New methods--more questions: a commentary on interdisciplinary dialogues.

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New methods—more questions: A commentary on interdisciplinary dialoguesNew methods—more questions: A commentary on interdisciplinary dialogues
Jacques P. Barber a; Brian A. Sharpless a
a Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania, Philadelphia,
Pennsylvania, USA
First Published:November2009
To cite this ArticleTo cite this Article Barber, Jacques P. and Sharpless, Brian A.(2009)'New methods—more questions: A commentary on
interdisciplinary dialogues',Psychotherapy Research,19:6,644 — 648
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INTERDISCIPLINARY DIALOGUES
New methods*more questions: A commentary on
interdisciplinary dialogues
JACQUES P. BARBER & BRIAN A. SHARPLESS
Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
(Received 11 May 2009; accepted 11 May 2009)
Commentary on Steele, Steele and Murphy
Steele, Steele, and Murphy describe the relevance of
the Adult Attachment Interview (AAI) for psy-
chotherapy research. Although the authors focus
more specifically on this one measure of adult
attachment style, the issues they raise hold a more
general relevance for the evaluation of both attach-
ment patterns and reflective functioning during
psychotherapy. Undoubtedly, many clinicians and
researchers believe that these overlapping constructs
are important for the practice of psychotherapy in
general and psychotherapy research in particular.
Steele et al. focus their article on addressing three
key issues. They first describe two main streams of
research related to attachment representation and
organization. The first stream arises from the devel-
opmental psychology literature and the other from
social psychology. Also of note, use of the AAI
originated primarily from researchers interested in
longitudinal research, whereas self-report measures
have more often been used in cross-sectional de-
signs.
Unfortunately, these two different methods of
assessing attachment patterns do not converge. The
fact that self-report measures of attachment were
often developed to assess the quality of romantic
relationships, whereas the AAI was developed to
assess how adults conceptualize their relational world
(including their childhood), could be responsible for
this notable lack of convergence (e.g., Shaver, &
Fraley, 2004). Another difference is that self-report
attachment measures ask participants to generalize
their style from many situations and sometimes from
many relationships. In contrast, AAI interviewers
inquire into specific relationships with specific people
(mostly focusing on the relationship with mother and
father). Of course, one could ask the respondents to
complete the self-report questionnaire for different
people or relationships. Using a self-report version of
the core conflictual relationship theme (CCRT),
McCarthy, Gibbons, and Barber (2008) used this
very approach to get a better assessment of the
respondent core conflict. However, the convergence
between the repeated administrations of the self-
report measure of core conflicts and the expert judge
ratings obtained via the clinical method has not yet
been examined.
A second issue the authors address is the history of
how the AAI emerged out of Bowlby’s work on
unresolved mourning in the field of developmental
psychology and, specifically, the ways in which these
experiences color the individual’s attachment pat-
terns (and subsequent relationships). AAI interviews
result in the interviewee being given a classification
of ‘‘(1) secure, (2) insecure-dismissing, (3) insecure-
preoccupied, or (4) unresolved with respect to past
loss or trauma.’’ These styles are clearly traced to the
parenting behavior of the participants’ caregivers,
and these styles have been shown to be stable over
time.
As part of their covering of the AAI’s history,
Steele et al. also describe some of its psychometric
properties. Good interjudge reliability is obtained by
certified raters who have taken a 2-week AAI
institute training course and passed the subsequent
test of interrater reliability on 30 interviews. Finding
appropriate interrater reliability when rating the
Correspondence concerning this article should be addressed to Jacques P. Barber, Center for Psychotherapy Research, Department of
Psychiatry, University of Pennsylvania, Room 648, 3535 Market Street, Philadelphia, PA 19104-3309, USA. E-mail:
Barberj@mail.med.upenn.edu
Psychotherapy Research, November 2009; 19(6): 644?648
ISSN 1050-3307 print/ISSN 1468-4381 online # 2009 Society for Psychotherapy Research
DOI: 10.1080/10503300903045131
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Page 3

same interview after such an extensive training
regimen is reassuring but ultimately not very im-
pressive. What is impressive, however, is the fact that
there is indeed some evidence that the AAI is reliable
when assessed by two independent interviewers
conducting two different interviews (van Ijzendoorn,
1995), and that these comparisons yield adequate
test?retest reliability. However, we were unable to
locate evidence for what is arguably one of the most
fundamental assumptions of the AAI: namely, that
participants provide similar responses across differ-
ent relationships. In other words, we have not found
evidence that clearly addresses whether or not the
AAI responses are stable across different relation-
ships and situations. It would be challenging to study
whether people have similar attachment styles with
different people. However, it may be more feasible to
study whether or not narrative coherence or integra-
tion of affect (just to mention a few characteristics of
attachment style) are similar across different inter-
actions with similar significant others and different
interactions with different others. In other words, is
it likely that individuals act secure in some relation-
ships but insecure in others? If this is the case, a
measure of attachment should be able to document
this possibility at pretherapy assessment. This would
also help psychotherapy researchers locate where
and when particular changes occur as a result of
treatment. It would also be interesting to examine
whether individuals evidence different levels of
reflective functioning when they are involved in
different situations with the same others or with
different others. Researchers could also ask whether
patients with similar diagnoses are more likely to be
consistent across relationships than other diagnostic
groups or normal individuals.
