344
(e.g., Kernberg, 2006; Wallerstein, 1993). However, there has been curiously little
investigation into the experiences of other psychotherapeutic practitioners undertaking a mandatory training therapy. There are certainly moving and persuasive
personal testaments to the value of practitioners own therapy (Geller, 2005; Hill,
2005; Little, 1990) and quantitative surveys overwhelmingly attest to the satisfaction
of large numbers of therapists undertaking therapy (e.g., Orlinsky et al., 1999a,
Orlinsky, Botermans, & Ronnestad, 2001; Orlinsky, Norcross, Ronnestad, &
Wiseman, 2005). But there are only a handful of published qualitative studies
examining the subjective experience of personal therapy from the perspective of
practitioners themselves (Grimmer & Tribe, 2001; Macran, Stiles, & Smith, 1999;
Murphy, 2005; Rake & Paley, 2009; Wiseman & Shefler, 2001). Aware of this gap in
the literature, we recently undertook a qualitative study exploring nine senior
counselling psychologists experiences of personal therapy (Rizq & Target, 2008a,
2008b). Whilst therapy was found to be valuable in promoting awareness of different
aspects of the self, we also found that attachment experience emerged as a significant
organising framework within participants accounts, with several individuals
describing the salience of difficulties in early family relationships to the development
of a nascent reflective capacity that they honed in personal therapy and subsequently
deemed crucial to effective, empathic clinical work.
345
the caregiver, ensures that the developing infants internal feeling states become
meaningful and manageable. It is this process, closely aligned to Bions
(1962a,1962b) notion of containment, that is assumed to play an important role
in the childs eventual capacity to manage his or her own feeling states and nascent
self-organisation (Fonagy, Gergely, Jurist, & Target, 2002). Security of attachment is
thus generally associated with higher levels of mentalisation, whilst hostile, neglectful
or abusive caregiving is associated with inhibited mentalising skills (Fonagy, Target,
Gergely, Allen, & Bateman, 2003b). Fonagy, M. Steele, H. Steele, Higgitt, and
Target (1994) suggest that this capacity, operationalised as reflective function,
may be particularly advantageous to those with adverse histories, since it is their
ability to represent and reflect on early traumatic or neglectful experience that
appears to interrupt the intergenerational cycle of disadvantage. Indeed, Pearson,
Cohn, P. Cowan, and C. Cowan (1994) adopted the phrase earned secure to
describe those who had managed to overcome neglectful or abusive early childhood
experiences that might otherwise be associated with insecure attachment.
Given that mentalisation underlies the capacity to see and respond to others as
psychological beings, therapists levels of reflective function would appear to be
central to effective, empathic clinical work. Whilst some studies have examined the
role of psychotherapy in improving reflective function in clients (Karlsson &
Kermott, 2006; Levy et al., 2006), only one published study has examined therapist
attachment status and reflective function. Diamond, Stovall-McClough, Clarkin,
and Levy (2003) explored the impact of both therapist and client attachment states of
mind and reflective function on therapeutic process and outcome. The authors argue
that the quality of mentalisation in the therapeutic dyad can be conceptualised as a
bidirectional process in the therapists and clients levels of reflective function appear
to be mutually and reciprocally influential. They found that therapeutic progress was
associated with the therapists capacity to adjust his or her level of mentalisation to
slightly above that of the client, rather than mirroring the clients low level of
mentalisation directly.
346
Procedure
Selection and recruitment of participants
IPA is increasingly characterised by purposive homogeneous sampling, using small
numbers of participants selected for their experience in the subject under investigation and their ability to illuminate specific research questions or areas (Smith &
Osborn, 2003). The current sample were selected from UK counselling psychologists
who were chartered between 2000 and 2004 i.e., who at the time of recruitment had
been qualified and practising for between 3 and 7 years. Recruitment methods
included mailshot, advertisement and chain referral. Overall, 12 individuals agreed to
participate in the study and interviews took place over a 10-month period.
