Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 22, 83–95 (2015)

Published online 29 October 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1875

Practitioner Report
The Relation between Prototypical Processes and
Psychological Distress in Psychodynamic Therapy
of Five Inpatients with Borderline Personality
Disorder
Geoff Goodman,1* Keiha Edwards1 and Hyewon Chung2
1
Clinical Psychology Doctoral Program, Long Island University, Brookville, NY, USA
2
Department of Education, Chungnam National University, Daejeon, Korea

Five inpatients with borderline personality disorder (BPD) participated in 6 months of three times per
week psychodynamic therapy (PDT). Patients completed a measure of psychological distress every
week. A total of 127 sessions were audiotaped and coded using the psychotherapy process Q-set
(PQS) and correlated with PQS prototypes of five treatment models—PDT, cognitive-behaviour therapy
(CBT), interpersonal therapy, transference focused psychotherapy and dialectical behaviour therapy.
Prototypical CBT process was most prevalent in three of the five PDT-labelled treatments. Prototypical
PDT process significantly decreased over time in three of the five treatments. Prototypical process
correlations with time were inversely proportional to prototypical process correlations with distress
levels. In a multiple regression model that included all five prototypical process correlations across
these three treatments, CBT and transference focused psychotherapy predicted distress reduction,
whereas PDT predicted increases in distress. PQS items most negatively correlated with distress
included the therapist’s emphasis on feelings, empathic attunement and control over the interaction.
Discussion of dreams or fantasies and therapist aloofness were most positively correlated with distress.
An effective PDT treatment model for severely disturbed BPD inpatients requires technical flexibility
to supplement CBT processes such as control over the interaction that can structure intense
interpersonal dysregulation and stabilize distress. Copyright © 2013 John Wiley & Sons, Ltd.

Key Practitioner Message:

• Practitioners and their patients sense which prototypical processes to increase or decrease over time to
reduce patients’ distress.
• An effective PDT treatment model for severely disturbed BPD patients needs to integrate and encourage the
emergence of empathically attuned interactions in the context of a highly structured therapy experience.
• Practitioners need to be flexible enough to change intervention strategies when they seem to be increasing
distress in severely disturbed BPD patients.

Keywords: psychiatric hospitalization, psychotherapeutic processes, treatment outcomes, treatment proto-

types, naturalistic study

While many treatment models exist to treat patients
diagnosed with borderline personality disorder (BPD), the
identification of effective intervention strategies, regardless
of treatment model, has received comparatively less
attention, especially for psychiatrically hospitalized BPD
patients. Mentalization-based treatment (Bateman & Fonagy,
*Correspondence to: Geoff Goodman, Ph.D., Clinical Psychology
Doctoral Program, Long Island University, 720 Northern Blvd.,
Brookville, NY 11548, USA.
E-mail: ggoodman@liu.edu
2004b), transference focused psychotherapy (TFP; Clarkin,
Yeomans, & Kernberg, 2006), dialectical behaviour therapy
(DBT; Linehan, 1993) and schema-focused therapy (Young,
Klosko, & Weishaar, 2003) are all specifically designed for
BPD patients in once or twice per week outpatient treatment.
One of the reasons for this lack of interest in treating BPD
inpatients is the cost of psychiatric inpatient treatment:
managed care companies are more likely to pay for day
treatment and outpatient programmes (Sharfstein, 1992;
Tischler, 1990). Research on the effectiveness of treatment
for BPD inpatients has been similarly lacking. The literature

Copyright © 2013 John Wiley & Sons, Ltd.

