Re-learning from teaching: a personal reflection on Jeremy Safran's legacy.

Jeremy Safran's pedagogical style was singular in its emphasis on experiential learning through role-plays, use of session video recordings, and his full-hearted embrace of therapists' subjectivity as a tool for therapeutic change. This paper is a personal reflection on the author's experiences as Jeremy Safran's student and how they have translated into her own teaching and supervision. She shares how teaching has been a means of reconnecting with her experiences learning from Jeremy, and the ways in which she tries to carry forward his unique contributions to the next generation of students and trainees.

Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process.

Objective: In this paper, we test the reliability and validity of two novel ways of assessing mentalizing in the therapy context: the Reflective Functioning scale (RF) applied to code psychotherapy transcripts (In-session RF), and the Exploring scale of the Patient Attachment Coding System (PACS), which measures in-session autonomy and is linked with secure attachment in psychotherapy. Method: Before treatment, 160 patients in different types of psychotherapy and from three different countries were administered the Adult Attachment Interview (AAI), which was rated with the RF scale. One early psychotherapy session for each patient was independently rated with the In-session RF scale and with the PACS Exploring scale. Results: Both scales were found to be reliable and to have concurrent validity with the RF scale rated on the AAI, with the PACS Exploring scale found to be a better predictor of RF on the AAI. Conclusions: These results suggest that the PACS Exploring scale might be a practical method for assessing RF in psychotherapy research and a way for researchers and clinicians to track patients' RF on an ongoing basis. These results also provide information regarding the ways in which differences in RF manifest during psychotherapy sessions. Clinical or methodological significance of this article Researchers and clinicians can assess patients' mentalizing based on any single psychotherapy transcript, in many therapeutic modalities The Exploring scale of the Patient Attachment Coding System can yield a reliable measure of reflective functioning based on any single psychotherapy transcript, in many therapeutic modalities Client differences in mentalizing manifest in part independently of the therapist's contributions.

Resolving Alliance Ruptures from an Attachment-Informed Perspective.

In this article, we examine how the different attachment patterns enable or hinder the resolution of ruptures in the therapeutic alliance. We try to show that secure and insecure patients alike may experience ruptures in the therapeutic alliance, but that their ability to participate in resolving such ruptures differ markedly. Recent findings with the Patient Attachment Coding System (PACS) show that attachment classifications manifest in psychotherapy as distinct ways of communicating about present internal experience. Secure patients disclose their present experience openly and invite attunement from the therapist, while insecure patients either minimize their contributions to the dialogue (avoidant) or the contributions of the therapist (preoccupied). Using examples from session transcripts, we demonstrate how secure patients are particularly responsive to resolution strategies that focus on here-and-now experience, while insecure patients' characteristic ways of communicating pose significant challenges to the resolution process.

Assessing Attachment in Psychotherapy: Validation of the Patient Attachment Coding System (PACS).

The authors present and validate the Patient Attachment Coding System (PACS), a transcript-based instrument that assesses clients' in-session attachment based on any session of psychotherapy, in multiple treatment modalities. One-hundred and sixty clients in different types of psychotherapy (cognitive-behavioural, cognitive-behavioural-enhanced, psychodynamic, relational, supportive) and from three different countries were administered the Adult Attachment Interview (AAI) prior to treatment, and one session for each client was rated with the PACS by independent coders. Results indicate strong inter-rater reliability, and high convergent validity of the PACS scales and classifications with the AAI. These results present the PACS as a practical alternative to the AAI in psychotherapy research and suggest that clinicians using the PACS can assess clients' attachment status on an ongoing basis by monitoring clients' verbal activity. These results also provide information regarding the ways in which differences in attachment status play out in therapy sessions and further the study of attachment in psychotherapy from a pre-treatment client factor to a process variable. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The Patient Attachment Coding System is a valid measure of attachment that can classify clients' attachment based on any single psychotherapy transcript, in many therapeutic modalities Client differences in attachment manifest in part independently of the therapist's contributions Client adult attachment patterns are likely to affect psychotherapeutic processes.

AAI predicts patients' in-session interpersonal behavior and discourse: a "move to the level of the relation" for attachment-informed psychotherapy research.

There is currently little empirical evidence regarding how patients' attachment patterns manifest in individual psychotherapy. This study compared the in-session discourse of patients classified secure, dismissing, and preoccupied on the Adult Attachment Interview (AAI). Rather than focusing on content or form alone, this study analyzed how patients' discourse elicits and maintains emotional proximity with the therapist. The AAI was administered to 56 patients prior to treatment and one session for each patient was rated with the Patient Attachment Coding System (PACS) by four independent raters, blind to patients' AAI classification. Significant differences were found in the discourse of patients with different attachment patterns. Namely, secure and preoccupied patients showed more contact-seeking behavior than dismissing patients, who avoided emotional proximity more, while preoccupied patients resisted therapists' help more than did secure and dismissing patients. These results suggest that the different attachment patterns may have distinctive manifestations in the psychotherapy process that can be tracked by external observers.

