Countertransference types and their relation to rupture and repair in the alliance.

Background Ruptures in the alliance are co-constructed by clients and therapists, reflecting an interaction between their respective personality configurations [Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press]. In order to work effectively with ruptures, therapists should be aware of their own feeling states, acknowledging the subjectivity of their perceptions [Safran, J. D. (2002). Brief relational psychoanalytic treatment. Psychoanalytic Dialogues, 12(2), 171-195. https://doi.org/10.1080/10481881209348661]. Lack of such awareness may be a product of countertransference (CT), which has been shown to be inversely related to outcome. However, when effectively managed, CT contributes to positive outcome [Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507. https://doi.org/10.1037/pst0000189]. Objectives: The present study examined the associations between types of CT and therapists' reports of ruptures and resolutions. Method: Data were collected from 27 therapists, who treated 67 clients in yearlong psychodynamic psychotherapy. CT patterns were assessed based on therapists' Core Conflictual Relationship Themes with their parents, which were repeated in narratives about their clients [Tishby, O., & Wiseman, H. (2014). Types of countertransference dynamics and their impact on the client-therapist relationship. Psychotherapy Research, 24(3), 360-375. https://doi.org/10.1080/10503307.2014.893068]. Results: Negative CT patterns were associated with more ruptures and less resolution. Positive patterns predicted resolution when the therapists repeated positive patterns with parents, but predicted ruptures when they tried to "repair" negative patterns with the parents. These results point to the importance of therapists' awareness of their CT in order to deal effectively with ruptures and facilitate resolution.

Using dynamical systems mathematical modeling to examine the impact emotional expression on the therapeutic relationship: A demonstration across three psychotherapeutic theoretical approaches.

Objective: The purpose of this paper is to describe an approach to dynamical systems (DS) using a set of differential equations, and how an application of these equations can be used to address a critical element of the therapeutic relationship. Using APA's Three Approaches to Psychotherapy with a Female Client: The Next Generation and Three Approaches to Psychotherapy with a Male Client: The Next Generation videos, DS models were created for each of the six sessions with expert clinicians (Judith Beck, Leslie Greenberg, and Nancy McWilliams) from the three theoretical approaches. Method: A second-by-second observational coding system of the emotional exchanges of the therapists and clients was used as the data for the equations. Results: DS modeling allowed for a side-by-side comparison between the three approaches as well as between the two clients. Examining the graphs created by plotting the results of the DS equations (in particular, phase-space portraits) revealed that there were similarities among the three theoretical approaches, and there were notable differences between the two clients. Conclusions: DS modelling can provide researchers and clinicians with a powerful tool to investigate the complex phenomenon that is psychotherapy.

Changes in the level of personality functioning in inpatient psychotherapy.

Background: The model of Operationalized Psychodynamic Diagnosis and the model of Personality Organization influenced the concept of the Level of Personality Functioning (LPF) in DSM-V. The LPF is becoming a key variable for diagnostics, treatment and outcome measurement, but there are few studies which integrate the LPF in the study design. This study pursues to expand this body of knowledge by investigating the research question: would an inpatient psychotherapy lead to significant improvements in the LPF? Methods: The study included 156 inpatients at the Psychiatric Hospital Münsterlingen, Switzerland. Exclusion criteria were aggression, psychosis, mental retardation, and participation in another study. The LPF was measured with the Operationalized Psychodynamic Diagnosis-Structure Questionnaire (OPD-SQ) and the short version of the Inventory of Personality Organization (IPO-16) at admission and termination of treatment about eleven weeks later. A repeated-measures ANOVA controlled for age, symptom load, treatment duration and gender was conducted. Results: Data revealed significant, medium improvements for OPD-SQ (F(2,88) = 8.24, p < .01, ηp2 = 0.09) and IPO-16 (F(2,91) = 6.09, p < .05, ηp2 = 0.06) between admission and termination of psychotherapy and a different change pattern for OPD-SQ and IPO-16. Conclusion: Inpatient psychotherapy is associated with improvements in LPF.

