Self-Image as a Moderator of Change in Psychotherapy

MARGRETHE S. HALVORSEN & JON T. MONSEN

University of Oslo
(Received 16 December 2003; revised 1 December 2005; accepted 7 December 2005)
Abstract
This study used the Structural Analysis of Social Behavior (SASB) introject model to investigate the relationship between
patients self-image at pretreatment and change during psychotherapy. Data were obtained from the Norwegian Multisite
Study of Process and Outcome in Psychotherapy, including 233 completed therapies. The patients were classified into four
self-image profile groups (i.e., self-attack, self-control, intermediate attackcontrol, and self-love) based on their initial
SASB pattern coefficients. Overall, the results indicated that response to treatment was contingent on self-image at
pretreatment. Patients with a self-attacking self-image showed larger reductions in symptoms and sum criteria on Axis II
during psychotherapy than those with less pathological self-images. As expected, the primary change in self-image was along
the affiliation dimension, although patients with elevated pretreatment levels of self-control revealed substantial changes
along the interdependence dimension as well.
Inadequate development of self-perception is com-
monly assumed to be a core mechanism in a broad
range of psychopathology (Bergner & Holmes,
2000), and positive changes in self-image may,
therefore, have considerable consequences in a
persons life. Thus, positive changes in a persons
perceptions of self and others are considered to be
necessary components of successful psychotherapy
(Arnold, Farber, & Geller, 2000). This assumption
is supported by research indicating that changes in
patients values in relation to different aspects of
their self-image are important outcome factors in
psychotherapy. Connolly and Strupp (1996) asked
patients to describe important changes they had
experienced in psychotherapy. Their analysis re-
vealed two clusters, improvements in symptoms
and self-concept, and the authors argue for the
importance of including a measure of changes in
self-concept in psychotherapy research. Paradoxi-
cally, the relationship between self-image and change
over time during psychotherapy has received little
empirical clarification.
Many definitions of self-image exist. According
to interpersonal theory and object relations theory,
self-image is established and modified through
qualities of interpersonal relationships and is main-
tained as a relatively stable psychological structure
in conjunction with the establishment of mental
representations of self and others. The most basic
principle of interpersonal theory is that people learn
to treat themselves as they have been treated by
others (Sullivan, 1953), and these early internalized
influences form a hypothesized personality structure
termed the introject, which consists of a relatively
stable conscious and unconscious repertoire of ways
of treating oneself (Henry, Schacht, & Strupp,
1990). Psychologically healthy individuals are
thought to have introjects that are relatively friendly
and self-accepting most of the time. Persons with
emotional problems, in contrast, tend to have hostile
introjects that are self-critical or self-negligent
(Henry, 1996). As a relatively stable personality
structure, the introject is hypothesized to play a
central role in recurrent maladaptive relationship
patterns that underlie symptomatic presentation.
Because of its theoretically central role in maintain-
ing problematic affective and interpersonal patterns,
a measure of the introject is an important element
during evaluating change in psychotherapy.
The Structural Analysis of Social Behavior (SASB;
Benjamin, 1974, 1982, 1984) has proven to be a
useful tool for investigating how interpersonal rela-
tions contribute to the development and mainte-
nance of an individuals self-image. The model
implies that all interpersonal behavior may be
represented as variables arranged in a circumplex
Margrethe S. Halvorsen and Jon T. Monsen, Department of Psychology, University of Oslo, Oslo, Norway.
Correspondence concerning this article should be addressed to Margrethe S. Halvorsen, Department of Psychology, University of Oslo,
P.O. Box 1094, N0317 Oslo, Norway. E-mail: m.s.halvorsen@psykologi.uio.no
Psychotherapy Research, March 2007; 17(2): 212225
ISSN 1050-3307 print/ISSN 1468-4381 online # 2007 Society for Psychotherapy Research
DOI: 10.1080/10503300600608363
expressed by two dimensions: affiliation (self-love vs.
self-attack) and interdependence (self-emancipation
vs. self-control).
The introject is operationalized as the third of
three interrelated surfaces of the SASB model (see
Figure I for a description of the model). Each surface
presents, in a two-dimensional space, 36 interperso-
nal behaviors representing a unique combination of
the two dimensions. Each SASB surface defines a
particular focus of interpersonal transactions. Sur-
face 1 represents focus on another person (transitive
action); Surface 2, focus on the self (intransitive
focus); and Surface 3, intrapsychic actions that result
when the focus of the other (Surface 1) is directed on
the self (introjection). (See Benjamin, 1974, 1982,
1984, for a more comprehensive description of the
model.) Benjamin (1993) has further suggested that
adaptive and maladaptive attachment patterns can
be identified at the poles of the affiliation dimension.
Secure attachment is related to elements of self-
affirmation, self-love, and self-protection (attach-
ment group [AG]), whereas maladaptive attachment
patterns include the elements of self-blame, self-
attack, and self-neglect (disrupted attachment group
[DAG]). The AGDAG distinction of the SASB
model has had some empirical support (Pincus,
Dickinson, Schut, Castonguay, & Bedics, 1999).
Given the relatively stable structure of the self-
image, it is reasonable to ask whether profound
changes during comparatively short-term therapies
are likely to occur. Henry (1996) answers this
question by noting that the introject is not theore-
tically defined as unchangeable, and new formative
relations are hypothesized to stimulate changes in
self-perception. In real life, however, early patterns
of behavior are sustained by built-in connections
among action, prediction, and meaning systems in
our automated behavior repertoire and tend to be
continuously reinforced through new interpersonal
transactions.
An important issue, therefore, is whether self-
image changes during psychotherapy and, if so, how.
A small number of studies have addressed these
questions. Henry et al. (1990) analyzed how the
interpersonal process in therapeutic dyads affects
outcome. They used introject changes along the
SASB affiliation dimension to group patients into
poor- and good-outcome cases, and the results
indicated a relationship between the therapists
statements and changes in the patients self-image.
Interpersonal actions by the therapist that confirmed
a negative patient introject were related to poor
outcome. Hillard, Henry, and Strupp (2000) elabo-
rated on this further and explored how patient and
therapist early parental relations were related to
therapeutic alliance and outcome. The introject
was measured by the SASB-weighted affiliation
score, and the results indicated an indirect effect
of the interpersonal history of both patient and
therapist on outcome, mediated by the process.
