Psychotherapy: Theory, Research, Practice, Training
2005, Vol. 42, No. 3, 324 –339
A MODEL OF THERAPEUTIC ACTION GROUNDED IN THE
PATIENTS’ VIEW OF CURATIVE AND HINDERING
FACTORS IN PSYCHOANALYTIC PSYCHOTHERAPY
PETER LILLIENGREN AND ANDRZEJ WERBART
Institute of Psychotherapy, Stockholm County Council
The patients’ view of curative and hin-
dering factors in psychoanalytic psycho-
therapy was explored, starting from con-
ducting the Private Theories Interview
with 22 young adult patients at termina-
tion of their therapies. A tentative theo-
retical model of therapeutic action was
constructed using grounded theory meth-
odology. Talking About Oneself, Having
a Special Place and Relationship, and
Exploring Together With the Therapist
were perceived as curative factors by the
patients, leading to therapeutic impacts
such as New Relational Experiences and
Expanding Self-Awareness. Hindering
aspects included experiencing that Talk-
ing Is Difficult and that Something Was
Missing in therapy, interacting with nega-
tive impacts such as Self-Knowledge Is
Not Enough and Experiencing Mismatch.
Methodological issues, the question of
common versus specific factors, and im-
Peter Lilliengren and Andrzej Werbart, Institute of Psycho-
therapy, Stockholm County Council, Stockholm, Sweden.
Peter Lilliengren is now at Södermalm-Gamla Stan Psychi-
atric Outpatient Services, Stockholm County Council.
This study is a part of the Young Adult Psychotherapy
Project conducted at the Institute of Psychotherapy, Stock-
holm County Council, and the Psychotherapy Section, De-
partment of Clinical Neuroscience, Karolinska Institutet. The
project is supported by a grant from the Bank of Sweden,
Tercentenary Foundation. The project has been approved by
the Regional Research Ethics Committee at the Karolinska
Institutet, and all participants have given their informed consent.
Correspondence regarding this article should be addressed
to Andrzej Werbart, PhD, Institute of Psychotherapy,
Björngårdsgatan 25, SE-118 52, Stockholm, Sweden. E-mail:
andrzej.werbart@sll.se
324
Copyright 2005 by the Educational Publishing Foundation
0033-3204/05/$12.00 DOI: 10.1037/0033-3204.42.3.324
plications for clinical practice are
discussed.
Keywords: psychoanalytic psychother-
apy, patients’ view, curative and hin-
dering factors, therapeutic action,
grounded theory
[I]t is the client more than the therapist who implements the
change process. (Lambert, Garfield, & Bergin, 2004, p. 814)
Probably the first description of a patient’s
view of therapeutic action in psychotherapy can
be found in Breuer and Freud’s seminal work
Studies in Hysteria (1895/1955). When Breuer’s
patient Anna O. referred to her treatment as “the
talking cure” and to the therapeutic process as
“chimney-sweeping” (p. 30), she also gave us a
hint as to how she experienced the curative as-
pects of her treatment. Anna O’s experience
eventually led Freud, in his effort to find the
active ingredients in the therapy he conducted at
that time, to formulate the theory of “cathartic
cure.”
Since Freud’s early attempts to understand the
nature of therapeutic action, there have been nu-
merous suggestions from later schools of psycho-
analysis as to how psychoanalysis and psychoan-
alytic therapy work. However, no sufficient
theoretical explanation for therapeutic action has
been proposed, and even today analysts do not
fully understand, nor do they claim to, why and
how their treatment works (Fonagy, 2003). Most
psychoanalytic therapists accept that there prob-
ably exist several pathways to change besides the
classical notion of “making the unconscious con-
scious” (Freud, 1917/1963, p. 435), including, for
example, mutative interpretations (Strachey,
1934), regression (Ferenczi, 1931/1980a, 1919/
1980b; Winnicott, 1954/1987) and a “new begin-
ning” (Balint, 1932/1985, 1968), “new-object re-
lationship” (Bibring, 1937), corrective emotional
experience (Alexander, 1946), introjection of the

analyst’s containing function (Rosenfeld, 1972),
making a shift to activity (Schafer, 1976, 1983),
learning a coherent story of oneself (Appelbaum,
1978), creating new meaning (Gedo, 1979), and
self-object internalization (Kohut, 1984). In an
overview of psychoanalytic concepts of therapeu-
tic effectiveness, Cooper (1989) concluded that
there has been
a change of view from the earliest days of analysis, when a
single therapeutic element was sought to explain the effects of
analysis, to the present, when we see the therapeutic effect
depending upon multiple interacting processes, none of which
can be assigned clear priority in our present state of igno-
rance. (p. 24)
Although no single therapeutic element can be
assigned priority, one might discern two major
lines of thought within the psychoanalytic tra-
dition relating therapeutic action to either “in-
sight” or “relational impact” (Abend, 1988;
Aron, 1990, 2000; Jones, 1997; Michels, 1985;
Mitchell, 1988). Other recent attempts to un-
derstand the curative process are inspired by
research on child development and focus on
creation of relational “moments of meeting”
between the caretaker and the infant as well as
between the therapist and the patient (Stern,
2004; Stern et al., 1998).
However, theories of therapeutic action tend
to be therapist centered and are often built on
the therapist’s view of the therapeutic process
(see discussion in Bohart, 2000). The patient’s
perspective on what works in therapy has been
largely neglected and has not been the basis for
the building of clinical theory, regardless of
psychotherapeutic orientation. In the psychoan-
alytic tradition the empirical observational data
are filtrated by the subjectivity of the analyst,
and the patient’s own construction of meaning
is often disregarded (Sachs, 2001; Schwaber,
1996).
