the role of attachment status in counselling psychlogists experience of personal therapy_mmr

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.


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


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.


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


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


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


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


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)


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


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


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)


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


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


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


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


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


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


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


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


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


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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