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Therapist Intersubjective Negotiation as a Predictor of Therapeutic Change
A Dissertation Defense
(Journal Article)
Medea M. Elvy, M. A.
The New School for Social Research
Dissertation Committee:
Dr. Jeremy Safran
Dr. Christopher Muran
Dr. Lisa Rubin
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Introduction:
In the last fifty years of psychotherapy research, the most consistent finding is that the
therapeutic alliance is one of the best predictors of treatment outcome, regardless of the
treatment modality being practiced (Horvath & Symonds, 1991). This finding has been replicated
multiples times, across many treatment modalities. Other findings indicate that poor outcome
cases demonstrate greater evidence of negative interpersonal process (e.g., hostile interactions
between patient and therapist or deterioration in the quality of the alliance) than good outcome
cases (e.g., Coady, 1991; Henry, Schacht, & Strupp, 1986; Samstag, 1999). Partially due to this
result, there has been a shift in focus from understanding the therapeutic relationship as a oneperson psychology to more of a relational interaction involving two subjectivities at play, which
both influence and create therapeutic dynamics. This shift has created a heightened interest in
therapist variables and in therapists’ ability to negotiate both the alliance in general and
therapeutic impasses in particular (See Safran & Muran, 2000; Binder & Strupp, 1997; Bordin,
1994; Foreman & Marmar, 1985; Horvath, 1995).
The main aim of this study was to re-focus therapeutic alliance and rupture theory
through the wide-angle lens of developmental intersubjectivity, in order to illuminate how the
therapist’s capacity to accept unwanted parts of themselves and “say the unsayable” (Safran &
Muran, 2000) during ruptures could significantly distinguish difference in outcome. This project
uniquely offers an operationalization of Safran & Muran’s relational model as well as Jessica
Benjamin’s theory of mutual recognition through a re-interpreted version of the Therapist
Experiencing Scale (TES), (Klein et al., 1986), renamed as the Therapist Intersubjective
Negotiation Scale (TINS). The main focus was on addressing rupture events, utilizing Safran
and Muran’s (2000) relational model, in hopes of highlighting the therapeutic variables that
facilitate negotiating a fundamental struggle between two subjectivities and their respective
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needs for dependency and recognition. Focusing on therapeutic ruptures has become essential
for ongoing psychotherapy research because these events can constitute the very heart of
transformation: “One might say that the processes of developing and resolving problems in
alliance are not a prerequisite to change but rather the essence of the change process” (Safran &
Muran, 2000). This project utilized both Safran & Muran’s process of therapist
metacommunication as well as Benjamin’s developmental theory of intersubjectivity in order to
conceptualize this “struggle between two subjectivities” and to understand how the therapist’s
ability/inability to accommodate the patient’s subjectivity, while simultaneously retaining their
own internal space, during rupture events distinguishes therapeutic outcome and is related
significantly to therapeutic process.
This study will review Safran and Muran’s Brief Relational model of therapy and
metacommunication, theories of intersubjectivity and Benjamin’s developmental theory in
particular, a brief history of the Experiencing Scales (Klein et al., 1986), and finally, a reinterpretation of the Therapist Experiencing Scale will be offered as an operationalization of a
developmental theory of intersubjectivity.
The Brief Relational Model and Metacommunication:
The move from one-person focused treatment to two-person focused treatment has affected the
way that countertransference and therapeutic action is conceptualized: “this relational
perspective makes the analyst’s countertransference central not merely as a source of information
but as unconscious communication that demonstrates the effect the patient can have, an effect
that the analyst must process and return to the patient in more useable form” (Mitchell, 1988).
Through examining the therapeutic process as a relational endeavor, it has become apparent that
both breakdown and repair of the alliance are inevitable parts of the therapeutic process and that
the once assumed “objectivity” of the therapist is an illusion; the therapist must accept not only
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the inevitability, but the necessity of becoming involved in enactments with their patients,
“becoming part of the problem is how we become part of the solution” (Mitchell, 1997;
Benjamin, 2004a).
Based on these theoretical innovations (as well as others), Safran and Muran (2000) have
developed a therapeutic model, which takes into account how central the negotiation of self/other
needs and therapeutic ruptures/repairs are on the process and ultimate outcome of the therapeutic
endeavor. This approach (referred to as Brief Relational Therapy or BRT) synthesizes principles
derived from their research program, relational psychoanalysis, humanistic/experiential
psychotherapy, and contemporary theories on cognition and emotion (see Safran et al., 2001).
Some of the key characteristics of the model are as follows (Safran & Muran, 2000):
1.
2.
3.
4.
5.
6.
7.
8.
It assumes a two-person psychology and a constructivist epistemology (or, to be more precise what
Hoffman, 1998, refers to as a dialectical constructivist perspective).
There is an intensive focus on the here and now of the therapeutic relationship.
There is an ongoing collaborative exploration of both patients’ and therapist’ contributions to the
interaction.
It emphasizes in-depth exploration of the nuances of patients’ experience in the context of unfolding
therapeutic enactments and is cautious about making transference interpretations that speculate about
generalized relational patterns.
It makes intensive use of therapeutic metacommunication (defined as: “an attempt to bring ongoing
awareness to bear on the interactive process as it unfolds”) and countertransference disclosure.
It emphasizes the subjectivity of the therapist’s perceptions.
It assumes that the relational meaning of interventions is critical.
It views termination as an ultimate alliance rupture, a valuable opportunity to deal with critical issues
surrounding acceptance, being alone, separation, and loss.
Much of what Safran and Muran present incorporates an underlying developmental theory of
intersubjectivity. Safran and Muran argue that one of the main tools a therapist has in order to
effectively negotiate a therapeutic rupture is their ability to reestablish their own internal space
when they feel threatened by the interaction with their patient. Safran writes: “I have come to
believe that when an intervention helps to heal an alliance rupture, it does so, not because the
therapist has found the right words, but because the words reflect the fact that the therapist has
managed to enter the right state of mind” (Safran, 2003). What this paper hopes to contribute is
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an in-depth discussion of how the meta-theory of intersubjectivity can provide additional
richness and dimension to the dialogue about essential therapist variables and the subtleties of
the successful negotiation of therapeutic ruptures. The above outlined model reflects the shortterm 30-session therapy that was offered in this study.
Intersubjectivity, Mutual Recognition, and Surrender:
The movement toward a two-person psychology has also created more of an interest in
examining how the therapist’s experience affects the therapeutic process, as seen above in the
discussion of Safran and Muran’s relational model. In turn many perspectives called
“intersubjective” have appeared in the literature and their appearance “represent[s] a shift away
from viewing the therapeutic relationship in terms of discrete enactments involving transference
and countertransference and to viewing the relationship as an ongoing interplay of separate
subjectivities” and this ongoing interplay can be especially significant during times of ruptures
(Safran & Muran, 2000; Muran, 2001). One important distinction among theories of
“intersubjectivity” seems to be whether or not they carry a developmental achievement within
them. This becomes a difference between mutual regulation, which speaks to ongoing
unconscious influence between patient and therapist (see Orange et al., 1997) that occurs in all
human relationships and mutual recognition, which Benjamin argues is the inconsistently
maintained ability to hold onto one’s subjectivity while simultaneously recognizing the other.
