked in emotional depth, became stalled or was terminated prematurely.
The idea that patients’ fear of closeness hinders treatment may be interpreted as
reflecting the psychoanalytic notion of “resistance” (Breuer & Freud, 1895/1955; Freud,
1926/1959). Increased patient resistance may signal that important emotional conflicts are
being activated in the therapeutic relationship, which then needs the therapist’s careful
attention (Frederickson, 2013; Coughlin Della Selva, 1996; Muller, 2010). However, neither
the model based on the patients’ or the therapists’ view included a link between the hindering
factors and the joint exploratory work, possibly indicating that such experiences were not
often addressed, worked-through or resolved in treatment.
Looking at the results of study I and II together, it seems sadly evident that therapists
and patients may sometimes get caught up in a “vicious circle” of “blaming the other” for the
perceived obstacles in treatment. Perhaps some therapists responded to patients’ negative
reactions by holding tighter to the specific factors in their treatment model, which then
provoked even more negative reactions from the patient. The lack of connection between
hindering factors and the joint exploratory work could also indicate that the therapists were
simply unaware of their patients’ dissatisfaction and that disappointed patients preferred to
keep such experiences to themselves. In a study that specifically focused on dissatisfied
patients’ views of hindering factors in the YAPP sample, von Below and Werbart (2012)
identified an underlying theme of abandonment, which reflected these patients’ profound lack
of confidence in the relationship with the therapist whom they perceived as lacking in
direction, responsiveness and flexibility. Perhaps some patients had trouble discussing
negative experiences openly in fear of eliciting negative responses from the therapist, which
would only risk increasing their sense of isolation and abandonment.
From an attachment perspective, it is notable that the hindering factors that emerged
in both models involved distancing (which was typically attributed to the other) and distrust.
This may indicate that insecure attachment strategies (perhaps deactivation in particular) were
evoked and maintained in some therapeutic dyads. In line with a cyclical view of attachment
pattern maintenance (Wachtel, 2014), one interpretation is that the therapists’ strategies for
managing patients’ insecure attachment strategies (perhaps deactivation in particular)
sometimes led to their preservation rather than their resolution. It is also possible that negative
reactions from patients activated insecure strategies in some therapists, which may have led
them to withdraw and become less flexible. Thus, the lack of links between negative
experiences and the joint therapeutic work in both models may reflect that insecure
attachment strategies inhibited the exploratory systems. One hypothesis is that the therapeutic
process in such cases may become disconnected and characterized by “pseudo-mentalizing”
(Allen & Fonagy, 2006). The patient and therapist may look like they are engaged in a
therapeutic dialogue, but the reflective process lack genuine cognitive-affective integration.
45 This will have limited impact on the patient, perhaps indicated by some patients’ experience
that self-knowledge was insufficient for change.
Assessing attachment to therapist with PAT-RS
A new assessment instrument for patient-therapist attachment, PAT-RS, was developed as
part of this thesis. In contrast to previously constructed self-report measures (i.e., CATS;
Mallinckrodt et al., 1995; CAQ-T; Parish & Eagle, 2003a, 2003b), PAT-RS utilizes observerratings of patients’ spontaneous descriptions of the therapeutic process, as well as the
therapist as a person, typically collected in research interviews. This makes the instrument
less susceptible to self-report biases and at the same time more receptive to implicit indicators
of attachment quality, provided that independent observers are able to detect them reliably.
PAT-RS also differs from the AAI-based procedure proposed by Diamond and colleagues
(2003), which evaluates the patient’s “attachment state of mind” in relation to the therapist.
Rather than focusing on linguistic aspects, the scoring procedure in PAT-RS involves
comparing patient narratives with prototypical descriptions of an attachment relationship,
adapted to the therapy context. Consequently, in comparison to an AAI-based procedure,
PAT-RS may require less specialized training to use.
PAT-RS is designed as a relationship-specific measure. That is, rather than assessing
the patient’s attachment style, the aim is to assess the attachment quality of his or her specific
relationship with the therapist. However, one might question if this is really what the
instrument captures. Since the assessment is based on only the patient’s descriptions of the
therapeutic process, it may be argued that what is really assessed is the patient’s mental
representation of the relationship, not the relationship “in itself”. Since we do not have any
data on the actual interaction in therapy, we cannot know how that representation relates to
what transpired in the relationship. On the other hand, similar to findings for the alliance
(Horvath et al., 2011), it may also be argued that the patient’s experience of the relationship is
likely what is most important for process and outcome.
The initial examination of the psychometric properties of PAT-RS in study III
encourages further development and refinement of the instrument. The Security subscale was
rated with satisfactory inter-rater reliability and the pattern of correlations with other
measures support its construct validity. The strong negative correlation with the insecurity
index (r = −.92) further suggests that the Security subscale captures a general secure-insecure
dimension of patients’ attachment to their therapists and, consequently, may be useful for
assessing the overall quality of patient-therapist attachment. In line with adult attachment
theory, the results of study IV also indicated that Security relate to change during treatment
and that its unique variance may predict improvement in functioning during follow-up, which
further support for the validity of the subscale.
