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Counselling Psychology QuarterlyVol. 23, No. 4, December 2010,
343369
We had a constant battle. The role of attachment status
incounselling psychologists experiences of personal therapy:
Some results from a mixed-methods study
Rosemary Rizqa* and Mary Targetb
aResearch Centre for Therapeutic Education, Department of
Psychology, RoehamptonUniversity, 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
experiencesof psychotherapeutic practitioners undertaking a
mandatory trainingtherapy. We present results from a
qualitatively-driven mixed-methodsstudy designed to explore the way
in which counselling psychologistsattachment status and levels of
reflective function intersect with how theyexperience the
therapeutic relationship within their personal therapy.Participants
were interviewed twice: once using Main and Goldwyns(1998) Adult
Attachment Interview (AAI) to explore representations ofearly
childhood relationships; and subsequently using a
semi-structuredinterview format, analysed via Interpretative
Phenomenological Analysis(IPA), to explore experiences of personal
therapy. Meshing results fromboth sets of data showed that
insecurely-attached participants experiencedtheir personal therapy
differently from secure or earned-secure participants,and were more
troubled by a perceived disparity of institutional andinterpersonal
power within the therapeutic relationship. Results areconsidered in
terms of the power dynamics within training therapy.Implications
for training and future research in this neglected field arebriefly
discussed.
Keywords: counselling psychology; mixed-methods research;
personaltherapy; psychotherapy; qualitative research;
psychotherapeutic training
Introduction and background
Ever since Freuds (1910/1937) endorsement of personal analysis
as the vehicle ofpsychoanalytic training, psychoanalytic training
institutions have specified amandatory training analysis for
candidates, usually comprising three to fivesessions per week for
several years. Whilst personal therapy has subsequently playeda
central role within many counselling and psychotherapy training
courses, in theBritish Psychological Society it is only the
Division of Counselling Psychology(DCoP) that specifies a mandatory
minimum period of 40 hours of personal therapyfor trainees
undertaking either an accredited training course, or the
SocietysQualification in Counselling Psychology via the Independent
Route.
The vicissitudes of candidates undergoing a training analysis
havebeen recognised for many years within psychoanalytic training
institutions
*Corresponding author. Email: [email protected]
ISSN 09515070 print/ISSN 14693674 online
2010 Taylor & FrancisDOI: 10.1080/09515070.2010.534327
http://www.informaworld.com
-
(e.g., Kernberg, 2006; Wallerstein, 1993). However, there has
been curiously littleinvestigation into the experiences of other
psychotherapeutic practitioners under-taking a mandatory training
therapy. There are certainly moving and persuasivepersonal
testaments to the value of practitioners own therapy (Geller, 2005;
Hill,2005; Little, 1990) and quantitative surveys overwhelmingly
attest to the satisfactionof 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 studiesexamining the subjective experience of personal
therapy from the perspective ofpractitioners themselves (Grimmer
& Tribe, 2001; Macran, Stiles, & Smith, 1999;Murphy, 2005;
Rake & Paley, 2009; Wiseman & Shefler, 2001). Aware of this
gap inthe literature, we recently undertook a qualitative study
exploring nine seniorcounselling psychologists experiences of
personal therapy (Rizq & Target, 2008a,2008b). Whilst therapy
was found to be valuable in promoting awareness of differentaspects
of the self, we also found that attachment experience emerged as a
significantorganising framework within participants accounts, with
several individualsdescribing the salience of difficulties in early
family relationships to the developmentof a nascent reflective
capacity that they honed in personal therapy and subsequentlydeemed
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 fortherapists as for clients, there has been
surprisingly little research on the attachmentstatus of therapists
and its impact on clinical work. Obegi and Berant (2008), in
arecent review of attachment-informed psychotherapy research, point
out that securetherapists are likely to possess alliance-enhancing
characteristics and sensitivity (eg.warmth, sensitivity) and
therefore better able to create the atmosphere of securitythat
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-clientattachment style and
therapeutic outcome. Dozier et al. (1994) argue that thesecurely
attached clinician is characterised not only by an ability to
provide acounter-response to their clients relational expectations
i.e., to provide discon-firming feedback but also by a willingness
to intervene in ways that may bepersonally uncomfortable.
Similarly, Tyrell et al. (1999) found that case managerswith
attachment strategies that were non-complementary to their clients
were themost clinically effective. In a related argument, Holmes
(1993) points out that thefit between the attachment style of the
therapist and patient might be an importantdeterminant of the
outcome of therapy. In a review of the client-therapist
attachmentmatching literature, Bernier and Dozier (2002) found some
support for thesignificance for attachment complementarity early on
in treatment, with a mismatchin attachment styles found to be more
effective later on in treatment.
From a developmental perspective, Fonagy and Target (1996)
suggest that thequality and status of early attachment
relationships indexes the childs capacity toconsider the self and
others as psychological beings to mentalise or adopt theintentional
stance (Dennett, 1978). A secure and containing attachment
relation-ship through which internal psychological experiences are
represented in the mind of
344 R. Rizq and M. Target
-
the caregiver, ensures that the developing infants internal
feeling states becomemeaningful and manageable. It is this process,
closely aligned to Bions(1962a,1962b) notion of containment, that
is assumed to play an important rolein the childs eventual capacity
to manage his or her own feeling states and
nascentself-organisation (Fonagy, Gergely, Jurist, & Target,
2002). Security of attachment isthus generally associated with
higher levels of mentalisation, whilst hostile, neglectfulor
abusive caregiving is associated with inhibited mentalising skills
(Fonagy, Target,Gergely, Allen, & Bateman, 2003b). Fonagy, M.