Benjamin begins by tracing the psychic-cultural structure of dualism and domination as
far back as the primary relationship between mother and infant and as wide as the omnipresent
social archetypes of gender. She states “the anchoring of the structure of domination is so deep
in the psyche that it gives domination the appearance of inevitability, makes it seem that a
relationship in which both participants are subjects—both empowered and mutually respected—
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is impossible” (Benjamin, 1988). Benjamin’s developmental theory has grown own out of
Hegel’s premise on competing wills which results in the paradox of recognition: at the very
moment of realizing our independence, we are dependent upon another to recognize it”
(Benjamin, 1988). This inherent tension means that breakdowns in intersubjectivity are to be
expected in dyadic relations. Where Benjamin expands this notion is that negation of the other
and breakdown (while necessary) are not the end of the story. She argues that there is the
possibility of restoring the tension of recognition and allowing an opportunity for mutual sharing
of separate subjectivities. Relational theorists such as Aron and Mitchell and especially earlier
object relations theorists like Klein and Winnicott have greatly influenced Benjamin’s theory of
mutual recognition. Benjamin builds upon Winnicott’s theory about the “use of an object”
(1971) and she argues that: “the critical move beyond Klein lay in Winnicott’s demonstration of
what the containing subject can do for the other subject. He showed both how the subject can
become a giver of recognition and how it is possible to appreciate the externality and aliveness of
encountering uncontrollable otherness” (Benjamin, 2005).
Benjamin’s theory contributes an important dimension to the therapeutic alliance and
rupture literature in that she offers a very realistic and eloquent theoretical description of certain
enactments or impasses that make it especially difficult for either party to gain a sense of clarity
about what is occurring in the moment. When there is a breakdown of tension into
complementarity, there often is “a doer-and-done-to” kind of interaction where the two
subjectivities are participating in a reversible pattern of submission and domination. Each person
feels done-to by the other and every attempt one party makes at regaining the dominant position
(fighting for there own survival) negates the other and, in effect, negates them as well,
perpetuating the breakdown because without a recognizing other there is only omnipotence,
negation, and loss. This kind of interaction often feels like a crazy-making maze, which results
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in both parties feeling like either you are wrong/bad/crazy or I must be wrong/bad/crazy
(Benjamin, 1988).
In the Vanderbilt Study II, (Henry et al., 1993) the authors concluded that training is
filtered through a therapist’s predisposed qualities due to the finding that therapists participating
in a training aimed at helping them manage negative interpersonal process increased their
adherence but not necessarily their ability. Safran and Muran (2000) also arrive at the notion
that much of a therapist’s success will have to do with their “inner growth” alongside their
patients and their capability to recognize rejected/unwanted versions of themselves and articulate
them in the here-and-now with their patients. Benjamin’s theory concurs with this and
contributes, what may be, the most elemental and important quality when it comes to a
therapist’s ability to negotiate and take responsibility during negating enactments with patients:
“In effect we tell ourselves whatever we have done that has gotten us into the position of being in
the wrong is not so horribly shameful that we cannot own it. It stops being submission to the
patient’s reality because, as we free ourselves from shame and blame, the patient’s accusation no
longer persecutes us, hence we are no longer in the grip of their helplessness” (Benjamin,
2004a). Her theory speaks to and explicates the internal process that allows the therapist to
accept the less than desirable parts of themselves as a vital part of their subject-hood, even in the
face of attempted negation. “If it is no longer a matter of which person is sane, right, healthy,
knows best, or the like, and if the analyst is able to acknowledge the patient’s suffering without
stepping into the position of badness, then the intersubjective space of thirdness is restored”
(Benjamin, 2004a). It appears that one of the most essential underlying characteristics of the
therapist is faith that they will be “good enough,” that they will be able to simultaneously soothe
and hold onto their sense of self, especially when it appears impossible.
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Safran & Muran (2000) have also come to see this process as one that begins internally
for the therapist. They describe how a rupture in which the therapist feels attacked can at first
paralyze the therapist due to internal conflicts about aggressive feelings that get stirred up in the
interaction with their patient. This creates a collapse of internal space where the therapist feels
unable to act. In this model, a way out of the collapse is the therapist’s ability to “play” with the
sense of themselves that is being presented to them. That is, a la Bromberg, (1996), to be able to
try on the undesirable self-state they are being accused of without having to cave into the
patient’s reality that this is “all” that they are. This process allows the therapist to move from
internal to external, to begin to disembed from the negative interaction and find acceptance for
the less favorable parts of themselves and to begin to “say the unsayable” in the moment. Safran
(2003) reflects on this process further when he states: “At a broad level the relevant state of mind
seems to have something to do with self-acceptance . . . this state of mind seems to involve a
process of ‘letting go’ and surrendering to one’s experience, while at the same time reflecting on
it in a nonjudgmental fashion.” In many cases, this means the therapists goes first, becomes
vulnerable, and takes some responsibility for their part in the interaction, making space for their
own subjectivity as well as their patient’s.
The Experiencing Scales and Intersubjectivity:
The Experiencing Scales (Klein et al., 1986) were developed from Gendlin’s experiential
and Rogers’ client-centered theories in order, “to capture the essential quality of a client’s
involvement in psychotherapy.” Rogers and Gendlin contributed to the process theory of the
scale in unique and synergistic ways. Rogers and Gendlin’s understanding of the therapeutic
process, especially the role of the therapist evolved over time. Rogers concentrated on the idea
of focusing closely on the patient’s experience of exploration and he classified “good therapy” as
practicing a kind of patient-tracking empathy. He states that: “at a high level of accurate
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empathy the message ‘I am with you’ is unmistakably clear so that the therapist’s remarks fit the
client’s mood and content” (Rogers, 1958). Later on Gendlin modified his understanding of
client-centered therapy fairly dramatically by viewing the therapeutic interaction as much more
bi-directional, getting closer to an intersubjective understanding of the therapeutic endeavor. He
came to see that “therapeutic attitudes manifest themselves in interactive behaviors through
genuine therapist self-expression and that this open interaction itself affects the nature of the
client’s present experiencing process” (Gendlin, 1967, Mathieu & Klein, 1985). Although there
is this shift toward a two-person understanding, there remain ways that the scale’s theoretical
underpinnings differ from a developmentally intersubjective understanding of the therapeutic
encounter and therapeutic change including debate on the importance of the therapist’s
subjectivity in treatment, specifically the extent to which it should be included and explicitly
introduced with the patient. The scales authors argue for a conservative use of the therapist’s
experience and mainly see the therapist’s role as “a manner of listening in which the therapist
always strives for and responds to experiential concreteness and specificity” (Mathieu & Klein,
1985).
Despite these departures between theories, early on, both Rogers and Gendlin
foreshadowed the more recent interest in theories and research focusing on therapist variables
and characteristics. Gendlin described the therapist’s role as listening, teaching the patient to
focus, and drawing out the patient’s experience. He also was aware of the fact that two
subjectivities are at play in any therapy: “The therapist’s presence and responses as an
experiencing person have an inescapable influence on the interaction” (1967). Rogers focused
on accurate empathy and genuineness as necessary therapist variables. He measured progress in
patient’s self-awareness as “a shift from self-as-object to self-as-subject” (1958). This focus here
on both the therapist and patient indicates a two-person psychology and marks the beginnings of
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an intersubjective understanding of the therapist-patient interaction and the process of
therapeutic change.