Regarding the insecure subscales, the results of study III also suggest that the
Deactivation subscale may be useful for its purposes. The inter-rater reliability was somewhat
low, but still within the “good range”, and associations with other measures indicate that the
subscale likely captures deactivating strategies. More caution should be taken regarding the
Hyperactivation and Disorganization subscales. Although both subscales likely tap insecure
forms of attachment to therapist, the Hyperactivation subscale had poor inter-rater reliability
and could not be distinguished from the Disorganization subscale regarding the patterns of
46 correlations with other measures. Hence, the Hyperactivation subscale needs particular
attention and refinement before further use2.
Our exploratory factor analysis resulted in a three-factor solution, which does not
correspond with the underlying theoretical model (see figure 2). However, this result likely
reflects sample characteristics and should be interpreted with caution given the small sample
size. In terms of future studies, there is a need for testing PAT-RS in larger samples that also
include patients from clinical populations that are more likely to develop an insecure
attachment to the therapist (such as borderline or psychotic patients). Further, in order to
examine the convergent validity of the PAT-RS subscales in more detail, future studies should
optimally also include different methods for assessing attachment to therapist (i.e., self-report
such as the CATS or observer-rated measures such as PT-AAI). Recently, Talia and
colleagues (2014) developed the Patient Attachment Coding System (PACS), which may be
used to assess patient attachment to therapist directly from session transcript. While this
approach is new and may also need further refinement, one prospect for the future would be to
cross-validate the instruments by comparing PAT-RS-ratings of research interviews with
PACS-codings of session transcripts.
One unexplored issue concerns what kind of interview data is required for reliable
use of the PAT-RS. In study III we applied PAT-RS to data obtained with the PTI and ORI,
neither of which was specifically designed to tap patients’ attachment to their therapist. The
interview protocols involved just a few open-ended questions regarding the patient’s
retrospective view of the therapy process as well as asking the patient for a detailed
description of the therapist as a person. At present, this should be considered the minimum
requirements for patient narratives to be measured with PAT-RS. Until further studies have
clarified the optimal data for using the PAT-RS we recommend the use of multiple raters and
that inter-rater reliability is estimated independently for the particular material at hand.
Secure attachment to therapist and change
In line with an attachment perspective on therapeutic process and change, study IV indicated
that patients’ level of secure attachment to their therapist at termination was associated with
outcome. However, since we were only able to measure attachment to therapist at termination,
the associations cannot be interpreted as causal, or even predictive. For example, it is quite
possible that changes in distress led to a more secure attachment rather than the other way
around. Still, the results mirror the patients’ and therapists’ subjective views of therapeutic
action that emerged in study I and II. Further, given that secure attachment to therapist has
previously been linked to important in-session processes (i.e., Janzen et al., 2008;
Mallinckrodt et al., 2005; Romano et al., 2008; Saypol & Farber, 2010), as well as to
reduction of distress over time (Sauer et al., 2010), the results do suggest that the development
of a secure attachment to the therapist during therapy may be an important mechanism of
change underlying psychoanalytic psychotherapies.
Further in line with this notion, we found that the level of secure attachment to
therapist at termination predicted continued improvement in functioning during follow-up.
2
The current English version of PAT-RS is included in the appendix of this thesis. The prototypical descriptions were refined
during translation with particular attention to the issue of differentiating the insecure subscales. Thus, the English version of
PAT-RS differs somewhat from the original scale that was used in study III.
47 However, this was only true after patient-rated alliance had been accounted for, indicating the
presence of a “classic” suppression effect (Pandey & Elliott, 2010). This suggests that the
weight of Security increased when patient-rated alliance (with which it is correlated) was
entered in the model since the alliance removed irrelevant predictive variance from Security.
Thus, the association between Security and continued improvement was limited to the unique
variance of Security (i.e., not shared with patient-rated alliance), which may have implications
for the differentiation of the constructs (discussed further below).
Interestingly, the suppression effect was only present in terms of global functioning
and not for change in symptoms or interpersonal problems. This may indicate that the finding
was simply coincidental or perhaps an artifact of other variables not accounted for. Another
possible interpretation is that the establishment of a secure attachment to the therapist is
particularly important in terms of improving patients’ overall functioning. In their proposed
meta-model of the therapeutic relationship, Wampold and Budge (2012) suggest that the “real
relationship” (of which secure attachment to therapist may be considered a part; see Moore &
Gelso, 2011) is particularly related to improvements in functioning and quality of life. In
contrast, agreements on tasks and goals (i.e., the alliance), as well as specific therapeutic
techniques, may be more important for symptom change. The results of study IV seem to be
in line with this model.
