This article was downloaded by: [Karolinska Institutet, University Library]On: 20 February 2012, At: 07:34Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Psychoanalytic PsychotherapyPublication details, including instructions for authorsand subscription information:http://www.tandfonline.com/loi/rpps20

PRIVATE THEORIES ANDPSYCHOTHERAPEUTICTECHNIQUEBjörn Philips a , Andrzej Werbart a & Johan Schubert aa Institute of Psychotherapy, Björngårdsgatan 25,SE‐118 52 Stockholm, Sweden E-mail:

Available online: 18 Feb 2007

To cite this article: Björn Philips, Andrzej Werbart & Johan Schubert (2005): PRIVATETHEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE, Psychoanalytic Psychotherapy, 19:1,48-70

To link to this article: http://dx.doi.org/10.1080/02668730512331341573

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expresslyforbidden.

The publisher does not give any warranty express or implied or make anyrepresentation that the contents will be complete or accurate or up todate. The accuracy of any instructions, formulae, and drug doses should beindependently verified with primary sources. The publisher shall not be liablefor any loss, actions, claims, proceedings, demand, or costs or damageswhatsoever or howsoever caused arising directly or indirectly in connectionwith or arising out of the use of this material.

PRIVATE THEORIES AND PSYCHOTHERAPEUTICTECHNIQUE

BJORN PHILIPS, ANDRZEJ WERBART and JOHAN SCHUBERT

That if real success is to attend the effort to bring a man toa definite position, one must first of all take pains to findhim where he is and begin there. This is the secret of theart of helping others (Kierkegaard [1848] 1962, p. 27)

The aim of this study is to explore the importance, to thetherapeutic process, of the relation between the patient’s andthe therapist’s problem formulations and private theories ofpathogenesis and cure. Four cases of young adults inpsychoanalytic psychotherapy were compared, two withunequivocally positive and two with more ambiguous outcomeat termination. The patients and therapists were interviewedabout their private theories initially and at termination oftherapy, and a qualitative comparison was made between thecases. In the two more successful cases the therapists had earlyin therapy perceived obstacles for the therapeutic work in thepatients’ ways of thinking, feeling, and relating, and madeinterpretative interventions focusing on these. This was notobserved in the less successful cases. In the more successfulcases the patient’s and the therapist’s private theories were moresimilar at termination than initially, whereas the oppositedevelopment was found in the less successful cases. Onehypotheses generated is that the therapeutic process can befacilitated by a therapist listening to the patient’s privatetheories, making interpretative interventions focusing onobstacles to the therapeutic work, including contradictionsbetween their private theories, and monitoring the patient’sreactions to these interventions.

A recent review of the outcome-research literature (Lambert and Barley 2001)indicates that only 15% of the therapeutic outcome is due to specific technique.

Psychoanalytic Psychotherapy ISSN 0266-8734 print/ISSN 1474-9734 online# 2005 The Association for Psychoanalytic Psychotherapy in the NHS

http://www.tandf.co.uk/journals

DOI: 10.1080/02668730512331341573

48

Psychoanalytic Psychotherapy (March 2005)

Vol. 19, No. 1, 48–70

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

While expectancy effect contributes to another 15%, the therapeutic relation-ship is attributable to 30%, and extratherapeutic factors (including patientfactors) stand for 40%. Different schools of psychotherapy have their owntheories of therapeutic action, some in concordance with empirical researchfindings, some not. Psychoanalytic theorists have described a diverse collectionof curative factors; for example Appelbaum (1978) mentions insight, correctiveemotional experience, interpersonal relationship, overcoming apartness, emo-tional release, suggestion, coherence and mastery, the shift to activity, andaltered consciousness. According to Rangell’s (1992) summary of the classicalpsychoanalytic theory of change, the analysand has the possibility of a newidentification with the analyst’s analytic function from the experience of theanalytic relationship, the therapeutic alliance, the transference neurosis and theanalyst’s handling of it. Some argue that the crucial active component is likelyto vary from patient to patient, from time to time in each analysis, and from oneanalyst to another (Pine 1998).

The practice of psychoanalytic psychotherapy is based upon theoreticalmodels generated within psychoanalysis. A common approach is to regardpsychoanalytic psychotherapy as a modality in which psychoanalytictechniques are combined with supportive elements (Wallerstein 1995). Incontrast to this, Kernberg (1999) defines psychoanalytic psychotherapy as anexplorative and expressive treatment based on free association, whereclarification, confrontation, and interpretation in the ‘here and now’ are themain interpretive techniques, where transference analysis is modified by activeinterpretive connection with exploration of the patient’s daily life situation,and where technical neutrality is repeatedly abandoned because of the need toset limits. An intersubjective/relational view presented by Fosshage (1997) isthat there are two types of therapeutic action involved in psychoanalyticpsychotherapy: (1) interpretations lead to awareness of problematic relationalpatterns, to gradual freedom from these patterns, to new relationalexperiences, and to psychological reorganization, and (2) a therapist’s supportcreates a new relational experience and, in turn, leads to awareness of oldrelational patterns and to gradual formation of new organizing patterns. Recentresearch suggests that there might be different curative factors involved inpsychoanalysis and psychoanalytic psychotherapy. It has been found that agood outcome in psychotherapy is related to a therapist attitude of kindnessand supportiveness, as well as an emphasis on insight and neutrality. A moreorthodox attitude with less kindness and supportiveness, but still emphasis oninsight and neutrality, is related to worse outcome. Such significant differenceswere not found in psychoanalysis (Sandell et al. 2000, Grant and Sandell2003).

Just as every psychotherapist has his own theory of cure, partly shaped bytraining and partly idiosyncratic, so does every patient. Wile (1977) describedthese theories of clients and therapists as partially, or even entirely, unconscious

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

49

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

and closely related to character structure. He pointed out a number of differentcategories of theories. Different schools of psychotherapy, separate therapistsand individual clients have a bias towards some of these theory types. Accordingto Wile, ideological conflicts between client and therapist will arise if theparties are adherents of different theories of cure. This may have a major impacton the therapeutic outcome.

The patient’s creation of private theories of cure, as well as private theoriesof pathogenesis, is an example of the general human tendency to interpret andgive meaning to what happens in our lives. Several authors (Arlow 1981, 1986,Sandler 1983, Goldberg 1991, 1994) have shown that, in the context ofpsychoanalytic treatment, both the patient and the analyst are influenced byimplicit private theories about pathogenesis and cure. These private theories arecreated and shared by the patient and the analyst in a complex and continuousnegotiation. This is supposedly of importance for the course of the treatment.Werbart and Levander (2000) studied the private theories of pathogenesis andcure in patients with psychosomatic illness and psychosis, as well as thosetreating them. For patients with first psychotic episode they found that positiveoutcome was related to the clinician knowing about and respecting the patient’sprivate theories (Levander and Werbart 2003).

