Clinical Psychology and Psychotherapy Clin. Psychol. Psychother.

18, 498–511 (2011) Published online 27 May 2010 in Wiley Online Library ( DOI: 10.1002/cpp.704

Adult Attachment Insecurity and Narrative Processes in Psychotherapy: An Exploratory Study†
Sarah I. F. Daniel*
The University Clinic, Department of Psychology, University of Copenhagen, Denmark Different types of client attachment insecurity may affect the psychotherapeutic process in distinct ways. This exploratory study compared the in-session discourse of clients with dismissing and preoccupied attachment states of mind on Adult Attachment Interviews conducted prior to therapy in the context of a randomized clinical trial of psychoanalytic and cognitive–behavioural psychotherapy for bulimia nervosa. In a subsample of six sessions from each of eight therapy dyads, preoccupied clients were found to talk more and have longer speaking turns than dismissing clients, who in turn generated more pauses. Using the Narrative Processes Coding System, preoccupied clients were found to show more narrative initiative; whereas, differences in terms of narrative process modes were not as clearly interpretable. Contrary to expectations, the two insecure states of mind were equally different in the relationship-focused psychoanalytic therapy and in the symptom-focused cognitive–behavioural therapy. Suggestions for further investigations of the in-session discourse of clients with different attachment states of mind are given. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: • Client adult attachment patterns are likely to affect psychotherapeutic processes. • Client insecure dismissing and insecure preoccupied attachment may be detectable in distinct in-session discourse styles. • More research is needed on in-session manifestations of client attachment patterns and their relation to therapeutic outcome. Keywords: Adult Attachment, Psychotherapeutic Processes, Narrative Process, Verbal Productivity

In the literature on client characteristics that impact psychotherapy process and outcome, a growing attention is given to the topic of adult attachment (Daniel, 2006; Norcross, 2002; Obegi & Berant, 2009). Attachment theory was originated by Bowlby (1969/1997, 1973/1998, 1980/1998) and deals with the central role that early relations to caregivers play in psychological health and in shaping the ways in which later interpersonal relationships are approached and handled. Adult attachment patterns or styles are developmentally formed ways of

* Correspondence to: Sarah I. F. Daniel, Department of Psychology, 2A Oester Farimagsgade, 1353 Copenhagen, Denmark. E-mail: † This manuscript was prepared as part of a PhD project at the University of Copenhagen funded by a grant from the Danish Research Council for the Humanities. Transcription of therapy sessions was generously supported by the Aase & Ejnar Danielsen Foundation.

regulating affect and processing information with respect to close interpersonal relationships (Mikulincer & Shaver, 2007). Since adult attachment patterns are related to attitudes towards seeking and receiving help and to distinct ways of engaging in emotionally significant relationships, client attachment patterns are likely to affect psychotherapeutic processes. One of the central approaches to measuring adult attachment patterns is the Adult Attachment Interview (AAI) (George, Kaplan, & Main, 1996; Main, Goldwyn, & Hesse, 2002), which has been used extensively in developmental psychology research and has demonstrated good psychometric properties (Bakermans Kranenburg & Van Ijzendoorn, 1993; Crowell, et al., 1996; Sagi, van IJzendoorn, Scharf, & Koren-Karie, 1994). The AAI operationalizes adult ‘states of mind with respect to attachment’ in terms of different patterns of coherence and collaboration in narrating about attachment-related experiences (Main, Hesse, & Goldwyn, 2008). The classification system distinguishes between three main categories: secure interviews are balanced, open and coherent;

Copyright © 2010 John Wiley & Sons, Ltd.

In contrast. and Janssens (2006) found that secure attachment was related to a greater increase in reliance on the primary contact figure in the institution. The present study constitutes an explorative investigation of differences between psychotherapeutic process with dismissing and with preoccupied clients.Attachment and Narrative Process in Therapy dismissing interviews are overly brief and unemotional.. In contrast Clin. and Lee (2001) found that more deactivating clients spent less time on task when instructed to discuss an area of interpersonal difficulty with their case managers. Levy et al. (2008) studied mothers’ commitment to an early intervention programme for at-risk mothers with premature babies and found that secure mothers were more involved compared with dismissing mothers. Heinicke and Levine (2008) found that secure mothers were more and increasingly involved in home visitation work. & Cicchetti. whereas. 2008). A first step in that direction is more research on the in-treatment manifestations of the different insecure attachment patterns. positive evaluations of childhood experiences and lack of convincing autobiographical evidence. Dozier. Dozier and colleagues investigated correlates of attachment in a psychiatric setting using Kobak’s Q-sort method of coding AAIs. 18. Psychother. 498–511 (2011) . Teti et al. more preoccupied) clients. 1995. Dismissing mothers were less emotionally committed to treatment and more likely to prefer simple Copyright © 2010 John Wiley & Sons. A study by Tyrrell. insecure mothers were less and decreasingly involved. Dozier (1990) found that greater security was associated with more compliance with treatment. 499 companionship to supportive therapy or problem-solving help than secure mothers were. 2000. A few studies have inquired into the in-treatment behaviour of clients with different attachment states of mind. and that clients who were high on deactivation (i.. However. However. Korfmacher. Schuengel. They are able to recognize their need for attachment figures and. Persons with secure states of mind shift their attention flexibly between attachment and non-attachment related domains. 2009). which requires clients to engage in a collaborative dialogue about emotionally difficult topics and to provide a reasonably clear account of their situation in order for the therapist to empathize and intervene with precision (Daniel. In addition to providing information about the degree to which client attachment patterns may be detectable by clinicians through characteristic in-session processes. Psychol. Few studies have been able to compare the two primary groups of insecure clients. 1999. it is likely that the ‘road’ to security differs for these clients. Also. Main. more likely to reject help and less likely to self-disclose as compared with more hyperactivating (i. 1999). Toth. 1995. and Fallot (1999) suggests that dismissing clients may benefit more from working with therapists who challenge their distancing from emotions and interpersonal closeness. and Egeland (1997) investigated client behaviour in an intervention programme for mothers at risk.e. such research may also throw more light on the mechanisms behind possible differential treatment implications. Fonagy et al. preoccupied clients may benefit more from working with therapists who do not amplify their emotional experiences. more research is clearly necessary to posit such differential treatment implications confidently. Ltd. 2008). Slade.. more dismissing) were less likely to seek out help. and this may have important implications for psychotherapeutic technique (Holmes. partly because the preoccupied category is relatively infrequent in most western samples. Persons with dismissing states of mind direct their attention away from attachment-related experiences and from the attachment component of relationships in an attempt to deactivate the attachment behavioural system and related feelings of needing or longing for comfort. 1999. These different narrative ‘surface structures’ are thought to be related to particular ways of regulating attention and emotion with regards to attachment that have their roots in childhood experiences (Magai.. Thus. Dozier. & Albus. Mikulincer & Shaver.e. 2007). Both studies had insufficient numbers of preoccupied mothers to consider that group. Stovall. Evidence is emerging that it may be possible to facilitate client movement in the direction of secure states of mind through psychotherapy (Fonagy et al. 1999. remain psychologically separate. Such differences in attention. Zegers. van Ijzendoorn. at the same time. persons with preoccupied states of mind are continually caught up in attachment-related experiences and hyperactivate the emotional responses related to the attachment behavioural system. preoccupied interviews contain long-winded and confusing accounts that are marked by continued emotional entanglement. whereas. and a greater decrease in avoidance of contact with staff in the course of 10 months of treatment. In a related study. Teague. 2006. van Ijzendoorn & Bakermans Kranenburg. although it is more common in many clinical groups (Dozier. and often marked by inherent contradictions between general. the contrast between dismissing and preoccupied attachment insecurity merits attention. emotion-regulation and narrative coherence are clearly of relevance to psychotherapy.. Adam. In a study of adolescents treated at a youth institution. Lomax. there is a fair amount of evidence that attachment states of mind affect how clients engage in treatment and that secure clients are generally more involved and committed to treatment. since the challenges of working with clients who appear distant and emotionally unengaged are likely to be fundamentally different from the challenges of working with clients who appear overinvolved and demanding. Given the differences between the dismissing and the preoccupied categories. studying mothers who participated in a relation-based early intervention programme. Rogosch. whereas. Tyrrell. 1996. Ogawa.