Predictors and moderators of treatment dropout in cognitive-behavioral and psychodynamic therapies for panic disorder.

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients.Trial registration: ClinicalTrials.gov identifier: NCT00353470.

Dropout from mentalization-based group treatment for adolescents with borderline personality features: A qualitative study.

Objective: Premature termination, or dropout, is a major concern in psychotherapy in general and an issue of particular importance in treatments for borderline personality disorder (BPD). Yet few studies investigating dropout from therapy in adolescent BPD populations exist. This study investigates reasons for dropping out from group-based mentalization-based treatment (MBT-G) for BPD or borderline features in an adolescent population.Method: Ten semi-structured interviews were performed with female adolescents who had dropped out from group-based MBT for BPD. The data were analyzed qualitatively using Systematic Text Condensation.Results: The results point to the existence of a subgroup of adolescent BPD patients who do not perceive the treatment sufficiently helpful or worthwhile, who experienced treatment as emotionally demanding, time-consuming and connected with unpleasant experiences. Positive reasons for early termination were reported in the form of experienced improvement in condition. Dropping out became understood as a process of weighing perceived benefits against perceived costs of staying in treatment. This understanding of dropout as a process implies the existence of a window of time where intervention to prevent dropout is possible, presupposing the detection of at-risk patients.

Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents.

Objective: Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression. Method: The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated. Results: A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d = 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72). Conclusions: The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

Validation of computerized reflective function: A replication study.

Objective: The Reflective Function (RF) Scale is the original validated measure of mentalizing, applied to Adult Attachment Interview (AAI) transcripts. This study aimed to replicate the preliminary validation of Computerized RF (CRF), a computerized text analysis measure of RF.Methods: 49 women with borderline personality disorder (BPD; n = 20) and without (n = 29) completed diagnostic interviews and the AAI. AAIs were scored by certified coders using the RF Scale, and by computerized text analysis software using CRF dictionaries.Results: CRF significantly correlated with RF. The frequency of High CRF words had moderate-to-strong correlations with RF in the total sample (rs = .47), BPD group (rs = .61), and non-BPD group (rs = .41). Adding the frequency of Low CRF words to create a proportion of High and Low CRF words, and applying CRF to AAIs trimmed to include only items that "demand" RF, both produced significant, but not stronger, correlations with RF.Conclusion: CRF is an efficient alternative to the RF Scale that can estimate mentalization. Near average levels, neither RF nor CRF significantly differentiated between groups, indicating mentalizing deficits may not always be present, detectable, or defining in BPD samples. While more research is needed, CRF is a valid assessment of RF when codable text is available.

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning.

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.

Change processes underlying "good outcome": A qualitative study on recovered and improved patients' experiences in psychotherapy for major depression.

Aim: Exploring change processes underlying "good outcome" in psychotherapy for major depression. We examined the perspectives of patients who "recovered" and "improved" (Jacobson & Truax) following time-limited CBT and PDT. Method: In the context of an RCT on the treatment of major depression, patients were selected based on their pre-post outcome scores on the BDI-II: we selected 28 patients who recovered and 19 who improved in terms of depressive symptoms. A grounded theory analysis was conducted on post-therapy client change interviews, resulting in an integrative conceptual model. Results: According to recovered and improved patients, change follows from an interaction between therapy, therapist, patient, and extra-therapeutic context. Both helping and hindering influences were mentioned within all four influencing factors. Differences between recovered and improved patients point at the role of patients' agency and patients' internal and external obstacles. However, patients marked as "improved" described heterogeneous experiences. CBT- and PDT-specific experiences were also observed, although our findings suggest the possible role of therapist-related influences. Conclusion: From patients' perspectives, various change processes underlie "good outcome" that do not necessarily imply an "all good process". This supports a holistic, multidimensional conceptualization of change processes in psychotherapy and calls for more fine-grained mixed-methods process-outcome research.