Steele, H. Steele, Higgitt, andTarget (1994) suggest that this
capacity, operationalised as reflective function,may be
particularly advantageous to those with adverse histories, since it
is theirability to represent and reflect on early traumatic or
neglectful experience thatappears to interrupt the
intergenerational cycle of disadvantage. Indeed, Pearson,Cohn, P.
Cowan, and C. Cowan (1994) adopted the phrase earned secure
todescribe those who had managed to overcome neglectful or abusive
early childhoodexperiences that might otherwise be associated with
insecure attachment.
Given that mentalisation underlies the capacity to see and
respond to others aspsychological beings, therapists levels of
reflective function would appear to becentral to effective,
empathic clinical work. Whilst some studies have examined therole
of psychotherapy in improving reflective function in clients
(Karlsson &Kermott, 2006; Levy et al., 2006), only one
published study has examined therapistattachment status and
reflective function. Diamond, Stovall-McClough, Clarkin,and Levy
(2003) explored the impact of both therapist and client attachment
states ofmind and reflective function on therapeutic process and
outcome. The authors arguethat the quality of mentalisation in the
therapeutic dyad can be conceptualised as abidirectional process in
the therapists and clients levels of reflective function appearto
be mutually and reciprocally influential. They found that
therapeutic progress wasassociated with the therapists capacity to
adjust his or her level of mentalisation toslightly above that of
the client, rather than mirroring the clients low level
ofmentalisation directly.
Rationale for the current study
The above samples from the attachment literature underline the
significance ofattachment states of mind and mentalisation in
understanding the way individualsrepresent and experience adult
relationships. We suggest that, by extension, theseissues are also
relevant to understanding how practitioners experience and
describethe relationship with their own therapists during training,
and to how that experienceis transmuted and subsequently deployed
within their clinical practice. Indeed, giventhe subjectively-rated
importance of personal therapy to the professional develop-ment of
many psychotherapists (Orlinsky et al., 2001) and the increased
attention tothe person of the therapist in the psychotherapy
outcome literature (Aveline, 2005;Lambert & Baldwin, 2009), it
would seem that the relevance of the therapistsattachment and
reflective function to the experience of personal therapy
withintraining is an important area for investigation. To date,
however, we know of nosuch work. Building on our previous studies
then, the current paper presents a subsetof results from an
exploratory mixed methods study examining the role ofattachment
status and reflective function in counselling psychologists
accounts ofpersonal therapy, focusing specifically on aspects of
the therapeutic relationship.
Counselling Psychology Quarterly 345
-
A parallel paper, exploring the impact of personal therapy on
counsellingpsychologists clinical work has just been published
(Rizq & Target, 2010).
Study design and methodology
A qualitatively-driven (Mason, 2006) mixed-methods study was
designed to elicitcounselling psychologists subjective accounts
both of their early attachmentexperiences and of their personal
therapy. Interpretative methodological analysis(IPA) was selected
as particularly appropriate for the analysis of
participantsaccounts of personal therapy. IPA (Smith & Osborn,
2003) is a form of qualitativeinquiry which aims to explore in
detail participants personal experiences orlifeworld. Rooted within
the phenomenological tradition (Heidegger, 1962), it is
alsotheoretically indebted to symbolic interactionism (Blumer,
1962) in its recognitionthat the researchers own views, bias and
lifeworld are necessarily implicated in theprocess of gaining
understanding of another. The choice of IPA as methodology forthis
part of the study was based on the requirement for an idiographic
approach, inwhich the centrality and meaning of participants
subjective experiences of personaltherapy 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 ofthe interviewees early
childhood attachment experiences and the impact of these onhis or
her current functioning. The AAI classification and coding system
is based noton the content of the childhood memories themselves,
nor on the extent to whichadults experienced supportive or loving
relationships, but rather on narrativediscourse markers that are
deemed indicative of an underlying representation of andstance
towards early childhood attachment experiences. Similarly, the
Reflective-SelfFunction Scale (Fonagy, H. Steele, Moran, M. Steele,
& Higgitt, 1991), an additionalscale for AAI transcripts,
operationalises and assesses the interviewees capacity tounderstand
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 toseparate conventions: Adult Attachment Interviews,
analysed and coded accordingto Mains (1998) criteria; and the
semi-structured personal therapy interviews,analysed according to
the principles of IPA suggested by Smith (1995). Meshing orlinking
of the data (as discussed by Mason, 2006) occurred after data
analysisfrom both interviews was completed.
Procedure
Selection and recruitment of participants
IPA is increasingly characterised by purposive homogeneous
sampling, using smallnumbers of participants selected for their
experience in the subject under investi-gation and their ability to
illuminate specific research questions or areas (Smith &Osborn,
2003). The current sample were selected from UK counselling
psychologistswho were chartered between 2000 and 2004 i.e., who at
the time of recruitment hadbeen qualified and practising for
between 3 and 7 years. Recruitment methodsincluded mailshot,
advertisement and chain referral. Overall, 12 individuals agreed
toparticipate in the study and interviews took place over a
10-month period.
346 R. Rizq and M. Target
-
Sample characteristics
Three men and nine women took part, with ages ranging from 3565.
All were whiteCaucasian with the exception of two participants who
were Asian and black Afro-Caribbean. Participants had spent varying
lengths of time in therapy: nine hadundertaken extensive therapy
prior to their training, and three of these had alsocontinued after
completion of their training. There were three further
participantswho had undertaken only the mandatory minimum period of
40 hours during theirtraining. Theoretical orientations of personal
therapy were varied and included:psychoanalytic, gestalt,
cognitive-behavioural, and existential models. Participantscurrent
clinical work included both NHS and private practice. Whilst we are
awarethat such a mix of different therapeutic orientations in one
sample may be consideredoverly heterogeneous within an IPA study,
the variety of theoretical modelsexperienced by our participants in
their personal therapy is nonetheless adistinguishing feature
within Counselling Psychology training courses and hencethe sample
was thought to be characteristic of the profession.
