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Psychoanalytic Psychology
2015, Vol. 32, No. 2, 235254

2014 American Psychological Association


0736-9735/15/$12.00 http://dx.doi.org/10.1037/a0038517

ATTUNING TO THE UNSPOKEN:


The Relationship Between Therapist Nonverbal
Attunement and Attachment Security
in Adult Psychotherapy
Else Hvs, MSc

Martin Svartberg, MD, PhD

Srlandet Hospital, Arendal,


Norway

Oslo, Norway

Pl Ulvenes, PhD
Modum Bad Psychiatric Center, Vikersund, Norway

This study investigated the relationship between affect attunement and subsequent improvement in attachment insecurity in adult psychotherapy. Particular
attention was given to nonverbal aspects of therapist affect attunement, as
defined and measured with the Affect Attunement Scales (AAS; Svartberg,
2005). Forty-nine patients diagnosed with cluster C personality disorders were
randomly assigned to 40 sessions of short-term psychodynamic psychotherapy
or cognitive therapy. Based on patients self-reports on the Inventory of Interpersonal Problems (Horowitz, Rosenberg, Baer, Ureo, & Villaseor, 1988),
attachment styles and attachment security were determined, following procedures described by Hardy and Barkham (1994). On the basis of audio data from
video recordings of an early session, trained raters used the AAS to determine
level of therapist attunement. Results showed that initial higher levels of
nonverbal matching of affect (one of the AAS scales) by the therapist predicted
a decrease in avoidant attachment style at termination, whereas nonverbal
matching of affect as well as nonverbal openness and regard for the patients
experiences (another AAS scale) predicted a decrease in ambivalent attachment
style. In contrast, verbal aspects of attunement did not predict attachment
outcome when the influence of nonverbal aspects were taken into account.
Being consistent with findings in infant studies (Beebe et al., 2000), our findings

This article was published Online First December 22, 2014.


Else Hvs, MSc, Department of Psychiatry, Srlandet Hospital, Arendal, Norway; Martin Svartberg, MD, PhD, Oslo, Norway; Pl Ulvenes, PhD, Modum Bad Psychiatric Center, Vikersund, Norway.
Correspondence concerning this article should be addressed to Else Hvs, MSc, Srlandet
Sykehus HF, DPS Aust-Agder, Postboks 783, Stoa, 4809 Arendal. E-mail: elsehav@hotmail.com

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HVS, SVARTBERG, AND ULVENES

regarding nonverbal attunement lend support to the intimate connection between


nonverbal affect attunement and attachment security across the life span.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Keywords: attachment, nonverbal affect attunement, affect regulation


This article reports on the first empirical study of the relationship between therapist affect
attunement and patient outcome in adult psychotherapy. The main purpose of the study
was to shed light on nonverbal mechanisms of therapeutic change. To that end, we
examined the relationship between nonverbal aspects of attunement assessed during an
early session and attachment security at termination.
The concept of attachment plays a central role in this study. Attachment pertains
essentially to the fundamental need in humans to form and maintain close affectional
bonds to an attachment figure in order to ensure safety and protection (Bowlby, 1969).
When bonds break or are threatened, specific attachment-seeking behaviors, characteristic
of the individual, are activated. These behaviors have been classified by Ainsworth (1978)
as either reflecting a secure attachment style, an insecure style of the ambivalent type, or
an insecure style of the avoidant type. Individuals with an ambivalent style are presumed
to have had experiences of the attachment figure as an unreliable and unpredictable source
of security and comfort, be prone to great distress when bonds are threatened, and either
resist or cling to the attachment figure. Individuals exhibiting an avoidant style, on the
other hand, are presumed to have had their bids for security and comfort rejected, tend to
dismiss attachment, and to inhibit affects in close relationships. The ambivalent style
corresponds roughly to Mains and Bartholomews preoccupied category (Horowitz,
Rosenberg, & Bartholomew, 1993; Main, 1996), whereas the avoidant style corresponds
roughly to Mains dismissing and Bartholomews dismissing-avoidant and fearfulavoidant categories. (For a detailed definition and elaboration of attachment terms and
issues, see below.)
Attachment status has been used as a measure of therapy outcome and has been found
to relate to a number of extratherapeutic and therapeutic variables such as mental health
indices, treatment outcome, and the therapeutic alliance. As far as mental health indices
are concerned, avoidant and ambivalent attachments have been associated with lower and
higher levels, respectively, of general, self-reported psychiatric distress (Pianta, Egeland,
& Adam, 1996). With respect to specific symptom disorders, avoidant attachment has
been found to relate to depression mediated through self-criticism, whereas the relationship between ambivalent attachment and depression was mediated through dependence
(Catarzano & Wei, 2010). Moreover, among patients with a diagnosis of PTSD both
avoidant and ambivalent attachment styles were observed to relate to PTSD symptoms
such as intrusion, behavioral avoidance, and hyperarousal (Ein-Dor, Doron, & Solomon,
2010), and insecure attachment in general was significantly more prevalent among patients
with eating disorders as compared with normal controls (Illing, Tasca, & Balfour, 2010).
Regarding personality disorders, patients with Cluster B and C disorders have been found
to show much insecurity of the ambivalent attachment type, whereas those with Cluster A
disorders had predominantly a style of avoidant attachment (Crawford et al., 2006).
Furthermore, Horowitz et al. (1993) found patients with a fearful-avoidant attachment
style to struggle primarily with interpersonal problems such as introversion, exploitability
and subassertiveness, whereas patients with a preoccupied style were found to be overly
expressive. In sum, the above findings converge to indicate that ambivalent and avoidant
attachment styles alike are related to diagnostic criteria of common disorders such as

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AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

