You are on page 1of 28

Counselling Psychology Quarterly

Vol. 23, No. 4, December 2010, 343369

We had a constant battle. The role of attachment status in


counselling psychologists experiences of personal therapy:
Some results from a mixed-methods study
Rosemary Rizqa* and Mary Targetb
a

Research Centre for Therapeutic Education, Department of Psychology, Roehampton


University, London, UK; bPsychoanalysis Unit, Research Department of Clinical,
Educational and Health Psychology, University College London, London, UK
(Received November 2009; final version received March 2010)
There has been curiously little empirical investigation into the experiences
of psychotherapeutic practitioners undertaking a mandatory training
therapy. We present results from a qualitatively-driven mixed-methods
study designed to explore the way in which counselling psychologists
attachment status and levels of reflective function intersect with how they
experience the therapeutic relationship within their personal therapy.
Participants were interviewed twice: once using Main and Goldwyns
(1998) Adult Attachment Interview (AAI) to explore representations of
early childhood relationships; and subsequently using a semi-structured
interview format, analysed via Interpretative Phenomenological Analysis
(IPA), to explore experiences of personal therapy. Meshing results from
both sets of data showed that insecurely-attached participants experienced
their personal therapy differently from secure or earned-secure participants,
and were more troubled by a perceived disparity of institutional and
interpersonal power within the therapeutic relationship. Results are
considered in terms of the power dynamics within training therapy.
Implications for training and future research in this neglected field are
briefly discussed.
Keywords: counselling psychology; mixed-methods research; personal
therapy; psychotherapy; qualitative research; psychotherapeutic training

Introduction and background


Ever since Freuds (1910/1937) endorsement of personal analysis as the vehicle of
psychoanalytic training, psychoanalytic training institutions have specified a
mandatory training analysis for candidates, usually comprising three to five
sessions per week for several years. Whilst personal therapy has subsequently played
a central role within many counselling and psychotherapy training courses, in the
British Psychological Society it is only the Division of Counselling Psychology
(DCoP) that specifies a mandatory minimum period of 40 hours of personal therapy
for trainees undertaking either an accredited training course, or the Societys
Qualification in Counselling Psychology via the Independent Route.
The vicissitudes of candidates undergoing a training analysis have
been recognised for many years within psychoanalytic training institutions
*Corresponding author. Email: rosierizq@tiscali.co.uk
ISSN 09515070 print/ISSN 14693674 online
2010 Taylor & Francis
DOI: 10.1080/09515070.2010.534327
http://www.informaworld.com

344

R. Rizq and M. Target

(e.g., Kernberg, 2006; Wallerstein, 1993). However, there has been curiously little
investigation into the experiences of other psychotherapeutic practitioners undertaking a mandatory training therapy. There are certainly moving and persuasive
personal testaments to the value of practitioners own therapy (Geller, 2005; Hill,
2005; Little, 1990) and quantitative surveys overwhelmingly attest to the satisfaction
of large numbers of therapists undertaking therapy (e.g., Orlinsky et al., 1999a,
Orlinsky, Botermans, & Ronnestad, 2001; Orlinsky, Norcross, Ronnestad, &
Wiseman, 2005). But there are only a handful of published qualitative studies
examining the subjective experience of personal therapy from the perspective of
practitioners themselves (Grimmer & Tribe, 2001; Macran, Stiles, & Smith, 1999;
Murphy, 2005; Rake & Paley, 2009; Wiseman & Shefler, 2001). Aware of this gap in
the literature, we recently undertook a qualitative study exploring nine senior
counselling psychologists experiences of personal therapy (Rizq & Target, 2008a,
2008b). Whilst therapy was found to be valuable in promoting awareness of different
aspects of the self, we also found that attachment experience emerged as a significant
organising framework within participants accounts, with several individuals
describing the salience of difficulties in early family relationships to the development
of a nascent reflective capacity that they honed in personal therapy and subsequently
deemed crucial to effective, empathic clinical work.

Therapist attachment status and reflective function


Although Slade (2000) has pointed out that attachment issues may be as salient for
therapists as for clients, there has been surprisingly little research on the attachment
status of therapists and its impact on clinical work. Obegi and Berant (2008), in a
recent review of attachment-informed psychotherapy research, point out that secure
therapists are likely to possess alliance-enhancing characteristics and sensitivity (eg.
warmth, sensitivity) and therefore better able to create the atmosphere of security
that Bowlby (1988) viewed as a prerequisite for productive therapeutic work (p.
466). This is supported by research by Dozier, Cue, and Barnett (1994), and Tyrell,
Dozier, Teague, and Fallot (1999) which explores the interaction of therapist-client
attachment style and therapeutic outcome. Dozier et al. (1994) argue that the
securely attached clinician is characterised not only by an ability to provide a
counter-response to their clients relational expectations i.e., to provide disconfirming feedback but also by a willingness to intervene in ways that may be
personally uncomfortable. Similarly, Tyrell et al. (1999) found that case managers
with attachment strategies that were non-complementary to their clients were the
most clinically effective. In a related argument, Holmes (1993) points out that the
fit between the attachment style of the therapist and patient might be an important
determinant of the outcome of therapy. In a review of the client-therapist attachment
matching literature, Bernier and Dozier (2002) found some support for the
significance for attachment complementarity early on in treatment, with a mismatch
in attachment styles found to be more effective later on in treatment.
From a developmental perspective, Fonagy and Target (1996) suggest that the
quality and status of early attachment relationships indexes the childs capacity to
consider the self and others as psychological beings to mentalise or adopt the
intentional stance (Dennett, 1978). A secure and containing attachment relationship through which internal psychological experiences are represented in the mind of

Counselling Psychology Quarterly

345

the caregiver, ensures that the developing infants internal feeling states become
meaningful and manageable. It is this process, closely aligned to Bions
(1962a,1962b) notion of containment, that is assumed to play an important role
in the childs eventual capacity to manage his or her own feeling states and nascent
self-organisation (Fonagy, Gergely, Jurist, & Target, 2002). Security of attachment is
thus generally associated with higher levels of mentalisation, whilst hostile, neglectful
or abusive caregiving is associated with inhibited mentalising skills (Fonagy, Target,
Gergely, Allen, & Bateman, 2003b). Fonagy, M. Steele, H. Steele, Higgitt, and
Target (1994) suggest that this capacity, operationalised as reflective function,
may be particularly advantageous to those with adverse histories, since it is their
ability to represent and reflect on early traumatic or neglectful experience that
appears to interrupt the intergenerational cycle of disadvantage. Indeed, Pearson,
Cohn, P. Cowan, and C. Cowan (1994) adopted the phrase earned secure to
describe those who had managed to overcome neglectful or abusive early childhood
experiences that might otherwise be associated with insecure attachment.
Given that mentalisation underlies the capacity to see and respond to others as
psychological beings, therapists levels of reflective function would appear to be
central to effective, empathic clinical work. Whilst some studies have examined the
role of psychotherapy in improving reflective function in clients (Karlsson &
Kermott, 2006; Levy et al., 2006), only one published study has examined therapist
attachment status and reflective function. Diamond, Stovall-McClough, Clarkin,
and Levy (2003) explored the impact of both therapist and client attachment states of
mind and reflective function on therapeutic process and outcome. The authors argue
that the quality of mentalisation in the therapeutic dyad can be conceptualised as a
bidirectional process in the therapists and clients levels of reflective function appear
to be mutually and reciprocally influential. They found that therapeutic progress was
associated with the therapists capacity to adjust his or her level of mentalisation to
slightly above that of the client, rather than mirroring the clients low level of
mentalisation directly.

Rationale for the current study


The above samples from the attachment literature underline the significance of
attachment states of mind and mentalisation in understanding the way individuals
represent and experience adult relationships. We suggest that, by extension, these
issues are also relevant to understanding how practitioners experience and describe
the relationship with their own therapists during training, and to how that experience
is transmuted and subsequently deployed within their clinical practice. Indeed, given
the subjectively-rated importance of personal therapy to the professional development of many psychotherapists (Orlinsky et al., 2001) and the increased attention to
the person of the therapist in the psychotherapy outcome literature (Aveline, 2005;
Lambert & Baldwin, 2009), it would seem that the relevance of the therapists
attachment and reflective function to the experience of personal therapy within
training is an important area for investigation. To date, however, we know of no
such work. Building on our previous studies then, the current paper presents a subset
of results from an exploratory mixed methods study examining the role of
attachment status and reflective function in counselling psychologists accounts of
personal therapy, focusing specifically on aspects of the therapeutic relationship.

346

R. Rizq and M. Target

A parallel paper, exploring the impact of personal therapy on counselling


psychologists clinical work has just been published (Rizq & Target, 2010).

