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.

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

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

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

and the therapists were not informed about client attachment patterns. dismissing or preoccupied in their narrative style. etc. 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. In contrast to the three primary AAI classifications. The other 11 scales evaluate different aspects of the speaker’s ‘state of mind with respect to attachment’.0. Three other certified AAI coders scored a random sample of four of the eight AAIs to check inter-rater reliability. 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. clients were included as e. CBT for Bulimia CBT for bulimia was developed by Christopher Fairburn (2008) and is one of the best validated treatments for bulimia (Agras.g. dismissing or preoccupied was used. & Kraemer. When scoring the AAIs. preoccupied: M = 26. the author was blind with regards to which treatment type the clients had been assigned to. Williams. 1994) (dismissing: M = 1. Measures AAI The AAI is a semi-structured interview with 20 questions and standardized probes (George et al. Crowell et al. and their responses aim at helping clients to acknowledge and Copyright © 2010 John Wiley & Sons. . 498–511 (2011) Treatments PPT for Bulimia PPT for bulimia (Lunn & Poulsen. only the three-way classification of secure. Interviews classified as unresolved or cannot classify are also given a secondary classification as secure. clients who dropped out before the completion of 20 therapy sessions were not included. To keep the sample as homogenous as possible except for type of attachment insecurity. dismissing even if they were also unresolved. and for whom usable sound recordings of the therapy sessions were available. All had completed the equivalent of high school education. 2005) and were supervised bi-weekly by Susanne Lunn and Stig Poulsen (PPT) or Christopher Fairburn (through video conference) (CBT). I. No clients in the sample had the same therapist. two out of three additional coders agreed with the classification made by the author. interviews are assigned to one of five major categories: secure. The therapists were trained according to the specific treatment manuals (Fairburn. and therapists consistently focus on the eating disorder.24) (possible scores range from 0 to 4).91. The clients were women of Scandinavian origin with an average age of 25. dismissing. Six therapists were female and two were male. who fulfilled the selection criteria in terms of attachment and distribution across therapy types.. Thus. the bulimic symptoms are not necessarily discussed in every session. Gibbon.5 years (standard deviation [SD] = 5.502 in CBT). The therapists were experienced psychologists or psychiatrists with expert training in either PPT or CBT. four were students and four were employed.38. The groups of dismissing and preoccupied clients were relatively comparable in terms of age (dismissing: M = 25. the AAI was administered by post-graduate psychology candidates who were trained and supervised by certified AAI coders. The interviewee is asked about the relationship to childhood attachment figures and attachment-related topics such as separations. preoccupied. 18.0. and to be able to sample from a comparable range of sessions.. It is a highly structured therapy consisting of 20 sessions with fixed agendas. Therapists allow clients to direct the choice of topics. Clients are given homework assignments. Walsh. Based on scores on the ‘state of mind’ scales and on the presence of global category descriptors.29. 2002). dismissing and/or preoccupied (Main et al. The clients included in the study were the first eight clients in the Bulimia Trial. that is. 1996). losses. and in two cases. preoccupied: M = 1. SD = 0. Psychother. unresolved or cannot classify. The author. all three additional coders agreed with the classification made by the author. scored the AAIs from the intake assessment. Fairburn. being ill. In general. The AAI has been found to have good reliability and discriminant validity (Bakermans et al. The interview is transcribed verbatim and rated on 16 nine-point scales. 2000). who is certified as an AAI coder. In two cases.. Ltd. Daniel reflect on their inner world of experience.2. F. 1996). When selecting the current sample.. To code the AAI. Five of these scales evaluate aspects of childhood experience as inferred by the coder. Wilson. SD = 7. 1993. S. SD = 3. Psychol. 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 unresolved classification may be assigned based on brief passages in interviews that are otherwise secure. and these are systematically explored. interviews categorized as Clin. In the Bulimia Trial. 2008. & First.. Lunn & Poulsen.3). 1990). The therapy consists of weekly sessions for a period of 2 years. 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 = 0. 1999).

