Research Sweden

Empirical psychoanalytic and psychodynamic studies in Sweden

(Members of Spaf marked with *)

Projects 2000—2012

Empirical psychoanalytic and psychodynamic studies in Sweden
(Members of the Swedish Psychoanalytical Association marked with *)
Projects 2000—2012

Gunnar Carlberg (principal investigator
Turning points in child psychotherapy
The Erica Foundation, Stockholm, Sweden
Aim. To investigate the nature and content of change, and factors underlying change
processes in psychodynamic child psychotherapy.
Method. Data from crucial, data-rich episodes in several child psychotherapies were
systematically collected in four studies. The narratives of the psychotherapists were
supplemented with data from questionnaires and analyses of process notes. Data were
collected from fourteen child psychotherapies through interviews, process records and
questionnaires. In addition, examples of changes in 102 psychotherapies were collected
through a questionnaire. Both qualitative and quantitative methods were used in the
analysis of data.
Results. Different kinds of turning points could be described. A few were turning points
in the sense of a sudden, unexpected change that persisted. Some were best categorised
as ‘the process goes on’. It was often possible to reconstruct a process leading up to the
change. How one categorises an identified change is dependent on factors such as ‘the
severity of the child’s disorder’ and on ‘the way the psychotherapist organises his
experience of psychotherapy processes’. The therapists’ experiences of turning points
can be seen as a part of their way of creating meaning. In the beginning of therapy
turning points were connected with ‘the therapeutic alliance’ and later with ‘conflict’
and ‘working through’. From the analysis of factors seen as underlying change
processes, a description of conditions beneficial for change was given. The meeting
between two subjects, mutually influencing each other could be considered the nucleus
of change.

Gunnar Carlberg (principal investigator)
Memories of significant episodes in psychodynamic child psychotherapy
The Erica Foundation, Stockholm, Sweden
Aim. To study psychotherapists’ memories of significant episodes in relation to experiences of
process and outcome in child psychotherapy.
Method. Therapists (n=31) were asked to retrieve emotionally valenced therapy episodes by
using an autobiographical memory approach, with cue words to elicit specific episodes (e.g.
irritated, ashamed, loving, and elated).
Results. All participants were able to retrieve memories of episodes. When asked to rate each
memory, negative memories were returned to less often, and overall positive memories were
rated as more easy to recall and more vivid. Memories derived from positive cue words also
were judged to have a more positive importance for outcome compared to negative.
Surprisingly, memories derived from the cue word irritated were seen as having more
positive than negative importance for outcome.

Gunnar Carlberg (principal investigator) & Fredrik Odhammar
The Erica Process and Outcome Study (EPOS)
The Erica Foundation, Stockholm, Sweden
Financial support. The study is supported by a research grant from Stiftelsen Marcus and
Amalia Wallenbergs Minnesfond.
Aim. To study outcome and process in goal-directed, time-limited child psychotherapy with
parallel parental counselling.
Method. Extensive data was collected from 38 cases. Child guidance clinics from different
parts of Sweden and Denmark were involved in the project. The children were between 5 and
10 years of age at the beginning of therapy. Therapy frequency was 1-2 sessions a week with
duration of 1-2 years. The parents met their counsellor once a week or at least every fortnight.
Therapists and parents formulated goals and frames for the therapies as carefully as possible
at the start of therapy. Besides questionnaires, interviews and routine psychological
assessment at the start of therapy the following instruments was used: DSM-IV, HCAM–The
Hampstead Child Adaption Measure, and SDQ–Strength and Difficulties Questionnaire
(parent and teacher versions). The same instruments were used after therapy. In connection
with each session the child psychotherapist and the parental counsellor made process notes
and completed a form, FWC–Feeling Word Checklist. Data collection has been completed.

Gunnar Carlberg (principal investigator), & Anders Shiöler
Outcome in psychodynamic child and adolescent psychotherapy
The Erica Foundation, Stockholm, Sweden
Financial support: The study is supported by Gålöstiftelsen.
Aim. To study outcome in child psychotherapy (4-12 years of age at start of therapy ? 10
sessions) and psychotherapies with young people (16-24 years at start of therapy ? 10
Method. Data is continuously collected from child and adolescent psychotherapies. Pre- and
post measures with CGAS/GAF, SDQ, DSM-IV, SCL-90. The database contains
approximately 200 child psychotherapies and 150 psychotherapies with adolescents and
young people (Dec. 2010).
Results. Published reports and master thesis (in Swedish). International publications planned.

Jan Carlsson (principal investigator), doctoral project
Psychotherapeutic identity: A research project on psychotherapists’ professional
development during and the first years after training

Department of Clinical Neuroscience, Karolinska Institutet, Stockholm.
Financial support: Stockholm County Council and Stockholm Centre for Psychiatric
Research and Education (CPF)
Background: The idea that the person of the therapist is crucial for the therapeutic process is
dating back to Freud’s work. However, psychotherapy research has tended to focus on the
therapy itself rather than on the therapist, as if the effectiveness of psychotherapy’s methods
and techniques is independent of the therapist using them. Research about training of
psychotherapists has been neglected in psychotherapy research.
Aim: To study the professional development of students during and after an advanced training
program in psychodynamic psychotherapy.
Method: With a longitudinal design students in a 3-year therapy training program in Sweden
were asked to answer a questionnaire about psychotherapeutic identity on three occasions
during training and once after. All students that completed the questionnaire on four occasions
were also interviewed.
Results: The training emphasized technical and methodological aspects to the relative neglect
of personal. The students stay close stay close to attitudes of their supervisors and kept a
psychoanalytic ideal during training, but become eclectic afterwards. An ambition was to
achieve recognition as psychotherapists and they wanted their preformed professional self to
be acknowledged rather then changed.
Discussion: Important developmental aspects are not properly addressed during training.
Students’ search for recognition as therapists strongly influences the process during training,
making it emotionally intense and creating a dilemma for teachers whether to confirm or
challenge students’ preconceptions. The preformed professional self must be adequately
addressed by teachers and supervisors possibly by using meta-communication and by
negotiating the supervisory alliance.

Jan Carlsson & Joakim Norberg (principal investigators), doctoral project
A narrative study of psychotherapy training: On the hardship of becoming a licensed

Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, and Department of
Psychology, Stockholm University.
Financial support: Stockholm County Council and Karolinska Institutet.
Background: Becoming a psychotherapist is a complex and idiosyncratic process.
Aim: In this study, a narrative analysis of interviews with three licensed psychotherapists
trained at an advanced course in psychotherapy was used to understand the complexities
involved in psychotherapy training.
Method: The respondents were asked to describe how they perceived their professional
development during training and the first years after it. The analysis was made in a group of
four researchers. As a first step, three researchers worked on one interview each, looking for
significant events and plots. In the next step, all three interviews were jointly analysed. The
emerging plots were then discussed and challenged with alternative explanations in the
research group.
Results: The analysis resulted in four plots 1) I want to belong; 2) Protecting the professional
self; 3) Surviving the training, and 4) Metamorphosis. Together they show the complexities
involved in being in training and striving to becoming a psychotherapist.

Jan Carlsson & Joakim Norberg (principal investigators), doctoral project
Hearing the other side of the story: What supervisors have to say about relationships to

Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, and Department of
Psychology, Stockholm University.
Financial support: PHI award 2010.
In a previous study (Carlsson & Norberg et al., 2010), 18 former psychotherapy students at a
training institute in Stockholm were interviewed about how they perceived their professional
development during training and the first years after it. A main finding was that relationships
to seniors, especially supervisors, were of great importance to the students during their
training. Supervisors were perceived as either god or bad, depending on whether they
corroborate or discourage supervisees’ own ideas about therapy. This resulted in either lost or
increased self confidence in students. As a continuation and to deepen the knowledge about
the processes in this project, the supervisors will be interviewed about the supervisory
relationship, emphasizing issues concerning how they dealt with supervisees’ prior ideas
about therapy. The results will then be compared to the previous study

Fredrik Falkenström & Rolf Holmqvist (principal investigators)
Linköping University Relational and Interpersonal Psychotherapy Project (LURIPP)
Linköping University
Financial support: Swedish Council for Working Life and Social Research
Background: Interpersonal Psychotherapy (IPT) and Brief Relational Therapy (BRT) are both
brief psychotherapies based on interpersonal theory, but differ mainly in type of relational
focus. IPT is focused on helping the patient solve specific interpersonal problems in the
patient’s life outside therapy that are thought to maintain the patient’s depression. BRT is
based on attachment theory, relational psychoanalysis and research on ruptures and resolution
of the therapeutic alliance. Previous research indicates that more self-critical patients have
worse outcome in brief psychotherapy (including IPT), probably because self-critical
personality traits create strains in the therapeutic alliance. Thus, BRT is hypothesized to be
better for self-critical patients because of the focus on ruptures in the alliance, while IPT is
hypothesized to work better for less self-critical patients.
Aim: To compare the efficacy and to study moderators and mediators of outcome in the
respective treatments.
Method: Patients with Major Depressive Disorder are randomized to 16 session of either IPT
or BRT. Outcome measures include Hamilton Depression Rating Scale, Patient Health
Questionnaire – 9, Outcome Questionnaire – 45, Inventory of Interpersonal Problems,
Depressive Experiences Questionnaire, Five Facet Mindfulness Inventory, Quality of Life
Inventory and Adult Attachment Interview scored with the Reflective Functioning Scale.
Process measures include the Working Alliance Inventory (12-item version) and the Feeling
Result: 17 patients have completed treatment, but no results are available yet.
Discussion: The study fulfils several purposes; it tests BRT against a treatment with already
established efficacy and allows for testing hypothesized moderator effects between treatment
modality and patient characteristics.

Kjell Granström (principal investigator), *Stephan Hau, Michael Rosander, Johan Näslund,
Gunilla Guvå, & Ingrid Rylander
The influence of revolting minority groups on mass situations
IBL, Linköping University
Financial support: The Swedish Civil Contingencies Agency (MSB)
Aim: Central for understanding how a mass event develops is to know which processes take
place between different groups and how the police choose to assess and treat a specific crowd
as a unit or not. In other words: Does the police have antiquated ideas on how masses
function? Within the frame of the project different types of mass events were studied, political
demonstrations as well as sport events.
Methods: 5 different types of mass events were systematically investigated using different
evaluation methods: permitted political demonstrations with a specific aim, not permitted
political demonstrations with a specific aim, street parties (often not permitted), counter-
demonstrations, supporter actions in the context of major sport events.
Results: The results of the project made it clear similarities and dissimilarities on how mass
events developed and how these processes were handled by the police. An important factor
defining differences between different forms of demonstrations was the extent of its
organisation and which aim was present. Depending on these factors the police acted
differently. A detailed description of the results can be found in the book: Granström, K.
(Red.) (2010). Demonstrationer och sporthändelser: Om poliser, demonstranter,
idrottssupportrar, kravaller och folkfest
. Lund: Studentlitteratur.