84
that does exist has yielded inconsistent recommendations.
For example, Silk and his colleagues (Silk et al., 1994) have
argued in favour of a focused, time-limited approach to
treating BPD inpatients that includes cognitive-behaviour
therapy (CBT) strategies that serve to structure the patient’s
experience and thereby stabilize the crisis. To the best of our
knowledge, however, there is no empirical support for this
model. On the other hand, in a naturalistic study of
inpatients diagnosed with BPD and post-traumatic stress
disorder, trauma-focused psychodynamic therapy (PDT)
was associated with improvements in trauma-specific
symptoms, general psychiatric symptoms, frequency of
self-mutilating behaviour and number of hospitalizations
during the 1-year follow-up period (Sachsse, Vogel, &
Leichsenring, 2006).
In the absence of a consensus from the literature
advocating a particular treatment model, one might
consider an assimilative psychodynamic psychotherapy
(Gold & Stricker, 2001; Stricker & Gold, 1996, 2005).
Assimilative psychodynamic psychotherapy is one of
several attempts at combining therapeutic techniques
across theoretical orientations. Messer (1992, 2001)
defined ‘assimilative integration’ as ‘the incorporation of
attitudes, perspectives or techniques from an auxiliary
therapy into a therapist’s primary, grounding approach’
(Messer, 2001, p. 1).
Assimilative psychodynamic psychotherapy (Stricker &
Gold, 1996, p. 50) is organized into three tiers: overt
behaviour (Tier 1), conscious cognition, affect, perception
and sensation (Tier 2), and unconscious mental processes,
motives, conflicts, images and representations of signifi-
cant others (Tier 3). According to this approach,
techniques of many treatment approaches are used from
time to time as determined by the patient’s ongoing
psychological needs. These different techniques ultimately
serve a psychodynamic conceptualization of treatment
and accomplish the twin therapeutic goals of symptom
reduction and personality integration.
The therapist’s skill is then used in part to evaluate the
treatment phase in which the use of a particular technique
would be helpful in achieving these goals. The criteria that
the therapist needs to consider in his or her decision
making include the patient’s ‘level of suffering and ability
to tolerate that suffering, capacity to delay gratification,
and his or her psychological sophistication and interest
in self-understanding’ (Stricker & Gold, 2005, p. 225).
Considering these criteria in beginning treatment with
BPD inpatients, Stricker and Gold (2005) recommended
an active treatment model such as CBT because it ‘allows
more fragile or volatile patients…to experience early
success in therapy’ (p. 225). According to the authors, this
treatment approach, used in the beginning phase with
these patients, contributes to improved self-esteem, an
expanded sense of competence and a perception of the
therapist as a benign, positive and helpful presence. Later
Copyright © 2013 John Wiley & Sons, Ltd.
G. Goodman et al.
in the treatment, after stabilization has occurred, the
therapist can ‘move gradually toward psychodynamic
work as the patient improves’ (p. 225). For these patients
at this beginning stage of treatment, therefore, therapeutic
success comes from conducting clinical work at Tier 1 and
Tier 2, which gradually yields to clinical work on a deeper
level at Tier 3. The current study represents a preliminary
attempt to test this model with five BPD inpatients.
With the proliferation of randomized controlled clinical
trials (RCTs) to evaluate treatment outcomes, psychother-
apy process researchers, who study the interactions
between therapists and patients, have raised questions
about the therapeutic ingredients of manualized treatment
models (Ablon, Levy, & Katzenstein, 2006; Goodman,
2010). Effective psychotherapy process sometimes has
little to do with the treatment model the therapist
purports to be using (Ablon & Jones, 1998, 1999, 2002;
Jones & Pulos, 1993). Even therapists participating in
RCTs can be engaged in a therapeutic process outside
the parameters of their manualized treatment model. For
example, Ablon and Jones (1998) asked experts in PDT
and CBT to rate the 100 items of the psychotherapy
process Q-set (PQS) to reflect the ideal psychotherapy pro-
cess from their particular theoretical orientation, yielding
two composited prototypical Q-sorts of PDT process and
CBT process. None of the 20 most characteristic items of
each theoretical orientation overlapped. Ablon and Jones
(1998) then applied these two PQS prototypes to their
examination of three archival psychotherapy data sets
and found that the CBT process did not predict positive
symptomatic treatment outcome, whereas PDT process
did predict positive symptomatic treatment outcome, in
both PDT and CBT treatments.
In a later study (Ablon & Jones, 2002), the CBT proto-
type was positively correlated with a prototype of inter-
personal therapy (IPT). Six of the 20 most characteristic
items of each theoretical orientation overlapped. Recently,
Goodman (2013) developed prototypes for two additional
manualized treatment models specifically designed for
BPD patients—TFP and DBT—and found that both treat-
ment models were positively correlated with PDT (for val-
idation of these prototypes, see Goodman, 2013).
In the current study, the PQS prototypes of PDT, CBT,
IPT, TFP and DBT were applied to the PDT sessions of five
BPD patients on a psychiatric inpatient unit. Are prototyp-
ical processes associated with any of these treatment
models effective in reducing the distress of BPD
inpatients? On the basis of the literature (Stricker & Gold,
2005), it would be expected that in this early phase of
inpatient treatment, prototypical CBT process might be
more helpful than prototypical PDT process, even though
the therapy offered on this inpatient unit is supposedly
PDT-based.
In summary, to the best of our knowledge, the psycho-
therapy process of BPD inpatients treated with PDT has
Clin. Psychol. Psychother. 22, 83–95 (2015)
Prototypical Processes and Psychological Distress
never been studied. The current study used the PQS to
correlate interactions between two PDT-supervised thera-
pists and two reliably diagnosed BPD inpatients with five
session prototypes and then to correlate these prototypical
process scores with weekly patient-reported psychological
distress levels. The goal was to identify effective interven-
tion strategies that therapists could incorporate into their
clinical work to decrease psychological distress in severely
disturbed BPD outpatients in crisis. Process and outcome
data are presented from the treatments of five BPD
inpatients who participated in approximately 6 months
of three times per week PDT.
Six hypotheses were formulated: (1) BPD inpatients
would experience improvement in levels of psychological
distress (tested using a series of Pearson correlations); (2)
prototypical process scores would vary within and be-
tween therapist–patient dyads over time (tested using a se-
ries of Pearson correlations and by visual inspection); (3)
prototypical process scores would be significantly corre-
lated with distress levels (tested using a series of Pearson
correlations); (4) consistent with the nature of this inpatient
unit, prototypical PDT process would be more prevalent
than prototypical processes associated with four other
treatment models (by visual inspection); (5) consistent with
Stricker and Gold (2005), prototypical CBT process would
be predictive of distress levels over and above the others
(tested using a multiple regression analysis); and (6) in an
exploratory analysis, some PQS items regardless of PQS