347
Sample characteristics
Three men and nine women took part, with ages ranging from 3565. All were white
Caucasian with the exception of two participants who were Asian and black AfroCaribbean. Participants had spent varying lengths of time in therapy: nine had
undertaken extensive therapy prior to their training, and three of these had also
continued after completion of their training. There were three further participants
who had undertaken only the mandatory minimum period of 40 hours during their
training. Theoretical orientations of personal therapy were varied and included:
psychoanalytic, gestalt, cognitive-behavioural, and existential models. Participants
current clinical work included both NHS and private practice. Whilst we are aware
that such a mix of different therapeutic orientations in one sample may be considered
overly heterogeneous within an IPA study, the variety of theoretical models
experienced by our participants in their personal therapy is nonetheless a
distinguishing feature within Counselling Psychology training courses and hence
the sample was thought to be characteristic of the profession.
The main researcher (Rizq), a chartered counselling psychologist specialising in
psychotherapy, had several years experience in clinical work and teaching from a
mainly psychoanalytic perspective. The second researcher (Target), a clinical
psychologist and psychoanalyst, had extensive experience in clinical work, teaching
and research.
348
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.
349
Negative RF (10)
Lacking in RF (12).
Low or questionable RF (34)
Ordinary RF (56)
Marked RF (78)
Exceptional (9).
350
Number of
participants
Reflective
function rating
Secure
Earned secure
Dismissive
Preoccupied
Unresolved
1
2
Cannot classify
3
4
5
7
7
7
4
2
3
1.5
8
0
including the full range of dismissive, unresolved, preoccupied and cannot classify
categories.
In line with the previously-mentioned developmental research suggesting that RF
is an index of attachment security, RF scores were found in general to be higher with
the secure/earned secure participants, with four out of the six secure/earned-secure
participants having RF scores of 4 or above and four out of the six insecurelyattached participants having RF scores of between 0 and 3. As is consistent with a
qualitative study, a representative sample had not been sought, but it is nonetheless
evident that the current group of participants includes a relatively high proportion of
individuals with problematic early attachment histories. Clearly, a larger scale study
would be needed to establish whether these results are characteristic of the profession
as a whole.
351
Key
Earne -secure
Name
Laura
Clare
RF
7
7
Sara
Judy
Carol
Anna
3
5
4
7
Establishing
trust
Resisting
engagement
Secure
= presence of
the me
= absence of
theme.
Name
Aida
Hannah
Mary
David
Martin
Malcolm
RF
1.5
Establishing
trust
Resisting
engagement
Key
Unresolved
Dismissive
8
4
Cannot classify
2
0
3
Preoccupied
= presence of
theme
= absence of
theme.
I know I kept my guards up, I know I kept her at a distance; I know I didnt let her in
too much. (Aida)
352
resist engaging with therapists felt to be unsafe or untrustworthy. Five out of the six
insecurely-attached participants contributed to the theme of resisting engagement
and described ways in which they strongly opposed their therapists attempts to draw
out feelings and memories:
I think I was probably quite defended in my time with her, to be honest, though I think
we did do some good work as well, but Um Ive, I felt it was her agenda and not
mine ( . . . ) and I wasnt going to give in to it. (Hannah)
Aida was clear that she only undertook personal therapy for the University.
