Adm Policy Ment Health (2017) 44:614–625
DOI 10.1007/s10488-017-0790-5
ORIGINAL PAPER
Therapist Reflective Functioning, Therapist Attachment Style
and Therapist Effectiveness
John Cologon1 · Robert D. Schweitzer1 · Robert King1 · Tobias Nolte2
Published online: 28 January 2017
© Springer Science+Business Media New York 2017
Abstract This study investigated the relationship between
two therapist attributes (reflective functioning and attach-
ment style) and client outcome. Twenty-five therapists
treated a total of 1001 clients. Therapists were assessed
for reflective functioning and attachment style using the
Adult Attachment Interview and the Experiences in Close
Relationships Scale. Clinical outcome was measured using
the Outcome Questionnaire (OQ-45). Data were analysed
using hierarchical linear modelling. Results indicated that
therapist reflective functioning predicted therapist effective-
ness, whereas attachment style did not. However, there was
evidence of an interaction between therapist attachment
style and therapist reflective functioning. Secure attach-
ment compensated somewhat for low reflective functioning
and high reflective functioning compensated for insecure
attachment. Possible implications for the selection of ther-
apy training candidates and therapist training are discussed.
Keywords Mentalization · Reflective functioning ·
Attachment · Psychotherapy outcome · Adult attachment
interview · Therapist effectiveness · OQ-45 · Therapist
factors
This study was conducted as part of the Ph.D. of the primary
author.
* John Cologon
john@jcologon.com
1
Queensland University of Technology, Brisbane, Australia
2
Research Department of Clinical, Educational and Health
Psychology, The Anna Freud Centre, University College
London, London, UK
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Vol:.(1234567890)
Therapist Reflective Functioning, Attachment
and Effectiveness
The findings of large scale naturalistic studies (Saxon and
Barkham 2012) suggest that differences between therapists
contribute to psychotherapy outcome. While the propor-
tion of outcome attributable to therapist differences (6–8%)
is not large, it is potentially important. If we can optimise
the therapist contribution to outcome, there is potential to
lift overall therapy outcomes. At a time when it is increas-
ingly clear that the contribution of the specific form of psy-
chotherapy is minor (cf. Wampold 2001), it is important
to understand other variables that we have the potential to
control and optimise.
Current research suggests that many therapist factors
have little, if any, impact on client outcomes. Previously
researched factors include therapist gender, theoretical ori-
entation, experience, education and training (Baldwin and
Imel 2013; Lambert 2013a). These findings suggest that
any therapist factors which do contribute to client outcome
are not acquired through training or experience. It is pos-
sible that the factors which differentiate between therapists
are personality characteristics that are not amenable to
change through training or experience. However, it is also
possible that these personality factors have not been the
focus of training, or may not be salient when therapists are
acquiring experience.
The current study aimed to investigate two variables
that have some face validity as characteristics that might
contribute to therapist effectiveness. One variable, thera-
pist reflective functioning, should contribute to therapist
capacity to understand and empathise with a client. The
other variable, therapist attachment, should contribute to
the therapist’s ability to enter into a supportive and stable
relationship with the client. As outlined below, current
Adm Policy Ment Health (2017) 44:614–625
literature indicates that these variables are relevant to inter-
personal functioning. It has been argued that they also be
relevant to client outcomes in psychotherapy. However, to
our knowledge these factors have not been investigated as
predictors of therapist effectiveness.
Therapist Attachment and Effectiveness
Attachment is a complex construct with biological and psy-
chological components. It is thought to be central to human
social functioning. Developmentally, attachment refers
to the bond between parents and children, which forms a
template for subsequent intimate relationships. Difficulties
in early attachment are thought to have enduring implica-
tions for subsequent relationships (Mikulincer and Shaver
2007). The term ‘attachment style’ refers to a characteris-
tic orientation to the other person in interpersonal relation-
ships. Attachment style is thought to have origins in early
attachment relationships with parents or other key figures
(Brumbaugh and Fraley 2007).