237

depression, PTSD, eating disorders and personality disorders; however, patients with
ambivalent and avoidant styles report different levels of psychiatric distress and types of
interpersonal problems and are diagnosed with different types of personality disorders. It
is worth noting that the relationship of personality disorders to attachment status underscores the relevance of using attachment security/insecurity as an outcome measure in this
studys sample of patients diagnosed with Cluster C personality disorders.
Attachment status at the start of therapy has in several studies been found to relate to
therapy outcome. Fonagy et al. (1996) found initial attachment status to predict global
psychososial functioning as assessed with the GAF at the end of inpatient group and
individual psychoanalytic treatment. Interestingly, they observed that those with dismissing attachment improved the most during treatment, a finding that led Meyer and Pilkonis
(2001) to suggest that once they are helped to overcome their detached stance and
connect emotionally with the therapist, improvement may be all the more dramatic. On
the other hand, this finding was not replicated by Meyer, Pilkonis, Proietti, Heape, and
Egan (2001), who found secure attachment to predict improvement, whereas insecure
attachment was unrelated to outcome. Additionally, fearful-avoidant attachment at the
start of therapy and preoccupied attachment later in therapy have been found to predict
poor outcome of psychotherapy (Reis & Grenyer, 2004). In yet another study (Strauss et
al., 2006) preoccupied patients were found to be more likely to have poor outcomes,
whereas securely attached patients were found to be more likely to benefit from therapy.
Finally, fearful-avoidant patients have been found to improve at a slower rate from a major
depressive episode than other patients (Cyranowski et al., 2002).
Attachment status and insecurity as an outcome measure has been examined in several
studies. Fonagy et al. (1996) and Travis, Bliwise, Binder, and Horne-Moyer (2001;
time-limited dynamic psychotherapy) found that patients shifted attachment status from
insecure to secure during treatment, and Watson, Steckley, and McMullen (2013) found
that patients perception of therapists empathy was significantly associated with improvement in attachment insecurity in brief experiential therapy for depression.
Finally, several researchers (e.g., Levy, Ellison, Scott, & Bernecker, 2011; Mikulincer
& Shaver, 2007) consider a patients attachment status a central component in the
development of the therapeutic alliance. Holmes (2001) even understood the therapeutic
alliance as an attachment bond to the therapist. It is therefore not surprising that significant
and positive relationships between attachment and alliance in psychotherapy have been
observed (Diener & Monroe, 2011; Levy et al., 2011).
Despite theorized relationships, very little research has linked attachment with
in-session affective processes in general and nonverbal affective processes in particular. However, other nonverbal aspects of the psychotherapy process have been
studied. On the basis of a number of noncontrolled studies on the effects of nonverbal
synchrony, Ramseyer and Tschacher (2011) noted that evidence suggested that
synchrony might be linked to enhanced quality of the therapeutic relationship as well
as to improved patient outcomes (Ramseyer & Tschacher, 2011; see also Rubin &
Niemeier, 1992). This impression was confirmed in their own controlled study of
nonverbal synchrony (Ramseyer & Tschacher, 2011), which showed synchrony of
patient-therapist body movements to be associated with enhanced relationship quality
and positive patient outcomes.
The present study, which examines empirically the relationship between in-session
ratings of nonverbal aspects of affect attunement and outcome, adds to previous processoutcome research in at least three ways. First, it represents a systematic study in adult
psychotherapy of the construct of affect attunement, which in infant studies (e.g., Stern,

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HVS, SVARTBERG, AND ULVENES

1985) has been shown to facilitate an entry into another persons affect world and the
sharing of affects and, thus, to likely widen and deepen the affect focus found to be
associated with positive outcomes (Diener, Hilsenroth, & Weinberger, 2007). Second, this
study looks beyond the verbal content of the interaction to the content-free, nonverbal
dyadic coordination of affect states. Such coordination has the potential to activate and
modify preverbal experiences encoded in procedural, implicit memory (Beebe et al., 2000)
and, thus, to facilitate presymbolic emotion processing (Bucci, 1977), particularly relevant
in this sample of patients with deep-rooted character problems. In fact, nonverbal dyadic
cordination of affect states with children at 4 months has been found to predict their
attachment style and security at 12 months (Beebe et al., 2000) and, as well, the quality
of such coordination at 4 months has been found to predict secure versus disorganized
attachment outcomes at 12 months (Beebe et al., 2012). Third, to our knowledge the
present study represents the first attempt to evaluate nonverbal patient-therapist affective
processes as observed directly in adult psychotherapy and at the same time study the
relationship of those processes to attachment outcome, thereby filling a gap in the research
literature.
The design, procedures and research hypotheses of the present study were inspired and
informed by attachment theory and classification, affect regulation theory and research,
the concept of affect attunement, as defined in infant research (Stern, 1985) and adult
psychotherapy (Svartberg, 2005) as well as research on nonverbal dyadic coordination of
affect states (Beebe et al., 2000). Each of these areas will be elaborated on in some detail
in the following paragraphs.
Using a laboratory procedure known as the Strange Situation, Ainsworth (1978)
systematically observed 1-year-old infants behaviors on separation from and reunion with
their mothers and, as a result, was able to classify a child as exhibiting either a secure
attachment style, an insecure attachment style of the ambivalent type or an insecure
attachment style of the avoidant type. A fourth category, the disorganized style, has later
been added (Main, 1996; Main, Kaplan, & Cassidy, 1985). This study focused on the
avoidant and ambivalent styles only.
The securely attached infant reacts with some distress when separated, is easily
comforted and reassured when reunited with the mother, and returns readily to play upon
reunion; thus, she is able to use the mother as a secure base from where to explore the
environment. In contrast, the insecurely attached child of the ambivalent type responds to
separation with great distress, resists attempts at being comforted when reunited, is unable
to play and explore, and remains preoccupied with the mother whom she either resists or
clings to (showing ambivalence). Ainsworth (1978) observed that mothers of ambivalently
attached infants failed in the tender holding of the baby and were inconsistently and
unpredictably available. On the other hand, infants exhibiting insecure attachment of the
avoidant type show little distress when separated from the mother and turn away from and
refuse contact with the mother upon reunion (showing avoidance) before returning to play.
Ainsworth (1978) found that their mothers tended to reject attachment behaviors, in
particular physical touch. Ainsworths main findings have later been replicated in many
studies (Main, 1996). Attachment behaviors tend to continue throughout life, are activated
in times of emotional stress, and reflect internal representations of self with significant
others, especially what to expect from the other. In light of the above attachment
characteristics, the adult patient with an ambivalent attachment style is likely to experience the therapist as inconsistently and unreliably available as a source of security and
comfort, to become easily overwhelmed with heightened affects, and to be preoccupied
with interactive regulation of those affects. On the other hand, the patient with an avoidant

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AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