One unexpected finding was that length of therapy was unrelated to the level of
secure attachment to therapist at termination. This was surprising since “having time”
emerged as an important factor related to the establishment of a safe therapeutic relationship
from both the patients’ and the therapists’ view in studies I and II. Also, duration of treatment
has been associated with a more secure attachment to the therapist in some studies (Bachelor
et al., 2010; Mallinckrodt et al., 1995), although the timeframe of the treatments were much
shorter than in the present sample. Our results suggest that treatment duration (at least beyond
2 months which was the shortest treatment course in YAPP) is not automatically associated
with the development of a more secure attachment to the therapist. Certainly, the
establishment of a secure therapeutic relationship is a complex process, involving the
interaction of several patient and therapist factors, particular in-session processes, as well as
the adaptation and timing of specific interventions (Frederickson, 2013; Janzen et al., 2008;
Muller, 2010), and should not be considered a simple matter of time.
We were also surprised that we did not find any indication of between-therapist
variability in terms of the level of secure attachment to therapist at termination, especially
since there was indication (albeit non-significant) of such variability in terms of the alliance.
This may have been due to low power, but another interpretation could be that therapist
differences in terms of strategies for fostering a secure therapeutic attachment were small in
this sample. Although no manual was used in YAPP, perhaps the therapists worked quite
similar in this regard. Another possibility is that the development of a secure attachment in
therapy was more dependent on patient factors that were not measured in the study (such as,
for example, the patients’ pre-treatment attachment status).
Secure attachment to therapist and the alliance constructs revisited
The results of study IV may have important implications when it comes to differentiating
secure attachment to therapist from the therapeutic alliance. First, we found that the
correlation between Security and patient-rated alliance (r = .47) was notably weaker
48 compared with studies that used self-report to measure both constructs (Bachelor et al., 2010;
Lunsford, 2010; Mallinckrodt et al., 1995, 2005; Romano et al., 2008; Sauer et al., 2010).
This indicates that an observer-based approach for assessing secure attachment to therapist
may be useful for reducing common method bias associated with the use of self-reports only.
Further, Security remained significantly associated with changes in both symptoms and global
functioning when the alliance was accounted for in our models. Thus, trained raters may
capture the specific attachment-related functional qualities of the relationship that relate to
outcome beyond the patient’s experience of a positive alliance.
The idea that secure attachment to therapist and the therapeutic alliance comprise
qualitatively different aspects of the therapeutic relationship related to outcome is further
supported by the suppression effect found in study IV. This indicated that the unique variance
of patient-rated alliance was associated with deterioration in functioning during follow-up,
while secure attachment to therapist was related to further improvement. One possible
interpretation is that patient-rated alliance in later stages of therapy includes a “good-bye
effect”, leading some patients to overestimate the quality of the collaboration with the
therapist when approaching termination. Another possibility is that, over the course of therapy
some patient-therapist dyads may have formed alliances that had insecure qualities from the
view of attachment theory. Such alliances may be considered “strong” by the patient but the
therapeutic process may not have had an optimal impact on an emotional level, leading to less
robust results in the long run. Our result may indicate that an observer-rated approach for
assessing attachment to therapist is more sensitive to detecting such nuances, leading to better
differentiation of the attachment to therapist and alliance constructs.
Importantly, however, it should be kept in mind that patient-rated alliance is not the
same as the alliance construct “in itself”, but rather reflects one particular perspective on the
alliance (Muran & Barber, 2010). Hence, the relationships between alliance and secure
attachment may differ depending on the perspective used when assessing each construct. In
study III we included therapist-rated alliance and it related to secure attachment with a similar
moderate strength (r = .40) as patient-rated alliance, indicating that our observer-approach
also differentiates secure attachment from the therapist perspective on the alliance. Yet,
perhaps the alliance would relate more strongly to Security if also rated by an independent
observer (although assessing both constructs with observers would of course re-introduce the
issue of common method bias). Future studies should include both self-report and observerrated measures of attachment to therapist, as well as the alliance, in order to clarify their
respective relations and associations with outcome.
Psychoanalytic psychotherapy with young adults
Since all patients included in the studies were young adults, some of the results may be
specific for psychoanalytic work with this age group. For example, Jacobs (1988) suggests
that since young adults are in a transient life situation, they may be very focused on “realworld issues” and therefore lack motivation for reflecting upon themselves and past
experiences. Perhaps the findings of study I, indicating that some patients experienced selfknowledge as insufficient for change and wished for a more active therapist, is typical of
patients in this age group. However, not all patients in our sample described such experiences
and the curative factors that emerged in the same model contrast the view that young adults
are not motivated for exploratory work. Further, similar findings regarding negative
49 experiences to specific factors in psychoanalytic psychotherapy were also reported in the
study by Nilsson and colleagues (2007), in which the mean patient age was 43. Consequently,
negative reactions of this kind seem likely to be related to factors other than age, such as
patient personality characteristics and/or the therapists’ specific way of relating and
intervening in the therapeutic process.
Further, since young adults are in the process of separating from internal and external
parental figures, it has been suggested that engaging in a close therapeutic relationship with a
therapist roughly of the same age as their parents may be a particular challenge for young
adults (e.g., Barnett, 1971; Escoll, 1987; Jacobs, 1988; Pearl, 2008; Perelberg, 1993).