Attachment style is broadly categorised as secure or
insecure. Secure attachment is characterised by a confident
and optimistic orientation to others. By contrast, insecure
attachment is characterised by a fearful, avoidant or over-
dependent orientation towards others (Mikulincer and
Shaver 2007). Reliable measures of attachment style have
been developed, as a result of which a substantial body of
empirical research has demonstrated that attachment style
is a predictor of the trajectory of adult relationships (Fraley
et al. 2000). It is therefore reasonable to expect that thera-
pist attachment style may affect the quality of the therapeu-
tic relationship.
It has been proposed that therapists with a secure attach-
ment style may achieve better client outcomes than inse-
curely attached therapists, due to the impact of attachment
style on variables such as the therapeutic alliance (Black
et al. 2005; Sauer et al. 2003) and countertransference
(Mohr et al. 2005). It has also been argued that effective
therapists need to provide a secure base for the client (Far-
ber et al. 2009). Securely attached therapists may be bet-
ter able to establish this base than insecurely attached
therapists.
Reflective Functioning and Therapist Effectiveness
Reflective functioning (or mentalization) refers to the
ability to conceptualise, identify, and understand mental
states in the self and others. It involves both cognitive and
affective aspects. Reflective functioning also requires an
understanding of the complex relationships between fac-
tors which constitute human motivation, and which predict
human behaviour. These factors include conflicting desires,
goals, and other intentional mental states. Reflective
615
functioning frequently involves holding in mind multiple,
concurrent points of view. For example, a therapist may
concurrently track both the probable mental processes of
the client, and their own reactions within a session. Thus,
reflective functioning bears close relationships to constructs
such as theory of mind, mind-mindedness, metacognition,
psychological mindedness, mind reading, and perspective
taking (Allen 2006; Choi-Kain and Gunderson 2008; Fon-
agy 2015). It is also a component of empathy, which has
long been considered an important component of therapist
effectiveness (Rogers 1957/2007).
Reflective functioning is seen to play a key role in the
development of attachment security. In Fonagy’s evolving
conceptualisation, attachment and reflective functioning
are seen as “loosely coupled” (Fonagy and Bateman 2006,
p. 420). Reflecting this coupling, securely attached children
have been observed to develop reflective capacities earlier
than children who are less securely attached (Fonagy and
Bateman 2006). This finding has been interpreted to mean
that the development of reflective functioning contrib-
utes to the development of secure attachment. It has been
hypothesised that this occurs in part through interpersonal
processes that underpin the development of epistemic
trust, a capacity for openness to benign others as a source
of knowledge about the world (Fonagy 1998; Nolte et al.
2011).
The Interface Between Attachment and Reflective
Functioning
It has been argued that childhood secure attachment is
facilitated by parental reflective functioning. For example,
a mother’s ability to treat their child as a mental agent has
been found to predict the attachment status of their child
(Fonagy et al. 1991). In addition, reflective functioning has
been found to mediate the relationship between experiences
of abuse and the development of borderline personality
disorder. Persons with a history of abuse and low reflec-
tive functioning are most at risk of developing the disorder
(Fonagy et al. 1996).
The transgenerational mechanism described above may
have application beyond the parent–child relationship.
Given the centrality of the dyadic relationship to the pro-
cess of therapy, it is possible that a parallel process occurs
in psychotherapy. A therapist with high mentalizing capaci-
ties may be better able to create the secure and reflective
interpersonal space that allows for therapeutic change.
This proposition is consistent with Fonagy and Bateman’s
(2006) argument that the therapist’s capacity to “keep the
patient’s mind in mind” is major mechanism of change in
psychotherapy (Fonagy and Bateman 2006, p. 415).
Given this potential parallel between parenting and psy-
chotherapy (Farber et al. 2009), it can be theorized that
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616
reflective functioning plays a part in effective therapy. In
addition, it has been argued that mentalizing mediates the
relationship between the therapist’s internal working model
and the attachment processes of the patient within the ther-
apeutic relationship (Holmes 2011). One of the key roles
of the therapist is thus to use their own reflective function-
ing to develop the patient’s reflective functioning. (Fonagy
and Bateman 2006). Therapists who have a greater capacity
for reflective functioning should have a greater capacity to
facilitate this process.