Study design and methodology


A qualitatively-driven (Mason, 2006) mixed-methods study was designed to elicit
counselling psychologists subjective accounts both of their early attachment
experiences and of their personal therapy. Interpretative methodological analysis
(IPA) was selected as particularly appropriate for the analysis of participants
accounts of personal therapy. IPA (Smith & Osborn, 2003) is a form of qualitative
inquiry which aims to explore in detail participants personal experiences or
lifeworld. Rooted within the phenomenological tradition (Heidegger, 1962), it is also
theoretically indebted to symbolic interactionism (Blumer, 1962) in its recognition
that the researchers own views, bias and lifeworld are necessarily implicated in the
process of gaining understanding of another. The choice of IPA as methodology for
this part of the study was based on the requirement for an idiographic approach, in
which the centrality and meaning of participants subjective experiences of personal
therapy could be explored and engaged with.
Attachment status was assessed via the Adult Attachment Interview (AAI) (Main
& Goldwyn, 1990). The AAI is a clinical instrument designed to elicit a full story of
the interviewees early childhood attachment experiences and the impact of these on
his or her current functioning. The AAI classification and coding system is based not
on the content of the childhood memories themselves, nor on the extent to which
adults experienced supportive or loving relationships, but rather on narrative
discourse markers that are deemed indicative of an underlying representation of and
stance towards early childhood attachment experiences. Similarly, the Reflective-Self
Function Scale (Fonagy, H. Steele, Moran, M. Steele, & Higgitt, 1991), an additional
scale for AAI transcripts, operationalises and assesses the interviewees capacity to
understand mental states and their readiness to consider these in the self and others.
Thus the design of the study includes two sets of data, analysed according to
separate conventions: Adult Attachment Interviews, analysed and coded according
to Mains (1998) criteria; and the semi-structured personal therapy interviews,
analysed according to the principles of IPA suggested by Smith (1995). Meshing or
linking of the data (as discussed by Mason, 2006) occurred after data analysis
from both interviews was completed.

Procedure
Selection and recruitment of participants
IPA is increasingly characterised by purposive homogeneous sampling, using small
numbers of participants selected for their experience in the subject under investigation and their ability to illuminate specific research questions or areas (Smith &
Osborn, 2003). The current sample were selected from UK counselling psychologists
who were chartered between 2000 and 2004 i.e., who at the time of recruitment had
been qualified and practising for between 3 and 7 years. Recruitment methods
included mailshot, advertisement and chain referral. Overall, 12 individuals agreed to
participate in the study and interviews took place over a 10-month period.

Counselling Psychology Quarterly

347

Sample characteristics
Three men and nine women took part, with ages ranging from 3565. All were white
Caucasian with the exception of two participants who were Asian and black AfroCaribbean. Participants had spent varying lengths of time in therapy: nine had
undertaken extensive therapy prior to their training, and three of these had also
continued after completion of their training. There were three further participants
who had undertaken only the mandatory minimum period of 40 hours during their
training. Theoretical orientations of personal therapy were varied and included:
psychoanalytic, gestalt, cognitive-behavioural, and existential models. Participants
current clinical work included both NHS and private practice. Whilst we are aware
that such a mix of different therapeutic orientations in one sample may be considered
overly heterogeneous within an IPA study, the variety of theoretical models
experienced by our participants in their personal therapy is nonetheless a
distinguishing feature within Counselling Psychology training courses and hence
the sample was thought to be characteristic of the profession.
The main researcher (Rizq), a chartered counselling psychologist specialising in
psychotherapy, had several years experience in clinical work and teaching from a
mainly psychoanalytic perspective. The second researcher (Target), a clinical
psychologist and psychoanalyst, had extensive experience in clinical work, teaching
and research.

Data collection: interview procedures


Each participant was interviewed twice: first using the AAI and subsequently using a
semi-structured interview about their personal therapy. All participants signed
consent procedures including an agreement to examine interview transcripts for
information that might violate confidentiality. Biographical and professional details
were also collected. None of the participants had previously undertaken an AAI,
though all were broadly familiar with its clinical significance. All were informed that
the scoring of the AAI would be done by an independent rater, but that participants
would be invited to discuss results at a future date if they wished. All the AAI
interviews were taped and transcribed according to the protocol designed by Main
(1998) using a Windows XP voice-file.
Most participants were interviewed about their personal therapy 12 weeks after
the AAI. The semi-structured interview schedule included: personal and professional
background information; experiences during training; personal therapy experiences;
personal therapy in clinical practice; and views on the place of personal therapy in
current training programmes. Each interview was once again taped and transcribed
verbatim using a Windows XP voice-file.
The analysis and results of the AAIs were not completed until some time after all
interviews and the IPA cross-case analysis were finished. At the time of the second
interview, the interviewer, who was not trained in AAI coding, was not aware of the
final attachment classification of each participant.

Analysis and validity checks


Analysis of personal therapy transcripts followed the analytic procedure for IPA
outlined by Smith (1995) and Smith, Jarman, and Osborn (1999). Detailed reading

348

R. Rizq and M. Target

and re-reading of each transcript produced an initial list of significant issues,


topics and ideas from the data; later more abstract, psychological terms and concepts
were used to describe features of participants accounts. Clustering of similar topics
and concepts resulted in a list of themes for each of the participants who were then
sent a transcript of their personal therapy interview along with an extended letter
documenting themes that had emerged from the interview, along with some
preliminary hypotheses. This was to ensure a degree of testimonial validity
(Stiles, 1993) in the emerging analysis. Five of the 12 participants accepted an
invitation to provide feedback, and several made minor changes to the transcripts to
ensure confidentiality. A further validity check was then undertaken by an
independent counselling psychologist and academic at a UK university who agreed
to examine the preliminary analysis of transcripts from three participants who had
not responded to the feedback invitation. The auditor concurred with the emerging
themes but generated some additional ideas and issues that were later incorporated
into the developing analysis.
Further stages of the analysis included a cross-case comparison, construction of a
table of master-themes, and writing up a cross-case analysis in narrative form. When
the first draft of a cross-case analysis was completed, the entire set of transcripts, the
feedback letters to participants, and the draft analysis was examined by a further
independent auditor who was a clinical psychologist, psychotherapist and researcher
from a US university. This more extensive audit again concurred that the emerging
analysis was justified.

AAI analysis
The AAI transcripts were independently analysed by two separate raters, both of
whom had been trained and accredited in AAI and reflective-self function coding.
Both were highly experienced, and one had been extensively involved in training
professionals in the use of Adult Attachment Interviews and Reflective Function
scoring. Scoring followed protocols by Main (1998) and Fonagy, Target, H. Steele
and M. Steele (1998) respectively.
All transcripts were rated for inferred parental behaviour and state of
mind. Each rater then assigned transcripts to one of three main attachment
categories indicative of that individuals overall state of mind with respect
to attachment:
(1) Dismissing of attachment (D)
(2) Preoccupied with, or entangled by, past attachments (E)
(3) Freely valuing, autonomous or secure with respect to attachment (F)
In addition to these three categories, raters made a decision in each case as to
whether the alternative classifications of unresolved with respect to trauma/loss
(U) or cannot classify (CC) could be considered appropriate. Finally, raters
also decided on the basis of transcripts whether any individuals could be described as
earned secure. This description reflects those secure/autonomous individuals who
describe negative or traumatic childhood experiences and relationships but do so in a
coherent and contained manner.

Counselling Psychology Quarterly

349

Reflective function coding


Coding for reflective function followed the procedures in Fonagy, Target, Steele, and
Steele (1998). The reflective-function scale has good interjudge reliability (r 0.89)
and has been extensively validated in research (see overview in Fonagy et al., 1998).
All transcripts were additionally rated and classified according to the following scale:
.
.
.
.
.
.

Negative RF (10)
Lacking in RF (12).
Low or questionable RF (34)
Ordinary RF (56)
Marked RF (78)
Exceptional (9).

Integration of the data


A full IPA analysis was undertaken independently of the results from the AAIs.
After the IPA was completed, the table of master themes derived from the IPA was
colour-coded for attachment status in order to re-examine all the themes in the light
of the participants attachment status and level of reflective function, and to explore
any patterns or features of interest in how participants recalled, described and felt
about their experiences in personal therapy. In presenting our results, particular
efforts have been made to exclude or obscure details that might threaten the
confidentiality of participants. For this reason, a decision was made to omit
information about each individuals early history and background and to include
only the primary attachment classification from the AAI along with each
participants level of reflective-function.
The IPA analysis yielded eight master themes overall each with a number of subthemes. The following section focuses on a sub-set of results from the above
integration of results from the two sets of data. The analysis aims to examine
participants accounts in the light of their main attachment classifications and
reflective function scores, noting any emerging patterns in the way personal therapy
is subjectively experienced, recalled and described. In the subsequent discussion, we
will attempt to link results with some of the relevant literature and to critically assess
the validity of our inferences and conclusions in the light of this particular
methodology.
Whilst all the master-themes by definition included material that emerged
strongly from participants accounts, for reasons of space the current discussion will
focus only on two master-themes: emotional safety and control; and struggling
with ambivalent feelings. Results from the AAI are presented first.