Contrary to our expectations, however, patients rarely mentioned the therapists’ age as an
issue in the interviews. Rather, the age and experience of the therapist was typically viewed as
a positive factor, contributing to the experience of a “special kind of relationship” and likely
also to the “stronger wiser” component of the attachment.
In connection to this, it is notable that the only age-specific category that emerged in
the qualitative analyses was “young adults intrinsic developmental force” in study II. Here,
the therapists described the transitional period of young adulthood as a positive, as well as a
potentially negative, contributor to the therapeutic process. On the positive side, the young
adults were described as having an inherent curiosity in themselves and others, which
enhanced motivation and engagement in treatment. Further, the therapists noted that the
young adult patients typically had to face new situations outside the therapy office (i.e.,
starting a new job, engaging in romantic relationship, etc.), which provided natural
opportunities for corrective experiences. On the negative side, the therapists also experienced
that the young adults mobility could interfere with the establishment of a close therapeutic
relationship. Sometimes therapists interpreted the practical problems that typically emerged
when patients switched jobs or moved away for studying as signs of resistance related to
patients’ fear of engaging in a close relationship. However, considering that young adulthood
involves a general striving toward individuation, avoidance of closeness and dependency may
be a natural tendency in this age and should not automatically be interpreted as resistance.
Thus, psychoanalytic work with young adults may require more flexibility than usual on the
therapist’s part as well as an openness to explore when such practical problems may be signs
of resistance and when they are not in a non-defensive and non-controlling manner.
The therapists’ generally positive view of young adults “intrinsic developmental
force” seem in line with the notion that young adulthood involves a strong potential for
personality change and emotional growth (Tanner & Arnett, 2009). In this regard, it is also
interesting to note that we did not find any relationship between the length of treatment and
outcome, nor between treatment length and a more secure attachment to the therapist, in study
IV. Perhaps this reflects young adults potential for rapid engagement and change, which also
challenges the commonly held belief (among lay persons, as well as some experienced
therapists alike) that psychoanalytic psychotherapy must necessarily be “long-term” in order
to produce lasting change. In fact, contrary to our expectations, longer therapy predicted
deterioration in symptoms and interpersonal problems during follow-up in study IV. Since
length of treatment was associated with more symptoms and interpersonal problems at intake,
this may reflect that patients who were more troubled tended to stay longer in treatment
(perhaps due to difficulties in establishing a secure attachment to the therapist) and were more
likely to relapse after termination.
50 Methodological considerations
Strengths
All four studies in this thesis are based on data collected in the context of a naturalistic,
longitudinal project, evaluating psychoanalytic psychotherapy as it was routinely practiced at
the Institute of Psychotherapy in Stockholm. The overall design of the project contains several
features that may be considered strengths with regards to external validity (Kazdin, 2003;
Leichsenring, 2004; Seligman, 1995). For example, just as in ordinary clinical practice, the
treatments were self-corrective, meaning that the therapists were allowed to adjust the
treatment according to their clinical judgment of each patient’s needs. Further, the treatments
were not fixed in duration but rather continued until the therapist and patient agreed upon
termination or the patient dropped out. The patients’ were also self-selected for psychotherapy
and sought treatment for a mixture of psychological complaints, including low self-esteem,
depression, anxiety and relational difficulties. Further, inclusion in the project, as well as the
allocation to either individual or group therapy, was based on clinical judgment of suitability
in conjunction with the patients’ own preferences. Thus, the data was collected under
conditions that are highly representative of clinical practice.
Another strength of the project involves the extensive qualitative data collection.
This data provided an opportunity to explore the patients’ own meaning construction in study
I, as well as highly educated and experienced therapists clinical thinking in study II. The
qualitative methodology followed formalized steps and two researchers collaborated in the
later stages of the coding process. Efforts were made to “bracket” existing theory and own
values (Elliott et al., 1999; Malterud, 2001). In order to validate the results and reduce
researcher subjectivity, feedback from four respondents was integrated in the coding process
of study II. The amount of interview data was sufficient to reach saturation points in the
qualitative analyses.
The rich qualitative material also allowed us to explore the utility of a new observerrated instrument for patient-therapist attachment in study III. Before using PAT-RS, the raters
were trained by the developer of instrument. During the rating procedure all raters were kept
blind with regards to patient outcome in terms of the quantitative measures. Further, the
standardized measures used in study III and IV tapped multiple domains of distress and
functioning from both observer and patients’ self-reported perspectives, providing a broad
picture of outcome. Comparing with the few studies that have investigated secure attachment
to therapist and outcome so far (i.e., Sauer et al., 2010; Wiseman & Tishby, 2014), study IV
has several novel features that may add to the literature: we assessed secure attachment to
therapist at termination of long-term therapy, used a new observer-rated measure to assess
patient-therapist attachment quality, and included change during follow-up in the analyses.
An overall strength of this thesis is that therapeutic action is explored from different
perspectives (patient, therapist, observer) and that both qualitative and quantitative methods
were used. The general correspondence of the results across the four studies strengthens the
conclusions drawn.