Although the patients’ view of the therapeutic
process is a largely neglected area in psychother-
apy research (Howe, 1993; McLeod, 1990), there
have been several studies into the patients’ per-
spective on helpful aspects in therapy since the
1960s (e.g., M. Beutler & Rasting, 2002; Grafa-
naki & McLeod, 1999; Llewelyn, 1988; Strupp,
Fox, & Lessler, 1969). As has been shown re-
peatedly, patients report factors that are common
to all psychotherapeutic traditions as most helpful
in therapy. As summarized by Elliott and James
(1989), the common factors most frequently re-
Patients’ View of Therapeutic Action
ported by patients across therapies are (a) facili-
tative therapist characteristics, (b) self-expression
permitted, (c) experiencing a supportive relation-
ship, (d) gaining self-understanding, and (e) ther-
apist encouraging extratherapy practice.
Recently there has been some debate regard-
ing which approach is most adequate when
studying patients’ subjective experience of
therapy (Arnkoff, Glass, Elkin, Levy, & Ger-
shefski, 1996; Rennie, 1996). Most studies of
the patients’ experience of curative factors in
therapy have been based on quasi-qualitative
methodology, using predetermined categories
when analyzing the patients’ reports (cf. Ger-
shefski, Arnkoff, Glass, & Elkin, 1996; Levy,
Glass, Arnkoff, Gershefski, & Elkin, 1996;
Llewelyn, Elliott, Shapiro, Hardy, & Firth-
Cozens, 1988; Llewelyn & Hume, 1979). This
approach has advantages making it possible to
statistically determine how different helpful as-
pects, as reported by patients, relate to out-
come, as measured with some quantitative
measure. However, qualitative researchers such
as Rennie (1992, 1996) have argued that when
approaching qualitative data with precon-
structed categories, one is not really studying
the patient’s experience but rather how well
reported experience fits with the researcher’s
previous knowledge.
Further, using preconstructed categories tends to
lead to a rather static representation of the patient’s
experience. Typically, the results are presented as a
list of frequently reported curative factors, such as
the five factors summarized by Elliott and James
(1989). This might have limitations when it comes
to the application of the results in clinical practice,
as we know very little about the possible interaction
between different common factors and factors that
are more specific to a given therapeutic modality.
We know even less about how such factors might
interact with the patient’s experience of negative or
hindering aspects. In order to create a more com-
prehensive model of the possible interrelation be-
tween different curative and hindering factors, built
on patients’ implicit knowledge (Frommer & Lan-
genbach, 2001), other methodological approaches
are needed.
The aim of the present study is to explore pa-
tients’ experience of curative and hindering aspects
in psychoanalytic therapy, as reported at termina-
tion, in order to construct a tentative theoretical
model of therapeutic action. The specific research
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Lilliengren and Werbart
questions are as follows: What do patients perceive
as curative and as hindering factors in psychoana-
lytic psychotherapy? What in the therapy contrib-
uted to the experienced change, and what hindered
change, according to the patients’ view? How are
these factors interrelated?
Method
Procedures
This study was conducted as a part of the
Young Adult Psychotherapy Project (YAPP), a
naturalistic, prospective, and longitudinal study
of young adults (aged 18 –25) in psychoanalytic
psychotherapy. The psychotherapies included
were conducted within the ordinary work of the
Institute of Psychotherapy in Stockholm, Swe-
den, where subsidized psychotherapy is provided
for people with various psychological problems.
The young adults applied through the institute’s
telephone service and were admitted as openings
became available. A minority of patients came
via referral from psychiatric outpatient clinics.
Psychotherapists accepted patients for psycho-
therapy on the basis of motivation and suitability
for the treatment at hand, without making a psy-
chiatric diagnosis. A total of 134 self-referred
patients between 1998 and 2002 were included,
of whom 92 enrolled in individual psychotherapy
and 42 in group therapy. Every second patient
who was assigned to individual therapy (the re-
search group; n ⫽ 47) and all patients applying
for group therapy were interviewed before start
of the treatment, at termination (generally within
2 weeks), and 1.5 and 3 years after termination.
All patients completed a background and person-
ality questionnaire at four points in time: at base-
line, at termination, and at follow-ups. The pa-
tients were informed before treatment about the
research procedures, and they gave their written
consent to participate in the project.
Participants
At the time of the study (July 2002), 26 out of
47 patients in the research group had terminated
their therapy. In 4 of these cases the interview
data were missing. Thus, a total of 22 interview
transcripts at termination could be included.
Three of the informants were male (14%) and 19
female (86%); the average age was 22.5 years at
326
the start of therapy. The total gender distribution
in individual psychotherapy in YAPP (92 cases)
was 23% male and 77% female, and the average
age was the same as in this sample.
Eight of the patients (36%) lived alone, 5
(23%) lived with their parents, and 9 (41%) lived
with a partner. None was married or had a child.
The most common occupation was work, in 10
cases (45%) full time and in a further 4 in com-
bination with studies (18%), followed by full-
time study in 8 cases (36%). None defined him-
or herself as unemployed. Sixteen of the patients
(73%) were born in Sweden and had both parents
of Swedish origin, a further 2 were born in Swe-
den and had one of their parents of foreign origin
(a Scandinavian country in one case and an Asian
country in the other), and 1 additional patient was
adopted as an infant from an Asian country by
Swedish parents. Three of the patients were born
in, and had both parents from, another country
(Scandinavia, Asia, and Latin America). In all, 17
patients (77%) had at least one parent with a
university degree. Nine of the patients (41%) had
previous outpatient or inpatient psychiatric con-
tact (in 4 cases only on one occasion), and 9 had
previous psychotherapeutic contact.
Common complaints were depressive mood,
anxiety, problems in relationship with parents,
and low self-esteem (Wiman & Werbart, 2002).