Results and discussion


Primary classifications from the Adult Attachment Interviews along with reflectivefunction scores are illustrated in Table 1. Out of the 12 participants in the current
study, four were found to have secure states of mind with respect to attachment, with
a further two classified as earned secure. The remaining six participants were
found to have insecure states of mind with respect to attachment with classifications

350

R. Rizq and M. Target


Table 1. Primary attachment classifications and reflective-function
rating (n 12).
Primary attachment
classification

Number of
participants

Reflective
function rating

Secure

Earned secure

Dismissive

Preoccupied
Unresolved

1
2

Cannot classify

3
4
5
7
7
7
4
2
3
1.5
8
0

including the full range of dismissive, unresolved, preoccupied and cannot classify
categories.
In line with the previously-mentioned developmental research suggesting that RF
is an index of attachment security, RF scores were found in general to be higher with
the secure/earned secure participants, with four out of the six secure/earned-secure
participants having RF scores of 4 or above and four out of the six insecurelyattached participants having RF scores of between 0 and 3. As is consistent with a
qualitative study, a representative sample had not been sought, but it is nonetheless
evident that the current group of participants includes a relatively high proportion of
individuals with problematic early attachment histories. Clearly, a larger scale study
would be needed to establish whether these results are characteristic of the profession
as a whole.

Emotional safety and control


In the first master-theme, managing feelings about therapy and the therapeutic
relationship emerged as a central preoccupation. Participants experienced the
imposition of a mandatory period of personal therapy in a variety of ways, many
conveying concerns about establishing a sense of trust and safety within the
relationship and the importance of retaining a feeling of emotional control. Tables 2a
and 2b show the contribution of each participant to the master-theme of ensuring
emotional safety.
Whilst almost all participants described feeling a degree of wariness about
embarking on a therapeutic relationship, insecurely-attached participants appeared
to be particularly cautious and suspicious. Their accounts of personal therapy
included statements such as:
I was very guarded, had learnt to be very guarded, perhaps from early childhood.
(David)
Im not saying I was conscious of this [ . . . ] at the time, but I think Id already made up
my mind that I didnt go there for therapy. (Mary)

351

Counselling Psychology Quarterly

Table 2a. Ensuring emotional safety: presence/absence of themes in secure/earned secure


participants accounts (n 6).

Master theme 1: ensuring


emotional safety

Key
Earne -secure

Name
Laura
Clare

RF
7
7

Sara
Judy
Carol
Anna

3
5
4
7

Establishing
trust

Resisting
engagement

Secure
= presence of
the me
= absence of
theme.

Table 2b. Ensuring emotional safety: presence/absence of themes in insecurely- attached


participants accounts (n 6).

Master theme 2: ensuring emotional safety

Name
Aida
Hannah
Mary
David
Martin
Malcolm

RF
1.5

Establishing
trust

Resisting
engagement

Key
Unresolved
Dismissive

8
4

Cannot classify

2
0
3

Preoccupied
= presence of
theme
= absence of
theme.

I know I kept my guards up, I know I kept her at a distance; I know I didnt let her in
too much. (Aida)

This experience of anxiety or wariness about the safety of the therapeutic


relationship in some cases seemed to be mirrored by some participants tendency to

352

R. Rizq and M. Target

resist engaging with therapists felt to be unsafe or untrustworthy. Five out of the six
insecurely-attached participants contributed to the theme of resisting engagement
and described ways in which they strongly opposed their therapists attempts to draw
out feelings and memories:
I think I was probably quite defended in my time with her, to be honest, though I think
we did do some good work as well, but Um Ive, I felt it was her agenda and not
mine ( . . . ) and I wasnt going to give in to it. (Hannah)

For some, resistance seems to have been associated with feelings of


resentment about having to undertake a personal therapy in the first place, and
feelings of anger and frustration emerged in accounts of the way in which the
requirement was presented in training. Some insecurely-attached participants
experienced this as an overt display of power by tutors and staff as Aidas comment
suggests:
you have to do it; no arguments, you have to do it. No discussion of, yes, it brings up
uncomfortable feelings, lets look at it. I didnt get that from my tutors . . . it was never
explored. It was just left as: these are the requirements; you have to follow them
through. (Aida)

Aida was clear that she only undertook personal therapy for the University.
She is determined to refuse her therapist access to personal sort of stuff and seems
to have already decided that this was just going to be an exercise:
. . . bearing in mind that again the motivation was I had to be there for the University,
so I remember it being on a very superficial level and holding things back and
determined I wasnt going to let her into personal sort of stuff, and this was just going to
be an exercise I went through. (Aida)

Resistance appeared for several of the insecurely-attached participants to continue


throughout entire episodes of therapy, often accompanied by feelings of considerable
antipathy and resentment. By contrast, even though some of the secure/earned secure
participants had initially found it difficult to trust their therapists, they were eventually
able, to varying degrees, to develop more trusting relationships. Laura welcomed
sharing and working through often acutely painful material with her therapist:
. . . there were times when I felt so overwhelmed with pain and sadness that I just wept
and wept and wept and wept and felt ok to do that, well, all right to do that (it was
possible to do that?) he made it possible by the way that he was. (Laura)

Judys growing trust in her therapist resulted in twice-weekly therapy where she
felt she could engage more deeply in the work:
I started going to see him twice a week. What made you do that? Because I knew that it
went onto a whole . . . I felt I was ready to go on to a whole other level, which, which is
what did happen. It was much more, I think going twice a week is much more than
double [ . . . ] it just took it to, into a whole new realm, really. So the work really,
deepened. (Judy)

Master theme 2: struggling with ambivalent feelings


For insecurely-attached participants, the combination of lack of trust and a tendency
to resist engaging freely in the therapeutic relationship appeared to go hand-in-hand
with significant difficulties in managing negative or ambivalent feelings that emerged

Counselling Psychology Quarterly

353

in the context of their therapy. Feelings of being undermined or of psychological


threat appeared to be related to an experience of the therapist as akin to a powerful
parental figure, arousing either feelings of intense admiration and love, or of extreme
anxiety and ambivalence; in other cases, feelings of disappointment and disillusion
predominated where the therapist was experienced as inadequate or insufficiently
skilled. Several participants described their discomfort with a felt power imbalance
within the therapeutic relationship, and all discussed difficulties with confronting
therapists with their negative feelings.
Tables 3a and 3b show the contribution of each participant to the master-theme
of struggling with ambivalent feelings.
Five participants overall contributed to the sub-theme of disappointment and
disillusion. However, unlike the two securely-attached participants, whose feelings
of disappointment or anger tended to be therapist-specific and temporary, the
insecurely-attached participants described feelings of frustration with therapists that
appeared to be grounded in a far more comprehensive and global sense of
dissatisfaction, impacting on the entire experience of therapy. This is perhaps best
exemplified in Martins comment below:
I was disappointed cos I didnt stop smoking. I was disappointed cos I didnt feel a huge
shift in myself, of some kind of, you know, positive change, and I was disappointed that
we didnt have any more time to get there, or do anything else. (Martin)

These participants were well aware of long-standing personal and relationship


problems, and had been keen to undertake personal therapy; however, most failed to
find therapists in whom they could trust or who were sufficiently skilled, as David
pointed out:
They, they just didnt have enough, they didnt have enough knowledge of psychopathology, and enough, and also enough gentleness to, to, to say: look, this isnt so very
terrible. Not a terrible human being cos youre fucked up. (David)

Table 3b also shows that three of the insecurely attached participants contributed
to the sub-theme of Experiencing the therapist as parent. Whilst one of these,
Hannah, invoked notions of transference, and described the way in which she saw
her therapeutic relationship mirroring a troubled early relationship with her mother,
the other two participants rejected the notion of the therapists symbolic
parental role, or referred to it only in highly intellectualised terms. By contrast,
Table 3a shows that five of the six securely-attached individuals contributed to
the same theme, most speaking freely about the parental role fulfilled by their
therapists, and the impact this had on the therapeutic relationship. Illustrative
examples include:
He was my mother, to me. The mother Id wished Id had (tearful). (Judy)
I [ . . . ] gradually came to realise that she was a type of parental in some ways the
relationship was parental but a kind of reparative relationship, the kind of mother that
might have been better for me. [ . . . ](Anna)
I did . . . yes, I did look on her very much as a mother figure [ . . . ] She was very mumsy.
She was a retired nurse, and so, yes, she was, she was a mother figure. She was the good
mother. (Carol)
I mean he was my dad, he was, he was, he was as a surrogate dad for quite a while and I
looked up to him, he was a role model as well for a therapist for quite some time . . . .
(Laura)

Anna

Sara

Clare

Carol

Laura

Judy

RF

Name

Disappointment
and disillusion

Experiencing
the therapist
as parent
relationship

An unequal

(+/)
(+)
()
(+/)
(+/)
(+)

Challenging
and changing
therapist
Avoiding () vs
confronting (+)

Master theme 3: Struggling with ambivalent feelings

= presence of
theme
= absence of
theme.