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

8–73 minutes). the agreement was κ = 0. who had an MA in psychology. There was no evidence of formation of coding subcultures in the coder pairs.78 (range 0. it is possible to take into consideration the random variation between superordinate clusters of data (in this case. the marked transcript was passed on to two narrative sequencing coders.79) on the line-by-line presence of topic shifts. . During the coding period. the analyses also allowed for a random slope for time (defined by session number) within therapy dyads. since the intra-class correlation coefficients of the dependent variables range from 0.66–0. since they were considered ambiguous with respect to whether they should be allocated to the ‘landscape of action’ or the ‘landscape of consciousness’. The narrative sequencing coders achieved an agreement of κ = 0. Psychother. Out of the 30 088 transcript lines in the data material. Each of the 48 sessions was first given to two topic segmenting coders. This level of agreement was considered satisfactory. The coder. 2008). and when they had negotiated a consensus coding. Since the material was considered difficult to code. All analyses allowed for random intercepts for therapy dyads. and since there might also be dyad-dependent variation in the rate of change. which occurred only in PPT.68 (range 0. the total number of transcript lines minus the number of shifts agreed upon and the number of shifts disagreed upon). Since some of the dependent variables might change with time across the six months of therapy.5%) were coded as internal by one or both coders. and direct instruction from the therapist with respect to what clients should do (n = 17). which was also very rare in the material. all coders were asked to recode a session from the training material to check for possible rater drift. Subsequently. the coders achieved an agreement of κ = 0.85).72. such an approach is definitely called for. 18.77) on classifying transcript lines as external.59–0. Ltd. 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. 2007). and the narrative sequencing coders achieved an average agreement with the author of κ = 0. RESULTS Data Set and Data Analysis The data set consisted of six sessions from each of eight therapy dyads. the coders negotiated a consensus coding.71 (range 0.94). F. distributed as evenly across therapy types and client attachment categories as allowed by coding logistics. Even though most sessions lasted about 50 minutes. the topic segmenting coders achieved an average agreement with the author of κ = 0. the coders worked in pairs. it became necessary to include an extra coder in the team of topic segmenters.75–0. only 148 lines (0. the agreement was κ = 0. At the end of training. A small number of narrative sequences (21 out of 1292) could not be coded Copyright © 2010 John Wiley & Sons.20. Only the consensus coding was used in the further analyses. The dependent variables examined were all measured at the level of sessions.57–0. NPCS Coding Procedure The NPCS coders were blind with regards to client attachment categorization as well as the hypotheses of the study.72–0.504 shifts (i. 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. Daniel for narrative process mode. In distinguishing external from other codes. Cohen’s κ was also calculated separately for each of the three narrative process modes.90).90. and thus raw counts of the number of words and pauses Clin. The agreement on coding of narrative initiator was κ = 0. which is not accounted for by the explanatory variables: client attachment state of mind and therapy type.e. In multilevel analysis.88 (range 0. These were descriptions of events taking place in dreams (n = 4). Each member of a pair first coded each session individually and submitted the coding to the author who calculated inter-rater agreement.91. which occurred only in CBT. Each coder coded between 12 and 24 sessions. Since coding of who initiates narrative sequences can only be compared when coders agree on the delineation of narrative sequences. These sequences were also excluded from the analysis pertaining to narrative process modes. Towards the end of the coding period that lasted about a year. 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.83–0. therapy dyads).71.. Because of the low inter-rater agreement on the internal narrative mode. I.83). Since sessions from the same dyad are non-independent. S.75 (range 0. these sequences were excluded from the analysis pertaining to narrative process modes.59 to 0. given that all sessions were subsequently consensus-coded. the sessions were of unequal duration (range 36. and in distinguishing reflexive from other codes.81 (range 0. data analysis was conducted by means of multilevel mixedeffects modelling (Rabe-Hesketh & Skrondal. The topic segmenting coders achieved an average agreement with the author of κ = 0. In the present study.83. 498–511 (2011) Inter-rater Agreement and Stability of NPCS Coders When coding the study material. in distinguishing internal from other codes. internal or reflexive. Psychol. the topic segmenting coders achieved an agreement of κ = 0. The main explanatory variables: client attachment state of mind and therapy type were measured at the level of therapy dyads.