Development and validation of the Gestalt Therapy Fidelity Scale.

Objective: Three studies were conducted to develop and validate the Gestalt Therapy Fidelity Scale (GTFS), a 21-item measure of treatment adherence for Gestalt Therapy (GT).Method: Thirty five items for possible inclusion in the GTFS were generated on the basis of a literature review. In Study 1, a Delphi methodology consulting 63 international GT experts was used to select items for the GTFS. In Study 2, six experts used the scale to rate video-based sessions of GT, and provided feedback on the usability of the scale. In Study 3, 176 participants from 18 countries used the GTFS to rate GT and not-GT video recorded sessions.Results: The Delphi study consensus method resulted in 25 items for consideration in the GTFS. The scoring system and items were subsequently revised following further feedback from experts (Study 2). The GTFS was found to significantly discriminate between GT and not-GT based sessions (Study 3): raters scored GT sessions significantly higher than not-GT sessions. High levels of internal and inter-rater reliability were found.Conclusion: The GTFS is supported as a psychometrically sound measure of treatment adherence for GT, and hence can be used to assess the degree to which therapists are administering GT.

Early treatment response in psychotherapy for depression and personality disorder: links with core conflictual relationship themes.

Objective: Depressed personality disorder patients showing an early rapid response (or sudden gain) in psychotherapy have better outcomes. Early responders are five times more likely to recover, despite equivalent ratings of working alliance. We explored core conflictual relationship themes (CCRTs) of early responders compared to others to further elucidate process-outcome links. Method: Patients (N = 20) with diagnosed major depression and personality disorder received 16 weeks of psychodynamic therapy. Early response was defined as a 50% reduction in Beck Depression Inventory symptoms during the first six sessions. Transcripts of therapy session three for early responders (n = 10) and others (n = 10) were analyzed using the CCRT Leipzig/Ulm method, identifying 728 components scored by two independent judges. Results: Relationship narratives showed CCRT-wish satisfaction was lower for those not having an early response, for both CCRT "Response of Other" and "Response of Self" components. These patients told narratives of others as more unreliable, aggressive, and less supportive, with less feelings of being loved and a lower experience of being self-determined. Conclusions: Specific negative relationship patterns may inhibit the ability to benefit from both therapy and extra-therapy relationships, contributing to a slower treatment response.

Differential effects of alliance and techniques on Panic-Specific Reflective Function and misinterpretation of bodily sensations in two treatments for panic.

ABSTRACTObjective: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. Method: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT. Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. Results: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. Conclusion: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.

Enhancement of self compassion in psychotherapy: The role of therapists' interventions.

Aim: Self Compassion (SC) has been consistently linked to decreased emotional distress and is offered as a mechanism of change in several therapeutic approaches. The current study aimed to identify therapists' interventions that enhance clients' SC within individual psychodynamic psychotherapy. We examined a diverse set of interventions as predictors of clients' SC, on treatment and session levels. We hypothesized that improvement in SC will be associated with greater use of directive or common factor interventions. Method: Client/therapist (N = 89) dyads from a university-based community clinic participated in the study. Therapists' interventions and changes in clients' SC level were monitored at each psychotherapy session. Results: Clients' SC in a given session was not predicted by therapist use of interventions from any of the three clusters in the previous session. However, positive change in SC across treatment was predicted by greater use of directive interventions. Furthermore, among clients with low pretreatment SC, a positive change in SC across treatment was predicted by lesser use of common factor interventions. Discussion: The results highlight the importance of understanding clients' pretreatment characteristics when selecting therapeutic interventions and suggest that the integration of directive interventions into the psychodynamic therapeutic practice may be beneficial in enhancing clients' SC.

"It was hard work every session": Therapists' view of successful psychoanalytic treatments.