One view on how a psychotherapist should approach and use the patient’sprivate theory of change in order to promote a good therapeutic result ispresented by Duncan and Miller (2000). They propose that the therapist oughtto honour the client’s theory of change and adapt the therapeutic methodaccordingly. This version of integrative psychotherapy is based upon theresearch findings that clients in general are resourceful – the client is in fact themost potent contributor to outcome (Asay and Lambert 1999, Miller et al.1997). Listening carefully to the patient’s theory of change and adapting thetherapeutic method hereafter may also enhance the quality of the therapeuticrelationship, which has been found by research to be the second strongest factorcontributing to therapeutic outcome. A crucial aspect of the therapeuticrelationship is the therapeutic alliance, which has been found to be a strongpredictor of outcome (Horvath and Symonds 1991, Orlinsky et al. 1994, Martinet al. 2000). From a psychoanalytic perspective, and in contrast to Duncan andMiller’s recommended approach, the client’s theory of change may sometimesbe closely related to his/her defence organization and the unconscious processesimpelling the psychopathology. If the therapist totally adapts to the patient’stheories the result may be collusion, a counter-productive avoidance of clinicallysignificant material (Langs 1975, 1976, Frankel 1993, Roughton 1994). Thetherapist’s task may sometimes be to disturb the patient’s usual ways ofthinking.

The aim of the present study is to explore the importance, to the therapeuticprocess, of the relation between the patient’s and the therapist’s problemformulations, and their private theories of pathogenesis and cure.

BJORN PHILIPS ET AL.

50

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

METHOD

Design

The Young Adult Psychotherapy Project1 (YAPP) is an ongoing naturalistic,long-term study of 134 patients with an age span of 18–25 years. In a subgroup of47 patients in individual psychoanalytic psychotherapy (hereafter called ‘theresearch group’) patients and therapists are interviewed both initially and attermination. The patients are additionally interviewed 1.5 and 3 years aftertermination. All patients complete a background and personality questionnaireon all these occasions.

In the present study quantitative and qualitative methods were combined inthe following way. Four cases were chosen retrospectively from the researchgroup, using quantitative measures to distinguish two cases with unequivocallypositive, and two with less favourable outcome at termination. The interviewtexts of both the patients and the therapists were analysed using qualitativemethods. In order to make contrasts and comparisons this kind of selection is afrequently used strategy in qualitative research (Miles and Huberman 1994).

Treatments

The individual psychoanalytic psychotherapies were conducted at the Instituteof Psychotherapy, within the normal work of the Institute and following theusual standards. The patients applied through the Institute’s telephone service.The psychotherapists accepted the patients for psychotherapy on the basis of apsychoanalytic case formulation, emphasizing motivation and suitability,without making a psychiatric diagnosis. The treatments were not manualized.There were variances among the therapists in their preferences regarding theoryand psychotherapeutic technique, but they all worked within a psychoanalyticframe of reference. The duration and frequency of the therapies were decidedjointly by the therapist and the patient, and were written down in a contractafter the initial sessions. The terms of the contract were re-negotiable and werenot dictated by the research project. However, some therapists seemed to thinkthat the treatments should be limited to one year.

Participants

At the time of this study eight psychotherapies in the research group wereterminated with completed data collection up to and including termination. Of

1 This project is conducted at the Institute of Psychotherapy, Stockholm County Council, and the

Psychotherapy Section, Department of Clinical Neuroscience, Karolinska Institute. The project is

supported by a grant from the Bank of Sweden, Tercentenary Foundation. The project has been

approved by Karolinska Institute’s ethical committee and all participants have given informed

consent.

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

51

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

these, four cases were chosen for further analysis. The four patients in this studywere between 23 and 25 years old when therapy began. Three were female, onemale. Three were born in Sweden with Swedish parents and one was animmigrant. All had siblings. All patients were unmarried with no children, butthey all had partners of the opposite gender. All had a college education, as didall their parents. One of them had earlier experience of psychotherapy, whileanother had had a single visit to a psychiatric outpatient centre. None of themhad ever taken psychoactive drugs.

The four therapists, in their fifties and sixties, were licensed psychotherapistswho specialized in psychoanalytic psychotherapy, with decades of clinicalexperience. Three were psychologists and psychoanalysts, and the fourth was asocial worker. Three were female, one male. The therapists worked as teachersand supervisors in the Advanced Psychotherapy Training Programme. They hadworked for a long time at the Institute of Psychotherapy.

Quantitative outcome criteria

A combination of three outcome criteria was used: Global Symptom Index(GSI) of the Symptom Checklist–90 (SCL-90; Derogatis 1994), GlobalAssessment of Functioning (GAF; American Psychiatric Association 1994),and the Differentiation-Relatedness Scale (DRS; Diamond et al. 1995, Blatt andAuerbach 2001). SCL-90 is a self-rating scale and the standardized Swedishtranslation was used (Fridell et al. 2002). GAF and DRS are both expert ratings,which were assessed by a group of trained judges. DRS ratings were based on thepatient’s brief descriptions of his/her mother, father, him/herself, and aftertermination also the therapist, obtained from the Object Relation Interview(ORI; Auerbach and Blatt 1996). All these assessments were made pre- andpost-treatment. With this choice of criteria, there was coverage of both manifestsymptoms and inner psychic structure, and with the double perspective ofpatients’ self-ratings and experts’ judgements.

The successful cases were defined as having a decrease on the GSI and anincrease of GAF and DRS scores between pre-treatment and termination. In allcriteria the successful case should preferably show a change that was clinicallysignificant. This demands both a transition from the dysfunctional to thefunctional spectrum and a change being reliable according to the ReliableChange Index (RCI; Jacobson and Truax 1991). The means for the patientpopulation’s pre-treatment scores, as well as the cut-off scores between thefunctional and the dysfunctional spectrum, and the change needed to obtain anRCI.1.96 for the three outcome criteria are shown in table 1.

The results of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q)prior to treatment were used to provide some information about the patients’character pathology. Even if this instrument should not be used alone to diagnosepersonality disorders without complementary interviews or observations

BJORN PHILIPS ET AL.

52

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

(Ottosson et al. 1995), the patient’s self-rated personality problems might be aprognostic factor.

Interviews and qualitative analysis

The patients and the therapists were interviewed using the Private TheoriesInterview (PTI; Ginner et al. 2001) and the Object Relation Interview (ORI;Auerbach and Blatt 1996). PTI is a semi-structured in-depth interview, aimed atcollecting narratives, concrete examples and illustrative episodes concerningthe following themes: (1) problem formulations; (2) private theories ofpathogenesis; (3) private theories of cure; and (4) descriptions of change(included after terminated therapy). The aim of the interviews is to capture the‘private theories’ of the patients and the therapists, i.e. their conscious and pre-conscious ideas in these areas, shaped by their personal experiences andopinions. Thus the therapists recount something else and something more thantheir declared public theoretical orientation. The interviews were conducted byexperienced psychotherapists and psychologists trained in the PTI technique.The patients were interviewed before the first encounter with their therapist,whereas the therapists were interviewed after some introductory meetings withthe patient and two therapy sessions. Both were interviewed again shortly aftertermination. The interviews were tape-recorded and transcribed verbatim. The

Table 1 Patient population’s means, cut-off points between functional and dysfunctional spectrum,

and size of change necessary for reliable change, for GSI, GAF, and DRS

Outcome criteria

YAPP population pre-

treatment means

Cut-off for functional

spectrum

Change needed for

RCI.1,96

Global Symptom Index (GSI) Women 1.35 Women 0.92 0.54

Men 1.15 Men 0.79

Total 1.30

Global Assessment of

Functioning (GAF)

56.7 71 13

Differentiation-Relatedness

Scale (DRS), mean MFS

6.5 6.0 2.0

Cut-off for GSI is computed with the formula given by Jacobson and Revenstorf (1988) and based on

the non-clinical samples of women and men, respectively, 20–25 years old, in the Swedish

standardization of SCL-90 (Fridell et al. 2002). The change needed on GSI is based on the reliability

coefficient (0.90) recommended by Hansen and Lambert (1996) and the standard deviation for the

patient population’s pre-treatment ratings.