prototypes would be negatively correlated with distress
levels (tested using a series of Pearson correlations). These
hypotheses were tested in the following naturalistic,
quantitative single-case research study with five cases.
METHOD
Participants
Experts
The role of the experts in this study was to rate the 100
PQS items to reflect the ideal psychotherapy process from
their particular theoretical orientation. All experts in this
study were approached and selected because of their
nationally recognized expertise in PDT, CBT, IPT, TFP or
DBT. Each expert had published work concerning his or
her domain. TFP and DBT experts were either known to
the author or referred to the author by other nationally rec-
ognized experts. Regarding the credentials of the three TFP
experts, all three experts were practicing TFP therapists. All
three experts had also completed many years of training
under Otto Kernberg and his clinical supervision team.
Regarding the credentials of the three DBT experts, all three
experts were certified DBT trainers, personally trained and
clinically supervised by Marsha Linehan and now training
other DBT therapists (Goodman, 2013). The 32 experts
Copyright © 2013 John Wiley & Sons, Ltd.
85
representing the other three treatment models (i.e., PDT,
CBT and IPT) were similarly approached and selected by
Ablon and Jones (1998, 2002).
Therapists
Three of the four participating therapists (for patients 1–3)
were completing post-doctoral fellowship or residency train-
ing programmes and were receiving weekly clinical PDT
supervision on their psychotherapy cases admitted to an
inpatient unit dedicated to the psychodynamic treatment
of patients diagnosed with BPD. The fourth therapist treated
patients 4 and 5. He was one of the clinical PDT supervisors
of trainees on this inpatient unit (although he did not super-
vise the other three therapists). All four therapists were
approached to participate after one of their patients was
already enrolled in the study. No therapist refused to
participate. The therapists of patients 1 and 3 were women,
whereas the therapists of patients 2, 4 and 5 were men.
Patients
The patients were five women diagnosed with BPD who
were admitted to this inpatient unit in crisis and undergo-
ing intensive treatment. All patients satisfied criteria for
BPD as evaluated by senior-level psychologists at
admission, using the Structured Clinical Interview for
Personality Disorders (SCID-II; Spitzer, Williams, &
Gibbon, 1987). All patients were also evaluated by
senior-level psychologists for comorbid axis I disorders
at admission, independently of axis II disorders, using
the SCID-patient version (SCID-P; Spitzer, Williams, &
Gibbon, 1990). All five patients had been admitted to this
unit because they posed grave danger to their own safety.
All five patients experienced painful childhoods with
neglectful, unprotective or abusive caregivers. Brief,
appropriately disguised descriptions of each patient are
provided below.
Patient 1 was a 26-year-old, single, college-educated
Caucasian woman with no prior psychiatric hospitaliza-
tions. She was diagnosed with major depressive disorder
on Axis I and BPD on Axis II, according to her hospital
records. She was taking medication for depression. She
was on disability at the time of admission. Patient 1 had
made three suicide attempts, including one that precipi-
tated her hospitalization.
Patient 2 was a 31-year-old, divorced, college-educated
Caucasian woman with six prior psychiatric hospitaliza-
tions. She was diagnosed with bipolar disorder, anorexia
nervosa and bulimia nervosa on Axis I and BPD on Axis
II, according to her hospital records. She was taking
medication for bipolar disorder. She was unemployed at
the time of admission. Patient 2 had made six suicide
attempts, including one that precipitated her current
hospitalization and engaged in sexual promiscuity and
Clin. Psychol. Psychother. 22, 83–95 (2015)
86
drug and alcohol abuse. Notably, she had experienced the
abrupt termination of her treatment by several previous
therapists. She had a history of severe self-destructive
behaviour and complained of inner deadness. Patient 2
also was reportedly sexually abused as a child by her
parents and a neighbour.
Patient 3 was a 29-year-old, single, college-educated
Caucasian woman with five prior psychiatric hospitaliza-
tions. She was diagnosed with dysthymic disorder,
obsessive-compulsive disorder, alcohol dependence and
cocaine dependence on Axis I and BPD on Axis II,
according to her hospital records. She was taking medica-
tion for depression. Patient 3 had made numerous suicide
attempts and gestures, which precipitated her current hos-
pitalization. She also engaged in self-mutilation. Patient 3
also was reportedly sexually abused as a child by a sibling.
Patient 4 was a 35-year-old, single Caucasian woman
who had completed 2 years of college. She had five prior
psychiatric hospitalizations. She was diagnosed with
bipolar disorder on Axis I and BPD on Axis II, according
to her hospital records. She was taking medication for
bipolar disorder. She was unemployed at the time of
admission. Patient 4 had made numerous suicide
attempts, including one that precipitated her current
hospitalization and engaged in self-mutilation and drug
and alcohol abuse. Notably, she had undergone many
trials of electroconvulsive shock treatment. She reportedly
physically attacked family members. She reported brief
auditory and visual hallucinations. At the end of the
study, Patient 4 terminated her hospital treatment against
medical advice because, according to hospital records, she
became aware that her family was adapting to life without
her. She was permitted to leave the hospital because she
no longer posed an acute suicide risk.
Patient 5 was a 41-year-old, married, college-educated
Caucasian woman with 17 prior psychiatric hospitalizations.
She was diagnosed with major depressive disorder on axis I
and BPD on axis II, according to her hospital records. She
was taking medication for depression. She was a teaching
assistant at the time of admission. Patient 5 had made
numerous suicide attempts, including one that precipitated
her current hospitalization. Notably, Patient 5 reported a
long history of sexual and physical abuse perpetrated by a
family member and a neighbour during childhood. She
was reportedly raped multiple times as an adult. She also
reported brief auditory and visual hallucinations.
It is noteworthy that the five inpatients enrolled in this
study were typical of BPD patients treated on this psychi-
atric unit. The enormous number of prior hospitalizations
for BPD patients was well within the mean of 5.45
reported by Hull, Yeomans, Clarkin, Li, and Goodman
(1996), as well as the presence and number of comorbid
Axis I disorders reported by Goodman and his colleagues
(Goodman, Hull, Clarkin, & Yeomans, 1998).
Copyright © 2013 John Wiley & Sons, Ltd.
G. Goodman et al.
Treatment
All five patients were treated in three times per week
individual PDT. The four therapists were trained and
supervised to practice a manualized PDT that focuses on
the clarification, confrontation and interpretation of trans-
ference on an inpatient unit founded by a prominent
psychoanalyst who treats BPD patients (Kernberg, Selzer,
Koenigsberg, Carr, & Appelbaum, 1989). This treatment
manual (Kernberg et al., 1989) defines the predecessor of
what would later become TFP. The current TFP treatment
manual (Clarkin et al., 2006) is much more explicit in its
treatment description and intervention strategies.
No adherence checks were conducted. The treatment
regimen consisted of PDT in combination with an inten-
sive milieu programme that included a weekly group for
