Clinical Psychology and Psychotherapy Clin. Psychol. Psychother.

18, 498–511 (2011) Published online 27 May 2010 in Wiley Online Library (wileyonlinelibrary.com). 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

INTRODUCTION
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: sarah@selskabet.org † 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.

1995. more likely to reject help and less likely to self-disclose as compared with more hyperactivating (i. Persons with secure states of mind shift their attention flexibly between attachment and non-attachment related domains. Both studies had insufficient numbers of preoccupied mothers to consider that group. Zegers. Dozier (1990) found that greater security was associated with more compliance with treatment. more dismissing) were less likely to seek out help. 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. at the same time. Slade. 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. Given the differences between the dismissing and the preoccupied categories.e. (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.e. and Janssens (2006) found that secure attachment was related to a greater increase in reliance on the primary contact figure in the institution.. 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.Attachment and Narrative Process in Therapy dismissing interviews are overly brief and unemotional. Dismissing mothers were less emotionally committed to treatment and more likely to prefer simple Copyright © 2010 John Wiley & Sons. However. whereas. although it is more common in many clinical groups (Dozier. Thus. studying mothers who participated in a relation-based early intervention programme. Korfmacher. A first step in that direction is more research on the in-treatment manifestations of the different insecure attachment patterns. Dozier. In contrast. remain psychologically separate. 2007). more preoccupied) clients. Ltd.. Ogawa. 18. 1999. 1996. Such differences in attention. it is likely that the ‘road’ to security differs for these clients. Psychol. Tyrrell. partly because the preoccupied category is relatively infrequent in most western samples. In contrast Clin. In a related study. However. preoccupied clients may benefit more from working with therapists who do not amplify their emotional experiences. 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. 2008). Mikulincer & Shaver. such research may also throw more light on the mechanisms behind possible differential treatment implications. insecure mothers were less and decreasingly involved. 1999. and Egeland (1997) investigated client behaviour in an intervention programme for mothers at risk. whereas. & Cicchetti. Teti et al. van Ijzendoorn. 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. 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. 1999. Fonagy et al. preoccupied interviews contain long-winded and confusing accounts that are marked by continued emotional entanglement. A study by Tyrrell. Schuengel. Dozier. 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. emotion-regulation and narrative coherence are clearly of relevance to psychotherapy. 498–511 (2011) . Adam.. and often marked by inherent contradictions between general. They are able to recognize their need for attachment figures and. more research is clearly necessary to posit such differential treatment implications confidently. Dozier and colleagues investigated correlates of attachment in a psychiatric setting using Kobak’s Q-sort method of coding AAIs. 2009). the contrast between dismissing and preoccupied attachment insecurity merits attention. Main. 2000. 1999)... Lomax. In addition to providing information about the degree to which client attachment patterns may be detectable by clinicians through characteristic in-session processes. positive evaluations of childhood experiences and lack of convincing autobiographical evidence. 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. van Ijzendoorn & Bakermans Kranenburg. Toth. Teague. and Fallot (1999) suggests that dismissing clients may benefit more from working with therapists who challenge their distancing from emotions and interpersonal closeness. and a greater decrease in avoidance of contact with staff in the course of 10 months of treatment. & Albus. Levy et al. Rogosch. In a study of adolescents treated at a youth institution. 2008). Psychother. whereas. 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. 499 companionship to supportive therapy or problem-solving help than secure mothers were. 2006. 1995. and this may have important implications for psychotherapeutic technique (Holmes. Stovall. Also. The present study constitutes an explorative investigation of differences between psychotherapeutic process with dismissing and with preoccupied clients. Heinicke and Levine (2008) found that secure mothers were more and increasingly involved in home visitation work. Few studies have been able to compare the two primary groups of insecure clients.