The in-session discourse of unresolved/disorganized psychotherapy patients: An exploratory study of an attachment classification.

The Unresolved/disorganized (U/d) attachment classification has generated considerable interest among clinicians. This is in part based on its empirical associations with adult mental health, parenting practices, and treatment outcomes. Despite decades of theorizing, however, we have little empirical information regarding how patients with a U/d classification assigned by accredited coders actually behave or speak in psychotherapy sessions. Here, we take a step towards bridging this gap by reporting our observations of the psychotherapy session transcripts of 40 outpatients who were independently classified as U/d on the Adult Attachment Interview (AAI), the gold standard measure of adult attachment research. These patients were extracted from a larger sample of 181 and compared to others without a U/d classification. In this paper, we discuss two different discourse styles associated with a U/d classification. Some U/d patients did not seem to sufficiently elicit the therapist's endorsement of what they said. For example, they did not justify their claims with examples or explanations, or did not consider others' intentions or experiences. Other U/d patients were credible, but left the listener uncertain as to the underlying point of their discourse, for example, by glaringly omitting the consequences of their experiences, or interrupting their narratives mid-way. In the discussion, we place these observations in the context of recent thinking on attachment and epistemic trust, and discuss how this study may form the basis for future quantitative studies of psychotherapy.

An exploratory study on how attachment classifications manifest in group psychotherapy.

Recently, attachment-informed researchers and clinicians have begun to show that attachment theory offers a useful framework for exploring group psychotherapy. However, it remains unclear whether patients with differing attachment classifications would behave and speak in distinct ways in group therapy sessions. In this study, we conducted an exploratory analysis of the discourse of patients in group therapy who had independently received different classifications with gold standard interview measures of attachment in adults. Each patient participant attended one of three mentalization-based parenting groups. Before treatment, the Adult Attachment Interview (AAI) or the Parent Development Interview (PDI) were administered to each patient, and interviews were transcribed and coded to obtain the patient's attachment classification. Groups included 2, 5, and 5 patients, respectively, and any session was led by at least two co-therapists. A total of 14 group sessions were transcribed verbatim. Sessions were analysed through a semi-inductive method, in order to identify markers that would typify patients of different attachment classifications in session. Through transcript excerpts and narrative descriptions, we report on the differing ways in which patients of different attachment classifications communicate in group psychotherapy, with the therapist and with each other. Our work provides useful information for group therapists and researchers regarding how differences in attachment status may play out in group sessions.

Advances in research on attachment-related psychotherapy processes: seven teaching points for trainees and supervisors.

While the rich body of attachment theory and research has inspired many psychotherapists, trainees and less experienced clinicians interested in attachment-informed work can often feel unsure about what processes are attachment-related and how to attend to them during therapy. Recent advances in attachment-informed psychotherapy research offer some practical guidance. Studies published over the last five years show that patients and therapists of different attachment classifications communicate in distinct ways during therapy sessions. In particular, Talia and his colleagues have introduced the Patient Attachment Coding System and the Therapist Attunement Scales, two measures that accurately predict patients' and therapists' Adult Attachment Interview and Reflective Functioning score based on the occurrence of distinct communication markers during therapy sessions. This paper discusses the implications of these recent studies for psychotherapy training and presents seven teaching points for supervisors and for the next generation of clinicians.

Patients' Adult Attachment Interview classification and their experience of the therapeutic relationship: are they associated?

In the last decade of his career, Jeremy Safran became increasingly interested in investigating the ways in which attachment representations influence the therapeutic relationship. In this paper, we test such influence in a sample of thirty outpatients who received Brief Relational Therapy by comparing their independently coded pre-treatment Adult Attachment Interview (AAI) with their narratives in a post-treatment interview about the relationship with the therapist (the Patient Relationship Interview at Termination, PRI-T). The PRI-T was coded with the following three measures: i) The Patient Attachment to Therapist Rating Scale (PAT-RS), which assesses the quality of the patient's attachment relationship to the therapist; ii) the Coherence scale from the AAI, adapted for use on the PRI-T; and iii) the Patient Attachment Classification System (PACS), which measures generalized differences in how individuals convey their experiences and feelings. Results suggest that patients' AAI predicts how they experience, represent, and communicate about the therapeutic relationship at the end of treatment, as shown by the PAT-RS, the Coherence scale adapted for use on the PRI-T, and the PACS applied to the PRI-T. These findings lend support to Safran and others' hypothesis that patients' AAI-status plays a role in patients' representations of the relationship with the therapist.