Returning to the context of psychotherapy re-
search, however, another important issue is how
these phenomena may be impacted through different
forms of psychotherapy. For example, does narrative
coherence increase in a general way (i.e., most or all
significant relationships) with dynamic therapy, or is
change observable only in the specific relationships
that are the primary therapeutic foci? Finally, it
would be interesting to discover whether certain
aspects of the therapist?patient relationship (e.g., the
transference) are similar or different from attach-
ment patterns displayed with parental figures and
how these representations change by the end of
therapy.
As a brief aside, one reason why such evidence is
needed is because of the controversial status of trait
theory as well as the increasingly prominent view
that human behavior is due to a combination of trait
and situational variables. In a preliminary test of this
assumption in the CCRT, Barber, Foltz, DeRubeis,
and Landis (2002) found little evidence for the
consistency of interpersonal themes across different
situations and across different relationships. Of
course, the CCRT is not the same as the AAI, but
they do share the same general assumption that
clinicians can infer traitlike behaviors/states of mind
that are consistent (or at least prominent) across
different situations with the same other or consistent
across different relationships.
The third goal of Steele et al.’s article is to
demonstrate that the AAI should hold diagnostic
appeal for clinicians, and that the AAI can indeed
serve as a potentially useful index of change in a
therapy outcome context. From our perspective, this
is the most important section of the article for
psychotherapy research. In particular, we would
have liked to hear more of the authors’ thoughts on
the relation between the AAI measures and the
construct of reflective functioning.
Reflective functioning has been operationalized as
the metacognitive capacity to reflect on, and under-
stand, one’s own and other’s behaviors in terms of
internal mental states (e.g., Fonagy et al., 1995; Levy
et al., 2006). Undoubtedly, changes in this construct
would be relevant to many types of therapy. In fact,
both attachment and reflective functioning have
been found to be important outcomes of psychother-
apy as well as potential mechanisms of change in
dynamic psychotherapies (e.g., Rudden, Milrod,
Target, Ackerman, & Graf, 2006, Levy et al.,
2006). If one of the goals of a specific therapy is to
change attachment style or reflective functioning,
then assessment of them is undoubtedly needed.
Using data from a study that demonstrated that
patients with borderline personality disorder who
received dynamic therapy showed similar sympto-
matic improvements compared with patients who
received dialectical behavior therapy, Levy et al.
(2006) further analyzed the results and found that
those patients who received transference-focused
therapy were more likely to develop a secure attach-
ment representation than those who received dialec-
tical behavior therapy. Similarly, they showed that
level of reflective functioning and narrative coher-
ence increased in dynamic therapy, but not in
dialectical behavior therapy. Using a measure of
metacognitive coping skills (Barber & DeRubeis,
1989) that is very different from the AAI, Connolly
Gibbons et al. (in press) showed that those skills
improved inboth psychodynamic/interpersonal
therapies and in cognitive behavioral approaches.
As Steele et al. seem to recommend, attachment
style, narrative coherence, and reflective functioning
levels are more likely to be assessed as moderator
variables (e.g., McBride, Atkinson, Quilty, & Bagby,
2006). Additional data on both the moderational
More questions
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and mediational role of these variables would be of
great value to the field. Therefore, we are indebted to
the authors for reminding us that these issues should
be studied carefully, because both clinicians and
researchers find the general concept of attachment
style intuitively appealing and clinically relevant.
Commentary on Relational Psychophysiology
The article on relational psychophysiology intro-
duces psychotherapy researchers to the intricacies
of biological measures of relational behavior. The
authors make many interesting points and, of course,
only a few can be addressed in this commentary.