Clin. On the other hand. These variables speak to how active clients are in contributing to the therapy dialogue. Culver. Holmes. a demonstration that clients’ in-session discourse is parallel in style to their discourse in the AAI would not be a trivial finding. 2008). there are no published studies systematically investigating the in-session discourse of psychotherapy clients. & Jasnow. PPT is non-directive. Wallin. Daniel The current study was conducted in the context of a randomized clinical trial of psychoanalytic psychotherapy (PPT) and cognitive-behavioural psychotherapy (CBT) for bulimia nervosa. whose attachment states of mind have been independently assessed. in terms of several discourse dimensions. the number of words uttered). this is not necessarily the case. Thus. 1995). & Hesse. 18. perhaps. whereas. the focus of the present study is on dialogical and narrative features. Thus. 1991. Hardtke. Second. who consistently pushes for immersion in attachment themes. Main et al. insecure attachment states of mind are prominent in bulimia nervosa and other eating disorders. Ltd. 1998. a tendency that is also found in other parts of the attachmentrelated literature (Isabella & Belsky. which is a measure of narrative concreteness. it may be hypothesized that attachment-related differences in in-session discourse of clients will be more easily detectable in PPT than in CBT. preoccupied transcripts scored highest. it is frequently assumed that the narrative characteristics exhibited in the AAI are similarly evident in psychotherapy process (Fish & Dudas. Bouffard. attachment relationships are often discussed in PPT. and Levitt (1996). Parish & Eagle. It might be that psychotherapy is an attachment-relevant situation by design.. Sandros. 1996. However. since theoretically. PPT and CBT for bulimia are very distinct treatment forms that make it possible to explore whether intreatment expression of discourse patterns related to attachment states of mind is conditional on therapeutic exploration of attachment relationships. in psychotherapy. and both dismissing and preoccupied patterns are represented in this group (Candelori & Ciocca. the related discourse patterns (Dozier & Bates. This sample is relevant to the present purpose in two ways... at present. Jaffe. Thus.500 to the primary focus on engagement and commitment in previous studies. Furthermore. PPT for bulimia is based on the theoretical premise that the eating disorder symptoms have their roots in difficulties in affect regulation that are primarily interpersonal in their origin. Mergenthaler & Bucci. Malatesta. 2003). Goldwyn. Since one of the features that typically distinguishes dismissing and preoccupied speakers in the AAI is verbal productivity.. In the literature on client attachment and psychotherapy. Preoccupied interviews offer extended and often long accounts with many (frequently irrelevant) details. Psychother. To date. I. and (c) the number of pauses occurring in sessions. CBT is highly therapist-directed. Lewin. (1996) found that when applying an AAIlike classification strategy to an interview about employment experiences. In addition to the variables related to verbal productivity.. this has not been demonstrated empirically. secure transcripts were in between and dismissing transcripts were the lowest. Buchheim and Mergenthaler (2000) conducted a computer-assisted linguistic analysis of 30 AAIs categorized into the three main attachment states of mind. which is brought about by the interviewer’s query into attachment history (Main. attachment relationships are not necessarily discussed. They evaluated the transcripts with respect to emotion words. In fact. there was no overlap of classification in persons assessed with both interviews. On all these measures. specificity and imagery devised by Bucci (1995. 1999). 2001. Ramacciotti et al. Because of the limited knowledge in the area. 2004). and whether they pause before responding or fall silent in the course of their speaking turns. 2001. Fonagy et al.e. in that the process of seeking help might activate the attachment behavioural system and thus. 498–511 (2011) . they may be flooded by emotion to the point where cooperation with the interviewer breaks down. 2001). In contrast. and the verbal activity of the therapist may be very different from that of the AAI interviewer. Crown. 2004. F. 1989). It is an integrative psychotherapy process coding system. Feldstein. The NPCS conceptualizes the therapy dialogue as a narrative process in which client and therapist collaboratively explore and re-evaluate aspects of client ‘life stories’ (Angus. 2007). (b) the length of client speaking turns. Thus. Dismissing interviews cut short the examination of attachment relationships and offer little detail. Tesman. Consequently. this study investigated three variables related to this: (a) the total amount of verbal production by the client in sessions (i. Psychol. whether they ‘hold the floor’ for long segments or quickly return the speaking turn to therapists. the present study took an exploratory and descriptive approach to the investigation of in-session discourse. 1999. Indeed. 2002. Dismissing and preoccupied AAIs differ markedly in their narrative style. 2006. the discourse characteristics exhibited in the AAI are thought to be specifically related to the activation of the attachment behavioural system. attachment issues are seldom discussed in detail. Ward et al. this study also investigated the narrative material generated using the Narrative Processes Coding System (NPCS) devised by Angus. Crowell et al. they are unemotional or attempt to minimize emotion. which play a central role in the AAI coding system (Main. S. & Rotondi-Trevisan. First. Copyright © 2010 John Wiley & Sons. & Shepard. Beebe. 2001. abstraction and referential activity. CBT for bulimia is a highly structured treatment that focuses on the eating disorder symptoms and takes a behavioural approach towards regulating these. the prototypical dismissing and preoccupied interviews represent opposite extremes with the secure category occupying the ‘middle range’.