Paivio and Greenberg (1995) used the SASB-
weighted affiliation score to study changes in percep-
tions of self and others in patients with unresolved
feelings related to significant others. The patients
were assigned to either experiential therapy or an
attention-placebo group. Patients in the experiential
therapy condition showed significantly greater im-
provements in perceptions of self and others than the
those in the placebo group.
The weighted affiliation score of the SASB system
is made up of both affiliative and disaffiliative
clusters, and Hillard et al. (2000) have argued
that the combined use of these codes may
mask the variability in the disaffiliative codes. To
preclude such problems, Junkert-Tress, Schnierda,
Hartkamp, Schmitz, and Tress (2001) separated the
positive and negative scores of the weighted affilia-
tion dimension of the SASB and analyzed the effect
1. Self-emancipate
2. Self-affirm
3. Self-love
4. Self-protect
5. Self-control
6. Self-blame
7. Self-attack
8. Self-neglect
I
n
t
e
r
d
e
p
e
n
d
e
n
c
e
Affiliation
Figure I. The Structural Analysis of Social Behavior (SASB), introject surface (self-image). Note . The SASB introject surface was patterned
after Benjamins (1995, 1996) models.
Self-image and change 213
of short-term dynamic psychotherapy on patients
with neurotic, somatoform, and personality disorder
problems. Generally, they found a lesser effect on the
negative introject than the positive introject.
Further, they found that the somatoform group
reported most affiliative, self-directive behavior at
the end of therapy. Granberg and Armelius (2003)
used the weighted affiliation and interdependence
scores to analyze changes in self-image in patients
with neurotic, borderline, and psychotic distur-
bances in a naturalistic 5-year follow-up program
of milieu treatment. Their results showed change
after treatment in the affiliation dimension and
almost no change in the interdependence dimension
in all patients. Further, the results indicated that the
improved overall affiliation scores in the neurotic
and psychotic patients were due to a less attacking
self-image, whereas for the borderline patients it was
due to more self-love. In sum, the aforementioned
studies indicate that considerable changes occur in
self-image during psychotherapy, that the changes
are more pronounced along the affiliation dimension
than the interdependence dimension, and that dif-
ferent groups of patients show diverse patterns of
change in affiliation (i.e., more self-love, less self-
attack). A few single studies differ from these general
findings. Malmgren-Olsson, Armelius, and Armelius
(2001) reported small changes in both the DAG and
AG clusters in a sample of patients with nonspecific
musculoskeletal disorders, and, contrary to other
research, Svartberg, Seltzer, and Stiles (1996) found
substantial changes in the interdependence dimen-
sion in a sample of patients with anxiety disorders.
The purpose of the present study was twofold.
First, we were interested in exploring the relation-
ship between patients self-image at pretreatment
and change in psychotherapy. More specifically, we
were interested in how different types of self-image
configurations were related to outcome. Second, we
were interested in the effect of treatment on self-
image. Usually, research has compared changes
in self-image across different diagnostic groups.
However, there may be considerable variability in
self-image profiles among individuals within a diag-
nostic category. Assuming that self-image is a core
mechanism in a broad range of psychopathology,
it is reasonable to assume that different types of self-
image entail different patterns of change and out-
come. To explore this hypothesis, patients in the
present study were classified according to their
pretreatment self-image profiles. Based on findings
from a previous validation study of the SASB
introject surface, the following categories were iden-
tified: self-attack (ATK), self-love (LOV), self-
control (CTR), self-emancipate (EMA), and inter-
mediate self-attack/control (IAC) self-image
(Monsen, von der Lippe, Havik, Halvorsen, &
Eilertsen, 2005).
The main questions we raise in the present study
involve how these different self-image configurations
are related to change and outcome in psychotherapy:
How do these samples of outpatients relate to
themselves at the beginning of therapy? What kinds
of problems do they present? Does self-image
moderate changes in other outcome measures?
What is the effect of treatment on self-image?
From a statistical point of view, it is reasonable to
anticipate the greatest changes in the most severely
disturbed group, in this sample represented by the
ATK group. This group has the greatest potential for
change. From a clinical point of view, however, the
hostile introject of these patients and the corre-
sponding high level of psychopathology may impede
change. Because the majority of the psychotherapies
in this study are open ended, we expect longer
lasting treatments in the ATK group than in the
other groups. In the earlier validation study (Monsen
et al., 2005), the CTR and IAC groups had
equivalent levels of general psychopathology. Both
groups were clearly less disturbed than the ATK
sample but were still at a severe level. Because the
present sample is a subsample of the outpatients
included in the validation study, we anticipate
similar findings here. Consequently, compared with
the ATK sample, we expect somewhat shorter
treatments for the CTR and IAC groups but still
large changes in symptoms, interpersonal problems,
and general level of psychopathology. By definition,
the self-image profile of the LOV group is almost
identical to that of the normal reference sample.
Therefore, we expect no change in self-image in this
group, and most likely their problems are more
delimited to symptoms at a moderate level of
severity. Accordingly, we expect shorter treatments
than for the other groups and mainly symptom-
related changes at a small to medium level. On the
basis of previous research, we generally expected that
changes in self-image would imply positive changes
along the affiliation dimension and only minor
changes in interdependence.
Method
The present study reports data from the Norwegian
Multisite Study of Process and Outcome in
Psychotherapy (NMSPOP) at the University of
Oslo (Havik et al., 1995).
1
The project is based on
a naturalistic design with measurements before
treatment, during treatment, at termination, and at
follow-up. Pre- and posttreatment data are used.
Data from a Norwegian normal reference sample
214 M. S. Halvorsen & J. T. Monsen
(Monsen & von der Lippe, 1999) are included for
comparison.
Participants
Outpatient sample . The patients in the NMSPOP
were selected to be representative of Norwegian
outpatient clinics, with the exception that half of
the sample should have a personality disorder
diagnosis (Axis II) according to the Diagnostic and
Statistical Manual of Mental Disorders (4th ed.; DSM-
IV; American Psychiatric Association, 1994). Of the
374 patients included in the NMSPOP, 233 with
complete data on the instruments used in the present
study made up the outpatient sample. Patients with
ongoing treatments, dropouts, and patients with less
than 5 or more than 100 sessions of treatment were
excluded from the study. The patient sample in-
cluded 172 (74%) women and 61 (26%) men. This
gender distribution was reflected in all the subsam-
ples except from the ATK profile group, which
included slightly more women (86%). The mean
age of the patient sample was 35 years (range/
1859, SD/11.4). There were no age differences
among the four groups. Eighty-eight percent of the
patients had a DSM-IV Axis I diagnosis; 40% had an
Axis II diagnosis; and 9% had no diagnosis. The
distribution of Axis I and Axis II diagnoses at
pretreatment across different self-image groups is
shown in Table I.