The main researcher (Rizq), a chartered counselling psychologist
specialising inpsychotherapy, had several years experience in
clinical work and teaching from amainly psychoanalytic perspective.
The second researcher (Target), a clinicalpsychologist and
psychoanalyst, had extensive experience in clinical work,
teachingand research.
Data collection: interview procedures
Each participant was interviewed twice: first using the AAI and
subsequently using asemi-structured interview about their personal
therapy. All participants signedconsent procedures including an
agreement to examine interview transcripts forinformation that
might violate confidentiality. Biographical and professional
detailswere also collected. None of the participants had previously
undertaken an AAI,though all were broadly familiar with its
clinical significance. All were informed thatthe scoring of the AAI
would be done by an independent rater, but that participantswould
be invited to discuss results at a future date if they wished. All
the AAIinterviews 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 afterthe AAI. The semi-structured interview schedule
included: personal and professionalbackground information;
experiences during training; personal therapy experiences;personal
therapy in clinical practice; and views on the place of personal
therapy incurrent training programmes. Each interview was once
again taped and transcribedverbatim using a Windows XP
voice-file.
The analysis and results of the AAIs were not completed until
some time after allinterviews and the IPA cross-case analysis were
finished. At the time of the secondinterview, the interviewer, who
was not trained in AAI coding, was not aware of thefinal attachment
classification of each participant.
Analysis and validity checks
Analysis of personal therapy transcripts followed the analytic
procedure for IPAoutlined by Smith (1995) and Smith, Jarman, and
Osborn (1999). Detailed reading
Counselling Psychology Quarterly 347
-
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.
348 R. Rizq and M. Target
-
Reflective function coding
Coding for reflective function followed the procedures in
Fonagy, Target, Steele, andSteele (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 wascolour-coded for attachment status
in order to re-examine all the themes in the lightof the
participants attachment status and level of reflective function,
and to exploreany patterns or features of interest in how
participants recalled, described and feltabout their experiences in
personal therapy. In presenting our results, particularefforts have
been made to exclude or obscure details that might threaten
theconfidentiality of participants. For this reason, a decision was
made to omitinformation about each individuals early history and
background and to includeonly the primary attachment classification
from the AAI along with eachparticipants level of
reflective-function.
The IPA analysis yielded eight master themes overall each with a
number of sub-themes. The following section focuses on a sub-set of
results from the aboveintegration of results from the two sets of
data. The analysis aims to examineparticipants accounts in the
light of their main attachment classifications andreflective
function scores, noting any emerging patterns in the way personal
therapyis subjectively experienced, recalled and described. In the
subsequent discussion, wewill attempt to link results with some of
the relevant literature and to critically assessthe validity of our
inferences and conclusions in the light of this
particularmethodology.
Whilst all the master-themes by definition included material
that emergedstrongly from participants accounts, for reasons of
space the current discussion willfocus only on two master-themes:
emotional safety and control; and strugglingwith ambivalent
feelings. Results from the AAI are presented first.
Results and discussion
Primary classifications from the Adult Attachment Interviews
along with reflective-function scores are illustrated in Table 1.
Out of the 12 participants in the currentstudy, four were found to
have secure states of mind with respect to attachment, witha
further two classified as earned secure. The remaining six
participants werefound to have insecure states of mind with respect
to attachment with classifications
Counselling Psychology Quarterly 349
-
including the full range of dismissive, unresolved, preoccupied
and cannot classifycategories.
In line with the previously-mentioned developmental research
suggesting that RFis an index of attachment security, RF scores
were found in general to be higher withthe secure/earned secure
participants, with four out of the six
secure/earned-secureparticipants having RF scores of 4 or above and
four out of the six insecurely-attached participants having RF
scores of between 0 and 3. As is consistent with aqualitative
study, a representative sample had not been sought, but it is
nonethelessevident that the current group of participants includes
a relatively high proportion ofindividuals with problematic early
attachment histories. Clearly, a larger scale studywould be needed
to establish whether these results are characteristic of the
professionas a whole.
Emotional safety and control
In the first master-theme, managing feelings about therapy and
the therapeuticrelationship emerged as a central preoccupation.
Participants experienced theimposition of a mandatory period of
personal therapy in a variety of ways, manyconveying concerns about
establishing a sense of trust and safety within therelationship and
the importance of retaining a feeling of emotional control. Tables
2aand 2b show the contribution of each participant to the
master-theme of ensuringemotional safety.
Whilst almost all participants described feeling a degree of
wariness aboutembarking on a therapeutic relationship,
insecurely-attached participants appearedto be particularly
cautious and suspicious. Their accounts of personal therapyincluded
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 upmy mind that I didnt go there for
therapy. (Mary)
Table 1. Primary attachment classifications and
reflective-functionrating (n 12).
Primary attachmentclassification
Number ofparticipants
Reflectivefunction rating
Secure 4 3457
Earned secure 2 77
Dismissive 2 42
Preoccupied 1 3Unresolved 2 1.5
8Cannot classify 1 0
350 R. Rizq and M. Target
-
I know I kept my guards up, I know I kept her at a distance; I
know I didnt let her intoo 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
Table 2b. Ensuring emotional safety: presence/absence of themes
in insecurely- attachedparticipants accounts (n 6).