all clients complete a battery of questionnaires assessing various aspects of personality and psychopathology and participate in diagnostic interviews and in the AAI (George et al. Each narrative sequence is also coded with respect to who initiates it. whereas. (2004). They will say more. clients and therapists complete a brief session evaluation form. Therapy sessions are recorded on minidisc by the therapists. Main et al. Exclusion criteria are (a) concurrent organic disorders. The attachment data for the entire client sample are still not available. schizophrenic spectrum disorders. Compared with dismissing clients. would theoretically be expected to be less common with dismissing clients than with preoccupied clients. 3. Psychol. hold the conversational turn longer and will pause less. 2002)..8% dismissing and 42. The sample consisted of four dismissing clients (two in PPT. which can be interpreted as an index of how active each speaker is in ‘shaping’ the pattern of shifting between topics and narrative modes. 1993. whereas both dismissing and preoccupied clients will have difficulties in coherently integrating these two narrative landscapes (Fonagy. or moderate or severe depression. and (f) difficulties in speaking and/or understanding the language. Psychother. Gergely. which may be discernible in a higher degree of narrative initiative. the three narrative modes can be conceptualized in terms of the ‘dual landscape’ of narrative outlined by Bruner (1986.. Clients are required to (a) be at least 18 years old. Preoccupied clients will show more narrative initiative than dismissing clients. the three-way distribution of attachment categories was 21. Participants Eight therapies from the Bulimia Trial were selected based on client intake AAI category and treatment type. outer reality. two in CBT) and four preoccupied clients (two in PPT. (c) current alcohol or substance abuse. it is tentatively hypothesized that. which consists of descriptions of feeling states. & Target. the internal narrative mode. two Clin. The NPCS has been found to distinguish between different therapy approaches and to make meaningful distinctions between different types of process in in-session dialogue (Levitt. and (c) reflexive narrative process where events or feelings are analysed and discussed with respect to patterns or meaning. but in an earlier study with a similar client population. 1996. Clients are recruited through advertisements in magazines. (b) internal narrative process where feelings and other subjective experiences are articulated. which is presently conducted at a university-based psychotherapy research clinic (Lunn & Poulsen. The therapy dialogue is divided into narrative sequences according to shifts between three different narrative process modes: (a) external narrative process where life events are related or facts or practical issues are described. Fourth Edition (DSM-IV) criteria for a diagnosis of bulimia nervosa. The differences between preoccupied and dismissing clients will be larger in PPT than in CBT. 36.Attachment and Narrative Process in Therapy which can be used in coding both of the relatively different therapy forms included in the sample. (e) pregnancy or other plans interfering with treatment. dismissing clients will tend to focus on the ‘landscape of action’. dismissing clients will engage in more external narrative processes. in public places and on the Internet. and preoccupied clients will tend to focus on the ‘landscape of consciousness’. the aim of the current study was to explore possible differences between in-session discourse with dismissing and preoccupied clients and to generate further suggestions for studies in the area. Thus. Levitt & Angus. substance-related disorders.1% preoccupied (Sandros. 1990). In summary. The external narrative mode comprises the ‘landscape of action’ or the ‘objective’. The internal and reflexive modes comprise the ‘landscape of consciousness’ or the ‘subjective’. 2006). as argued by Angus et al. and (c) give informed written consent to participate in the study. 18. 501 processes. (b) concurrent anxiety disorders. Preoccupied clients will engage in more internal and reflexive narrative Copyright © 2010 John Wiley & Sons. 498–511 (2011) . 2002). Clients are randomly assigned to the two treatments with block randomization stratifying for current psychopharmacological treatment and personality disorder. dissociative disorders. Jurist. 1999). Finally. Preoccupied clients will be more verbally productive in sessions than dismissing clients. or somatoform disorders if the disorder is judged to be a major obstacle to treatment of bulimia. METHOD Study Context The study was carried out in the context of a randomized clinical trial of PPT and CBT for bulimia nervosa (N = 70). The following hypotheses were posited: 1. 2. This classification is purely descriptive and does not imply an evaluation of the quality of these processes. After each session. preoccupied clients may be expected to engage more in the therapeutic dialogue.0% secure. Ltd. (b) fulfil the Diagnostic and Statistical Manual of Mental Disorders. Dismissing and preoccupied clients may differ in their attention to and willingness to discuss outer and inner/psychological realities with their therapists. At intake. manic and bipolar disturbances. Also. or they might not appear at all in CBT. (d) somatic illness that will interfere with psychotherapy. 2004). and through a network of clinics and psychiatric hospitals. psychological reality.