Cut-off for GAF is defined theoretically, as GAF.70 represents the spectrum of clinical normality.

The change needed on GAF is based on the reliability coefficient (0.65) given by Michels et al.

(1996) and the standard deviation for the patient population’s pre-treatment ratings.

Cut-off for DRS – the mean of the patient’s representations of mother, father, and self – is defined

theoretically, as DRS56 is the threshold value for neurotic personality structure. The change needed

on mean DRS is based on the reliability coefficient (0.71) of the Swedish standardization (Hjalmdahl

et al. 2001) and the standard deviation for the patient population’s pre-treatment ratings.

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

53

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

qualitative analysis was based on interview transcripts. Utterances from theinformants were categorized in accordance with the PTI coding manual; aprocedure which has been proven to be highly reliable (Ginner et al. 2001). Inthe words of Kvale (1996) a ‘categorization of meaning’ was performed.

Judgement of the relation between the patient’s and the therapist’s privatetheories

The relations between the two parties’ problem formulations and privatetheories of pathogenesis and cure were assessed for each case separately beforetreatment and at termination. For the four cases – with both parties beinginterviewed twice, i.e. a total of 16 interviews – six assessments of relations havebeen made per case, i.e. a total of 24 assessments of dominant patterns. Therelation between the parties’ theories was defined as consisting of two factors.

(1) A comparison between the two parties’ problem formulations, and theirprivate theories of pathogenesis and cure.

(2) A judgement of how the two parties approach and use each other’sprivate theories.

The patient’s and the therapist’s private theories were compared on fourdistinct dimensions, formulated and defined a priori, and one or more dominantpatterns of relation were identified.

(1) Similar theories: the two parties’ ideas are similar as to the content.

(2) Complementary theories: the two parties’ ideas complement each other.To read them both is like putting together two pieces in a jigsaw.Together they create a richer picture and a better understanding thaneach of them alone.

(3) Contradictory theories: the two parties’ ideas are contradictory. Oneparty’s idea is the opposite of the other’s.

(4) Irrelevant theories: the two parties’ ideas do not meet at any crucialpoint. Together they do not create a meaningful context.

Regarding the judgement of how the two parties approach and use eachother’s private theories, in the initial assessment only the therapist’s way ofapproaching the patient’s ideas could be examined, since the patient had not yetmet the therapist.

In the next step, a case summary of 4–6 pages was written down for each ofthe four cases. This summary contained the private theories of both parties andhow each of them relates to the other’s private theories. An effort was made topreserve the basic meaning of the original narrative as well as the idiosyncrasiesof each party’s language and wording. This ‘concentration of meaning’ (Kvale1996) resulted in a text reduction. The four case summaries were then comparedin order to examine the differences between the two more successful and the two

BJORN PHILIPS ET AL.

54

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

less successful cases. By contrasting more and less successful cases it was possible togenerate hypotheses in an inductive way, like in grounded theory (Glaser andStrauss 1967, Strauss 1987, Strauss and Corbin 1998). The qualitative analysiswas performed by the first author (BP), who was not blind to the outcome of thecases. In order to increase the credibility of the analysis it was reviewed by oneco-author (AW) followed by discussions until consensus was reached. For thepurposes of this presentation, the descriptions of each case were further reduced tovery brief vignettes; an effort being made to exclude or obscure details that mightthreaten the confidentiality of the participants. Note that these brief vignettes arebased entirely on the patients’ and the therapists’ interview narratives.

RESULTS

Contrasting outcome markers at termination

The outcome at termination in the four cases (here called Alice, Ben, Cindyand Diana) according to the criteria used is presented in table 2. There were noclear-cut negative outcomes in this study. All patients moved from thedysfunctional level of moderate symptoms or moderate impairment, to thenormal spectrum on the Global Assessment of Functioning (GAF). Three ofthem (Alice, Ben and Cindy) showed a reliable change and the fourth (Diana)was very close to this. Three patients improved and one of them (Diana)deteriorated in terms of differentiation-relatedness of self and object

Table 2 Therapeutic outcome in terms of GSI, GAF, and DRS pre-treatment (1) and post-

treatment (2) scores

GSI-1 GSI-2 GAF-1 GAF-2 DRS-1 DRS-2

Alice 1.08 0.84 59 78* M4 F6 S6 M7 F7 S7

Mean MFS55.3 Mean MFS57

T8

Ben 1.18 0.56* 53 74* M7 F8 S7 M9 F8 S8

Mean MFS57.3 Mean MFS58.3

T10

Cindy 1.31 1.34 52 73* M7 F7 S8 M7 F8 S8

Mean MFS57.3 Mean MFS57.7

T8

Diana 1.18 1.62 59 71 M6 F7 S6 M5 F6 S5

Mean MFS56.3 Mean MFS55.3

T5

GSI5Global Symptom Index of the SCL-90.

GAF5Global Assessment of Functioning.

DRS5Differentiation-Relatedness Scale. M5Mother, F5Father, S5Self, T5Therapist.

*Clinically significant change.

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

55

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

representations (DRS), but none of these changes were reliable. The criteriondistinguishing cases with unequivocally positive outcome at termination fromthose with somewhat more ambiguous outcome was self-rated symptoms (SCL-90, GSI). Two of the patients, Alice and Ben, moved from the dysfunctional tothe functional spectrum in the Global Symptom Index, and Ben’s change wasalso reliable. Cindy and Diana remained on the dysfunctional level, while Dianademonstrated a negative change.

Cases with positive outcome

Case 1: Alice

Alice was in therapy with a female therapist for one year, with a once-a-weekfrequency. She did not initially fulfil the general criteria of personality disorderaccording to DIP-Q, but reached the cut-off for obsessive-compulsivepersonality disorder.