18.97. Figure 1 shows the estimated number of pauses per session hour with dismissing and preoccupied clients Clin. SE = 15. Steer.0).0. Consequently. To control for the possible effect of this difference. p = 0.37. Psychother. z = 2..88. z = −2.40. which has in turn been related to the dismissing category in some studies (Patrick.2. Although narrative process modes have usually been evaluated in terms of relative frequencies of sequences categorized into different modes. To be assigned to the category unresolved.016).8) than in the group of preoccupied clients (M = 17. as session difficulty increased. SE = 10. Castle. p = 0. preoccupied clients in PPT uttered 132. i.25).0.001).3. z = −2. with session difficulty set to 4 and client unresolved score set to 1. SE = 3.06. p < 0. However.96. There was a significant main effect of client attachment state of mind (B = 61.46. SE = 1.75. z = 3. For the number of pauses per session hour.080) and of time (B = 4. p < 0. dismissing: M = 4. In the present sample. a significant main effect of session difficulty (B = −3. in the present sample.84. therapy type had no significant effect. A limitation of the current sample was that two of the four preoccupied clients were also categorized as unresolved on the AAI. client BDI score was included in these analyses as a fixed effect. client unresolved score and session difficulty did not affect this variable. starting with the full model and gradually excluding non-significant terms. Based on this model. preoccupied clients uttered 77.001).0. For the number of client words per session minute. Client depression.21. it was estimated that dismissing clients in PPT uttered 70.0. whereas. 1994).4 words per session minute. possible main effects of client attachment state of Copyright © 2010 John Wiley & Sons.4 words per session minute.2 words per speaking turn. The final model included a significant Client Attachment × Time interaction (B = −2. z = −3. z = −2. For the average number of words per client speaking turn. dismissing clients were estimated to utter 22. since the current level of depression of clients might affect the verbal productivity variables. there was no evidence of time-effects and no significant interaction between client attachment and therapy type. with session difficulty set to 4. neither alone or in interaction with client attachment or with time. Psychol.55. Hobson. z = 3. p = 0.1. SD = 8. Based on this model.8. dismissing clients were estimated to utter 46. it was estimated that dismissing clients in PPT uttered 107. Although not statistically significant. SD = 2.1.0. 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.6 words per session minute. p = 0. whereas.e.7 words per speaking turn. and all possible two-way interaction terms were considered. SD = 1.13. Ltd.5.1 words per speaking turn.7 words per speaking turn. Howard. z = −5. a significant main effect of therapy type (B = −61. standard error [SE] = 10. The number of words per client speaking turn decreased as session difficulty increased and as client unresolved score increased. whereas. the difficulty ratings of dismissing clients tended to be higher than those of preoccupied clients (preoccupied: M = 3. higher in the group of dismissing clients (M = 20. To maximize session variability. SE = 24. In the present sample. There was a significant main effect of client attachment state of mind (B = 31. z = −1. The number of client words per session minute decreased. and the number of pauses was divided by session duration in terms of hours to yield comparable and interpretable indices. which can range from 1. Main effects of client BDI-II score.0 has to be given on a rating scale for unresolved loss or trauma. a score of at least 5. and since session difficulty might conceivably affect some of the variables studied.002).88. The proportion variables were subjected to a logit transformation for inclusion in the linear analyses.001) and a significant main effect of session difficulty (B = −3.001).0. In CBT. client-rated session difficulty was included in the analyses as a fixed effect.41.Attachment and Narrative Process in Therapy were not directly comparable. & Maughan. SE = 12. preoccupied clients in PPT uttered 138.2. a significant main effect of therapy type (B = −48. 1996).6 words per session minute.004) and a significant main effect of client unresolved score (B = −9. depression scores on the BDI-II (Beck. the number of client words in sessions was divided by session duration in terms of minutes. SD = 1. p < 0. AAI unresolved score and session difficulty were also considered.52. SE = 0. there was no time-effect and no significant interaction between client attachment and therapy type. 1997). SD = 8.38. SD = 2.26. SE = 1. Client depression and client unresolved score were not related to this variable. client unresolved score was included in all analyses. proportion of narrative sequences initiated by the client (versus the therapist) and proportion of words coded as external (versus reflexive).027) as well as the main effects of client attachment state of mind (B = −42. p = 0. To control for this difference. 1996) ranged from 8 to 29 and were slightly.91.84. preoccupied clients uttered 84. p = 0.3.41. whereas. Lowered speech rate has been related to depression (Ellgring & Scherer. 18.0 to 9. 498–511 (2011) Verbal Productivity Variables When analyzing the variables related to verbal productivity. & Brown.5.027). z = −3. p = 0.2.8. therapy type and time. the preoccupied clients had higher unresolved scores than the dismissing clients (preoccupied: M = 4.03). In CBT. . 505 mind. SE = 1.7.50. The NPCS variables were evaluated in terms of proportions. dismissing: M = 1. though not significantly. sessions had been chosen based on high or low ratings of session difficulty on the SEF-C. Client depression did not affect this variable.