*Stephan Hau (principal investigator), Michael O. Russ, Wolfgang Leuschner, & Marianne
Characterising brain activity in sleep and dreaming with functional Magnet Resonance

Sigmund-Freud-Institut (Frankfurt/Main, Germany), Clinic of Neurology (University Hospital
Frankfurt/Main, Germany), Neurosurgery (Academic) at St. Bartholomew’s and The Royal
London School of Medicine
Financial support: Research grant from Neuropsychoanalysis
Aim: The aim of the project is to further our knowledge about basic physiological processes in
the tissue of the brain for sleeping and dreaming and to compare the findings with the
neurodynamic theory of dreaming by Kaplan-Solms and Solms.
Method: Evaluation time was limited to 60 minutes (Scanner: Siemens Magnetom Vison, 26
layers cover the cerebrum, including the brainstem), 18.720 images per session. In a first series
of exploratory experiments without EEG-recordings 4 out of 6 subjects fell asleep under the
conditions of the fMRT measurements. The next trial was performed as a systematic pre-study of
10 subjects (5 women, 5 men, age: 20-35) with complete polygraphic recordings (EEG, EOG,
EMG, EKG) and simultaneous fMRI-measurements. 4 out of 10 subjects fell asleep.
Results: Preliminary experiments demonstrated that it is possible to distinguish phases of sleep
with the fMRI method and to depict short events (e.g. sleep spindles). Dreams could be
collected. However, physiological and psychological data remained correlative phenomena.

*Stephan Hau (principal investigator), Sverre Varvin, Bent Rosenbaum, Vladimir Jovic, Tamara
Fischmann, Marianne Leuzinger-Bohleber
Posttraumatic dreams and symbolisation
Department of Psychology, Stockholm University, Sweden; Norwegian Centre for Violence and
Traumatic Stress Studies; IAN Center for Rehabilitation of Torture Victims, Belgrade, Serbia;
Psychiatric University Centre, Glostrup, Denmark, Sigmund-Freud-Institut, Frankfurt/Main,
Financial support: The Research Advisory Board of the International Psychoanalytical
Aim: The study aims to combine the investigation of the content of the dreams, the dream
work process and trauma. With a better understanding of the influence of trauma on dream
work we hope to further develop psychoanalytic understanding of dreams and the clinical
work with dreams.
Methods: In the frame of a larger study on psychological and physiological parameters of
PTSD (financed by the EU during 2005-2008) a group of 25 war veterans with PTSD related
to traumatic war experiences during the last Balkan war were investigated in the sleep
laboratory. They were selected from the larger group (N=100) as they all reported having
repetitive war-related dreams at least twice per week. More than 70 spontaneous dream
reports were collected under laboratory conditions. The standardized interviews – performed
by psychoanalysts in Belgrade - were tape recorded, transcribed and translated into English.
Two research groups, consisting of psychoanalysts from Germany, Norway, Denmark, and
Sweden are in the process of investigating the manifest dream narratives with two
sophisticated evaluation methods in order to describe symbolizing activity and relational
interactions in the dreams. At the same time, psychoanalysts from Belgrade will compare
these results with psychological measures such as: clinical symptomatology, personality
structure, stressful life events (prior to war and war-related), pre-war adjustment, and
cognitive and neuropsychological parameters.
Results: The dreams are still in the process of evaluation. Preliminary results will be presented
at the IPA Conference in Mexico City 2011.

*Stephan Hau (principal investigator), & *Gunnel Jacobsson
To become a psychotherapist: A clinical challenge for studnets and a pedagogic
challenge for teachers

Department of Psychology, Stockholm University
Financial support: Stockholm University, grant for Subject-Didactic Research.
Aim: Postgraduate psychotherapy education combines teaching of theoretical knowledge,
applied clinical experience as well as clinical practice under supervision. In an ongoing
naturalistic study, the interplay between learning declarative and procedural knowledge and
the development of a professional identity as a psychotherapist are investigated.
Methods: Two educational programs, both located at the Department of Psychology,
Stockholm university, are evaluated: A postgraduate psychotherapy education program and
the psychotherapeutic training taught during the later part of the MSc Psychology education
program. Much of the skills formed during the training concerns acquiring a procedural
clinical knowledge. At the same time the process of developing a psychotherapeutic identity
is very much linked to the capacity to form working alliances with patients, supervisors, and
teachers. However, these complex interactive processes have to be studied systematically in
order to improve the effectiveness of education programs. The processes of learning
procedural knowledge and the communicative aspects of the education are investigated by
means of interviews, questionnaires, student written summing-ups after psychotherapies and
performance measures. Students, supervisors, teachers, and patients are studied before, during
and after the educational programs. Conclusions can be drawn on how to further develop the
education for becoming a competent psycho-therapist by comparing the groups at two
different levels of education program.
Results: Preliminary results, based on student written summing-ups after psychotherapies and
interview data from the group of students, will be presented at the Society of Psychotherapy
Research 2011 International Meeting in Bern.

Ingrid M. Hedström (principal investigator), doctoral project
Psychotherapy – a room for my thoughts: Psychotherapy patients’ experiences of their

Institute of Communication, Aalborg University
The aim of this retrospective qualitative study is to get a deeper understanding of patients’ subjective experiences of their psychotherapy. Twenty-four former patients were interviewed with a semi-structured interview mirroring the psychotherapy process. The interview transcripts were analysed with two different qualitative analyses and a hermeneutic/phenomenological approach was used. First the different answers on the different questions, given by the persons, were picked out. Out of this material, themes were developed “ad hoc” from the statements of the group. In the interview the patient told his/her story of the psychotherapy and the next step was to interpret the interview, to see the interview as a whole and the context in which the narrative was told. In this analysis the
“hermeneutic circle” was used. Out of these analyses, living metaphors of psychotherapy could be discerned. Eleven metaphors were identified, picturing psychotherapy as: greenhouse, lifeline, fight, warm shelter, scheme of fault- tracing, magic, princess dream, childbirth, theatre, power station and tennis match. The metaphors could be joined together in four groups, each group characterized by one key concept and its opposite pole. Four group could be identified, “dependency-autonomy”, “idealization-reality adaptation”, “separateness-coherence, “externalization- internalization”. In these relational concepts different theories of development could be traced. Three attachment patterns could be identified: fearful, preoccupied and dismissing. In spite of one attachment style seems to dominate, there are in every group, traces of them all and they vary over time. See: Hedström, I. M. (2007).
Psykoterapi – ett rum för mina tankar: Om psykoterapipatientes upplevelse av psykoterapi.
Institut for Kommunikation, Aalborg Universitet; Denmark.

*Suzanne Kaplan (principal investigator)
Children in genocide: Extreme traumatization and affect regulation
The Hugo Valentin Centre, Uppsala University
With the background of the increasing traumatization of children in different war zones -
there is great reason to refine the theorizing about the after-effects of the victims when it
comes to affect regulating. Extensive research is carried out 1998–2012 concerning child
survivors of genocide with a starting point in the Holocaust and in the Rwanda genocide
1994. The psyche of different populations separated geographically and in time, but firmly
joined by shared experience of being victims of genocide is being explored. The aim is to find
indicators for overarching psychological phenomena. Grounded theory has been the method
for the analysis of 68 videotaped interviews. Categorizing is based on usage of the survivors’
expressions – affects and content - that are discussed in relation to psychoanalytic theory.
Hypotheses have been generated and have formed the basis for an emerging conceptual model
about trauma- and generational linking processes called the ‘affect propeller’. The concept of
linking implies an associative connection between affective states and major narrative
elements. The shape of a propeller is used to emphasize the dynamic process within each
individual. The blades of the propeller represent: affect invading, affect isolating, affect
activating and affect symbolizing. The ’affect propeller’ may be seen as an analytic tool for
the temporary present focus of the affect regulating of an individual as part of the trauma
process. The model as a whole may also be seen as an illustration to show how complex the
affect regulating is for traumatized individuals.

Marianne Leuzinger-Bohleber (principal investigator), Gerhard Hüther, *Stephan Hau, Bernhard
Rüger, Yvonne Brandl, Betty Caruso, Katrin Einert, Paula Herrmann, Jantje Heumann,
Gerlinde Göppel, Julia König, Jochen Lendle, Sibylle Steuber, Judith Vogel
Psychological and psychosocial integration of children with conspicuous behaviour in day
care centres. A prospective prevention study and intervention study in order to prevent
hyperactivity (according to ICD-10) and other social adjustment disorders in school

Sigmund-Freud-Institut (Frankfurt/Main, Germany), University of Göttingen, University of
Munich, Institut fur Analytische Kinder- und Jugendlichen-Psychotherapie, Frankfurt am
Main, City of Frankfurt
Financial support: The Zinkann Foundation, Hertie-Foundation and the Research Advisory
Board of the International Psychoanalytical Association
Aim: To apply in a prospective, representative and randomised controlled study a two year
psycho-social integrative intervention- and prevention program (no medication) in day care
centres. Statistically a significantly decreased number of children with psychosocial behaviour
disorders (especially ADHD) was expected at when beginning school.
Method: After a baseline evaluation of all public day-care centres (n=5300 children) a
representative sample of 14 day care centres with 500 children was selected and a similar control
group. From 2004-2006 the study was performed in these 14 day-care centres of the treatment
group which consisted of several modules (supervision of the teams, psychoanalytic-pedagogic
work with children in the day care centres on a weekly basis, work with parents, seminars for
teachers, individual and family therapies in the day-care centres in problematic cases.
Results: The main hypothesis could be proven as aggressive behaviour and anxiety level was
significantly lower in the treatment group than in the control group. However, as far as the
dimension hyperactivity was concerned, only the girls showed a significant decrease after the
intervention program.