Seven patients (32%) had a personality disorder
according to the Diagnostic and Statistical Man-
ual of Mental Disorders (4th ed., text revision;
American Psychiatric Association, 2000) Axis II:
1 in Cluster A, 2 in Cluster B, and 4 with per-
sonality disorder not otherwise specified. Self-
reported symptoms were measured with the
Swedish version of the Symptom Checklist–90
(Derogatis, Lipman, & Covi, 1973; Derogatis,
1994). As the nine included subscales are highly
correlated, the Global Symptom Index (GSI) was
used as an aggregate measure. The mean pre-
therapy levels of GSI for the 22 patients included
in this study, 1.31, clearly exceeded the mean of
the Swedish norm group, 0.58 (Fridell, Cesarec,
Johansson, & Malling Thorsen, 2002), and de-
creased at termination to 0.77. The mean pre-
therapy level of Global Assessment of Function-
ing (GAF; American Psychiatric Association,
1994) was 54.5, which corresponds to moderate
symptoms or moderate difficulties in functioning
in social, occupational, or school functioning. At
termination GAF mean increased to 67.3, which

corresponds to some mild symptoms or some
difficulty in social, occupational, or school func-
tioning. The 22 participants are a representative
sample of the entire patient group in YAPP, as
the demographic data for this sample, as well as
pre- and posttherapy levels of self-reported and
expert-rated symptoms and functioning, were
very close to the total percentages.
Treatment
The 22 patients in this study were treated by 16
therapists (of the total of 34 individual therapists
in the YAPP), of whom 11 had one patient each,
4 had two patients, and 1 had three patients in this
study. The therapists were all highly educated,
middle-aged specialists in psychoanalysis (7) or
psychoanalytic psychotherapy (9) with extensive
clinical experience and were engaged as teachers
and supervisors in a training program for psycho-
therapy. Four of the therapists were male and 12
female, all of Scandinavian origin. As to their
profession, 2 of the therapists were physicians, 7
psychologists, and 7 social workers. The thera-
pists shared a psychoanalytical frame of refer-
ence, even if they were working quite autono-
mously and had varying preferences regarding
theory and technique. All therapists met every
week in clinical teams, where treatment problems
and clinical experiences were discussed. The
treatments aimed at overcoming developmental
arrests and improving the patients’ ability to
manage developmental strains in young adult-
hood. The goals, duration, and frequency of psy-
chotherapy were adjusted to the individual pa-
tient’s needs and jointly formulated in a written
contract with the possibility of renegotiating. The
mean time in psychotherapy was 18.6 months
(between 7 and 32) with a frequency of one (12
cases) or two (10 cases) sessions a week (which
was about the same as in the total YAPP
population).
Interviews
The material for this study consisted of inter-
views conducted at termination. The semistruc-
tured Private Theories Interview (PTI; Ginner,
Werbart, Levander, & Sahlberg, 2001) is aimed
at collecting narratives, concrete examples, and
illustrative episodes concerning patients’ private
theories of pathogenesis and cure, as well as their
Patients’ View of Therapeutic Action
problem formulations and descriptions of
changes during and after therapy. The patients
were also asked about their retrospective view on
what in their therapy contributed to change, what
had been the obstacles, and what could have been
different. The 22 interviews were carried out by
13 interviewers trained in the PTI technique. The
interviewers were psychoanalysts and psycho-
therapists (1 physician, 5 psychologists, and 7
social workers); all but one were native Scandi-
navians. The audio-recorded interviews lasted
about 60 min and were transcribed verbatim.
Data Analysis
The qualitative analysis of interview tran-
scripts was conducted in four steps. The first two
steps were aimed at selection and condensation of
material for further analysis (textual-level work).
The third and fourth steps (conceptual-level
work) followed grounded theory methodology
(Glaser & Strauss, 1967; Rennie, 2001; Strauss,
1987; Strauss & Corbin, 1998). A computer soft-
ware interface known as ATLAS.ti (2000), a
powerful instrument for analysis of qualitative
data, was used in the process.
Step 1: Focusing on each patient’s report on
curative and hindering aspects. The 22 inter-
view transcripts were read one at a time. All
sections containing reports of helpful or hinder-
ing aspects in the therapy were extracted to a
separate document.
Step 2: Creating condensates. At this step
the extracted sections were further reduced using
concentration of meaning (Kvale, 1996); that is,
the utterances were formulated in a more concise
way without losing their essential meaning, for
example, by deleting redundant spoken language.
The 113 condensates created in this way caught
the central meaning or point in the informant’s
narrative, and distinct themes were separated (see
Figure 1).
Step 3: Coding and conceptualization. All 113
condensates were given an open code describing
the main content. The networking function of
ATLAS.ti was used to sort condensates that seemed
closely related in meaning, theme, or content and to
categorize groups of condensates. The graphical
software tools were applied to visually connect the
codes and categories into diagrams that outlined
their relations (see Figure 2). In the subsequent
comparative analysis the categories were compared
327
Lilliengren and Werbart

FIGURE 1. An example of creating condensates.

with each other, revised, and elaborated, and sub-
themes were identified and coded.
Step 4: Building a theoretical model. The aim
of this step was to examine the relationship among
the categories that emerged at Step 3 and to con-
struct a tentative theoretical model based on those
categories. This involved writing theoretical memos
and using graphical software tools of ATLAS.ti to
visualize the emerging model. The process of build-
ing the model raised further questions that were
taken back to Step 3. Thus, there was a continuous
back-and-forth movement between coding and con-
ceptualizing, and building and revising the tentative
model. Questions were also taken back to the orig-
inal interview transcripts in order to explore the
context in which the informant discussed his or her
experience. The networking function of ATLAS.ti
kept the links between condensates, codes, and cat-
egories throughout the conceptual-level work. This
process led to explication of the codes and catego-
rizations used and to elaboration of the model, until
further analysis did not seem to lead to additional
understanding (i.e., the saturation point).