This corresponds well to an initial strong behavioural focus in CBT. Narrative Initiative and Narrative Process Modes When analysing the NPCS variables. the estimated proportion of external process with dismissing clients in PPT is 25. 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. it was 20. both Client Attachment × Therapy Type and Therapy Type × Time were statistically significant.51. 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. Daniel 2 4 6 8 10 12 Session 14 16 18 20 Figure 1. There was a significant main effect of client attachment state of mind (B = 0. Based on this model.0%.0%. the corresponding number for preoccupied clients was 32. in PPT there is a slight increase in the proportion of external process. which eventually gives way to an increased focus on the cognitive distortions behind the eating disorder. z = −2.2%. with preoccupied clients in PPT it is 31. evidenced in a high proportion of external process. In CBT.05. the estimated percentage of narrative sequences initiated by dismissing clients was 68.05. with dismissing clients in CBT it is 68. possible main effects of client attachment state of mind.6%. there are more pauses.506 140 Dismissing 120 Pauses per session hour 100 80 60 40 20 0 Preoccupied S.014).3%.27. p < 0.001). Psychol.23. the estimated number of pauses per hour at session 10 was 91.6%. Thus.014).71. although the difference here is much smaller. SE = 0. starting with the full model and gradually excluding non-significant terms. whereas. in PPT.87. in terms of proportions of narrative modes. In CBT. SE = 0. the proportion of external process tends to decrease across the 20 sessions. For the proportion of narrative process categorized as external (versus reflexive) in each session. the proportion of external process is higher with dismissing clients than with preoccupied clients. the two therapy types are more different in the early sessions and more alike around session 20. resulting in higher proportions of reflexive process.46. Based on this model.17. z = 1. whereas. Ltd.001) and of time (B = 0. p = 0.78. SE = 0.9 with dismissing clients. p < 0. p = 0. z = −3. Copyright © 2010 John Wiley & Sons.17. Therapy Type × Time (B = −0.4%. p = 0. z = 4.067). Client unresolved score and session difficulty did not affect this variable. 18. and the number of pauses tends to increase across the 20 sessions.002).07. Psychother.61.12. 498–511 (2011) . of therapy type (B = 4. SE = 0. p = 0. in PPT. as well as the main effects of client attachment state of mind (B = 1. the corresponding number for preoccupied clients was 81. In therapies with dismissing clients. whereas.8%. Main effects of client AAI unresolved score and session difficulty were also considered. At session 10. Clin.83. In CBT. it is the other way around.16. and time. p < 0. whereas.10.04. the number of pauses in therapies with preoccupied clients tends to remain stable across the 20 sessions. z = 4. 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. The final model included Client Attachment × Therapy Type (B = −1.70. Client unresolved score and session difficulty did not affect this variable. SE = 0. therapy type. z = −12.98. and with preoccupied clients in CBT it is 39. the estimated percentage of narrative sequences initiated by dismissing clients was 19. whereas.2 with preoccupied clients. whereas. SE = 0.001) and a significant main effect of therapy type (B = −2. F. and all possible two-way interaction terms were considered. z = 2. SE = 1. I.46.