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style is likely to inhibit affect displays for fear of rejection, to dismiss attachment to the
therapist, and to appear self-sufficient and preoccupied with self-regulation (Alexander &
Anderson, 1994; Meyer & Pilkonis, 2001).
Affect attunement, which is at the core of this study, pertains fundamentally to
regulation of affects. Affect regulation can be described as psychological strategies
designed to maintain or restore biological and psychological homeostasis during times of
overwhelming emotions. It has been shown empirically that attuned responsiveness by
caregivers has pervasive effects on a childs capacity for self-regulation of affects (Beebe
& Lachmann, 1998, 2002; Sander, 1983, 1985; Schore, 2001) and on the development of
a sense of self (Stern, 1985). In addition, psychoanalytic theory (e.g., Stolorow, Brandchaft, & Atwood, 1987) has emphasized the pivotal role played by affect attunement in
organizing affect life in general and in repairing disruptions in particular. According to
Sander (1994); Beebe et al. (2000), and Beebe and Lachmann (1998), affect states are
regulated in principally two different ways: (a) through the individuals own agency in
initiating actions to self-regulate (implying singularity) and (b) through ongoing interactions with a significant other (implying relatedness or intersubjectivity). These two ways
of regulation are often referred to as the pole of being distinct from the other and the
pole of being together with the other, respectively (Sander, 1994). We have termed this
the bipolar model of affect regulation. According to the above authors, the chief developmental goal to be attained by the child is for these two poles to become loosely coupled;
that is, for both to become comfortable possibilities that enable the growing child to switch
flexibly between the two. However, when interactive regulation becomes predominant at
the expense of self-regulation in the developing child, the poles become tightly coupled,
which is typically seen in disorganized and ambivalent attachment styles. In the opposite
case, when self-regulation comes to predominate over interactive regulation, the poles
become too loosely coupled, as is seen in avoidant attachment style.
The validity of this bipolar model of self and interactive regulation, along with its
developmental implications, has been well supported by empirical research in infants and
caregiver-infant interactions (Beebe et al., 2000; Beebe & Lachmann, 1998, 2002; Sander,
1977, 1985). More specifically, a loose coupling of the poles has been shown to facilitate
access to, awareness of, regard for, and ability to use inner affect states in the growing
child and adult (Sander, 1977, 1985). Development of a loose coupling of the poles is
thought to rely on the caregivers ability to steadily attune to the childs emotional needs
and states (Sander, 1995; Stern, 1985). Optimal attunement is thought to give rise to what
Sander (1995) referred to as moments of meeting. In turn, they are followed by the
emergence of an open space in time (Sander, 1977, 1994) during which the child is
temporarily disengaged from the need for interactive regulation with the caregiver,
self-initiates actions, and sets its own goals, thereby enhancing greatly the capacity to
self-regulate. A hallmark of a tight coupling of poles is poorly developed self-regulatory
capacities.
As far as affect attunement is concerned, Stern (1985) provided a shorthand definition
of affect attunement as a recasting, a restatement of a subjective state in the infant. Stern
and colleagues (Haft & Slade, 1989; Stern, 1985) then went on to hypothesize that two
basic dimensions underpinned the concept of affect attunement; that is, the caregivers
regard for and openness to the infants affective experience and the caregivers matching
of aspects of that experience such as intensity, timing and shape/contour. As noted by
Beebe and Lachmann (1998, 2002) there are similarities between adult-infant and adultadult interactions with respect to affect coordination in general and nonverbal aspects of
such coordination in particular. With that in mind, the second author developed the Affect

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Attunement Scales (AAS; Svartberg, 2005), which can be considered an expanded,


detailed and operationalized definition of affect attunement in the context of adult
psychotherapy. As can be seen in Appendix, the AAS comprise four scales. Each scale
defines and specifies degrees of therapist attunement and malattunement. In line with
Sterns conception of affect attunement, two basic dimensions are assumed to underlie the
four scales of the AAS, that is (a) the therapists openness and regard for the patients
ongoing subjective experiences and (b) the therapists matching of those experiences in
terms of type of affect, intensity and timing. These two dimensions may be considered the
core definition of affect attunement in the adult psychotherapy setting. Two scales of the
AAS, one capturing verbal responsiveness (scale 1A) and one capturing nonverbal
responsiveness (2A), reflect the dimension of therapist openness and regard, whereas the
two remaining scales (1B: verbal responsiveness; 2B: nonverbal responsiveness) reflect
the dimension of therapist matching of aspects of patient experiences.
As per above, the primary interest of this study was to examine the relationship
between in-session scores on the two nonverbal scales of the AAS in an early session and
improvement in attachment insecurity during therapy. As can be seen in Appendix, scale
2A captures degrees of therapist facilitation of patient self-exploration (reflecting attunement) and degrees of therapist hindrance of such exploration (reflecting malattunement),
respectively. Self-exploration is facilitated through a listening stance characterized by
increasing attentiveness, interest and compassion, while self-exploration is hindered by
increasing frequency of interruption of patient speech. The scale can be viewed as
reflecting dyadic coordination of rhythms of behavior such as sound (degrees of therapist
interruption) and silence (degrees of therapist listening). With such a strong focus on
self-exploration it is reasonable to expect that positive scores on this scale may improve
access to inner states in certain patients. The other nonverbal scale, scale 2B, reflects the
extent to which the therapists vocal qualities at any given moment in time are in
dissonance (representing malattunement) or resonance (representing attunement) with the
level of arousal associated with the patients ongoing feeling state. Dissonance and
resonance can be viewed as representing dyadic, content-free uncoordination (mismatch)
and coordination (match), respectively, of therapist voice qualities and physiologic arousal
on the part of the patient. Such matching of emotional arousal was by Stern (1985) termed
joining or state sharing and has the potential to bring two partners into a similar state,
facilitating intimacy and attachment (Beebe & Lachmann, 2002).
To our knowledge no empirical study has yet been conducted to examine in-session
ratings of therapist attunement and its relationship to patient outcome in adult psychotherapy. However, the study by Beebe et al. (2000) on infants parallels the present study
in some ways. Their study showed that nonverbal elements such as vocal rhythm
coordination with children at 4 months of age predicted their attachment style and security
at 12 months of age. Moreover, they found that secure attachment relied on flexible dyadic
coordination at a medium range level. Excessively high coordination was predictive of
ambivalent and disorganized attachment, whereas extremely low coordination predicted an avoidant attachment style. They interpreted these findings to mean that the
highest degree of coordination limited the childs opportunity for open space experiences, subsequently leading to poor access to inner experiences. These children can
be viewed as being preoccupied with interactive regulation, or, in the parlance of
Sander (1994), as having the poles of self and interactive regulation tightly coupled.
The lowest degree of coordination, on the other hand, was by Beebe et al. (2000) and
thought to lead to the infant withdrawing into preoccupation with self-regulation of
distress states or, according to Sander (1994), developing a too loose coupling of the