Marianne Leuzinger-Bohleber (coordinator)1, *Stephan Hau8, Tamara Fischmann1, Nicole
Pfenning1, Katrin Luise Läzer1, Manfred Beutel2, Antje Haselbacher2, Eve-Marie Engels3,
Elisabeth Hildt3, Regina Sommer3, Rachel Blass4, Yair Tzivoni4, Varidella Meiner5, Nili
Yanai5, Gideon Bach5, John Tsiantis6, Vassiliki Vassilopoulou6, Gerasimos Kolaitis6, Eugenia
Soumaki6, Stelios Christogiorgos6, Vera Lagari6, Konstantina Kostakou6, Nikolas Tzavaras7,
Maria Samakouri7 , Miltos Livaditis7, Konstantia Ladopoulou7, Evgenia Tsatalmpasidou7,
Göran Collste9, Anders Nordgren9, Hans Wessel10, The-Hung Bui11, Ingrid Mogren12, Helen
Statham13, Joanie Dimavicius14, Gherardo Amadei15, Diletta Fiandaca15, Ilaria Bianchi15,
Donatella Quagliarini16, Riccardo Lingeri17, Vito Tummino17, Edgardo Caverzasi18, Irene
Cirillo18, Filippo Sarchi18, Laura Montanari18, & Alessia Arossa18
Ethical dilemmas due to prenatal and genetic diagnostics: interdisciplinary assessment of
effects of prenatal and genetic diagnostics on women, their partners, and on their
relationship in different European cultures (Specific Targeted Research Project, FP6)
Sigmund-Freud-Institute, Frankfurt, 2 Department of Psychosomatic Medicine, University of
Mainz, 3 Chair for Ethics in the Life Sciences, University of Tübingen, 4 Department of
Psychology, Hebrew University of Jerusalem, 5 Hadassah Hebrew University Hospital,
Jerusalem, 6 Department of Child Psychiatry, Athens University, Medical School “Agia
Sophia” Children’s Hospital, Athens, 7 Department of Psychiatry, Democritus University of
Thrace, 8 Institutionen för beteendevetenskap, Linköping University, 9Centre for Applied
Ethics, Linköping University, 10 Foetal Medicin Centre, Department of Women's Health,
University Hospital Karolinska Solna, 11 Centrum för fostermedicin & Kliniskt genetiska
avdelningen, University Hospital Karolinska, 12 Institutionen för klinisk vetenskap, obstetrik
och gynaekologi, Umeå universitet, 13 Centre for Family Research, Faculty of Social and
Political Sciences, University of Cambridge, 14Antenatal Results and Choices, London, 15
Universita' Cattolica di Milano, Milan, 16Clinica Mangiagalli, Milan, 17 Ospedale S. Anna,
Como, 18 University of Pavia, IRCCS Policlinico San Matteo, Pavia
Aim: The premise of this study is that enormous achievements in genetic research bring in
their course critical ethical dilemmas which need to be subject to reflection and debate in our
modern societies. Ethical dilemmas can be characterized as situations in which a person has a
strong moral obligation to choose each of two alternatives for action, but the person cannot
fulfil both. Denial of the ambivalences that the ethical dilemmas arouse constitutes a threat
both to society and to the individual person within it. One aim of the present study is to
investigate these dilemmas in detail in a field of genetic research which seems particularly
challenging: prenatal diagnostics. The availability of diagnostic data regarding genetic
abnormalities confronts the pregnant woman and her partner with ethical dilemmas regarding
the life and death of the unborn child, the responsibility for the unborn child and the desire for
a healthy child, the right to know and the right not to know, conflicting individual and social
expectations in specific cultures, etc. These dilemmas have not received due attention and
reflection in our society and often remain latent. This is a source of distress for all women and
their partners and may be a burden on their relationship (with some couples apparently coping
with their decision better then others, particularly if they are supported by empathic and
competent professionals). More research, however, is needed to identify those with
vulnerability to severe depression or other psychopathology consequent to genetically
indicated abortion or to giving birth to severely handicapped children (the pathology
sometimes first appearing only years after the decision regarding the pregnancy.). These
couples need professional support. The study will also describe patterns of care and
supportive interventions across participating centres.
Methods: Data was collected in 2 sub-studies in Germany, Greece, Israel, Italy, Sweden and
the United Kingdom. All results were integrated into a discourse on ethical dilemmas. Study
(A) recruited two groups of couples (positive or negative PND, total n= 1687). Experiences
with PND and connected dilemmas have been explored (questionnaires, interviews). Results
have been discussed in interdisciplinary research groups. Study (B) interviewed
psychoanalysts and their long-term patients who showed severe psychopathologies as
reactions to the dilemmas mentioned.
Results: Results were published in the book: Leuzinger-Bohleber, M., Tsiantis, J., & Engels,
E-M. (Eds.) (2008). The Janus face of prenatal diagnostics: A European study bridging
ethics, psychoanalysis and medicine
. London: Karnac

Peter Lilliengren (doctoral project), *Andrzej Werbart, (main supervisor), and Pia Risholm
Mothander (co-supervisor)
Attachment to therapist and long-term change after psychoanalytic psychotherapy with
young adults

Department of Psychology, Stockholm University.
Background: According to Bowlby, the therapist ideally functions as an attachment figure for
the patient, enabling safe affective exploration and corrective emotional experience in the
therapeutic relationship.
Aim: To investigate patient attachment to therapist at termination of treatment in relation to
long-term outcome of psychoanalytic psychotherapy with young adults. Specific research
questions: 1. Does the quality of attachment to therapist predict long-term outcome? 2. Does
attachment to therapist moderate progress after treatment termination?
Method: A new measure of patient attachment to therapist is being developed for the specific
aims of this study. The Patent Attachment to Therapist Rating Scale (PAT-RS) aims to measure
the quality of the attachment to therapist based on patient descriptions of the therapist as a
person, how the patient experienced the therapeutic relationship and how he or she behaved in
relation to specific attachment related issues. For testing the hypotheses a series of multiple
regressions will be preformed looking at the predicative and moderating role of quality of
attachment to therapist for long-term outcome.
Results: In an on-going pilot study the reliability and validity of the PAT-RS is tested.
Financial support: Department of Psychology, Stockholm University, and Vårstavi

Gudrun Olsson (principal investigator)
The beginning of psychotherapy
Institute of Communication, Aalborg University
This is a qualitative study based on patients’ diaries written while undergoing psychoanalytic
psychotherapy or psychoanalysis. The purpose of the study is to explore how patients may
experience the beginning of psychotherapy or psychoanalysis. It is concluded that how one
deals with one’s ambivalence is crucial. The ambivalence can be understood as emanating
from the earliest experience of hope and despair, wish and fear, order and chaos. The
ambivalence gets fuelled by the uncertainty in the initial psychotherapeutic encounter, based
on an asymmetrical power balance, where expectations often are implicit and where a
constant, unconscious negotiation about roles takes place. It is suggested that the therapist
might misinterpret the patient’s ambivalence as lacking of motivation if own ambivalence is
warded off and not contained. Further, it is suggested that more general patterns of beginning
as well as the beginning of life are reflected in the beginning of psychotherapy.

Gudrun Olsson (principal investigator)
To handle complexity
Institute of Communication, Aalborg University
In a qualitative study it is examined how psychoanalytically oriented psychotherapists at
different levels of experience handle complexity in psychotherapy. This is assumed to be
reflected in the way they understand and deal with the patient’s breaking of the frame. In
interviews psychotherapists are asked to tell narratives about patients’ frame deviations. The
analysis is inspired by Paul Ricoeur’s work on text interpretation. Beginners interpret the
deviation of the frame in only one single way. In dealing with the frame deviation, they tend
to rigidly stick to rules, or they adopt a laissez-faire attitude. It is concluded that beginners
deny complexity. Therapists who have acquired some experience of therapy accept different
layers of meaning. Also they may imagine different ways of coping. However, there is a gap
between understanding and coping. They do not communicate their understanding directly to
the patient. Complexity is both accepted and rejected. The experienced therapists not only
interpret a deviation of the frame in several ways, but they also directly use their
interpretations in the dialogue. These therapists are able to capture the context in which the
deviation occurred. They may perceive how they themselves contributed to the patient’s
breaking of frames and how the patient may understand this contribution. They may perceive
in what kind of emotional tone the patient carried out the break. They use all these cues in
restoring the frame and in understanding. Complexity in the human encounter is contained.

Gudrun Olsson (principal investigator)
Psychotherapists’ self-representations in good moments
Institute of Communication, Aalborg University
The broader aim of this study is to articulate the experience of good psychotherapeutic
practice. More specifically it is asked: How can we characterize those moments in
psychotherapy when something favourable seems to have happened and how do
psychotherapists’ self-representations appear at those good moments? One point of departure
is the notion that we organize our experience by narrating. The study is based on
psychotherapists’ narrative ways of knowing. After having finished a psychoanalytic
psychotherapy education, psychotherapists are asked to write stories about good moments in
their work with patients. About 100 written stories are analysed according to a
phenomenological/hermeneutic approach. The following therapists’ representations of selves
can be identified: The therapist in search for her/his own voice in dealing with idealized
theories, the therapist using the patient - therapist relationship in the purpose of change, the
therapist capable of standing objectification and control, the therapist’s containing psychic
pain, the therapist as a guardian of the psychotherapeutic frame, the therapist as a juggler,
open to several ”truths”, prepared to explore own motives, and the reflecting therapist
becoming reconciled with own shortcomings. It is discussed how a particular image of self is
claimed by emphasizing the problematic feature of a situation and then formulating a turning
point. It is stressed that even written documents are addressed to an imagined reader or
listener, which must be taken into consideration in every analysis.

Gudrun Olsson (principal investigator)
Gravel in the machinery: Bad moments in psychotherapy
Institute of Communication, Aalborg University
The purpose of this narrative study is to explore how psychotherapists depict those situations
in psychotherapy when they think something therapeutically unfavourable has happened.
According to the philosophical pragmatism, it is through our habits we inhabit the world, but
at the same time the world can be known to us only after our habits are interrupted. In the
same vein, what is expected in psychotherapy can be known only after something unexpected
and unfavourable has occurred. About 100 written stories from psychoanalytically oriented
psychotherapists are analysed using “double hermeneutics”. What moral can be extracted
from the narratives? Which representations of professional selves are conveyed in these bad
moments? Strategies used to maintain self-respect when asked to remember something
painful are noticed. A common feature in all bad moment stories is the psychotherapist
struggling with being drawn into the patient’s old dialogue scenarios. For example, the
therapist experiencing herself or himself being abandoned, dammed up, cross-examined,
poisoned or seduced acts from this position and shapes a dialogue deriving from the patient’s
as well as own unconscious drama. On the one hand, letting oneself being drawn into the
patient’s old dialogues can be the only way to understanding, but being incapable of
reflection-in-action and distancing may be devastating on the other hand. It is discussed how
in a complex pattern of internalized self-object dynamics the dialogue behind the dialogue can
be hearable and talkable.

Gudrun Olsson (principal investigator)
Why does it take such a long time?
Gothenburg Institute of Psychotherapy
This is a collaborative project between practitioner and researcher and its purpose is to
describe different aspects of time as it is experienced by patients in long term
psychoanalytically oriented psychotherapy. Patients are interviewed after having finished
their psychotherapy and the focus of the interview is what time meant to them. The analysis
of the interview transcripts is carried out by the phenomenological/hermeneutic inspired
guidelines about contextualisation (naive reading by challenging the natural attitude and
adopting a phenomenological, reflective attitude to get a preliminary understanding of the
interview as a whole), de-contextualisation (structural analysis to find patterns of meaning)
and re-contextualisation (comprehensive reading to find an interpreted whole). Five themes
emerged, considering the question what it is in the psychotherapeutic work that demands a
certain amount of time: It takes time to get in, it takes time to go over again and again, it takes
time to reach a bottom, it takes time to become one in the crowd and it takes time to let go. It
is discussed how our life narrative is in constant movement provided that one takes one’s time
to let it happen. Further, it is discussed how language not only represents reality but also
constructs reality. Thus, the formative function of language is stressed.