Reflective functioning has been researched from the per-
spective of multiple paradigms, using varied tools. Some of
these measures focus on cognitive aspects, whereas others
tap affective processes (Choi-Kain and Gunderson 2008;
Ensink and Mayes 2010; Fonagy et al. 2011). However, as
with attachment, this research has mainly been focussed
on the reflective functioning of parents and psychotherapy
clients. There remains a paucity of research investigating
therapist reflective functioning in relation to therapeutic
effectiveness.
The Present Study
The current study examines the relationship between key
therapist variables and therapy effectiveness. Specifically,
the current study investigates the relationship between ther-
apist reflective functioning and psychotherapeutic effec-
tiveness. We also aim to examine the relationship between
therapist attachment security and therapist effectiveness,
and any potential relationship between these two predictors.
Method
Participants
Therapists
Twenty-five therapists (4 males, 21 females) participated in
the study. The therapists included 16 students participating
in postgraduate courses, and 9 therapists working at a uni-
versity counselling centre. Therapists ranged in age from
24 to 56 years, with a mean age of 41. 9 years (SD = 9.7).
Years of experience ranged from 0 to 30, with a mean of
7.3 years (SD = 7.7). Eleven of the therapists reported their
primary therapeutic orientation as psychodynamic. A fur-
ther six therapists indicated a commitment to Acceptance
and Commitment Therapy (ACT). The next most preva-
lent orientation was integrative (four therapists), followed
by humanistic/client-centred (two therapists). One thera-
pist indicated CBT as their primary orientation, and one
therapist ticked “other”. The number of clients per therapist
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Adm Policy Ment Health (2017) 44:614–625
varied from 4 to 219, with a mean of 38.84 clients per ther-
apist (SD = 57.84).
Clients
Data from 1001 clients were included in this study. Clients
were included in the study on the condition that they had
attended more than one therapy session, and had completed
a standard outcome measure on at least two occasions. Cli-
ents ranged in age from 18 to 64 years, with a mean age
of 33.7 years (SD = 11.3). The gender balance in the client
group was 67% females to 33% males. The main presenting
problems were depression and anxiety, with a smaller pro-
portion of clients citing relationship difficulties, PTSD, and
drug or alcohol issues.
Materials
Measures for Assessing Therapists
Adult Attachment Interview (AAI)
The AAI (George et al. 1985), was scored as a measure
of reflective functioning. The AAI is a semi-structured
interview which explores an adult’s early childhood expe-
riences and the perceived impact of these experiences on
later development. Reflective functioning is assessed using
a coding scheme developed by Fonagy et al. (1998). This
scoring reflects the extent to which the interviewee is able
to mentalize, or reflect from differing viewpoints, on the
material presented in the interview. Reflective functioning
is scored on an 11-point scale, with possible scores ranging
from −1 (rejection of reflective functioning) to 9 (excep-
tional reflective functioning) A score of 5 reflects “ordinary
reflective functioning” (Fonagy et al. 1998).
The Reflective Functioning scale is reported to have
inter-rater reliability in the order of .70–.75 (Fonagy et al.
1991). The inter-rater reliability depends on the training of
raters, who are required to be trained to demonstrate inter-
rater reliability of at least .70 with pre-existing test-AAIs.
The AAIs with therapists were conducted by the first
author. Interviews were transcribed according to the proto-
col set out in the AAI manual and then coded for reflective
functioning by two trained coders who had been certified as
reliable.
Experiences in Close Relationships Scale (ECR)
The ECR (ECR: Brennan et al. 1998) is a 36-item self-
report measure of attachment style. The scale was devel-
oped through factor analysis of 60 self-report measures of
attachment. The developers selected two sets of 18 items,
Adm Policy Ment Health (2017) 44:614–625
which loaded most strongly on each of the two underly-
ing factors: attachment anxiety and attachment avoidance.
Items are rated on a 7-point Likert scale. Internal consist-
ency for the anxiety subscale is reported as .94 and for the
avoidance subscale as .91. Test–retest reliability for the
anxiety subscales is reported as .90 and for the avoidance
subscale as .91 (Fraley et al. 2000). As is common practice
(Mikulincer and Shaver 2007), the wording of items was
modified to make the scale more relevant to the context.