1993.3). two out of three additional coders agreed with the classification made by the author. preoccupied. The clients were women of Scandinavian origin with an average age of 25.38. Five of these scales evaluate aspects of childhood experience as inferred by the coder. 18. Measures AAI The AAI is a semi-structured interview with 20 questions and standardized probes (George et al. the bulimic symptoms are not necessarily discussed in every session. and to be able to sample from a comparable range of sessions. 2000). and the therapists were not informed about client attachment patterns. being ill. Therapists allow clients to direct the choice of topics. losses. CBT for Bulimia CBT for bulimia was developed by Christopher Fairburn (2008) and is one of the best validated treatments for bulimia (Agras. coders have to attend a 2-week training workshop with approved trainers and to achieve at least 80% agreement with the norm on a subsequent reliability check consisting of 30 interviews (Hesse. SD = 3. The interview is transcribed verbatim and rated on 16 nine-point scales. 1999). In the Bulimia Trial..24) (possible scores range from 0 to 4). . 1996).. The groups of dismissing and preoccupied clients were relatively comparable in terms of age (dismissing: M = 25. The therapists were experienced psychologists or psychiatrists with expert training in either PPT or CBT. Clients are given homework assignments. 2005) is a nondirective therapy based on a psychoanalytic understanding of the bulimic symptoms that are thought to be rooted in difficulties in affect awareness and regulation. Daniel reflect on their inner world of experience. Crowell et al. Wilson. No clients in the sample had the same therapist. 2008. In two cases. that is. The author. the unresolved classification may be assigned based on brief passages in interviews that are otherwise secure. and in two cases. clients who dropped out before the completion of 20 therapy sessions were not included. When selecting the current sample. dismissing or preoccupied in their narrative style. dismissing or preoccupied was used. Two clients in each group were diagnosed with one or more personality disorders based on the Structured Clinical Interview for DSM-III-R Personality Disorders (Spitzer. The interviewee is asked about the relationship to childhood attachment figures and attachment-related topics such as separations. the AAI was administered by post-graduate psychology candidates who were trained and supervised by certified AAI coders. Three other certified AAI coders scored a random sample of four of the eight AAIs to check inter-rater reliability. S. preoccupied: M = 1. and for whom usable sound recordings of the therapy sessions were available. Psychother. SD = 0. Psychol.29.0. Based on scores on the ‘state of mind’ scales and on the presence of global category descriptors. In contrast to the three primary AAI classifications.0.91. interviews are assigned to one of five major categories: secure. preoccupied: M = 26. The clients included in the study were the first eight clients in the Bulimia Trial. I. only the three-way classification of secure. 1996). When scoring the AAIs. Six therapists were female and two were male. four were students and four were employed. The other 11 scales evaluate different aspects of the speaker’s ‘state of mind with respect to attachment’. 498–511 (2011) Treatments PPT for Bulimia PPT for bulimia (Lunn & Poulsen. Williams. the author was blind with regards to which treatment type the clients had been assigned to. SD = 0. All had completed the equivalent of high school education. Ltd. 2002). Interviews classified as unresolved or cannot classify are also given a secondary classification as secure. and therapists consistently focus on the eating disorder. The therapists were trained according to the specific treatment manuals (Fairburn. Walsh. F. 2005) and were supervised bi-weekly by Susanne Lunn and Stig Poulsen (PPT) or Christopher Fairburn (through video conference) (CBT). To keep the sample as homogenous as possible except for type of attachment insecurity. To code the AAI. & Kraemer.5 years (standard deviation [SD] = 5. all three additional coders agreed with the classification made by the author. Lunn & Poulsen. The therapy consists of weekly sessions for a period of 2 years. & First. 1994) (dismissing: M = 1. Thus. It is a highly structured therapy consisting of 20 sessions with fixed agendas. dismissing. clients were included as e... unresolved or cannot classify. Gibbon. 1990).2. and their responses aim at helping clients to acknowledge and Copyright © 2010 John Wiley & Sons. scored the AAIs from the intake assessment. dismissing and/or preoccupied (Main et al.502 in CBT). dismissing even if they were also unresolved. who is certified as an AAI coder. SD = 7. who fulfilled the selection criteria in terms of attachment and distribution across therapy types. The aim of CBT is to break the vicious cycle of dieting and bingeing by establishing a regular eating pattern and correcting the cognitive distortions related to the disorder..3) and in terms of overall psychological distress as measured by the general severity index of the Symptom-Checklist-90-R (Derogatis. The AAI has been found to have good reliability and discriminant validity (Bakermans et al. In general. interviews categorized as Clin.g.. etc. and these are systematically explored. Fairburn.