A Modification of the Therapist Experiencing Scale: the Therapist Intersubjective
Negotiation Scale:
This section will focus specifically on how the Therapist Experiencing Scale (Klein et al.,
1986) (or TES) can be used as a measure of the developmental theories of intersubjectivity that
Safran & Muran and Benjamin construct. The Therapist Experiencing Scale’s roots are based in
Gendlin and Roger’s theories about client-focused and empathically attuned therapy. The TES is
an observer-rated coding system where therapists receive four scores for each session: Therapist
Referent Mode, Therapist Referent Peak, Therapist Manner Mode, and Therapist Manner Peak.
The scale is meant to assess how much the therapist is engaged in the patient’s immediate
experiencing of his or her own “inner felt referents.” The TES has two subscales: referent and
manner. “Referent is that aspect or level of the patient’s experiential process that is pointed by
the therapist’s words. Manner is the level of the therapist’s own experiential involvement in the
interchange” (Klein et al., 1986). The mode rating captures the overall level of the session which
is representative of the most frequent experiencing level; the peak rating is given where the
highest level of experiencing is reached, even if it is only momentary. Both referent and manner
are coded based on seven possible levels of experiencing (to be discussed in further detail
below).
As aforementioned, it is argued by Benjamin that the ability to recognize an “other” as a
separate subject is innately tied to one’s need to, in turn, be mutually recognized by that “other”
as a subject. Through two seven point subscales, the TES takes into account the therapist’s
ability to track what the patient is experiencing in the session (referent subscale) and the
therapist’s own quality of engagement during the session (manner subscale). More specifically,
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the referent subscale measures the patient’s here and now experience that is indicated by the
therapist’s speech. Referent is reflective of the patient’s process and, in essence, measures the
therapist’s ability to hold onto the patient’s subjective experience in session. The manner
subscale indicates the therapist’s experiential involvement and reflects their ability to hold their
own subjectivity in mind as well as share it empathically with the patient during the therapeutic
interaction. As the therapist increases in experiencing levels, it becomes apparent that he/she is
able to integrate both their own and the patient’s subjective reality in a co-created emergent
experience. Negotiation between both the therapist’s and the patient’s subjectivities becomes
necessary to the cyclical process of negation and recognition which one can measure as the
therapist moves from the lower levels of experiencing to higher levels of experiencing
throughout a session.
Attempting to utilize the TES to measure this theory of intersubjectivity requires an
examination of how each level of each subscale does/does not map onto Benjamin’s construct of
mutual recognition. Because the scale is not an exact match, but rather a close approximation,
some small adjustments in the understanding of each level will be employed. These changes are
believed to be small enough that one can still draw upon the few instances of past success with
this scale to boost confidence of its reliability and clinical validity (Davis & Hadiks, 1994;
Bachelor et al., 1990, to be discussed in more detail in the measures section).
The TES was re-interpreted through the lens of intersubjectivity theory; the authors began
with the TES and saw immediate potential for the scale to operationalize an intersubjective
negotiation between patient and therapist during ruptures. Each level was re-interpreted in order
to measure a therapist’s ability to regain internal space through holding both the patient’s and
their own sense of subjectivity. One explicit structural change was made to accommodate the
aims of the study. In the TES manual, Manner Level Three includes beneficial implicit
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disclosures on the therapist’s part about their experience, but for the purposes of the study,
explicit defensive disclosures were added as code-able under Manner Level Three in order to be
able to capture less productive interventions that would otherwise have to be coded Manner
Level Four or Five as far as manual-based evidence. This was done with the understanding that
there is a critical marker between Manner Level Three and Manner Level Four as far as
intersubjective negotiation. Only at Manner Level Four does the therapist explicitly become a
separate subject that the patient can utilize as a vulnerable and accessible other.
Below, find a brief comparison between the TES and the newly renamed Therapist
Intersubjective Negotiation Scale on the levels of both sub-scales with some clinical samples
from the study included for explication.
Level
TES Referent
TINS Referent
TES Manner
TINS Manner
1
T refers to event
that are external.
T’s inability to
grasp P’s
subjectivity.
T is impersonal
and detached
affectively.
T is misattuned to P or
exhibits a defensive
refusal to engage with P.
2
T focuses on
external events
related to P,
intellectual
elaboration.
T’s limited
intellectual
understanding of P,
possible emotional
distancing from P.
T’s interested
through intellectual
self referents.
T limits subjective
involvement to intellectual
or didactic interventions.
3
T focuses on P’s
reaction to
external/feelings
limited to
behavioral
description.
T’s displays a
limited grasp of P’s
subjectivity. An
implicit sense of P
as a subject.
T is reactive and
emotionally
involved.
Implicit involvement of T
as a subject (“We are
coming up against our
expectations of one
another in here.”) or
explicit defensive
disclosure of T’s
subjectivity (“I can’t be
helpful to you right now,
you make me feel
helpless.”)
4
T gives description
of P’s feelings and
personal
experiences.
T effectively and
holistically holds
P’s subjectivity In
mind.
T is empathic, T
elaborates feelings
explicitly.
T is available as a separate
subject, controlled nondefensive
acknowledgment of P’s
impact on T’s subjectivity.
(T: “Well I feel a little
stuck, so I guess I start to
feel really defensive when
you start to question things
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and I mean we haven’t
really, I guess in some
sense agreed on what the
work is between us.”
5
T offers
propositions about
P’s problems or
personal
experiences.
T not only takes in
global state but also
displays a close
observation of P’s
emerging struggles.
T uses own
feelings to explore
P’s feelings.
T is vulnerable, discloses
struggle/takes
responsibility/reestablishes
internal space. (T: Where
do you think the tension in
me is coming from? P: I
don’t know. Maybe you
are frustrated because . . . I
am not focusing on the
things you would like me
to focus on or you cannot
get control of what
direction I am going in. . .
T: Yeah, it comes from
this feeling in me of not
just being able to tolerate
being so ineffective. Not
liking that-wanting to be
sort of competent and
helpful and have you feel
that I am competent and
helpful. P: I feel like that
is your problem not mine .
. . No one wants to be
blamed for someone else’s
feelings and no one is
responsible. T: I am
responsible for these
feelings but I am also not
putting them out there to
blame you. I am putting
them out there to explore
them. P: I learned
something (laughs) . . . I
feel in here like I am really
stubborn with you
sometimes.)
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T focuses on P’s
emergent feelings
and their impact.
T’s highly tailored
grasp of P as
separate subject
with shifting states
possibly impacted
by discussion of
conflict/problem.
T uses own
emergent feelings
to affirm P’s
feelings.
T discloses how change in
P reflexively effects
change in T’s subjective
state.
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T captures P’s
facility to move
from one inner
referent to another.
T observes,
integrates P’s
new/emerging selfstates.
Expansive
integration of P
and T.