Reference sample . The reference sample consisted
of 302 well-functioning adults. Half of the sample
comprised undergraduate psychology students and
the other half employees recruited among relatives
and acquaintances of the psychology students. None
of these individuals received treatment in the psy-
chiatric health care system, nor did they report any
specific problems related to job performance or
social functioning. Sixty-one percent of the sample
were women, and the mean age was 31.1 years
(range/1868, SD/10.9).
Treatment
The treatments in the NMSPOP were mainly open
ended, with the exception of one site in which
treatment was predefined to 40 sessions. The mean
number of sessions in the patient sample in this
study was 34 (range / 5100). Fifty-two percent of
the patients completed more than 30 sessions, and
10% completed fewer than 12. Eighty-two therapists
(62% women; mean age/40.7 years, range/24
59) provided the treatment. The mean clinical
experience of the therapists was 11 years (range /
0.526 years). Fifteen of the therapists were gradu-
ate students. The theoretical orientation of the
therapist sample was as follows: psychodynamic,
67%; cognitive, 16%; humanistic, 5%; unspecified,
10%.
SASB INTREX Questionnaire
In the present study, we used the Norwegian
translation of the SASB Long Form INTREX
Introject Questionnaire (Benjamin, 1983). The IN-
TREX, a self-report measure assessing the introject
in terms of the SASB model, consists of 36 items,
each of which is rated on a scale from 0 (never, not at
all ) to 10 (always, perfectly). There is fairly extensive
research on the psychometric properties of the
instrument (Benjamin, 1974, 1983, 1984, 1996).
Table I. Diagnostic Description of the Samples.
ATK (n/ 36) CTR (n/64) IAC (n/101) LOV (n/32)
Variable n % n % n % n %
Axis I
Affective disorder 23 64 23 36 46 46 11 34
Anxiety disorder 28 78 42 66 59 58 12 38
Alcohol, drug abuse 1 3 3 5 2 2
Somatoform disorder 10 28 17 27 26 26 10 31
Eating disorder 4 11 4 6 4 4 3 9
No Axis I diagnosis * * 9 14 11 11 7 22
Axis II
a
Cluster A 7 19 8 13 12 12 1 3
Cluster B 1 3 2 3 6 6
Cluster C 16 44 16 25 19 19 5 16
No Axis II diagnosis 12 33 37 58 64 63 26 81
No diagnosis 7 11 8 8 6 19
Note. ATK/attack profile pattern, CTR/control profile pattern, IAC/intermediate attack/control profile pattern, LOV/love profile
pattern.
a
Cluster A may include one or more Cluster B or C diagnoses. Cluster B may include one or more Cluster C diagnoses.
Self-image and change 215
The testretest reliabilities are typically greater than
.80 in normal populations and somewhat less stable
in psychiatric populations (Constantino, 2000).
Generally, the test retest reliabilities for dimensional
ratings (weighted affiliation [AFF] and interdepen-
dence [AUT] scores) of the INTREX have ranged
from .66 to .93 (Benjamin, 1974, 1995; Hillard et
al., 2000; Quintana & Meara, 1990). Test retest
reliabilities were .76 (AFF) and .70 (AUT) in the
outpatient sample and .82 (AFF) and .76 (AUT) in
the normal reference sample.
In the present study, the introject is assessed as
How you usually see yourself, and the measures
are the eight cluster scores (see Figure I). The cluster
scores are summarized scores of four or five items,
and the dimensions are a weighting of the eight
clusters with reference to their position on the
affiliative pole on the horizontal axis or the auton-
omy pole of the vertical axis (Benjamin, 1995). The
pattern coefficients attack and control represent
correlations with theoretical profiles peaking on
clusters located at the poles of the two dimensions.
As a result of the bimodal distributions of these
correlation coefficients, Pincus, Newes, Dickinson,
and Ruiz (1998) propose that these coefficients best
represent a categorical assignment of social percep-
tion of self. In the present study, patients were
assigned to different self-image profile groups ac-
cording to their self-descriptions at pretreatment,
and Benjamins (1995) cutoff value of .82 for
significant pattern coefficients was used as a criterion
in the categorization of the different self-image
profiles. The ATK profile implies that the relation-
ship to oneself is highly organized around the attack
pole of the SASB model, indicating a hateful and
self-attacking attitude toward oneself. A LOV profile
indicates a relationship to oneself mainly organized
around the affiliative pole (i.e., representing an
active self-loving and cherishing relationship toward
oneself). Similarly, scores highly organized around
the poles of the interdependence dimension give rise
to either a CTR profile, implying a restrained and
protecting relationship to oneself or, at the opposite
pole, an EMA profile. To the extent that the EMA
profile represents psychopathology, we believe that
the most likely pattern is one with high scores on
Clusters 1, 7, and 8 (self-emancipate, self-attack,
and self-neglect). This pattern indicates a mixture of
self-hostility and impulsivity and should probably be
labeled a self-neglect profile. The combination of
Clusters 1, 2, and 8 (self-emancipate, self-affirm,
and self-neglect) is contradictory and unlikely to
occur. In addition to these four self-image profiles,
representing the four poles of the SASB introject
dimensions, less distinct profile patterns will also
exist. A pattern characterized by moderate scores on
both dimensions, as reflected in intermediate attack
and control coefficients (both pattern coefficients
have values between .82 and .82), has been labeled
an IAC pattern (Monsen et al., 2005).
Other Measures of Psychopathology
Symptom Checklist-90-Revised (SCL-90-R). The
Global Symptom Index (GSI) of the SCL-90-R
(Derogatis, 1983; Derogatis, Rickles, & Rock,
1976) was used as an overall measure of symptoma-
tology. The SCL-90-R is a self-report questionnaire
composed of 90 items, each rated on a scale from 0
(not at all ) to 4 (very much). The GSI is the mean
score of all 90 items. Several examinations of
normative samples have established clinical signifi-
cant cutoff values for the GSI. Values above 0.97
(with confidence band: 0.761.19) are usually
regarded as indicators of severe psychopathology
(Lambert, Burlingame, & Hansen, 1996). Both the
patient sample and the reference sample responded
to the SCL-90-R.