Master theme 2: ensuring emotional safety
Name RFEstablishing trust
Resisting engagement
Aida 1.5Hannah 8Mary 4David 2Martin 0Malcolm 3
Key
Dismissive
Cannot classify
Preoccupied
= presence of theme
= absence of theme.
Unresolved
Table 2a. Ensuring emotional safety: presence/absence of themes
in secure/earned secureparticipants accounts (n 6).
Master theme 1: ensuring emotional safety
Name RF Establishing trust
Resistingengagement
Laura 7 Clare 7Sara 3Judy 5Carol 4Anna 7
Key
= presence of the me
= absence of theme.
Secure
Earne -secure
Counselling Psychology Quarterly 351
-
resist engaging with therapists felt to be unsafe or
untrustworthy. Five out of the sixinsecurely-attached participants
contributed to the theme of resisting engagementand described ways
in which they strongly opposed their therapists attempts to drawout
feelings and memories:
I think I was probably quite defended in my time with her, to be
honest, though I thinkwe did do some good work as well, but Um Ive,
I felt it was her agenda and notmine ( . . . ) and I wasnt going to
give in to it. (Hannah)
For some, resistance seems to have been associated with feelings
ofresentment about having to undertake a personal therapy in the
first place, andfeelings of anger and frustration emerged in
accounts of the way in which therequirement was presented in
training. Some insecurely-attached participantsexperienced this as
an overt display of power by tutors and staff as Aidas
commentsuggests:
you have to do it; no arguments, you have to do it. No
discussion of, yes, it brings upuncomfortable feelings, lets look
at it. I didnt get that from my tutors . . . it was neverexplored.
It was just left as: these are the requirements; you have to follow
themthrough. (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 seemsto 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 anddetermined I wasnt
going to let her into personal sort of stuff, and this was just
going tobe an exercise I went through. (Aida)
Resistance appeared for several of the insecurely-attached
participants to continuethroughout entire episodes of therapy,
often accompanied by feelings of considerableantipathy and
resentment. By contrast, even though some of the secure/earned
secureparticipants had initially found it difficult to trust their
therapists, they were eventuallyable, to varying degrees, to
develop more trusting relationships. Laura welcomedsharing 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 weptand wept and wept and wept and felt ok to
do that, well, all right to do that (it waspossible 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 shefelt 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 itwent onto a whole . . . I felt I was ready to
go on to a whole other level, which, which iswhat did happen. It
was much more, I think going twice a week is much more thandouble [
. . . ] 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 tendencyto resist engaging freely in the therapeutic
relationship appeared to go hand-in-handwith significant
difficulties in managing negative or ambivalent feelings that
emerged
352 R. Rizq and M. Target
-
in the context of their therapy. Feelings of being undermined or
of psychologicalthreat appeared to be related to an experience of
the therapist as akin to a powerfulparental figure, arousing either
feelings of intense admiration and love, or of extremeanxiety and
ambivalence; in other cases, feelings of disappointment and
disillusionpredominated where the therapist was experienced as
inadequate or insufficientlyskilled. Several participants described
their discomfort with a felt power imbalancewithin the therapeutic
relationship, and all discussed difficulties with
confrontingtherapists with their negative feelings.
Tables 3a and 3b show the contribution of each participant to
the master-themeof struggling with ambivalent feelings.
Five participants overall contributed to the sub-theme of
disappointment anddisillusion. However, unlike the two
securely-attached participants, whose feelingsof disappointment or
anger tended to be therapist-specific and temporary,
theinsecurely-attached participants described feelings of
frustration with therapists thatappeared to be grounded in a far
more comprehensive and global sense ofdissatisfaction, impacting on
the entire experience of therapy. This is perhaps bestexemplified
in Martins comment below:
I was disappointed cos I didnt stop smoking. I was disappointed
cos I didnt feel a hugeshift in myself, of some kind of, you know,
positive change, and I was disappointed thatwe didnt have any more
time to get there, or do anything else. (Martin)
These participants were well aware of long-standing personal and
relationshipproblems, and had been keen to undertake personal
therapy; however, most failed tofind therapists in whom they could
trust or who were sufficiently skilled, as Davidpointed out:
They, they just didnt have enough, they didnt have enough
knowledge of psychopa-thology, and enough, and also enough
gentleness to, to, to say: look, this isnt so veryterrible. Not a
terrible human being cos youre fucked up. (David)
Table 3b also shows that three of the insecurely attached
participants contributedto 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 sawher therapeutic
relationship mirroring a troubled early relationship with her
mother,the other two participants rejected the notion of the
therapists symbolicparental role, or referred to it only in highly
intellectualised terms. By contrast,Table 3a shows that five of the
six securely-attached individuals contributed tothe same theme,
most speaking freely about the parental role fulfilled by
theirtherapists, and the impact this had on the therapeutic
relationship. Illustrativeexamples 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 therelationship was parental but a kind of
reparative relationship, the kind of mother thatmight 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 goodmother.
(Carol)
I mean he was my dad, he was, he was, he was as a surrogate dad
for quite a while and Ilooked up to him, he was a role model as
well for a therapist for quite some time . . . .(Laura)
Counselling Psychology Quarterly 353
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Table
3a.Strugglingwithambivalentfeelings:presence/absence
ofthem
esin
secure/earned
secure
participantsaccounts(n6).
Mas
ter t
hem
e 3:
Stru
gglin
g w
ith a
mbi
vale
nt fe
eling
s
Nam
e R
FD
isapp
oint
men
t an
ddi
sillu
sion
Expe
rienc
ing
the
ther
apist
as
par
ent
An
uneq
ual
rela
tions
hip
Chal
leng
ing
and
chan
ging
th
erap
istA
void
ing
() vs
co
nfro
ntin
g (+
) La
ura
7 (+
/)
Clar
e 7
(+
) Sa
ra
3
()
Ju
dy
5 (+
/)
Caro
l 4
(+
/)
Ann
a 7
(+
)
Key
=
pr
esen
ce o
f th
eme
=
ab
sence
of
th
eme.