Perhaps T is able to fill in
some gaps in
understanding of
interaction using a blend
of both T and P’s
emerging subjective
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needs.
Purpose of Study:
This study assumes that the process of breakdown and repair is innate to the therapeutic
interaction and hopes to reveal how therapists’ ability/inability to hold both their own sense of
subjectivity as well as that of the patient (without retaliating or withdrawing) during rupture
events can contribute to recreating the negotiation between the two subjectivities at play in the
therapeutic relationship. Specifically this investigated 1) whether therapist’s scores on both
subscales of the Therapist Intersubjective Negotiation Scale predicted differences in outcome
groups significantly and 2) whether TINS scores were significantly related to the patient and
therapist ratings of the working alliance during rupture sessions.
Hypotheses:
It was hypothesized that both the referent subscale and the manner subscale of the TINS would
be significant predictors of patients’ change in therapy and would represent a therapist’s
ability/inability to hold intersubjective tension in mind during ruptures. The authors predicted
that peak scores would be more sensitive predictors of therapeutic change than mode scores for
both subscales. Drawing on Benjamin’s theory, intersubjective tension is not necessarily held
for long periods of time but is a finite process where breakdown is essential for growth. It is not
expected that therapists would be able to achieve mutual recognition for entire sessions (which
would be more reflective of mode scores) but rather that there would be a cyclical process of
momentary collapse and repair and that therapists' best moments could often be the most
transformative for patients (which would be more reflective of peak scores). It was also
hypothesized that achievement of intersubjective negotiation within rupture sessions would
positively and significantly correlate with ratings of the working alliance from that same session.
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Research Design:
This research utilized data from the Brief Psychotherapy Research Program at Beth Israel
Medical Center where patients are seen for short-term therapy by therapists and therapists-intraining. All of the subjects in this project were engaged in 30-session Brief Relational
Treatment (previously described). There are twenty-two dyads included in this study and each
dyad has two to three rupture sessions, selected from different times of their thirty-session
treatment. Multiple rupture sessions for each dyad were chosen in hopes of capturing a wellrounded picture of intersubjective negotiation during difficult interactions. Rupture sessions that
were chosen fell between session five and session twenty-eight for each of the dyads. This
window of time was selected with the rationale that sessions before five may be too early to
capture possible intersubjective tension/collapse and sessions after twenty-eight may confound
termination issues with what this study hoped to measure.
Each dyad’s rupture sessions were systematically matched with the other dyads, based on
data availability, in three ways to attempt to control for differences among dyads: 1) in total
number of rupture events, 2) in timing of ruptures throughout the treatment, and 3) the average
expert score given to rate validity of the rupture based on the patient’s narrative of the rupture on
a Post-Session Questionnaire (to be discussed more below). Nine of these dyads have good
therapeutic outcomes, nine have poor therapeutic outcomes, and four are prematurely terminated
cases (drops). The drop cases are only four in number based on data limitations but were
included in an exploratory hope of learning more about possible differences between outcome
groups. Outcomes of treatment are based on a rank order factor methodology for the standard
outcome battery of self-report instruments: The Symptoms Checklist 90-Revised, The Inventory
of Interpersonal Problems, Target Complaint ratings for both patient and therapist, and the
Global Assessment of Functioning. Verbatim transcripts of the rupture sessions were coded with
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the Therapist Intersubjective Negotiation Scale and each session yielded four global scores. This
research also utilized working alliance totals from patient and therapist self-report forms, which
were correlated with the levels of therapist intersubjective negotiation in the separate ruptures
events for each dyad.
Patients:
Twenty-two patients took part in this study. Inclusion criteria for patients participating included:
(1) adults between the ages of 21 and 65 years of age, (2) willingness to complete additional
assessments and be videotaped, (3) no evidence of organic brain syndrome or mental retardation,
(4) no evidence of psychosis or need for hospitalization, (5) no evidence of active substance
abuse or dependence, (6) no evidence of DSM-IV diagnosis of Bipolar Disorder, (7) no current
Axis III medical diagnosis, (8) no history of violent behavior or impulse control, (9) no evidence
of active suicidal behaviors, (10) no evidence of paranoid, schizoid, schizotypal, narcissistic, or
borderline personality disorders, (11) no use of psychotropic medication within the last year prior
to beginning treatment, (12) evidence of at least one current close relationship, and (13) no
concurrent psychotherapy. Patients are evaluated for treatment appropriateness prior to
assignment to a therapist and, upon being accepted into treatment, are asked to provide informed
consent. Patients pay a fee for treatment based on a sliding scale and their reported income level.
Patients were diagnosed by research assistants who are reliably trained to employ the SCID
interview based on DSM diagnoses (Spitzer et al., 1997).
Patients demographics were as follows: 59% were females, 41% were males, 45.4%
reported they were single, never married, 36.4% reported that they were married, 18.2% reported
that they were divorced, 18.2% were between the ages of 20-30 years old, 27.3% were between
the ages of 30-40 years old, 18.2% were between the ages of 40-50 years old, 9% were between
the ages of 60-70 years old, 13.6% reported some college education, 50% reported that they were
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college graduates, 4.5% reported that they had some post-graduate education, 31.9% reported
they had earned a graduate degree, 86% reported that they were employed, 14% reported that
they were unemployed, 77.3% reported that they were of White/Non-Hispanic origin, 4.5%
reported that they were of Hispanic origin, 13.6% reported that they were of Asian or Pacific
Islander origin, 4.5% chose not to report their race, 45.5% reported that were of no religious
tradition, 27.3% reported they were Jewish, 13.6% reported they were Catholic, 4.5% reported
they were of an “other” religious tradition, 4.5% reported they were Protestant, and 4.5% chose
not to report religion. On Axis I: 22.8% were diagnosed with Dysthymia, Primary, 18.4% were
diagnosed with V Codes, 9% were diagnosed with Major Depressive Disorder, Recurrent, 9%
were diagnosed with Major Depressive Disorder, Single Episode, 9% were diagnosed with
Depression NOS, 9% were diagnosed with Social Phobia, 4.5% were diagnosed with Dysthymia,
Secondary, 4.5% were diagnosed with a Past Major Depressive Episode, 4.5% were diagnosed
with Generalized Anxiety Disorder, 4.5% were diagnosed with Single Phobia, and 4.5% were
diagnosed with Adjustment Disorder NOS. On Axis II: 36.4% were diagnosed with Personality
Disorder NOS, 27.3% were diagnosed with Avoidant Personality Disorder, 22.8% had no
diagnosis on Axis II, 9% were diagnosed with Obsessive-Compulsive Personality Disorder, and
4.5% were diagnosed with Histrionic Personality Disorder.
Therapists:
Nineteen therapists participated in this study; three therapists carried two cases each. The
therapists included in this study were advanced doctoral psychology students and graduates of
doctoral programs in psychology and were trained in Brief Relational Therapy (BRT). Training
in BRT included both experiential and didactic tutorials including weekly group supervision
where videotaped sessions were reviewed and supervised by an expert clinician. All the
18
therapists included in this study met reliability requirements in order to qualify as compliant
BRT therapists.