Inventory of Interpersonal Problems (IIP). The
circumplex version with 64 items (IIP-C; Alden,
Wiggins, & Pincus, 1990), a subset of the 127-item
IIP by Horowitz, Rosenberg, Baer, Uren o, and
Villasen or (1988), was used. The IIP-C is divided
into two sections. The first 39 items begin with the
phrase It is hard for me to . . . and the next 25
items describe things that you do too much. For
each item, participants indicate the degree of diffi-
culty or distress on a response scale ranging from 0
(not at all ) to 4 (extremely). Both the patient sample
and the reference sample responded to the IIP-C.
DSM-IV diagnoses. These were determined by the
local research coordinator at each site. The total
number of criteria on Axis II has been shown to be a
good indicator of general psychopathology (Monsen,
Havik, von der Lippe, & Svartberg, 2003) and is
used as a measure of severity or overall psycho-
pathology in the present study. Only the patient
sample was evaluated according to the Structured
Clinical Interview for DSM-IV (SCID-II). An
independent research coordinator performed the
evaluation.
Statistical Analyses
The research design in this study includes four self-
image profile groups based on the pretreatment
pattern coefficients of the SASB INTREX. The
outcome measures include three psychopathology
scales and eight SASB clusters, all measured at pre-
and posttreatment.
216 M. S. Halvorsen & J. T. Monsen
Pretreatment group differences in psychopathol-
ogy were tested by entering the three global pre-
treatment measures in a multivariate analysis of
variance (MANOVA), with self-image profile groups
as a between-subject factor. This overall analysis was
followed by univariate analyses of each measure.
The main research design implies an 11 (scale)/2
(time)/4 (group) analysis of variance (ANOVA).
Because this will lead to a large number of main and
interaction effects, and differences in change across
groups (i.e., the Time/Group interaction) are the
main focus of this study, we chose to analyze data
with prepost difference scores as dependent vari-
ables.
The overall pre- to posttreatment changes in
psychopathology were analyzed by entering the three
global indexes (difference scores on SCL-90-R, IIP-
C, and sum criteria Axis II) in a MANOVA, with one
between-subject factor (group). Further examina-
tion of the group differences was made by univariate
F tests for each dependent variable. The effect of
treatment on self-image was examined by entering
the eight SASB clusters (difference scores) in a
MANOVA, with one between-subject factor (group).
Separate univariate F tests were applied for the eight
cluster scores (difference scores). Tests of the overall
effects in MANOVA were based on Wilkss lambda,
and Tukeys corrections were applied for all post hoc
contrasts. The magnitude of the changes was further
examined by estimating effect size (ES). In order not
to underestimate error and inflate the effect sizes, we
used a pooled estimate of the standard deviations of
the difference scores as denominator when estimat-
ing effect sizes (ES/[post pre difference score]/
[pooled standard deviation of difference scores]).
When evaluating effect sizes, Cohens (1977) stan-
dards were applied: 0.2 (small), 0.5 (medium), and
0.8 (large). To estimate the posttreatment status of
the four profile groups, a group mean deviating less
than 1.5 SD from the mean of the normal reference
sample was used as a criterion of nonpathological
posttreatment status.
Figure II. Self-image proles at pre- and posttreatment compared with the normal reference sample.
Self-image and change 217
Results
Pretreatment Descriptions
Of the total sample, 132 patients (57%) had a
significant or extremely distinct introject profile at
pretreatment. Only 3 (1%) showed a significant
profile on the emancipate pole of the interdepen-
dence dimension. Because of the small sample size in
this subgroup, these were excluded from the further
analyses. There were 36 patients (15%) with a
marked ATK profile, 64 (27%) with a CTR profile,
and 32 (14%) with an LOV profile. The largest
subgroup was the IAC profile group (n/ 101
patients [43%]).
The mean pre- and posttreatment profiles of the
four groups are presented in Figure II, including the
means of the reference sample. Mean levels and
standard deviations at pre- and posttreatment are
presented in Table II.
A MANOVA of the three global indexes of
psychopathology showed a strong and statistically
significant group effect, F(9, 547.74)/10.26, pB/
.001, and univariate F tests showed that the groups
differed significantly at pretreatment in (a) general
symptom level: GSI, F(3, 227)/22.85, p B/.001;
(b) global interpersonal problems index: IIP-C, F(3,
227)/27.96, p B/.001; and (c) general level of
psychopathology: sum criteria Axis II, F(3, 227)/
10.14, p B/.001. Tukeys post hoc analyses showed
that the groups displayed a consistent rank order of
problem severity, with highest levels in the ATK
group, followed by the CTR and the IAC groups,
and finally the LOV group. This finding is consistent
with earlier findings from the larger NMSPOP
sample (Monsen et al., 2005). Further, there was a
significant group difference in treatment duration,
F(3, 227)/3.60, p B/.05. Patients with an LOV
profile pattern were involved in significantly shorter
treatments (M/26 sessions, SD/13) than those
with an ATK profile (M/39, SD/25) and those
with an IAC profile (M/37, SD/21). There were
no group differences in duration of problems
(range/6.812.5 years; p/.07).
Change in Symptoms, Interpersonal Problems,
and General Level of Psychopathology
Entering the three indexes of change in psycho-
pathology (difference scores) in a MANOVA showed
a strong and statistically significant group effect,
F(9, 530.70)/ 2.84, p/ .003.
Tukeys post hoc analysis demonstrated that the
ATK group showed larger changes in symptoms and
sum criteria on Axis II than the other three groups.
Significant between-group differences and effect
sizes for the psychopathology measures are pre-
sented in Table III (first part). As shown in Table
III, the ATK, CTR, and IAC groups showed large
to medium changes in symptoms, interpersonal
problems, and general level of psychopathology,
and at posttreatment these groups scored within
1.5 SD from the mean of the normal reference
sample on both symptoms and interpersonal pro-
blems. The LOV group showed medium changes in
symptoms and small changes in interpersonal pro-
blems. At posttreatment their scores were practically
identical to those of the normal reference sample on
all measures and even somewhat better in the level of
interpersonal problems.