Ham and Tronick’s article clearly illustrates a
potentially powerful means of examining the process
of therapy using methods not often utilized by
psychotherapy researchers. Given their interesting
review of the limited studies of the psychophysiolo-
gical correlates of psychotherapy, as well as the
description of currently available technologies (e.g.,
skin conductance sampling at a rate of 100 times per
minute), a potential may exist to more thoroughly
examine the moment-to-moment, nonlinear dy-
namic interactional systems that are thought to
comprise the psychotherapeutic encounter. The
authors discuss a certain set of techniques that may
help to move the field beyond speculation.
In their discussion of the background of their
research into mother?infant interactions, the authors
focus specifically on the use of measures of skin
conductance (SC) and respiratory sinus arrhythmia
(RSA) and further discuss ways in which these
psychophysiological measures may serve as relevant
operationalizations of constructs relevant to psy-
chotherapy researchers. Briefly, RSA is used by the
authors as an indication of the parasympathetic
system. Higher levels of RSA would be indicative
of the heart rate fluctuations associated with states of
rest and digestion. Further, research is reviewed in
which decreased RSA is associated with several types
of adult psychopathology. Thus, it seems plausible
that increased levels of RSA may be associated with
greater psychological health or, at the very least, less
chronic anxiety and more physiological flexibility.
Similarly, as discussed by the authors, SC is taken to
be a proxy for sympathetic nervous activity. It is
widely used in psychological research, and most
researchers would agree that it is a relatively broad
measure of emotional arousal and activation.
As is implicit in their review, RSA and SC are not
typical ways of exploring the questions that psy-
chotherapy researchers often pose. Their methodo-
logical novelty should encourage researchers to
consider theseandmanyother seeminglyunorthodox
sources of data. As therapists, we often encourage our
patients to respond to situations in novel and flexible
ways, and we could certainly benefit from taking our
own advice by not privileging certain modes of
inquiry over others. Should the psychological corre-
lates and implications of these psychophysiological
methods be more thoroughly understood and found
to be valid, the reliability and precision of their
measurement should also encourage researchers to
utilize them more frequently, as power demands in
analyses may be significantly reduced because of their
exactness.
However, utilization of these methods raises a
number of intriguing questions. First, we wonder
how the psychophysiological information could be
most usefully interpreted within a more traditional
psychotherapy research context (i.e., not a mother?
infant dyad). Given that one half of the mother?
infant dyad lacks the power of traditional expressive
speech, physiological measures could conceivably be
a very useful means for collecting such data, because
information may be difficult to gather in more
traditional ways (apart from observational infer-
ences). We wonder how this context and information
might differ when applied to dyads (or even groups)
of older patients whose capacity to describe their
internal world and experiences is more sophisticated
and nuanced (i.e., higher levels of self-reflection,
self-reflective consciousness, and reflective function-
ing that are able to be explicitly described). Can the
use of physiological data yield information that
would be unavailable through the more traditional
methods of research? Alternatively, and related to
the previous question, can physiological data be used
in an adjunctive manner with traditional methods of
psychotherapy research, and will this allow research-
ers to gather information over and above the use of
either method alone?
As one example of this type of speculation, we
could conceive of instances in which a patient’s
physiological reactivity during session may have its
causal origin outside of the session, and we wonder
whether the psychophysiological measures could
differentiate between the two potential sources of
the activation. This is an important issue, because
sympathetic activation in the patient half of the dyad
may occur not in response to the other half of the
present dyad (i.e., the therapist) but as a result of the
patient’s interactions with an internalized other (or
possibly even an internal dialogue). In this case, the
presence of the other half of the dyad in the room,
and any lack of physiological concordance in the
dyad, may be purely coincidental and not directly
reflective of patient?therapist interaction. However,
given the fact that concurrent data on the perceived
reasons behind activations are available (assuming
that the patient is open to such disclosures), placing
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the psychophysiological results in a broader context
certainly seems possible. Because we are not experts
in this area, we are unsure whether deliberate
combinations of these approaches have yet taken
place and what type of data they could yield. Some
interesting research questions may be able to be
answered as well (e.g., in a transferential context, are
there physiological ways to differentiate between
internal and external others?).
From a psychodynamic standpoint, we wonder
whether patients may physiologically respond to
troubling or emotionally laden topics of which they
have little conscious awareness. It would be fascinat-
ing to empirically assess whether or not a patient’s
SC spiked while discussing topics that were later
revealed to have profound dynamic importance.