She is determined to refuse her therapist access to personal sort of stuff and seems
to have already decided that this was just going to be an exercise:
. . . bearing in mind that again the motivation was I had to be there for the University,
so I remember it being on a very superficial level and holding things back and
determined I wasnt going to let her into personal sort of stuff, and this was just going to
be an exercise I went through. (Aida)
Judys growing trust in her therapist resulted in twice-weekly therapy where she
felt she could engage more deeply in the work:
I started going to see him twice a week. What made you do that? Because I knew that it
went onto a whole . . . I felt I was ready to go on to a whole other level, which, which is
what did happen. It was much more, I think going twice a week is much more than
double [ . . . ] it just took it to, into a whole new realm, really. So the work really,
deepened. (Judy)
353
Table 3b also shows that three of the insecurely attached participants contributed
to the sub-theme of Experiencing the therapist as parent. Whilst one of these,
Hannah, invoked notions of transference, and described the way in which she saw
her therapeutic relationship mirroring a troubled early relationship with her mother,
the other two participants rejected the notion of the therapists symbolic
parental role, or referred to it only in highly intellectualised terms. By contrast,
Table 3a shows that five of the six securely-attached individuals contributed to
the same theme, most speaking freely about the parental role fulfilled by their
therapists, and the impact this had on the therapeutic relationship. Illustrative
examples include:
He was my mother, to me. The mother Id wished Id had (tearful). (Judy)
I [ . . . ] gradually came to realise that she was a type of parental in some ways the
relationship was parental but a kind of reparative relationship, the kind of mother that
might have been better for me. [ . . . ](Anna)
I did . . . yes, I did look on her very much as a mother figure [ . . . ] She was very mumsy.
She was a retired nurse, and so, yes, she was, she was a mother figure. She was the good
mother. (Carol)
I mean he was my dad, he was, he was, he was as a surrogate dad for quite a while and I
looked up to him, he was a role model as well for a therapist for quite some time . . . .
(Laura)
Anna
Sara
Clare
Carol
Laura
Judy
RF
Name
Disappointment
and disillusion
Experiencing
the therapist
as parent
relationship
An unequal
(+/)
(+)
()
(+/)
(+/)
(+)
Challenging
and changing
therapist
Avoiding () vs
confronting (+)
= presence of
theme
= absence of
theme.
Secure
Earne -secure
Key
Table 3a. Struggling with ambivalent feelings: presence/absence of themes in secure/earned secure participants accounts (n 6).
354
R. Rizq and M. Target
Malcolm
Martin
David
Mary
Hannah
Aida
Name
RF
1.5
8
4
2
0
3
Disappointment
and disillusion
Experiencing
the therapist
as parent
An unequal
relationship
(+)
()
()
()
()
()
Challenging
and changing
therapist
Avoiding ()
vs
confronting
(+)
= presence
of theme
= absence
of theme
Preoccupied
Cannot
classify
Dismissive
Unresolved
Key
Table 3b. Struggling with ambivalent feelings: presence/absence of themes in insecurely-attached participants accounts (n 6).
356
Similarly, when Clare recalls her first training therapist, whom she felt was
unhelpful, she is able to reflect equally on this therapists positive and negative
features:
I just felt this woman didnt really get me, didnt understand me, I felt she wasnt on the
same wavelength that she couldnt (mm) . . . And I dont know if it was a mismatch
there, but part of my sense was that she hadnt gone very far herself . . . and I think that
was the rub, I think she was a good enough person, I think she was probably a very
nice person, but for me, she wasnt right. (Clare)
It is noticeable that Clare and Laura above, both of whom are classified as
earned-secure are able to offer a balanced picture of their therapeutic relationships, and their negative experiences are recounted with forgiveness, humour, and
acceptance. By contrast, insecurely-attached participants appeared particularly
angry, let down and disappointed when therapists failed to live up to what appeared
to be very high standards. Malcolm describes how he seems to need his therapist to
be more than good enough and how running over time at the end of a session
appears to spoil[s] something:
I dont know why I feel they have to be good enough, or more than good
enough really. Why sometimes it feels like it spoils something. Like it, why did
you have to say that, or, you were doing so well, and youre so perfect [ . . . ]
(Malcolm)
Martin takes this further and appears to blame his therapist for what he feels is a
disappointing lack of personal change:
it was her responsibility, she could have done something differently. (Martin)
357
From Table 3b, it is clear that the theme of inequality in the therapeutic
relationship was raised by all but one of the six insecurely-attached participants.