The therapists demographics were as follows: 57.9% were male, 42.1% were female,
79% had earned an M.A. graduate degree, 21% had earned an Ph.D. graduate degree, 26.3%
were between the ages of 20-30 years old, 63.2% were between the ages of 30-40 years old,
10.5% were between the ages of 40-50, 73.7% had zero years of clinical experience prior to this
study, 10.5% had between 2-5 years of clinical experience prior to this study, 15.8% had
between 5-7 years clinical experience prior to this study, 84.1% reported they were of
White/Non-Hispanic origin, 5.3% reported that they were of Black/Non-Hispanic origin, 5.3%
reported that they were of “Other” origin, 5.3% declined to report their race, 31.6% reported that
they were of “Other” religious traditions, 26.3% reported that they were Jewish, 26.3% declined
to report their religious tradition, 10.5% reported that they were Protestant, 5.3% reported that
they were Protestant, 89.5% reported that they had participated in their own personal therapy,
5.3% reported that they had not participated in their own personal therapy, and 5.3% declined to
report whether or not they had participated in their own personal therapy.
Measures:
Modified Therapist Experiencing Scale (Klein et al., 1986):
The TES is an observer-rated coding system where therapists receive four scores for each
session: Therapist Referent Mode, Therapist Referent Peak, Therapist Manner Mode, and
Therapist Manner Peak. The scale is meant to assess how much the therapist is engaged in the
patient’s immediate experiencing of his or her own “inner felt referents.” The TES has two
subscales: referent and manner. “Referent is that aspect or level of the patient’s experiential
process that is pointed by the therapist’s words. Manner is the level of the therapist’s own
experiential involvement in the interchange” (Klein et al., 1986). The mode rating captures the
19
overall level of the session which is representative of the most frequent experiencing level; the
peak rating is given where the highest level of experiencing is reached, even if it is only
momentarily. Both referent and manner are coded based on seven possible levels of
experiencing (previously reviewed). The TES has not been frequently cited in the literature to
date and therefore formal reliability statistics are not available at this time but in a recent study
on the relationship between nonverbal therapist gestures and therapist experiencing, two of the
scale’s authors were able to independently achieve “near-unanimous agreement for both
‘referent’ and ‘manner’ codes on the TES” (Davis & Hadiks, 1994). In one other study, which
investigated the relationship between drop out rates and therapist/patient experiencing, Bachelor
et al. (1990) were able to train two graduate students to code TES on ninety segments of therapy
transcripts and those students achieved reliability coefficients ranging from .73 to 1.00.
Target Complaints Questionnaire (Battle et al., 1966):
The TCQ is a self-report measure developed to identify and assess patients’ presenting problems.
Patients and therapists describe and then rate identified target complaints on a Likert scale in
terms of degree of severity. Both patients and therapists rate the severity of the problems at
intake, mid-phase, and termination. This questionnaire has been found to be psychometrically
valid and reliable and the measure is scored by averaging the three reported problems to create
an overall mean score.
Symptom Checklist-90 Revised (Derogatis, 1983):
The SCL-90R is a self-report 90-item inventory that assesses general psychiatric
symptomatology in terms of experienced severity rated on a Likert scale. The scale has been
assessed with normative comparison groups and acceptable psychometric properties have been
reported. In this study the Global Severity Index (GSI) will be used, providing an overall mean
score.
20
Global Assessment Scale (Endicott et al., 1976):
The GAS is an established measure, to be rated by clinicians regarding the overall psychiatric
health and functioning of a patient. Ratings are based on a scale of 1-100, in which ‘1’
represents the lowest functioning patient and ‘100’ the highest. These ratings exist on a
continuum. Therapists are trained to a reliable standard on rating this measure.
Inventory of Interpersonal Problems (Horowitz et al., 2000):
The IIP is a self-report developed to assess an individual’s interpersonal difficulties within social
contexts. There are two versions of the IIP and both are Likert-type scales; the 64-item version
is filled out by patient while the shorter 32-item inventory is to be filled out by the therapist. The
short form was developed through a factor analysis to identify the most salient items for both
patients and clinicians. Psychometric evaluations of this measure have demonstrated normative
data as well as acceptable reliability and validity. The IIP is based on a circumplex model of
interpersonal functioning whereby control and affiliation make up the organizing axes. To
determine outcome an overall mean score of the measure’s eight subscales (Domineering,
Intrusive, Overly Nurturant, Exploitable, Nonassertive, Socially Avoidant, Cold, and Vindictive)
will be used.
The Working Alliance Inventory (Horvath & Greenberg, 1989):
The WAI is filled out by both the patient and the therapist after each session and determines the
quality of the alliance between the dyads through averaging likert scale ratings of statements
assessing the different facets of the working alliance.
Research Methods:
Rupture sessions were first identified by patients’ quantitative score of three or higher on Post
Session Questionnaires (patients rated on a seven point Likert scale the degree to which they
experienced tension in the session); patients’ qualitative statements regarding that tension were
21
then rated by three expert and independent judges in order to determine whether or not these
preliminarily chosen sessions reflected genuine therapeutic ruptures. The TES (Klein et al.,
1986) was re-intepreted though the lens of intersubjectivity at each level in order to create the
TINS. There was one direct change made to Manner Level Three in that, not only implicit
beneficial disclosures on the part of the therapist were scored (as in the TES manual) but, explicit
defensive disclosures on the part of the therapist were also made codable under Manner Level
Three in order to capture less productive interventions. Seven independent coders examined
transcripts of the rupture sessions and coded both Therapist Referent (mode and peak) and
Therapist Manner (mode and peak) on a 1-7 level scale (previously reviewed). The coders were
five masters-level psychology students, only one of whom had clinical experience as a social
worker, and two advanced doctoral students, each with 1-2 years of clinical experience. The
coders were trained by the primary author and coded practice material until they reach a .80
coefficient for reliability when compared against a modified Experiencing Training Manual
(Mathieu-Coughlan & Klein, 1984) and transcripts coded by Marjorie Klein and colleagues.
Once reliability was achieved on these materials, coders proceeded to rate transcripts from the
actual data set. They rated each therapist speech turn as long as a verbal phrase was uttered. If a
therapist’s speech turn exhibited multiple levels then coders provided multiple scores for that
turn as the level shifted. Each transcript was rated by two independent coders to ensure that
there was no rater drift between reliability checks and pairs of coders rotated every transcript on
a standard round-robin schedule. Every third cycle through the round robin, the entire group of
coders rated the same transcript independently in order to maintain a group reliability; on all of
the group reliability checks, the coders ranged from a .92 to a .97 coefficient for reliability. If
two coders’ reliability coefficient fell below the necessary .80, the primary author or another
reliable coder rated that transcript independently and the parties involved found consensus within
22
a 2-point difference of global scores, so that at least a .80 reliability was maintained. If at any
time if there had more than one instance of this rater slip within every third cycle of the round
robin, coding of the data set would have stopped and practice coding would have recommenced
until reliability conditions were again satisfied. There were two instances where consensus was
reached by a third coder independently coding the manuscript, once in the first round-robin cycle
and once in the last round robin cycle and all reliability criteria were met in order to proceed with
coding. There were four global TINS ratings for each rupture session from each dyad.