Case 1 initially

Problems: Alice described being in a crisis after a tragic accident in herboyfriend’s family. She felt sad, fragile and out of balance – as if everything wasfalling apart. She worried about her boyfriend ending up in a crisis. Thetherapist regarded it as problematic that Alice located the problems outsideherself. The therapist was of the opinion that Alice worrying about herboyfriend had more to do with her fear of having a breakdown herself.Pathogenesis: Alice reported that she had tried to help her boyfriend and hisfamily after the tragic event and she had ‘gathered up a lot of grief’. Besides this,her mother was ill and had recently been admitted to hospital. The therapistfocused on Alice’s childhood and family background – her identification withthe mother, the beginning of her mother’s illness, the family climate ofconcealment, denial, inhibition of aggression and overprotection. Cure: Alicewanted to talk to someone herself, and together with her boyfriend, and she alsothought that it would help her if her boyfriend would receive help on his own.The therapist thought that Alice did not need much support in the therapy butmore insight-oriented work and help in distinguishing between her ownproblems and those of others. The therapist brought up this issue in the initialsessions and Alice was open to this.

Case 1 at termination

Problems: Alice said that she was too demanding regarding both herself andothers, too compassionate, easily offended, and formal in the company of others.She was afraid of burning herself out like her mother. The therapist said thatAlice was still overly serious, ambitious and responsible. Pathogenesis: Alicethought that she had absorbed her parents’ high demands. She could recognize

BJORN PHILIPS ET AL.

56

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

herself in her mother’s personality. She had focused too little on what sheherself wanted. The therapist spoke of Alice’s mother’s narcissistic traits, howher perfectionism was nourished by her children’s achievements, and how shewas regarded in the family as omnipotent. Her mother’s falling ill, in Alice’searly teens, laid the grounds for a catastrophic anxiety, awoken again by latertrauma. Cure: It had been helpful for Alice, she said, to talk to the therapist, toreceive help with processing, to analyse the causes behind the problems, and tolook at the family picture. The therapist described how they worked in therapywith putting back inside Alice what she had believed to be her boyfriend’sproblems. The therapist offered Alice a space to talk about herself, includingsuch ‘forbidden’ subjects as envy and jealousy.

Case 1: Relations between the patient’s and the therapist’s private theories

Alice’s and the therapist’s initial problem formulations as well as private theoriesof pathogenesis and cure were to a great extent contradictory (table 3). However,the therapist knew about Alice’s private theories, regarded them as a substantialpart of the problem, namely externalizing her own problems onto others, andconfronted Alice in the initial sessions with their different perspectives. Attermination, both parties’ ideas of problems, pathogenesis, and cure were rathersimilar as to content, and the dissimilar parts were complementary. A notablechange across time was that Alice came closer to the therapist’s ideas.

Case 2: Ben

Ben stayed for two years in therapy, once a week, with a male therapist. He didnot fulfil the criteria of any personality disorder according to DIP-Q before thetherapy.

Table 3 Dominant patterns of relation between the patient’s and the therapist’s private theories,

initially and at termination

Dominant patterns initially Dominant patterns at termination

Alice Problems: Contradictory Problems: Similar/Complementary

Pathogenesis: Contradictory Pathogenesis: Similar/Complementary

Cure: Contradictory Cure: Similar/Complementary

Ben Problems: Similar/Complementary Problems: Similar

Pathogenesis: Similar/Complementary Pathogenesis: Similar

Cure: Similar/Complementary Cure: Similar

Cindy Problems: Similar/Complementary Problems: Complementary

Pathogenesis: Similar/Complementary Pathogenesis: Complementary

Cure: Complementary/Contradictory Cure: Complementary

Diana Problems: Similar/Complementary Problems: Complementary

Pathogenesis: Similar Pathogenesis: Similar/Complementary

Cure: Similar/Complementary Cure: Similar/Complementary

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

57

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Case 2 initially

Problems: Ben mentioned that he had recently had panic attacks and otherstrong, unpleasant feelings. He had difficulties in setting limits with regard toothers and was too obliging to his family and his girlfriend. The therapist saidthat Ben was ‘carrying strong feelings, which he was only partly in contact with’;he was ‘warding off his more sick parts’. Pathogenesis: Ben was a child of politicalrefugees. As a child he had experienced traumatic events, these arising from thefamily being persecuted and endangered in their homeland, and their escapefrom it. Both parents had difficult background histories and Ben had problemsin letting his feelings out because he was eager not to upset his parents. Thetherapist added that Ben was a very strong person who succeeded in containinghis strong feelings. The parents also helped him to ‘code and contain strongfeelings’, and this enabled a continued psychological development. Cure: Benthought that he needed therapy to process his feelings, obtain help tounderstand himself, have the opportunity of being egoistic and only talk abouthimself. The therapist claimed that Ben needed to encounter a crisisconstructively in order to work through his past. The therapist could helphim by interpreting transference, work that had already started in the initialsessions.

Case 2 at termination

Problems: Ben said that he now had no problems, except financial ones. Thetherapist said that the basic structure was still there, but that Ben no longerbecame paralysed by new difficulties and was able to find solutions. Pathogenesis:Ben thought that he had taken on too much responsibility for others, mainly hisfamily, because of his fear that they would die if he were not kind andconscientious enough. Doing things exclusively for others was an obstacle to hisself-realization. The therapist said that Ben’s background was special, but hisparents cared for him. Ben was forced to grow up prematurely, and this revealedhis great talent, although he had probably a price to pay for it. Cure: Ben saidthat in therapy he had to talk and put words to his feelings. It was good that thetherapist was male, because he had never been able to talk about feelings withhis father or any man. The therapist thought that the continuity and the spacehe provided, as well as his interest, were helpful in therapy. Ben also made use ofevents in his active life.

Case 2: Relations between the patient’s and the therapist’s private theories

Ben’s and his therapist’s ideas of problems, pathogenesis, and cure were initiallyrather similar. However, they were complementary to an even greater extent(table 3) in the sense that the therapist’s ideas deepened and developed those ofthe patient’s. At termination their private theories became clearly similar. Overtime both parties’ ideas changed slightly in each other’s direction.

BJORN PHILIPS ET AL.

58

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Cases with more ambiguous outcome

Case 3: Cindy

Cindy was in therapy once a week for one year with a female therapist. Cindydid not initially fulfil the general criteria of personality disorder according toDIP-Q, but reached the cut-off for narcissistic and paranoid personalitydisorders.

Case 3 initially

Problems: Cindy reported mood swings, depression, anxiety, difficultiesexpressing her feelings to friends and family, and rage attacks directed atboyfriends. She was involved in a secret, complicated love affair, and this wasvery stressful. The therapist mentioned that Cindy had a pattern of secrecy,which prevented her from being intimate and deepening relationships. Shetransformed fear of her own feelings into conflicts with others. She was quiteneurotic and had problems with her aggressiveness. Pathogenesis: Cindydescribed a happy childhood in a good family, her parents divorced in aproblem-free way shortly before her teens. However, she had begun tounderstand that conflicts were feared and never really expressed in her family.The therapist said that Cindy came from a family where strong feelings wereforbidden; they could not have conflicts that threatened to separate them. Cure:Cindy thought that there might be things inside her that needed to be dug up.At the same time she said that her personal troubles and relationships werethings that she had to handle herself. She wanted peace and quiet, and to meetnew people. The therapist thought that in therapy Cindy might become moreopen and understanding towards her own feelings. They would not have time toprocess a large amount of transference material, but rather would be working on‘corrective emotional experience’, which the therapist described as treatingCindy in a different way to that in which her parents had done.