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

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

SD = 7. 1996). In contrast to the three primary AAI classifications. dismissing or preoccupied was used. only the three-way classification of secure. being ill. SD = 3. In general. losses. The AAI has been found to have good reliability and discriminant validity (Bakermans et al. When scoring the AAIs. The author. who fulfilled the selection criteria in terms of attachment and distribution across therapy types. dismissing and/or preoccupied (Main et al.38.. I. 498–511 (2011) Treatments PPT for Bulimia PPT for bulimia (Lunn & Poulsen. Three other certified AAI coders scored a random sample of four of the eight AAIs to check inter-rater reliability. scored the AAIs from the intake assessment. Williams. 2005) and were supervised bi-weekly by Susanne Lunn and Stig Poulsen (PPT) or Christopher Fairburn (through video conference) (CBT).. Psychother.2. dismissing or preoccupied in their narrative style. Crowell et al.0. dismissing even if they were also unresolved. & Kraemer. When selecting the current sample. . unresolved or cannot classify. 1990). To code the AAI.3) and in terms of overall psychological distress as measured by the general severity index of the Symptom-Checklist-90-R (Derogatis. 2000).0. 18. Fairburn.. and therapists consistently focus on the eating disorder. 1996).. SD = 0. the author was blind with regards to which treatment type the clients had been assigned to. 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. Five of these scales evaluate aspects of childhood experience as inferred by the coder. preoccupied: M = 1. 1994) (dismissing: M = 1. Psychol. The therapy consists of weekly sessions for a period of 2 years. In the Bulimia Trial. preoccupied: M = 26.3). 1993. 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. clients were included as e. Based on scores on the ‘state of mind’ scales and on the presence of global category descriptors. The clients included in the study were the first eight clients in the Bulimia Trial. All had completed the equivalent of high school education. To keep the sample as homogenous as possible except for type of attachment insecurity.91. The other 11 scales evaluate different aspects of the speaker’s ‘state of mind with respect to attachment’.. The clients were women of Scandinavian origin with an average age of 25. SD = 0. In two cases. etc. who is certified as an AAI coder. interviews are assigned to one of five major categories: secure. The interviewee is asked about the relationship to childhood attachment figures and attachment-related topics such as separations. 2008. Measures AAI The AAI is a semi-structured interview with 20 questions and standardized probes (George et al. Daniel reflect on their inner world of experience.24) (possible scores range from 0 to 4). and in two cases. and for whom usable sound recordings of the therapy sessions were available. dismissing. interviews categorized as Clin. 2002). Walsh. 1999). the AAI was administered by post-graduate psychology candidates who were trained and supervised by certified AAI coders. and their responses aim at helping clients to acknowledge and Copyright © 2010 John Wiley & Sons.29. The therapists were experienced psychologists or psychiatrists with expert training in either PPT or CBT. Therapists allow clients to direct the choice of topics. 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. No clients in the sample had the same therapist. all three additional coders agreed with the classification made by the author. preoccupied. The interview is transcribed verbatim and rated on 16 nine-point scales.502 in CBT). The groups of dismissing and preoccupied clients were relatively comparable in terms of age (dismissing: M = 25. Gibbon. 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. & First. Six therapists were female and two were male. clients who dropped out before the completion of 20 therapy sessions were not included. that is. and to be able to sample from a comparable range of sessions. Wilson. four were students and four were employed. S.g. Ltd. Interviews classified as unresolved or cannot classify are also given a secondary classification as secure. The therapists were trained according to the specific treatment manuals (Fairburn. the bulimic symptoms are not necessarily discussed in every session. Clients are given homework assignments.5 years (standard deviation [SD] = 5.. and these are systematically explored. It is a highly structured therapy consisting of 20 sessions with fixed agendas. Lunn & Poulsen. and the therapists were not informed about client attachment patterns. the unresolved classification may be assigned based on brief passages in interviews that are otherwise secure. Thus. F. two out of three additional coders agreed with the classification made by the author.