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AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

241

poles. Beebe et al. (2000) also highlighted the power of nonverbal dyadic coordination
of affect states to modify presymbolic representations through altering behavioral
expectancies organized at the procedural, nonsymbolic level in implicit memory.
As mentioned earlier, we were particularly interested in examining the relationship
between in-session scores on the nonverbal scales of the AAS in an early session and
improvement in attachment insecurity during therapy. Because nonverbal dyadic coordination of affect states as represented by the nonverbal scales presumably has the potential
to process and transform very early experiences organized at the procedural level (Beebe
et al., 2000; Bucci, 1977), we hypothesized that higher levels of therapist nonverbal
attunement in general (the nonverbal scales pooled) would be related to less attachment
insecurity at termination in this sample of patients with deep-rooted character problems.
In the absence of previous empirical studies of attunement in adult psychotherapy, our two
specific hypotheses were informed by attachment theory (Main, 1996; Main et al., 1985;
Meyer & Pilkonis, 2001) and infant studies (Stern, 1985; Beebe & Lachmann, 2002).
Patients with an ambivalent attachment style are presumed to have had experiences of the
attachment figure as an unreliable and unpredictable source of security and comfort, and
be prone to overaroused states. We reasoned that consistent nonverbal openness and
regard for the patients ongoing experiences (scale 2A) would establish the therapist as a
trusting and available presence as well as a manager of excessive arousal and a facilitator
of self-exploration and thinking in these patients. Hence, we specifically hypothesized that
higher scores on scale 2A would be associated with a significant decrease in ambivalent
attachment insecurity at termination in patients with an ambivalent attachment style at
intake. On the other hand, patients with an avoidant attachment style are presumed to have
had their bids for security and comfort rejected, tend to dismiss attachment, and to inhibit
affects in close human encounters. Nonverbal matching of patient affect (scale 2B) may
give rise to joining or state sharing experiences, which by Stern (1985) has been shown
to have the potential to bring partners into a similar affect state and, as a result, to facilitate
affect expression and connection. We therefore specifically hypothesized that higher
scores on scale 2B would predict a significant decrease in avoidant attachment insecurity
at termination in patients with an avoidant attachment style at intake.

Method
Patients, Treatments, and Therapists
Forty-nine patients between the ages of 18 and 65 who met criteria for one or more
DSMIIIR cluster C personality disorder diagnosis (i.e., avoidant, obsessive
compulsive, dependent, passive-aggressive, and self-defeating disorder) were included in
the study. In terms of Axis I-diagnoses, most patients met criteria for various depression
or anxiety diagnoses.
This study used outcome data from an original study by Svartberg, Stiles, and Seltzer
(2004). In relation to the original patient sample, one patient had to be excluded because
of incomplete video recordings of treatment sessions. Hence, in the present study 25
patients received 40 sessions of short-term dynamic psychotherapy (STDP; Vaillant,
1997). The overall goal of this model of STDP is for previously avoided affects such as
sadness/grief, anger, or tenderness to be experienced bodily and mentally and then
expressed adaptively by the patient. All therapists were experienced psychiatrists and
clinical psychologists in full-time clinical practice (except for one). Twenty-four patients
received 40 sessions of cognitive therapy (CT; Beck & Freeman, 1990). Through a variety

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of cognitive techniques, the CT therapist helps the patient develop new and more adaptive
core beliefs as well as more adaptive problem-solving interpersonal behaviors. All CT
therapists were experienced clinical psychologists who, except for one, were in full-time
clinical practice. For a full description of the patient sample, therapists, and treatments, see
Svartberg et al. (2004).

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Measures
Attachment Classification and Insecurity
In the original study patients completed the Inventory of Interpersonal Problems-125
(Horowitz, Rosenberg, Baer, Ureo, & Villaseor, 1988) at intake, midtherapy, and
termination. By factor-analyzing the IIP-125, Hardy and Barkham (1994) showed that 14
of the IIP-125 items reflected in a valid way an avoidant attachment style (internal
consistency .88) whereas seven items reflected an ambivalent attachment style (internal
consistency .76). Internal consistency coefficients (alphas) based on pretherapy values
in our patient sample were .87 for the avoidant attachment scale and .59 for the ambivalent
attachment scale. Based on patients IIP-125 scores and following the procedures described by Hardy and Barkham (1994), we computed for each patient a score on the
avoidant factor and a score on the ambivalent factor.

Therapy Outcome
Patients scores at termination on the avoidant and ambivalent factors were used as
outcome measures. They purport to represent degrees of attachment insecurity/security.

Prediction of Change
The Affect Attunement Scales (AAS; Svartberg, 2005) comprise four Likert-type rating
scales each with six response options ranging from 3 (extreme malattunement or
nonattunement) to 3 (optimal or communing attunement; see Appendix). Two scales
capture verbal responsiveness (1A and 1B) and two scales capture nonverbal responsiveness (2A and 2B). As noted previously, scales 1A and 2A are presumed to reflect the
underlying dimension of therapist openness and regard for the patients ongoing subjective experiences, whereas scales 1B and 2B are presumed to reflect the dimension of
therapist matching of aspects of the patients experience. The AAS lend themselves to be
applied by trained raters to taped recordings of therapy dyads. In order to render the AAS
as widely applicable as possible, they were originally designed to be used with audiotaped
recordings. Thus, visual markers of attunement are not included in the scales. The AAS
can be considered transtechnical in the sense that raters who use the AAS to assess degrees
of attunement and malattunement are not concerned with the specific techniques applied
by the therapist; that is, whether they are characteristic of psychodynamic therapy (e.g.,
transference interpretation), cognitive therapy (e.g., disputing core maladaptive beliefs) or
any other approach to therapy. Rather, raters are concerned with whether the specific
technique applied is considered an attuned or malattuned response to the patients ongoing
experience. Formally, the AAS can be classified as a responsiveness measure (Llewelyn
& Hardy, 2001) as it purports to capture the extent to which the therapist is responsive or
unresponsive to the emotional needs of the patient at any given point in time.
The AAS provide a detailed description of what the attunement-malattunement process may look like in practice. The first verbal scale, 1A, reflects the extent to which the