Gudrun Olsson (principal investigator)
Behind the scene: Glimpses of a research process
Gothenburg Institute of Psychotherapy
The purpose of this qualitative study is to capture the group members’ experience of
participating in the research process of the previous project. Participants are asked to give
their written documents considering question such as: Expectations on self and others,
including the relationship between the members and the senior researcher? Difficulties and
highlights? When was the group work rewarding and when was it hindering? Different phases
in the process can be identified. A short initial period of enthusiasm was followed by a long
phase of mixed feelings. Before the group meetings, there was a sense of being lost. After the
group meetings, joy and confidence prevailed. During group meetings there was a playful
atmosphere but this phase was also characterized by worry, for example about conducting a
tape recorded research interview. The worry about the patient’s participation was
considerable. The next short phase was characterized by a turning point, when a structure in
the material became visible. There was now a need to work on one’s own. It was first after
each member had written a text that the group became a “group-thinking-together”. This was
expressed in the final consolidating phase, where members of the group commented upon
each other’s texts. To conclude, the research process, as probably every creative act, can be
understood as a struggle between despair and trust. If despair, ambivalence and chaos can be
contained, new connections can be visible.

Gudrun Olsson (principal investigator)
Gothenburg Institute of Psychotherapy.
This work in progress is a qualitative study, based on a joint endeavour between practitioner
and researcher. Its purpose is to explore what meaning all the different separations from
patients might have to psychotherapists. To say goodbye to a person in whom great
involvement has been invested is assumed to influence psychotherapists in different ways,
both professionally and in private life. Tape recorded interviews are carried out with
psychotherapists working in the psychoanalytically oriented tradition. The interviews focus
on narratives about farewells from patients that psychotherapists remember in some special
way. It is thus up to the therapists to choose what type of farewells they want to talk about. In
the material, about 30 different farewell narratives could be identified. They are analysed with
the help of questions such as: What type of farewell are we talking about? What does it mean
to the psychotherapist? What is the point of the story, as it is conveyed by the interviewee and
as it is understood by the research team? On a general level, the study is supposed to give us
some knowledge about the norms and values inherent in the psychotherapeutic culture about
what constitutes the good goodbye.

Gudrun Olsson (principal investigator)
A short dynamic trip: Patients’ experience of short term psychotherapy
Gothenburg Institute for Psychotherapy, Supervision and Education
This in-progress study is based on close co-operation between practitioner and researcher.
The purpose is, from a life-world perspective, to investigate patients’ experience of time-
limited psychodynamic psychotherapy. In tape recorded interviews patients are asked to
imagine their finished therapy as a trip including preparations and a fixed deadline when the
trip is over. On a short trip one cannot see everything. What was the focus of this trip, and
what type of trip was it? Strict guiding or own discovery, or both? Impressions of the guide?
Which highlights and hardships came to the fore on the trip? Can it be recommended to a
friend? Why? Why not? What will be particularly remembered from the trip? In applying
“double hermeneutics” (capturing the patient’s self-understanding by putting oneself in the
patient’s situation, and interpreting this self-understanding by distancing and critical
reflection), the analysis is based on some main questions: What repeated maladaptive patterns
of living can be identified? Are there some indications that those patterns are understood and
challenged? What “evidence” is there that the present is interpreted in more nuanced ways
than only being based on interpretations of the past? The search for “evidence” is directed
towards the patient’s impressions of the therapist and their interaction as well as towards the
patient-interviewer interaction. The co-construction of narratives by narrator and interviewer
is specially noticed in the analysis.

Gudrun Olsson (principal investigator)
Looking back: Psychotherapists’ career narratives
Gothenburg Institute for Psychotherapy, Supervision and Education
A broader aim of this on-going project is an attempt to formulate a theory of science that is
specific for practical knowledge. How can a practitioner know how to do the right thing to the
right person in the right moment? The project is based on an epistemology of knowledge
about the human being as holistic, relational and contextual rather than atomistic and
fragmented into separable, well defined variables. The more limited aim is to capture the
psychotherapeutic experience as it is reflected in repeated interviews about career stories told
by senior psychotherapists. Following the narrative research tradition, narratives about
specific situations, concrete events and important meetings with people are elicited. There is a
special interest in illuminating the experience of psychotherapists being in ethical difficult
situations, and stories of regrets are therefore asked for. Participants are psychoanalytically
oriented psychotherapists, psychoanalysts and psychotherapists/psychoanalysts who also are
researchers. In the interpretations of the narratives, analytic instruments such as content and
structure, part and whole, the ordering according to time and space, plot and turning point will
be used. Vital metaphors are especially noticed as they are supposed to define our perception
of the world.

Björn Philips (principal investigator)
Matching and Outcome of Psychotherapy at Addiction Clinics in Sweden (MOPACS)
Centre for Dependency Disorders, Karolinska University Hospital, Stockholm Sweden
Financial support: Stockholm County Council.
The MOPACS project aims at studying the effectiveness of various forms of psychotherapy
for patients with substance use disorders and to investigate the impact of a number of
variables on therapy matching. Psychotherapies include psychodynamic therapy (PDT),
cognitive therapy (CT) and cognitive behaviour therapy (CBT) in individual format; group
analytic group therapy (GT); and systemic-eclectic family therapy (FT). Variables that are
hypothesised to be important for therapy matching include motivation, psychotherapy
expectancies, treatment goals and coping style. Trajectories for the patients’ development are
based on a number of measures administered every sixth month: prior to treatment, during
therapy and after completed therapy. Outcome measures include OQ-45, AUDIT, DUDIT-E
and information about health care utilization. Psychotherapy process measures include WAI,
SOFTA-S and PEX. Data was collected between 2006 and 2009. The project included 230
patients at the Centre for Dependency Disorders, Stockholm County Council. Results until
now: The Swedish version of OQ-45 has good psychometric properties. The concordance
between patients’ expectations prior to therapy and their experiences of therapy is related to
alliance early in therapy. Controlled motivation and amotivation are negatively related to
retention in therapy.

Björn Philips (principal investigator)
Mentalization Based Treatment for Dual Diagnoses (MBTDD): A randomized
controlled trial

Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm Sweden
Financial support: Swedish Council for Working Life and Social Research, and the
Secretariat for Research and Development, Stockholm County Council,
Objectives: The aim of the study is to examine the efficacy of Mentaliation Based Treatment
(MBT) as a complement to Medication Assisted Treatment (MAT) for Opiate Dependence,
compared to MAT for Opiate Addiction alone in patients with Borderline Personality
Methods: The study is a randomized, parallel-group, observer-blinded clinical trial. Patients
are recruited through dependency disorder clinics in Stockholm County, case-finding among
the social service offices in the region and through advertising in newspapers. The patients
included should be on ongoing MAT for Opiate Dependence. Patients are randomized to one
of two treatment arms, both lasting 18 months: 1) 40 patients subjected to psychotherapeutic
treatment with MBT as a complement MAT for Opiate Dependence or 2) 40 patients
receiving MAT for Opiate Dependence alone. MBT in accordance to a manual consists of
individual and group psychotherapy. Patients are subjected to six almost identical
assessments. The first occurs at the baseline before randomization to validate inclusion and
exclusion criteria. The second and third assessment occurs 6 and 12 months after the baseline
assessment. The fourth assessment (18 months; end point) occurs when the treatment
programs have just finished. The fifth and the final assessment occurs 24 and 36 months after
the baseline assessment to evaluate long term effects of the treatment. Assessments of the
primary outcome variable are done in accordance with the Borderline Personality Disorder
Severity Index, based on a semi-structured clinical interview.

Michael Rosander (principal investigator), *Stephan Hau, Johan Näslund
Collaboration and interaction in the context of aggressive expressions of activist and youth
groups: Collective self-images and ideas of other groups

Department of Behavioural Sciences and Learning, University of Linköping, & Department of
Psychology, Stockholm University
Financial support: The Swedish Civil Contingencies Agency (MSB)
Aim: Focus lies on identification processes and social identity processes in the context of
subgroups which can be identified during mass events. Identification and social identity
processes in subgroups are pronounced within the police organisation but can also be found in
different activist groups. How can the different views on the own group as well as on the
other groups be described and how do they influence behaviour in the context of mass events.
How do these different groups interact?
Methods: Members of different subgroups were interviewed as well as two mass events were
observed systematically.
Results: Will be presented at the European Association of Social Psychology Conference in
Stockholm, Summer 2011.

*Björn Salomonsson (principal investigator)
Mother-Infant Psychoanalysis Project of Stockholm (MIPPS), Part 1
Karolinska Institutet
Financial support: Ahrén, Ax:son Johnson, Engkvist, Golden wedding of King Oscar II and
Queen Sophia, Groschinsky, Jerring, Kempe-Carlgren, Mayflower Charity, Solstickan and
Wennborg foundations, and the Research Advisory Board of the International
Psychoanalytical Association
Background: Mother-infant psychotherapies need systematic evaluations.
Aims: (1) To explore clinical applicability and underlying theory of Mother-Infant
Psychoanalytic treatment (MIP) practiced in Stockholm. (2) To investigate a mother-report
questionnaire on infant functioning. (3) To compare outcomes of MIP with Child Health
Centre (CHC) care in an RCT.
Methods: For (1), tape-recorded single-case vignettes. For (2) and (3), an RCT of 80 mothers
and infants below 1.5 years. They were recruited from CHCs or advertisements on the internet
and at the Karolinska University Hospital. Follow-up assessments made after six months.
Instruments: The Ages and Stages Questionnaire: Social Emotional (ASQ:SE), the
Emotional Availability Scales (EAS), the Edinburgh Postnatal Depression Scale (EPDS), the
Symptom Check List-90 (SCL-90), the Parent-Infant Relationship Global Assessment Scale
(PIR-GAS), the Swedish Parental Stress Questionnaire (SPSQ), patient and treatment factors
from interviews.
Results: (1) Infant research supported that infants grasp emotional aspects of the analyst’s
address. Semiotic theory described this address. Psychoanalytic theory supported that MIP
functions via the analyst’s containing the anxieties of mother and baby and translating their
communication into more comprehensible messages.
(2) The baby questionnaire, the ASQ:SE, associated with maternal distress (EPDS, GSI,
SPSQ) but not with externally rated baby functioning (EAS, PIR-GAS), especially for
depressed mothers. Measuring infant functioning in clinical samples is thus problematic.
(3) MIP yielded significantly better effects on the EPDS, maternal sensitivity (EAS), and the
PIR-GAS, and nearly significant effects on the SPSQ. Qualitative pre-treatment assessments
moderated outcomes. “Participator” mothers improved on sensitivity (EAS), more from
MIP. “Affected” babies improved on PIR-GAS scores, and their mothers on sensitivity
(EAS), more from MIP.