Table II. Mean Levels (9/ Standard Deviations) for the Patient Sample at Pre- and Posttreatment and the Reference Sample
ATK CTR IAC LOV
Measure Pre Post Pre Post Pre Post Pre Post Ref. sample
SCL-90 1.829/0.55 0.939/0.65 1.139/0.56 0.679/0.51 1.299/0.57 0.849/0.59 0.759/0.43 0.399/0.50 0.459/0.40
IIP-C 1.899/0.42 1.449/0.58 1.369/0.42 1.149/0.56 1.539/0.51 1.159/0.54 0.909/0.41 0.719/0.43 0.979/0.44
SumaxisII 13.39/8.8 7.19/7.1 7.59/6.3 5.09/5.2 8.39/6.7 5.09/5.9 4.29/4.5 2.49/2.5
SASB
1. Eman 23.39/14.2 25.99/11.5 17.39/11.1 26.49/12.9 35.89/17.3 34.09/15.1 37.59/14.9 36.59/12.8 39.09/13.2
2. Affirm 9.69/7.6 34.49/23.4 28.59/18.9 50.59/23.4 31.79/19.0 46.79/23.8 62.69/16.5 66.69/25.0 63.49/19.0
3. Love 20.89/10.1 37.29/19.1 42.59/15.5 53.89/21.4 39.19/15.5 49.89/21.0 64.69/15.6 66.79/25.3 59.89/18.6
4. Protect 42.89/12.9 51.99/16.5 60.09/14.8 63.59/14.4 57.69/14.8 56.79/15.9 61.69/15.3 59.49/16.3 61.49/16.5
5. Control 60.99/17.3 51.89/22.9 59.99/18.2 47.19/19.6 45.29/21.4 40.49/23.6 29.09/18.1 30.39/23.4 37.69/19.4
6. Blame 70.09/16.0 40.69/27.7 43.49/17.4 25.39/21.0 40.59/23.1 27.19/23.0 9.19/10.2 13.19/21.8 17.69/19.2
7. Attack 63.19/13.4 33.69/23.2 32.19/15.3 21.29/14.9 43.49/17.4 28.79/21.2 15.29/10.1 15.19/16.2 19.79/15.8
8. Neglect 40.29/17.1 24.99/20.7 14.49/12.0 12.59/13.5 33.99/18.7 22.09/19.6 13.79/15.5 14.89/21.1 18.39/15.5
Note. ATK/attack profile pattern; CTR/control profile pattern; IAC/intermediate attack/control profile pattern; LOV/love profile
pattern.; SCL-90/Symptom Checklist-90; IIP-C/Inventory of Interpersonal Problems, circumplex version; SumaxisII/summary Axis
II; SASB/Structural Analysis of Social Behavior; Eman/emancipate.
218 M. S. Halvorsen & J. T. Monsen
Table III. Mean Difference Scores, t Values, Effect Sizes, and Between-Group Differences in Change for the Four SASB Prole Patterns
ATK CTR IAC LOV Differences in change
Measure Diff. score t ES Diff. score t ES Diff. score t ES Diff. score t ES F Group differences
SCL-90 0.99/0.8 6.9** 1.4 0.59/0.6 6.3** 0.6 0.59/0.7 6.8** 0.8 0.49/0.5 4.4** 0.6 4.9 A/C, I, L
IIP-C 0.59/0.6 4.7** 1.0 0.29/0.5 3.4** 0.6 0.49/0.5 7.7** 0.6 0.29/0.4 2.5* 0.4 2.5 No differences
SumaxisII 6.09/7.5 4.6** 1.1 2.79/5.4 3.9** 0.4 3.29/5.5 5.3** 0.6 1.89/4.5 2.3* 0.3 3.4 A/C, I, L
SASB
1. Eman. 2.69/12.5 1.2 0.2 9.29/11.6 6.3** 0.6 /1.79/18.8 0.9 0.1 /1.09/13.6 0.4 0.1 6.9 C/I, L
2. Affirm 24.89/23.6 6.3** 1.1 22.09/20.0 8.8** 0.9 15.09/25.2 6.2** 0.6 4.09/25.9 0.9 0.2 5.7 A, C/L
3. Love 16.39/22.2 4.4** 0.8 11.39/20.4 4.4** 0.5 10.79/20.7 5.2** 0.5 2.29/23.6 0.5 0.1 2.6 A/L
4. Protect 9.19/18.1 3.0** 0.5 3.59/16.9 1.7 0.2 /0.99/18.5 0.3 0.1 /2.29/17.1 0.7 0.1 3.5 A/I, L
5. Control 9.29/17.7 3.1** 0.4 12.89/22.4 4.6** 0.6 4.79/21.1 2.2* 0.2 /1.39/22.9 0.3 0.1 3.8 C/L
6. Blame 29.49/28.9 6.1** 1.1 18.29/23.1 6.3** 0.7 13.59/28.8 4.7** 0.5 /4.09/21.3 1.1 0.2 9.5 A/I/L & C /
7. Attack 29.59/20.7 8.5** 1.4 10.99/18.0 4.9** 0.5 14.89/23.5 6.3** 0.7 0.19/14.7 0.0 0.0 12.2 A/C, I, L & I/L
8. Neglect 15.39/17.6 5.2** 0.8 1.99/13.3 1.1 0.1 11.89/22.0 5.4** 0.6 /1.29/23.1 0.3 0.1 7.4 A, I/C, L
Note. ATK/attack profile pattern; CTR/control profile pattern; IAC/intermediate attack/control profile pattern; LOV/love profile pattern; ES/prepost effect size with a pooled estimated
of the standard deviations of the difference scores; SCL-90/Symptom Checklist-90; IIP-C/Inventory of Interpersonal Problems, circumplex version; SumaxisII/summary Axis II;
SASB/Structural Analysis of Social Behavior; Eman/emancipate.
*p B/.05. **p B/001.
S
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f
-
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m
a
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e
a
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d
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e
2
1
9
Change in Self-Image Profile
Table IV shows the pattern of change in profile
classification. Eighty percent of the patients with an
ATK pattern changed their profile classification, and
approximately half of them ended treatment with an
IAC or LOV profile pattern. Seventy percent of the
patients with a CTR profile pattern changed toward
an IAC or LOV pattern. Sixty percent of the
IAC patients changed profile classification, and the
majority of these ended treatment with an LOV
pattern. Of the patients with an LOV profile, 70%
maintained their self-affirming self-image, whereas
16% changed toward a less affirming self-image and
ended treatment with an IAC profile. Overall, there
was a change toward less negative self-image profiles,
and at posttreatment 40% of the total sample
presented a self-loving self-image. A small number
of patients changed toward more negative self-image
profiles.
Change in SASB Cluster Scores
Entering the eight SASB clusters in a MANOVA
showed a strong and statistically significant group
effect, F(24, 641.57)/4.20, pB/ .001. To further
analyze the between-group differences, univariate F
tests were performed for each cluster. The effects of
the between-group factor were statistically signifi-
cant for all clusters. To estimate the direction and
magnitude of change in self-image within each
profile group, effect sizes for each SASB cluster
were computed. Effect sizes and group differences
are presented in Table III.