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therapist allows the patient to sit with his or her feelings without intervening to prematurely alter or end them as well as the extent to which the therapist facilitates patient
self-exploration. Malattuned responses range from extreme malattunement such as telling
the patient in an insensitive and expert-like way how he or she should feel, through less
extreme malattunement such as correcting the patients feeling, or draining off the
emotional aspect of the experience, or dampening the emotional intensity, to mild forms
of malattunement such as changing or prematurely closing a topic, or summarizing patient
material in a too conclusive manner, or ignoring affective cues. The other verbal scale, 1B,
describes (a) malattunement in terms of the degree to which the therapist misidentifies
type of affect (e.g., mistakes sadness for anger, or anxiety for despair) and misjudges the
intensity of the patients experience, and (b) attunement in terms of how accurately and
specifically the therapist recognizes type and intensity of patient affect. The first nonverbal
scale, 2A, assesses malattunement in terms of frequency of interruption of patient
self-exploratory speech, and attunement in terms of listening qualities such as listening
with increasing attentiveness, interest and compassion. It should be noted that therapist
interventions do not qualify as an interruption if they take the form of encouraging or
supportive prompts with the intention to further or deepen the patients selfexplorations. The other nonverbal scale, 2B, assesses the extent to which the therapists vocal qualities are deemed to be in dissonance or resonance with the patients
ongoing feeling state as well as whether the therapists response reflects sincere and
wholehearted engagement with the patient or not. Dissonance and resonance represent
a mismatch and a match, respectively, of therapist vocal qualities and patient level of
emotional arousal. An example of a mismatch between the two would be if the
therapist responds in a loud, high-pitched, fast and sharp voice to a patient who, while
crying, talks slowly and softly. In this case the patients affect state is characterized
by low energy and activation, whereas the therapists vocal qualities leave the
opposite impression.
Attunement ratings in this study were performed by two graduate clinical psychology
students who had been trained in using the AAS and were blind to treatment type and
outcome, and who rated videotapes (n 49) of an early session, typically the sixth. For
rating purposes sessions were divided into 2-min segments. After reviewing each
session segment, raters independently of each other made a score from 3 to 3
describing the therapists level of attunement-misattunement in that segment. Each
raters segment ratings were then pooled to a mean session score to be subsequently
included in the data analyses. The analysis of interrater reliability yielded an intraclass
correlation coefficient (ICC [2,2]; Shrout & Fleiss, 1979) of .81 for nonverbal
matching (scale 2B), .88 for nonverbal openness and regard (scale 2A). For the two
verbal scales ICCs were .82 (for verbal matching; scale 1B) and .85 (for verbal
openness and regard; scale 1A).
The AAS have also been tested as to interrater reliability in previous studies. ICCs
have ranged from .85 to .88 for verbal openness and regard, was .82 for verbal
matching, ranged from .87 to .88 for nonverbal openness and regard and ranged from
.81 to .86 for nonverbal matching (Gallefoss & Utgarden, 2006; Olsen, 2006). In
addition, ICCs for the verbal scales pooled was .73, .67 for the nonverbal scales
pooled, and .70 for all scales pooled (Be, 2005). In two previous studies the validity
of the AAS has been examined. As theoretically expected, the AAS showed fairly high
correlations with patients affective experiencing (ranging from .61 to .84 for the four
scales; Gallefoss & Utgarden, 2006) and small to moderate correlations with the

244

HVS, SVARTBERG, AND ULVENES

patients experience of the therapeutic alliance (ranging from .20 to .28 for the four
scales; McNaughtan, 2008).

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Results
Mean avoidant attachment score in the patient sample at intake was 1.67 (SD .74) and
1.41 (SD .69) at termination. A dependent t test showed a significant reduction in
avoidant attachment scores from before to after treatment (t(48) 2.74, p .01). Mean
ambivalent attachment score at intake was 1.90 (SD .64) and 1.45 (SD .78) at
termination. A dependent t test showed a significant reduction in ambivalent attachment
scores from before to after treatment, t(48) 4.40, p .001.
In order to assess the relationship between therapist affect attunement in an early
session and outcome, hierarchical multiple regression analyses were run for each of the
outcome variables, that is, avoidant attachment score and ambivalent attachment score at
termination. In each of the six regression models (see Tables 1 and 2), the influence of
several variables was controlled for, that is, age (entered in the first step), gender (in the
second step; in addition to age), intake scores on the outcome variable (in the third step;
in addition to age and gender), verbal attunement (in the fourth step; in addition to age,
gender and intake scores), and nonverbal attunement, the variable of special interest (in
the last and fifth step; in addition to the other covariates). As central demographic
variables, age and gender were entered a priori, whereas intake scores on the outcome
variables and verbal attunement were entered to partial out variance accounted for by
these two covariates. The results of the regression analyses are presented in Table 1
(avoidant attachment as outcome) and Table 2 (ambivalent attachment as outcome).
Table 1 shows that nonverbal attunement in general (scales 2A and 2B pooled) had a
statistically nonsignificant (p .06) and moderately large effect (Cohens d .55; d
.50 is medium, d .80 is large; Cohen, 1988) on avoidant attachment scores at
termination, whereas nonverbal matching (scale 2B) had a statistically significant and
close to large effect (d .75). By including nonverbal matching as a predictor in Step 5,
explained variance increased by 10%, which was statistically significant. Nonverbal
openness and regard (scale 2A), however, had a statistically nonsignificant and small
effect (d .24) on avoidant attachment scores at termination. The direction of the
relationship between nonverbal matching and attachment improvement was such that
higher scores on nonverbal matching in an early session were associated with lower
avoidant attachment scores (less insecurity) at termination. Table 1 also shows that before
including nonverbal aspects of attunement as predictors in the last steps, verbal aspects of
attunement did not relate to avoidant attachment improvement.
Table 2 shows the results of another three regression analyses, now with ambivalent
attachment scores at termination as the outcome variable. It can be seen that nonverbal
attunement in general, nonverbal matching, as well as nonverbal openness and regard, all
had statistically significant and moderately large effects (ds .72, .69 and .69, respectively) on ambivalent attachment scores at termination. Explained variance increased by
9%, 8% and 8%, respectively, and all increases were statistically significant. Table 2 also
shows that before including nonverbal aspects of attunement as predictors in the last steps,
verbal attunement in general, verbal matching, and verbal openness and regard all related
significantly and positively to ambivalent attachment improvement. It can also be seen,
however, that when nonverbal aspects of attunement were included as predictors in the last
steps, the relationships involving verbal attunement were no longer statistically signifi-

AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

245

Table 1
The Effects of Predictors on Avoidant Attachment Outcome
Step

Predictor

SE

Beta

R2

R2

1
2

Age
Age
Gender
Age
Gender
Avoidant attachment score at intake
Age
Gender
Avoidant attachment score at intake
Verbal attunement
Age
Gender
Avoidant attachment score
Verbal attunement
Nonverbal attunement
Age
Age
Gender
Age
Gender
Avoidant attachment score at intake
Age
Gender
Avoidant attachment score at intake
Attunement: verbal matching
Age
Gender
Avoidant attachment score at intake
Attunement: verbal matching
Attunement: nonverbal matching
Age
Age
Gender
Age
Gender
Avoidant attachment score at intake
Age
Gender
Avoidant attachment score at intake
Attunement: verbal openness/regard
Age
Gender
Avoidant attachment score at intake
Attunement: verbal openness and regard
Attunement: nonverbal openness/regard

.012
.010
.294
.006
.156
.494
.005
.143
.475
.164
.002
.099
.502
.350
.576
.012
.010
.294
.006
.156
.494
.005
.150
.471
.157
.000
.073
.499
.402
.619
.012
.010
.294
.006
.156
.494
.005
.136
.481
.163
.005
.128
.494
.085
.287

.013
.013
.207
.011
.180
.120
.011
.178
.119
.116
.010
.174
.116
.289
.299
.013
.013
.207
.011
.180
.120
.011
.178
.120
.122
.010
.169
.113
.241
.236
.013
.013
.207
.011
.180
.120
.011
.177
.118
.109
.011
.178
.120
.314
.340

.143
.113
.212
.070
.112
.533
.058
.103
.512
.178
.027
.072
.541
.379
.607
.143
.113
.212
.070
.112
.533
.058
.108
.507
.164
.002
.053
.538
.418
.667
.143
.113
.212
.070
.112
.533
.059
.098
.518
.187
.05
.09
.53
.10
.30

.34
.45
.16
.58
.39
.00
.65
.43
.00
.17
.83
.57
.00
.23
.06
.34
.45
.16
.58
.39
.00
.65
.41
.00
.20
.99
.67
.00
.10
.01
.34
.45
.16
.58
.39
.00
.64
.45
.00
.14
.676
.478
.000
.788
.404

.02

.02

.06

.04

.34

.30*

.37

.03

.42
.02

.05
.02

.06

.04

.34

.30*

.36

.02

.46
.02

.10*
.02

.06

.04

.34

.30*

.37

.03

.38

.01

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1
2
3

1
2
3

* p .05.

246

HVS, SVARTBERG, AND ULVENES

Table 2
The Effects of Predictors on Ambivalent Attachment Outcome
Step

Predictor

SE

Beta

R2

1
2

Age
Age
Gender
Age
Gender
Ambivalent attachment score at intake
Age
Gender
Ambivalent attachment score at intake
Verbal attunement
Age
Gender
Ambivalent attachment score at intake
Verbal attunement
Nonverbal attunement
Age
Age
Gender
Age
Gender
Ambivalent attachment score at intake
Age
Gender
Ambivalent attachment score at intake
Attachment: verbal matching
Age
Gender
Ambivalent attachment score at intake
Attachment: verbal matching
Attachment: nonverbal matching
Age
Age
Gender
Age
Gender
Ambivalent attachment score at intake
Age
Gender
Ambivalent attachment score at intake
Attunement: verbal openness/regard
Age
Gender
Ambivalent attachment score at intake
Attachment: verbal openness/regard
Attachment: nonverbal openness/regard

.007
.007
.013
.007
.044
.669
.010
.000
.593
.346
.013
.051
.599
.374
.812
.007
.007
.013
.007
.044
.699
.010
.008
.581
.362
.015
.061
.594
.210
.636
.007
.007
.013
.007
.044
.669
.009
.007
.606
.321
.010
.023
.599
.411
.849

.015
.015
.243
.013
.208
.163
.012
.196
.155
.131
.011
.185
.146
.311
.322
.015
.015
.243
.013
.208
.163
.012
.196
.156
.137
.011
.187
.148
.271
.264
.015
.015
.243
.013
.208
.163
.012
.197
.155
.124
.011
.186
.147
.330
.358

.077
.076
.008
.073
.028
.534
.099
.000
.473
.329
.135
.032
.478
.355
.749
.077
.076
.008
.073
.028
.534
.102
.005
.464
.330
.150
.039
.475
.192
.600
.077
.076
.008
.073
.028
.534
.095
.004
.484
.322
.107
.014
.478
.413
.788

.61
.62
.96
.58
.84
.00
.43
.99
.00
.01
.26
.78
.00
.24
.02
.61
.62
.96
.58
.84
.00
.42
.97
.00
.01
.21
.75
.00
.44
.02
.61
.62
.96
.58
.84
.00
.45
.97
.00
.01
.37
.90
.00
.22
.02

.01

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1
2
3

1
2
3

* p .05.

R2

.01

.00

.29

.28*

.39

.10*

.48
.01

.09*
.01

.01

.00

.29

.28*

.39

.10*

.47
.01

.08*
.01

.01

.00

.29

.28*

.39

.10*

.47

.08*

AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

247

cant. In essence, Table 2 shows that nonverbal aspects of attunement had significant
effects over and above those of verbal aspects.