*Rolf Sandell (principal investigator)
Stockholm Outcome of Psychotherapy and Psychoanalysis Project (STOPPP)
Institute of Psychotherapy, Stockholm County Council, and Linköping University
Financial support: Funded by Stockholm County Council
In view of the relative lack, internationally, of studies of the effects of psychoanalysis
and long-term psychotherapy, the purpose of this project was to make a systematic
evaluation of these treatments. On the basis of an analysis of 200+ referrals for
psychoanalysis or long-term psychotherapy, it was concluded that analysands, as a
group, are educationally and vocationally very qualified, yet quite vulnerable and
distressed from a psychiatric point of view. A three-wave panel survey among 700+
patients revealed striking improvement, particularly among analysands, in self-ratings
of symptom distress, morale, and (to a lesser degree) social adjustment, during and,
particularly, after treatment. Repeated personal follow-up interviews in a subsample of
patients tended to support this. Moreover, self-analysis was found as a strongly
contributing factor in post-treatment improvement. Outcomes were unrelated to
subsidization but positively related to treatment frequency and duration. Positive
development among patients was also related to a cluster of therapist experience
variables involving age, years in private practice, years since licensing, caseload, and
psychoanalytic training. Also, patient outcome was related to therapist ideals and
values, where an orthodox psychoanalytic orientation was found inferior to an eclectic
stance in psychotherapy but not in psychoanalysis. Self-reports on absenteeism, health
care utilization etc. showed substantial individual differences, with the majority of the
patients remaining on initially very low levels.

*Rolf Sandell (principal investigator)
Primary prevention of psychological ill-health among young people though socio-
emotional training i school

Linköping University
Financial support: Funded by the Social Science Research Council and the Swedish
Council for Working Life and Social Research
The purpose of the project was to evaluate a systematic, manualized program for
training of students' socio-emotional functioning in the classroom. After one school
year of training of the participating class teachers, the program was implemented in a
number of classes in grades 0-9 in two schools in a Stockholm suburb from 2001 on.
Two classes in each grade in two other schools served as controls, that is, without any
corresponding systematic training. The years 2001-2005 an extensive questionnaire was
administered to all students in the participating classes to assess changes in self-esteem,
psychological well-being, and social functioning. A special test for the assessment of
emotional intelligence was also developed in the project. An interesting incidental
finding of this unusually long panel study under field conditions was that several factors
contributed to large progressive attrition: turnover among students, teachers, and school
management, besides lack of “study discipline” among students and teachers. Also,
indifferent or negative attitudes among the school management generate serious threats
against field studies of this kind. Follow-along assessments after two and five years into
the program revealed, nevertheless, significant positive effects on self-esteem,
internalised and externalised problems, optimism and self-efficacy, and contentment in
school, as well as abuse of narcotic drugs and alcohol, sniffing and smoking. Interviews
with the teachers reflected generally positive experiences of working in the project.
Among other things, many teachers gave evidence of calmer atmosphere in the
classroom and greater involvement in school work among the students. A general
conclusion of the project is that a carefully supervised socio-emotional training
program, continuous and long-term, with the benign interest and support of the school
management, may positively influence students’ social functions and mental health.

*Rolf Sandell (principal investigator), Lars-Gunnar Lundh, Mats Fridell, Håkan
Johansson, Gardar Viborg, Martin Svensson, & Thomas Nilsson
Psychotherapy Outcome and Self-selection Effects for panic disorder (POSE)
Department of Psychology, Lund University
Panic disorder (PD), with or without agoraphobia, is a widespread phenomenon;
Scandinavian studies suggest a point prevalence of 2-3% for PD. Although CBT has shown
good effects in well-conducted studies, a significant number of patients who have completed
their treatments still suffer from PD symptoms while, too, a significant number of patients
have dropped out before completing theirs. One reason for these outcomes may be that CBT
does not work for all patients. A reasonable guess is that some other form of therapy may suit
these non-responders better. A manualised brief form of psychotherapy, Panic-Focused
Psychodynamic Psychotherapy (PFPP), has shown good effects on PD patients, and the
purpose of this project is to compare PFPP with a well-established form of CBT, Panic
Control Treatment (PCT) under two different conditions. In one condition the patient is
assigned to one of the treatments on a chance basis, as in a randomized clinical trial. In the
other condition the patient is offered to choose his or her treatment after having been
informed about the two alternatives. Our assumptions are that the freedom to choose
generates a stronger treatment alliance and that the patients’ self-awareness helps to identify
the more suitable treatment. Accordingly, it is expected that, in the self-selection condition,
treatment outcomes will be generally superior to those in the randomized condition and that
the two treatments will have more or less equal outcomes. The therapies are conducted by
trained licensed psychotherapists under supervision. We plan to include about 300 patients.

Agneta Thorén (principal investigator)
Short-term psychotherapy for children and young people
The Erica Foundation, Stockholm, Sweden
Financial support: Research grant from Stockholm County Council.
Aim. To study process and outcome in time limited psychotherapy (12 sessions) with children
(5-9 years of age) and young people (16-24 years of age).
Method. In this study the process of change is followed with the help of various specific
research instruments, questionnaires and interviews. Waiting-list control. Besides routine
psychological assessment at the start of therapy the following instruments are used: DSM-IV,
CGAS/GAF, SCL-90, SDQ (parent and teacher versions). The same instruments are used
after therapy. In connection with each session the child psychotherapist and the parental
counsellor make process notes and complete a form, FWC–Feeling Word Checklist and a
“process-diary”, in order to follow the therapists' counter-transference feelings, work with
central theme/focus of each therapy. Data will be analysed using both qualitative and
quantitative methods.
Time schedule: Collection of data started in 2009. Data collection will be completed 2011.
Results. Published reports and master thesis (in Swedish). International publications planned.

*David Titelman (principal investigator)
Suicide-nearness as expressed in the writings of Primo Levi
National Prevention of Suicide at Karolinska Institutet (NASP), Karolinska Insitutet
To elucidate suicide-nearness, the perspectives of the death drive and narcissism are
applied Financial support: The Bertil Wennborg Foundation.
to the writings of Primo Levi. Emerging themes are Levi’s struggle to maintain his self-
regard from his year as a prisoner in Auschwitz and onward, and his observations on
xenophobia, violence, and the need for love. The gradual increase of depressive content
in Levi’s work is noted, as are his identifications with others who succumbed in the
Holocaust or took their lives after surviving it. The conflict between the wish for peace
and the need for love is seen as impossible to resolve under the threat of extermination
and as reemerging in the prevailing sense of loneliness that Levi described.

*David Titelman (principal investigator), Alf Nilsson, et al.
Studies on depression, anxiety and psychological defence suicide-nearness, using the
Percept-genetic Object Relation Test (PORT)

National Prevention of Suicide at Karolinska Institutet (NASP), Karolinska Insitutet
Financial support: Research associate stipend, Department of Public Health Sciences,
Karolinska Institutet.
In a pilot study and a recently completed replication study of 40 suicide attempters and
90 normal controls we investigated the reliability and validity of a “suicide cluster” of
signs or response patterns in PORT, the Percept-genetic Object Relation Test. PORT
documents subliminal perception of object-relation pictures and registers the influence
of depressive affect, anxiety, and psychological defences on the tested individual’s
perception. The subject’s responses to the stimulus pictures are documented in a
protocol that is coded by one or more trained judges, who are blind to whose protocols
they are coding. In both studies a significant impact of high levels of anxiety, defensive
operations that obliterate the relatedness aspect of the projected figures (“Lack of
attachment relationships”), signs reflecting a tendency to act out (“Motoric activity”),
and faulty reality testing (“No C-phase”) were documented – these were the signs of the
suicide cluster. In the replication study the correspondence between the assessments of
two independent judges of the suicide-cluster signs was 95-100%. The results are
discussed in relation to response patterns found in other clinical groups tested with
PORT. The discussion also includes an application of psychoanalytic and attachment-
theory perspectives to the results. Although a vitalizing internal object appeared to be
lacking in the suicidal participants as a group, in individual cases the test situation
stimulated reflection on the traumatic background of their suicidality; this also applied
to participants characterized as “alexithymic” in their medical records. We conclude that
the suicide cluster in PORT is valid and reliable, but also that we remain open both to
whether suicide-nearness is a state or a trait and to individual variations of coexisting
primitive and mature sides of the personality in suicidal crises.

*David Titelman (principal investigator), & *Anne Stefenson
Studies on suicide among persons with long-term psychosis
National Prevention of Suicide at Karolinska Institutet (NASP), Karolinska Insitutet
Financial support: Stockholm County Council, Secretariat for Research and Development.
a. Interviews with psychotic patients who have attempted suicide and those who have not
done so (N=20). Planned report 2011
b. Retrospective analyses (“psychological autopsies”) of all cases of suicide among
psychotic and nonpsychotic psychiatric patients in Stockholm County during 1 year
(N=100). Planned report 2012.
c. Complementary interviews with close relatives and selected care persons of individuals
with long-term psychosis. Planned report 2013-14.

*Andrzej Werbart, principal investigator, David Forsström, and Madeleine Jeanneau
Long-term outcomes of psychodynamic residential treatment for severely disturbed
young adults: A naturalistic study at a Swedish therapeutic community

Institute of Psychotherapy, Stockholm, Department of Psychology, Stockholm University,
Department of Public Health Sciences, Karolinska Institutet, Competence Center of
Psychotherapy, Stockholm County Council, Sweden
Background: Psychodynamic inpatient treatments, often combining milieu therapy and
psychotherapy, used to be one of the treatments of choice for patients with severe psychiatric
diagnoses. However, due to the scarcity of well-conducted outcome studies, such combined
treatment is increasingly rare in Western countries.
Aim: This study examined the long-term effectiveness of a treatment model at a Swedish
therapeutic community for young adults with severe personality disorders, combining milieu
therapy and in-patient long-term psychodynamic psychotherapy.
Method: Data were collected for the 56 residents between 1994 and 2008 at intake,
termination and 2-year follow-up. Patient residency ranged from 2 to 60 months, with average
psychotherapy duration of 30.2 months. Self-rated outcome was measured using the Symptom
Checklist-90-R. Expert-rated outcomes comprised the Global Assessment of Functioning, the
Strauss-Carpenter Outcome Scale and the Integration/Sealing-over Scale.
Results: All outcome measures showed significant improvement on a group level from intake
to discharge. Most patients had maintained the therapeutic gains at the 2-year follow-up. The
effect sizes were high and the Reliable Change Index provided evidence of good outcome for
92% of the patients at follow-up. The expert ratings gave somewhat larger effect sizes than
the patients’ self-ratings.
Conclusions: The effect sizes and success rates are at comparable level as in corresponding
studies of long-term treatments of personality disorders. Most patients had a substantial
individual improvement from intake to termination and follow-up. This indicates the
effectiveness of this highly specialized and intensive treatment approach for severely
disturbed young adult patients.