78–0. All 48 sessions were transcribed by a professional agency using a slightly modified version of the transcription guidelines developed by Mergenthaler and Stinson (1992). Greenberg. and reflexive process refers to analysis and interpretation of events or feelings. & Hardtke. and two of the preoccupied clients in the current sample were also unresolved. Topic segments and narrative sequences are also coded with respect to who initiates them. internal or reflexive. Training of NPCS Coders Eleven university students volunteered to code the therapy sessions. The author had five to six 2-hour meetings with the coders. After each session. Levitt. The number of pauses at or above 3 seconds in all sessions were counted using the search and replace function of an ordinary word processor. good inter-rater agreement has been found on identification of topic segments as well as on coding of narrative process (Cohen’s κ = 0. Line numbers in the therapy transcripts served as a rough ‘time unit’ in comparing the coding of raters. The coders practiced on material from a pilot study. 503 based on client ratings of session difficulty on the SEF-C. Whereas client ratings of items 1.86) (Angus. respectively. the number of shifts identified only by rater B and the number of agreements on the non-presence of Clin. To obtain a varied sample of therapy process. Sessions are first subdivided into topic segments according shifts in semantic content. During the training period.. the number of shifts identified only by rater A. in which sessions from therapies with bulimic clients were transcribed and coded with NPCS by the author. Steer. The intake session that consisted mostly of history-taking and introduction to the treatment was not included. sessions were selected Copyright © 2010 John Wiley & Sons. and difficulties in rating the sessions were thoroughly discussed. Client Version (SEF-C) The SEF-C is a four-item questionnaire developed specifically for use in the Bulimia Trial. Clients categorized as cannot classify were not included. & Brown. Psychol. 1996). (2) the degree to which they consider the session to have been difficult. NPCS inter-rater reliability in terms of Cohen’s κ was calculated using methods described in Bakeman and Gottman (1997). NPCS The NPCS is a psychotherapy process coding system that is applied to session transcripts (Angus et al. External process refers to the description of events or facts. Scores are summed to give a total score that may range from 0 to 63 (Beck. With raters trained for 20–25 hours.Attachment and Narrative Process in Therapy unresolved are most frequently secondarily classified as preoccupied. The BDI-II is widely used and has shown good psychometric properties. & Angus. Pauses were timed by the transcriber and were indicated in the session transcripts. Three seconds was chosen as the lower limit of meaningful silence based on previous research (Frankel. The topic segments are further subdivided in terms of three narrative process modes: external. who was trained and supervised by Lynne Angus. Beck Depression Inventory II (BDI-II) The BDI-II is a 21-item self-report instrument that asks clients to rate different depressive symptoms on a fourpoint scale. 2003). (3) the degree to which they felt understood by their therapist in the session. Levitt. All coders attended an introductory lecture on the NPCS. internal process refers to the description of feelings or other inner experiences. Ltd. Speaking Turns and Pauses Counts of the number of words uttered by clients per session and per speaking turn were conducted using the C-I-SAID software (Cartwright. who coded one or two full sessions between meetings. At the meetings. 18. it was administered at intake as part of a larger battery of self-report instruments NPCS Inter-rater Reliability Procedure Selection of Therapy Sessions A sample of six of the first 20 sessions from each of the eight therapy dyads was selected for further analysis. 2006). In the Bulimia Trial. They were split in two teams that specialized in dividing the sessions into topic segments and in dividing topic segments into narrative sequences. clients are requested to give their ratings on a seven-point Likert scale of (1) the degree to which they consider the session to have been valuable/useful. Session Evaluation Form. Murray. 3 and 4 are generally highly skewed towards the high end of the scale. yielding 991 transcript pages. the coders received detailed feedback. For each client. 498–511 (2011) . Counts of Words. 1999). 1996). On recommendation from Lynne Angus. Six were undergraduate psychology students. coders were considered to agree on a topic shift if they placed shifts less than six transcript lines apart (the average length of topic segments in the material was 50 transcript lines). each coder coded at least seven full sessions. Kappa was calculated based on the number of topic shifts agreed upon. Psychother. the three sessions experienced as most difficult and the three sessions experienced as least difficult were selected. Sessions without a usable sound recording and sessions with participation of family members (in CBT) were excluded. ratings of session difficulty utilize the whole seven-point scale. and five were graduate psychology students. and (4) the degree to which they had trust in their therapist in the session.

These sequences were also excluded from the analysis pertaining to narrative process modes. S. Subsequently. the topic segmenting coders achieved an agreement of κ = 0. Because of the low inter-rater agreement on the internal narrative mode. RESULTS Data Set and Data Analysis The data set consisted of six sessions from each of eight therapy dyads. This indicated problems with the coding for internal process. and in distinguishing reflexive from other codes.68 (range 0. These were descriptions of events taking place in dreams (n = 4). who had an MA in psychology. 498–511 (2011) Inter-rater Agreement and Stability of NPCS Coders When coding the study material.88 (range 0. 2007).71 (range 0. The narrative sequencing coders achieved an agreement of κ = 0. During the coding period. the sessions were of unequal duration (range 36. the analyses also allowed for a random slope for time (defined by session number) within therapy dyads. the topic segmenting coders achieved an average agreement with the author of κ = 0. which is not accounted for by the explanatory variables: client attachment state of mind and therapy type.85). The coder. Even though most sessions lasted about 50 minutes. it is possible to take into consideration the random variation between superordinate clusters of data (in this case.90.71. In multilevel analysis.78 (range 0. the total number of transcript lines minus the number of shifts agreed upon and the number of shifts disagreed upon). The dependent variables examined were all measured at the level of sessions. given that all sessions were subsequently consensus-coded.94). which was also very rare in the material. In the present study. Each member of a pair first coded each session individually and submitted the coding to the author who calculated inter-rater agreement. In distinguishing external from other codes. 18. and thus raw counts of the number of words and pauses Clin. the coders worked in pairs. and when they had negotiated a consensus coding.81 (range 0. it became necessary to include an extra coder in the team of topic segmenters. Each of the 48 sessions was first given to two topic segmenting coders. Psychother.75 (range 0. since they were considered ambiguous with respect to whether they should be allocated to the ‘landscape of action’ or the ‘landscape of consciousness’.5%) were coded as internal by one or both coders. Only the consensus coding was used in the further analyses.83–0. Psychol. was similarly trained by the author and achieved a reliability of κ = 0.504 shifts (i. This level of agreement was considered satisfactory. Out of the 30 088 transcript lines in the data material.79) on the line-by-line presence of topic shifts. Each coder coded between 12 and 24 sessions.72. in distinguishing internal from other codes.66–0.77) on classifying transcript lines as external. I. The agreement on coding of narrative initiator was κ = 0.59–0. Since some of the dependent variables might change with time across the six months of therapy. The topic segmenting coders achieved an average agreement with the author of κ = 0. which occurred only in PPT. Ltd. and since there might also be dyad-dependent variation in the rate of change.e. only 148 lines (0. Towards the end of the coding period that lasted about a year. such an approach is definitely called for.83. the coders negotiated a consensus coding. Since coding of who initiates narrative sequences can only be compared when coders agree on the delineation of narrative sequences. distributed as evenly across therapy types and client attachment categories as allowed by coding logistics. since the intra-class correlation coefficients of the dependent variables range from 0. all coders were asked to recode a session from the training material to check for possible rater drift.75–0. NPCS Coding Procedure The NPCS coders were blind with regards to client attachment categorization as well as the hypotheses of the study. the coders achieved an agreement of κ = 0.57–0.72–0. Since the material was considered difficult to code. There was no evidence of formation of coding subcultures in the coder pairs. 2008). data analysis was conducted by means of multilevel mixedeffects modelling (Rabe-Hesketh & Skrondal. Inter-rater reliability on narrative sequencing was calculated as time-based kappa’s of the line-by-line agreement on narrative mode categorization using the GSW software (Bakeman & Quera. and direct instruction from the therapist with respect to what clients should do (n = 17).83).20. therapy dyads). F. the marked transcript was passed on to two narrative sequencing coders.59 to 0. . The main explanatory variables: client attachment state of mind and therapy type were measured at the level of therapy dyads. the agreement was κ = 0. At the end of training. and the narrative sequencing coders achieved an average agreement with the author of κ = 0.. the agreement was κ = 0. inter-rater agreement on narrative initiative was calculated based on all instances where coders started new narrative sequences within two transcript lines of each other.8–73 minutes). internal or reflexive. which occurred only in CBT.90). and the narrative sequencing coders achieved an average agreement with the author of κ = 0. these sequences were excluded from the analysis pertaining to narrative process modes. Daniel for narrative process mode. Since sessions from the same dyad are non-independent.91. A small number of narrative sequences (21 out of 1292) could not be coded Copyright © 2010 John Wiley & Sons. All analyses allowed for random intercepts for therapy dyads. Cohen’s κ was also calculated separately for each of the three narrative process modes.