Case 3 at termination

Problems: Cindy talked about her own high demands concerning both workperformance and social behaviour. Perhaps she had a ‘hole’ in her self-esteem.The therapist mentioned that Cindy had an attitude of not needing anyone, wassecretive towards people around her, and had a tendency to terminaterelationships because of her fear of being abandoned. Pathogenesis: Cindy saidthat her parents had transmitted the high demands they made on themselves toher. Their demands concerned both achievements and having a stiff upper lip,i.e. not to whine. The therapist described Cindy’s background of holding backher feelings of concern for her weak mother, and her orientation towardsachievement to make her father proud. Her symptoms were a consequence of‘putting a lid on her feelings’. Cure: In her therapy Cindy came to see that she

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

59

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

had to lower her ambitions, allow herself to fail, and admit the need for help.She must not base her identity solely on what she has achieved. The therapistthought that Cindy made good use of therapy. She wanted Cindy to continue toreflect upon herself, and to dare to try love and genuine dependence in arelationship.

Case 3: Relations between the patient’s and the therapist’s private theories

Initially, Cindy’s and her therapist’s problem formulations and theories ofpathogenesis were rather similar and highly complementary (table 3). Theirideas of cure were also complementary, but with some contradictory elements.The therapist was probably unaware of these contradictions, as she did notmention anything about them in her narrative. At termination, their ideas ofproblems, pathogenesis, and cure were complementary, with Cindy focusingsingle-handedly on problems with self-esteem and her own high demands, whilethe therapist placed an equal emphasis on her ways of relating to others and heraffect management.

Case 4: Diana

Diana was in therapy once a week with a female therapist. After 9 months oftherapy Diana and her therapist were interviewed before a planned half-yearinterruption for studies abroad. The studies were prolonged and the therapy wastherefore not resumed. According to the initial DIP-Q, Diana did not fulfil thegeneral criteria of personality disorder, but clearly exceeded the cut-off forobsessive-compulsive personality disorder.

Case 4 initially

Problems: Diana sought therapy because of the painful re-emergence of achildhood memory of a situation in which she was with her mentally disturbedmother. She was terrified of becoming like her mother. While meeting hermother she was torn between strong feelings such as anxiety and hatred, andended up emotionally worn out. Diana also had an exaggerated need for control.The therapist added that Diana’s complicated relationships with both herparents made her ongoing liberation process difficult. Diana also had a tendencyto be suspicious, had migraine, and slight hypochondria. Pathogenesis: Dianadescribed her background of growing up with a mentally disturbed mother.Diana was, for example, isolated when she was ill instead of being taken care of,because her mother was afraid of infections. The therapist added that Diana’sfather also had psychological problems and was absent after the parents’ divorcewhen Diana was very small. Cure: Diana said that she had to deal with things intherapy before they became worse. It was also helpful for her to talk to herboyfriend and obtain his support. The therapist thought it important for Dianato dare to enter and stay in a therapeutic relationship. Her fear of intimacy

BJORN PHILIPS ET AL.

60

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

restrained her and she regulated the distance by cancelling sessions. Thetherapist’s contribution to the cure was not acting out her counter-transferenceof irritation.

Case 4 at termination

Problems: Diana reported remaining difficulties in talking to her parents, becauseshe became angry with them. Lately she had been sad, weary, had cried a lot,and had had migraine. She struggled with frustration and touchiness. Thetherapist described Diana’s problems approximately in the same way as in thefirst interview. Pathogenesis: In addition to what she had previously said abouther background, Diana now described new sides of her mother – episodes oftender interaction between them. The therapist’s description remainedunchanged from the first interview. Cure: Regarding the therapy, Dianaemphasized the fact that the therapist gave objective summaries and helped herto find viable methods of problem solving. Diana also said that she haddeveloped the ability to cry. According to the therapist the curative factor intherapy was that Diana dared to attach to her, and dared to bring up difficultmatters in therapy. She also received feedback from the therapist.

Case 4: Relations between the patient’s and the therapist’s private theories

Diana’s and her therapist’s initial private theories of pathogenesis were highlysimilar (table 3). Their initial ideas of problems and cure were rather similarand, furthermore, the therapist’s ideas complemented those of Diana, partly bysuggesting unconscious psychodynamics, and partly by pointing out behavioursof Diana that the therapist (but not necessarily Diana herself) foundproblematic, with several examples from the therapeutic situation. Attermination their problem formulations were complementary, whereas theirideas of pathogenesis and cure were rather similar, the differences between theirideas being complementary. Compared with the initial interviews the therapist’sideas were largely the same, whereas Diana’s ideas had changed considerably.Diana had a more positive picture of her mother as well as a more positive viewof herself, her problems, and the therapy.

Comparisons between the successful and the less successful cases

The simple comparison between the patient’s and the therapist’s initial privatetheories, identifying the dominant patterns of relation between the theories,showed no striking differences between the more successful and the lesssuccessful cases (table 3). The successful case of Ben and the more ambiguouscases of Cindy and Diana contained practically the same dominant patterns.The case that differed most from the others was Alice, whose private theorieswere contradictory to the therapist’s for all categories. Contradictions alsoappeared in the relation between Cindy’s and her therapist’s theories of cure.

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

61

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Widening the scope to include how the therapist initially approached thepatient’s private theories, one common factor was evident in the two moresuccessful cases, although imperceptible in the two less successful cases. Early intreatment Alice’s and Ben’s therapists perceived obstacles to the therapeuticwork in their patients’ ways of thinking, feeling and relating. They madeinterpretative interventions (i.e. clarification, confrontation or interpretationper se) focusing on these obstacles, and received a positive response from thepatient. In the first case the obstacle involved ideas of Alice that werecontradictory to those of her therapist, namely her tendency to locate problemsoutside herself although they were really her own. Alice’s therapist confrontedher with this during the initial sessions and Alice was ready to begin thinkingalong these lines. In the second case the obstacle was Ben’s fear in thetransference of becoming weak and helplessly dependent on the therapist, aswell as his dread that the therapist would become as weak and incapable as hisfather. The therapist’s interpretation of Ben’s fear in the transference made Ben‘almost overjoyed’ and immediately strengthened the emotional and instru-mental bond between them.

Also in the two less successful cases of Cindy and Diana both partiesmentioned in the initial interviews several potential obstacles to the therapeutictask. Cindy was convinced that she had to manage her personal difficultiesherself and she wanted peace and quiet, ideas that were contradictory to thetherapist’s theory of cure, i.e. of Cindy becoming more open with other peopleand to her own feelings. Cindy was afraid of conflicts in relationships and had apattern of secrecy, impeding her ability to be intimate and deepen herrelationships. These factors could prevent Cindy from entering into a deeper,dependent relation with the therapist. In the interview with the therapist attermination it was obvious that she noticed this obstacle, but nothing in thematerial available suggested that the therapist intervened along those lines. Inthe case of Diana, the therapist strongly emphasized in both interviews that thepatient’s cancellations of many sessions constituted an obstacle to thetherapeutic work. However, no interventions focusing on this were mentioned,and the therapist described her contribution to the cure as containing andhandling her own counter-transference rather than interpreting transference.Did she, for example, interpret that Diana avoided her therapist in the samemanner as she avoided her mentally disturbed mother? Could it be that Dianaperhaps feared that her therapist was insane too?