Secure

Earne -secure

Key

Table 3a. Struggling with ambivalent feelings: presence/absence of themes in secure/earned secure participants accounts (n 6).

354
R. Rizq and M. Target

Malcolm

Martin

David

Mary

Hannah

Aida

Name

RF
1.5
8
4
2
0
3

Disappointment
and disillusion

Experiencing
the therapist
as parent
An unequal
relationship

Master theme 3: struggling with ambivalent feelings

(+)

()

()

()

()

()

Challenging
and changing
therapist
Avoiding ()
vs
confronting
(+)

= presence
of theme
= absence
of theme

Preoccupied

Cannot
classify

Dismissive

Unresolved

Key

Table 3b. Struggling with ambivalent feelings: presence/absence of themes in insecurely-attached participants accounts (n 6).

Counselling Psychology Quarterly


355

356

R. Rizq and M. Target

Many of these securely-attached or earned-secure participants movingly


described feelings of trust, closeness and intimacy towards their therapists and, in
some cases, great love. These participants did mention feelings of frustration
where their therapists failed them in various ways, but, in contrast to the way in
which insecurely-attached participants experiences of therapy seemed to be
permanently coloured by their feelings of dissatisfaction, they did not appear to
be overcome by these more negative feelings and memories and were able to
sustain a more balanced picture of their therapists. Even when Laura is discussing
her sense of shock at her very trusted therapists inappropriate behaviour and
comments, she seems able to uphold a sense of this therapist as nonetheless helpful
to her:
it made me question the nature of things a bit, but you know, given the nature of my
relationship with my dad, I have done a lot of therapy on it, thanks to him in part ( . . . ),
and you know, I am, at this point, able to hold the two things together, I dont think the
one has to invalidate the other. (Laura)

Similarly, when Clare recalls her first training therapist, whom she felt was
unhelpful, she is able to reflect equally on this therapists positive and negative
features:
I just felt this woman didnt really get me, didnt understand me, I felt she wasnt on the
same wavelength that she couldnt (mm) . . . And I dont know if it was a mismatch
there, but part of my sense was that she hadnt gone very far herself . . . and I think that
was the rub, I think she was a good enough person, I think she was probably a very
nice person, but for me, she wasnt right. (Clare)

It is noticeable that Clare and Laura above, both of whom are classified as
earned-secure are able to offer a balanced picture of their therapeutic relationships, and their negative experiences are recounted with forgiveness, humour, and
acceptance. By contrast, insecurely-attached participants appeared particularly
angry, let down and disappointed when therapists failed to live up to what appeared
to be very high standards. Malcolm describes how he seems to need his therapist to
be more than good enough and how running over time at the end of a session
appears to spoil[s] something:
I dont know why I feel they have to be good enough, or more than good
enough really. Why sometimes it feels like it spoils something. Like it, why did
you have to say that, or, you were doing so well, and youre so perfect [ . . . ]
(Malcolm)

Martin takes this further and appears to blame his therapist for what he feels is a
disappointing lack of personal change:
it was her responsibility, she could have done something differently. (Martin)

More seriously, for some insecurely-attached participants, disappointment with


personal therapy seems to have led to a loss of hope that a relationship could be
therapeutic at all. Davids unfavourable experiences have led him fundamentally to
question the role of the relationship in therapy, despite its accepted centrality within
the discipline of counselling psychology:
we get all this, dont we, in the counselling psychology stuff, all built on this. I, I cant
um say I own it [the therapeutic relationship] tremendously as such a major ingredient,
and I suppose Im meant to. (David)

Counselling Psychology Quarterly

357

From Table 3b, it is clear that the theme of inequality in the therapeutic
relationship was raised by all but one of the six insecurely-attached participants.
Illustrative excerpts include:
You know, she had all these certificates, not that I pay much credence to whats in the
room, but . . . .And it was kind of, like, um, : look at me, Ive done so much Ive all these
years of experience ( . . . ). it left me a little bit in awe. (Aida)
It was awful! She was invested with all the sort of authority of God, basically, and she
would start the sessions by praying [ . . . ] which I have to say I would never ever do with
a client! So, she prayed, and then we would start. Well, by then, the power imbalance
was enormous! (Hannah)
I think theres a way of people imposing their own sort of reasoning on you and, you
know, it just comes over you, youve got to get inside their own way of thinking and
their own theory (David)

These participants all conveyed, in varying ways, the extent to which they felt
particularly diminished, disempowered or frustrated either by the imposition of a
personal therapy training requirement or by the perceived status, behaviour, and
emotional demands of their therapists. Their experiences of coercion and sensitivity
to power emerge forcefully:
Now what people have done to me is: do you want to talk about your childhood? Full
stop! [ . . . ] that was wrong. Cos Id say: no. Im terrified [ . . . ] or Im embarrassed.
And so there was a lot, a lot of implicit force under these therapies, so Im very very
sensitive to implicit force. (David)
. . . we had a constant battle cos she wanted me to go twice a week and I only ever went
once a week. (Hannah)
I was still young; Id been, I wasnt therapy-wise at the time so, so I wasnt able to,
you know, it was always . . . .struggling against . . . the, this authority figure,
who . . . had social power to make decisions about me, or descriptions about me
that could remain on public record. Um . . . as if they were facts, when theyre not.
(Malcolm)
Maybe that was me being a bit angry that the BPS had said you have to go, so I said:
yes, I want to be a chartered counselling psychologist, Ill do what I need to do; Ill do it
on my own terms. (Mary)
it was put across, you know, you have to do it; no arguments, you have to do it.
No discussion of, yes, it brings up uncomfortable feelings, let look at it. I didnt
get that from my tutors, didnt get the sense of lets talk about this, yes you have to
do it, hey, thats the given, but lets look at what, why might you be feeling
uncomfortable. (Aida)

It was clear that all participants, in varying ways, were found to be sensitive to
different aspects of power and authority within their personal therapy; and Tables 3a
and 3b illustrate that both secure and insecurely-attached participants alike discussed
the difficulties of challenging or changing their therapists. However, those who
recalled this difficulty within their therapy as most preoccupying, problematic and
significant tended to be insecurely-attached; and all but one of the insecurelyattached group spoke about how they felt unable to confront their therapists with
their negative feelings. This difficulty was raised frequently in their accounts, and for
many, seems to have been implicated in a general backdrop of dissatisfaction with

358

R. Rizq and M. Target

therapy in which their feelings of discontent, in some cases anxiety or anger, were
neither voiced nor acknowledged. Mary exemplifies this in her comment below:
Maybe that was one of the things I didnt learn in my own personal therapy, that I had
the power to say to my therapist Im not happy about something. (Mary)

For many of these insecurely-attached participants, a complex constellation of


feelings involving submission, anger, fear and anxiety seemed to constitute an
ongoing, problematic and unresolved feature of the therapeutic relationship. Some
highlighted imagined fears of reprisal within the training course, an anxiety best
exemplified by Martin, whose therapist had been suggested to him by the Course
Director of his training institution. In the following extract he assumes that they both
know each other well, and is explicit that he doesnt want to piss her off:
Anyway, xxxx was very much my tutor, leader of the course, and hed found her, so
clearly they knew each other. I mean, I knew nothing about this incestuous thing, you
know what I mean? And I was oh well, they must be, they must know each other.
Thats why I didnt want it to go back to the course. Didnt want to piss her off. So
maybe that would have been the barrier to me expressing myself freely about concerns
and disappointments. (Martin)