the entire psychiatric unit, a weekly team meeting
consisting of seven or eight patients and weekly voca-
tional and activity groups that all patients attended. These
treatment components were designed to help patients
examine their interpersonal relationships and develop
job opportunities upon discharge. Multimodal treatment
regimens are typical of inpatient treatment settings for
severely disturbed patients.
Measures
Psychotherapy Process Q-Set
The PQS (Jones, 2000) is a 100-item instrument that
assesses the processes of therapeutic change within an
entire audiotaped or videotaped 45-min psychotherapy
session. All 100 PQS items are sorted into nine piles in a
forced-choice (ipsative) procedure ranging from most
uncharacteristic (pile 1) to most characteristic (pile 9) of
the session being rated. This ipsative procedure forces
raters to place items in a normal distribution that charac-
terizes both the high and low ends of a construct. Approx-
imately one-third of the PQS items were designed to
capture aspects of the therapist’s actions and attitudes,
one-third designed to capture aspects of the patient’s
attitude and behaviour or experience and one-third
designed to capture aspects of the interaction of the
therapist–patient dyad or the climate or atmosphere of
the encounter (Jones, 2000).
The PQS items were selected from the psychotherapy
literature and from leading experts to cover psychotherapy
processes found in a wide variety of theoretical orienta-
tions, including cognitive-behavioural, psychodynamic,
gestalt, humanistic/existential, interpersonal and rational-
emotive (Ablon & Jones, 1998, 1999, 2002; Jones, Cumming,
& Horowitz, 1988; Jones, Hall, & Parke, 1991; Jones &
Pulos, 1993). Every item was constructed to cover a unique
aspect of psychotherapy process not duplicated by any
other item and to guarantee maximum variability across
sessions and across patients. The reliability and validity of
the PQS have been demonstrated across a variety of
Clin. Psychol. Psychother. 22, 83–95 (2015)
Prototypical Processes and Psychological Distress
archived treatment samples (Ablon & Jones, 1998, 1999,
2002; Jones et al., 1988; Jones et al., 1991; Jones & Pulos,
1993). Mean intraclass correlations (ICCs) have ranged
between 0.73 and 0.89 per rater pair across samples (Ablon
et al., 2006; Goodman, 2010). Reliability analyses for indi-
vidual PQS items have also ranged between 0.50 and 0.95
across samples (Ablon et al., 2006). Construct and discrimi-
nant validity has also been demonstrated across samples
(Jones et al., 1988; Jones et al., 1991; Jones, Krupnick, &
Kerig, 1987; Jones & Pulos, 1993).
Structured Clinical Interview for Personality Disorders
(SCID-II) and SCID-Patient Version
The SCID-II (Spitzer et al., 1987) semistructured
interview was used to confirm the diagnosis of BPD
(Clarkin, Hull, & Hurt, 1993). Two senior-level psycholo-
gists independently evaluated the patients’ audiotaped
responses and assigned scores for the BPD criteria.
Interrater agreement for BPD on the basis of this rating
system was 100%. The SCID-patient version (SCID-P)
(Spitzer et al., 1990) semistructured interview was used
to establish comorbid Axis I diagnoses (Clarkin et al.,
1993). Adequate reliability and validity data are presented
in the SCID-II (Spitzer et al., 1987) and SCID-P (Spitzer
et al., 1990) manuals.
Symptom Checklist-90-Revised
The measure of weekly symptoms used in this study was
the symptom checklist-90-revised (SCL-90-R; Derogatis,
1983). The SCL-90-R is a self-report symptom checklist in
which patients are asked to rate the severity of 90 symptoms
over the previous week, using a 5-point Likert-type Scale
(0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit;
4 = extremely). This assessment takes 12–15 min to adminis-
ter and is organized into 10 scales: somatization, obsessive-
compulsive, interpersonal sensitivity, depression, anxiety,
hostility, phobic anxiety, paranoid ideation, psychoticism
and the Global Severity Index (GSI). Test–retest reliability
coefficients for all scales have ranged between 0.80 and
0.90 (Derogatis, 1983).
Because the GSI was designed to assess overall
psychological distress, it was the only symptom measure
used in this study. Weekly GSI scores comprised the
dependent variable. Mean Cronbach’s alpha coefficient
of the GSI in this sample was 0.67.
Procedure
The expert raters used a common vocabulary of 100 PQS
items to characterize prototypical psychotherapy process
in an ideally conducted session from their theoretical
perspective. Expert raters were contacted by email and
Copyright © 2013 John Wiley & Sons, Ltd.
87
requested to sort the 100 PQS items relevant to psycho-
therapy process—as they see this process occurring within a
prototypical psychotherapy session from their theoretical
perspective (i.e., PDT, CBT, IPT, TFP or DBT process).
Expert raters provided their prototypical PQS ratings on
the basis of their understanding of an ideally conducted
session rather than an actual recorded session; they were
given extensive instructions on how to rate these items
and were encouraged to contact the investigator with
any questions. Expert raters were paid honoraria for their
participation in this Institutional Review Board-approved
study. Expert raters’ prototypical PQS ratings within each
treatment model were composited by adding all the
ratings and dividing by the number of experts and used
in all statistical analyses, yielding five session prototypes.
Stuart Ablon provided the composited prototypical PQS
ratings of the PDT, CBT and IPT treatment models.
Patients were approached consecutively to participate in
a study of the effectiveness of psychotherapy for patients
diagnosed with BPD. Eight patients were approached;
patient recruitment was closed after five patients had
agreed to participate. For the purposes of this study,
patients were contacted 1 to 2 weeks after admission—after
their adjustment to the unit and completion of an extensive
psychiatric evaluation that lasted three to six sessions (for
additional details, see Goodman et al., 1998). All patients
signed informed consent forms and consented to have
their sessions audiotaped. At this time, patients were
administered the SCID-II and SCID-P to obtain Axis I and
Axis II diagnoses. Patients 2 and 4 refused to complete
the SCL-90-R.
Data collection took place during the first 6 months of hos-
pitalization. The length of stay varied according to the
patients’ rate of symptom remission and the social worker’s
ability to make adequate discharge plans. Every session was
audiotaped, but only every third session was transcribed
verbatim and coded—typically the final session of each
week. Patients completed the SCL-90-R at this session.
Financial limits prevented transcription of all sessions. Every
third session was selected for transcription because the
researchers wanted a representation of treatment from
every week to have evenly spaced data points. Patient 1
was audiotaped and transcribed for 23 sessions (out of
the total 69 sessions), patient 2 for 31 sessions (out of the
total 93 sessions), patient 3 for 21 sessions (out of the total
63 sessions), patient 4 for 32 sessions (out of the total 96
sessions) and patient 5 for 20 sessions (out of the total
60 sessions).
Two teams, each consisting of two clinical psychology
doctoral students, coded verbatim transcriptions of all
127 sessions of the five patients enrolled in this study
using the PQS. Thus, two coders coded every transcrip-
tion independently of each other. The four doctoral
students were given extensive training on coding prac-
tice sessions using the PQS until all coders’ interrater
Clin. Psychol. Psychother. 22, 83–95 (2015)
88 G. Goodman et al.