Interesting results were found concerning how the dominant patterns ofinterplay between the patient’s and the therapist’s private theories changed inthe course of therapy (table 3). In the two more successful cases, Alice and Ben,the patient’s and the therapist’s private theories were more similar aftertermination than they were initially, whereas the opposite development wasobserved in the cases of Cindy and Diana, in which the differences increased inthe course of time.

BJORN PHILIPS ET AL.

62

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Specific differences between two of the cases

In order to sharpen the contrast, the cases most similar to each other regardingpatient and process characteristics, yet differing in outcome, have beencompared directly with each other. This direct contrasting between the cases ofAlice and Cindy generated further hypotheses about what might have led to afavourable and a less favourable outcome, respectively.

The following differences were found.

N In both therapies there were initially contradictions between thepatient’s and therapist’s theories of cure. Alice’s therapist perceivedthese contradictions early in treatment and she soon confronted Alicewith them. Neither Cindy nor her therapist spontaneously commentedon the differences in their ideas; perhaps this had not been an issue intheir initial meetings.

N Alice’s therapist thought that the frame of a one-year therapy might havepositive effects. In spite of this time-limitation, she intended early in thetherapy to work with insight and interpretation rather than support. Incontrast, Cindy’s therapist claimed in the initial interview that the frameof a one-year therapy had the consequence that they could not carry outany substantial work with transference, and that the curative factorwould be limited to a ‘corrective emotional experience’. The therapist didnot mention anything about prolonging the therapy in order to makeother processes possible.

N The instruments used indicated more severe character pathology inCindy, with narcissistic and paranoid traits. The content of thetherapist’s initial narrative suggested that she had not fully perceivedCindy’s character pathology and did not focus her approach and herinterventions on such potential therapeutic obstacles.

DISCUSSION

In this study it was found that the crucial issue was how the two persons relatedto each other, including how they utilized each other’s ideas in the course of thetherapeutic process, and not how their ideas were related to each other on amore conceptual level. The two more successful therapists in this study wereready to listen to their patients’ private theories, to make interpretativeinterventions focusing on obstacles including dissimilarities in the theories ofcure, and to monitor the patients’ reactions to those interventions. Theinterviews at termination suggested that these interactions had a lasting impact.

A further finding was that the patient’s and the therapist’s ideas changedacross time in the direction of coming closer to each other in more successfulcases while diverging in less successful cases. This conclusion is in accordwith the observations made in a retrospective follow-up of psychoanalysis

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

63

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

(Leuzinger-Bohleber et al. 2001, Leuzinger-Bohleber 2002, p. 151). In that studythe patient and the analyst recounted the same story in successful cases,reported the same key episodes, and had a shared view of the global results. Inthe less successful cases, often involving patients with severe personalitydisorders, the stories told by the patient and the analyst were so dissimilar that itwas difficult to understand that they were talking about the same analysis.

In the two more successful cases in the present study, a joint exploration ofdivergences in private theories seems to have taken place, a process described bySafran and Muran (2000) as a part of negotiating the therapeutic alliance. Theearly interventions in these therapies were effective in building up andstrengthening productive therapeutic collaboration. These two examplesconfirm that a strong therapeutic alliance is a result of, rather than aprerequisite for, good therapeutic work, as suggested by several recent studies. Agood alliance needs to be established early in therapy, otherwise it is likely thatthe client will either discontinue therapy prematurely or fail to commit thenecessary energy to achieve change (Horvath 2000). Accurate interpretations ofthe Core Conflictual Relationship Themes early in therapy are associated withstrong alliance and good outcome (Crits-Christoph et al. 1988, 1993, Luborskyand Crits-Cristoph 1990). Focusing on the current strains in the therapeuticsituation can repair ruptures in the alliance (Safran et al. 1990, 1994).Furthermore, the research at the Menninger Clinic (Frieswyk et al. 1994)showed that the repair of ruptures in collaboration could have a cumulativeimpact, ultimately resulting in positive outcome.

In one of the successful cases in this study the therapist confronted thepatient early with the pathological aspects of her private theories, which werecontradictory to the therapist’s ideas. Thus, the ‘ideological conflict’ betweenthe patient and the therapist, in the words of Wile (1977), was resolved with thetherapist’s confrontation and the patient’s acceptance of it. This approach wasclearly in conflict with Duncan and Miller’s (2000) proposal that the therapistshould adapt to the client’s theory of change. From a psychoanalytic point ofview there are also internal conflicts involving private theories within theperson, besides the external conflicts between the parties. The patientmentioned above had conflicting wishes of resolving her problems throughher boyfriend receiving help and processing her own problems in therapy.Another patient had a conflict between the wish to self-sufficiently handle allher troubles by herself and the wish to enter into a dependent relationship withher therapist. Yet another patient had a conflict between the wish to avoid the(in her fantasies perhaps crazy) therapist and the wish to meet and relate to thelatter. The patient’s acceptance of the therapist’s confrontation in the moresuccessful of these cases confirms that patient, besides her manifest privatetheories, also had more latent theories that were in agreement with thetherapist’s theories. The therapists in the less successful cases do not seem tohave interpreted their patients’ internal conflicts about cure, thus missing an

BJORN PHILIPS ET AL.

64

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

opportunity to facilitate conflict resolution, both within the patient andbetween the parties’ private theories.

The findings in this study are coherent with findings in other ongoingstudies within the Project. It has been found that the young adults’ expectationsabout their coming psychotherapy were to talk about their lives, to explore theirinner life thoroughly, to reach an understanding to help them to change theirthoughts and feelings, and to acquire a new perspective. What the patientsviewed as helpful after therapy centred on the talking about oneself, the specialrelationship with the therapist and the joint explorative work, leading to newrelational experiences and expanding self-awareness. A positive view of thetherapist after termination included more general attributes such as empathy,warmth and genuineness, but also the therapist’s professionalism, technicalneutrality, active contribution to the creation of meaning, and active promotionof the patient’s taking his/her own responsibility. A negative view attermination included the therapist’s passivity, anonymity, impersonal attitudeand negative distance. Overall, the patients’ ideas appeared as quitesophisticated and clearly in concordance with a psychoanalytic approach.This might be due to the fact that the patients were self-referred to apsychoanalytical institution, but also that psychoanalytic thinking permeatesthe mass-culture surrounding them. However, more unconscious wishes andfears of the patients might be in conflict with these manifest privatetheories.