As Table III illustrates, the ATK group showed
largest changes in DAG Clusters 6 (self-blame), 7
(self-attack), and 8 (self-neglect) and AG Clusters 2
(self-affirm) and 3 (self-love). The ANOVA demon-
strated that the ATK group changed significantly
more than the other groups on DAG Clusters 6 (self-
blame) and 7 (self-attack) and more than the CTR
and LOV groups on Cluster 8 (self-neglect). At
posttreatment all indexes were within 1.5 SD from
the means of the normal reference sample, with
exception of Cluster 2 (self-affirm). Patients with a
CTR profile pattern also showed large to medium
changes on DAG Clusters 6 (self-blame) and 7 (self-
attack) and AG Clusters 2 (self-affirm) and 3 (self-
love) as well as medium changes on the interdepen-
dence Clusters 1 (self-emancipate) and 5 (self-
control). The ANOVA indicated that the CTR group
changed significantly more than the LOV and IAC
groups on Cluster 1 (self-emancipate) and more
than the LOV group on Cluster 5 (self-control). At
posttreatment all indexes were within 1 SD from the
normal reference sample. Patients with an IAC
profile pattern showed large to medium changes on
DAG Clusters 6 (self-blame), 7 (self-attack), and 8
(self-neglect) and AG Clusters 2 (self-affirm) and 3
(self-love). The ANOVA indicated significantly lar-
ger changes than the CTR and LOV groups on
Cluster 8 (self-neglect). At posttreatment all indexes
were within 1 SD from the normal reference sample.
As expected, patients with an LOV profile pattern
showed no significant changes on the SASB indexes.
Discussion
The purpose of the present study was to investigate
how patients self-image at pretreatment is related to
change and outcome in psychotherapy in an out-
patient sample. Overall, the results showed a clear
and meaningful distinction between different self-
image profiles at pretreatment, with a consistent
pattern of change among these during therapy. The
distribution of self-image profiles and the group
differences at pretreatment indicated a ranking of
general severity of psychological disorders, from the
ATK as the most severe pattern to the CTR and the
IAC patterns and finally the LOV pattern. This rank
order is in accordance with our former validation
study (Monsen et al., 2005) and also supports
Benjamins suggestion that psychopathology is
Table IV. Change in Prole Classication From Pre- to Posttreatment
Posttreatment
ATK CTR IAC LOV
Profile n n % n % n % n %
Pretreatment
ATK 36 7 19 13 36 9 25 7 19
CTR 64 2 3 17 27 18 28 27 42
IAC 101 9 9 14 14 40 40 38 38
LOV 32 2 6 3 9 5 16 22 69
Posttreatment 233 20 8.5 47 20 72 31 94 40
Note . ATK/attack profile pattern; CTR/control profile pattern; IAC/intermediate attack/control profile pattern; LOV/love profile
pattern.
220 M. S. Halvorsen & J. T. Monsen
associated with not only hostility, as marked by high
scores on the DAG clusters (6, 7, 8), but
also extreme scores on the control or emancipate
poles (Benjamin, 2003; Pincus et al., 1999; Pincus,
Gurtman, & Ruiz, 1998).
The findings may indicate that initial self-image
status moderates response to treatment. Quite
unexpectedly, patients with an ATK self-image
showed larger changes in symptoms and general
level of psychopathology than the other subgroups.
This finding is inconsistent with previous research,
suggesting that negative aspects of patients self-
relatedness, defined as self-defensiveness and con-
striction, were linked to poor outcome, whereas
patients openness and acceptance of their own
feelings were associated with positive outcome (Or-
linsky, Rnnestad, & Willutzki, 2004). One possible
explanation for the present results may be that
patients with more hostile self-images benefit more
from psychotherapy because of their initially greater
potential for change (i.e., high levels of subjective
distress at pretreatment), combined with the rela-
tively long-term treatments in the present study
compared with other outcome studies. According
to Hansen, Lambert, and Forman (2002), the
average number of sessions in clinical trial studies
ranges from 12 to 16. It appears from this research
tradition that 50% of patients entering psychother-
apy show clinically meaningful changes after ap-
proximately 20 sessions, but the more disturbed a
patient is initially, the longer that treatment is
needed for the patient to achieve adequate changes
(Lambert, Bergin, & Garfield, 2004).
This finding is in line with the present results;
patients with an ATK profile pattern were involved
in significantly longer treatments (M/39 sessions)
than less disturbed patients. The ATK pattern
reflects extreme forms of devaluating and destructive
forms of self-relatedness. This pattern probably
poses some specific challenges to the development
of the therapeutic alliance, particularly in terms of
how therapists can help patients make a constructive
contribution to their treatment. It is reasonable to
believe that these patients rigid forms of self-
hostility require numerous repetitions of corrective
experiences in therapy before they are able to change
toward more self-acceptance and confidence. Ob-
viously, this is a time-consuming process. However,
if and when such changes in the self-concept first
occur, this may generate comprehensive changes
both interpersonally and in the level of subjective
distress. The larger effect sizes on the outcome
measures in the ATK group compared with the
other subgroups in the present study support this
interpretation. We may then have two opposing
factors affecting the magnitude of change: an initial
level effect (i.e., greater potential for change) and a
severity effect (i.e., resistance to change requiring
longer treatment). Being involved in sufficiently
long-term treatments, the most severe patients
were able to achieve profound and meaningful
changes. As the effect sizes indicated, the ATK
group reached considerable changes during treat-
ment, and at posttreatment the group mean scores
were within 1.5 SD from the mean of the normal
reference sample. Still, the posttreatment status
makes room for additional change. It is beyond the
scope of this study to explore this matter further, but
one may question if the most disturbed patients
would show even greater changes with prolonged
treatment.
The CTR and IAC groups presented equal levels
of psychopathology at pretreatment, and the results
showed equal degrees of change in symptoms,
interpersonal problems, and general level of psycho-
pathology. This may indicate that elevated levels of
self-control are decisive neither for the general level
of psychological problems nor for the prognosis of
therapeutic outcome. The controlled self-image of
the patient may, however, have implications for the
therapeutic interaction and the process of change.
Patients with an LOV profile pattern primarily
presented symptom-related problems, although at a
somewhat higher level than expected. This finding
seems to oppose the general notion that persons with
emotional problems tend to have hostile introjects
that are self-critical or self-negligent (Henry, 1996).