The coding was carried out by Peter Lillien-

FIGURE 2. An example of sorting and categorizing condensates using the networking function of ATLAS.ti. Numbers in the
rectangles refer to the serial numbers of condensates.

328

gren. During the conceptual-level work Andrzej
Werbart reviewed the material and collaborated
in the process. When differences in opinions
emerged, a discussion was initiated until consen-
sus was reached. On the basis of these audits, the
model was judged to be grounded.
Lilliengren is a 30-year-old male graduate
from the 5-year professional psychologist pro-
gram. He has a special interest in psychotherapy
integration and is a member of the Society for the
Exploration of Psychotherapy Integration. Wer-
bart is a middle-aged male psychoanalyst and
member of the International Psychoanalytical As-
sociation and the Society for Psychotherapy Re-
search. Owing to the authors’ professional back-
grounds, the psychoanalytic literature regarding
the therapeutic action in psychoanalysis and psy-
choanalytic therapy was largely known to them
prior to the study, as was a considerable amount
of the published research regarding patients’ per-
spective on curative and hindering factors.
FIGURE 3. A tentative theoretical model of therapeutic action grounded in the patients’ view. Curative factors are indicated by
solid line rectangles, hindering aspects by dashed-line rectangles, therapeutic impacts by dotted ellipses, and negative impacts by
dashed-line stars.
Patients’ View of Therapeutic Action
Throughout the analysis, efforts were made to
“bracket” existing and preferred theoretical
models.
Results
The analysis resulted in a final model consist-
ing of 9 main categories and 16 subcategories
(numbers in brackets refer to the numbering of
categories in Figure 3). No effort was made to
construct one core category; rather, a hierarchical
process model emerged. Three categories were
defined as curative factors (Talking About One-
self [1], Having a Special Place and a Special
Kind of Relationship [3], and Exploring Together
[5]), and two represented hindering aspects
(Talking Is Difficult [2] and Something Was
Missing [8]). Further, the model included two
categories representing therapeutic impacts (New
Relational Experiences [4] and Expanding Self-
Awareness [6]) and two representing negative
329
Lilliengren and Werbart
impacts (Self-Knowledge Is Not Always Enough
[7] and Experiencing Mismatch [9]). The connec-
tions between the main categories are represented
in the model in terms of curative interactions,
potential hindering interactions, unilateral influ-
ences, and looser associations. The included cat-
egories are further elaborated below and illus-
trated by verbatim citations from interview
transcripts.
Talking About Oneself (1)
The first curative factor that emerged in the
analysis was Talking About Oneself. Many pa-
tients spontaneously expressed that “talking” had
been helpful and that expressing themselves in
therapy was curative. Further, the patients de-
scribed talking about themselves in two different
modes. One mode involved expressing, reflect-
ing, and labeling one’s own thoughts and feel-
ings. Several patients indicated that it “felt good
to talk” and “to ventilate” their own thoughts and
feelings, which seemed to result in a sense of
relief. This mode of talking also involved reflect-
ing on what was expressed: “[It was helpful] to
have a monologue with oneself and to hear one-
self talk about oneself. To hear how it sounds, in
a way.” Talking and using words helped the
patients to express and label their feelings: “to
put feelings into words” and “to sort out my
feelings instead of being overwhelmed by some
sort of gloom.”
Another mode involved talking as a “storytell-
ing” activity. This included remembering, “going
through,” revising, and “working through” one’s
personal history: “I have talked to the therapist
and it has helped me to look at my life, that what
happened really wasn’t that decisive. I have
worked it through.” Characteristic of both modes
was that the patients presented themselves as
active agents and initiators of the activity. The
therapist was pictured rather as a “background
presence” or a “witness” to the patient’s talking.
A typical formulation indicated the therapist’s
role as a “listening other”: “It felt very good to
come and talk to someone and to start
somewhere.”
Talking Is Difficult (2)
At the same time as talking about oneself was
described as a curative factor, many patients also
330
expressed that it was difficult to talk in the ther-
apy. Although it felt good to talk to the therapist,
talking about oneself could be anxiety provoking
and energy consuming: “It takes a lot of energy
and it is difficult to talk about [the problem].” “I
feel that ‘talking therapy’ helps me even though it
is really tough.”
The ambiguity of talking in therapy was some-
times clearly stated: “It has been good talking to
the therapist. It hasn’t been easy. It took me a
long time before I could really start talking.” The
experience that talking was difficult seemed to
represent a hindering aspect, because it interacted
with talking about oneself as a curative factor.
For example, some patients indicated that it took
time for them to trust the therapist and really start
talking about themselves: “I find it difficult to
trust others so it was really difficult for me to talk
. . . It took a long time for me to get used to this
kind of therapy.”
Having a Special Place and a Special Kind of
Relationship (3)
The next curative factor that emerged was the
patients’ experience of the therapeutic setting and
of the relationship with the therapist. The reports
indicated that the therapy became “a special
place” and that the relationship with the therapist
was “of a special kind.” Further, the patients’
experience seemed to form a whole, where the
experience of a “special place” and of a “special
kind of relationship” could not really be sepa-
rated. Describing the therapy, several patients
used expressions like “a breathing space,” “an
important channel,” “a neutral zone,” and “a
place to unwind.” The experience of uniqueness
of the setting and of the therapeutic relationship
involved three main themes: a special emotional
atmosphere, the therapist being an “outside per-
son,” and having time and continuity.
The special emotional atmosphere was com-
posed of the experience of being accepted, re-
spected, supported, and seen by the therapist. The
unique “being-with experience” involved sharing
one’s problems with someone, being listened to,
and taken seriously. Of great importance was
having been allowed to express and share one’s
emotions: “That I’ve had the right to experience
all emotions, that it’s not bad to be angry and
such. To be allowed.”