Illustrative excerpts include:
You know, she had all these certificates, not that I pay much credence to whats in the
room, but . . . .And it was kind of, like, um, : look at me, Ive done so much Ive all these
years of experience ( . . . ). it left me a little bit in awe. (Aida)
It was awful! She was invested with all the sort of authority of God, basically, and she
would start the sessions by praying [ . . . ] which I have to say I would never ever do with
a client! So, she prayed, and then we would start. Well, by then, the power imbalance
was enormous! (Hannah)
I think theres a way of people imposing their own sort of reasoning on you and, you
know, it just comes over you, youve got to get inside their own way of thinking and
their own theory (David)
These participants all conveyed, in varying ways, the extent to which they felt
particularly diminished, disempowered or frustrated either by the imposition of a
personal therapy training requirement or by the perceived status, behaviour, and
emotional demands of their therapists. Their experiences of coercion and sensitivity
to power emerge forcefully:
Now what people have done to me is: do you want to talk about your childhood? Full
stop! [ . . . ] that was wrong. Cos Id say: no. Im terrified [ . . . ] or Im embarrassed.
And so there was a lot, a lot of implicit force under these therapies, so Im very very
sensitive to implicit force. (David)
. . . we had a constant battle cos she wanted me to go twice a week and I only ever went
once a week. (Hannah)
I was still young; Id been, I wasnt therapy-wise at the time so, so I wasnt able to,
you know, it was always . . . .struggling against . . . the, this authority figure,
who . . . had social power to make decisions about me, or descriptions about me
that could remain on public record. Um . . . as if they were facts, when theyre not.
(Malcolm)
Maybe that was me being a bit angry that the BPS had said you have to go, so I said:
yes, I want to be a chartered counselling psychologist, Ill do what I need to do; Ill do it
on my own terms. (Mary)
it was put across, you know, you have to do it; no arguments, you have to do it.
No discussion of, yes, it brings up uncomfortable feelings, let look at it. I didnt
get that from my tutors, didnt get the sense of lets talk about this, yes you have to
do it, hey, thats the given, but lets look at what, why might you be feeling
uncomfortable. (Aida)
It was clear that all participants, in varying ways, were found to be sensitive to
different aspects of power and authority within their personal therapy; and Tables 3a
and 3b illustrate that both secure and insecurely-attached participants alike discussed
the difficulties of challenging or changing their therapists. However, those who
recalled this difficulty within their therapy as most preoccupying, problematic and
significant tended to be insecurely-attached; and all but one of the insecurelyattached group spoke about how they felt unable to confront their therapists with
their negative feelings. This difficulty was raised frequently in their accounts, and for
many, seems to have been implicated in a general backdrop of dissatisfaction with
358
therapy in which their feelings of discontent, in some cases anxiety or anger, were
neither voiced nor acknowledged. Mary exemplifies this in her comment below:
Maybe that was one of the things I didnt learn in my own personal therapy, that I had
the power to say to my therapist Im not happy about something. (Mary)
One implication of the above dynamic is that for some participants at least,
therapists were seen as potentially in bed with training institutions, and thus not
able to provide a truly impartial or protected space. As a result, they resigned
themselves to staying with therapists with whom they continually felt uncomfortable,
dissatisfied or disappointed. These insecurely-attached participants also seemed to
deploy various mechanisms to counteract painful feelings of powerlessness and
frustration that they were unwilling or unable to voice in therapy. Several dismissed
or minimised such feelings, often for fear of invoking their therapists imagined
anger. Others kept their therapists at a distance, refusing them access to significant
personal information. In one more complex case, Hannah remained reluctantly and
ambivalently with her training therapist, partially sustained by a complex fantasy
concerning power and health. She reluctantly describes an uncomfortable feeling of
contempt for this therapist, locating the source of this disdain in the therapists slight
physical disability. This seems to afford her some covert relief that, despite her
therapists constant attempts to make her acquiesce to her demands, Hannah is
somehow more powerful (i.e., healthy) than her therapist:
The very first time I met her . . . .we went upstairs and she has a funny leg; she cant, I
mean, its not very bad, but she couldnt, shes not in a wheelchair or anything, but she,
its quite noticeable that she has to drag her leg up . . . possibly she had polio as a child or
something. And something about that made me . . . oh dear! I dont know, it made
me . . . .I think I felt she wouldnt be a threat? . . . somehow it gave me a feeling of, I
dunno, power? (Hannah)
From an attachment perspective, these kinds of strategies might be conceptualised as the means by which preoccupied, unresolved, dismissive and other insecurely
attached participants variously regulate the interpersonal distance and dynamics
within the therapeutic relationship. However, from a more phenomenological
perspective, participants accounts can be seen to emerge in the context of what
appears for some to have felt like a battle, where establishing a position of equality
and mutuality or in some cases a feeling of superiority and control appeared to be
central to participants retaining a sense of identity or personal integrity. For these
participants, the experience of therapy revolved around the need to establish and
359
sustain a felt sense of personal power within the therapeutic relationship, rather than
simply relinquishing control to, or being subsumed by, an authoritative therapist.