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. & Angus. and difficulties in rating the sessions were thoroughly discussed. (2) the degree to which they consider the session to have been difficult. All coders attended an introductory lecture on the NPCS. Six were undergraduate psychology students. who was trained and supervised by Lynne Angus. In the Bulimia Trial. External process refers to the description of events or facts. Training of NPCS Coders Eleven university students volunteered to code the therapy sessions. Greenberg. the coders received detailed feedback. To obtain a varied sample of therapy process. & Brown. During the training period. and two of the preoccupied clients in the current sample were also unresolved. 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). The intake session that consisted mostly of history-taking and introduction to the treatment was not included. 1996). the number of shifts identified only by rater A. 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. All 48 sessions were transcribed by a professional agency using a slightly modified version of the transcription guidelines developed by Mergenthaler and Stinson (1992). the three sessions experienced as most difficult and the three sessions experienced as least difficult were selected. Client Version (SEF-C) The SEF-C is a four-item questionnaire developed specifically for use in the Bulimia Trial. 1996). Sessions without a usable sound recording and sessions with participation of family members (in CBT) were excluded. Sessions are first subdivided into topic segments according shifts in semantic content. The coders practiced on material from a pilot study. With raters trained for 20–25 hours. Three seconds was chosen as the lower limit of meaningful silence based on previous research (Frankel. and reflexive process refers to analysis and interpretation of events or feelings. NPCS The NPCS is a psychotherapy process coding system that is applied to session transcripts (Angus et al.. Clients categorized as cannot classify were not included. 503 based on client ratings of session difficulty on the SEF-C. 18. and (4) the degree to which they had trust in their therapist in the session. Murray. Scores are summed to give a total score that may range from 0 to 63 (Beck. the number of shifts identified only by rater B and the number of agreements on the non-presence of Clin. On recommendation from Lynne Angus. Psychol. At the meetings. internal process refers to the description of feelings or other inner experiences. 3 and 4 are generally highly skewed towards the high end of the scale. After each session.78–0. respectively. Line numbers in the therapy transcripts served as a rough ‘time unit’ in comparing the coding of raters. 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. yielding 991 transcript pages. and five were graduate psychology students. Psychother. Topic segments and narrative sequences are also coded with respect to who initiates them. NPCS inter-rater reliability in terms of Cohen’s κ was calculated using methods described in Bakeman and Gottman (1997). The author had five to six 2-hour meetings with the coders. The topic segments are further subdivided in terms of three narrative process modes: external. sessions were selected Copyright © 2010 John Wiley & Sons. 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. 1999). They were split in two teams that specialized in dividing the sessions into topic segments and in dividing topic segments into narrative sequences. who coded one or two full sessions between meetings. 498–511 (2011) . 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. 2006). Whereas client ratings of items 1. For each client. (3) the degree to which they felt understood by their therapist in the session. Ltd. Levitt. Pauses were timed by the transcriber and were indicated in the session transcripts. Kappa was calculated based on the number of topic shifts agreed upon.86) (Angus. Session Evaluation Form. & Hardtke. ratings of session difficulty utilize the whole seven-point scale. Steer. in which sessions from therapies with bulimic clients were transcribed and coded with NPCS by the author. Counts of Words. good inter-rater agreement has been found on identification of topic segments as well as on coding of narrative process (Cohen’s κ = 0. The BDI-II is widely used and has shown good psychometric properties.Attachment and Narrative Process in Therapy unresolved are most frequently secondarily classified as preoccupied. 2003). each coder coded at least seven full sessions. Levitt. internal or reflexive.