One implication of the above dynamic is that for some participants at least,
therapists were seen as potentially in bed with training institutions, and thus not
able to provide a truly impartial or protected space. As a result, they resigned
themselves to staying with therapists with whom they continually felt uncomfortable,
dissatisfied or disappointed. These insecurely-attached participants also seemed to
deploy various mechanisms to counteract painful feelings of powerlessness and
frustration that they were unwilling or unable to voice in therapy. Several dismissed
or minimised such feelings, often for fear of invoking their therapists imagined
anger. Others kept their therapists at a distance, refusing them access to significant
personal information. In one more complex case, Hannah remained reluctantly and
ambivalently with her training therapist, partially sustained by a complex fantasy
concerning power and health. She reluctantly describes an uncomfortable feeling of
contempt for this therapist, locating the source of this disdain in the therapists slight
physical disability. This seems to afford her some covert relief that, despite her
therapists constant attempts to make her acquiesce to her demands, Hannah is
somehow more powerful (i.e., healthy) than her therapist:
The very first time I met her . . . .we went upstairs and she has a funny leg; she cant, I
mean, its not very bad, but she couldnt, shes not in a wheelchair or anything, but she,
its quite noticeable that she has to drag her leg up . . . possibly she had polio as a child or
something. And something about that made me . . . oh dear! I dont know, it made
me . . . .I think I felt she wouldnt be a threat? . . . somehow it gave me a feeling of, I
dunno, power? (Hannah)

From an attachment perspective, these kinds of strategies might be conceptualised as the means by which preoccupied, unresolved, dismissive and other insecurely
attached participants variously regulate the interpersonal distance and dynamics
within the therapeutic relationship. However, from a more phenomenological
perspective, participants accounts can be seen to emerge in the context of what
appears for some to have felt like a battle, where establishing a position of equality
and mutuality or in some cases a feeling of superiority and control appeared to be
central to participants retaining a sense of identity or personal integrity. For these
participants, the experience of therapy revolved around the need to establish and

Counselling Psychology Quarterly

359

sustain a felt sense of personal power within the therapeutic relationship, rather than
simply relinquishing control to, or being subsumed by, an authoritative therapist.
The above strategies of insecurely-attached participants can be contrasted with
those of securely-attached or earned-secure participants, five of whom, whilst
similarly struggling with feelings of disappointment and frustration, nonetheless
appeared to be more confident and able to express their negative feelings within the
relationship, as Carol was able to do:
I remember her once saying youre very angry; I remember being furious with her.
How dare she tell me Im angry! {laughs} Dont tell me Im angry!{laughs}. So, er, I
remember telling her I wanted to throw her pot plants around the room once and she
just sat there calmly. (Carol)

This confidence may have been a consequence of a greater degree of perceived


mutuality within their therapeutic relationships. Table 3a shows that only one of the
secure/earned-secure participants described feelings of inequality in the therapeutic
relationship, suggesting that the majority of securely-attached participants may have
felt less personally compromised by the perceived imbalance of power within therapy
and were perhaps more able or willing to convey both positive and negative feelings.
Indeed, rather than continue to struggle with difficulties and dissatisfaction, securely
attached/ earned-secure participants seemed willing, where necessary, to leave their
therapists and seek alternative therapeutic relationships. Anna is decisive in leaving
her therapist who has applied for a job as her line manager in her place of work:
I said, I dont think, as youre applying for this, its not appropriate for us to um to have
any further contact. Youve made it clear where your priorities lie [ . . . ] so you can just
fuck off. Yeah, well I didnt say fuck off but thats what I should have said! (Anna)

It is possible that these participants greater security of attachment may have


provided them with a more robust working model of relationships characterised by
confidence in their ability to find and sustain a satisfying therapeutic relationship.
Moreover, their generally higher levels of reflectiveness appeared to underpin a
curiosity about why their therapy had not worked or been satisfactory, and a
determination to experience something better, as Clare illustrates:
I left both those therapies, . . . , the shorter one and the long one. I left them feeling,
knowing, I had lots more to do, on myself ( . . . ) I knew that. (Clare)

In this respect, it was noticeable that even serious difficulties within some of these
participants therapeutic relationships did not appear to dissuade them from
continuing to seek other therapists.

Discussion
Results from the analysis of participants AAI narratives show that half of the 12
participants had insecure states of mind with respect to attachment, with a further
two classified as earned secure. This relatively high proportion of insecurelyattached individuals is perhaps unsurprising. In common with much of the
wounded healer literature (e.g., Jackson, 2001), AAI narratives showed that
many participants, from a young age, had undertaken roles that involved them in the
emotional care of family members, in some cases, depressed, mentally ill or abusive
parents. This concurs with Glickhauf-Hughes and Mehlmans (1995) notion of
parentification which they use to describe the emotional role into which the future

360

R. Rizq and M. Target

therapist may be cast within the family; they suggest that such children
develop emotional antennae which can predispose them to joining a therapeutic
profession. Whilst there is very little literature on the background of counselling
psychologists, Halewood and Tribe (2003) suggest that a high degree of
narcissistic injury, related to the perceived quality of early attachment relationships,
may be particularly prevalent amongst counselling psychology trainees.
Similarly, DiCacavvo (2002) found that counselling psychology trainees reported
significantly lower maternal care and higher levels of self-efficacy in care than did art
students.
The wide range of attachment classifications was mirrored by a spread of
reflective function scores. In line with earlier research, those who were securelyattached tended to have higher RF scores than those who were insecurely-attached.
Of note are the marked RF scores of the two earned-secure participants, whose
narratives in both the AAI and personal therapy interviews were exceptionally
thoughtful and reflective, showing strong coherence and richness of recall. This can
perhaps be seen as an index of their ability to reflect on and largely resolve early
experiences with an abusive parent in one case and a seriously mentally ill parent on
the other. Indeed, it was noticeable that both these participants strongly attributed
the resolution of their longstanding family and relationship issues to their highly
positive experiences within personal therapy.
Despite disappointments and set-backs within the therapeutic relationship, secure
and earned-secure participants alike described the generally beneficial impact of their
experiences within personal therapy. However, insecurely-attached participants
appeared to recall their personal therapy somewhat differently. They were more
reluctant to attend therapy, and appeared to have been more resistant, cautious and
suspicious of therapists during the period of their therapy. They discussed a range of
negative feelings about the imposition of a mandatory training therapy and about
the relationships established with their therapists. Prominent in their accounts were
sometimes intense levels of unease and anxiety about a perceived imbalance of power
in the therapeutic relationship and, in contrast to their securely-attached counterparts, most of these participants had been strikingly unable to voice feelings of anger
and frustration in therapy; nor, in many cases, had they felt able to leave therapists
they found unsafe or unsatisfactory. Why should this be? Whilst bearing in mind that
recurrence of a theme within a participants account may be an imperfect index of its
overall importance, one possibility that we wish to raise is that for those participants
who have insecure states of mind with respect to attachment, the interplay of power
dynamics may constitute a particularly troubling, problematic and preoccupying
feature of their experiences within personal therapy.
Maguire (1995) has pointed out that experiences of powerlessness and
helplessness are inevitable in childhood (p. 120), and certainly therapies of all
orientations recognise that the therapist, like the parent, may come to be perceived as
a powerful, authoritative figure in the clients life. For those whose childhoods were
characterised by frightening, abusive, inconsistent or absent caregivers, it is likely
that actual and symbolic authority figures may evoke working models of relationships that are characterised by feelings of distrust, anger, fear, resistance, or
avoidance. It was noticeable that in the AAIs, virtually all the insecurely-attached
individuals had described early attachment relationships that were characterised by
fear of violence, intimidation, loss and, in some cases, precocious parenting of
mentally ill, abusive or neglectful caregivers. Whilst some had been fortunate to have

Counselling Psychology Quarterly

361

other family members who could offer more loving and reliable care, experiences of
powerlessness and vulnerability were nonetheless strikingly apparent in some of their
attachment narratives. These insecurely-attached participants went on to describe
relationships with therapists that were in many cases characterised by mistrust,
conflict, disagreement and, in some cases, a degree of resentful submission and
frustration. Whilst guarding against any attempt at a premature or simplistic
synthesis, one possibility is that concern with institutional and interpersonal power
dynamics we have seen emerging from participants accounts of personal therapy
may come to be recruited into participants pre-existing working models of
relationships. For insecurely attached participants, whose dismissive, preoccupied
or unresolved attachment status may render them more vulnerable to and
preoccupied with actual and symbolic authority figures (Maroda, 1994), the
obligation to undergo a training therapy may come to acquire particular psychological significance and force.
In addition, RF scores were generally considerably lower for these insecurelyattached participants than for their more securely-attached colleagues. It is therefore
possible that not only were insecurely-attached participants more troubled by
perceived disparities of power within the therapeutic relationship, but that this
entailed serious difficulties in engaging with and constructively using therapy in
order to reflect on and so resolve these and other feelings. This suggests that the
experience and value of personal therapy for participants may, in part at least, have
depended on as well as contributed to their reflective capacity. In other words, those
with ordinary or marked levels of RF may not only have been more interested in
undertaking a personal therapy in the first place, but their superior levels of RF may
have rendered them better able to manage and resolve ambivalent feelings arising in
the context of power dynamics in a training therapy, thus, presumably, freeing them
to use their therapy more productively in subsequent clinical work. Conversely, those
with negative, lacking or low levels of RF may have been less interested in or even
resistant to gaining self-awareness, which may have resulted in a reduced capacity
to tolerate and resolve problematic dynamics in personal therapy. Indeed, it is
possible that insecurely-attached participants psychological preoccupation with
issues of power and authority in personal therapy may have emerged in part at least
as a consequence of their generally lower levels of RF, which in some cases seemed to
preclude an ability to move beyond such dynamics in order to make effective use
of personal therapy in the service of client work.