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Discussion
As expected, nonverbal affect attunement in general predicted significantly less ambivalent attachment insecurity and close to significantly less avoidant attachment insecurity at
termination. With respect to the specific aspects of nonverbal attunement, however, the
results differed for avoidant and ambivalent attachment styles. For avoidant attachment
improvement, nonverbal matching of affect proved, as expected, a statistically significant
and strong predictor, whereas nonverbal openness and regard did not, as expected, have
any significant influence on avoidant attachment insecurity at termination. For ambivalent
attachment improvement, on the other hand, both matching of affect and openness and
regard for the patient experience proved statistically significant and fairly strong predictors of outcome. The finding that matching of affects was a significant predictor of
ambivalent attachment improvement runs counter to our initial specific hypothesis.
Regarding verbal attunement, neither verbal attunement in general, verbal matching,
nor verbal openness and regard related to avoidant attachment improvement; however,
these verbal aspects of attunement related significantly and positively to ambivalent
attachment improvement before taking into account the influence of nonverbal aspects of
attunement (Step 4 in Table 2). Once this influence was taken into account, however,
verbal aspects of attunement did not predict ambivalent attachment improvement. Nonverbal aspects of attunement, on the other hand, had a significant effect over and above
those of verbal aspects of attunement. This is in line with Be (2005) who found that
nonverbal affect attunement assessed in an early segment of a session predicted greater
patient affective experiencing in a later segment independently of verbal attunement,
whereas the reverse was not true. Taken together, this may imply, if replicated, that
verbally attuned responses have little impact on outcomes if they do not go hand in hand
with adequate nonverbally attuned responses. In other words, verbal responses would fall
on deaf ears if nonverbal attunement is not in place. Stated differently and more formerly,
the relationship between verbal and nonverbal attunement found in this study with respect
to ambivalent attachment outcome may suggest that nonverbal attunement is mediating
the relationship between verbal attunement and outcome (Baron & Kenny, 1986). Notwithstanding this point, this studys main finding highlights the potentially pivotal role
played by nonverbal, procedural factors in adult psychotherapy, and thus adds to the
findings by Ramseyer and Tschacher (2011) regarding nonverbal body movement synchrony.
Overall, the results are consistent with the general finding by Beebe et al. (2000) that
nonverbal aspects of the caregivers responses played a significant role in bringing about
attachment security in the baby. The results may also point to and specify what the Boston
Change Process Group (Stern et al., 1998) had in mind when they highlighted the
importance of the something more than interpretation in effecting change. This something, they argued, was too poorly understood in psychoanalytic psychotherapy. Finally,
the results of this study also support Schores proposals (Schore, 2011; Schore & Schore,
2008) about the central role played by nonverbal, right brain mechanisms in effecting
positive outcomes in adult therapy.
Clinically speaking, the findings of this study may imply that with patients with an
avoidant attachment style such as many of those diagnosed with avoidant or schizoid

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248

HVS, SVARTBERG, AND ULVENES

personality disorders, therapists would do well in coordinating aspects of their vocality


such as loudness, tone and pitch with the affective state and arousal of the patient at a
given point in time (scale 2B). A clinical example of uncoordination or mismatch is given
in the description of the AAS. Whether one interrupts or listens to the patients selfexplorations (scale 2A) seems to matter less for this patient group. However, for patients
with an ambivalent attachment style such as many of those diagnosed with borderline
personality disorder or many traumatized patients in general, both dimensions of nonverbal attunement (nonverbal matching as well as nonverbal openness and regard) seem to
matter with respect to positive outcome. This finding makes clinical sense as these
patients, prone as they may be to overaroused states, can be very sensitive to abrupt
interruptions by the therapist and may react with strong emotions to such interruptions,
possibly leading to serious disruptions in the relationship.
One may speculate as to what processes mediate the effects of nonverbal attunement
on improvement in attachment insecurity during therapy. Sanders (1994) bipolar conception of affect regulation, which was elaborated on earlier, may shed some light on this.
As far as affect regulation is concerned, the chief developmental goal according to Sander
is for self- and interactive regulation to become loosely coupled poles, that is, for both to
become comfortable possibilities for the growing child and adult. The poles become
tightly coupled when, as a result of developmental derailment, there is a predominance of
interactive regulation (being together with) at the expense of self-regulation (being
distinct from) of affects. Conversely, the poles become too loosely coupled when
self-regulation predominates over interactive regulation. Patients with an ambivalent
attachment style (along with those with a disorganized attachment style) may be considered prototypical of a tight coupling of poles, whereas patients with an avoidant
attachment style may be considered prototypical of a too-loose coupling. As shown in
this study both nonverbal matching of affects and openness and regard for the patient
experiences were associated with less attachment insecurity in patients with an
ambivalent attachment style. Hence, in light of Sanders model, both of these attuned
responses can be said to have served the function of disjoining the poles, thereby
creating a better integration or balance of the poles. As a consequence, the repertoire,
functionality and effectiveness of their overall regulatory capacity, in particular
self-regulation, are likely expanded and improved, subsequently leading to greater
attachment security at treatment termination.
For patients with an avoidant attachment style, on the other hand, we assume that
nonverbal matching of affects may have served the function of bringing the poles closer
together, rendering interactive regulation (being together with) less threatening and
more feasible. As a consequence, for these patients steady nonverbal matching may have
expanded on and improved the repertoire, functionality and effectiveness of their overall
regulatory capacity, in particular interactive regulation, thereby leading to greater attachment security at treatment termination. In sum, patients with an ambivalent attachment
style may benefit from a particular pattern of nonverbal dyadic coordination characterized
by matching and openness and regard, whereas patients with an avoidant attachment style
may benefit from a pattern of dyadic coordination primarily characterized by nonverbal
matching. Thus, different patterns of dyadic coordination may contribute to favorable
outcomes among different patients. It needs to be borne in mind, however, that the
findings of this study should be considered preliminary and await replication in larger
patient samples, in long-term treatments, across various outcome measures and in research
designs where attunement is assessed in later phases of therapy.