The results revealed medium changes in symptoms
and interpersonal problems, and at posttreatment
the LOV group seemed to be at a functional level
equivalent to the normal reference sample. One
possible explanation may be that individuals with
positive self-images are dealing with more situational
stresses, and their symptoms and interpersonal
problems are less chronic. In the present study, there
was a tendency for shorter duration of problems in
the LOV group. The considerably shorter treatment
duration in this group is, however, consistent with
this assumption and indicates a different readiness to
change compared with patients with higher levels of
self-hostility.
The results reveal an extensive change in self-
image profile classification during treatment. Gen-
erally, there was a change toward a healthier self-
image in the overall sample. Examination of the
cluster scores reveals that the ATK group showed the
largest changes along the affiliation dimension,
consistent with past research (Granberg & Armelius,
2003; Junkert-Tress et al., 2001; Paivio & Green-
berg, 1995), with medium change in interdepen-
dence as well. The large change in affiliation in the
ATK group included both the DAG and AG
Self-image and change 221
clusters, with significantly larger changes in the DAG
clusters than the other groups. This finding differs
from that of Malmgren-Olsson et al. (2001), who
reported small changes in both the DAG and AG
clusters in a sample of patients with nonspecific
musculoskeletal disorders. This inconsistency most
likely reflects different potentials for change in the
two samples. Our findings indicate that patients with
a hostile introject are able to let go of this self-critical
pattern and change toward a more affiliative self-
image. On a group level, patients with an ATK
profile changed toward a less disapproving and more
affirmative and loving self-image, and at posttreat-
ment the shape of the profile resembled a control
profile, although at a considerably more moderate
level. The CTR and the IAC groups showed almost
identical magnitudes of change along the affiliation
dimension, with medium to large changes in the
AGDAG clusters. However, the larger effect size
on Cluster 2 (self-affirm) for the CTR group
indicates larger improvement on the positive aspect
of self-image, reflecting confidence in ones self-
experience. At termination, the status on the affilia-
tion clusters was slightly more optimal for the CTR
group than the IAC group (see Figure II). Addition-
ally, although the primary change of the IAC group
was along the affiliation dimension, the CTR group
showed almost equal changes along relevant clusters
on both dimensions. Altogether, these differences
indicate more comprehensive changes for the CTR
group than for the IAC group (i.e., toward a more
loving, less critical, and more spontaneous self-
image). Although not reflected on general levels of
psychopathology, these different patterns of change
in self-perception most likely reflect different treat-
ment processes as well. The medium to large change
in interdependence opposes most other SASB re-
search, in which little or no change along the
interdependence dimension is reported (Granberg
& Armelius, 2003; Junkert-Tress et al., 2001; Paivio
& Greenberg, 1995). As far as we know, the only
study also reporting substantial changes in interde-
pendence is Svartberg et al. (1996). The sample in
Svartberg et al.s study was characterized by high
levels of self-control at pretreatment, as was the
CTR group in the present study, and, therefore, had
large potential for change along the interdependence
dimension. The patients were involved in short-term
anxiety-provoking psychotherapy, and the primarily
goal was to obtain a more self-freeing self-image.
These findings highlight the interaction between
sample characteristics, the nature of the targeted
problem, and selected treatment, which may be
especially important when assessing the relevance
of the interdependence dimension. As the distribu-
tion of diagnoses at pretreatment in the present
study also indicated, there was high variability of
self-image profiles within diagnostic categories. This
may have implications when estimating change in
self-image within and between discrete diagnostic
categories, because different patterns of change may
counterbalance each other.
To evaluate the magnitude of change in the
present study, a comparison with the general results
of change in psychotherapy research may be of
interest. According to a review by Lambert and
Ogles (2004) regarding the efficacy of psychother-
apy, the average effect size in a broad collection of
meta-analytic reviews ranges from 0.22 to 1.05. The
present results show that patients in the most severe
ATK group overall reached beyond these effect sizes,
whereas those in the less severe CTR and IAC
groups reached large to medium effect sizes well
within this general range.
The present study may enhance the knowledge
about psychotherapy in naturalistic settings. Natur-
alistic outcome studies contribute substantially to
the field of psychotherapy research because of their
external validity and direct relevance for clinical
practice (Junkert-Tress et al., 2001). However, it is
often difficult to control for influences such as
repeated testing, instrumentation, history, and ma-
turation (Shadish, Cook, & Campbell, 2002). There
is no reason to expect such factors to influence the
profile groups differentially, and we regard such
factors to be of minor concern in the present design.
Because the SASB dimensions and, accordingly, the
profile groups are associated with severity of psy-
chopathology, statistical regression to the mean may
be a confounding factor. However, both changes
during therapy and the between-group differences in
the present study seemed too large and consistent to
be attributed to such factors.
Conclusions
The present results indicate that self-image status at
pretreatment has implications for patterns and
magnitudes of change in self-image, symptom level,
interpersonal problems, and general level of psycho-
pathology. Patients with a hostile self-image showed
larger changes than those with less pathological self-
images. The SASB introject model seems to capture
dimensions of self-relatedness influencing outcome
and treatment duration. The present categorization
in self-image profiles may be a valuable tool to gather
complementary information about severity and
prognosis (e.g., patients with a self-loving self-image
at pretreatment will probably present more distinct
problems and be in need of shorter treatment than
more self-hostile patients). Along with other research
using the SASB introject model, our results indicate
222 M. S. Halvorsen & J. T. Monsen
that the primary change in self-image occurs along
the affiliation dimension. However, both subgroups
with elevated levels of self-control changed substan-
tially along the interdependence dimension as well.
Most likely, this finding reflects the nature of the
targeted problem and different processes of change
and demonstrates the importance of including both
SASB dimensions in future psychotherapy research.
Acknowledgements
The study has used data from the Norwegian
Multisite Study of Process and Outcome in Psy-
chotherapy, which was supported by grants from the
Norwegian Research Council and the National
Council for Mental Health/Foundation for Health
and Rehabilitation.
Note
1
Further information can be obtained from Odd E. Havik,
Department of Clinical Psychology, University of Bergen, N-
5015 Bergen, Norway.
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Zusammenfassung
Das Selbstbild als ein Moderator fu r Vera nderungen
in der Psychotherapie
In dieser Studie wurde das Introjektmodell der strukture-
llen Analyse von sozialem Verhalten (Structural Analysis of
Social Behavior, SASB) verwendet, um die Beziehung
zwischen dem Selbstbild der Patienten vor der Behandlung
und den Veranderungen wahrend der Psychotherapie zu
untersuchen. Die Daten stammen von der norwegischen
Multisite-Studie zu psychotherapeutischen Prozessen und
Ergebnissen, die 233 abgeschlossene Therapien umfasst.