Power dynamics in training therapy


The priority participants afforded the therapeutic relationship with their therapists
focuses our attention more closely on the nature of power dynamics within a training
therapy. The complex psychological status of a trainee-patient has been recognised
for many years within psychoanalytic training institutions (e.g., Kernberg, 2006).
Indeed, the phrase subservient analysis (Meyer, 2003) has been coined to denote
the distortions in an individuals training analysis as a result of power and authority
struggles within psychoanalytic training institutions. Kernberg (2006) trenchantly
points out that that the role of training analyst often carries with it an appointment
as supervisor, seminar leader and potential member of the administrative leadership

362

R. Rizq and M. Target

of the institute . . . their monopolistic combination represents simply a power grab


by a privileged minority (p. 1654). Criticisms like this led to Kirsner (2000) and
others to advocate a reform of psychoanalytic training structures that now ensures
that candidates analysts are kept separate from the training institution; that they are
not included in any assessment procedures; and that no reports of progress within the
training analysis are given to the institution. This is also important for ethical
reasons such as the avoidance of possible conflicts of interests.
It is instructive to compare the above with the experience of participants in the
current study. Counselling Psychology training institutions, which are largely
university-based, are very different from analytic institutes and there has always been
an emphasis on maintaining clear boundaries between the training course and the
trainees own therapist. There are no reporting requirements between the two parties.
Nevertheless, it is notable that high levels of dissatisfaction and frustration with
perceived inequalities within the therapeutic relationship were experienced by our
participants too. However, it was the insecurely-attached group who seemed to
experience this most forcefully and who in many cases, unlike their more securelyattached counterparts, perceived power to have filtered down from the BPS through
to their training institutions and from there into their relationships with training
therapists. These therapists thus appeared to them to be unwanted ambassadors of
an unreasonable and demanding professional body. As an example, let us remind
ourselves of Mary who made a decision that I didnt go there for therapy, and
purposely limits what she is prepared to share with her therapist:
Maybe that was me being a bit angry that the BPS had said you have to go, so I said:
yes, I want to be a chartered counselling psychologist, Ill do what I need to do; Ill do it
on my own terms. (Mary)

Part of being a bit angry here seems to be that Mary feels that BPS is almost a
person who says you have to go to personal therapy. The intrusiveness of the BPS
into her personal life means that the instigator of this intrusion is felt no longer to be
an anonymous institution, but rather someone with whom she has an imaginary
dialogue, almost an argument. There is a sense of struggle here that means she is
determined to undertake therapy according to my own terms, which will, she feels,
implicitly redress a power balance that has so far been in the BPSs favour. Elsewhere
however, she notes:
Im not saying I was conscious of this [ . . . ] at the time, but I think Id already made up
my mind that I didnt go there for therapy, and I know that sounds really stupid [ . . . ].
I didnt go there for someone to dig, to sort of go into areas that I wasnt ready to go to,
myself. (Mary)

So the covert power struggle now continues, although its locus appears to have
shifted from the institutional level of the BPS to the interpersonal level of the
therapeutic relationship. The struggle seems to crystallise around Marys feeling that
the therapist, like the BPS, is digging in areas that I wasnt ready to go to
myself. It eventually manifests in an attempt to limit what she will share with her
therapist. It is this, perhaps, that constitutes doing therapy on my own terms a
necessary psychological strategy that enables Mary to assert personal control and
maintain a sense of integrity within the therapeutic relationship.
The way in which power dynamics percolate down from professional and
institutional bodies into the fabric of the therapeutic relationship itself, has of
course been extensively discussed in post-modern, social constructionist and

Counselling Psychology Quarterly

363

deconstructionist approaches to psychotherapy (e.g., Foucault, 1980; Lefebvre, 1991;


Rose, 2001). Indeed, it should be remembered that our participants accounts of their
personal therapy experiences emerge from the post-modern epistemology of
counselling psychology, in which notions of theoretical pluralism, the significance
of a relational, non-pathologising stance and a collaborative rather than an expert
approach are privileged within training and clinical practice. There is clearly the
potential here for a mismatch of expectation between our participants and therapists
trained within single-model approaches. However, Guilfoyle (2005) reminds us that
that subject positions (Foucault, 1982) people adopt in therapy are governed,
delimited and circumscribed by the positions of therapist and client to which both
are expected to conform. He goes on to suggest that even in explicitly collaborative
therapies, clients may still . . . perceive and thus hear the therapist as expert
(pp. 339340). This is certainly supported by the experiences of some of our
participants. However, we wish to propose the possibility of a rather more complex
relationship between institutional and interpersonal aspects of psychotherapeutic
power; a relationship that we see as coloured by individuals internal working models
of attachment relationships and their capacity to reflect on and so modify these in
the context of a training therapy. Naturally, a larger-scale study would be needed to
examine the generalisability of this contention, and to study its validity in the context
of different training institutions and philosophies.

Validity issues
The interpolation of an attachment framework within a predominantly phenomenological study, whilst novel, presents complex validity issues which have not yet
been addressed in the literature on mixed-methods research. Given the highly
exploratory nature of this study, it is important to recognise that the above results
can only reflect our own interpretation of the data: it is possible that different
researchers would have found different themes within the personal therapy
interviews, which could have resulted in different inferences being drawn when
examined alongside results from the AAIs. How then can we establish confidence in
the validity of the findings outlined above?
Drawing on Dellinger and Leechs (2007) notion of inferential consistency, we
think it is reasonable to claim that results are consistent given what is known from
prior understandings, past research and theory (p. 324). Whilst the suggestion that
insecurely-attached trainee-patients may be more vulnerable to power dynamics in a
training therapy has not, to date, been discussed in the empirical literature, such a
notion has considerable face validity, as well as being consistent with psychotherapy
outcome research documenting the difficulties of helping insecurely-attached
individuals in psychotherapy (Dozier, 1990; Fonagy & Target, 1996). It also links
with recent speculation by Farber and Metzger (2008) that insecure therapists may be
less well-equipped to repair ruptures to the therapeutic alliance, something that
Safran et al. (2002) have argued is crucial to successful therapeutic outcome.
The small sample and qualitatively-driven design of the study mean that it is also
important to consider validity in the context of Masons (2006) argument for
retaining key qualities and principles (p. 22) of qualitative approaches in mixed
methodology research. Key principles here might include the relevance of maintaining a reflexive and critical approach to the inclusion of an attachment-theory

364

R. Rizq and M. Target

framework and of providing credibility checks (Elliott et al., 1999) that permit
exploration of the meaning of an attachment theory framework to participants
themselves. Indeed, given the salience of power dynamics that emerged within
insecurely-attached participants accounts of personal therapy, it is clear that the
imposition of a clinically-oriented framework risks replicating and perpetuating what
some participants strongly resisted within their therapy: the tendency to pathologise
and categorise lived experience within an overarching theoretical framework that
situates their accounts within a reductive clinical typology.
For this reason, there was as much an ethical as a methodological imperative to
honour the relational, collaborative values implicit in qualitative research by seeking
participants feedback at all points in the research cycle, and being transparent with
our findings. However, there were complex ethical concerns involved in offering
participants feedback about their AAI results, as these included potentially highly
sensitive information about their attachment status and reflective function. As
clinicians ourselves, we were not only conscious of confidentiality issues, but were
also aware that these results might be construed by participants as professionally or
personally compromising in some way. Particular care was taken during the research
cycle to offer further meetings to participants in order to provide sufficient time and
explanation to those who wanted to hear about their attachment status. In the event,
although three participants had initially expressed an interest in hearing about their
AAI results, only one eventually accepted the offer and attended a meeting. One
possible explanation for this limited take-up is that participants chose to re-establish
professional boundaries felt to have been blurred after two such highly personal
interviews with a fellow counselling psychologist.