OBJECTIVE: To explore therapists' experiences of the therapeutic process in successful cases of psychoanalytic psychotherapy. METHOD: A two-stage, mixed-method design was used. Sixteen successful cases were drawn from a sample of 92 young adults in psychoanalytic psychotherapy according to Jacobson's criteria for reliable and clinically significant improvement. Therapist interviews at baseline and termination were analyzed applying Inductive Thematic Analysis. RESULTS: Three core themes emerged: Being Particularly Motivated to be This Patient's Therapist, Maintaining a Safe and Attentive Therapeutic Position, and Assiduous Work Every Session. The therapists experienced positive feelings towards the patient from the outset of treatment and described active, relational work that included paying attention to incongruities in the patient's self-presentation and being mindful of patient's avoidant behavior. The therapist's motivation and attentive position made it possible to balance support and challenge in the therapeutic relationship. CONCLUSIONS: Successful therapeutic work presupposes positive expectations, an active therapeutic stance and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads. Clinical or methodological significance of this article: Our study indicates several factors that seem to characterize therapist expertise and can inform psychotherapy training. Successful therapeutic work presupposes positive expectations, an active therapeutic stance, courage to challenge the patient, and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.

Changing character: A narrative review of personality change in psychotherapies for personality disorder.

Objective: Personality disorder (PD) is a negative prognostic indicator for treatment, and absolute improvements in functioning among these patients are often modest. This may be because personality features that give rise to dysfunction in PD are not targeted optimally during most treatments. Method: Attachment, mentalization, core beliefs, and personality organization/defense use were identified as personality constructs that have been pursued in treatment studies and that are proposed to underlie PD. Results: All constructs correlate with psychiatric symptoms, PD diagnosis, and functioning. Defense mechanisms and core beliefs further distinguish specific PDs, whereas personality organization separates more versus less severe PDs. Evidence from treatment and naturalistic studies indicate that maturation of defense mechanisms temporally precedes improvements in symptoms and functioning. Changes in attachment and mentalization correlate with some outcomes, but mediation of improvement has not been established. In psychodynamic therapy, transference interpretations may promote amelioration of personality dysfunction. With the exception of attachment, the experimental literature is lacking that could explicate the mechanisms by which these personality constructs maintain psychosocial dysfunction. Conclusions: Future research should aim to identify changes in these mechanisms that mediate positive outcomes in PD, as well as the specific therapeutic procedures that best promote positive change in PD.

"It was like having half of the patient in therapy": Therapists of nonimproved patients looking back on their work.

Objective: To explore therapists' experiences of therapeutic process in psychoanalytic psychotherapy with nonimproved young adults. Method: Eight nonimproved cases were identified according to the criterion of reliable and clinically significant change in self-rated symptoms. Transcripts of therapist interviews (8 at baseline and 8 at termination) were analyzed applying grounded-theory methodology. Results: A tentative conceptual process model was constructed around the core category Having Half of the Patient in Therapy. Initially, the therapists experienced collaboration as stimulating, at the same time as the therapeutic relationship was marked by distance. At termination negative processes predominated: the patient reacted with aversion to closeness and the therapist experienced struggle and loss of control in therapy. The therapists described therapy outcome as favorable in form of increased insight and mitigated problems, while core problems remained. Conclusions: This split picture was interpreted as a sign of a pseudo-process emerging when the therapist one-sidedly allied herself with the patient's capable and seemingly well-functioning parts. The therapists' experiences could be compared to the nonimproved patients' "spinning one's wheels" in therapy. The therapists seem not to have succeeded in adjusting their technique to their patients' core problems, despite attempts to meta-communicate.

Juggling thoughts and feelings: How do female patients with borderline symptomology and substance use disorder experience change in mentalization-based treatment?