Another theme was the therapist being an “out-

side person” with no relation to the patient’s
family or friends and not involved in the patient’s
emotional storms. The patients indicated that
talking to the therapist was something completely
different from talking to friends or relatives, often
described as not very helpful:
It becomes a way of talking that you can’t do with anyone
else. My boyfriend gets upset and angry for my sake when I
talk about how my mother behaved and such. So he can’t help
me in the same way.
. . . you don’t have to be careful and pick the right words
because you’re afraid to hurt someone. You can talk about
how you experience reality without having to consider what
consequences it will have when you step out of the door. It’s
an enormous help.
A further theme concerned having time and
continuity:
Time is incredibly important since it takes time to sort out
one’s thoughts and put them together. I mean, if time wasn’t
an aspect then we would understand the patterns from the start
and we don’t.
That we have talked about [the problem] and it hasn’t been
forgotten, because often you repress or think about something
else, to keep it hidden in a way. Now it has been kept alive all
the time, every week, so I have worked it through in a
different way than if I had not been here.
New Relational Experiences (4)
Talking About Oneself and Having a Special
Place and a Special Kind of Relationship were
associated with the therapeutic impact of New
Relational Experiences. The reports indicated
that the special emotional atmosphere, the thera-
pist being an outside person, time, and continuity
contributed to the experience of therapy as a safe
place to explore difficult thoughts and feelings,
thus helping the patients to overcome the diffi-
culties associated with talking about oneself. This
“overcoming” was in itself an important new
relational experience:
It has been a permissive and respectful atmosphere here and
I have dared to open up too. I have dared to talk about things
that I have not talked about to so many others before, even
though I’m usually an open person.
Further, the patients’ narratives suggested that
this feeling of safety provided them with a plat-
form for trying out new ways of being and relat-
ing to other people, thus increasing the probabil-
ity of new relational experiences between
sessions:
Patients’ View of Therapeutic Action
It felt very meaningful to be in therapy, and it became an
important channel of sorts. I started almost purposefully to
influence my family to start talking about deeper feelings.
And that I could talk about things with my sister and my
parents that we have never touched on before has been very
important to me personally.
Exploring Together (5)
The last curative factor was labeled Exploring
Together. Here, the narratives indicated that the
patient and the therapist were engaged in a mu-
tual collaboration with a distinct “exploring”
quality. The therapist’s participation was de-
scribed with words such as “asked questions,”
“summarized,” “provided new perspectives,”
“connected,” “linked together,” “pointed out,”
and “helped me to open my eyes.”
One recurrent theme concerned analyzing
background factors to one’s problems and finding
connections to one’s past. The patients described
their discussing with the therapist as part of an
effort to make sense of their difficulties and to
find out “why”:
Perhaps one only sees the problem in the beginning, so that
one discusses all of it and finds reasons, then you notice that
you can write off some feeling. That one notices that the
feeling one had earlier is perhaps without substance today.
Also, the interventions made by the therapist
seemed to have encouraged the patients’ own
exploratory and self-reflective activity:
It helps me incredibly to sit with the therapist, and that she is
able to summarize what I’ve said and say it in a sort of
objective way, “Yes, but could it be like this?” . . . And then
one sees a pattern, “But God that’s what I do, of course,” and
why I do it.
Another theme involved the therapist helping
the patient to discover and challenge self-
defeating thoughts and negative interpretations of
the self and the world:
I can imagine that one sort of accuses oneself, and one makes
so many mistakes, everyone else is so good, but I am so bad.
And suddenly I could understand when I had spoken about it
a lot that it isn’t actually like that. It is just strange interpre-
tations of oneself.
A further aspect involved the therapist focus-
ing on what the patient wanted to get out of life,
for example, by asking questions that encouraged
self-reflection, exploration, and finding of “own
answers”:
I think it was that all the time, I heard things like: “But what
about you? Think about yourself!” And then I have begun to
think things like: “But what about me then? What do I want?”
331
Lilliengren and Werbart
and try not to care so much about others. I think that has
probably been the most helpful actually, to think about things
a little more from my own perspective instead of that of those
around me.
The explorative collaboration with the therapist
also involved “defining problems” and “setting
goals” for the treatment. This structuring aspect
could lead to a clearer picture of the difficulties
and ways of coping with them:
Giving structure to the problem has provided an intellectually
clearer picture and a feeling of confirmation so that the
problem is perhaps easier to manage. By defining the problem
we have in some way undermined it so that it has solved itself.
Expanding Self-Awareness (6)
Talking About Oneself and Exploring To-
gether were associated with several therapeutic
impacts, gathered here under the label of Expand-
ing Self-Awareness. One impact was the experi-
ence of having “sorted out” something not clear
before, whether thoughts and feelings or experi-
ences and memories of the past. Several patients
used metaphors such as “to begin unraveling a
ball of string,” leading to a sense of greater self-
coherence: “To bring out what caused or what it
comes from. . . . Perhaps it is a matter of creating
connections to why one reacts in a certain way or
why one feels so . . . .”
Another impact was “discovering patterns” in
one’s personality and linking them to one’s fam-
ily history. In this context, the patients used such
metaphors as “to fit the pieces of a jigsaw puzzle
together.” “I have opened my eyes to problems in
my family, certain patterns. That I am able to
recognize myself in my mom’s personality.” This
“pattern-finding” activity also seemed to open
new possibilities for the patients to relate to im-
portant others in a new way:
I think it’s probably that that I want to emphasize the most,
that I have learned to see patterns in how I behave and why I
behave in that way, which makes it possible to avoid doing it
in that way the next time.
Further impact was learning “new ways of
thinking”:
I haven’t worked out exactly what it is that has made me have
problems, but it feels as if I have been dealt the cards for how
to solve it, or the key. I have understood roughly what one can
do. I’ve been to a lot of places, but it was first in therapy that
I received an explanation from the therapist as to how to
think, and that was great.