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

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

H. Bruner. Pennebaker (Ed. Bakermans Kranenburg.M. Bowlby. Cambridge. 55(10). investigations of the specificity. future studies should utilize more fine-grained discourse analysis. TX: The Psychological Corporation. A psychometric study of the Adult Attachment Interview: Reliability and discriminant validity. including the AAI proper. Such investigations might utilize an instrument such as the recently developed Coherence Q-sort (Beijersbergen. & Hardtke. York University. 8(4).. 87–101). Bakermans Kranenburg. 18.H. & van Ijzendoorn. W.. J. B. it may be that engagement in psychotherapy inherently activates the attachment behavioural system.J. 3. L. The power of the narrative: A multiple code account. D. often involving relational experiences. & Clin. (1997). Bowlby. ACKNOWLEDGMENTS The author would like to thank Susanne Lunn. but the estimated coefficients of the interaction term were also small for most variables.). Developmental Psychology. attachment states of mind are evaluated based on a composite of different discourse markers. Levitt. Bouffard. 870–879. T. Loss.. C.. 1975. Bowlby. (2004). Actual minds. 2008). This kind of process seemed equally predominant with dismissing and preoccupied clients. North York. J. Training Manual. even when the therapy dialogue does not directly address attachment. 498–511 (2011) . Cambridge. Perhaps. A. & Van Ijzendoorn. (1996). Attachment and loss: Vol. sessions from two relatively different therapy forms were investigated.. In the AAI. Angus.5). On the other hand. some of the markers relied upon in AAI classification depend more narrowly on activation of the attachment behavioural system (e. (1990). (2006). Inc.. Angus. 2006). it requires more statistical power to detect an interaction effect than to detect main effects.. Psychol. J. In L. (2007). most of the differences between dismissing and preoccupied clients identified in this study were similar in both therapies. & van Ijzendoorn. 1255–1270. K. & Brown. R.. Beck. L. J. (1995). Since client attachment states of mind might be expressed more clearly in therapies that focus on attachment relationships. In spite of the marked difference between the relationship-focused PPT and the symptom-focused CBT. and non-experts. M. W. Stig Poulsen. The topic is worthy of further investigation. V. Bruner. Archives of General Psychiatry. H.. (1999). In J. & Rotondi-Trevisan. New York: Cambridge University Press. Observing interaction: An introduction to sequential analysis (2nd. Attachment and Human Development. H. MA: Harvard University Press. the difference between client attachment states of mind was larger in CBT than in PPT. Wilson.. M. Ontario. ‘What’s the story?’ Working with narrative in experiential psychotherapy. Bucci. The only variable for which a Client Attachment × Therapy Type interaction effect was noted was the relative proportion of external (versus reflexive) process in sessions. Acts of meaning. Ltd. M.. neutral conversations and different kinds of psychotherapy... CA: Sage Publications. 509 in different contexts would contribute importantly to our understanding of attachment states of mind and their psychotherapeutic implications. As already mentioned. 1. 353–369. 459–466. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Fairburn. J. linguists. theory.1. & Quera. Obviously. Unpublished manuscript.T. The Narrative Processes Coding System: Research applications and implications for psychotherapy practice. coherence and emotional valence of the in-session autobiographical memory narratives might very well reveal differences. G. R. Bakeman. M. verbosity). Attachment.C. Thus. (1973/1998). A special thank you to Lynne Angus and the dedicated NPCS coders. whereas. which is based on the Gricean maxims incorporated in the AAI coding system (Grice. Beijersbergen.). Attachment and loss: Vol. ed. and in this case. General Sequential Querier for Windows (Version 4. Bakermans Kranenburg..D. & Gottman. (1996). W. (1993). London: Pimlico. G. preoccupied anger). H. The concept of coherence in attachment interviews: Comparing attachment experts. Angus & J. More elaborate and detailed information on the ‘linguistic fingerprints’ of attachment states of mind Copyright © 2010 John Wiley & Sons.E. The handbook of narrative and psychotherapy: Practice.T. Steer.g. possible worlds. disclosure. nevertheless. J. perhaps including a consideration of the content of the therapeutic dialogue rather than focusing only on narrative modes. the lack of Client Attachment × Therapy Type interaction effects in this study may also be related to the particular choice of dependent variables.S. Hardtke. MA: Harvard University Press. San Antonio. London: Pimlico.). K.A.J.. (2000). Bakeman.Attachment and Narrative Process in Therapy of episodes from the client’s life. and research (pp. Emotion. (1980/1998). The results of the present study suggest that the different insecure attachment states of mind may not be differentiated by distinct in-session narrative process at the relatively broad level picked of by the coding for NPCS narrative process modes. Main et al... J. Separation. but are expressed in a wider range of contexts (e. other characteristics may be more general discourse traits that are also related to specific attachment histories.. R. applying a detailed level of discourse analysis across a range of discourse contexts. REFERENCES Agras. Lewin.. Thousand Oaks. and the rest of the Bulimia Trial research team.g. M. (1986). L. 57(5). & Kraemer. Canada. McLeod (Eds. Angus. Journal of Clinical Psychology.. Department of Psychology.K. Attachment and loss: Vol. Narrative Processes Coding System. 29(5). Psychother. (1969/1997).. 2.G. Walsh. & Levitt. London: Pimlico. Beck Depression Inventory—Second edition Manual.