Earn
e-se
cure
Secu
re
354 R. Rizq and M. Target
-
Table
3b.Strugglingwithambivalentfeelings:presence/absence
ofthem
esin
insecurely-attached
participantsaccounts(n6).
Mas
ter t
hem
e 3:
stru
gglin
g w
ith a
mbi
vale
nt fe
eling
s
Nam
e R
FD
isapp
oint
men
t an
d di
sillu
sion
Expe
rienc
ing
the
ther
apist
as
par
ent
An
uneq
ual
rela
tions
hip
Chal
leng
ing
and
chan
ging
th
erap
istA
void
ing
()
vs
con
fron
ting
(+)
Aid
a1.
5 ()
H
anna
h8
()
M
ary
4()
Dav
id2
()M
artin
0 ()
M
alco
lm
3 (+
)
Key
=
pr
esen
ce
o
f th
eme
=
ab
sence
o
fthe
me
Unr
esol
ved
Dism
issiv
e
Cann
otcl
assif
y
Preo
ccup
ied
Counselling Psychology Quarterly 355
-
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 myrelationship 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 theone 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 thesame wavelength that she couldnt (mm) . .
.And I dont know if it was a mismatchthere, but part of my sense
was that she hadnt gone very far herself . . . and I think thatwas
the rub, I think she was a good enough person, I think she was
probably a verynice 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 relation-
ships, 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
goodenough really. Why sometimes it feels like it spoils something.
Like it, why didyou 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 cantum say I own it [the therapeutic
relationship] tremendously as such a major ingredient,and I suppose
Im meant to. (David)
356 R. Rizq and M. Target
-
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 theroom, but . . . .And it was kind of, like,
um, : look at me, Ive done so much Ive all theseyears 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 shewould start the sessions by praying [ . . .
] which I have to say I would never ever do witha client! So, she
prayed, and then we would start. Well, by then, the power
imbalancewas enormous! (Hannah)
I think theres a way of people imposing their own sort of
reasoning on you and, youknow, it just comes over you, youve got to
get inside their own way of thinking andtheir 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? Fullstop! [ . . . ] 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
verysensitive to implicit force. (David)
. . .we had a constant battle cos she wanted me to go twice a
week and I only ever wentonce 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 methat 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 iton 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 didntget that from my tutors, didnt get
the sense of lets talk about this, yes you have todo it, hey, thats
the given, but lets look at what, why might you be
feelinguncomfortable. (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 insecurely-
attached 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
Counselling Psychology Quarterly 357
-
therapy in which their feelings of discontent, in some cases
anxiety or anger, wereneither 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 hadthe power to say to my therapist Im not
happy about something. (Mary)
For many of these insecurely-attached participants, a complex
constellation offeelings involving submission, anger, fear and
anxiety seemed to constitute anongoing, problematic and unresolved
feature of the therapeutic relationship. Somehighlighted imagined
fears of reprisal within the training course, an anxiety
bestexemplified by Martin, whose therapist had been suggested to
him by the CourseDirector of his training institution. In the
following extract he assumes that they bothknow 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, soclearly they knew each other. I mean, I knew
nothing about this incestuous thing, youknow 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.
Somaybe that would have been the barrier to me expressing myself
freely about concernsand 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 notable to provide a truly
impartial or protected space. As a result, they resignedthemselves
to staying with therapists with whom they continually felt
uncomfortable,dissatisfied or disappointed. These
insecurely-attached participants also seemed todeploy various
mechanisms to counteract painful feelings of powerlessness
andfrustration that they were unwilling or unable to voice in
therapy. Several dismissedor minimised such feelings, often for
fear of invoking their therapists imaginedanger. Others kept their
therapists at a distance, refusing them access to
significantpersonal information. In one more complex case, Hannah
remained reluctantly andambivalently with her training therapist,
partially sustained by a complex fantasyconcerning power and
health. She reluctantly describes an uncomfortable feeling
ofcontempt for this therapist, locating the source of this disdain
in the therapists slightphysical disability. This seems to afford
her some covert relief that, despite hertherapists constant
attempts to make her acquiesce to her demands, Hannah issomehow
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, Imean, 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 orsomething. And something about that made me . .
. oh dear! I dont know, it mademe . . . .I think I felt she wouldnt
be a threat? . . . somehow it gave me a feeling of, Idunno, power?
(Hannah)
From an attachment perspective, these kinds of strategies might
be conceptua-lised as the means by which preoccupied, unresolved,
dismissive and other insecurelyattached participants variously
regulate the interpersonal distance and dynamicswithin the
therapeutic relationship. However, from a more
phenomenologicalperspective, participants accounts can be seen to
emerge in the context of whatappears for some to have felt like a
battle, where establishing a position of equalityand mutuality or
in some cases a feeling of superiority and control appeared to
becentral to participants retaining a sense of identity or personal
integrity. For theseparticipants, the experience of therapy
revolved around the need to establish and
358 R. Rizq and M. Target
-
sustain a felt sense of personal power within the therapeutic
relationship, rather thansimply relinquishing control to, or being
subsumed by, an authoritative therapist.