91.72–0. the topic segmenting coders achieved an agreement of κ = 0. 498–511 (2011) Inter-rater Agreement and Stability of NPCS Coders When coding the study material. All analyses allowed for random intercepts for therapy dyads. the coders achieved an agreement of 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. the topic segmenting coders achieved an average agreement with the author of κ = 0.8–73 minutes). was similarly trained by the author and achieved a reliability of κ = 0. and the narrative sequencing coders achieved an average agreement with the author of κ = 0. This indicated problems with the coding for internal process. which was also very rare in the material. and thus raw counts of the number of words and pauses Clin. and when they had negotiated a consensus coding. since the intra-class correlation coefficients of the dependent variables range from 0.90.83. and the narrative sequencing coders achieved an average agreement with the author of κ = 0.83–0. Subsequently. therapy dyads). The dependent variables examined were all measured at the level of sessions. internal or reflexive.94). the agreement was κ = 0. Cohen’s κ was also calculated separately for each of the three narrative process modes. Each coder coded between 12 and 24 sessions. which occurred only in CBT. it is possible to take into consideration the random variation between superordinate clusters of data (in this case. the analyses also allowed for a random slope for time (defined by session number) within therapy dyads. The narrative sequencing coders achieved an agreement of κ = 0. Since some of the dependent variables might change with time across the six months of therapy. Out of the 30 088 transcript lines in the data material. the marked transcript was passed on to two narrative sequencing coders. Since the material was considered difficult to code.75 (range 0. In distinguishing external from other codes. Since coding of who initiates narrative sequences can only be compared when coders agree on the delineation of narrative sequences. Each of the 48 sessions was first given to two topic segmenting coders..85). the agreement was κ = 0. given that all sessions were subsequently consensus-coded.72.71. distributed as evenly across therapy types and client attachment categories as allowed by coding logistics. Psychol. Because of the low inter-rater agreement on the internal narrative mode. S. Only the consensus coding was used in the further analyses. data analysis was conducted by means of multilevel mixedeffects modelling (Rabe-Hesketh & Skrondal. In the present study.75–0. Since sessions from the same dyad are non-independent. which occurred only in PPT. RESULTS Data Set and Data Analysis The data set consisted of six sessions from each of eight therapy dyads.78 (range 0. who had an MA in psychology. it became necessary to include an extra coder in the team of topic segmenters. in distinguishing internal from other codes. The coder. since they were considered ambiguous with respect to whether they should be allocated to the ‘landscape of action’ or the ‘landscape of consciousness’. and direct instruction from the therapist with respect to what clients should do (n = 17). all coders were asked to recode a session from the training material to check for possible rater drift.504 shifts (i.20. In multilevel analysis. This level of agreement was considered satisfactory. which is not accounted for by the explanatory variables: client attachment state of mind and therapy type. the sessions were of unequal duration (range 36. A small number of narrative sequences (21 out of 1292) could not be coded Copyright © 2010 John Wiley & Sons.88 (range 0. F.77) on classifying transcript lines as external.68 (range 0.59 to 0.66–0.83). the total number of transcript lines minus the number of shifts agreed upon and the number of shifts disagreed upon). 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.81 (range 0. The main explanatory variables: client attachment state of mind and therapy type were measured at the level of therapy dyads. the coders worked in pairs. 18. These were descriptions of events taking place in dreams (n = 4). 2008). I. The agreement on coding of narrative initiator was κ = 0. Towards the end of the coding period that lasted about a year.71 (range 0.5%) were coded as internal by one or both coders. .90).59–0. At the end of training. the coders negotiated a consensus coding.57–0. 2007). Each member of a pair first coded each session individually and submitted the coding to the author who calculated inter-rater agreement. and in distinguishing reflexive from other codes. Ltd. these sequences were excluded from the analysis pertaining to narrative process modes.e. The topic segmenting coders achieved an average agreement with the author of κ = 0. and since there might also be dyad-dependent variation in the rate of change. such an approach is definitely called for. Psychother. only 148 lines (0. Even though most sessions lasted about 50 minutes. There was no evidence of formation of coding subcultures in the coder pairs. NPCS Coding Procedure The NPCS coders were blind with regards to client attachment categorization as well as the hypotheses of the study. Daniel for narrative process mode.79) on the line-by-line presence of topic shifts. During the coding period. These sequences were also excluded from the analysis pertaining to narrative process modes.