The last impact involved gaining a new per-
spective on oneself and one’s problems:
332
I can feel that I have received help through getting perspec-
tives. When I have come and talked to my therapist about
something unpleasant that has taken place during the week,
my therapist was always able to say something like, “but if
you see it in this way instead” and turn the problem over.
One important aspect of Expanding Self-
Awareness was that the patients could internalize
the therapist’s activities and then continue the
conversation within themselves: “To receive help
to understand how one analyzes a problem. That
someone puts the question, ‘why is that?’ Now I
am able to hold the conversation myself in my
head, so I don’t get so angry.”
Self-Knowledge Is Not Always Enough (7)
Although Expanding Self-Awareness was ex-
perienced as therapeutic by many patients, others
reported that even if they might have achieved
better self-knowledge, therapy had not been that
helpful, as they had not received any help to
change the problem in practice:
Of course by meeting and talking about it, going over it, or
looking at what happens everyday, one has become a little
more aware and sees that it is the same thing that recurs. So
that’s good of course. But I can’t really see that I have
received any actual help in how I should deal with it. I don’t
really feel directly better, unfortunately.
The experience of having gained greater self-
awareness without experiencing any change in
one’s underlying problems was associated with
the patient’s disappointment in the treatment and
was regarded as a negative impact of therapy.
Something Was Missing (8)
The disappointment in therapy was also con-
nected with the experience that Something Was
Missing, which represented another hindering as-
pect. A recurrent theme in this category was that
the therapist had been too passive, which was
perceived as an obstacle to the cure. A more
“active” stance from a therapist who focuses
more actively on “what was important” and is
more “effective” would have been preferred by
some patients:
The therapist should have been more effective so that one
didn’t talk so much nonsense but concentrated on something
important. There were some things that I really didn’t care to
talk about and she let it go a little. . . . We touched on it but
didn’t go any deeper than that.
A further “missing aspect” was the patients’
wish for more feedback, guidance, and advice:

I felt that I got very little feedback. It was mostly she who
listened. And that was fine, of course, as one always comes up
with something a little new. But I have brooded a lot over my
problems, so I would ideally have needed a little more advice
about how to think.
Some patients wanted more “concrete advice” on
how to handle a troublesome situation,
for example, how should I deal with the trouble with my
mom. “Leave” or “do this,” or I don’t know, in other words,
“say this” or “talk to so-and-so instead” . . . something wise
one can say that I can’t think of myself.
In this context, some patients expressed the
wish for the therapist to take on the role of an
“expert,” an “outside person” who can give ob-
jective answers, or of a “good parental figure”:
An expert who has experience. . . . They can stand outside and
see and perhaps say . . . how it can be connected with things.
Perhaps I have missed more of “Yes, but couldn’t you con-
sider doing this or that?” More like a mother figure, perhaps,
in that I haven’t had that in my earlier life.
Other patients wanted more structured and
“action-oriented” interventions between sessions,
such as homework, linking therapy to ordinary
life:
In a way it is very good that one doesn’t steer in any way. But
I could feel that I needed more information about “how,” in
other words perhaps one could have done something on the
side, almost assignments to do at home, so to speak . . .
something to think about, perhaps. More like a diary, one
could write.
Experiencing Mismatch (9)
The last negative impact was Experiencing
Mismatch. Several patients expressed concerns
that therapy might not have been “right” for their
problems or that a change to another form of
therapy or medication might suit them better:
[I] think that a long-term individual therapy, such as cogni-
tive, can be better for the type of problem I have. I think it
would suit me better. Have thought a little about changing the
type of therapy, but now it feels that medication and periodic
therapy would be the best.
Other patients wondered how they as persons
“fitted together” with their particular therapist:
“Perhaps one doesn’t fit well with all thera-
pists. . . . I felt that perhaps it wasn’t right. Either,
maybe, that it was that me and my therapist didn’t
fit so well, or that it was this type [of therapy].”
In some cases the mismatch concerned the pa-
tient’s private theory of pathogenesis and the
actual form of therapy: “To sit and talk didn’t
Patients’ View of Therapeutic Action
have any effect on it, as the problem is
neurological.”
Experiencing Mismatch had a negative influ-
ence on the experience of a Special Place and
Special Relationship with the therapist. Typically
in such cases the therapists were described in
negative terms, and the patients doubted that the
therapy was the “right” treatment for them or
their particular problems:
I don’t think that the therapy has helped. I really believed in
this, I have attended the Child and Adolescent Psychiatric
Unit before, but I don’t think I have had a good therapist. I
don’t think I have received any help at all here.
Discussion
Advantages and Limitations of the Method
Employed
The aim of this study was to construct a ten-
tative theoretical model of therapeutic action in
psychoanalytic psychotherapy grounded in the
experiences of the patients rather than relying on
expert models. In order to explore the patients’
view of curative and hindering aspects, a quali-
tative and discovery-oriented approach was used.
Such a methodology has the advantage of being
closer to the narrative constructions of each
unique individual than coding according to some
fixed, preconstructed scheme. The patients’ sub-
jective perspective is easily lost when qualitative
data are to be “fitted” into theory-driven catego-
ries (Rennie, 1996). On the other hand, qualita-
tive approaches are more open to the influence of
the researcher’s subjectivity. Thus we concur
with those qualitative researchers who “believe
that their self-reflective attempts to ‘bracket’ ex-
isting theory and their own values allow them to
understand and represent their informants’ expe-
riences and actions more adequately than would
be otherwise possible” (Elliott, Fischer, & Ren-
nie, 1999, p. 216; cf. Malterud, 2001). Arguably,
the subjective influence of the researcher is re-
duced when formalized qualitative methodology
is carefully followed. The powerful computer
software used at the conceptual level of work
made it possible to graphically outline the com-
plex relations of codes and categories in a for-
malized way. The methodology used here is an
example of how models can be derived from the
narratives of patients in psychotherapy. Yet ther-
apists also have implicit theories. Thus, their nar-
ratives, rather than their official theories, can be a
333
Lilliengren and Werbart
starting point for constructing empirically
grounded models. In fact, it is the objective of an
ongoing study of all therapists in YAPP.