51 Limitations
In contrast to the strength in terms of external validity, the naturalistic design of YAPP was
typically weak in terms of its internal validity (i.e., no control group, no randomization to
treatments, no manual or treatment fidelity checks, etc.). By design, naturalistic studies do not
permit any strong causal conclusions (Kazdin, 2007, 2009). Therefore, it should be kept in
mind that the aim of this thesis was exploratory and the results must be evaluated in relation
to other studies that may have stronger designs in terms of internal validity.
Further, it should also be kept in mind that the material in all four studies was
analyzed at the group level. Hence, we cannot say if our results may differ between different
subgroups of patients. For example, perhaps the conceptual models that emerged in study I
and II would have been different if the studies were focused on patients that primarily sought
treatment for a particular anxiety disorder, depression or maladaptive personality traits. Also,
the associations between secure attachment to therapist and outcome found in study IV might
be stronger or weaker in different subgroups (e.g., patients who differ in terms of their pretreatment attachment status or other personality characteristics).
Also, the patients included in the studies should not be considered as representative
of all young adults in distress. The gender distribution in the sample was uneven and most
came from highly educated families, residing in the greater Stockholm area. Likewise, the
therapist involved in YAPP should not be considered a representative sample of all
psychoanalytically oriented therapists. The therapists were highly educated with long clinical
experience. Further, the therapists were also involved as teachers and supervisors at the
Institute of psychotherapy, which was a specialized unit for treatment, training and research in
psychoanalytic psychotherapy.
As already mentioned, no manual was used. However, the therapists shared a
psychoanalytic frame of reference and attended regular clinical meetings during the study,
ensuring that the treatments delivered were psychoanalytic in orientation. Still, it is not clear
to what extent the results may generalize to different forms of psychoanalytic psychotherapy.
For example, it is possible that patients’ and therapists’ views of therapeutic action, as well as
the impact of a secure attachment to therapist, differ in focused short-term psychodynamic
psychotherapies compared with long-term treatments or psychoanalysis. Further, although the
qualitative data was rich in terms of patients’ and therapists’ overall views of curative and
hindering factors and processes, the interviews did not contain much information at the level
of specific therapist interventions. Thus, the issue of when and how particular interventions
may aid or thwart the development of a secure therapeutic attachment remains.
Some study-specific limitations also warrant mentioning. In study I and II, the
interview material was selected based on availability. Although the patients and therapists
seemed representative of their respective samples in YAPP, we cannot rule out the possibility
that they differed in some respect. Further, in terms of the data analytic strategies employed in
study I and II, some deviations from strict grounded theory methodology had to be accepted.
The semi-structured interview manual was constructed in advance and interviewers other than
the researchers themselves conducted the interviews, which may have limited the researchers
sensitivity to the data. Further, there was no collection of new data (i.e., “theoretical
sampling”) to deepen categories, as recommended by Strauss and Corbin (1998). This may
have limited the specificity of the results, as it is possible that important experiences and
processes were not captured in the interviews.
52 A major limitation in study III was that the interviews protocols were not specifically
focused on assessing the patients’ attachment to their therapist. This led to large variation in
terms of how much specific data was available for rating each component in PAT-RS. The
inter-rater reliability of the PAT-RS subscales may be better if PAT-RS is applied to
interviews were the interviewer probes more for attachment specific material. Another
limitation in study III was the lack of other measures of attachment to therapist or of patients’
attachment styles, with which we could explore the convergent validity of PAT-RS subscales.
Also, characteristics of the sample, as well as the use of termination as assessment point,
likely limited the variability of the insecure subscales in PAT-RS.
As already mentioned above, a major limitation of study IV was that we were only
able to assess attachment to therapist from the interviews at termination. Although the
assessment involved the patients’ retrospective account of the psychotherapy process, we
have no control over the temporal relationship between Security and outcome. Consequently,
we cannot say if secure attachment to therapist preceded improvements or was the result of
them or of other factors. Further, we did not have access to patients’ pre-treatment attachment
characteristics. It is possible that patients who had a predominantly secure attachment style at
the start of therapy mainly accounted for the association between secure attachment to
therapist and outcome in this study. However, previous studies have found mixed results
regarding the relationship between patients’ global attachment status and the quality of
patients’ specific attachment to their therapist (Mallinckrodt et al., 1995, 2005; Moore &
Gelso, 2011; Romano et al., 2008; Sauer et al., 2010; Wiseman & Tishby, 2014). Hence, the
relationships between secure attachment style and relationship-specific secure attachment to
the therapist should not be assumed to be strong.
Concluding thoughts
Two tentative process models
The aim of this thesis was to explore therapeutic action in psychoanalytic psychotherapy.
Clearly, the included studies do not provide any definite answer to this complex issue and
much more research is needed before (if ever) a comprehensive model, accepted by all strands
of psychoanalytic thought, will be reached (Gabbard & Westen, 2003; Fonagy & Kächele,
2009; Kernberg, 2007). Still, the overall result of this thesis suggests that the establishment of
a secure attachment to therapist may be an important mechanism of therapeutic change.