46. For the average number of words per client speaking turn. In the present sample. Client depression and client unresolved score were not related to this variable. To maximize session variability. AAI unresolved score and session difficulty were also considered.080) and of time (B = 4.4 words per session minute. The proportion variables were subjected to a logit transformation for inclusion in the linear analyses. SD = 1. . and the number of pauses was divided by session duration in terms of hours to yield comparable and interpretable indices. depression scores on the BDI-II (Beck.75. 1996). since the current level of depression of clients might affect the verbal productivity variables. Hobson. z = −5. 18.88. possible main effects of client attachment state of Copyright © 2010 John Wiley & Sons. The final model included a significant Client Attachment × Time interaction (B = −2. SE = 1.1. Psychother. Main effects of client BDI-II score.7 words per speaking turn. To control for this difference.84. SD = 2. higher in the group of dismissing clients (M = 20. A limitation of the current sample was that two of the four preoccupied clients were also categorized as unresolved on the AAI. & Maughan. it was estimated that dismissing clients in PPT uttered 70. SD = 1.0.0).Attachment and Narrative Process in Therapy were not directly comparable. Client depression.7. neither alone or in interaction with client attachment or with time. SD = 2. preoccupied clients uttered 77. 1994). with session difficulty set to 4. p = 0. it was estimated that dismissing clients in PPT uttered 107.2. p = 0.2. Although not statistically significant. p = 0. the preoccupied clients had higher unresolved scores than the dismissing clients (preoccupied: M = 4. and since session difficulty might conceivably affect some of the variables studied.027) as well as the main effects of client attachment state of mind (B = −42. preoccupied clients in PPT uttered 132. SE = 1.e. Client depression did not affect this variable. client BDI score was included in these analyses as a fixed effect. therapy type and time.0 to 9. SD = 8. In the present sample. client-rated session difficulty was included in the analyses as a fixed effect. Lowered speech rate has been related to depression (Ellgring & Scherer. Although narrative process modes have usually been evaluated in terms of relative frequencies of sequences categorized into different modes.5.25).2 words per speaking turn. a significant main effect of therapy type (B = −48.7 words per speaking turn. p = 0. dismissing: M = 4.6 words per session minute. p < 0. SE = 0. with session difficulty set to 4 and client unresolved score set to 1.1 words per speaking turn.0.41.8) than in the group of preoccupied clients (M = 17. To control for the possible effect of this difference.2.97. However.001). The number of words per client speaking turn decreased as session difficulty increased and as client unresolved score increased.38. z = 2. z = −2.96. p < 0. 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.3. though not significantly. The number of client words per session minute decreased. p = 0. SE = 12.40. In CBT. preoccupied clients uttered 84. standard error [SE] = 10.027). client unresolved score was included in all analyses. & Brown. Figure 1 shows the estimated number of pauses per session hour with dismissing and preoccupied clients Clin. starting with the full model and gradually excluding non-significant terms. z = 3.4 words per session minute. therapy type had no significant effect. which can range from 1.5. there was no evidence of time-effects and no significant interaction between client attachment and therapy type. a significant main effect of session difficulty (B = −3. Based on this model. i. whereas.8. there was no time-effect and no significant interaction between client attachment and therapy type.41. p < 0.016).0.13. z = −2. There was a significant main effect of client attachment state of mind (B = 61. in the present sample.0 has to be given on a rating scale for unresolved loss or trauma. whereas. The NPCS variables were evaluated in terms of proportions.26. Castle. a significant main effect of therapy type (B = −61. SE = 24.0. preoccupied clients in PPT uttered 138. For the number of client words per session minute. Ltd. p = 0. the number of client words in sessions was divided by session duration in terms of minutes. dismissing clients were estimated to utter 22. In CBT.001).6 words per session minute. proportion of narrative sequences initiated by the client (versus the therapist) and proportion of words coded as external (versus reflexive).55. and all possible two-way interaction terms were considered.18. 498–511 (2011) Verbal Productivity Variables When analyzing the variables related to verbal productivity. Steer..06. sessions had been chosen based on high or low ratings of session difficulty on the SEF-C. Howard.37.001). z = −1.88. Based on this model. whereas.0. z = −3.002). SE = 3. SD = 8. 1997). the difficulty ratings of dismissing clients tended to be higher than those of preoccupied clients (preoccupied: M = 3.0. client unresolved score and session difficulty did not affect this variable.3.001) and a significant main effect of session difficulty (B = −3. as session difficulty increased. z = −3.91.50. dismissing: M = 1.84. z = 3. SE = 1. 505 mind. 1996) ranged from 8 to 29 and were slightly. To be assigned to the category unresolved. SE = 10. For the number of pauses per session hour. which has in turn been related to the dismissing category in some studies (Patrick.52.03). SE = 15. Psychol.1. There was a significant main effect of client attachment state of mind (B = 31. Consequently. dismissing clients were estimated to utter 46.21. p = 0.8. a score of at least 5. whereas.004) and a significant main effect of client unresolved score (B = −9. z = −2.