Conclusions and future research directions


Results have suggested that perceived disparities in power dynamics between
participants and their therapists and/or training institutions were a particularly
salient feature of insecurely-attached participants experiences. Clearly, the small
scale of the study, and the self-selecting nature of the sample involved means that a
much larger-scale quantitative study would be needed to establish whether the high
proportion of insecurely-attached participants found in the current study is
representative of the profession as a whole. If so, it would raise potentially
significant implications for the role of personal therapy in training and the way it is
presented and discussed on a training course.
Given that several participants felt that the rationale offered to them by their
training institutions was inadequate and, in some cases, actively unhelpful, it seems
likely that offering a more transparent and acceptable rationale for the inclusion of a
personal therapy in training would enhance trainees appreciation of the potential
benefits of undertaking their own therapy in the context of their future professional
work. However, one of the difficulties here is the temptation to pathologise or
otherwise unhelpfully label trainees, which, as results have already suggested, risks
perpetuating or even augmenting precisely the same unhelpful dynamic to which
some insecurely-attached trainees may already be highly sensitised. The risk of
pathologising trainees is endemic within psychoanalytic training institutions
(Davies, 2008) and it is precisely this danger that the decoupling of personal therapy

Counselling Psychology Quarterly

365

from the usual accountability structures within counselling psychology training


institutions was designed to avoid.
However, our results suggest that trainee-clients neglectful, abusive or violent
early attachment experiences may have a complex and recursive impact on the way in
which a training therapy and perhaps, by extension, an entire training programme
is experienced as either helpful or unhelpful. This then draws us further into more
intricate questions about the aims of a training therapy (Cabaniss & Bosworth,
2006), and the extent to which a personal therapy can or should be expected to
produce healthy practitioners. (If so, by what criteria could be established at
selection?). We would argue that if the field of counselling psychology attracts a high
proportion of individuals with insecure working models of relationships, then the
onus is on the profession to establish how, to what extent and by what means a
mandatory personal therapy can enable these individuals to harness these
experiences and to transform them into effective work with clients.
One likely focus of interest for future research could be those practitioners
deemed earned secure, as we found that these individuals in the current study
specifically attributed the resolution of their personal histories and problems to their
personal therapy, and found it indispensable in their professional work. Detailed
case studies, documenting the complex interrelationship between earned secure
therapists attachment relationships, levels of reflective function, and the way their
personal therapy is recalled and deployed in clinical practice would help the
profession to develop a more convincing educational rationale for the inclusion of
personal therapy in training as well as a model for its putative clinical impact.
Finally, it is interesting that, despite an increasingly forceful political and
economic agenda within the NHS (e.g., Layard, 2004), the field has yet to overturn
L. Luborsky, Singer, and E. Luborskys (1975) original dodo bird verdict
demonstrating that all psychotherapies are similarly effective. Perhaps for this reason
there is renewed interest in the contribution of the therapist to psychotherapy
outcome, with recognition that variations, for example, in skilfulness and the self
of the therapist may account for significant individual differences in therapists
clinical outcomes (Krause & Lutz, 2009; Lambert & Baldwin, 2009; Luborsky,
McLellan, Digure, Woody, & Seligman, 1997; Okiishi, Lambert, Neilsen, & Ogles,
2003; Okiishi et al., 2006). Given the presumed impact of personal therapy in
facilitating more effective clinical outcomes, we hope our study may indirectly
contribute to this literature by elucidating the complexity of how attachment security
interacts with the experience of a personal therapy in the context of counselling
psychology training.
Declaration of interest: The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.

Notes on contributors
Dr Rosemary Rizq, PhD, is a Chartered Counselling Psychologist and Senior Practitioner
member of the British Psychological Societys Register of Psychologists Specialising in
Psychotherapy. She is Principal Lecturer in Counselling Psychology at Roehampton
Universitys Research Centre for Therapeutic Education and is Specialist Lead for Research
and Development for Ealing PCTs Mental Health and Well-being Service where she also has
a clinical and supervisory role. She is Submissions Editor for Psychodynamic Practice.
Professor Mary Target, PhD, is a Fellow of the British Psycho-Analytical Society and
Professional Director of the Anna Freud Centre. She has been a member of the Curriculum

366

R. Rizq and M. Target

and Scientific Committees, and Chair of the Research Committee of the British
Psychoanalytic Society, and former Chair of the Working Party on Psychoanalytic
Education of the European Psychoanalytic Federation. She is a member of the Research
Committee (Conceptual Research) of the International Psychoanalytic Association. She is
Course Organiser of the UCL MSc in Psychoanalytic Theory, and Academic
Course Organiser of the UCL/Anna Freud Centre Doctorate in Child and Adolescent
Psychotherapy. She is Joint Series Editor for Karnacs new Developments in Psychoanalysis
series. She has active research collaborations in many countries in the areas of developmental
psychopathology, attachment and psychotherapy outcome. She is Consultant to the Child
and Family Program at the Menninger Department of Psychiatry at Baylor College of
Medicine, USA.

References
Aveline, M. (2005). The person of the therapist. Psychotherapy Research, 15, 155164.
Bernier, A., & Dozier, M. (2002). The client-counselor match and the corrective emotional
experience. Evidence from interpersonal and attachment research. Psychotherapy: Theory,
Research, Practice, Training, 39, 3243.
Bion, W. (1962a). Learning from experience. London: Heinemann.
Bion, W. (1962b). A theory of thinking. International Journal of Psycho-Analysis, 43, 306310.
Blumer, H. (1962). Society as symbolic interaction. In A. M. Rose (Ed.), Human behavior and
social process: An interactionist approach. Boston, MA: Houghton-Mifflin.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development.
New York: Basic Books.
Cabaniss, D., & Bosworth, H. (2006). The aim of the training analysis. Journal of the American
Psychoanalytic Association, 54, 203229.
Davies, J. (2008). The transformative conditions of psychotherapeutic training: An
anthropological perspective. British Journal of Psychotherapy, 24, 5064.
Dellinger, A., & Leech, N. (2007). Towards a unified validation framework in mixed methods
research. Journal of Mixed Methods Research, 1, 309332.
Dennett, D. (1978). Brainstorms. Cambridge, MA: MIT Press.
Diamond, D., Stovall-McClough, C., Clarkin, J.A., & Levy, K.N. (2003). Patient-therapist
attachment in the treatment of borderline personality disorder. Bulletin of the Menninger
Clinic, 67, 224257.
DiCaccavo, A. (2002). Investigating individuals motivation to become counselling
psychologists: The influence of early caretaking roles within the family. Psychology and
Psychotherapy: Theory, Research and Practice, 75, 463472.
Dozier, M. (1990). Attachment organization and treatment use of adults with serious
psychopathological disorders. Development and Psychopathology, 2, 4760.
Dozier, M., Cue, K., & Barnett, L. (1994). Clinicans as caregivers: Role of attachment
organisation in treatment. Journal of Consulting and Clinical Psychology, 62, 793800.
Elliott, R., Fischer, C., & Rennie, D. (1999). Evolving guidelines for publication of qualitative
research studies in psychology and related fields. British Journal of Clinical Psychology, 38,
215229.
Farber, B., & Metzger, J. (2008). The therapist as secure base. In J. Obegi & E. Berant (Eds.),
Attachment theory and research in clinical work with adults. New York: Guilford Press.
Fonagy, P., & Target, M. (1996). Playing with reality: 1. Theory of Mind and the normal
development of psychic reality. International Journal of Psychoanalysis, 77, 217233.
Fonagy, P., Steele, H., Moran, G., Steele, M., & Higgett, A. (1991). The capacity for
understanding mental states: The reflective self in parent and child and its significance for
security of attachment. Infant Mental Health Journal, 13, 200217.