Morgan (Eds... A. Steele. research. & Levine. Attachment organization and treatment use for adults with serious psychopathological disorders. and narrative style: A computer-based text analysis of the Adult Attachment Interview.I. Greenberg. Levitt. A. Logic and conversation. K.. New York: Guilford Press. 74(6). Vocal indicators of mood change in depression. Korfmacher. (2003). B.). and response to psychotherapy. Tyrell. (2008). & Kernberg. & Dudas. New York: Academic Press. Daniel. Adult attachment: Implications for the therapeutic process in a home visitation intervention. F. ColonDowns. & Poulsen. K. Cassidy & P. H. Lunn. Attachment. scoring and procedures manual (3rd ed. Levy. The relationship among attachment representation. Discriminant validity of the Adult Attachment Interview. 83–110. D. (1996). The distribution of adult attachment representations in clinical groups: A meta-analytic search for patterns of attachment in 105 AAI studies. emotion-abstraction patterns. research. Department of Psychology. L. 9(3). E. 43–52. Clin. observerblinded clinical trial. J. Leigh. Hillsdale. Grice.. Attachment issues in psychopathology and intervention (pp. Lomax. H. MN: National Computer Systems.N.R. S. Isabella.. J.. (1994).. Goldberg & R. A. Steele...R.. Meehan. 64(1). J. H.. Ogawa. The developmental roots of narrative expression in therapy: Contributions from attachment theory and research. Steele. Hesse... Handbook of attachment: Theory. Daniel. Clinical Social Work Journal. D. E. Unpublished thesis.. 20(2).W. C... Target. Psychother. (2006). 62(2). (2004). (1996). In J. K. methods. & Albus. Speech acts (pp. & Bates. Psykoanalytisk psykoterapi med bulimi—En behandlingsmanual.H. M. and borderline states: The predictive specificity of the Adult Attachment Interview and pathological emotional development. (1999). H. 93–122). M. & Belsky. (2001). Roberts & J. 390– 407..P. Waters. Weber. M. 16(5). Adam. Attachment theory and psychotherapy. (2001). S. New York: Guilford Press. Cole & J. Holmes. Attachment and Human Development. Dozier. Stovall.). T. G. Unpublished manuscript..). J. J. In L. Unpublished manuscript. Minneapolis. Syntax and semantics. Leigh. M. 1(1). (1999).. 167–180).B..L. 395–433). Steele & M..). The challenge of treatment for clients with dismissing states of mind. Psychotherapy Research. Clinical Applications of the Adult Attachment Interview (pp. (1997). (1996). 62–76. Beebe.C. G..). York University. M.). O. The AAI anticipates the outcome of a relation-based early intervention. & Poulsen. The search for the secure base.). University of Copenhagen. Muir (Eds. Cassidy & P. Rome: Societa Editrice Universo. SCL-90-R: Administration. C. Crowell. K. O’Connor. London: Lawrence Erlbaum Associates. & Feider. P.R. & Egeland. Shaver (Eds. In G.. 27–40. E. Bria & A.L. & Target. H. vi–131.. Practice. Daniel Frankel. Research. Treboux. (1998).D. 2584–2599. T. George. Candelori. I..M. P.C.6. Attachment and psychopathology in adulthood. Canada. S. Mattoon. Reynoso. M. & Ciocca. Assessing silent processes in psychotherapy: An empirically derived categorization system and sampling strategy. S. E. Shaver (Eds. 615–625.. The relevance of attachment research for adult narratives told in psychotherapy. Steele (Eds. M. Kaplan.S. J. the reflective self. & Gerber. Kelly. 301–316.E. Steele & M.. R. In S... New York: Other Press. The Bulimia pilot trial. New York: Guilford Press. C. 498–511 (2011) . Development and Psychopathology.). Applied Developmental Science.. K. Cognitive behaviour therapy versus psychoanalytic psychotherapy for bulimia nervosa—A randomised. In P. G. Fairburn. Monographs of the Society for Research in Child Development. (1995). (2002). and results (pp. Psychotherapy process measure research and the evaluation of psychotherapy orientation: A narrative analysis.M. R. (2009).F. Interactional synchrony and the origins of infant-mother attachment: A replication study. Attachment state of mind and the treatment relationship. (1996). 26(8). and the development of the self. NJ. Clarkin.M. and clinical applications (pp. S. 1027–1040.. Handbook of attachment: Theory. M.). 