Owing to the design of the research project,
several deviations from the more strict grounded
theory methodology had to be accepted. The
semistructured interview manual was constructed
in advance. Also, interviewers other than the re-
searchers themselves were trained to conduct the
large number of interviews. The number of inter-
views included was dictated by the accessible
material, even if the 22 available interviews re-
trieved enough data to reach a saturation point in
the analysis (Strauss & Corbin, 1998). Because
the interview manual covered several areas out-
side the aim of this study, it was necessary to
focus the material on what was important for the
study at Step 1 in the analysis. Further, the data
were reduced using “concentration of meaning”
at Step 2, a procedure often used in qualitative
research (Kvale, 1996). As always when one de-
limits the qualitative material in this way, one
runs the risk of losing important meanings.
In the naturalistic setting of the research
project, the participants were self-referred and
not representative of all young adults in distress,
especially as the gender distribution for the sam-
ple was uneven. It is also possible that some
specific expectations before psychotherapy inter-
fered with the patients’ experience of treatment
(Glass, Arnkoff, & Shapiro, 2001), even if some
research results suggest diminishing impact of
expectancies across time in long-term treatments
(Weinberger & Eig, 1999). As indicated by an-
other investigation using a sample from the same
patient population (Bengtsson, 2004), the patients
were rather well informed before the treatment
and expected an approach compatible with psy-
choanalytic psychotherapy, a factor limiting the
variance in the material. However, this did not
prevent at least some of them from mentioning
several hindering aspects. Further, it is impossi-
ble to know in detail how the treatments actually
were conducted in each individual case, as the
therapy sessions were not recorded. Therefore, it
should be kept in mind that the level of analysis
here is the patient group.
Interpretation and Evaluation of Main Findings
The main curative factors in the presented
model are all helpful aspects that have been
334
found in previous empirical research on patients’
view of therapy (Elliott & James, 1989). How-
ever, this study enables us to take a closer look at
interrelations among curative factors, hindering
aspects, and therapeutic impacts as experienced
by the patients. The model indicates that these
factors interact in important ways. For example,
the activity of talking was connected to a sense of
relief but was also experienced as painful and
anxiety provoking. Talking in therapy was thus
experienced both as a curative factor and as a
hindering aspect by the patients.
The presented model further suggests that the
hindering aspect of talking could be overcome
within a Special Kind of Relationship. The
“opening up” and talking freely with the therapist
was described as a new relational experience that
could break repetition of old patterns and lead to
testing of new ways of relating between sessions.
In the psychoanalytic tradition the importance of
new relational experiences has been stressed,
among others, by Balint (1985), Alexander
(1946), Winnicott (1987), Loewald (1960), and
Kohut (1984). The model of therapeutic action,
grounded in the patients’ view, is in accord with
the interpersonal rather than the intrapsychic con-
cept of therapeutic action (Aron, 1990; Jones,
1997; Michels, 1985; Mitchell, 1988; Stern,
2004; Stern et al., 1998). However, it is not a real
relationship with the therapist as a whole and
unique person but rather a background presence
of a benevolent, listening, and seeing witness to
the patient’s own activity.
Within the frames of the Special Place and Spe-
cial Kind of Relationship, the patients ideally de-
scribed themselves as engaged in an explorative
collaboration with the therapist. Here, the therapist
is experienced as an active participant who inter-
venes by questioning, making connections, summa-
rizing, and so forth. The importance of discovering
patterns in one’s behavior and connecting them
with the past is the kernel of the psychoanalytic idea
of cure (Freud, 1917/1963). A postmodern addition
is the importance of creating a coherent history of
oneself (Schafer, 1992). It is interesting to note that
the patients tended to describe the therapeutic im-
pacts in cognitive terms, such as setting goals and
defining problems, highlighting and challenging
negative thoughts about oneself, and finding out
what one wants in life. Also, the transference and
countertransference aspect, central in the psychoan-
alytic theory, is rarely mentioned by the patients,

nor is the affective “working through.” However,
the patients’ descriptions of Exploring Together and
Expanding Self-Awareness might imply joint work
on what is actualized in the therapeutic relationship.
Probably the transference– countertransference ma-
trix and the affective aspects are implicit rather than
manifest in the patients’ narratives, and are repli-
cated in the relationship with the interviewer
(Leuzinger-Bohleber, 2002; Schlessinger & Rob-
bins, 1983). Such aspects can be studied using a
theory-anchored rather than grounded theory meth-
odology; however, doing so may present an open-
ing for additional researcher bias.
Although expanding self-awareness was expe-
rienced as a curative impact by many patients,
there was also evidence that others experienced
self-knowledge as insufficient. Of the main com-
mon factors found in previous research (Elliott &
James, 1989), “encouragement of gradual prac-
tice” seemed to fall in the Something Was Miss-
ing category for the patients experiencing mis-
match in the present study. For other patients, this
practice could be found under the heading of
New Relational Experiences. Surprisingly, there
is no link in the model between the categories
Exploring Together and Something Was Missing
or Experiencing Mismatch. Nothing in the narra-
tives of displeased patients suggested that the
experience of things lacking and mismatch was
brought up and explored together with the thera-
pist. One possibility is that the patient’s and the
therapist’s ideas of cure in such cases were so
incompatible that the therapeutic modality did
not suit the patient. Another possibility is that
some therapists never explored together with
their patients the incompatibilities between their
initial views of the cure.