Table 1. Cross-classified random effects modelling results for the five prototypical process scores as individual outcome variables

PDT CBT IPT

p p
Fixed Effect Coefficient SE T ratio value Coefficient SE T ratio value Coefficient SE

Mean initial status 0.139 0.018 7.766 <0.001 0.256 0.028 8.993 <0.001 0.139 0.018
Mean growth rate !0.004 0.003 !1.493 0.138 0.001 0.002 0.330 0.742 !0.001 0.002
Random Effect Variance df χ2 p value Variance df χ2 p value Variance df
component component component
Initial status, b00j 0.012 4 26.903 <0.001 <0.001 4 4.463 0.347 <0.001 4
Growth rate, b10j <0.001 4 10.568 0.031 <0.001 4 6.498 0.164 <0.001 4
Therapist effect, c00k <0.001 3 2.959 >0.500 <0.001 3 4.729 0.191 <0.001 3
Level-1 error, eijk 0.022 0.026 0.011

PDT = psychodynamic therapy. CBT = cognitive-behaviour therapy. IPT = interpersonal therapy. TFP = transference focused psychotherapy. DBT =
dialectical behaviour therapy. SE = standard error.

reliabilities among themselves were sufficiently high
(i.e., mean ICC ≥ 0.70) to begin coding the current
sample. Doctoral students were aware of the five
patients’ primary diagnosis of BPD but were blind to
all other information about the patients and therapists.
Doctoral students were trained to code the transcrip-
tions in front of them on the basis of the verbal
exchanges recorded in each transcription, not on any
prior theoretical ideas or clinical or personal experiences.
Throughout the duration of the coding process, weekly
coding team meetings were held to go over discrepant
PQS items to improve coding accuracy and to prevent
interrater drift. As coding team leader, the first author also
consulted with Stuart Ablon on a regular basis during this
process whenever questions arose within the teams
regarding coding specific items. Sessions from all five
patients were randomly assigned to these two coding
teams in random order. Thus, session 19 from patient 5
might be coded 1 week, and then session 6 from patient
2 might be coded the following week. The mean ICC
between each pair of coder ratings aggregated across all
127 sessions was 0.73 (range: 0.52–0.87). A mean reliability
of 0.73 exceeds the generally acceptable criterion of 0.70
used to determine acceptable reliability in psychotherapy
process and outcome research (Orlinsky & Howard,
1986). Fleiss and his colleagues (Fleiss, 1981; Fleiss &
Cohen, 1973; Shrout & Fleiss, 1979) would interpret
the magnitude of the range of ICC values as good
to excellent.
Each pair of coder ratings was composited by adding
the two ratings and dividing by 2. These 127 composited
PQS ratings of psychotherapy process were used to
calculate prototypical process scores—the Pearson
correlation coefficients between each of the five
composited PQS prototypical Q-sort ratings and the
127 composited PQS ratings. Higher correlations
indicate greater prevalence of that treatment model’s
prototypical process.
Data Analysis: Psychotherapy Process Q-Set
Prototype Process Scores (Cross-Classified Random
Effects Modelling)
The data were structured with assessment time points
(measured in weeks) cross-classified by patients and
therapists (Raudenbush & Bryk, 2002). Prior to descriptive
analyses, a cross-classified random effects (CCRE) model
was used to test the hierarchical and cross-classified
structure of the data. CCRE models uniquely test such
structures, and the HCM2 model program (Scientific
Software International, Inc., Skokie, Illinois, USA) within
HLM software (Raudenbush, Bryk, Cheong, Congdon, &
du Toit, 2004) was used to conduct these analyses.
With this knowledge of the multiple weeks nested within
patients and therapists, creation of the cross-classified
models for the data was the next step. The model would
consist of multiple time points cross-classified by patients
and therapists. Thus, an unconditional CCRE model was
created, with each of the five sets of PQS prototypical
process scores as individual outcome variables.
Table 1 summarizes the results for the five sets of PQS
prototypical process scores using CCRE modelling. As
seen in Table 1, no statistically significant variance was
found between therapists and patients. The location of
variation revealed that the majority of the variance
occurred between repeated measures (see PDT prototypi-
cal process scores), indicating that neither therapists nor
patients were affecting individual growth variably.
RESULTS
Hypothesis 1: Distress Levels over Time
Three of the five patients in this study completed the
SCL-90-R every week. The GSI (a measure of psycholog-
ical distress) from the SCL-90-R was used as the outcome

Copyright © 2013 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 22, 83–95 (2015)
Prototypical Processes and Psychological Distress 89
Table 1. (Continued)

IPT TFP DBT

T ratio p value Coefficient SE T ratio p value Coefficient SE T ratio p value

7.766 <0.001 0.260 0.050 5.160 <0.001 !0.062 0.013 !4.902 <0.001
!0.400 0.689 !0.003 0.002 !2.133 0.035 0.001 0.001 0.732 0.466

χ2 p value Variance component df χ2 p value Variance component df χ2 p value

2.063 >0.500 0.010 4 23.229 <0.001 <0.001 4 8.367 0.078
4.799 0.308 <0.001 4 3.022 >0.500 <0.001 4 8.057 0.088
3.402 0.334 <0.001 3 4.174 0.242 <0.001 3 3.089 0.379
0.019 0.005

measure (Figure 1). The GSI scores were correlated with
time measured in weeks. Cohen’s (1992) d effect sizes based
on these Pearson correlations are reported in Table 2. A
negative effect size indicates that distress decreased over
time. All three patients (designated patient 1, patient 3 and
patient 5) demonstrated a medium effect size in distress
reduction. Patient 5, the most symptomatically disturbed
of the three patients, showed the most dramatic improve-
ment, followed by patient 3 and Patient 1.
Hypotheses 2 and 3: Psychotherapy Process Q-Set
Prototypical Process Scores and Distress Levels
over Time
Each of the five sets of 127 PQS prototypical process
scores was correlated with weeks and the GSI scores.
The prototypical process scores were significantly corre-
lated with both time and distress levels (Table 2).
Figure 2 indicates the various contributions that each
prototypical process made to the treatment of each of the
five patients. Visual inspection of Figure 2 suggests that
the constellation of prototypical process scores uniquely
characterizes the psychotherapy process of each of these
five treatments. No two treatments appear similar to each
other. To underscore these differences in the magnitude of
these prototypical process scores across treatments, it
should be pointed out that prototypical PDT process was
most prevalent in patient 2’s treatment but least prevalent
in patient 4’s treatment. Although the means of the first four
sets of prototypical process scores are generally in the
positive range, the DBT prototypical process scores are
always in the negative range. Prototypical DBT process
was the least prevalent prototypical process measured.
Hypothesis 4: Prevalence of Prototypical
Psychodynamic Therapy Process
Interestingly, prototypical CBT process was most preva-
lent in three of the five PDT-labelled treatments (Figure 2).
Prototypical PDT process was most prevalent in only one
treatment (Figure 2) and significantly decreased over time
in three of the five treatments (Table 2).
Hypothesis 5: Predictors of Distress Levels within and
across Treatments
The five sets of PQS prototypical process scores were
entered as predictors of distress levels into three multiple
regression models with time as a control variable within
each of the three treatments with distress data available
(i.e., 1, 3 and 5). Patient 1’s regression model was not
significant. Time was significant for patient 3’s
(β = !0.74, p < 0.01) and patient 5’s (β = !0.78, p < 0.05)
treatments. None of the five sets of prototypical process
scores were significant.
The five sets of prototypical process scores were
entered as predictors of distress levels in a multiple
regression model with time as a control variable
across all three treatments with distress data available (i.e.,
64 sessions). This model accounted for 37% of the variance
(F[6, 57] = 5.47, p < 0.001), with significant effects for
time (β = !0.26, p < 0.05), prototypical PDT process (β = 0.51,
p < 0.05), prototypical CBT process (β = !0.65, p < 0.001)
and prototypical TFP process (β = !0.84, p < 0.001).
Thus, prototypical PDT process predicted increases in
distress, whereas prototypical CBT and TFP process
predicted decreases.
Hypothesis 6: Psychotherapy Processes Significantly
Correlated with Distress Levels
In an exploratory analysis, the 100 PQS items, regardless
of PQS prototypes, were correlated with the GSI scores.
Table 3 lists the mean pile numbers of the most and least
characteristic PQS items for all five patients over 127
sessions. Table 4 lists the eight PQS items significantly
correlated with distress levels at p < 0.001 (after a
Bonferroni correction was applied to control for type I