the proportion of external process tends to decrease across the 20 sessions.0%. z = 1. the estimated number of pauses per hour at session 10 was 91. Therapy Type × Time (B = −0.46. therapy type.6%. Based on this model.9 with dismissing clients. z = 4. Copyright © 2010 John Wiley & Sons. z = −3. At session 10. and time.067). In CBT. Client unresolved score and session difficulty did not affect this variable. in PPT. the proportion of external process is higher with dismissing clients than with preoccupied clients. whereas. there are more pauses. as well as the main effects of client attachment state of mind (B = 1. and with preoccupied clients in CBT it is 39. Psychother. possible main effects of client attachment state of mind. whereas. SE = 0. In CBT. 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. whereas.61.17. z = 4.07. the two therapy types are more different in the early sessions and more alike around session 20. SE = 1.0%. in PPT there is a slight increase in the proportion of external process. Based on this model.17. SE = 0. starting with the full model and gradually excluding non-significant terms. p = 0.002). p < 0.001).46. 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. p < 0.2%.014).71. the corresponding number for preoccupied clients was 32. which eventually gives way to an increased focus on the cognitive distortions behind the eating disorder. This corresponds well to an initial strong behavioural focus in CBT. Narrative Initiative and Narrative Process Modes When analysing the NPCS variables.04. SE = 0. Main effects of client AAI unresolved score and session difficulty were also considered. with dismissing clients in CBT it is 68. 498–511 (2011) . p = 0. Ltd.10. in PPT.8%.014).23.16. In therapies with dismissing clients. 18. Daniel 2 4 6 8 10 12 Session 14 16 18 20 Figure 1.83.87.12.6%. F.3%.98. There was a significant main effect of client attachment state of mind (B = 0. In CBT.001) and a significant main effect of therapy type (B = −2. Thus. SE = 0. in terms of proportions of narrative modes.78. the number of pauses in therapies with preoccupied clients tends to remain stable across the 20 sessions. whereas. the estimated percentage of narrative sequences initiated by dismissing clients was 19. p < 0. SE = 0. Client unresolved score and session difficulty did not affect this variable. Clin. z = −2.70. with preoccupied clients in PPT it is 31. p = 0.506 140 Dismissing 120 Pauses per session hour 100 80 60 40 20 0 Preoccupied S. whereas. although the difference here is much smaller. p = 0.4%. the estimated proportion of external process with dismissing clients in PPT is 25. and the number of pauses tends to increase across the 20 sessions. it is the other way around. evidenced in a high proportion of external process. and all possible two-way interaction terms were considered. I.27. the corresponding number for preoccupied clients was 81. of therapy type (B = 4. z = 2. whereas. 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. Psychol. resulting in higher proportions of reflexive process.001) and of time (B = 0.05. SE = 0. For the proportion of narrative process categorized as external (versus reflexive) in each session. both Client Attachment × Therapy Type and Therapy Type × Time were statistically significant.51. The final model included Client Attachment × Therapy Type (B = −1. it was 20.2 with preoccupied clients. the estimated percentage of narrative sequences initiated by dismissing clients was 68. z = −12.05.