Statistical Analyses:
A factor-based rank order list of the cases, based on outcome measures, was used to differentiate
the nine good outcome cases and the nine poor outcome cases. The drop cases were defined by
patients who prematurely terminated their treatment before the 30 sessions were completed.
Due to the fact that this study utilizes dependent data (meaning there are multiple
sessions per the same case), simple ANOVA and regressions could not be calculated without
controlling for the nested data. The authors utilized a technique in Stata (StataCorp, 2009) that
corrected for clustering which employs a Huber Sandwich Correction (Huber, 1967) to get
Robust Standard Error, which is the corrected estimate. In order to examine whether the global
TINS scores could significantly predict differences between outcome groups good, poor, and
drop cases, an ANOVA-type procedure was completed that corrected for non-independence of
the data. A procedure in Stata called DESMAT was used to create a matrix of dummy variables
that represented the outcome groups and those group membership variables were then regressed
against the global TINS sub-scale of interest. This procedure not only corrected for the
dependent data but also created models that were corrected for the fewer amount of drops than
the good and poor cases. Uncorrected post-hoc SIDAK tests in Stata were also completed in
order to gain the real means of the three outcome groups on the four TINS sub-scales.
23
In order to investigate possible relationships between therapists’ ability to sustain
intersubjective tension and therapeutic alliance, the four global TINS sub-scales were correlated
with the corresponding patient and therapist-rated working alliance average from the same
rupture session. Again the Huber Sandwich Correction was employed to correct for the
dependency of the data.
Results:
Intersubjective Predictions of Differences in Outcome Groups (Based on TINS Sub-Scale Scores):
Average Level of Therapists’ Ability to Hold Patients’ Subjectivity in Mind (Referent Mode)’s Prediction of
Differences in Outcome Groups:
Outcome Group
R-squared
F
P
N
Model F-stat
Real Means
Good
.2
(2, 21)
< .01
22
6.16**
3.6
Poor
.2
(2, 21)
< .01
22
6.16**
3.09
Drop
.2
(2, 21)
< .01
22
6.16**
3
Highest Level of Therapists’ Ability to Hold Patients’ Subjectivity in Mind (Referent Peak)’s Prediction of
Differences in Outcome Groups:
Outcome Group
R-squared
F
P
N
Model F-stat
Real Means
Good
.5
(2, 21)
< .01
22
21.8**
5.27
Poor
.5
(2, 21)
< .01
22
21.8**
4.43
Drop
.5
(2, 21)
< .01
22
21.8**
4.25
Average Level of Therapists’ Ability to Hold Their Own Subjectivity in Mind (Manner Mode)’s Prediction of
Differences in Outcome Groups:
Outcome Group
Good
R-squared
.267
F
(2, 21)
P
< .01
N
22
Model F-stat
7.2**
Real Means
3.2
24
Poor
.267
(2, 21)
< .01
22
7.2**
2.84
Drop
.267
(2, 21)
< .01
22
7.2**
3
Highest Level of Therapists’ Ability to Hold Their Own Subjectivity in Mind (Manner Peak)’s Prediction of
Differences in Outcome Groups:
Outcome Group
R-squared
F
P
N
Model F-stat
Real Means
Good
.71
(2, 21)
< .01
22
67.55**
5.23
Poor
.71
(2, 21)
< .01
22
67.55**
4
Drop
.71
(2, 21)
< .01
22
67.55**
3.94
TINS Sub-Scale Scores Correlations with Patient and Therapist-Rated WAI:
Average Level of Therapists’ Ability to Hold Patients’ Subjectivity in Mind (Referent Mode)’s Correlation With
Patient and Therapist-Rated Working Alliance:
TES Sub-Scale
R-squared
R
F
P
N
Referent Mode
and PT WAI
.07
.26
(1, 21)
.12
22
Referent Mode
and TH WAI
.044
.21
(1, 21)
.13
22
Peak Level of Therapists’ Ability to Hold Patients’ Subjectivity in Mind (Referent Peak)’s Correlation with Patient
and Therapist-Rated Working Alliance:
TES Sub-Scale
R-squared
R
F
P
N
Referent Peak
and PT WAI
.065
.25
(1, 21)
.19
22
Referent Peak
and TH WAI
.1
.32*
(1, 21)
.02
22
Average Level of Therapists’ Ability to Hold Their Own Subjectivity in Mind (Manner Mode)’s Correlation with
Patient and Therapist-Rated Working Alliance:
TES Sub-Scale
R-squared
R
F
P
N
25
Manner Mode
and PT WAI
.06
.24*
(1, 21)
.023
22
Manner Mode
and TH WAI
.12
.35**
(1, 21)
.0006
22
Peak Level of Therapists’ Ability to Hold Their Own Subjectivity in Mind (Manner Peak)’s Correlation with Patient
and Therapist-Rated Working Alliance:
TES Sub-Scale
R-squared
R
F
P
N
Manner Peak
and PT WAI
.06
.24
(1, 21)
.12
22
Manner Peak
and TH WAI
.18
.42**
(1, 21)
.001
22
Discussion:
These results support the authors’ hypothesis that the therapist’s ability to negotiate therapeutic
ruptures intersubjectively would predict significant differences among outcome groups: good,
poor, and drop. It is important that both the Referent subscales and the Manner subscales were
significant predictors given that, only together, do the scales represent the therapist’s ability to
achieve mutual recognition with their patient (holding both their own and their patient’s
subjectivity in mind). This finding can be interpreted as reflective of the kind of “surrender” that
Safran and Muran (2000) discuss when reflecting on how the therapist must not only survive the
patient’s attack but go on to re-open both internal and analytic space, citing the necessity for
finding a way out of the bind and achieving “an attitude of intense curiosity about one’s inner
experience as it unfolds” (Safran, 2003). These results can also be seen as marking the
therapist’s ability to “stand in the spaces” (Bromberg, 1996) or to hold different self-states that
encompass both the patient’s fears as well as the therapist’s faith that change is still possible.
These results also may lend some credence to earlier findings that there may be intrinsic
therapist variables that vitally affect outcome regardless of training as discussed earlier. All of
26
the therapists in this study were trained on and reliable with the Brief Relational Model, which
offers special insights into negotiating ruptures and has demonstrated empirical evidence of
lower drop-out rates than Cognitive Behavioral Therapy (Muran, Safran, Samstag, & Winston,
2005) and, even with this specialized training for all therapists, results still demonstrated
significant differences among outcome groups when it came to therapists’ ability to hold
intersubjective tension with their patients. This finding speaks to Safran and Muran’s concerns
about training clinicians when dealing with negative interactions in treatment and reflects the
importance of continued focus on the therapist’s “inner growth” as a possibly essential factor in
outcome. Again reflecting Benjamin’s point that what is most essential to therapeutic change is
the therapist’s ability to accept limitations internally and simultaneously contain the patient’s
fears, metabolize the patient’s attempts at negation, and articulate an acceptance of their own
shortcomings, without losing the sense that they are “good enough,” at least momentarily.
The fact that all four subscales were significant predictors of outcome was also
interesting to the authors. It was hypothesized that, due to the nature of intersubjective tension as
momentary and cyclical, peak scores would be more sensitive predictors for both subscales.