49–66). Journal of Consulting and Clinical Psychology. 27(1).. E. L. 139–153). O. Publishers. C. (2001). Department of Psychology.. Adult attachment patterns and individual psychotherapy: A review. 279–300. Attachment theory: Social. Unpublished manuscript. S. J. & Angus. J.. Mattoon. Clinical Psychology Review. Psychotherapeutic issues on eating disorders: Models. Levitt..510 health (pp. (2008). Ciocca (Eds. Affect regulation. In J. New York: Guilford Press.J. Dozier. University of California at Berkeley. A comparative analysis of the Narrative Process Coding System and three standardized psychotherapy process measures: A multi-modal analysis.0).. Journal of Consulting & Clinical Psychology. Heinicke. van Ijzendoorn. mentalization.I. (1975).. Washington DC: American Psychological Association. In P. London: Brunner Routledge. 46(3). 69–98). Gergely. The relation of attachment status. Attachment and eating disorders. L. R.M. Psychotherapy Research. (1990). (2000). Rhythms of dialogue in infancy: Coordinated timing in development. Copyright © 2010 John Wiley & Sons.. Psychotherapy: Theory. M. K. S. Jaffe.C. (1991). 67(5). Child Development. In H. 18. C.. 373–384. & Bakermans Kranenburg. The adult attachment interview: Historical and current perspectives.F. Fonagy. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. 3(1). C.F.. Ellgring. Child Development. Crown... Z. [Psychoanalytic psychotherapy for bulimia—A treatment manual]. & Angus. Lunn. 47–60.S.. Ltd. Holmes (Eds. developmental. Jurist. M. Feldstein. & Scherer. and clinical applications (pp.F. C. psychiatric classification. K.. P. Code-A-Text Integrated System for the Analysis of Interviews and Dialogues (Version 3. L. M. & Main. Levitt. Steele. (2008). & Lee. (1999).S. Dozier. E. Goldberg (Eds. Kennedy... M. A. 22–31. L. Fish.. Journal of Psychotherapy Integration. H.). 41–58). M. Inc. (2005). S. Dozier. Fonagy. Clinical applications of the Adult Attachment Interview (pp.). Steele (Eds. & Jasnow. B.A.. Defensive and creative uses of narrative in psychotherapy: An attachment perspective. & Target. M. B. 2(1).. 66(2). Holmes. S.. In H. 233–278). L. Adult Attachment Interview (3rd ed.R. & Mergenthaler. Volume 3.. (1993).. Kennedy. H. Murray. M. 10(4). B.L. Derogatis. (2006). Cartwright. Cognitive behavior therapy and eating disorders. (1999).. 968–984. (2004). Journal of Nonverbal Behavior.A. Healing stories: Narrative in psychiatry and psychotherapy (pp. London: Oxford University Press. Fonagy. 497–519). (2006).. Psychol.E. New York: Guilford Press. Atkinson & S. Training.. Buchheim. (1999). 99–125). and clinical perspectives (pp. N. England: Analytic Press.. J.

L. M. Sagi. British Journal of Medical Psychology. S.. J.. New York: Guilford Press. J. M. (1992).. and clinical applications (pp. (2002). Teti. (2006). (1989). Psychiatry Research. University of California at Berkeley.. & Shepard. Main. M. 67(5). Halfon. Journal of Consulting and Clinical Psychology. O.J. Stability and discriminant validity of the Adult Attachment Interview: A psychometric study in young Israeli adults. & Goldwyn. 271–286. Main.. 18. M. (1999). & Fallot. Steele (Eds. Attachment in Psychotherapy. Mikulincer. Studying differences in language usage in recounting attachment history: An introduction to the AAI. In H. and change.. Unpublished manuscript.). R.. & Eagle. New York: Guilford Press. Teague.A. 375–388. Williams. DC: American Psychiatric Press. & Janssens. 74(4). New York: Oxford University Press. Rogosch.M. 48(4). (2008). Patrick. 6(2). College Station.. (2009).. C. Multilevel and longitudinal modeling using Stata (2nd ed... 30(5).Attachment and Narrative Process in Therapy University Clinic. Castle. (2007). (1999). 725–733. Corcos.L. Ramsay. M. The organized categories of infant. Psychotherapy transcription standards. Shaver (Eds. D.. and clinical perspectives (pp. R. M. Attachment representations of institutionalized dolescents and their professional caregivers: Predicting the development of therapeutic relationships. Killeen. D. (2007). van Ijzendoorn. Perez Diaz. 1–104.. Department of Psychology. Turnbull. P. E.L. 72(3). J. 6. Speranza. (Eds. G. Vismara. Rabe-Hesketh. A. NJ: Analytic Press. Handbook of attachment: Theory. TX: Stata Press.. Sandros. American Journal of Orthopsychiatry. & Shaver. (2005). A. Hillsdale. Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. Zegers. Steele (Eds. R. developmental. Tesman. 125–142. & Maughan. H. O. 54(1–2). B. Steele. Psychoanalytic Psychology. Steele & M. Affect.. In J. Monographs of the Society for Research in Child Development. Developmental Psychology... Adult attachment. dynamics. & Cicchetti.. Steele & M.. M. E. In H. and developmental outcomes in an African American sample. Malatesta. Clin. M. and attachment: Working models of interpersonal affect and the socialization of emotion. Attachment in anorexia nervosa: A transgenerational perspective. (1994).. & First. J.. Eating and Weight Disorders. E.A. Guilbaud. Clinical Applications of the Adult Attachment Interview (pp.. Miller. J. M. R.H. Tyrrell. & Berant. E. Psychother. Hess. M. child. M.N. (2000). C. Cassidy & P. parental commitment to early intervention. M. Linking verbal and nonverbal representations: Computer analysis of referential activity. Slade. Department of Psychology... Mancone. Steele (Eds. Structured clinical interview for DSM-III-R personality disorders (SCID-II).A... Mergenthaler. Department of Psychology. Main. Psychol. research.). Ltd. M. J.. 498–511 (2011) . J. A. Psychotherapy Research. M. A. 31–68).. Hobson. Attachmenttheory-informed intervention and reflective functioning in depressed mothers.. (2008). Clinical applications of the Adult Attachment Interview (pp. C. A... M. & Hesse.).M.). W. E. Steele & M. University of Copenhagen. M..Z.P. D. Flament. 325–334 Copyright © 2010 John Wiley & Sons. M. (2008).M. M. (1999). Sorbello.R. Washington. In H.B. 407–474). F. R. British Journal of Medical Psychology.B. Parish. 166–170. 339–354. A. F. 154–174).. D. R. S. C.H. Attachment in adulthood: Structure. Attachment processes in eating disorders. P.M..H. Venisse. University of Copenhagen.. New York: The Guilford Press. New York: Guilford Press. Dozier. Obegi. Development and Psychopathology.L. (2006). Version 7. Howard... & Stinson. (2002). B.. Shaver (Eds.. & Koren-Karie. 76(3). Cassidy & P. G. & Treasure. Candelaria. M.). Gibbon. Scharf.L. The development of emotion expression during the first 2 years of life. (1990). Main. S. A. Handbook of attachment: Theory. New York: Guilford Press.A. R. 135(2). In J. Goldberg & R. Unpublished PhD thesis. Wallin. Culver. Bizouard. C. Stephan. Goldwyn. Pazzagli. C. with selected implications for clinical work. (1999). Toth.. 1055–1096. Attachment theory and research: Implications for the theory and practice of individual psychotherapy with adults..). Hesse. Muir (Eds. Attachment patterns among young women diagnosed with bulimia nervosa and their mothers. & Skrondal. & Bucci.W. 575–594)... and adult attachment: Flexible vs. P. Ward. 153–163.. 787–802). Depressive personality dimensions and alexithymia in eating disorders. N. (2001).. Effective treatment relationships for persons with serious psychiatric disorders: The importance of attachment states of mind. Inc. M. 126– 153). C. New York: Guilford Press. 2(2). and clinical applications (pp. Attachment to the therapist. inflexible attention under attachment-related stress. 771–777. Attachment theory and research in clinical work with adults.. Magai. C. Clinical Applications of the Adult Attachment Interview (pp. M. M. research.... Recent studies in attachment: Overview.C. Adult Attachment Scoring and Classification Systems. P.. Steele. (1995). Schuengel.. New York: Guilford Press. Spitzer. W.. In S. R D. R. (2001). L..).1. Personality disorder and the mental representation of early social experience. Attachment theory: Social. 20(2). & Pallanti. (1994). Journal of the American Psychoanalytic Association. (2008).. (2003).H.R. imagery.B. 497–505. S.R. New York: Guilford Press.. Norcross. & Jeammet.. 511 Ramacciotti. & O’Connell.). van IJzendoorn. Loas. Mergenthaler.

users may print. . However. Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. or email articles for individual use. download.Copyright of Clinical Psychology & Psychotherapy is the property of John Wiley & Sons.