Copyright © 2013 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 22, 83–95 (2015)
90 G. Goodman et al.

Figure 1. Plot of SCL-90-R GSI Scores by Weeks in Treatment

Figure 2. Five Mean Prototypical Ratings for each Patient

Table 2. Effect sizes of prototypical process scores and distress correlated with distress levels. Two PQS items positively
levels over time correlated with distress levels were the therapist’s aloof-
Weeks PDT CBT IPT TFP DBT
ness (item 9) and the discussion of dreams or fantasies
(item 90). The only PQS item that appeared in both this
Patient 1 table and the table of most characteristic items over the
Weeks — !1.11** 0.48 !0.18 !0.76* !0.39 127 sessions (Table 3) had to do with the therapist’s show
SCL-90-R !1.03** 0.43 !0.26 0.63* 0.22 0.55* of interest in the patient (item 31).
Patient 2
Weeks — 0.74* 0.60* !0.04 !0.20 0.46
SCL-90-R — — — — — —
Patient 3
DISCUSSION
Weeks — !0.53* 0.43 0.49 !0.23 !0.73* This study demonstrated that severely disturbed BPD
SCL-90-R !1.73** 0.76* !0.45 !0.20 0.66* 0.03 inpatients can respond to intensive PDT over a 6-month
Patient 4 period, which supports the first hypothesis. The PQS
Weeks — !0.45 !0.31 !0.61* !0.34 !0.07 prototypical process scores also varied within and be-
SCL-90-R — — — — — — tween therapist-patient dyads over time, thus supporting
Patient 5 the second hypothesis. The magnitude of the five prototypi-
Weeks — !0.53* !0.60* 0.22 !0.80** 0.80** cal process scores gave each therapeutic dyad its own
SCL-90-R !2.05** 0.49 0.23 !0.29 0.70* !0.38 unique shape.
*Cohen’s (1992)d ≥ absolute value of 0.50 (medium effect size). Who is responsible for the unique shape of these
**Cohen’s (1992)d ≥ absolute value of 0.80 (large effect size). treatments—the therapist or the patient? Because the same
PDT = psychodynamic therapy. CBT = cognitive-behaviour therapy. IPT = therapist treated both patient 4 and patient 5, any differ-
interpersonal therapy. TFP = transference focused psychotherapy. DBT =
dialectical behaviour therapy. SCL-90-R = symptom checklist-90-revised. ences between these two treatments in the constellation of
prototypical process scores would implicate the patient’s
characteristics (or the unique reciprocal interaction between
errors associated with conducting 100 statistical tests). The the patient’s characteristics and the therapist’s characteris-
PQS item most negatively correlated with distress levels tics) as the driving force behind these differences. When
was the therapist’s emphasizing the patient’s feelings the therapist was held constant, the constellation of
(item 81), whereas the second most negatively correlated prototypical process scores across these two patients
PQS item with distress levels was the therapist’s actively nevertheless varied (Figure 2). In truth, the therapist’s
exerting control over the dyadic interaction (item 17). different responses to these two patients could have just
Therapist clarification (item 65) was also negatively as significantly originated in different aspects of his

Copyright © 2013 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 22, 83–95 (2015)
Prototypical Processes and Psychological Distress 91

Table 3. Most and least characteristic psychotherapy process Table 4. Significant correlations between psychotherapy process
Q-set items for 127-session sample Q-set items and symptom checklist-90-revised Global Severity Index