The small number of cases included in the present study might be consideredas a methodological limitation. However, the restriction to four cases was seenas sufficient and appropriate for the in-depth exploration of 16 extensiveinterview texts aimed at generating hypotheses. The moderate differencesbetween the cases with regard to outcome could also be regarded as a limitation,but on the other hand this might enable the detection of finer nuances ofqualitative differences. The fact that the person making the qualitative analysiswas not blind to the outcome could imply a risk for selective and prejudicedjudgements, but this risk was counteracted by the analysis being reviewed byanother person. The different paths of the four cases can, of course, not beexclusively attributed to the parties’ private theories. Patient and processcharacteristics have to be taken into consideration, as well as the parties’ abilityto handle the possible separation crisis at therapy termination. The length oftherapy might of course be an important factor contributing to outcome, withone successful therapy in this study lasting for two years and one less successfultherapy lasting for only 9 months. However, there are also process factorsinfluencing what the duration of a therapy will be. Making the analysis at thetime of termination gave the opportunity to capture the participants’ immediateexperiences of the therapeutic process, although with the drawback of notincluding the patient’s further development in the years after therapy. Thepatients experienced being interviewed and completing questionnaires pre- and

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

65

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

post-therapy positively, but this had probably not any major impact on outcome,as it was a limited interference in comparison to the total psychotherapeuticexperience.

Interesting questions arise about what were the most important therapeuticactions involved. In the successful cases the therapists made interpretativeinterventions focusing on obstacles to the therapeutic work. Does this implythat psychotherapeutic technique was the most powerful curative factor, asexemplified by these interventions or did these interventions have the functionof improving the relationship between patient and therapist, with the followingnew relational experience acting as the crucial curative agent? Anotherpossibility is that the patient’s self-exploration is the most important curativeagent. The therapist’s task may be to create a safe relationship in which the self-exploration can take place and to interpret obstacles to it, i.e. the patient’savoidance of self-exploration and active self-deception. Probably all thesetherapeutic actions co-exist and interact.

Hypotheses generated

The findings of this study suggest that the therapeutic process can be facilitatedby the following.

(1) A therapist listening to the patient’s private theories, makinginterpretative interventions focusing on obstacles to the therapeuticwork, and monitoring the patient’s reactions to these interventions.

(2) A therapist being especially sensitive to contradictions in the theoriesof cure, and directing interpretative interventions towards these.

(3) A therapist focusing on explorative and interpretative work in spite ofa limited time frame, alternatively not using a time frame that he/shefeels is restricting.

(4) A therapist early and accurately perceiving the patient’s characterpathology and confronting the patient with this potential obstacle tothe joint therapeutic work.

REFERENCES

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental

Disorders, 4th edn (Washington, DC: APA)

Appelbaum, S. A. (1978) Pathways to change in psychoanalytic therapy. Bulletin of the

Menninger Clinic, 42, 239–251

Arlow, J. A. (1981) Theories of pathogenesis. Psychoanalytic Quarterly, 50, 488–514

Arlow, J. A. (1986) The relation of theories of pathogenesis to psychoanalytic therapy. InA. D. Richards and M. S. Willick (eds) Psychoanalysis: The Science of Mental Conflict

(Hillsdale, NJ: Analytic Press, 49–63)

BJORN PHILIPS ET AL.

66

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Asay, T. and Lambert, M. (1999) The empirical case for the common factors in therapy.

In M. Hubble, B. Duncan and S. Miller (eds) The Heart and Soul of Change

(Washington, DC: APA Books, 33–55)

Auerbach, J. and Blatt, S. J. (1996) Self-representation in severe pathology: the role of

reflexive self-awareness. Psychoanalytic Psychology, 13, 297–341

Blatt, S. J. and Auerbach, J. S. (2001) Mental representation, severe psychopathology,

and the therapeutic process. Journal of the American Psychoanalytic Association, 49,

113–159

Crits-Cristoph, P., Barber, J. B. and Kurcias, J. S. (1993) The accuracy of the therapists’

interpretations and the development of the therapeutic alliance. Psychotherapy

Research, 3, 25–35

Crits-Christoph, P., Cooper, A. and Luborsky, L. (1988) The accuracy of therapists’

interpretations and the outcome of dynamic psychotherapy. Journal of Consulting and

Clinical Psychology, 56, 490–495

Derogatis, L. R. (1994) Symptom Checklist-90-R: Administration, Scoring and Procedures

Manual, 3rd edn (Minneapolis, MI: National Computer Systems)

Diamond, D., Blatt, S., Steyner, D. and Kaslow, N. (1995) Differentiation-relatedness of

self and object representations (revised scale; manuscript) (New Haven, CT: Yale

University)

Duncan, B. L. and Miller, S. D. (2000) The client’s theory of change: consulting the

client in the integrative process. Journal of Psychotherapy Integration, 10, 169–188

Fosshage, J. L. (1997) Psychoanalysis and psychoanalytic psychotherapy. Psychoanalytic

Psychology, 14, 409–425

Frankel, J. (1993) Collusion and intimacy in the analytic relationship. In L. Aron and

A. Harris (eds) The Legacy of Sandor Ferenczi (Hillsdale, NJ: The Analytic Press,

227–247)

Fridell, M., Cesarec, Z., Johansson, M. and Malling Thorsen, S. (2002) Svensk normering,

standardisering och validering av symtomskalan SCL-90 [Swedish norms, standardisa-

tion, and validation of the symptom scale SCL-90] (Vastervik: Statens institutions-

styrelse (SiS))

Frieswyk, S. H., Gabbard, G. O., Horwitz, L., Allen, J. G., Colson, D. B., Newsom, G. E.

and Coyne, L. (1994) The role of the therapeutic alliance in psychoanalytic therapy

with borderline patients. In A. O. Horvath and L. S. Greenberg (eds) The Working

Alliance: Theory, Research, Practice (New York: John Wiley, 199–224)

Ginner, H., Werbart, A., Levander, S. and Sahlberg, B. (2001) Tillforlitlighet i studier av

subjektiva forklaringssystem: Ett kodningssystem for privata teorier om patogenes och

kur. [Reliability in studies of subjective explanatory systems: a coding system for

private theories of pathogenesis and cure.] Psykoterapi: Forskning och utveckling,

rapport 19 (Stockholm: Sektionen for psykoterapi och Psykoterapiinstitutet)

Glaser, B. G. and Strauss, A. (1967) The Discovery of Grounded Theory: Strategies for

Qualitative Research (Chicago: Aldine)

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

67

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Goldberg, S. H. (1991) Patients’ theories of pathogenesis. Psychoanalytic Quarterly, 60,

245–275

Goldberg, S. H. (1994) The evolution of patients’ theories of pathogenesis. Psychoanalytic

Quarterly, 63, 54–83

Grant, J. and Sandell, R. (2003) Close family or mere neighbours? Some empirical data

on the differences in long-term psychoanalytic psychotherapy. In P. Richardson, H.

Kachele and C. Renlund (eds) Research on Psychoanalytic Psychotherapy with Adults

(London: Karnac, 81–108)

Hansen, N. B. and Lambert, M. J. (1996) Brief report: assessing clinical significance using

the Inventory of Interpersonal Problems. Psychological Assessment, 3(2), 133–136

Hjalmdahl, Y., Claesson, M., Werbart, A. and Levander, S. (2001) Bedomning av

differentiering-relaterande i sjalv- och objektrelationer. I: En validitetsstudie.