Consistent physiological ratings during the early
sessions of therapy could yield such data. Specifi-
cally, when the unconscious issues manifest and
become a focus of session time, prior sessions’
physiological reactivity during discussions of the
same material could be reviewed to determine
whether there was any ‘‘spiking.’’ Such a finding
could have interesting clinical implications.
We are also interested in the potential parallels
between the mother?infant research paradigm and
psychotherapy. As the authors contend, psychother-
apy may indeed be akin to the reunion episodes
described in their mother?infant interaction para-
digm. Dynamic therapists in particular are certainly
receptive to the idea that therapy can often elicit
recapitulations of earlier relationships and experi-
ences. However, as the authors know, concordance
and warmth do not exhaust therapist’s techniques in
psychotherapy. In fact, one could conceive of a
caricature of classical psychoanalysis as being similar
to the ‘‘still-face’’ paradigm (i.e., presenting the
patient with a ‘‘blank screen’’). Although a blank
screen approach in dynamic therapy (and analysis) is
neither methodologically desirable nor epistemolo-
gically possible, it is certainly true that not all
approaches to psychotherapy are intended to soothe
and support, but instead may serve to stimulate and
provoke (e.g., Davanloo, 1980).
This stimulation does have a goal, however.
Namely, one aspect common to many (if not all)
psychotherapies is the (tacit or explicit) creation of
a novel environment or context whose goal is to
diminish the response priority of habitual behaviors.
This novelty is indeed effective for the genesis of
new learning (Nakamura & Broen, 1965), and we
would not necessarily distinguish between the
warm and accepting environment self-consciously
created in Rogerian therapy or those created to be
more confrontational and activating. In fact, most
dynamic psychotherapy offers a balance on the
supportive-expressive
movement between the two eventually evolves in
response to the constantly shifting presentation and
needs of the patient (e.g., Sharpless & Barber,
2009). Thus, therapists are responsive to the
patient’s idiosyncratic needs and fluctuations when
delivering therapy (Stiles, Honos-Webb, & Surko,
1998). Addressing these constantly shifting em-
phases and goals is a necessary precondition when
applying psychophysiological
chotherapy research. Thus, we wonder whether
concordance is always the goal and whether only
concordance is associated with good outcome. We
believe indirect evidence exists that demonstrates
that a lack of concordance between treatment and
personality style could indeed be associated with
good outcome in the treatment of depression
(Barber & Muenz, 1996). A more sophisticated
hypothesis could perhaps take the stage of therapy
more into account. For example, in the early stages
of treatment, a therapist may need to be more
concordant, but as the alliance develops and more
techniques are incorporated into sessions, therapy
often becomes more of a rich dialectic between
discordance and concordance (e.g., Bonanno &
Castonguay, 1994).
A number of possibilities may also exist to explore
physiological reactions and responses to very specific
techniques in therapy. For instance, one of cognitive
therapy’s most common techniques is to encourage
patients to generate alternative hypotheses and
appraisals. When entertaining other hypotheses and
evaluating evidence in cognitive therapy, is it possi-
ble that physiological changes can occur that are
measurable (e.g., increased RSA amplitude during
hypothesis generation)? Further, will amplitude
either decrease or increase as the patient becomes
more comfortable and ‘‘playful’’ with other possibi-
lities during a specific session and as therapy
progresses (presumably, it would be the latter when
these metacognitive skills are more internalized, as in
Barber & DeRubeis, 1989)? If so, this could be a
potentially powerful way to assess short-term out-
comes in response to very specific interventions.
This may be especially helpful in the early stages of
therapy when patients are not yet able to comfor-
tably detect and describe their reactions to novel
behaviors and situations.
In closing, we found this special section of Psy-
chotherapy Research to be thought provoking. Both
articles, although using very different methodologies,
can be seen as arising from similar research traditions
in which the experiences of childhood are taken
seriously and are viewed as foundational for later
life. We look forward to the accrual of additional
empirical and theoretical developments that not only
spectrum, anda regular
methodsto psy-
More questions
647
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build on these frameworks but also take into account
the real (yet methodological complex) fact that adult
psychological life entails certain qualitative differ-
ences from childhood. Just as there appear to be
important challenges in moving back and forth
between physiological and verbal streams of data,
there appear to be similar challenges involved in
moving back and forth between decades of different
types of experiences. Using these approaches will
increase the methodological pluralism in psychother-
apy research (e.g., Barber, 2009) and will help
provide a more comprehensive description of the
therapeutic process.