OBJECTIVE: The aim of this study was to explore the experience of central psychological change processes for female patients with borderline symptomology and substance use disorder in mentalization-based treatment. METHOD: Semi-structured qualitative interviews on experiences from mentalization-based treatment with 13 participants were conducted. The interview material was analysed within a hermeneutical-phenomenological epistemology, with emphasis on researcher reflexivity. RESULTS: The following themes regarding central psychological change processes were found: "by feeling the feeling," "by thinking things through," "by walking in your shoes to see myself" and "by stepping outside of own bad feelings in seeing you." Two of these themes dealt with intra-psychic modes of how to relate to own mind-states. First, they had a shift from avoiding emotions into tolerating emotions. Second, they discovered the ability to think mental states through. Two themes dealt with mental stances for dealing with interpersonal situations, where one mode included a self-reflective stance in difficult encounters, and the other mode entailed an empathic reflective stance by exploring others' intentionality. CONCLUSIONS: The findings are in line with theoretical assumptions that increasing mentalizing capacity is a central change process for these patients. Furthermore, the findings demonstrate the complex interaction between different modes of mentalizing. Clinical or methodological significance of this article: The article explores change processes in manualized psychotherapy for patients with comorbid borderline personality disorder and substance use disorder, a focus which is not researched in the clinical literature. We claim that putting attention to this patient group and investigating their potential in psychotherapy is of clinical significance. Methodologically, this article utilizes thematic analyses within an epistemology following a specific procedure that is step based and transparent, thus it is of interest for qualitative researchers who also utilize thematic analyses.

Moderators in psychotherapy meta-analysis.

Psychotherapy meta-analyses sometimes generate heterogeneous results, partially due to key methodological characteristics which vary between studies (e.g., psychotherapy conditions are contrasted with structurally different control conditions). Examining these potential moderator variables can help explain heterogeneous results within and between psychotherapy meta-analyses. The present manuscript provides an overview of moderators that are highly relevant to test the generalizability of effects across psychotherapy trials. These moderators mainly fall into one of the following groups: (a) structural equivalence of interventions, (b) preferences/allegiances, (c) therapist effects, and (d) sample representativeness. Individual moderators include: Bona fide psychotherapy, proximity to psychological interventions, psychotherapy orientation, pre-training of therapists, supervision, caseload of therapists, dosage, homework, patient preferences, researcher and therapist allegiance, therapist effects in nested designs, aspects of sample representativeness, multiple outcomes, and time of assessment. Our analysis of 15 psychotherapy meta-analyses published in 2016 suggests that the structural equivalence of psychotherapeutic conditions, patient and therapist preferences/allegiances, therapist effects and nested data structures as well as sample representativeness were often neglected and little-discussed as potential moderators. The manuscript describes further conceptual and methodological challenges when conducting moderator analyses such as the categorization of psychological treatments and the importance of interrater coding. We encourage meta-analysts to consider moderators which have previously shown utility in explaining heterogeneous results in the psychotherapy literature. Clinical or methodological significance of this article: Relevant moderator variables help explain heterogeneous results in psychotherapy meta-analyses. Though these variables are often overlooked, they should be regularly incorporated in meta-analyses.

"If those tears could talk, what would they say?" Multi-method analysis of a corrective experience in brief dynamic therapy.

We analyzed master theorist/therapist Hanna Levenson's six-session work with "Ann" in American Psychological Association's Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist's and client's own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann's "same old story"; the frequency, type, and depth of immediacy; and the client's and therapist's behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson's session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client's corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to "bring down the wall"-by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson's suggestion to risk behaving more authentically with a friend and with her romantic partner.

Responding to mentalization invitations in psychotherapy sessions-A conversation analysis approach.

OBJECTIVE: Increase in the capacity to mentalize has been proposed to be an important mechanism of change in psychotherapy. However, mentalization has primarily been studied as an individual skill that people either possess or lack, rather than as an interactional phenomenon. METHOD: In this study, excerpts from three different sessions in a therapy that aimed at increasing the patients mentalizing capacity were identified and studied using conversation analysis. RESULTS: The analysis indicated that resistance to mentalizing may not only be due to lack of capacity but also may be seen as a linguistic resource in which this resistance demonstrates precisely the ability to mentalize. CONCLUSIONS: Consequences for psychotherapy practice and process research are discussed.