Although not statistically significant. z = 2. z = −2. Client depression.e. whereas.46. proportion of narrative sequences initiated by the client (versus the therapist) and proportion of words coded as external (versus reflexive). The proportion variables were subjected to a logit transformation for inclusion in the linear analyses. dismissing: M = 4. preoccupied clients in PPT uttered 132.0. preoccupied clients uttered 84. since the current level of depression of clients might affect the verbal productivity variables. which has in turn been related to the dismissing category in some studies (Patrick. p = 0. whereas. z = −3. client unresolved score and session difficulty did not affect this variable. and the number of pauses was divided by session duration in terms of hours to yield comparable and interpretable indices..6 words per session minute. In the present sample.06. neither alone or in interaction with client attachment or with time.3. p = 0. dismissing: M = 1.2. Figure 1 shows the estimated number of pauses per session hour with dismissing and preoccupied clients Clin. 498–511 (2011) Verbal Productivity Variables When analyzing the variables related to verbal productivity. the preoccupied clients had higher unresolved scores than the dismissing clients (preoccupied: M = 4. SD = 1. sessions had been chosen based on high or low ratings of session difficulty on the SEF-C.8. it was estimated that dismissing clients in PPT uttered 70. Main effects of client BDI-II score. client BDI score was included in these analyses as a fixed effect. depression scores on the BDI-II (Beck. There was a significant main effect of client attachment state of mind (B = 31. For the number of client words per session minute.8. SD = 2. The NPCS variables were evaluated in terms of proportions.1. Based on this model. z = −1.2. SE = 1.21. and all possible two-way interaction terms were considered. & Maughan. there was no evidence of time-effects and no significant interaction between client attachment and therapy type. p = 0. In the present sample. Ltd. 1994).7 words per speaking turn. i.001).0 has to be given on a rating scale for unresolved loss or trauma.7. SE = 1.0 to 9.26. The final model included a significant Client Attachment × Time interaction (B = −2. p = 0.50. with session difficulty set to 4 and client unresolved score set to 1. dismissing clients were estimated to utter 22. Consequently. z = −3.4 words per session minute. To control for this difference. whereas. SE = 10. whereas. dismissing clients were estimated to utter 46.0. a significant main effect of therapy type (B = −48. p < 0. For the number of pauses per session hour. 1997). In CBT. p < 0.25). SD = 8. with session difficulty set to 4. 18.0. SD = 2. starting with the full model and gradually excluding non-significant terms.84. it was estimated that dismissing clients in PPT uttered 107.5. though not significantly.40. which can range from 1. The number of words per client speaking turn decreased as session difficulty increased and as client unresolved score increased.1.7 words per speaking turn. SE = 24. z = −2. However.0.6 words per session minute. the difficulty ratings of dismissing clients tended to be higher than those of preoccupied clients (preoccupied: M = 3. therapy type had no significant effect. z = 3. this study instead evaluated relative durations of narrative modes in sessions (in terms of word counts) to more accurately reflect the ‘time-budget’ representation of the different narrative process modes (Bakeman & Gottman. AAI unresolved score and session difficulty were also considered.8) than in the group of preoccupied clients (M = 17.4 words per session minute. SE = 15. higher in the group of dismissing clients (M = 20.001) and a significant main effect of session difficulty (B = −3.0. Client depression did not affect this variable.88. p < 0.001).38. A limitation of the current sample was that two of the four preoccupied clients were also categorized as unresolved on the AAI. p = 0.004) and a significant main effect of client unresolved score (B = −9.027) as well as the main effects of client attachment state of mind (B = −42.13. Psychol. client unresolved score was included in all analyses. Howard. To be assigned to the category unresolved.5.3.37. p = 0.88.18.Attachment and Narrative Process in Therapy were not directly comparable.080) and of time (B = 4. in the present sample. z = −5.75.2 words per speaking turn.001). To control for the possible effect of this difference.52. & Brown.002). there was no time-effect and no significant interaction between client attachment and therapy type. a score of at least 5.1 words per speaking turn. Although narrative process modes have usually been evaluated in terms of relative frequencies of sequences categorized into different modes. SE = 12. Castle. . p = 0. therapy type and time. possible main effects of client attachment state of Copyright © 2010 John Wiley & Sons.03). Client depression and client unresolved score were not related to this variable. a significant main effect of therapy type (B = −61. For the average number of words per client speaking turn. To maximize session variability. 1996) ranged from 8 to 29 and were slightly. z = −2. Psychother.027). preoccupied clients uttered 77.41. 505 mind. Hobson.41. The number of client words per session minute decreased. SD = 1.97. as session difficulty increased. client-rated session difficulty was included in the analyses as a fixed effect.91. z = 3. 1996). SD = 8. Lowered speech rate has been related to depression (Ellgring & Scherer.2. Based on this model. Steer. SE = 0. a significant main effect of session difficulty (B = −3.96. In CBT. and since session difficulty might conceivably affect some of the variables studied. SE = 1.84.0).016). preoccupied clients in PPT uttered 138. There was a significant main effect of client attachment state of mind (B = 61. standard error [SE] = 10. SE = 3.0. the number of client words in sessions was divided by session duration in terms of minutes.55.