The above strategies of insecurely-attached participants can be
contrasted withthose of securely-attached or earned-secure
participants, five of whom, whilstsimilarly struggling with
feelings of disappointment and frustration, nonethelessappeared to
be more confident and able to express their negative feelings
within therelationship, 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, Iremember telling her I wanted to
throw her pot plants around the room once and shejust sat there
calmly. (Carol)
This confidence may have been a consequence of a greater degree
of perceivedmutuality within their therapeutic relationships. Table
3a shows that only one of thesecure/earned-secure participants
described feelings of inequality in the therapeuticrelationship,
suggesting that the majority of securely-attached participants may
havefelt less personally compromised by the perceived imbalance of
power within therapyand were perhaps more able or willing to convey
both positive and negative feelings.Indeed, rather than continue to
struggle with difficulties and dissatisfaction, securelyattached/
earned-secure participants seemed willing, where necessary, to
leave theirtherapists and seek alternative therapeutic
relationships. Anna is decisive in leavingher 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 haveany further contact. Youve made it
clear where your priorities lie [ . . . ] so you can justfuck 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 haveprovided them with a more robust working model
of relationships characterised byconfidence in their ability to
find and sustain a satisfying therapeutic relationship.Moreover,
their generally higher levels of reflectiveness appeared to
underpin acuriosity about why their therapy had not worked or been
satisfactory, and adetermination 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 theseparticipants therapeutic
relationships did not appear to dissuade them fromcontinuing to
seek other therapists.
Discussion
Results from the analysis of participants AAI narratives show
that half of the 12participants had insecure states of mind with
respect to attachment, with a furthertwo classified as earned
secure. This relatively high proportion of insecurely-attached
individuals is perhaps unsurprising. In common with much of
thewounded healer literature (e.g., Jackson, 2001), AAI narratives
showed thatmany participants, from a young age, had undertaken
roles that involved them in theemotional care of family members, in
some cases, depressed, mentally ill or abusiveparents. This concurs
with Glickhauf-Hughes and Mehlmans (1995) notion ofparentification
which they use to describe the emotional role into which the
future
Counselling Psychology Quarterly 359
-
therapist may be cast within the family; they suggest that such
childrendevelop emotional antennae which can predispose them to
joining a therapeuticprofession. Whilst there is very little
literature on the background of counsellingpsychologists, Halewood
and Tribe (2003) suggest that a high degree ofnarcissistic 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 reportedsignificantly lower
maternal care and higher levels of self-efficacy in care than did
artstudents.
The wide range of attachment classifications was mirrored by a
spread ofreflective function scores. In line with earlier research,
those who were securely-attached 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, whosenarratives in
both the AAI and personal therapy interviews were
exceptionallythoughtful and reflective, showing strong coherence
and richness of recall. This canperhaps be seen as an index of
their ability to reflect on and largely resolve earlyexperiences
with an abusive parent in one case and a seriously mentally ill
parent onthe other. Indeed, it was noticeable that both these
participants strongly attributedthe resolution of their
longstanding family and relationship issues to their highlypositive
experiences within personal therapy.
Despite disappointments and set-backs within the therapeutic
relationship, secureand earned-secure participants alike described
the generally beneficial impact of theirexperiences within personal
therapy. However, insecurely-attached participantsappeared to
recall their personal therapy somewhat differently. They were
morereluctant to attend therapy, and appeared to have been more
resistant, cautious andsuspicious of therapists during the period
of their therapy. They discussed a range ofnegative feelings about
the imposition of a mandatory training therapy and aboutthe
relationships established with their therapists. Prominent in their
accounts weresometimes intense levels of unease and anxiety about a
perceived imbalance of powerin the therapeutic relationship and, in
contrast to their securely-attached counter-parts, most of these
participants had been strikingly unable to voice feelings of
angerand frustration in therapy; nor, in many cases, had they felt
able to leave therapiststhey found unsafe or unsatisfactory. Why
should this be? Whilst bearing in mind thatrecurrence of a theme
within a participants account may be an imperfect index of
itsoverall importance, one possibility that we wish to raise is
that for those participantswho have insecure states of mind with
respect to attachment, the interplay of powerdynamics may
constitute a particularly troubling, problematic and
preoccupyingfeature of their experiences within personal
therapy.
Maguire (1995) has pointed out that experiences of powerlessness
andhelplessness are inevitable in childhood (p. 120), and certainly
therapies of allorientations recognise that the therapist, like the
parent, may come to be perceived asa powerful, authoritative figure
in the clients life. For those whose childhoods werecharacterised
by frightening, abusive, inconsistent or absent caregivers, it is
likelythat actual and symbolic authority figures may evoke working
models of relation-ships that are characterised by feelings of
distrust, anger, fear, resistance, oravoidance. It was noticeable
that in the AAIs, virtually all the insecurely-attachedindividuals
had described early attachment relationships that were
characterised byfear of violence, intimidation, loss and, in some
cases, precocious parenting ofmentally ill, abusive or neglectful
caregivers. Whilst some had been fortunate to have
360 R. Rizq and M. Target
-
other family members who could offer more loving and reliable
care, experiences ofpowerlessness and vulnerability were
nonetheless strikingly apparent in some of theirattachment
narratives. These insecurely-attached participants went on to
describerelationships with therapists that were in many cases
characterised by mistrust,conflict, disagreement and, in some
cases, a degree of resentful submission andfrustration. Whilst
guarding against any attempt at a premature or simplisticsynthesis,
one possibility is that concern with institutional and
interpersonal powerdynamics we have seen emerging from participants
accounts of personal therapymay come to be recruited into
participants pre-existing working models ofrelationships. For
insecurely attached participants, whose dismissive, preoccupiedor
unresolved attachment status may render them more vulnerable to
andpreoccupied with actual and symbolic authority figures (Maroda,
1994), theobligation to undergo a training therapy may come to
acquire particular psycho-logical significance and force.