Mean Item # PQS item r

PQS # Most characteristic items over 127 sessions Pile #
81 Therapist emphasizes patient’s feelings !0.59
88 Patient brings up significant 7.37 in order to help him/her experience
issues and material them more deeply
69 Patient’s current or recent 7.34 17 Therapist actively exerts control over !0.57
life situation is emphasized the interaction
31a Therapist asks for more information 7.24 6 Therapist is sensitive to the patient’s !0.54
or elaboration feelings, attuned to the patient; empathic
46 Therapist communicates with patient 6.97 65 Therapist clarifies, restates or rephrases !0.49
in a clear, coherent style patient’s communication
23 Dialogue has a specific focus 6.91 28 Therapist accurately perceives the !0.45
86 Therapist is confident or 6.89 therapeutic process
self-assured (versus uncertain or defensive) 31 Therapist asks for more information !0.43
35 Self-image is a focus of discussion 6.87 or elaboration
63 Patient’s interpersonal relationships 6.87 90 Patient’s dreams or fantasies are discussed 0.44
are a major theme 9 Therapist is distant, aloof 0.52
12 Silences occur during the hour 6.74 (versus responsive and affectively involved)
26 Patient experiences discomforting or 6.73
painful affect p < 0.001. Bonferroni correction applied.
PQS = psychotherapy process Q-set.
Least characteristic items over 127 sessions
16 There is discussion of body functions, 3.76
physical symptoms, health reciprocal: a particular prototypical process causes changes
2 Therapist draws attention to patient’s 3.80
in patient distress levels, which in turn cause changes in a
nonverbal behaviour
11 Sexual feelings and experiences are discussed 3.90 prototypical process, which in turn causes changes in
100 Therapist draws connections 3.91 distress levels. Time-series analysis could provide greater
between the therapeutic relationship evidentiary weight in settling the direction of causality.
and other relationships Contrary to the fourth hypothesis, prototypical CBT pro-
87 Patient is controlling 3.95 cess was most prevalent in treatments 1, 4 and 5, whereas
24 Therapist’s emotional conflicts 3.98 prototypical PDT process was most prevalent only in
intrude into relationship
57 Therapist explains rationale behind t 4.00 treatment 2 and significantly decreased over time in treat-
echnique or approach to treatment ments 1, 3 and 5. A plausible explanation for these PDT
10 Patient seeks greater intimacy with therapist 4.04 therapists’ extensive use of CBT interventions is that they
a
realized that prototypical CBT process early in treatment
PQS item 31 is also listed as one of the eght most significantly correlated
items with the SCL-90-R GSI (Table 4).
facilitated building the therapeutic alliance, stabilized the
PQS = psychotherapy process Q-set. patients’ symptoms and was paving the way for later
‘bread-and-butter’ PDT interventions (e.g., questioning of
the patients’ views of herself and the therapist, exploring
the therapeutic relationship) after discharge to an outpatient
own personality, elicited by each patient’s different setting (Stricker & Gold, 2005). Perhaps, the treatment of
interaction pattern. severely disturbed BPD patients requires the temporary
The prototypical process scores were significantly use of more supportive CBT processes early in recovery
correlated with distress levels, thus supporting the third (i.e., tiers 1 and 2) that serve the treatment goals of
hypothesis. The magnitude of prototypical process scores alliance-building and stabilization before more ambitious
also varied over time (Table 2). The pattern of findings treatment models (i.e., tier 3) are attempted. Patients need
suggests that prototypical process correlations with time to feel secure enough after the crisis has passed to explore
were inversely proportional to prototypical process the contents of their own minds. It is possible that
correlations with distress levels. Prototypical process scores prototypical CBT process implemented within a CBT-
positively correlated with time were negativelycorrelated labelled treatment model might yield different results on
with distress levels and vice versa. The therapeutic dyad the basis of a difference in the ‘therapeutic background’
sensed which prototypical processes to increase or decrease created by the use of a different treatment model. A
over time to reduce the patient’s distress. hypothesis regarding the contextualization of treatment
Ultimately, whether changes in prototypical process strategies could be tested by comparing correlations
cause changes in distress levels or vice versa is not known. between prototypical processes and outcomes among
It is quite plausible that these change processes are differently labelled treatment models.