[Assessment of differentiation-relatedness of self and object representations. I: A

validity study.] Psykoterapi: Forskning och utveckling, rapport 20 (Stockholm:

Sektionen for psykoterapi och Psykoterapiinstitutet)

Horvath, A. O. (2000) The therapeutic relationship: from transference to alliance.

Journal of Clinical Psychology, 56, 163–173

Horvath, A. O. and Symonds, B. D. (1991) Relation between working alliance and

outcome in psychotherapy: a meta-analysis. Journal of Counselling Psychology, 38,

139–149

Jacobson, N. S. and Revenstorf, D. (1988) Statistics for assessing the clinical significance

of psychotherapy techniques: issues, problems, and new developments. Behavioral

Assessment, 10, 133–145

Jacobson, N. S. and Truax, P. (1991) Clinical significance: a statistical approach to

defining meaningful change in psychotherapy research. Journal of Consulting and

Clinical Psychology, 59(1), 12–19

Kernberg, O. F. (1999) Psychoanalysis, psychoanalytic psychotherapy and supportive

psychotherapy. International Journal of Psychoanalysis, 80, 1075–1091

Kierkegaard, S. (1848) Synspunktet for min Forfatter-Verksomhed. English translation: The

Point of View for my Work as an Author (New York: Harper & Brothers)

Kvale, S. (1996) InterViews: Introduction to Qualitative Research Interviewing (Thousand

Oaks, CA: Sage Publications)

Lambert, M. J. and Barley, D. E. (2001) Research summary on the therapeutic

relationship and psychotherapy outcome. Psychotherapy, 38, 357–361

Langs, R. (1975) Therapeutic misalliances. International Journal of Psychoanalytical

Psychotherapy, 4, 77–105

Langs, R. (1976) The Bipersonal Field (New York: Jason Aronson)

Leuzinger-Bohleber, M. (2002) A follow-up study – critical inspiration for our clinical

practice? In M. Leuzinger-Bohleber and M. Target (eds) Outcomes of Psychoanalytic

Treatments: Perspectives for Therapists and Researchers (London: Whurr, 143–173)

BJORN PHILIPS ET AL.

68

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

Leuzinger-Bohleber, M., Stuhr, U., Ruger, B. and Beutel, M. (2001) Langzeitwirkungen

von Psychoanalysen und Psychotherapien: Eine multiperspektivische, representative

Katamnesestudie. Psyche, 55, 193–277

Levander, S. and Werbart, A. (2003) Different views of a psychotic breakdown: complemen-

tary perspectives of a bewildering experience. Psychoanalytic Psychotherapy, 17, 163–174

Luborsky, L. and Crits-Christoph, P. (1990) Understanding Transference: The Core

Conflictual Relationship Theme Method (New York: Basic Books)

Martin, D. J., Garske, J. P. and Davis, M. K. (2000) Relation of the therapeutic alliance

with outcome and other variables: a meta-analytic review. Journal of Consulting and

Clinical Psychology, 68, 438–450

Michels, R., Siebel, U., Reyberger, H. J., Stieglitz, R.-D., Schaub, R. T. and Dilling, H.

(1996) The multiaxial system of ICD-10: evaluation of a preliminary draft in a

multicentric field trial. Psychopathology, 29, 347–356

Miles, M. B. and Huberman, A. M. (1994) Qualitative Data Analysis: An Expanded

Sourcebook (Thousand Oaks, CA: Sage Publications)

Miller, S. D., Duncan, M. A. and Hubble, M. A. (1997) Escape from Babel:

Toward a Unifying Language for Psychotherapy Practice (New York: Norton)

Orlinsky, D. E., Grawe, K. and Parks, B. K. (1994) Process and outcome in psychotherapy

– noch einmal. In A. E. Bergin and S. L. Garfield (eds) Handbook of Psychotherapy

and Behavior Change, 4th edn (New York: John Wiley)

Ottosson, H., Bodlund, O., Ekselius, L., von Knorring, L., Kullgren, G., Lindstrom, E. and

Soderberg, S. (1995) The DSM-IV and ICD-10 Personality Disorder Questionnaire

(DIP-Q): construction and preliminary validation. Nordic Journal of Psychiatry, 49,

285–291

Pine, F. (1998) Diversity and Direction in Psychoanalytic Technique (New Haven: Yale

University Press)

Rangell, L. (1992) The psychoanalytic theory of change. International Journal of

Psychoanalysis, 73, 415–428

Roughton, R. E. (1994) Repetition and interaction in the analytic process: enactment,

acting out, and collusion. Annual of Psychoanalysis, 22, 271–286

Safran, J. D. and Muran, J. C. (2000) Negotiating the Therapeutic Alliance. A Relational

Treatment Guide (New York: The Guilford Press)

Safran, J. D., Muran, J. C. and Samstag, L. W. (1994) Resolving therapeutic

alliance ruptures: a task analytic investigation. In A. O. Horvath and L. S.

Greenberg (eds) The Working Alliance: Theory, Research, Practice (New York: John

Wiley, 225–255)

Safran, J. D., Crocker, P., McMain, S. and Murray, P. (1990) The therapeutic alliance

rupture as a therapy event for empirical investigation. Psychotherapy, 27, 154–165

Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Broberg, J. and Schubert, J. (2000)

Varieties of long-term outcome among patients in psychoanalysis and long-term

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

69

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012

psychotherapy: a review of findings in the Stockholm Outcome of Psychoanalysis andPsychotherapy Project (STOPPP). International Journal of Psychoanalysis, 81, 921–942

Sandler, J. (1983) Reflections on some relations between psychoanalytic concepts andpsychoanalytic practice. International Journal of Psychoanalysis, 64, 35–46

Strauss, A. L. (1987) Qualitative Analysis for Social Scientists (Cambridge: CambridgeUniversity Press)

Strauss, A. and Corbin, J. (1998) Basics of Qualitative Research: Techniques and Proceduresfor Developing Grounded Theory, 2nd edn (Thousand Oaks, CA: Sage)

Wallerstein, R. S. (1995) The Talking Cures. The Psychoanalyses and the Psychotherapies(New Haven & London: Yale University Press)

Werbart, A. and Levander, S. (2000) Pain in the body – pain in the soul: the need ofprivate explanations when not feeling well. In P. Nilsson and K. Orth-Gomer (eds)Self-rated Health in European Perspective, FRN Report 2000: 2 (Stockholm: SwedishCouncil for Planning and Coordination of Research, 136–151)

Wile, D. B. (1977) Ideological conflicts between clients and psychotherapists. AmericanJournal of Psychotherapy, 31, 437–449

Bjorn PhilipsInstitute of Psychotherapy

Bjorngardsgatan 25SE-118 52 Stockholm, Sweden

e-mail: bjorn.philips@sll.se

BJORN PHILIPS ET AL.

70

Dow

nloa

ded

by [

Kar

olin

ska

Inst

itute

t, U

nive

rsity

Lib

rary

] at

07:

34 2

0 Fe

brua

ry 2

012