! " " # $%& " $%'( '%%% ! ) * +',-# .!/0 1 ! " . ! - - - ! " ! 1 ! - " " 1 - ! - " ! " 2 ! 3 ! ! - 4 ! '0 " " - - " - ! 1 - $% ! +5 6 ! " " 1 ! " 1 " - ! ! -" '( - ! - ! 1 ! '0 ! 6 ! - - " - ! 7 1 - - 8 - 1 ! " - ! ! 1 7 7 8 9 - " - ! " ) " - 8 # - ! - " ! ! $%'( ::" : ! ;<" !'==+>> 4?6>(0>'(5=>>'+> 4?6>(0>'(5=>>'=5 ! ! -'%5>' WHEN PSYCHOTHERAPY DOES NOT HELP Camilla von Below When psychotherapy does not help ...and when it does: Lessons from young adults' experiences of psychoanalytic psychotherapy Camilla von Below ©Camilla von Below, Stockholm University 2017 ISBN print 978-91-7649-913-9 ISBN PDF 978-91-7649-914-6 Printed in Sweden by Universitetsservice US-AB, Stockholm 2017 Distributor: Department of Psychology Cover image: Jerker Nyberg von Below It’s a form of human love to accept our complicated, messy humanity and not run away from it Martha Nussbaum ABSTRACT The process and outcome of psychoanalytic psychotherapy have been studied for a long time. However, the experiences of patients, particularly in therapies where goals were not met, have not yet been the target of extensive research. Psychoanalytic psychotherapy with young adults might face particular chal- lenges. The overall aim of this thesis was to explore the experiences of young adults in psychoanalytic psychotherapy, with a particular focus on differences between suboptimal therapies and therapies with generally good outcome. The setting was naturalistic, and perspectives of the patient, therapist and observer were combined. Qualitative and quantitative methods were used. Study I ex- plored experiences of psychotherapy process and outcome among seven pa- tients in psychoanalytic psychotherapy, who expressed dissatisfaction. Inter- views at termination and 18 months later were analysed using grounded theory and compared to therapist experiences. Patients experienced abandonment with their problems in and after therapy, since therapy according to the pa- tients lacked connections to daily life, as well as flexibility, activity and un- derstanding from the therapist. Therapists presented a different picture of the same therapies, mainly focused on the difficulties of the patients. Study II analysed the experiences of 20 non-improved or deteriorated young adult psy- chotherapy patients at termination of therapy and 36 months later. Non-im- provement and deterioration were calculated based on the reliable change in- dex on self-rating scores. The grounded theory analysis of interviews estab- lished spinning one’s wheels as a core category. The relationship to the thera- pist was described as artificial, although at times helpful. Participants experienced their own activity in life and active components of therapy as helpful, but thought focus in therapy was too much on past experiences. Study III explored the experiences of 17 young adult patients, in psychoanalytic in- dividual or group therapy, overcoming depression. The analysis of interviews from therapy termination and 18 months later indicated that finding an identity and a place in life were perceived as intertwined with symptom relief. Nega- tive experiences included difficulties to change oneself, fear of change, and problems in therapy, such as too little activity on the therapist’s part. The results were discussed in relation to young adulthood, therapeutic alli- ance, mentalization, and attachment. The conclusion was expressed in a com- prehensive process model of suboptimal therapy with young adults, with sug- gested ways to prevent such a development. The therapist’s meta-communi- cation and correct assessment of the patient’s mentalization capacity from mo- ment to moment are proposed as crucial. Regarding clinical implications, therapists of young adult patients need to establish meta-communication on therapy progress, as even experienced therapists might be unaware of dissat- isfaction or deterioration. Meta-communication could be considered part of the treatment itself, as it may foster mentalization and good outcome. Further, the period of young adulthood entails decisions and developing an adult life, and therapists need to make room for this by active interventions. Keywords: young adults, emerging adulthood, psychoanalytic, psychody- namic, psychotherapy, patient perspective, deterioration, dissatisfaction, mixed method, grounded theory, therapeutic alliance LIST OF PUBLICATIONS I. von Below, C., & Werbart, A. (2012). Dissatisfied psychotherapy patients: A tentative conceptual model grounded in the participants’ view. Psychoana- lytic Psychotherapy, 26(3), 211-229. Doi: 10.1080/02668734.2012.709536 II. Werbart, A., von Below, C., Brun, J., & Gunnarsdottir, H. (2015). “Spin- ning one’s wheels”: Nonimproved patients view their psychotherapy. Psycho- therapy Research, 25(5), 546-64. Doi: 10.1080/10503307.2014.989291 III. von Below, C., Werbart, A., & Rehnberg, S. (2010). Experiences of over- coming depression in young adults in psychoanalytic psychotherapy. Euro- pean Journal of Psychotherapy and Counselling, 12(2), 129-147. Doi: 10.1080/13642537.2010.482745 The original papers are reproduced with permission from the publisher. © Taylor and Francis (www.tandfonline.com) ABBREVIATIONS DSM-IV Diagnostic and Statistical Manual of Mental Disorders GAF Global Assessment of Functioning Scale GSI Global Severity Index of the SCL-90 GT Grounded Theory ORI Object Relations Interview PTI Private Theories Interview SCL-90 Symptom Checklist-90 SD Standard Deviation SSRI Selective Serotonin Reuptake Inhibitor YAPP Young Adults Psychotherapy Project CONTENTS INTRODUCTION ............................................................................................. 3 Psychoanalytic psychotherapy and its goals ................................................................. 4 Therapy that does not work: Negative outcome ....................................................... 6 The therapeutic alliance, outcome, and psychoanalytic psychotherapy ................... 8 Patient perspectives on psychotherapy ....................................................................... 10 Patient characteristics and outcome ...................................................................... 10 Why ask the patients? ........................................................................................... 10 Helpful and hindering processes from a patient perspective .................................. 12 Young adults in psychotherapy ................................................................................... 14 Developmental perspectives .................................................................................. 14 Mental health in emerging adulthood ..................................................................... 16 Young adult patients in research literature ............................................................. 17 Aims ............................................................................................................................ 19 Definitions of terms used in this thesis ........................................................................ 19 METHOD ....................................................................................................... 21 Research setting ......................................................................................................... 21 Psychotherapies ......................................................................................................... 21 Participants ................................................................................................................. 22 Study I: Dissatisfied psychotherapy patients .......................................................... 22 Study II: Non-improved psychotherapy patients ..................................................... 23 Study III: Patients with a depression diagnosis ...................................................... 24 Ethical considerations ................................................................................................. 25 Material ....................................................................................................................... 25 Quantitative measures ........................................................................................... 25 Interviews .............................................................................................................. 26 Analysis ...................................................................................................................... 27 Mixed method ........................................................................................................ 27 Qualitative