*Andrzej Werbart, principal investigator, and *Sonja Levander
Private theories of pathogenesis and cure: patients in psychoanalysis and their analysts

Institute of Psychotherapy, Stockholm, and Department of Psychology, Stockholm
University, Sweden
Background: Concerning official psychoanalytic theories of therapeutic action, the current
situation is characterized by the abundance of pluralism and lack of integration. Both patients
in different kinds of treatment and their clinicians develop implicit, private theories of
pathogenesis and cure.
Aim: To investigate vicissitudes of implicit ideas of how psychoanalysis might be of help with
the analysands’ psychological problems, and how concordance and discordance between the
participants interacts with the process of change.
Method: This prospective longitudinal study includs the total of 7 analyses. The Private
Theories Interviews (PTI) with analysands and their psychoanalysts are conducted at the start
of psychoanalysis, and then 6 months, 1.5 years, 3years, and 4.5 years after the first interview,
at termination of the analysis, and with the analysands 1.5 years post- termination. Transcripts
are investigated by means of a systematic multicase study methodology and inductive
thematic analysis.
Results: Both utopian ideas and ideas of more attainable cure were found in both parties. The
utopian ideas of wished-for cures persisted throughout the psychoanalytic process in both
participants in more than half of the cases. Utopian ideas often created feelings of
incompatibility between the analyst and the analysand. The abandonment of these ideas was
related to more positive experienced outcome of psychoanalysis. Furthermore, we found
personality differences in analysands’ response to specific dimensions of the analytic process.
Conclusions: The study suggests that the psychoanalytic process might profit from the
analyst’s observance of incongruities between the parties’ ideas and openness to work them
Financial support: The Bertil Wennborg Foundation and the Research Advisory Board,
International Psychoanalytical Association.

*Andrzej Werbart, principal investigator, David Forsström, et al.
Psychoanalysis in Public Service Setting (PPSS): Outcomes and individual patterns of

Institute of Psychotherapy, Stockholm, and Department of Psychology, Stockholm University
Background: There are only few studies of psychoanalysis in public service settings.
Aim: The aim of this study is an in-depth exploration of quantitative and qualitative data from
a series of psychoanalyses conducted in a Swedish public service setting. The hypothesis is
that patients categorized as anaclitic (focus on relatedness) and those categorized as
introjective (focus on self-definition) according to Blatt’s personality model display different
patterns of changes and differ as to their experiences of helpful and hindering factors in their
Method: 26 patients in psychoanalysis and their 10 analysts at the Institute of Psychotherapy
were included. Outcome measures included Symptom Checklist –90, Self-Rated Health,
SASB, Sense of Coherence and socio-demographic data. The patients were interviewd at
termination and 2-year follow-up sing the Change After Psychotherapy Interview (CHAP)
and classified as anaclitic or introjective. The case series method enables looking at the
questionnaire and interview data from different perspectives and focusing on clinically
relevant questions.
Results: Outcome data from a series of psychoanalyses conducted in a specialized public
service setting are explored in-depth. Outcome data collected by different self-rating and
expert-rating instruments are compared. In serial case studies we track the individual patterns
of change in order to better understand how the patients benefited from psychoanalysis. The
study is expected to result in identification of prototypical cases, representing different
outcome profiles and different pathways of change.
Financial support: The Research Advisory Board, International Psychoanalytical Association.

*Andrzej Werbart, principal investigator, Lena Johansson, Peter Lilliengren, Björn Philips
(doctoral project), et al.
Young Adult Psychotherapy Project (YAPP)
Institute of Psychotherapy and Karolinska Institutet, Stockholm
Background: The evidence base in psychotherapy research can be enriched adopting a
naturalistic stance and taking the patients’ view into account.
Aim: To study psychoanalytic psychotherapy with young adults from the viewpoints of
outcome and patients’ ideas of cure, and how these two aspects are related to each other.
Method: 134 patients were included. Measures included Symptom Checklist –90, Self-Rated
Health, GAF, IIP, SASB, Differentiation-Relatedness Scale and Helping Alliance. Ideas of
cure were explored using the Private Theories Interview. Qualitative methods included ideal-
type analysis and grounded theory.
Results: The patients were considerably more troubled than Swedish norm groups at intake.
The patients showed improvement on all outcome measures at termination. The largest
positive changes were with respect to the patients’ overall health and functioning. A majority
of the patients had ideas of cure that were in line with psychoanalytic psychotherapy. Patients
who terminated therapy prematurely were significantly closer to the ‘distancing’ pole
regarding ideas of cure, while completers closer the ‘approaching’ pole. Tentative theoretical
models of therapeutic action were construted, starting from the patients’ and the therapists’
perspective. The patients and therapists both stress the importance of establishing a special
kind of relationship enabling the patients to talk openly about their inner experiences.
However, both parties had incompatible, implicit theories regarding what the problem in
therapy was and what was needed to change it.
Conclusions: The introductory sessions seem to be of vital importance in helping patients to
engage in a potentially beneficial therapy.
Financial support: Söderström-Königska Nursing Home Foundation, the Bank of Sweden,
Tercentenary Foundation, and the Research Advisory Board of the International
Psychoanalytical Association.

*Andrzej Werbart and *Gunnel Jacobsson (doctoral project), principal investigators
Young Adult’s Own Thinking, Understanding, and Managing of Everyday Life

Institute of Psychotherapy, Stockholm, and Department of Education, Stockholm University
YOUTH is a study of private explanatory systems and personal strategies, created by young
adults (aged 18-25; non-clinical population) in confrontation with strains and challenges on
the threshold of adulthood.
Part 1: Using case study methodology, both successful and non-adaptive strategies are
investigated, as well as differences between women’s and man’s private theories about their
difficulties and ways of managing strains and challenges in life. The material includes PTI-
interviews with 24 young adults, as well as interviews, questionnaires, and rating scales used
in YAPP. Data is collected at 3 points of time: at the baseline, 1.5 and 3 years later.
Part 2: A survey in a representative random sample of young adults in Stockholm (N=630). In
this part of the research programme a Private Theories Questionnaire was constructed and
Part 3: A pilot study of private theories constructed by young adults in narratives collected
online on the Net.
Financial support: Stockholm County Council, Secretariate for Research and Development,
and the Research Advisory Board of the International Psychoanalytical Association.

*Andrzej Werbart (principal investigator), students at the Department of Psychology,
Stockholm University and at the Department of Clinical Neuroscience, Karolinska Institutet,
Changes in the representations of self, mother and father among young adults in
psychoanalytic psychotherapy

Background and aim: Studies of cognitive-affective schemas of self and significant others
provide a method for investigating therapeutic change. The present study explores the
changes in young adult patients’ representations of their parents from prior to psychotherapy
through long-term follow-up
Method: Twenty-five women and 16 men from the Young Adult Psychotherapy Project
(YAPP) were interviewed according to Sidney Blatt’s unstructured Object Relations
Inventory prior to psychoanalytic psychotherapy, at termination and at the 1.5-year follow-up,
comprising 123 interviews in all. Typologies of the 246 parental descriptions were
constructed by means of ideal-type analysis for male and female patients separately, and for
representations of mother and father separately.
Results: The analysis resulted in 5 to 7 ideal types of mother and father representations. Prior
to psychotherapy, women’s representations of their fathers and men’s representations of their
mothers seemed most problematic. As to the content, the most common descriptions of the
parent were the emotionally or physically absent parent, and the parent with his or her own
problems. In most cases, the descriptions of the parent changed over time in terms of
belonging to different ideal-type clusters. There were important improvements in the quality
of the descriptions, and the changes continued after termination of psychotherapy. However,
most of the parental representations were negative in all three interviews.
Discussion: The possible explanations of these findings are discussed.
Financial support: The Bank of Sweden, Tercentenary Foundation, the Secretariate for
Research and Development, Stockholm County Council, and the Research Advisory Board of
the International Psychoanalytical Association.

*Andrzej Werbart, principal investigator, Camilla von Below et al.
Depression among young men and women in psychotherapy: patient perspective on own
problems, medication and psychotherapy in relation to outcome

Institute of Psychotherapy, Stockholm County Council, and the Psychotherapy Section,
Department of Clinical Neuroscience, Karolinska Institutet.
Background: Growing incidence of mental ill-health and depression among young adults, and
women in particular, is reported in Sweden.
Aim: The first aim was a longitudinal follow-up of young adult psychotherapy patients with
diagnoses within the depression spectrum. The the second aim was to explore patients’
experiences of overcoming depression.
Method: The material consisted of data collected in YAPP. Of the 87 diagnosed cases in
YAPP, 23 patients (26%) had pre-treatment Mood Disorder diagnosis. Both quantitaive and
qualitative methods were used.
Results: At termination, 45% 16 of patients still had a diagnosis of Mood Disorder, while 1.5
years later 20% had this diagnosis. The percentage of patients on medication remained
unchanged. The patients significantly improved at termination and at 1.5 years follow-up in
respect of self-reported symptoms, self-rated health, positive and negative aspects of self-
concept, and the differentiation-relatedness of self and object representations.
Grounded theory analysis resulted in 15 distinct categories, organized into five general
domains: experiences of positive change, in-therapy contributions to positive change, extra-
therapeutic contributions to positive change, obstacles in therapy and negative experienced
outcomes. Exploration of interplay between these domains resulted in a process model for the
way out of depression. The positive changes experienced extended beyond symptom relief.
The patients emphasised finding out how they wanted to live and how they started forming
their lives in that direction. Obstacles in therapy interplayed with the experience of being
stuck in depression.
Discussion: These findings are related to age-specific challenges on the threshold of
Financial support: Bank of Sweden, Tercentenary Foundation, the Centre for Health Care
Science, the Clas Groschinsky Memorial Fund, and the Research Advisory Board of the
International Psychoanalytical Association.