Given the small sample of this study, it is not possible to significantly parse out which subscales
were best predictors of differences among outcome groups which unfortunately leaves this
hypothesis still unanswered. It is however notable that, although not statistically significant, the
raw data demonstrates that both peak subscales predictor models (referent and manner) had
much larger effect sizes than the mode subscale predictor models, meaning perhaps a larger
study could flesh out this hypothesis as well.
When reviewing the authors’ hypothesis that therapists’ ability to sustain mutual
recognition during ruptures would be significantly related to ratings of the working alliance, the
study yielded mixed results. The findings demonstrate that the therapist’s ratings of the working
27
alliance were moderately and significantly correlated with three of the TINS subscales (Referent
Peak, Manner Peak, and Manner Mode) and that the patient’s ratings of the working alliance
were insignificantly related to almost all of the four TINS subscales (except for one small but
significant relationship between patient working alliance and the Manner Mode subscale). This
overall difference between patient and therapist may reflect the internal aspect to intersubjective
negotiation during ruptures that might have more relationship to the therapist’s perception of
their performance and alliance than that of the patient. It makes some sense that, during sessions
where therapists were able to achieve even momentary mutual recognition, they might have felt
more bonded and aligned with their patient. It’s possible that the one significant correlation
between the patient-rated alliance and the Manner Mode subscale may reflect how the therapist’s
overall attempt at sharing their subjective experience allowed the patient to feel closer and more
aligned with them. This interpretation is interesting in light of the fact that the Experiencing
Scales’ authors caution the therapist to use their experience sparingly, reflecting the idea that
when a therapist does disclose their immediate experience to a patient, it can be jarring. In this
light the fact that only one of the four subscales correlated with the patient’s ratings of working
alliance may provide some evidence that mutual recognition is a different construct than alliance,
despite some overlap and the fact that both may contribute to better outcome. In other words,
therapeutic change may require both alliance and intermittent mutual recognition (especially
during ruptures) but they may be very different therapeutic processes, similar to differences in
constructs like empathy and intersubjectivity.
Limitations and Future Research:
Due to the small sample size of this pilot study, there are many limitations to address. The
study’s sample had little diversity in terms of race and religion, was skewed in terms of how it
was highly educated and employed, and there may have been a restriction of variance when it
28
came to the mainly neurotic-level diagnoses, all of which, makes this sample difficult to
generalize to other populations. The size of the sample also limited power so that it is not
possible to determine if the peak subscales were better predictors of outcome than the mode
subscales.
Other limitations are problems related to the design of the study including the fact that,
due to data limitations, the numbers of ruptures sessions per case were not standardized
(although this was controlled statistically), as well as, there were three therapists who had two
cases each. One shortcoming is that the sessions were coded by transcript so tonal or non-verbal
information did not contribute to coders’ understanding of patient-therapist interactions. Another
design limitation is that there are no baseline ratings of the therapists’ ability to hold
intersubjective tension. In other words, only rupture sessions were looked at due to a theoretical
argument that mutual recognition happens in the context of negotiating negative interactions but,
in future research, a baseline measured in non-rupture sessions may add to questions about other
factors that affect outcome as well as identify more about therapist variables. In this same vein,
another shortcoming of this study is that it measured mutual recognition in only one kind of
treatment modality and one that was somewhat pre-disposed to therapist experiential disclosure,
possibly limiting the variance of therapist characteristics.
Lastly, there is a structural issue
within the modified TINS scale that would need to be re-visited and revised in further studies.
Manner level three was adapted to reflect both beneficial implicit disclosures as well as more
defensive explicit disclosures on the therapist’s part with the belief that there was a critical
marker between Manner level three and four as far as the therapist becoming available as
separate subject to the patient. This reflects a shortcoming of the design in that it makes
interpreting the findings complicated due to Manner level three scores reflecting both something
positive and negative. All of the real mean averages in the good outcome groups on the two
29
Manner subscales were above 3.0, meaning the interpretation of the findings can still be seen as
valid but this complication may muddy the picture unnecessarily. In future research, perhaps
lower levels of the scale, say Manner level one or two will be further defined to capture, not only
emotional distancing but, more explicit harmful disclosures on the therapist’s part as well.
As previously discussed, there are different versions of “intersubjectivity.”
Further
research should continue to delineate these different conceptualizations as well as investigate
important divergence between terms like intersubjectivity, empathy, and alliance in order to
examine their separate contributions to therapeutic outcome and process. It is important for this
study to be replicated with a larger and more diverse sample, with different treatment modalities,
and to include non-verbal and tonal information. This larger study would hopefully gain validity
for this new operationalization of a developmental theory of intersubjectivity and further
articulate how, in the face of opposition, therapists can “negotiate their way from a state of mind
in which no possibilities for constructive therapeutic work exist to one in which internal space
reopens and new possibilities emerge” (Safran, 2003).
References
Aron, L. (1991). The patient’s experience of the analyst’s subjectivity.
Psychoanalytic Dialogues, 1, 29-51.
Aron, L. (2006). Analytic impasse and the third: Clinical implications of
Intersubjectivity theory. International Journal of Psychoanalysis, 87, 349-368.
Bachelor, A., Salame, R., Legendre, L. Marceau, G., & Morin, D. (1990). L’effect du
niveau d’experiencing du client et de l’aident sur l’abandon d’un process
therapeutique. Revue Canadienne des Sciences du Comportement, 22, 72-83.
Battle, C., Imber, S., Hoehn-Saric, R., Stone, A., Nash, E., & Frank, J. (1966). Target
complaints as criteria of improvement. American Journal of Psychotherapy, 20:
184-192.
Beebe, B. & Lachmann, F. (1992). The contribution of mother-infant mutual
30
influence to the origins of self and object representations. In N. J. Skolnick
& S.C. Warshaw (Eds.). Relational perspectives in psychoanalysis (pp. 83-118).
Hillsdale: NJ: Analytic Press.
Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism, and the problem of
domination. New York: Pantheon Books.
Benjamin, J. (1990). Recognition and destruction: An outline of intersubjectivity.
Psychoanalytic Psychology, 7, 33-47.
Benjamin, J. (1995). Like subjects, love objects: Essays on recognition and sexual
difference. New Haven: Yale University Press.
Benjamin, J. (1998). Shadow of the other: Intersubjectivity and gender in
psychoanalysis. London: Routledge, Inc.
Benjamin, J. (2002). The rhythm of recognition: Comments on the works of Louis
Sander. Psychoanalytic Dialogues, 12(1): 43-53.
Benjamin, J. (2004). Escape from the hall of mirrors: Commentary on paper by Jody
Messler Davies. Psychoanalytic Dialogues, 14(6): 743-753.
Benjamin, J. (2004a). Beyond doer and done to: An intersubjective view of thirdness.
Psychoanalytic Quarterly, 73: 5-46.
Benjamin, J. (2005). Creating an intersubjective reality: Commentary on paper by
Arnold Rothstein. Psychoanalytic Dialogues, 15: 447-457.
Benjamin, J. (2006). Two-way streets: Recognition of difference and the
intersubjective third. d i f f e r e n c e s: A Journal of Feminist Cultural
Studies, 17: 116-146.