Acknowledgements
This research was supported by National Institute of
Mental Health grant MH 070664.
References
Barber, J. P. (2009). Towards a working through of some core
conflicts in psychotherapy research. Psychotherapy Research, 19,
1?12.
Barber, J. P., & DeRubeis, R. J. (1989). On second thought:
Where the action is in cognitive therapy for depression.
Cognitive Therapy and Research, 13, 441?457.
Barber, J. P., Foltz, C., DeRubeis, R. J., & Landis, R. J. (2002).
Consistency of interpersonal themes in narratives about rela-
tionships. Psychotherapy Research, 12, 139?158.
Barber, J. P., & Muenz, L. R. (1996). The role of avoidance and
obsessiveness in matching patients to cognitive and interperso-
nal psychotherapy: Empirical findings from the Treatment for
Depression Collaborative Research Program. Journal of Con-
sulting and Clinical Psychology, 64, 951?958.
Bonanno, G., & Castonguay, L. G. (1994). On balancing
approaches to psychotherapy: Prescriptive patterns of atten-
tion, motivation, and personality. Psychotherapy, 31, 571?587.
Connolly Gibbons, M. B., Crits-Christoph, P., Barber, J. P.,
Wiltsey Stirman, S., Gallop, R., Goldstein, L., et al. (in press).
Unique and common mechanisms of change across cognitive
and dynamic psychotherapies. Journal of Consulting and Clinical
Psychology.
Davanloo, H. (1980). Short-term dynamic psychotherapy. New
York: Jason Aronson.
Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R.,
Mattoon, G., & Target, M. (1995). Attachment, the reflective
self, and borderline states. In S. Goldberg & J. Kerr (Eds),
Attachment research: The state of the art (pp. 233?278). New
York: Analytic Press.
Ham, J., & Tronick, E. (in press). Relational psychophysiology:
Lessons from mother?infant physiology research on dyadically
expanded states of consciousness. Psychotherapy Research.
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J., Weber,
M., Clarkin, J. F., & Kernberg, O. F. (2006). Change in
attachment patterns and reflective function in a randomized
control trial of transference-focused psychotherapy for border-
line personality disorder. Journal of Consulting and Clinical
Psychology, 74, 1027?1040.
McBride, C., Atkinson, L., Quilty, L. C., & Bagby, R. M. (2006).
Attachment as moderator of treatment outcome in major
depression: A randomized control trial of interpersonal psy-
chotherapy versus cognitive behavior therapy. Journal of Con-
sulting and Clinical Psychology, 74(6), 1041?1054.
McCarthy, K. S., Gibbons, M. B., & Barber, J. P. (2008). The
relation of rigidity across relationships with symptoms and
functioning: An investigation with the Revised Central Rela-
tionship Questionnaire. Journal of Counseling Psychology, 55,
346?358.
Muran, J. C. (in press). A fusion of horizons for psychotherapy
research: Introduction to special section. Psychotherapy Re-
search.
Nakamura, C. Y., & Broen, W. E. (1965). Facilitation of
competing responses as a function of ‘‘subnormal’’ drive
conditions. Journal of Experimental Psychology, 69, 180?185.
Rudden, M., Milrod, B., Target, M., Ackerman, S., & Graf, E.
(2006). Reflective functioning in panic disorder patients: A
pilot study. Journal of the American Psychoanalytic Association,
54, 1339?1342.
Sharpless, B. A., & Barber, J. P. (2009). Psychodynamic therapy.
In R. E. Ingram (Ed.), The international encyclopedia of depression
(pp. 460?465). New York: Springer.
Shaver, P. R., & Fraley, R. C. (2004). Self-report measures of adult
attachment. Retrieved April 22, 2009, from http://www.psych.
uiuc.edu/?rcfraley/measures/measures.html
Steele, H., Steele, M., & Murphy, A. (in press). The use of the
Adult Attachment Interview to measure process and change in
psychotherapy research. Psychotherapy Research, 19, xxx?xxx.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsive-
ness in psychotherapy. Clinical Psychology: Science and Practice,
5(4), 439?458.
van Ijzendoorn, M. H. (1995). Adult attachment representations,
parental responsiveness, and infant attachment: A meta-analy-
sis on the predictive validity of the Adult Attachment Interview.
Psychological Bulletin, 117, 387?403.
648
J. P. Barber and B. A. Sharpless
Downloaded By: [Barber, Jacques P.] At: 13:03 19 October 2009