In addition, RF scores were generally considerably lower for
these insecurely-attached participants than for their more
securely-attached colleagues. It is thereforepossible that not only
were insecurely-attached participants more troubled byperceived
disparities of power within the therapeutic relationship, but that
thisentailed serious difficulties in engaging with and
constructively using therapy inorder to reflect on and so resolve
these and other feelings. This suggests that theexperience and
value of personal therapy for participants may, in part at least,
havedepended on as well as contributed to their reflective
capacity. In other words, thosewith ordinary or marked levels of RF
may not only have been more interested inundertaking a personal
therapy in the first place, but their superior levels of RF mayhave
rendered them better able to manage and resolve ambivalent feelings
arising inthe context of power dynamics in a training therapy,
thus, presumably, freeing themto use their therapy more
productively in subsequent clinical work. Conversely, thosewith
negative, lacking or low levels of RF may have been less interested
in or evenresistant to gaining self-awareness, which may have
resulted in a reduced capacityto tolerate and resolve problematic
dynamics in personal therapy. Indeed, it ispossible that
insecurely-attached participants psychological preoccupation
withissues of power and authority in personal therapy may have
emerged in part at leastas a consequence of their generally lower
levels of RF, which in some cases seemed topreclude an ability to
move beyond such dynamics in order to make effective useof personal
therapy in the service of client work.
Power dynamics in training therapy
The priority participants afforded the therapeutic relationship
with their therapistsfocuses our attention more closely on the
nature of power dynamics within a trainingtherapy. The complex
psychological status of a trainee-patient has been recognisedfor
many years within psychoanalytic training institutions (e.g.,
Kernberg, 2006).Indeed, the phrase subservient analysis (Meyer,
2003) has been coined to denotethe distortions in an individuals
training analysis as a result of power and authoritystruggles
within psychoanalytic training institutions. Kernberg (2006)
trenchantlypoints out that that the role of training analyst often
carries with it an appointmentas supervisor, seminar leader and
potential member of the administrative leadership
Counselling Psychology Quarterly 361
-
of the institute . . . their monopolistic combination represents
simply a power grabby a privileged minority (p. 1654). Criticisms
like this led to Kirsner (2000) andothers to advocate a reform of
psychoanalytic training structures that now ensuresthat candidates
analysts are kept separate from the training institution; that they
arenot included in any assessment procedures; and that no reports
of progress within thetraining analysis are given to the
institution. This is also important for ethicalreasons such as the
avoidance of possible conflicts of interests.
It is instructive to compare the above with the experience of
participants in thecurrent study. Counselling Psychology training
institutions, which are largelyuniversity-based, are very different
from analytic institutes and there has always beenan emphasis on
maintaining clear boundaries between the training course and
thetrainees own therapist. There are no reporting requirements
between the two parties.Nevertheless, it is notable that high
levels of dissatisfaction and frustration withperceived
inequalities within the therapeutic relationship were experienced
by ourparticipants too. However, it was the insecurely-attached
group who seemed toexperience this most forcefully and who in many
cases, unlike their more securely-attached counterparts, perceived
power to have filtered down from the BPS throughto their training
institutions and from there into their relationships with
trainingtherapists. These therapists thus appeared to them to be
unwanted ambassadors ofan unreasonable and demanding professional
body. As an example, let us remindourselves of Mary who made a
decision that I didnt go there for therapy, andpurposely 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 iton my own terms.
(Mary)
Part of being a bit angry here seems to be that Mary feels that
BPS is almost aperson who says you have to go to personal therapy.
The intrusiveness of the BPSinto her personal life means that the
instigator of this intrusion is felt no longer to bean anonymous
institution, but rather someone with whom she has an
imaginarydialogue, almost an argument. There is a sense of struggle
here that means she isdetermined 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. Elsewherehowever,
she notes:
Im not saying I was conscious of this [ . . . ] at the time, but
I think Id already made upmy 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 haveshifted from the institutional level of the BPS to
the interpersonal level of thetherapeutic relationship. The
struggle seems to crystallise around Marys feeling thatthe
therapist, like the BPS, is digging in areas that I wasnt ready to
go tomyself. It eventually manifests in an attempt to limit what
she will share with hertherapist. It is this, perhaps, that
constitutes doing therapy on my own terms anecessary psychological
strategy that enables Mary to assert personal control andmaintain a
sense of integrity within the therapeutic relationship.
The way in which power dynamics percolate down from professional
andinstitutional bodies into the fabric of the therapeutic
relationship itself, has ofcourse been extensively discussed in
post-modern, social constructionist and
362 R. Rizq and M. Target
-
deconstructionist approaches to psychotherapy (e.g., Foucault,
1980; Lefebvre, 1991;Rose, 2001). Indeed, it should be remembered
that our participants accounts of theirpersonal therapy experiences
emerge from the post-modern epistemology ofcounselling psychology,
in which notions of theoretical pluralism, the significanceof a
relational, non-pathologising stance and a collaborative rather
than an expertapproach are privileged within training and clinical
practice. There is clearly thepotential here for a mismatch of
expectation between our participants and therapiststrained within
single-model approaches. However, Guilfoyle (2005) reminds us
thatthat subject positions (Foucault, 1982) people adopt in therapy
are governed,delimited and circumscribed by the positions of
therapist and client to which bothare expected to conform. He goes
on to suggest that even in explicitly collaborativetherapies,
clients may still . . . perceive and thus hear the therapist as
expert(pp. 339340). This is certainly supported by the experiences
of some of ourparticipants. However, we wish to propose the
possibility of a rather more complexrelationship between
institutional and interpersonal aspects of psychotherapeuticpower;
a relationship that we see as coloured by individuals internal
working modelsof attachment relationships and their capacity to
reflect on and so modify these inthe context of a training therapy.