Counselling Psychology Quarterly

367

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual, version
5.0, for Application to Adult Attachment Interviews. London: University College London.
Fonagy, P., Steele, M., Steele, H., Higgitt, A., & Target, M. (1994). The Emanuel Miller
Memorial Lecture 1992. The theory and practice of resilience. Journal of Child Psychology
and Psychiatry, 35, 231257.
Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization and
the development of the self. New York: Other Press.
Fonagy, P., Target, M., Gergely, G., Allen, J., & Bateman, A. (2003b). The developmental
roots of borderline personality disorder in early attachment relationships: A theory and
some evidence. Psychoanalytic Inquiry, 23, 412459.
Foucault, M. (1980). Power/knowledge: Selected interviews and other writings 19721977
(C. Gordon, Ed.). New York: Harvester Wheatsheaf.
Foucault, M. (1982). The subject and power. In H.L. Dreyfus, & P. Rabinow (Eds.),
Michel Foucault: beyond structuralism and hermeneutics (pp. 208226). Brighton
Harvester.
Geller, J. (2005). My experiences as a patient in five psychoanalytic psychotherapies.
In J. Geller, J. Norcross, & D. Orlinsky (Eds.), The Psychotherapists own psychotherapy:
Patient and clinician perspectives. Oxford: Oxford University Press.
Glickhauf-Hughes, C., & Mehlman, E. (1995). Narcissitic issues in therapists: Diagnostic and
treatment considerations. Psychotherapy, 32, 213221.
Grimmer, A., & Tribe, R. (2001). Counselling psychologists perceptions of the impact of
mandatory personal therapy on professional development an exploratory study.
Counselling Psychology Quarterly, 14, 287301.
Guilfoyle, M. (2005). From therapeutic power to resistance? Therapy and cultural hegemony.
Theory and Psychology, 15(1), 101124.
Halewood, A., & Tribe, R. (2003). What is the prevalence of narcissistic injury among trainee
counselling psychologists?. Psychology and Psychotherapy: Theory, Research and Practice,
76, 87102.
Heidegger, M. (1962). Being and time. Oxford: Blackwell.
Hill, C. (2005). The role of individual and marital therapy in my development. In J. Geller,
J. Norcross, & D. Orlinsky (Eds.), The psychotherapists own psychotherapy: Patient and
clinician perspectives. Oxford: Oxford University Press.
Holmes, J. (1993). John Bowlby and attachment theory. New York: Routledge.
Jackson, S. (2001). The wounded healer. Bulletin of Historical Medicine, 75(1), 136.
Karlsson, R., & Kermott, A. (2006). Reflective-functioning during the process in brief
psychotherapies. Psychotherapy: Theory, Research, Practice, Training, 43, 6584.
Kernberg, O. (2006). The coming changes in psychoanalytic education. International Journal
of Psychoanalysis, 87, 16491673.
Kirsner, D. (2000). Unfree associations Inside psychoanalytic institutes. London: Process Press.
Krause, M., & Lutz, W. (2009). Process transforms inputs to determine outcomes:
Therapists are responsible for managing process. Clinical Psychology, Science and
Practice, 16, 7381.
Layard, R. (2004). Mental health: Britains biggest social problem. Available from:
www.strategy.gov.uk/downloads/files/mh_layard.pdf
Lambert, M., & Baldwin, S. (2009). Commentary on Krause and Lutz. Clinical Psychology,
Science and Practice, 16, 8285.
Lefebvre, H. (1991). Critique of every day life. Trans.: John Moore. London: Verson.
Levy, K., Meehan, K., Kelly, K., Reynoso, J., Weber, M., Clarkin, J., & Kernberg, O. (2006).
Change in attachment patterns and reflective function in a randomised control trial of
transference-focused psychotherapy for borderline personality disorder. Journal of
Consulting and Clinical Psychology, 74, 10271040.
Little, M. (1990). Psychotic anxieties and containment. A personal record of an analysis with
Winnicott. Northvale, NJ: Jason Aronson.

368

R. Rizq and M. Target

Luborsky, L., Singer, B., & Luborsky, E. (1975). Comparative studies of psychotherapies. Is it
true that everyone has won and all must have prizes? Archives of General Psychiatry, 32,
9951008.
Luborsky, E., McLellan, A.T., Diguer, L., Woody, G.E., & Seligman, D.A. (1997). The
psychotherapist matters: Comparison of outcome across twenty-two therapists and seven
patient samples. Clinical Psychology: Science and Practice, 4, 5365.
Macran, S., Stiles, W., & Smith, J. (1999). How does personal therapy affect therapists
practice? Journal of Counseling Psychology, 46, 419431.
Maguire, M. (1995). Men, women, passion and power: Gender issues in psychotherapy. London:
Routledge.
Main, M. (1991). Metacognitive knowledge, metacognitive monitoring and singular
(coherent) vs. multiple (incoherent) models of attachment. In C.M. Parkes,
J. Stevenson-Hinde, & P. Morris (Eds.), Attachment across the life-cycle (pp. 127159).
London: Routledge.
Main, M., & Goldwyn, R. (1998). Adult attachment scoring and classification system.
Unpublished manuscript. University of California, Berkele, CA.
Maroda, K. (1994). The power of countertransference. London: Aronson.
Mason, J. (2006). Mixing methods in a qualitatively-driven way. Qualitative Research, 6,
925.
Meyer, I. (2003). Subservient analysis. International Journal of Psychoanalysis, 84, 12411262.
Murphy, D. (2005). A qualitative study into the experience of mandatory personal therapy
during training. Counselling and Psychotherapy Research, 5, 2732.
Obegi, J., & Berant, E. (Eds.) (2008). Attachment theory and research in clinical work with
adults. New York: Guilford Press.
Okiishi, J., Lambert, M., Neilsen, S., & Ogles, B. (2003). Waiting for supershrink: An
empirical analysis of therapist effects. Clinical Psychology and Psychotherapy, 10, 361373.
Okiishi, J., Lambert, M., Eggett, D., Neilson, S., Dayton, D., & Vermeersch, D. (2006). An
analysis of therapist treatment effects: Towards providing feedback to individual
therapists on their patients psychotherapy outcome. Journal of Clinical Psychology, 62,
11571172.
Orlinsky, D., Ambuhl, H., Ronnestad, M., Davis, J., Gerin, P., Davis, M., . . . , The SPR
Collaborative Research Network (1999a). Development of psychotherapists: concepts,
questions and methods of a collaborative international study. Psychotherapy Research, 9,
127153.
Orlinsky, D., Botermans, J.-F., & Ronnestad, M. (2001). Towards an empirically-grounded
model of psychotherapy training: Four thousand therapists rate influences on their
development. Australian Psychologist, 36, 139148.
Orlinsky, D., Norcross, J., Ronnestad, H., & Wiseman, H. (2005). Outcomes and impacts of
the psychotherapists own psychotherapy. A research review. In J. Geller, J. Norcross, &
D. Orlinsky (Eds.), The psychotherapists own psychotherapy: Patient and clinician
perspectives. Oxford: Oxford University Press.
Pearson, J., Cohn, D., Cowan, P., & Cowan, C. (1994). Earned- and continuous-security in
adult attachment: Relation to depressive symptomatology and parenting style.
Development and Psychopathology, 6, 359373.
Rake, C., & Paley, G. (2009). Personal therapy for psychotherapists: The impact on
therapeutic practice. A qualitative study using interpretative phenomenological analysis.
Psychodynamic Practice, 15, 275294.
Rizq, R., & Target, M. (2010). If thats what I need, it could be what someone else needs.
Exploring the role of attachment and reflective function in counselling psychologists
accounts of how they use personal therapy in clinical practice: A mixed methods study.
British Journal of Guidance and Counselling, 38, 459481.
Rizq, R., & Target, M. (2008a). The power of being seen. An interpretative phenomenological
analysis of how experienced counselling psychologists describe the meaning and

Counselling Psychology Quarterly

369

significance of personal therapy in clinical practice. British Journal of Guidance and


Counselling, 36, 131153.
Rizq, R., & Target, M. (2008b). Not a little Mickey Mouse thing: How experienced
counselling psychologists describe the significance of personal therapy in clinical practice
and training. Counselling Psychology Quarterly, 21(1), 120.
Rose, N. (2001). Power in therapy: Techne and Ethos. Academy for the Study of the
Psychoanalytic Arts. Available from: http://www.academyanalyticarts.org/rose2.htm.
Slade, A. (2000). The development and organisation of attachment: Implications for
psychoanalysis. Journal of the American Psychoanalytic Association, 48, 11471174.
Smith, J. (1995). Semi-structured interviewing and qualitative analysis. In J. Smith, R. Harre,
& L. Van Langenhove (Eds.), Rethinking methods in psychology (pp. 926). London: Sage
Publications.
Smith, J., & Osborne, M. (2003). Interpretative phenomenological analysis. In J. Smith (Ed.),
Qualitative psychology: A practical guide to research methods (pp. 5180). London: Sage.
Smith, J., Jarman, M., & Osborn, M. (1999). Doing interpretative phenomenological analysis.
In M. Murray & K. Chamberlain (Eds.), Qualitative health psychology: Theories and
methods. London: Sage.
Stiles, W. (1993). Quality control in qualitative research. Clinical Psychology Review, 13,
593618.
Tyrell, C., Dozier, M., Teague, G., & Fallot, R. (1999). Effective treatment relationships for
persons with serious psychiatric disorders: The importance of attachment states of mind.
Journal of Consulting and Clinical Psychology, 67, 725733.
Wallerstein, R.S. (1993). Between chaos and petrification: A summary of the Fifth IPA
Conference of Training Analysts. International Journal of Psychoanalysis, 74, 165178.
Wiseman, H., & Shefler, G. (2001). Experienced psychoanalytically oriented therapists
narrative accounts of their personal therapy: Impacts on professional and personal
development. Psychotherapy, 38, 129141.

Copyright of Counselling Psychology Quarterly is the property of Routledge 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.
However, users may print, download, or email articles for individual use.