Binder, J. L., & Strupp, H. H. (1997). Negative process: A recurrently discovered and
underestimated facet of therapeutic process and outcome in the individual
psychotherapy of adults. Clinical Psychology Science and Practice, 4: 121-139.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research, and Practice, 16: 252-260.
Bordin, E. (1994). Theory and research in the therapeutic working alliance: New directions.
In A. O. Horvath & L. S. Greenberg (Eds.). The working alliance: Theory, research,
and practice (pp. 13-37). New York: John Wiley.
Bromberg, P. M. (1996). Standing in the spaces: The multiplicity of self and the psychoanalytic
relationship. Contemporary Psychoanalysis, 32, 509-535.
Coady, N. (1991). The association between client in therapist interpersonal processes and
outcome on psychodynamic psychotherapy. Research on Social Work Process, 1, 122-
31
138.
Davis, M. & Hadiks, D. (1994). Nonverbal aspects of therapist attunement.
Journal of Clinical Psychology, 50: 393-405.
Derogatis, L. R. (1983). SCL-90R: Administration, scoring and procedures manual I.
Towson, MD: Clinical Psychiatric Research.
Foreman, F. A., & Marmar, C.R. (1985). Therapist actions that address initially poor therapeutic
alliances in psychotherapy. American Journal of Psychiatry, 142, 922-926.
Gendlin, E. T., Values and the process of experiencing. In A. R. Mahrer (Ed.), The
goals of psychotherapy. New York: Appleton-Century-Crofts, 1967.
Henry, W.P., Schacht, T.E., & Strupp, H.H. (1986). Structural analysis of social
behavior: Application to a study of interpersonal process in differential psychotherapeutic
outcome. Journal of Consulting & Clinical Psychology, 54, 27-31.
Henry, W.P., Strupp, H.H., Butler, S.F., Schacht, T.E., & Binder, J.L. (1993). Effects of
training in time-limited psychotherapy: Changes in therapist behavior. Journal of
Counseling & Clinical Psychology, 61, 434-440.
Horowitz, M., Rosenbaum, R., & Wilner, N. (1988). Role relationship dilemmas: A
potentially new process variable. Psychotherapy, 25: 241-248.
Horvath, A. O. & Greenberg, L. S. (1989). Development and validation of the working alliance
inventory. Journal of Counseling Psychology, 36, 223–233.
Horvath, A. O. & Symonds, B. D. (1991). Relation between working alliance and
outcome in psychotherapy: A meta-analysis. Journal of Counseling
Psychology, 38: 139-149.
Horvath, A. O. & Greenberg, L.S. (Eds.). (1994). The working alliance: Theory,
research, and practice. New York: Wiley.
Horvath, A. O. (1995). The therapeutic relationship: From transference to alliance.
In Session: Psychotherapy in Practice, 1, 7-18.
Huber, P.J. (1967). “The Behavior of Maximum Likelihood of Estimates under Nonstandard
Conditions,” Proceedings of the Fifth Berkeley Symposium on Mathematical
Statistics and Probability, Vol. I, pp. 221-33.
Klein, M., Mathieu, P., Gendlin, E., & Kiesler, D. J. (1970). The Experiencing Scale:
A research and training manual. Madison: Wisconsin Psychiatric Institute.
32
Klein, M. H., Mathieu-Coughlan, P., & Kiesler, D. J. (1986). The Experiencing Scales.
In L. S. Greenberg & W. M. Pinsof (Eds.). The psychotherapeutic process: A
research handbook (pp. 21-71). New York: Guilford Press.
Mathieu-Coughlan, P. & Klein, M. H. (1985). Experiential Psychotherapy: Key Events
in Client-Therapist Interaction. In L. N. Rice and L. S. Greenberg (Eds.).
Patterns of change: Intensive analysis of psychotherapy process (pp. 213-247).
New York: Guilford Press.
Mitchell, S. (1988). The intrapsychic and the interpersonal: Different theories, different
domains, or historical artifacts. Psychoanalytic Inquiry, 8: 472-496.
Mitchell, S. (1993). Hope and Dread in Psychoanalysis. Hillsdale, NJ: Analytic Press.
Mitchell, S. (1997). Influence and Autonomy in Psychoanalysis. Hillsdale, NJ: Analytic
Press.
Mitchell, S., & Aron, L. (1999). Relational Psychoanalysis: The Emergence of a
Tradition. Hillsdale, NJ: Analytic Press.
Muran, J. C. (Ed.). (2001). Self-relations in the psychotherapy process. Washington D.C.:
American Psychological Association.
Muran, J. C. & Safran, J. D. (2002). A Relational Approach to Psychotherapy. In M.
Kaslow, ed., Comprehensive Handbook of Psychotherapy. London: Oxford
Press.
Muran, J.C., Safran, J.D., Samstag, L., & Winston, A. (2005) .Evaluating an alliancefocused intervention for personality disorders. Psychotherapy: Theory, Research,
Practice, Training, 42, 532-545.
Orange, D. M., Atwood, G.E., & Stolorow, R. D. (1997). Working intersubjectively:
Contextualism in psychoanalytic practice. Hillsdale, NJ: The Analytic Press.
Piper, W. E., Azim, H., Joyce, A. S., & McCullum, M. (1991). Transference
interpretations, therapeutic alliance, and outcome in short term individual
psychotherapy. Archives of General Psychiatry, 48: 946-953.
Price, P. B. & Jones, E. E. (1998). Examining the alliance using the psychotherapy
process q-set. Psychotherapy, 35: 392-404.
Rogers, C. R. (1958). A process conception of psychotherapy. American Psychologist
13: 142-149.
Safran, J. D. & Muran, J. C. (1996). The resolution of ruptures in the therapeutic
alliance. Journal of Consulting and Clinical Psychology, 64: 447-458.
33
Safran, J. D. & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. New York: Guilford Press.
Safran, J. D., Samstag, L. W., Muran, J. C., & Stevens, S. (2001). Repairing alliance
ruptures. Psychotherapy, 38: 406-412.
Samstag, L.W. (1999). Difficult dyads and unsuccessful treatments: A comparison of
dropout, poor, and good outcome groups in brief psychotherapy. Dissertation
Abstracts International, 59, 5109.
Sander, L. (1998). The Event-Structure of Regulation in the Neonate-Caregiver
System as a Biological Background for Early Organization of Psychic
Structure. In A. Goldberg (ed.), Frontiers in self psychology. (pp 64-77)
Hillsdale, NJ: Analytic Press.
Spitzer, R. L., Williams, J. B., & Gibbons, M. (1997). Structured Clinical Interview for
DSM-III-R (SCID). New York State Psychiatric Institute, Biometrics Research.
StataCorp. 2009. Stata Statistical Software: Release II. College Station, TX: StataCorp LP.
Stern, D. N. (1985). The interpersonal world of the infant. New York: Basic Books.
Stiles, W.B. (1980). Measurement of the impact of psychotherapy sessions. Journal
of Consulting and Clinical Psychology, 48, 176-185.
Winnicott, D. W. (1971). The use of an object and relating through identifications. In:
Playing and Reality. Harmondsworth, UK: Penguin, 1974.