Patienten wurden in vier Selbstwertprofilgruppen einge-
teilt (namlich: Selbstangriff, Selbstkontrolle, Zwischen-
form von Angriff und Kontrolle und Selbstliebe), die auf
ihren anfanglichen SASB-Mustern beruhten. Insgesamt
weisen die Ergebnisse darauf hin, dass die Reaktion auf die
Behandlung mit dem anfanglichen Selbstbild u berein-
stimmt. Patienten mit einem Angriffsselbstbild zeigten
eine starkere Verringerung von Symptomen und bei den
Gesamtkriterien der Achse II wahrend der Psychotherapie
als Patienten mit einem weniger pathologischen Selbstbild.
Wie erwartet, waren die Hauptveranderungen auf der
Affiliationsdimension, obwohl Patienten mit einem erho h-
ten Niveau an Selbstkontrolle vor der Therapie auch
substantielle Veranderungen auf der Abhangigkeitsdimen-
sion zeigten.
Resume
Limage de soi comme moderateur du changement
en psychotherapie
Cette etude a applique le mode`le pour les introjectes de
lAnalyse Structurale du Comportement Social (SASB)
pour investiguer la relation entre limage de soi des
patients avant le traitement et le changement au cours de
la psychotherapie. Les donnees venaient de lEtude
Norvegienne Multisite du Processus et du Resultat en
Psychotherapie, incluant 233 therapies terminees. Les
patients etaient classes en 4 groupes de profile destime
de soi (auto-attaque, auto-contro le, attaque intermediaire,
amour de soi) sur la base de leur coefficients de pattern
SASB initiaux. Dans lensemble, les resultats indiquaient
que la reponse au traitement etait contingente avec limage
de soi avant le traitement. Les patients avec une image de
soi auto-attaquante montraient des reductions plus
grandes des sympto mes et des crite`res sommaires sur
laxe II pendant la psychotherapie que ceux avec une
image de soi moins pathologique. Comme attendu, le
changement primordial de limage de soi se faisait dans la
dimension de laffiliation, mais les patients avec des
niveaux eleves dauto-contro le avant le traitement re-
velaient des changements substantiels aussi dans la dimen-
sion de linterdependance.
Resumen
La autoimagen como moderador del cambio en
psicoterapia
Este estudio utilizo el modelo introyectado Analisis Es-
tructural de la Conducta Social (SASB) para investigar la
relacio n entre la autoimagen en el pretratamiento y el
cambio durante la psicoterapia. Los datos se obtuvieron
del Estudio del Proceso y Resultado de Psicoterapia del
Estudio Multicentrico de Noruega. Incluyo 233 terapias
completas. Los pacientes se clasificaron en cuatro grupos
de perfiles de autoimagen (v.g., autodan o, autocontrol,
ataque /control intermedio y amor a s mismo) basados en
sus patrones de coeficientes iniciales de SASB. En
224 M. S. Halvorsen & J. T. Monsen
conjunto, los resultados indican que la respuesta al
tratamiento dependio de la autoimagen de antes del
tratamiento. Los pacientes con una autoimagen de auto-
dan o mostraron reducciones mayores en los s ntomas y los
criterios de suma en el Eje II durante la psicoterapia que
los que ten an autoimagenes menos patolo gicas. Como se
esperaba, el cambio primario de la autoimagen se registro a
lo largo de la dimensio n de afiliacio n, si bien los pacientes
con niveles altos de autocontrol en el pretratamiento
revelaron tambien cambios substanciales a lo largo de la
dimensio n de interdependencia.
Resumo
A auto-imagem como moderador da mudanca em
psicoterapia
Este estudo usou o modelo introjectivo da Analise
Estrutural do Comportamento Social (AECS) para in-
vestigar a relacao entre a auto-imagem do paciente antes
do tratamento e a mudanca durante a psicoterapia. Os
dados foram obtidos a partir do Estudo Muti-centro
Noruegues sobre Processos e Resultados em Psicoterapia,
que incluia 233 terapias completas. Os pacientes foram
classificados em quatro grupos de perfis de auto-imagem
(i.e. auto-ataque, autocontrolo, ataque intermedio/con-
trolo e amor pro prio) baseados no seu padrao de coefi-
ciente inicial do AECS. Em geral, os resultados indicaram
que as respostas aos tratamentos foram contingentes a`
auto-imagem no pre-tratamento. Os pacientes com uma
auto-imagem de auto-ataque demonstraram maiores re-
duco es nos sintomas e no somato rio dos criterios do Eixo
II durante a psicoterapia do que aqueles com menor auto-
imagem patolo gica. Como esperado, a alteracao primaria
na auto-imagem deu-se na dimensao de afiliacao, embora
pacientes com elevados n veis de auto-controlo no pre-
tratamento tenham revelado tambem mudancas substan-
ciais na dimensao de interdependencia.
Sommario
Immagine di Se come moderatore di cambiamento
in psicoterapia.
Questo studio ha usato il modello introietto dellAnalisi
Strutturale del Comportamento Sociale (SASB) per in-
dagare la relazione tra limmagine di Se dei pazienti prima
del trattamento ed il cambiamento durante la psicoterapia.
I dati sono stati ottenuti dallo studio norvegese Multisite
sul processo e sullesito in psicoterapia, che ha incluso 233
terapeuti formati.
I pazienti sono stati classificati in 4 gruppi di profili di
immagine di Se (attacco al Se, controllo di Se, attacco/
controllo intermedio e amore di Se) basati sui loro iniziali
coefficienti del tipo SASB. I risultati hanno indicato
soprattutto che la risposta al trattamento era contingente
allimmagine di Se nel pre-trattamento. I pazienti con
unimmagine di Se di auto-attacco hanno mostrato piu`
ampie riduzioni nei sintomi e nella somma dei criteri
dellAsse II durante la psicoterapia rispetto a quelli con
immagini di Se meno patologiche. Come ci si aspettava, il
cambiamento principale nellimmagine di Se e` stato lungo
la dimensione affiliazione, sebbene i pazienti con livelli
elevati di controllo di Se nel pre-trattamento hanno
mostrato cambiamenti sostanziali anche lungo la dimen-
sione interdipendenza.
Self-image and change 225