Further, although the studies do not provide information at the level of specific therapist
interventions, the results indicate that certain interactions between patient and therapist may
facilitate or obstruct the development of a secure therapeutic relationship. Integrating the
results of all four studies, two tentative process models are proposed below that may be useful
for clinical practice and further research.
The first model integrates the curative factors that emerged in the studies and
suggests a broaden-and-build cycle of attachment security development and change (Figure
5). The model indicates that the process of opening up in treatment may typically lead to
corrective emotional experiences for the patient, leading to shifts toward greater attachment
security in the therapeutic relationship. This will enable mutual exploration, which may foster
53 Corrective emotional experiences in sessions “Opening up” Shift towards greater attachment security Reduction of symptoms and interpersonal distress Corrective emotional experiences outside sessions Mutual exploration Increased capacity for mentalization Increased sense of agency, self-­‐definition and self-­‐efficacy Figure 5. A broaden-and-built cycle of attachment security development and change.
an increased capacity for mentalization. In turn, increased ability to mentalize may strengthen
the patient’s sense of agency, self-definition and self-efficacy and promote further corrective
experiences outside the therapeutic setting. Reductions in symptoms and interpersonal distress
will increase the patient’s confidence in the treatment and willingness to open up and engage
even more.
Activation of insecure attachment strategies Negative reaction to specific treatment element Therapist countertransference Preservation of symptoms and interpersonal distress Therapist holding tighter to specific treatment factors Therapeutic process characterized by disconnection and/or pseudo-­‐
mentalizing Mutual exploration inhibited Figure 6. A react-and-disconnect cycle of attachment insecurity maintenance.
The second model integrates the hindering factors that emerged in a react-anddisconnect cycle of attachment insecurity maintenance that may lead to the preservation of
patients’ symptoms and distress (see Figure 6). This model suggests that patients’ negative
reactions to specific elements in treatment may activate insecure attachment strategies
(deactivation in particular). This, in turn, may evoke therapist countertransference and prompt
the therapist to hold even tighter to the specific factors in their treatment model.
Consequently, the therapeutic process becomes characterized by disconnection and/or pseudo54 mentalizing, blocking genuine exploration, integration and change. The preservation of
symptoms and distress may trigger even further negative reactions and disconnection;
however, in some cases the therapeutic alliance may still be rated strong from the view of the
patient (and possibly also by the therapist) due to the relative emotional “safety” provided by
the insecure attachment strategies.
The underlying arrows in the models suggest that the included factors follow each
other in a step-by-step fashion, but they are more likely to interact with each other in
reciprocal ways. Based on these models, some general implications for practice are suggested
below.
Implications for practice
The results of this thesis suggest that therapists should actively strive toward fostering a
secure attachment relationship in treatment. A sufficient sense of security is necessary for
activation of the exploratory system, which will enable the patient to approach painful
thoughts and feelings in the therapeutic process. A sense of security will also facilitate a
mutual exploration process that promotes mentalization (Allen et al., 2008). Further,
following Bowlby’s (1988) statement that: “…unless a therapist can enable his patient to feel
some measure of security, therapy cannot even begin” (p. 140), therapists should be attentive
to the process of attachment formation from the very first session. The first step of “opening
up” may be experienced as stressful by some patients’ and, consequently, insecure attachment
strategies may be evoked from the very beginning of treatment. Therapists should be attentive
to indicators of insecure strategies being activated in the relationship and specifically inquire
into the patient’s experiences when such indicators emerge. This may open the opportunity to
test and revise the patient’s expectations, potentially leading to corrective emotional
experiences and shifts towards greater attachment security.
Negative reactions to specific treatment elements may also signal that there are
important differences between patients’ and therapists’ implicit theories of cure that needs to
be elucidated and discussed (Philips, Werbart, & Schubert, 2005; Philips, Werbart, Wennberg,
Schubert, 2007; Werbart & Levander, 2006, 2011). If left unattended, such discrepancies may
otherwise lead to an experience of mismatch, which will obstruct the formation of a
collaborative alliance, as well as the establishment of a secure therapeutic attachment. Further,
perhaps due to the activation of insecure attachment strategies that inhibit mutual exploration,
therapists may not be aware of the negative experiences of their patients. Therefore, the
therapist needs to actively invite the patient’s view through out treatment in order to and
check his or her ideas with those of the patient (Hill & Knox, 2009; Satran, 1995).
Our results also indicate that patients who experience mismatch often have their own
ideas of what could improve the therapeutic work. The therapists should make efforts to
explore these ideas; however, a naive acceptance of the patient’s view is probably not curative
in itself. Research on the alliance ruptures (Safran & Muran, 2000; Safran et al., 2011)
indicates that the negotiation of divergences between patients’ and therapists’ views may
restore a collaborative alliance, as well as provide corrective emotional experiences that may
deepen the patients’ sense of security in treatment. On the other hand, if the patient’s and the
therapist’s ideas of the goals and tasks in treatment are incompatible and non-negotiable,
therapists should consider referring the patient to another therapeutic modality rather than
prolonging treatment in the hope that “time will do its work”.