Common Versus Specific Factors
The presented model also brings the question
of common versus specific therapeutic factors to
the fore (Luborsky, Singer, & Luborsky, 1975;
Norcross, 1995; Rosenzweig, 1936; Wampold,
2001b). However, there is little apparent agree-
ment among researchers regarding “the common-
alities among the therapeutic common factors”
(Grencavage & Norcross, 1990). Common fac-
tors in different therapeutic modalities can in-
clude expectancies, the therapeutic relationship,
exposure or confronting the problem, and expe-
rience of control or competence (Weinberger &
Patients’ View of Therapeutic Action
Eig, 1999). Butler and Strupp (1986) pointed out
that “nonspecific” interpersonal factors cannot be
separated from interventions by the therapist.
Usually, common factors are formulated and
grouped from the perspective of the researcher
(Lambert & Ogles, 2004, p. 172) or the therapist
(Tracey, Lichtenberg, Goodyear, Claiborn, &
Wampold, 2003). In contrast, the theoretical
model presented here is grounded in the patients’
implicit knowledge. The results showed that in
the view of the patients, the relational aspects are
rather experienced as a “background presence” to
the patient’s own activity of narrating, express-
ing, and reflecting about one’s experiences and
“going through” and revising one’s personal his-
tory. The patients also spoke about the more
specific action of exploring together and its im-
pact, namely, expanding self-awareness. Argu-
ably, these are rather specific aspects of psycho-
analytic psychotherapy.
In addition, the hindering aspects, as experi-
enced by some patients, seem to be modality
specific: the insufficiency of self-knowledge, the
therapist’s negative passivity, and the wish for
guidance, advice, and “action-oriented” interven-
tions. Typically, these patients had their own
ideas as to what could have been different, such
as homework or keeping a diary. They often
wanted the therapist to take on the role of an
“expert” or a “good parental figure” and reported
thoughts about trying other treatments or medi-
cation. These patients experienced mismatch be-
tween their own ideas of cure and the accom-
plished treatment, as well as their personal fit
with the particular therapist. Probably, a study of
the views of patients in cognitive– behavioral
therapy would point out a group of displeased
patients asking for more of the specific psycho-
analytic factors.
The presented model stresses the patients’ own
active participation in the “talking cure” and
gives support to the notion of the patient as an
“active self-healer” who uses what is offered in
therapy to promote self-change (Bohart, 2000;
Bohart & Tallman, 1999). Recently there has
been an increased interest in the patient’s “theory
of change” as a possible route to integration
across therapeutic modalities. Some authors
maintain that the therapist’s confirmation of the
patient’s explanation of his or her difficulties and
complaints, as well as of the patient’s own idea of
cure, is crucial to the therapeutic progress (Dun-
335
Lilliengren and Werbart
can & Miller, 2000; Frank, 1973; Gold, 1994;
Lyddon, 1989; Wampold, 2001a, 2001b; Zuber,
2000). However, a naive acceptance of the pa-
tient’s ideas is in itself not curative. In the present
investigation, the overcoming of difficulties in
therapeutic collaboration, such as talking about
oneself, was stressed by the patients. This is in
accord with the importance of negotiating rup-
tures in the alliance (Safran, Crocker, McMain, &
Murray, 1990; Safran, Muran, & Samstag, 1994).
Therapeutic tasks and goals, the two dimensions
of therapeutic alliance according to Bordin (1979,
1994), provide an important part of such negoti-
ation (Safran, 2003). On the other hand, if the
patient’s and the therapist’s ideas of the goals and
tasks in therapy are from the beginning incom-
patible and not negotiable, the third dimension of
Bordin’s therapeutic alliance—that is, the emo-
tional bond— can never be established. In such
cases, the work of overcoming cannot start.
Rather, another therapeutic modality might suit
the patient better.
Implications for Clinical Practice
The present investigation demonstrates that
most of the patients seem continually to ask
themselves whether the therapy and the person of
the therapist are “right” for their problems. They
also have their own ideas of what could improve
the therapeutic work. However, some of them
stayed as long as 1.5 years in therapy despite their
discontent and sense of lack or mismatch. One
clinical implication of the present study is that the
therapeutic collaboration might profit if the ther-
apist actively checks his or her ideas of cure and
sense of collaboration against the patient’s view.
Satran (1995) suggested taking a closer look at
what patients experience as therapeutic by asking
periodically what stands out as helpful. The sim-
ilarities and discrepancies between the parties’
implicit theories of cure need to be discussed
from the very beginning of the treatment. Such
exploration and negotiation is in itself a powerful
agent of change.
The patients’ experience that self-knowledge is
not enough, their feeling that something is miss-
ing, and their displeasure with a passive therapist
suggest that many patients might profit from be-
ing encouraged to use in real life what they have
acquired in therapy. In this context a selective
incorporation of action-oriented or educative in-
336
terventions has been advocated (Frank, 1999;
Gold & Stricker, 2001; Wachtel, 1997). In sum,
the model grounded in the patients’ view con-
firms “the role of patient moderators in determin-
ing the effectiveness of interventions. It seems
quite likely that all procedures have an effect
when used on a compatible patient, but this effect
averages to near zero when patient factors are not
considered” (L. E. Beutler et al., 2004, p. 291).
An unavoidable conclusion from the present
study is that the therapist-centered vision of the
therapeutic action must be left behind. This vi-
sion has resulted in a problematic relationship of
psychoanalytic theory to technique (Fonagy,
2003). Throughout the years, increasingly com-
plex psychoanalytic theories have been devel-
oped, and several disparate claims have been
made as to how psychoanalytic therapy works
(cf. Lifson, 1996). Fonagy concludes that clinical
practice is no longer deducible from currently
available theory and is mostly based on clini-
cians’ implicit knowledge. The present study sug-
gests that theoretical models can profit and better
guide clinical practice if grounded in the knowl-
edge implicit in the patients’ experiences.
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