16. The final model included Client Attachment × Therapy Type (B = −1.0%. There was a significant main effect of client attachment state of mind (B = 0. Based on this model. z = −3.2%.0%.4%. which eventually gives way to an increased focus on the cognitive distortions behind the eating disorder.6%.78. the estimated number of pauses per hour at session 10 was 91. SE = 0. Thus.70.23. the two therapy types are more different in the early sessions and more alike around session 20. Narrative Initiative and Narrative Process Modes When analysing the NPCS variables.46.04. whereas. p < 0. z = 4.001) and a significant main effect of therapy type (B = −2.27. SE = 0. p = 0. For the proportion of narrative sequences initiated by clients (versus therapists) in each session there was no time-effect and no significant interaction between client attachment and therapy type. possible main effects of client attachment state of mind. 498–511 (2011) . whereas. both Client Attachment × Therapy Type and Therapy Type × Time were statistically significant. Linear prediction of number of pauses ≥ 3 seconds per hour across sessions for each client attachment state of mind across the 20 sessions based on this model.51. and the number of pauses tends to increase across the 20 sessions. p < 0. Main effects of client AAI unresolved score and session difficulty were also considered.17. starting with the full model and gradually excluding non-significant terms. with dismissing clients in CBT it is 68. and time. z = −2. whereas. For the proportion of narrative process categorized as external (versus reflexive) in each session.6%.98.10. In CBT.2 with preoccupied clients.12. Based on this model. and all possible two-way interaction terms were considered. therapy type.014). the number of pauses in therapies with preoccupied clients tends to remain stable across the 20 sessions. the estimated percentage of narrative sequences initiated by dismissing clients was 68. In therapies with dismissing clients. p = 0. evidenced in a high proportion of external process.014).61. Daniel 2 4 6 8 10 12 Session 14 16 18 20 Figure 1. Client unresolved score and session difficulty did not affect this variable. and with preoccupied clients in CBT it is 39. it was 20. there are more pauses. the corresponding number for preoccupied clients was 81.17. whereas. the corresponding number for preoccupied clients was 32. in PPT there is a slight increase in the proportion of external process. SE = 0. In CBT. with preoccupied clients in PPT it is 31. Therapy Type × Time (B = −0. This corresponds well to an initial strong behavioural focus in CBT. Copyright © 2010 John Wiley & Sons. 18. z = 4.07. whereas. the proportion of external process tends to decrease across the 20 sessions.83. I.87. z = 2. Clin. although the difference here is much smaller.3%. Figure 2 shows the estimated percentage of narrative process categorized as external (versus reflexive) with dismissing and preoccupied clients in each therapy form across the 20 sessions based on this model. whereas.71. of therapy type (B = 4.001).001) and of time (B = 0.05. the estimated proportion of external process with dismissing clients in PPT is 25. p = 0. z = 1. At session 10.067). SE = 1. Client unresolved score and session difficulty did not affect this variable. Psychol. it is the other way around. in PPT. in PPT. SE = 0. p = 0.506 140 Dismissing 120 Pauses per session hour 100 80 60 40 20 0 Preoccupied S.46.002). p < 0. in terms of proportions of narrative modes.9 with dismissing clients. Ltd. resulting in higher proportions of reflexive process.8%.05. F. the estimated percentage of narrative sequences initiated by dismissing clients was 19. as well as the main effects of client attachment state of mind (B = 1. Psychother. z = −12. SE = 0. the proportion of external process is higher with dismissing clients than with preoccupied clients. In CBT. SE = 0.

Ltd. since the small sample size renders the study vulnerable to strong influences from idiosyncratic patterns of the particular client-therapist dyads included. by other therapist variables than therapy type.Attachment and Narrative Process in Therapy 100% 90% External mode percentage 80% 70% 60% 50% 40% 30% 20% 10% 0% 2 4 6 8 10 Session 12 14 16 18 20 Dismissing . Furthermore. Thus. or whether it is just the dismissing or the preoccupied group who constitute an extreme. the main value of the present study lies in the guidelines it provides for further research in the area.CBT 507 Figure 2. Also. whereas. This should be replicated and expanded in larger and more varied client samples. Clin. consisting only of women who completed at least 20 sessions of outpatient psychotherapy for bulimia nervosa. In the present study. Copyright © 2010 John Wiley & Sons. it does contribute to the distinction between types of insecurity. a number of significant differences between therapies with dismissing and preoccupied clients were detected. and by client–therapist relationship factors. these different styles might just be different ‘flavouring’ of the therapy interaction with no immediate relevance to treatment outcome. and the small sample size of this study increases the risk that accidental combinations of particular client and therapist characteristics in the eight dyads may have influenced the results. The verbal productivity difference between dismissing and preoccupied clients lends some support to the idea that attachment-related differences in discourse style are also detectable in psychotherapy sessions. verbal productivity in terms of words uttered per minute and length of speaking turns were relatively stable from session to session in each dyad. an attempt should be made to relate the verbal productivity variables to treatment outcome. The results should be interpreted with caution. which necessarily limits generalizability. The dependent variables analysed are likely to be affected by other client variables than attachment. Assuming that the difference in verbal productivity can be replicated in other studies. who may mainly differ in their degree of narrative coherence.PPT Dismissing . future studies should consider secure and unresolved attachment as well. whether secure clients are indeed ‘midrange’ as would be expected. Nevertheless. It is quite probable that verbal productivity does not contribute much to the distinction between secure and insecure clients. Linear prediction of percentage of external (versus reflexive) narrative process across sessions for client attachment states of mind in each of two therapy types DISCUSSION This exploratory study examined a small number of therapy dyads (N = 8) in relative detail. Psychother. Furthermore. which suggests that it would be sufficient to sample a few sessions from each dyad to test this finding in a larger sample.CBT Preoccupied . To evaluate the possible role that verbal productivity might play in an informal process evaluation of client attachment. with a middle range of productivity representing the most favourable therapeutic process. In spite of the low statistical power. respectively. some additional issues would need to be addressed to make sense of this difference and evaluate its clinical relevance and utility. Thus. it would be important to know. the client population was very select. Thus.PPT Preoccupied . Psychol. It seems reasonable to interpret the two extremes with respect to verbal productivity as ‘underproductive’ and ‘overproductive’. it would be important to investigate whether clients with low and high verbal productivity generally have poorer treatment outcomes. the present finding that client score on the AAI unresolved scale was related to the length of speaking turns suggests that even though unresolved status is not generally related to a particular overall narrative style. it may still be relevant in relation to in-session narrative process. 18. 498–511 (2011) .