Naturally, a larger-scale study would be needed toexamine the
generalisability of this contention, and to study its validity in
the contextof different training institutions and philosophies.
Validity issues
The interpolation of an attachment framework within a
predominantly phenome-nological study, whilst novel, presents
complex validity issues which have not yetbeen addressed in the
literature on mixed-methods research. Given the highlyexploratory
nature of this study, it is important to recognise that the above
resultscan only reflect our own interpretation of the data: it is
possible that differentresearchers would have found different
themes within the personal therapyinterviews, which could have
resulted in different inferences being drawn whenexamined alongside
results from the AAIs. How then can we establish confidence inthe
validity of the findings outlined above?
Drawing on Dellinger and Leechs (2007) notion of inferential
consistency, wethink it is reasonable to claim that results are
consistent given what is known fromprior understandings, past
research and theory (p. 324). Whilst the suggestion
thatinsecurely-attached trainee-patients may be more vulnerable to
power dynamics in atraining therapy has not, to date, been
discussed in the empirical literature, such anotion has
considerable face validity, as well as being consistent with
psychotherapyoutcome research documenting the difficulties of
helping insecurely-attachedindividuals in psychotherapy (Dozier,
1990; Fonagy & Target, 1996). It also linkswith recent
speculation by Farber and Metzger (2008) that insecure therapists
may beless well-equipped to repair ruptures to the therapeutic
alliance, something thatSafran 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 alsoimportant to consider validity in the context
of Masons (2006) argument forretaining key qualities and principles
(p. 22) of qualitative approaches in mixedmethodology research. Key
principles here might include the relevance of maintain-ing a
reflexive and critical approach to the inclusion of an
attachment-theory
Counselling Psychology Quarterly 363
-
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
364 R. Rizq and M. Target
-
from the usual accountability structures within counselling
psychology traininginstitutions was designed to avoid.
However, our results suggest that trainee-clients neglectful,
abusive or violentearly attachment experiences may have a complex
and recursive impact on the way inwhich a training therapy and
perhaps, by extension, an entire training programme is experienced
as either helpful or unhelpful. This then draws us further into
moreintricate questions about the aims of a training therapy
(Cabaniss & Bosworth,2006), and the extent to which a personal
therapy can or should be expected toproduce healthy practitioners.
(If so, by what criteria could be established atselection?). We
would argue that if the field of counselling psychology attracts a
highproportion of individuals with insecure working models of
relationships, then theonus is on the profession to establish how,
to what extent and by what means amandatory personal therapy can
enable these individuals to harness theseexperiences and to
transform them into effective work with clients.
One likely focus of interest for future research could be those
practitionersdeemed earned secure, as we found that these
individuals in the current studyspecifically attributed the
resolution of their personal histories and problems to
theirpersonal therapy, and found it indispensable in their
professional work. Detailedcase studies, documenting the complex
interrelationship between earned securetherapists attachment
relationships, levels of reflective function, and the way
theirpersonal therapy is recalled and deployed in clinical practice
would help theprofession to develop a more convincing educational
rationale for the inclusion ofpersonal therapy in training as well
as a model for its putative clinical impact.
Finally, it is interesting that, despite an increasingly
forceful political andeconomic agenda within the NHS (e.g., Layard,
2004), the field has yet to overturnL. Luborsky, Singer, and E.
Luborskys (1975) original dodo bird verdictdemonstrating that all
psychotherapies are similarly effective. Perhaps for this
reasonthere is renewed interest in the contribution of the
therapist to psychotherapyoutcome, with recognition that
variations, for example, in skilfulness and the selfof the
therapist may account for significant individual differences in
therapistsclinical 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 infacilitating
more effective clinical outcomes, we hope our study may
indirectlycontribute to this literature by elucidating the
complexity of how attachment securityinteracts with the experience
of a personal therapy in the context of counsellingpsychology
training.
Declaration of interest: The authors report no conflicts of
interest. The authors alone areresponsible for the content and
writing of the paper.
Notes on contributors
Dr Rosemary Rizq, PhD, is a Chartered Counselling Psychologist
and Senior Practitionermember of the British Psychological Societys
Register of Psychologists Specialising inPsychotherapy. She is
Principal Lecturer in Counselling Psychology at
RoehamptonUniversitys Research Centre for Therapeutic Education and
is Specialist Lead for Researchand Development for Ealing PCTs
Mental Health and Well-being Service where she also hasa clinical
and supervisory role. She is Submissions Editor for Psychodynamic
Practice.
Professor Mary Target, PhD, is a Fellow of the British
Psycho-Analytical Society andProfessional Director of the Anna
Freud Centre. She has been a member of the Curriculum
Counselling Psychology Quarterly 365
-
and Scientific Committees, and Chair of the Research Committee
of the BritishPsychoanalytic Society, and former Chair of the
Working Party on PsychoanalyticEducation of the European
Psychoanalytic Federation. She is a member of the ResearchCommittee
(Conceptual Research) of the International Psychoanalytic
Association. She isCourse Organiser of the UCL MSc in
Psychoanalytic Theory, and AcademicCourse Organiser of the UCL/Anna
Freud Centre Doctorate in Child and AdolescentPsychotherapy. She is
Joint Series Editor for Karnacs new Developments in
Psychoanalysisseries. She has active research collaborations in
many countries in the areas of developmentalpsychopathology,
attachment and psychotherapy outcome. She is Consultant to the
Childand Family Program at the Menninger Department of Psychiatry
at Baylor College ofMedicine, USA.
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