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AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

249

One limitation of this study concerns the measure used to classify attachment styles.
The two factors derived from the IIP-125 by Hardy and Barkham (1994) used in this study
have, as a classification measure of attachment styles, not been widely used and well
tested. It thus remains an open question whether the results would have been different if
a more widely used and well-tested measure such as the Adult Attachment Interview had
been employed.
It is also worth noting that the Affect Attunement Scales (AAS) were originally
developed to be employed by raters of audiotaped recordings of therapy sessions. As such,
they leave out visual patient markers of affect states, thereby limiting the scope and
validity of the ratings of attuned therapist responses.
The findings of this study may also have implications for the training and development
of therapists. In the hands of a psychotherapy supervisor we have found the AAS to be
valuable in several ways and have specifically been struck by (1) how quickly the AAS
take the supervisor through the often complex and bewildering layers of the therapistpatient interchanges to the core affective aspects of the relationship; (2) how the AAS may
serve as a guide in the search for consistent patterns in the ways a particular therapist
relates emotionally to his or her patient and, consequently, how efficiently the scales tease
out the idiosyncratic relational style of a particular therapist; (3) how concisely and
accurately the AAS enable the supervisor to feed back insights to the trainee; and (4) how
the AASs logic, underlying dimensions and specified therapist responses may provide
direct guidelines for the trainee in developing an attuned way of responding to patients
feeling states. In cultivating attunement among therapists another main point pertains to
the facilitating conditions for the attunement process to happen. Based on interviews with
attuning mothers, Stern (1985) noted that their personal reasons for responding in an
attuned way were to be with the infant, to share, to participate in or join in with
the infants experience. This is in contrast to a stance that tends to influence the infants
behavior in a certain direction. Translated to the context of adult psychotherapy, facilitating factors of the attunement process would include relinquishing any intention to
influence or change the patient at a particular moment in time, availability of attention,
emotional availability, the focusing of primary attention on the patients subjective
experiences, and letting oneself as a therapist be moved by the patients story and feelings.
It should be emphasized, however, that attuned responses, especially the nonverbal ones,
reflect essentially an intuitive, spontaneous and immediate therapist activity (i.e., perception-action based) and are to a lesser degree driven by cognitive processes. It is thus
reasonable to assume that this fact may limit the extent to which attuned responsiveness
can be fully learned.
The great majority of psychotherapy research studies have stopped short of examining
nonverbal dimensions of the therapeutic process. This limitation has arguably precluded
a fuller understanding of the therapeutic action of psychotherapy. The present study
illuminates quite clearly this problematic shortcoming. Had it not been for the fact that we
included nonverbal aspects of attunement as predictors in addition to verbal aspects, we
might easily have concluded that verbal attunement was a significant and strong predictor
of ambivalent attachment improvement and that that was the end of the story. In light of
this, future psychotherapy studies would do well in assessing and including nonverbal
aspects so as to get as complete a picture as possible of the therapeutic process. This brings
to focus the complex relationship between verbal and nonverbal dyadic coordination in
effecting change. It is for future studies to examine more fully the assumption that
presymbolic material mobilized through nonverbal coordination needs to be represented
symbolically through verbal interventions (Beebe et al., 2000) for lasting changes to

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250

HVS, SVARTBERG, AND ULVENES

happen. It would also be for future studies to examine whether nonverbal attunement
indeed operates as a mediator of the relationship between verbal attunement and patient
outcomes. Finally, the relationship between affect attunement and the formation of the
therapeutic alliance also awaits future investigations.
To our knowledge this study represents the first attempt to empirically examine affect
attunement and its potential effects in adult psychotherapy. Affect attunement by caregivers has been shown to be of fundamental importance for self and affect development
in the child. In light of that and this studys findings, further research on affect attunement
in general is warranted in adult psychotherapy, either by employing the AAS or some
other measure of attunement, yet to be developed.

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AFFECT ATTUNEMENT AND ATTACHMENT SECURITY

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Appendix
The Affect Attunement Scales
Patient ID:_______________Raters ID:____________Session#:_____
Session rating#:____Date rated:____

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Scale 1A
Therapist verbal responsiveness (openness to and regard for the patients subjective
experience)
3: Explicitly, T questions or disregards the legitimacy of the patients experience
(past or present); or unrelated to the patients experiences, T focuses attention on
him/herself.
2: Explicitly, T takes measures to alter the patients feeling state.
1: Implicitly, Ts comments seek to alter the patients feeling state.
1: T engages the patient in superficial exploration of his/her affective experience.
2: T engages the patient in more substantial exploration of his/her affective experience.
3: The patient is touched by Ts response and explores in depth his/her affective
experience.

Scale 1B
Therapist verbal responsiveness (matching of the patient affect state)
3: T is markedly off target in recognizing both the quality and the intensity of the
patients feeling state (past or present).
2: T is off target in recognizing either the quality or the intensity of the patients
feeling state (past or present).
1: T over- or undermatches aspects of the patients feeling state (past or present).
1: T refers specifically to cognitive, defensive or coping aspects of the patients
feeling state (past or present) and directly, yet nonspecifically, to affective aspects
of the patients feeling state (past or present).
2: T recognizes the specific feeling state of the patient as displayed and experienced
in the here and now or as related to a past incident.
3: T recognizes the patients specific feeling state and its intensity as displayed and
experienced in the here and now. The patient subsequently acknowledges (verbally or nonverbally) the accuracy of Ts response.

Scale 2A
Therapist nonverbal responsiveness (openness to and regard for the patients subjective
experience)
3: T abruptly and frequently interrupts the patients ongoing self-exploration of
feelings.
2: T interrupts the patients ongoing self-explorations.

(Appendix continues)

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1: T interrupts only now and then the patients self-explorations.


1: Without interrupting the patients speech (except for encouraging and supportive
prompts), T listens to the patients self-explorations.
2: Without interrupting the patients speech (except for encouraging and supportive
prompts), T listens attentively to the patients self-explorations. Ts voice qualities indicate some compassion with the patients feeling state.
3: Without interrupting the patients speech (except for encouraging and supportive
prompts), T listens attentively and with great interest to the patients selfexplorations. Ts voice qualities indicate great compassion with the patients
feeling state.

Scale 2B
Therapist nonverbal responsiveness (matching of the patient affect state)
3: Ts voice qualities (pitch, loudness, tone, tempo and pauses) are in sharp
dissonance with the patients feeling state as expressed vocally, facially and/or
motorically (i.e., marked over- or undermatching of the patients level of affective
arousal).
2: Ts voice qualities are dissonant with the patients feeling state (i.e., moderate
over- or undermatching of the patients level of affective arousal).
1: Ts dissonant voice qualities produce slight over- or undermatchings of aspects of
patients ongoing feeling state, or Ts vocal response sounds as if T is unengaged.
1: Ts voice qualities resonate with the patients feeling state.
2: Ts voice qualities resonate very well with the patients feeling state.
3: Ts voice qualities are in perfect resonance with the patients feeling state.