which only require transcription of sessions to be computed. 2005). e. the present study suggests that future studies inquiring into in-session emotionality related to client attachment states of mind should probably include a wider range of emotional expression. Thus. If preoccupied clients show more initiative.g. angry. Daniel ate whether they are more similar to dismissing or preoccupied clients in terms of overall number of pauses. speak more and for longer periods.508 Even if the variables studied here do not affect treatment outcome. confused. In the present study. clients with different insecure attachment states of mind may be difficult in very different ways. they generate less information on their experience. 498–511 (2011) . especially as treatment progresses. although less pronounced. The present study was inspired by the premise that although insecure clients are generally more difficult to treat than secure clients. preoccupied clients would focus more on the reflexive mode relating to inner or psychological realities. reflective and disengaged silences that may be evaluated as either productive. emotional. However. preoccupied clients engage in more psychological considerations. However. the higher number of pauses with dismissing clients may evidence more reflection. secure clients would be expected to show more productive and fewer obstructive silences than dismissing clients. The client group might also be important since eating disorders have been linked to difficulties in verbalizing feeling states (Speranza et al. they give therapists more material to work with. verbal productivity. secure clients should be included for comparison. the distribution of narrative process modes varied just as much from session to session within dyads as it did between dyads. The results of the present study suggest that it would be relevant to investigate whether therapist reactions to clients with different attachment states of mind are mediated by client in-session discourse style. With regards to the relative predominance of the external and reflexive narrative process modes. obstructive or neutral (Frankel et al. the NPCS is labour intensive. This might be related to the therapy forms. whereas. where larger proportions of internal process have been reported (Levitt & Angus. where the proportion of external process tended to be larger with dismissing clients than with preoccupied clients. Slade (1999. since neither PPT nor CBT have the same explicit focus on the detailed description and differentiation of feeling states that is found in process–experiential psychotherapy. whereas. it was tentatively hypothesized that dismissing clients would focus more on the external mode relating to descriptions of outer. it would be important to evaluate whether the silences exhibited by dismissing clients are reflective or perhaps disengaged. but they may be at risk of overwhelming therapists and may leave little room for reflection. Ltd. which distinguishes between different categories of silence such as e. the relevance of the NPCS to future studies on in-session narrative correlates of attachment states of mind has to be evaluated in the light of the considerable resources required to code a substantial number of therapy sessions from each dyad in a larger sample than the one used here. 2000) and non-verbal emotion expression. The finding that a dismissing state of mind was associated with more and an increasing number of pauses across the 6 months of therapy deserves further investigation.. Generally. most of the external process did not focus on the eating disorder. the coding of narrative process modes generated results that related more clearly to therapy type differences than to attachment states of mind.. 2006). Even though the difference detected in terms of narrative initiative is theoretically interesting. concrete realities. Thus. Furthermore. including both simple use of emotion words such as that captured by computerized dictionaries (Buchheim & Mergenthaler. F. which indicates that sampling just a few sessions from each dyad would be likely to misrepresent the narrative process. it may also reflect more emotional engagement. however. 588) argued that dismissing clients are likely to make therapists feel ‘caught in the same barren landscape as the patient’ and ‘utterly shut out’. whereas. Psychol. and dysregulated’. it may also reflect a greater reluctance to self-disclose. Psychother.. leaving no room for reflection. which would suggest defensiveness. PPT. which was also very rare in the material.. The difference between dismissing and preoccupied clients in CBT might be a result of dismissing clients electing to focus more on the tangible aspects of the eating disorder. but it would be relevant to evaluCopyright © 2010 John Wiley & Sons. I. 1999). Further studies on attachment states of mind and pauses should address qualitative aspects of silences to make sense of the quantitative findings. The relative absence of pauses with preoccupied clients may reflect a tendency to ‘fill’ the sessions with verbal activity. but rather on discussion Clin. Conversely. and does not easily lend itself to large-size studies. This may make it harder for therapists to attune empathically and may also generate doubts about the clients’ commitment to treatment. In her much cited chapter on attachment states of mind and psychotherapy. they may still affect therapist reactions to clients. On the other hand.g. S. This seemed to be the case in CBT. preoccupied clients make the therapist feel ‘swamped. and perhaps a rise in defensiveness as therapy increasingly pushes for involvement. helpless. speak less and with shorter speaking turns. but the tendency in PPT was in the opposite direction. Such experiences may be partly related to clients’ patterns of verbal productivity and narrative initiative. p. If dismissing clients show less initiative. This might be done using instruments such as the Pausing Inventory Categorization System. 18. Compared with the verbal productivity variables. The difference that had been expected for internal narrative process could not be evaluated because of low coding reliability for this mode. In.

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