The above strategies of insecurely-attached participants can be contrasted with
those of securely-attached or earned-secure participants, five of whom, whilst
similarly struggling with feelings of disappointment and frustration, nonetheless
appeared to be more confident and able to express their negative feelings within the
relationship, as Carol was able to do:
I remember her once saying youre very angry; I remember being furious with her.
How dare she tell me Im angry! {laughs} Dont tell me Im angry!{laughs}. So, er, I
remember telling her I wanted to throw her pot plants around the room once and she
just sat there calmly. (Carol)
In this respect, it was noticeable that even serious difficulties within some of these
participants therapeutic relationships did not appear to dissuade them from
continuing to seek other therapists.
Discussion
Results from the analysis of participants AAI narratives show that half of the 12
participants had insecure states of mind with respect to attachment, with a further
two classified as earned secure. This relatively high proportion of insecurelyattached individuals is perhaps unsurprising. In common with much of the
wounded healer literature (e.g., Jackson, 2001), AAI narratives showed that
many participants, from a young age, had undertaken roles that involved them in the
emotional care of family members, in some cases, depressed, mentally ill or abusive
parents. This concurs with Glickhauf-Hughes and Mehlmans (1995) notion of
parentification which they use to describe the emotional role into which the future
360
therapist may be cast within the family; they suggest that such children
develop emotional antennae which can predispose them to joining a therapeutic
profession. Whilst there is very little literature on the background of counselling
psychologists, Halewood and Tribe (2003) suggest that a high degree of
narcissistic injury, related to the perceived quality of early attachment relationships,
may be particularly prevalent amongst counselling psychology trainees.
Similarly, DiCacavvo (2002) found that counselling psychology trainees reported
significantly lower maternal care and higher levels of self-efficacy in care than did art
students.
The wide range of attachment classifications was mirrored by a spread of
reflective function scores. In line with earlier research, those who were securelyattached tended to have higher RF scores than those who were insecurely-attached.
Of note are the marked RF scores of the two earned-secure participants, whose
narratives in both the AAI and personal therapy interviews were exceptionally
thoughtful and reflective, showing strong coherence and richness of recall. This can
perhaps be seen as an index of their ability to reflect on and largely resolve early
experiences with an abusive parent in one case and a seriously mentally ill parent on
the other. Indeed, it was noticeable that both these participants strongly attributed
the resolution of their longstanding family and relationship issues to their highly
positive experiences within personal therapy.