55 Further, besides facilitating corrective emotional experiences in the therapeutic
relationship, therapists should also pay close attention to patients’ extra-therapy activities and
help promote corrective experiences outside the sessions. One of the main common factors
found in previous research is “encouragement of gradual practice” (Elliott & James, 1989),
which seemed to be absent from the view of disappointed patients in study I. From the
position of providing a “secure base” for the patient, therapists should actively encourage
patients to use what they have acquired in therapy for adaptive action in their lives. According
to an integrative relational psychoanalytic view (Frank, 1999; Gold & Stricker, 2001;
Wachtel, 2014) selective incorporation of “action-oriented” interventions may be considered
at some points in the therapeutic process. Focusing on the establishment of a secure
therapeutic relationship at the same time as attending to patients’ adaptive actions will also
facilitate mature forms of both relatedness and self-definition (Blatt, 2008).
One typical negative patient experience that emerged was related to perceived
therapist passivity. Although the passive psychoanalytic therapist is a caricature of the past in
many respects, some practicing therapists may still have been trained in a “less is more“
approach. Such therapists may feel uncomfortable with being active due to their training or
they may simply lack the skills for intervening actively in a manner that is consistent with
psychoanalytic theory (Katzman & Coughlin, 2013). Additionally, some therapists may also
resort to a more passive and/or inflexible stance due to countertransference and/or insecure
attachment strategies being evoked in them. From an attachment perspective, therapist
passivity may undermine mentalization processes (Allen, Fonagy, & Bateman, 2008). Thus,
therapists should be attentive to their own level of activity. Increased passivity and
disengagement may signal to the therapist that a react-and-disconnect cycle has been triggered
that needs particular attention.
As suggested above, patients’ avoidance of closeness may indicate that insecure
attachment strategies have been evoked in the treatment process and/or that patients’ and
therapists’ ideas of cure differ. In both instances, such experiences need the therapists’ active
attention. However, perhaps particularly in the context of psychotherapeutic work with young
adults, avoidance of closeness and dependency should not automatically be interpreted as
signs of resistance. The therapist needs to be able to explore perceived obstacles to the
therapeutic work in a non-defensive and non-controlling manner, also reflecting on their own
contribution to the co-construction of hindrances. Actively inviting the patient’s perspective
may foster the restoration of a collaborative therapeutic relationship, lead to corrective
experiences and shifts toward security and reestablished mentalization processes (Allen,
Fonagy, & Bateman, 2008).
Suggestions for future research
The results of this thesis suggest that the development of a secure attachment to the therapist
may be an important change mechanism in psychotherapy. Further, the formation and
maintenance of an insecure attachment to the therapist may obstruct the therapeutic process,
leading to non-improvement or even deterioration. However, in order to test these hypotheses
more thoroughly, future studies need to be specifically designed to evaluate the impact of
patient-therapist attachment quality on outcome. Due to a number of ethical and practical
reasons, direct experimental manipulation of the patients’ attachment to their therapist is not
56 feasible. The most realistic step in this direction would be to investigate attachment to
therapist as mediator of outcome (Kazdin, 2007, 2009).
In order to do this, it is imperative that future studies assess patient-therapist
attachment, as well as the target outcomes, at several points in time in order to establish the
temporal link between growth in attachment and change. Hypotheses regarding the temporal
development of secure attachment and outcome could be tested within a multilevel growth
model framework (e.g., Ljótsson et al., 2013) or with structural equation modeling (SEM).
Similar to the findings regarding alliance and outcome (Falkenström et al., 2013, 2014; Tasca
& Lampard, 2012; Zilcha-Mano et al., 2013), a reciprocal relationship between growth in
secure attachment to therapist and therapeutic gains might be expected, which would also be
theoretically consistent with the broaden-and-build cycle of attachment security development.
In contrast, higher levels of insecure attachment to therapist may be expected to relate to less
change or even predict deterioration.
One issue for future studies is how to measure attachment to therapist. While selfreport may still be the most economic and practical approach, the results of this thesis
suggests that an observer-based approach may be preferable, particularly if alliance is
assessed from the patients’ perspective in the same study. In such studies, conducting
attachment-focused interviews and assessing them with PAT-RS could be an appropriate
approach. However, if the development of attachment to therapist were to be studied in detail,
frequent interview assessments would likely be too cumbersome. An alternative would be to
assess attachment to therapist at session level using PACS (Talia et al., 2014) or, perhaps,
adopt PAT-RS for use on video recordings of sessions.
Additionally, patients’ pre-treatment attachment should be taken into account in
order to investigate the possible role of attachment to therapist as mediator between global
attachment styles and outcome. Recent research also indicates that the therapists’ attachment
styles, as well as the match between therapists and patients in terms of attachment (Petrowski,
Nowacki, Pokorny, & Buchheim et al., 2011; Petrowski, Pokorny, Nowacki, & Buchheim,
2013; Schauenburg et al., 2010; Wiseman & Tishby, 2014), may influence treatment outcome.