Copyright © 2013 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 22, 83–95 (2015)
92
Consistent with Stricker and Gold (2005) and in support
of the fifth hypothesis, prototypical CBT process predicted
distress reduction over and above the others. In the
three treatments with distress data available, prototypical
PDT process decreased over time and simultaneously
predicted increased distress over and above the others.
Quite plausibly, these therapists used fewer PDT
interventions over time because they learned that making
these technical adjustments—away from PDT—would
reduce their patients’ distress and facilitate alliance-building
and stabilization.
The fact that these patients improved with prototypical
CBT process in their sessions further supports the
hypothesis that these PDT-trained and supervised therapists
were being sensitive to what seemed to be working to
ameliorate their patients’ distress. It is noteworthy that the
PQS items that assess therapist confrontation (item 99),
transference interpretation (items 92, 98 and 100), defence
interpretation (item 36) and patient insight (item 32)—
important PDT interventions—were not significantly
correlated with distress levels.
Consistent with the sixth hypothesis, eight PQS items
were significantly correlated with distress levels, p < 0.001,
in the three treatments with distress data available. Only
one PQS item characteristic of prototypical PDT process
(Ablon & Jones, 1998, p. 75)—the therapist’s sensitivity to
the patient’s feelings (item 6)—was significantly correlated
with distress reduction. One PQS item also characteristic of
prototypical PDT process—the discussion of the patient’s
dreams or fantasies (item 90)—was significantly correlated
with increases in distress. On the other hand, three PQS
items characteristic of prototypical CBT process (Ablon &
Jones, 1998, p. 76)—the therapist actively exerts control
over the interaction (item 17), the therapist’s accurate
perception of the therapeutic process (item 28) and the ther-
apist asks for more information or elaboration (item 31)—
were significantly correlated with distress reduction.
No PQS items characteristic of prototypical CBT process
were significantly correlated with increases in distress.
These findings suggest that the prototypical treatment
model for severely disturbed BPD inpatients includes a
highly structured therapy experience in which the therapist
accurately perceives the therapeutic process through
eliciting elaboration (but not exploring dreams or fantasies),
as well as an acute sensitivity to the patient’s feelings,
emphasizing empathic attunement rather than confron-
tation or transference interpretation.
Bateman and Fonagy (2004b) suggested that TFP—a
BPD treatment model that prescribes therapist confronta-
tion and transference interpretation (Clarkin et al., 2006)
—expects too much agentive thinking from the patient,
which the patient could perceive as blaming. In contrast,
a therapist who practices mentalization-based treatment
‘would not expect the patient to understand much of the
discourse that the therapist might verbalize in relational
Copyright © 2013 John Wiley & Sons, Ltd.
G. Goodman et al.
terms’ (p. 117). The reason is that BPD patients experience
widespread ‘symbolic failure, particularly associated
with incongruent mirroring’ (p. 118). Thus, transference
interpretation, particularly with severely disturbed BPD
patients, whose symbolic capacity has clearly failed,
would be ineffective. Only after a primitive symbolic
capacity has become activated should a therapist attempt
transference interpretation with BPD patients. Conversely,
the non-confrontational and non-interpretive aspects of
TFP such as the high degree of structure, active therapist
stance and emphasis on clarification could account for
the significant contribution of prototypical TFP process
in the prediction of distress reduction.
Bateman and Fonagy (2004b) recommended cognitively
based mentalization—identifying the mental states in the
patient and others and connecting mental states to
behaviours—as the effective ingredient of BPD treatment
—not confrontation or transference interpretation. In fact,
five of the eight most characteristic PQS items signifi-
cantly correlated with distress reduction are consistent
with this recommendation (Table 4). On the basis of our
reading of Bateman and Fonagy’s (2004a, 2004b) defini-
tion, mentalization is the outcome of an empathically
attuned, sensitive therapist (item 6) accurately perceiving
the therapeutic process (item 28) and using this emotional
knowledge to emphasize the patient’s feelings in order to
help him or her experience them more deeply (item 81) by
getting the patient to elaborate (item 31) and by clarifying
the patient’s communications (item 65). Combine this
process with a highly structured therapy experience
characteristic of CBT (item 17), and one has all the
essential ingredients for an effective treatment for severely
disturbed BPD patients. This distress-reducing psycho-
therapy process sounds more Rogerian (Rogers, 1977)
and cognitive-behavioural than psychodynamic.
This study illustrates a powerful method for simulta-
neously assessing psychotherapy process and adherence
to a specific treatment model’s prototypical process using
the same instrument. In spite of a lack of adherence data,
some treatment models prematurely claim efficacy in the
treatment of BPD patients. For example, even though
TFP was shown to outperform DBT and supportive psy-
chotherapy (SPT) on some outcome measures in an RCT
(Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Levy
et al., 2006), it is not known whether the patients in the
TFP condition received pure TFP and not an alloyed ver-
sion. Clarkin and his colleagues (Clarkin et al., 2007)
reported that twice-weekly outpatient TFP was associated
with significant improvement in 10 of 12 symptom
domains, whereas once-weekly outpatient SPT was
associated with significant improvement in only six
domains and once-weekly outpatient DBT with once-
weekly skills training in only five domains. Levy and
his colleagues (Levy et al., 2006) similarly reported that
TFP was associated with significant changes from
Clin. Psychol. Psychother. 22, 83–95 (2015)
Prototypical Processes and Psychological Distress
insecure to secure attachment and significant increases in
mentalization compared with DBT and SPT. On the sur-
face, it would appear that TFP produces both symptom-
atic and structural change; however, neither of these
studies provided any quantitative information about
treatment adherence to TFP. Thus, these TFP therapists
could have been practicing CBT process, mentalization
process or no manualized process at all. The PQS proto-
types illuminate the processes actually taking place in ther-
apy sessions and can therefore resolve any doubts about
which treatment model therapists are implementing.
The limitations of this study are worthy of mention. The
small sample size prohibits facile generalizations to the
population of severely disturbed BPD patients. In a sense,
the current study can be considered hypothesis-generating
rather than hypothesis-testing even though hypotheses
were in fact tested. Future studies that use larger sample
sizes would be able to test these hypotheses more formally
and, if supported, would improve confidence in their
generalizability to this patient population.
Because managed care companies refuse to pay for
lengthy hospital stays, in all likelihood, patients with
BPD no longer receive long-term PDT on inpatient psychi-
atric units. The findings of this study are therefore also not
generalizable to PDT as currently practiced in outpatient
settings with stable BPD patients. Other prototypical
processes not identified in this study might characterize
other treatment models for BPD patients.
Moreover, symptom reduction in the short term—the
only outcome measure used in this study—is not an
appropriate yardstick for measuring enduring structural
change. In fact, PDT might purposely increase distress
levels in the service of a longer-term goal—personality
change. Follow-up data are not available on the patients
enrolled in this study to determine outcome trajectories.
Multiple methods of assessing weekly or monthly
treatment outcomes that include both symptomatic and
structural or personality change could address this
question about the enduring quality of both kinds of
changes experienced by these patients over the entire
course of treatment. Personality change in an inpatient
treatment setting, however, might be too ambitious a goal.
In addition, because they feel so overwhelmed, severely
disturbed BPD patients in crisis might experience diffi-
culty completing measures beyond a simple symptom
questionnaire. In the current study, two of the five
patients refused to complete the SCL-90-R because
responding to 90 items on a weekly basis felt over-
whelming to them. The other three patients seemed to
underreport their symptoms in a misguided attempt to
receive more privileges or an earlier discharge date.
In this study, only one-third of the sessions were
transcribed; thus, the data represent an outline of
psychotherapy process in these treatments rather than
a comprehensive picture.
Copyright © 2013 John Wiley & Sons, Ltd.
93
Because all inpatients on this BPD psychiatric unit
received intensive milieu therapy in addition to individual
psychotherapy three times per week, it is not clear
whether the decreases in distress levels can be attributed
to the psychotherapy process or whether the milieu
therapy influenced the psychotherapy process. In this
naturalistic study, internal validity was sometimes
sacrificed on the altar of ecological validity.
Future researchers need to investigate adherence to var-
iously labelled treatment models with various types of
BPD patients in various settings. Specifically, treatments
of BPD patients with various levels of disturbance or dif-
ferent constellations of symptoms (Clarkin et al., 1993),
treatments in various settings (e.g., inpatient, day
treatment and outpatient) and treatments that systemati-
cally study pairings of therapist and patient attachment
organizations or levels of mentalization could yield
findings that clarify the findings of this study.
In summary, an effective PDT treatment model for
severely disturbed BPD inpatients needs to integrate
and encourage the emergence of empathically attuned
interactions in the context of a highly structured therapy
experience. At the same time, these treatments require
technical flexibility to accommodate the patient’s unique
presentation in crisis.
ACKNOWLEDGEMENTS
These data were collected with a grant from the Fund for
Psychoanalytic Research of the American Psychoanalytic
Association awarded to James W. Hull (John F. Clarkin and
Frank E. Yeomans, co-investigators). The first author
secured additional funding for the completion of this study
from the International Psychoanalytical Association Research
Advisory Board (Celeste Schneider, co-investigator) and the
Long Island University Research Fund. Stuart Ablon,
Raymond Levy and Tai Katzenstein provided timely
consultation on the use of the PQS, and Bernard S. Gorman
provided additional statistical consultation. Stuart Ablon
graciously shared his PQS prototype data. We appreciate
the assistance of the two groups of expert raters who
provided PQS ratings of the prototypical psychotherapy
sessions characterizing TFP and DBT. Giacomo Buscaino,
Silvia Fiammenghi, Anna Marantidis and Alana Tappin
provided expert coding assistance. Mary Beth Brady
faithfully transcribed all 127 session audiotapes. Joyce
McFadden, Jennifer Neill and Freddy Aguero took time
out of their hectic work schedules to assist with the
retrieval of hospital records. Valeda Dent reproduced
the tables and figures in Microsoft Word, and Tina Lo
checked references. Finally, we want to thank the four
therapists and five patients for their participation in
this study.
Clin. Psychol. Psychother. 22, 83–95 (2015)
94
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