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

which indicates that sampling just a few sessions from each dyad would be likely to misrepresent the narrative process. the NPCS is labour intensive. angry. This seemed to be the case in CBT. Psychol. secure clients should be included for comparison. it would be important to evaluate whether the silences exhibited by dismissing clients are reflective or perhaps disengaged. 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. verbal productivity. p.. In her much cited chapter on attachment states of mind and psychotherapy. However. most of the external process did not focus on the eating disorder. but they may be at risk of overwhelming therapists and may leave little room for reflection. however. which would suggest defensiveness. emotional. obstructive or neutral (Frankel et al. Compared with the verbal productivity variables. reflective and disengaged silences that may be evaluated as either productive. 2006). This might be done using instruments such as the Pausing Inventory Categorization System. helpless. The relative absence of pauses with preoccupied clients may reflect a tendency to ‘fill’ the sessions with verbal activity. Daniel ate whether they are more similar to dismissing or preoccupied clients in terms of overall number of pauses.. Ltd. Such experiences may be partly related to clients’ patterns of verbal productivity and narrative initiative. The present study was inspired by the premise that although insecure clients are generally more difficult to treat than secure clients. whereas.. 2005). Conversely. S. but it would be relevant to evaluCopyright © 2010 John Wiley & Sons. Psychother. secure clients would be expected to show more productive and fewer obstructive silences than dismissing clients. and does not easily lend itself to large-size studies. 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. 18. they may still affect therapist reactions to clients. which was also very rare in the material.. confused. 498–511 (2011) . Thus. it may also reflect more emotional engagement. speak more and for longer periods. Generally. If preoccupied clients show more initiative. The client group might also be important since eating disorders have been linked to difficulties in verbalizing feeling states (Speranza et al. In the present study. clients with different insecure attachment states of mind may be difficult in very different ways. I. F. whereas. However. 1999). the distribution of narrative process modes varied just as much from session to session within dyads as it did between dyads.g.g. the coding of narrative process modes generated results that related more clearly to therapy type differences than to attachment states of mind. 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. although less pronounced. where larger proportions of internal process have been reported (Levitt & Angus. it may also reflect a greater reluctance to self-disclose. Slade (1999. leaving no room for reflection. In. Even though the difference detected in terms of narrative initiative is theoretically interesting. Furthermore. If dismissing clients show less initiative. especially as treatment progresses. where the proportion of external process tended to be larger with dismissing clients than with preoccupied clients.508 Even if the variables studied here do not affect treatment outcome. and perhaps a rise in defensiveness as therapy increasingly pushes for involvement. With regards to the relative predominance of the external and reflexive narrative process modes. which only require transcription of sessions to be computed. and dysregulated’. but rather on discussion Clin. On the other hand. but the tendency in PPT was in the opposite direction. Further studies on attachment states of mind and pauses should address qualitative aspects of silences to make sense of the quantitative findings. preoccupied clients engage in more psychological considerations. e. including both simple use of emotion words such as that captured by computerized dictionaries (Buchheim & Mergenthaler. PPT. The difference that had been expected for internal narrative process could not be evaluated because of low coding reliability for this mode. whereas. preoccupied clients make the therapist feel ‘swamped. the higher number of pauses with dismissing clients may evidence more reflection. 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. they give therapists more material to work with. 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. This may make it harder for therapists to attune empathically and may also generate doubts about the clients’ commitment to treatment. concrete realities. it was tentatively hypothesized that dismissing clients would focus more on the external mode relating to descriptions of outer. Thus. 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. which distinguishes between different categories of silence such as e. they generate less information on their experience. This might be related to the therapy forms. 588) argued that dismissing clients are likely to make therapists feel ‘caught in the same barren landscape as the patient’ and ‘utterly shut out’. speak less and with shorter speaking turns. preoccupied clients would focus more on the reflexive mode relating to inner or psychological realities. 2000) and non-verbal emotion expression.

Wilson..D. H. Bruner. Bakermans Kranenburg. often involving relational experiences. Bakermans Kranenburg. 1255–1270. Hardtke. and research (pp. possible worlds. & Gottman. More elaborate and detailed information on the ‘linguistic fingerprints’ of attachment states of mind Copyright © 2010 John Wiley & Sons. linguists. ed.. 1975. J. J. M. London: Pimlico. J. Training Manual. Bucci.. Inc. Acts of meaning. Since client attachment states of mind might be expressed more clearly in therapies that focus on attachment relationships. Separation. & Clin.J. The handbook of narrative and psychotherapy: Practice. and non-experts.A. Emotion. most of the differences between dismissing and preoccupied clients identified in this study were similar in both therapies. R. & Brown. Angus. (1990). but the estimated coefficients of the interaction term were also small for most variables. Beck. M.1. including the AAI proper. Attachment and loss: Vol.G. 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