Despite disappointments and set-backs within the therapeutic relationship, secure
and earned-secure participants alike described the generally beneficial impact of their
experiences within personal therapy. However, insecurely-attached participants
appeared to recall their personal therapy somewhat differently. They were more
reluctant to attend therapy, and appeared to have been more resistant, cautious and
suspicious of therapists during the period of their therapy. They discussed a range of
negative feelings about the imposition of a mandatory training therapy and about
the relationships established with their therapists. Prominent in their accounts were
sometimes intense levels of unease and anxiety about a perceived imbalance of power
in the therapeutic relationship and, in contrast to their securely-attached counterparts, most of these participants had been strikingly unable to voice feelings of anger
and frustration in therapy; nor, in many cases, had they felt able to leave therapists
they found unsafe or unsatisfactory. Why should this be? Whilst bearing in mind that
recurrence of a theme within a participants account may be an imperfect index of its
overall importance, one possibility that we wish to raise is that for those participants
who have insecure states of mind with respect to attachment, the interplay of power
dynamics may constitute a particularly troubling, problematic and preoccupying
feature of their experiences within personal therapy.
Maguire (1995) has pointed out that experiences of powerlessness and
helplessness are inevitable in childhood (p. 120), and certainly therapies of all
orientations recognise that the therapist, like the parent, may come to be perceived as
a powerful, authoritative figure in the clients life. For those whose childhoods were
characterised by frightening, abusive, inconsistent or absent caregivers, it is likely
that actual and symbolic authority figures may evoke working models of relationships that are characterised by feelings of distrust, anger, fear, resistance, or
avoidance. It was noticeable that in the AAIs, virtually all the insecurely-attached
individuals had described early attachment relationships that were characterised by
fear of violence, intimidation, loss and, in some cases, precocious parenting of
mentally ill, abusive or neglectful caregivers. Whilst some had been fortunate to have
361
other family members who could offer more loving and reliable care, experiences of
powerlessness and vulnerability were nonetheless strikingly apparent in some of their
attachment narratives. These insecurely-attached participants went on to describe
relationships with therapists that were in many cases characterised by mistrust,
conflict, disagreement and, in some cases, a degree of resentful submission and
frustration. Whilst guarding against any attempt at a premature or simplistic
synthesis, one possibility is that concern with institutional and interpersonal power
dynamics we have seen emerging from participants accounts of personal therapy
may come to be recruited into participants pre-existing working models of
relationships. For insecurely attached participants, whose dismissive, preoccupied
or unresolved attachment status may render them more vulnerable to and
preoccupied with actual and symbolic authority figures (Maroda, 1994), the
obligation to undergo a training therapy may come to acquire particular psychological significance and force.
In addition, RF scores were generally considerably lower for these insecurelyattached participants than for their more securely-attached colleagues. It is therefore
possible that not only were insecurely-attached participants more troubled by
perceived disparities of power within the therapeutic relationship, but that this
entailed serious difficulties in engaging with and constructively using therapy in
order to reflect on and so resolve these and other feelings. This suggests that the
experience and value of personal therapy for participants may, in part at least, have
depended on as well as contributed to their reflective capacity. In other words, those
with ordinary or marked levels of RF may not only have been more interested in
undertaking a personal therapy in the first place, but their superior levels of RF may
have rendered them better able to manage and resolve ambivalent feelings arising in
the context of power dynamics in a training therapy, thus, presumably, freeing them
to use their therapy more productively in subsequent clinical work. Conversely, those
with negative, lacking or low levels of RF may have been less interested in or even
resistant to gaining self-awareness, which may have resulted in a reduced capacity
to tolerate and resolve problematic dynamics in personal therapy. Indeed, it is
possible that insecurely-attached participants psychological preoccupation with
issues of power and authority in personal therapy may have emerged in part at least
as a consequence of their generally lower levels of RF, which in some cases seemed to
preclude an ability to move beyond such dynamics in order to make effective use
of personal therapy in the service of client work.
362
Part of being a bit angry here seems to be that Mary feels that BPS is almost a
person who says you have to go to personal therapy. The intrusiveness of the BPS
into her personal life means that the instigator of this intrusion is felt no longer to be
an anonymous institution, but rather someone with whom she has an imaginary
dialogue, almost an argument. There is a sense of struggle here that means she is
determined to undertake therapy according to my own terms, which will, she feels,
implicitly redress a power balance that has so far been in the BPSs favour. Elsewhere
however, she notes:
Im not saying I was conscious of this [ . . . ] at the time, but I think Id already made up
my mind that I didnt go there for therapy, and I know that sounds really stupid [ . . . ].