*Andrzej Werbart, principal investigator, and students at the Department of Psychology,
Stockholm University
Patients’ view of helpful and hindering factors in psychoterapy in relation to
longitudinal outcomes: Post-termination changes

Institute of Psychotherapy, Stockholm, Child- and Adolescent Psychiatry, Stockholm County
Council, Karlinska Institutet, and Department of Psychology, Stockholm University.
Background and aim: There is a need of long-term follow-up of the effects of psychotherapy,
as well as appplying the patient perspective on process and outcome.
Methods: The material consists of quantitative and qualitative data collected in YAPP.
Results: All outcome measures changed significantly from intake to follow-up. Lower
therapist-rated alliance predicted greater change in psychiatric suffering for patients reporting
more psychiatric symptoms at intake. A qualitative study of changes in parental
representations showed that most common descriptions of the parent were the emotionally or
physically absent parent, and the parent with his or her own problems. Dissatisfied patients
lacked confidence in their relationship to the therapist, felt unable to express their own
feelings, lacked direction in therapy and wanted more response from the therapist. They felt
abandoned by an insufficiently flexible therapist, a therapy lacking intensity, and links
missing between therapy and everyday life. In the most successful therapies, helpful factors in
therapy and in life reinforced each other in a positive feedback loop. In a growth-promoting
and secure relationship the patients and the therapists could overcome obstacles to their
collaboration. The patients obtained support in close relationships, could cope with strains in
life and continued to apply therapeutic experiences after termination. The therapists
experienced the therapeutic work in a strikingly similar way.
Conclusions: The long-term effectiveness of psychoanalytic psychotherapy for young adults
was supported. Hypotheses were generated about the benefits of a therapist listening to the
patient’s ideas and making interpretative interventions focusing on obstacles to the
therapeutic work.
Financial support: Secretariate for Research and Development, Stockholm County Council,
and the Research Advisory Board of the International Psychoanalytical Association.

*Andrzej Werbart, principal investigator, and Peter Lilliengren (doctoral project)
Therapists’ view of helpful and hindering factors in psychoterapy with young adults
Institute of Psychotherapy, Stockholm, and Department of Psychology, Stockholm
Background: Studying experienced therapists’ implicit theorizing may contribute to our
understanding of what is helpful and what hinders treatment with particular patient
Aim and method: In this study, 16 therapists’ views of curative factors, hindering factors and
outcome were explored in 22 interviews conducted at termination of individual
psychoanalytic psychotherapy with young adults. The material consists of data collected in
YAPP. Grounded theory methodology was used to construct a tentative model of therapeutic
action based on the therapists’ implicit knowledge.
Results: The results indicated that Developing a Close, Safe and Trusting Relationship was
viewed as the core curative factor in interaction with the Patient Making Positive Experiences
Outside the Therapy Setting and the therapist Challenging and Developing the Patient’s
Thinking about the Self. The therapeutic process was experienced as a joint activity resulting
in the patient Becoming a Subject and acquiring an Increasing Capacity to Think and Process
Problems. The Patient’s Fear about Close Relationships was seen as hindering treatment and
leading to Core Problems Remaining.
Discussion: The model is discussed in relation to major theories of therapeutic action in the
psychoanalytic discourse and previous research focusing on young adults’ view of curative
and hindering factors in psychotherapy. Implications for practice and further research are
Financial support: Clas Groschinsky Memorial Fund, the Centre for Health Care Science,
Karolinska Institutet, and the Research Advisory Board of the International Psychoanalytical

*Andrzej Werbart (principal investigator), Sverker Sikström and David Arvidsson
Changes in self- and object representations following psychotherapy measured by a
theory-free, computational, semantic space method

Institute of Psychotherapy, Stockholm, and Departments of Psychology, Stockholm
University, Lund University and Gothenburg University
Background: Theory-driven measures of object representations may be useful for evaluating
the particular theory they were designed for. However, they may be at risk of ignoring other
potentially important characteristics.
Aim: To propose a theory-neutral, computational and data-driven method for assessing
changes in semantic content of object representations following long-term psychodynamic
Method: Young adults in psychodynamic psychotherapy were compared with an age-
matched, non-clinical sample at three time points. Verbatim transcripts of descriptions of the
self and parents were quantified in a semantic space constructed by Latent Semantic Analysis.
Results: In the psychotherapy group, all representations changed from baseline to follow-up,
whereas no comparable changes could be observed in the comparison group.
Discussion: The semantic space method supports the hypothesis that long-term
psychodynamic psychotherapy contributes to sustained change of affective-cognitive schemas
of self and others.
Financial support: The Research Advisory Board of the International Psychoanalytical

*Andrzej Werbart, principal investigator, *Alexandra Billinghurst, *Johan Schubert, et al.
Quality Assurance of Psychotherapy in Sweden (QAPS)
Institute of Psychotherapy and Stockholm County Council
Background: There is a need for various sources of evidence and research methods in order to
build an empirical knowledge base applicable to routine psychotherapy practice.
Aim: To describe, follow up and evaluate the effectiveness of psychotherapy in public
services in a standardized way.
Method: QAPS is a core battery of well-established theory-neutral instruments with on-line
data entry. The patient questionnaire consists of socio-demographic data and the self-rating
scales SRH, SCL-90, QOLI, HAQ and CSQ-8, and is administrated at the beginning, during
and at the end of psychotherapy, and twice as follow-up. The psychotherapists fill in the
questionnaire at the beginning and end of psychotherapy.
Results: QAPS is running from 2007. At present, 15 psychiatric, psychotherapeutic units and
GP-units are involved in the project and the data base includes more than 1.500 patients and
320 therapists. QAPS offers great possibilities to extract different types of information from
the database. This can be done by the psychotherapists regarding their patients, by the units as
regards all patients at the unit there or the entire material. Questions which may be answered
include: who is in psychotherapy, what types and forms of psychotherapy are practiced, how
does the group of patients – and the treatment they get – change over time, what is the
outcome of the various psychotherapies and how does it differ between treatments?
Discussion: First experiences from the implementation of the system in routine psychiatric
care underline the clinical usefulness of monitoring patient progress and feedback to
Financial support: Stockholm County Council.

*Andrzej Werbart, principal investigator, Lars Levin, Mo Wang, and *Rolf Sandell
Which psychotherapy suits whom? A naturalistic study of interaction effects in
psychotherapy in public servrice settings

Stockholm Centre for Psychiatric Research and Education, Karlinska Institutet; Child- and
Adolescent Psychiatry, Stockholm County Council;, and Department of Psychology,
Stockholm University.
Background: Defining empirically supported treatments exclusively in terms of randomized
controlled trials has numerous limitations.
Aim: This naturalistic study presents patient pre-treatment characteristics and compares
outcomes for three psychotherapy types practised in psychiatric routine care. Further
comparisons include patients who did not start psychotherapy after the initial assessment and
patients who started their treatment, patients who discontinued and those who remained in
treatment, as well as patient-initiated and therapist-initiated dropout.
Method: Data were collected over a 3-year period at 13 outpatient psychiatric care services
participating in the online Quality Assurance of Psychotherapy in Sweden (QAPS) system. Of
the 1,498 registered patients, 14% never started psychotherapy, 17% dropped out from
treatment and 36% dropped out from data collection. Outcomes were studied for 180 patients
who received CBT, PDT or integrative/eclectic psychotherapy.
Results: There were no significant differences in psychological pre-treatment distress between
these three groups, and patients showed significant post-treatment improvements. There were
no statistically significant differences in effectiveness between psychotherapy types. Further
comparisons included patients who did not start psychotherapy after the initial assessment and
patients who started their treatment, patients who discontinued and those who remained in
treatment, improved patients and patients who did not show reliable improvement or
Conclusions: Overall, the psychotherapy delivered by the Swedish public health services
included in this study is effective for the majority of patients who complete treatment. The
theoretically different psychotherapy approaches had equivalent outcomes. Significantly more
nonstarters and dropouts were found at clinics with lower levels of organizational structure
and stability. Organizational factors predicted both starting and continuing in treatment.
Financial support: Stockholm County Council, Secretariate for Research and Development.

*Alexander Wilczek, *†Robert Weinryb, Marie Åsberg (principal investigators), et al.
Psychotherapy for suicidal women with a borderline personality disorder (BPD)
Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet.
Financial support: Stockholm County Council, the Bank of Sweden, Tercentenary
Foundation, Söderström-Königska Nursing Home Foundation, and Praktikertjänst AB.
Objective: To import, implement and test specific treatment for suicidal patients with a
(BPD). Dialectic behaviour therapy (DBT) and object relations psychotherapy (ORP) are
compared to conventional psychiatric treatment (TAU).
Background: Patients are women with BPD, a serious disturbance associated with major risk
of suicide, often leading to a long-term risk of inability to work and hospitalization. Scientific
evaluation of specific treatment of BPD among suicidal women is of major significance for
this patient group, for whom truly effective treatment has not been available to date.
Design and methods: Women, 18 to 50 years of age, with BPD and a history of at least two
suicide attempts, are included in the study. One hundred and six patients fulfilled inclusion
criteria and were randomized to the three treatment conditions. The outcome instruments used
for all assessments (intake, 1, 2 and 5 years after start of treatment) contain various measures
of pathology and of personality factors. Healthcare consumption and healthcare economics
were also examined.
Preliminary results: Preliminary findings indicate that treatment not only appears to improve
patients’ quality of life and reduce healthcare costs, but also to bring patients back to studies
and paid work. The effect is noted 4 to 5 years after the start of treatment, when patients who
received DBT or ORP had had considerably less days of sick leave than the control group.
Seven of the patients had committed suicide, 4 of whom were in the control group, 2 in the
DBT, and 1 in the ORP group.

Mona Wilhelmsson (principal investigator), doctoral project
Adult psychiatric patients participating in groups: A project for developing treatment in
groups in a psychiatric clinic

Adult Psychiatric Clinic of Boden–Luleå–Kalix
Financial support: Swedish Social Insurance Agency
Background: People with psychiatric problems often suffer from emotional and social
isolation. Group therapy has been argued to give opportunities to increase the ability to
understand ones own and others reactions in interaction.
Aim: The aim of this project was to examine the possibilities of using groups to help patients
with psychiatric disorders to increase their abilities to interact.
Method: 24 patients with different psychiatric diagnoses were selected to participate in group
sessions including conversation combined with activities like art therapy and cooking therapy.
Five groups met 12 to 22 sessions. To facilitate conduct groups with a combination of
conversation and activities, two group therapists with different professions like a nurse, a
social worker and an occupational therapist were selected to cooperate as group leaders. Each
patient filled in a questionnaire after ending the group treatment asking for their experiences.
Each of the nine therapists was interviewed asking for experiences about group treatment with
the combination of conversation and activities.
Results: Recognising feelings of loneliness and being misunderstood described by other group
members decreased the anxiety in these feelings and helped to conduct initiatives toward
others. The therapists described the combination of conversation and activity to have the
advantage of giving the patients more alternatives to explore difficulties and abilities. This
advantage was due to how the two therapists with different professions could make use of
their specific knowledge.
Discussion: Advantages and difficulties in providing a combination of conversation and
activity in group therapy settings was discussed.

