Studying experienced therapists' implicit theorizing may contribute to our understanding of what is helpful and what hinders treatment with particular patient populations. 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. Grounded theory methodology was used to construct a tentative model of therapeutic action based on the therapists' implicit knowledge. 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. 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 suggested.

Objective: To report on the development and initial psychometric properties of a new rating scale for patent-therapist attachment. Method: Seventy interviews from the Young Adult Psychotherapy Project (YAPP) were rated. Results: Excellent internal consistency (Cronbach's > .90) was observed for all four subscales (Security, Deactivation, Hyperactivation, and Disorganization). Three subscales showed good inter-rater reliability (ICC > .60), while one (Hyperactivation) had poor (ICC < .40). Correlations with measures of alliance, mental representations, and symptom distress support the construct validity of the reliable subscales. Exploratory factor analysis indicated three underlying factors explaining 82% of the variance. Conclusions: The Patient Attachment to Therapist Rating Scale is a promising approach for assessing the quality of attachment to therapist from patient narratives. Future development should focus on improving the discrimination of the insecure subscales.

Using a novel approach to assess attachment to therapist from patient narratives (Patient Attachment to Therapist Rating Scale; PAT-RS), we investigated the relationships between secure attachment to therapist, patient-rated alliance, and outcome in a sample of 70 young adults treated with psychoanalytic psychotherapy. A series of linear mixed-effects models, controlling for length of therapy and therapist effects, indicated that secure attachment to therapist at termination was associated with improvement in symptoms, global functioning and interpersonal problems. After controlling for the alliance, these relationships were maintained in terms of symptoms and global functioning. Further, for the follow-up period, we found a suppression effect indicating that secure attachment to therapist predicted continued improvement in global functioning whereas the alliance predicted deterioration when both variables were modeled together. While limited by the correlational design, this study suggests that the development of a secure attachment to therapist is associated with treatment gains as well as predictive of post-treatment improvement in functioning. Future research should investigate the temporal development of attachment to therapist and its interaction with alliance and outcome more closely. To ensure differentiation from patient-rated alliance, observer-based measurement of attachment to therapist should be considered.