I didnt go there for someone to dig, to sort of go into areas that I wasnt ready to go to,
myself. (Mary)
So the covert power struggle now continues, although its locus appears to have
shifted from the institutional level of the BPS to the interpersonal level of the
therapeutic relationship. The struggle seems to crystallise around Marys feeling that
the therapist, like the BPS, is digging in areas that I wasnt ready to go to
myself. It eventually manifests in an attempt to limit what she will share with her
therapist. It is this, perhaps, that constitutes doing therapy on my own terms a
necessary psychological strategy that enables Mary to assert personal control and
maintain a sense of integrity within the therapeutic relationship.
The way in which power dynamics percolate down from professional and
institutional bodies into the fabric of the therapeutic relationship itself, has of
course been extensively discussed in post-modern, social constructionist and
363
Validity issues
The interpolation of an attachment framework within a predominantly phenomenological study, whilst novel, presents complex validity issues which have not yet
been addressed in the literature on mixed-methods research. Given the highly
exploratory nature of this study, it is important to recognise that the above results
can only reflect our own interpretation of the data: it is possible that different
researchers would have found different themes within the personal therapy
interviews, which could have resulted in different inferences being drawn when
examined alongside results from the AAIs. How then can we establish confidence in
the validity of the findings outlined above?
Drawing on Dellinger and Leechs (2007) notion of inferential consistency, we
think it is reasonable to claim that results are consistent given what is known from
prior understandings, past research and theory (p. 324). Whilst the suggestion that
insecurely-attached trainee-patients may be more vulnerable to power dynamics in a
training therapy has not, to date, been discussed in the empirical literature, such a
notion has considerable face validity, as well as being consistent with psychotherapy
outcome research documenting the difficulties of helping insecurely-attached
individuals in psychotherapy (Dozier, 1990; Fonagy & Target, 1996). It also links
with recent speculation by Farber and Metzger (2008) that insecure therapists may be
less well-equipped to repair ruptures to the therapeutic alliance, something that
Safran et al. (2002) have argued is crucial to successful therapeutic outcome.
The small sample and qualitatively-driven design of the study mean that it is also
important to consider validity in the context of Masons (2006) argument for
retaining key qualities and principles (p. 22) of qualitative approaches in mixed
methodology research. Key principles here might include the relevance of maintaining a reflexive and critical approach to the inclusion of an attachment-theory
364
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.
365
Notes on contributors
Dr Rosemary Rizq, PhD, is a Chartered Counselling Psychologist and Senior Practitioner
member of the British Psychological Societys Register of Psychologists Specialising in
Psychotherapy. She is Principal Lecturer in Counselling Psychology at Roehampton
Universitys Research Centre for Therapeutic Education and is Specialist Lead for Research
and Development for Ealing PCTs Mental Health and Well-being Service where she also has
a clinical and supervisory role. She is Submissions Editor for Psychodynamic Practice.
Professor Mary Target, PhD, is a Fellow of the British Psycho-Analytical Society and
Professional Director of the Anna Freud Centre. She has been a member of the Curriculum
366
and Scientific Committees, and Chair of the Research Committee of the British
Psychoanalytic Society, and former Chair of the Working Party on Psychoanalytic
Education of the European Psychoanalytic Federation. She is a member of the Research
Committee (Conceptual Research) of the International Psychoanalytic Association. She is
Course Organiser of the UCL MSc in Psychoanalytic Theory, and Academic
Course Organiser of the UCL/Anna Freud Centre Doctorate in Child and Adolescent
Psychotherapy. She is Joint Series Editor for Karnacs new Developments in Psychoanalysis
series. She has active research collaborations in many countries in the areas of developmental
psychopathology, attachment and psychotherapy outcome. She is Consultant to the Child
and Family Program at the Menninger Department of Psychiatry at Baylor College of
Medicine, USA.
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