Mona Wilhelmsson (principal investigator), doctoral project
A greater zest for life: A qualitative study of patient’s experiences of problems and
changes after psychotherapy

The School of Health and Medical Sciences, Örebro University, and Psychiatric Research
Centre, Psychiatry and Rehabilitation, Örebro, Sweden,
Financial support: Psychiatric Research Centre, Psychiatry and Rehabilitation, Örebro
Background: Qualitative performed studies have shown that clients tend to use psychotherapy
in different ways for their unique requirements depending on how they perceive both their
problems and themselves. In psychotherapy, it is important to clarify the substance of the
patient’s problems and assess its implications for the patient’s life context.
Aim: Based on patients’ descriptions, the aim of this study was to gain a latent meaning of the
patients’ problems that led them to seek psychotherapy and of possible changes in these
problems after a course of psychotherapy.
Method: Fourteen patients, who were selected with variation according to gender, age,
number of sessions, and therapy orientation, were interviewed and videotaped 6-12 months
after terminating psychotherapy. A qualitative content analysis of the transcribed interviews
was performed.
Results: The theme of self-centeredness runs through the descriptions of problems and was
described as an obstacle to being involved in one’s own life context. Irrespective of therapy
orientation, learning tools how to handle this interplay made the problems less disabling after
psychotherapy. Self-centredness changed into an awareness of self-agency, which made the
optimal participation in the patients’ life context possible.
Discussion: The findings are discussed from a lens of attachment theory to consider changes
as having turned insecure attachment patterns into more secure ones after a course of

Mona Wilhelmsson (principal investigator)
Patients’ experiences of psychodynamic and cognitive behavioural psychotherapy: A
qualitative study

The School of Health and Medical Sciences, Örebro University, and Psychiatric Research
Centre, Psychiatry and Rehabilitation, Örebro, Sweden,
Financial support: Psychiatric Research Centre, Psychiatry and Rehabilitation, Örebro
Background: Researching patients’ experiences of what happens in psychotherapy has been
argued to help psychotherapy researchers, theoreticians and psychotherapists gain a better
understanding of the process of psychotherapy, and of how changes are translated from
therapeutic processes.
Aim: The aim of this study was to describe and gain an understanding of patients’ experience
of frame factors and processes in cognitive behavioural oriented therapy (CBT) and
psychodynamic-oriented psychotherapy (PDT).
Method: Fourteen participants, selected with a variation according to therapy orientation,
gender, age, and number of sessions, were interviewed after ending psychotherapy. The
transcribed interviews were analysed by a qualitative content analysis.
Results: To explore and change emotions, thoughts, and behaviours were described as
similarities in both psychotherapy orientations although differences of certain specific
techniques was found. Two themes emerged across the therapy orientations: The creation of a new context made it possible to focus on the patient and the patient’s problems and The
working method and cooperation with the therapist constituted a whole. Creating a sense of
security with the psychotherapist and the psychotherapy was a therapeutic process which was
ongoing at the same time as the application of techniques in both psychotherapy orientations.
Discussion: Recommendations for psychotherapy should take patient’s expectations, fears,
previous experience, and wishes with regard to specific therapy orientation into account.
Since cooperation with the therapist was described as being inextricably linked with the
method, it is equally important to take the personal traits of the therapist and frame factors
like limitations in the number of sessions into consideration.

Mona Wilhelmsson (principal investigator)
The relation between avoidant and anxious attachment styles and interpersonal
problems reported by patients starting psychotherapy

The School of Health and Medical Sciences, Örebro University, and Psychiatric Research
Centre, Psychiatry and Rehabilitation, Örebro, Sweden,
Background: Interpersonal problems are common reasons for seeking psychotherapy.
Interpersonal problems and psychopathology are characterised in attachment theory as well as
in interpersonal theory by overriding feelings of distrust, jealousy, hostility, neglect, fear and
Aim: The aim was to study the relationship between attachment styles and interpersonal
problems in a clinical sample of psychotherapy patients.
Method: Patients were included at the start of psychotherapy (n =168). Self-reported
attachment styles, measured by Attachment Style Questionnaire (ASQ), were correlated to
self-reported interpersonal problems measured by the Inventory of Interpersonal Problems
(IIP) by Spearman correlations.
Results: Eight percent of the sample reported a mainly secure attachment profile, while 50%
reported a mixed Avoidant and Anxious profile. Avoidant and anxious attachment scales
correlated positively to the total IIP scores. Inconsistent with findings in non-clinical samples,
specific interpersonal problems in the dominant and affiliative parts of the IIP correlated
positively to both the anxious and the avoidant attachment scales.
Discussion: The findings tell that a challenge for the therapist at the start of psychotherapy is
to balance providing security with encouraging exploration of feelings, thoughts and
behaviour in the patient’s interpersonal problems in current relationships. Exploring
individual profiles of attachment styles helps to clarify motives in behavioural excesses
expressed in specific interpersonal problems.

Mona Wilhelmsson (principal investigator)
Less insecure attachment styles and interpersonal problems after a course of

The School of Health and Medical Sciences, Örebro University, and Psychiatric Research
Centre, Psychiatry and Rehabilitation, Örebro, Sweden,
Background: Attachment styles have been studied as a moderator to outcome of
psychotherapy. To date few studies have been published regarding changes in attachment
styles during the course of psychotherapy. Results indicate that psychotherapy influenced in
patient’s insecure attachment styles in the direction to more confidence.
Aim: To examine if attachment styles change after a course of psychotherapy and to examine
if changes are related to changes in interpersonal problems and sociodomographic and clinical
Method: Patients were included consecutively after ending their psychotherapy (n=111).
Psychotherapy methods were psychodynamic psychotherapy or cognitive behavioural
therapy. Attachment styles, measured by Attachment Style Questionnaire (ASQ) and
interpersonal problems measured by the Inventory of Interpersonal Problems (IIP) were
reported before and after psychotherapy. Socioeconomics and diagnoses, trauma , orientation
of therapy, and amount of sessions were collected from the psychotherapy case records.
Univariate and multiple variate statistical methods were performed.
Results: Preliminary results indicate that patients reported less insecure avoidant and anxious
attachment and decreased interpersonal problems after a course of psychotherapy.
Correlations to socioeconomics and clinical factors have not yet been performed.
Discussion: Results are discussed from the perspective of attachment theory.

*Majlis Winberg Salomonsson (principal investigator),doctoral project, & *Björn
Mother-Infant Psychoanalysis Project of Stockholm (MIPPS), Part 2. Troubled babies –
troubled kids, a follow

Karolinska Intitutet
Background: Part 1 of the MIPPS found significant effects favouring Mother-Infant
Psychoanalytic treatment (MIP), compared with regular Child Health Centre (CHC) care, on
self-reported maternal depression, interviewer-rated relationship with the baby, and externally
rated maternal sensitivity, plus near-significant effects on maternal stress.
Aim: To assess treatment effects over time, i.e. how MIP and CHC in early infancy have
influenced the mother’s attachment, the mother–child interaction, and the child’s social,
emotional and cognitive development.
Material/Methods: A follow-up study of the 71 mothers and children from Part 1 four years
after treatment, when the children have reached 4½years. They will be interviewed and
assessed with the instruments mentioned below. Separate assessments will be made by day-
care teachers.
Instruments: The Working Model of the Child Interview (WMCI), the Ages and Stages
Questionnaire: Social Emotional (ASQ:SE), the Emotional Availability Scales (EAS), the
Edinburgh Postnatal Depression Scale (EPDS), the General Severity Index (GSI) of the
Symptom Check List-90, the Parent-Infant Relationship Global Assessment Scale (PIR-
GAS), the Swedish Parental Stress Questionnaire (SPSQ), the Machover test, the Story Stem
Assessment Profile (SSAP), the Wechsler Preschool and Primary Scale of Intelligence
(WPPSI), the Children’s Global assessment scale (CGAS).
Results: No results are available at the moment. The collection of data is planned to last
October 2009 to June 2012.

Helene Ybrandt (principal investigator), & Bengt-Åke Armelius, Kerstin Armelius, Inga
Effects of psychotherapists in training
Department of Psychology, Umeå University, Sweden
The purpose of the project is to study the effects of two independent variables on the
reduction of symptoms of the clients seeking psychotherapy. The independent variables are
educational level, basic vs. advanced, of the therapy training and the amount of professional
experience prior to psychotherapy training. In addition to the effects on the clients as the
dependent variable, the development of the psychotherapists will be studied as a separate
outcome. Participants in the study are clients, students and supervisors a) at the professional
psychology program, where students are usually low in professional experience and at a basic
level of psychotherapy training b) at a basic course in psychotherapy where students usually
have a relatively long professional experience before entering the basic level of
psychotherapy training and c) at the advanced psychotherapy program, where students already
have a basic psychotherapy education as well as long professional experience. Number of
therapists and clients during the years 2008-2010 in the groups are a) 160 therapists, 400
clients, b) 50 therapists, 100 clients and c) 96 therapists, 150 clients. Predictors, moderators
and mediators of the effects are studied. Results relating to client effects show that a more
negative self-image and higher levels of self-control before treatment predicted improvement
in both psychiatric symptoms and personality factors. An initial negative self-image can be
understood as an increased motivation for change. The design includes measurement points
before treatment starts, during treatment, end of treatment and a follow-up with registers one
year after treatment end.

Marie-Louise Ögren (principal investigator)
Research project in psychotherapy supervision in a group format
Department of Psychology, Stockholm University
Financial support: The Swedish Research Council and The Royal Academy of Science
Psychotherapy supervision is considered crucial for psychotherapists in training on different
levels. During the last decades, group supervision has been the most frequently used format of
psychotherapy supervision in many countries. Nevertheless, until recently, few studies had
evaluated the small-group format for clinical training. This project aimed to deepen the
knowledge in the area of group supervision. Questionnaires were used to collect supervisee
and supervisor reports about various issues of psychotherapy supervision in group. One
finding was that the group format contributed to an in-depth clinical experience. Also, both
supervisors and supervisees reported that the working climate in their groups improved over
time: a more flexible and collaborative style of interaction over time; the communication
became more flexible, the group members took less rigid positions; and fewer dysfunctional
subgroups were maintained. A third finding suggested that there was no difference between
supervisees and supervisors who worked with different psychotherapy orientations
(psychodynamic, CBT) in terms of how they perceived that the group actually had been used
as a didactic tool. In contrast, both supervisees and supervisors with a psychodynamic
approach reported that more focus ideally should be on group process issues. Another study
finding suggested that the organisational framework for psychotherapy supervision is of
considerable importance for the learning process. These findings open up a new area of
research which needs to be explored in future studies, and thus build bridges between
academia and clinical practice. Recommendations for future research endeavours are also






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