While more research on the match between patients’ and therapists’ global attachment styles
may yield important results, we suggest that future research might benefit even more from a
relationship specific view of attachment development in the therapeutic process. Such a view
could lead to more detailed process-oriented research focusing on how and when both secure
and insecure attachments strategies are evoked and maintained in particular therapeutic
relationships. This could potentially lead to the identification of specific in-session behaviors
that foster secure attachment, as well as dissolve insecure strategies, an area in need of further
research (Mallinckrodt, 2010; Obegi, 2008).
Lastly, since the attachment system is likely to influence any kind of helping
relationship (Farber et al., 1995; Obegi, 2008), the quality of patient-therapist attachment may
be regarded a common factor across psychotherapy orientations. Although emanating from
the psychoanalytic tradition, attachment theory has also been assimilated into several models
in the cognitive-behavioral tradition in the last decade (e.g., Gilbert, 2009; Liotti, 2007;
Young, 2003). Future studies should investigate the development and impact of patienttherapist attachment in different treatment modalities. As suggested by Connors (2011),
ttachment theory may provide a “secure base” for the future of psychotherapy integration. 57 58 ACKNOWLEDGEMENTS IN SWEDISH
Först av allt vill jag tacka alla patienter och terapeuter som medverkade i YAPP-projektet.
Utan er villighet att dela med er av era erfarenheter och upplevelser för forskning hade denna
avhandling inte varit möjlig. Tack också till de sekreterare, PTP-psykologer och annan
personal på forna Psykoterapiinstitutet som var med och samlade in materialet i YAPP. Era
ansträngningar har inneburit ett enormt privilegium för mig!
Jag vill uttrycka min djupaste tacksamhet till min huvudhandledare, Andrzej Werbart. Du
har visat en (närmast obegripligt) stor tilltro till mig från första början av min PTP-tjänst på
Psykoterapiinstitutet. Din tillförsikt och uppmuntran har varit ovärderlig i stunder när jag själv
tvivlat. Du har dessutom varit enormt generös och gett mig förtroende att arbeta vidare med
frågeställningar i YAPP som jag vet ligger dig själv varmt om hjärtat. Det har alltid varit
väldigt inspirerande att diskutera alla teoretiska och metodologiska frågor som dykt upp under
arbetets gång med dig. Även om vi kanske inte alltid sett saker på exakt samma sätt så har jag
alltid upplevt att du stöttat mig att komma fram till mina egna slutsatser. Tack för allt du
bidragit med – tid, engagemang, din breda och djupa kunskap på området samt lite
välbehövlig utmaning ibland också – det har fått mig att växa!
Jag vill även rikta ett stort tack till mina bihandledare Pia Risholm-Mothander och MarieLouise Ögren. Ni har båda utgjort en viktig ”trygg bas” för mig (ja, även efter det att du
slutade på Psykologiska Institutionen, Marie-Louise!). Tack för all uppmuntran, engagemang
och stöd, både vad gäller avhandlingsarbetet och när det gäller den undervisning jag har
genomfört på institutionen.
Stort tack också till Rolf Sandell. Redan under psykologutbildningen var du en viktig
inspirationskälla till att jag överhuvudtaget började intressera mig för psykoterapiforskning.
Tack för den nyfikenhet och intresse du visat för mitt avhandlingsarbete. Särskilt tack för din
hjälp med statistiken i studie III och IV – jag tror jag börjar greppa en del på egen hand nu!
Tack också till Fredrik Falkenström för samarbetet med revisionen av studie IV. Avund kan
ibland vara en värdefull drivkraft och kanske lyckas jag en dag lära mig göra multilevelanalyser lika självklart som du! Men det troliga är väl att jag mailar dig när kör fast nästa
gång igen… 
Tack till August Ekström och Susanna Sjögren för allt jobb ni la ner på kodningsarbetet till
studie III.
59 Jag vill också tacka Björn Philips för all värdefull feedback och uppmuntrande kommentarer
till de olika delstudierna.
Tack till Pehr Granquist för värdefull feedback på det första utkastet av PAT-RS.
Thanks to Alessandro Talia and Madeleine Miller-Bottome for inspiring discussions and
great company at the SEPI 2013 and SPR 2014 meetings. Looking forward to following your
scientific work and to meeting you again soon!
I also want to thank professor John Clarkin and professor Anna Buchheim for their valuable
feedback on the development of PAT-RS at the Research Training Program (RTP) of the
International Psychoanalytic Association in Berlin, 2012.
Jag vill tacka Paul Bjerre stiftelsen för de stipendiemedel som har gett mig möjlighet att skapa
goda kontakter med andra forskare på området och sprida mina arbeten vidare.
Tack också till Groshinsky fonden för de stipendiemedel som gjorde studie II möjlig att
genomföra.
Tack till familj och vänner för att ni varit nyfikna på avhandlingen och för att ni haft tålamod
med mina svårigheter att beskriva innehållet på ett begripligt sätt!
Till sist, varmt tack till Maud och Arvid. För att ni är de fantastiska människor ni är helt
enkelt och för ert tålamod med min mentala frånvaro under delar av skrivarbetet. Jag älskar
er.
Stockholm, oktober 2014
Peter Lilliengren
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