The words “romantic partner” were replaced with “peo-
ple”, “someone”, and “people I’m close to” as appropri-
ate, to make the scale more relevant to the therapy context
rather than the romantic one. Where such a wording would
not have made sense, the word “partner” was retained, but
the word “romantic” was dropped.
Measure for Assessing Client Outcome
Outcome Questionnaire 45 (OQ‑45)
The OQ-45 (Lambert et al. 2004) is a 45-item self-report
measure designed to track changes over the course of psy-
chotherapy. Items are scored on a 5-point Likert scale, rang-
ing from 0 = never to 4 = almost always. The instrument
yields three subscales: Subjective Distress (SD), Interper-
sonal Relations (IR), and Social Role (SR). Test–retest reli-
ability is reported to be r = .84, and internal consistency is
reportedly .93 (Doerfler et al. 2002). The OQ-45 is reported
to correlate with several other self-report measures, such
as the Beck Depression Inventory. It has been found to be
responsive to changes over time as a result of psychother-
apy (Vermeersch et al. 2000).
Data Collection Procedures
Following ethical approval from the Human Research Eth-
ics Committee of QUT, informed consent was obtained
from participating therapists. Therapists were interviewed
using the procedure specified in the AAI protocol. Follow-
ing the interview, the therapists were asked to complete the
ECR. Those therapists for whom client OQ-45 data was not
already available were then given client information sheets,
client consent forms, and instructions for collecting the
OQ-45 data from their clients after each therapy session.
Data Analysis
Data were analysed using hierarchical linear modelling
(HLM). HLM was chosen for multiple reasons. Firstly,
HLM deals satisfactorily with the dependency between
clusters in longitudinal and cross-sectional data that
involves hierarchical properties. Secondly, hierarchical lin-
ear models have the capacity to clarify trends even when
617
observations are missing for some persons across the waves
of data collection. Thirdly, hierarchical linear models can
also accommodate situations in which the time of data col-
lection varies across persons. Fourthly, hierarchical linear
models can handle missing data across levels of dependent
variables and allow for within-subjects and/or between-
subjects heterogeneity. Fifthly, hierarchical linear models
explicitly model the covariance structure of the data and
allow time to be treated as a fixed or random effect. Finally,
hierarchical linear models do not require the assumption of
sphericity (Bryk and Raudenbush 1988, 1992; Todd et al.
2005). The analysis was completed using the software pro-
gram HLM, version 7.22a.
The data were analysed twice, using HLM (Bryk and
Raudenbush 1992). Initially, a 3-level model was used, in
which therapy sessions were nested within clients, who
were nested within therapists. To examine the possibility of
differences between clinics, a 4-level model was also run,
in which therapy sessions were nested within clients who
were nested within therapists who were nested within clin-
ics. Since the results of the 4-level model were essentially
the same as the results of the 3-level model (i.e., the same
variables were significant or non-significant at the same
level of significance), it was concluded that differences
between clinics were not important and that the 3-level
model was more parsimonious. Hence, the results of the
3-level model are reported here.
Results Descriptive Statistics
Means, standard deviations, and ranges for the variables
analysed are reported in Table 1, below.
Correlations between the therapist level variables are
given in Table 2, below.
Normality
The dependent variable in this study was the OQ-45 score.
OQ-45 scores for the study had a kurtosis of .02, a stand-
ard error of kurtosis of .07, skewness of .04 and standard
error of skewness of .02. The distribution of the OQ-45
was examined for conformity to the normal distribution by
the maximum likelihood method. The procedure yielded
a χ2 of 31.6 (df = 8, p < .001), a Shapiro–Wilk statistic of
.99 (p < .001), and a Kolmogorov–Smirnov statistic of .02
(Lillefors p = .007). It was therefore concluded that the
sample was sufficiently normal for the analysis proposed.
Inter‑Rater Reliability
Since the main predictor variables for this study are based
on coding of the AAI for reflective functioning by trained
and accredited raters, it was important to assess inter-rater
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reliability. For reflective functioning, this was done in sev-
eral ways: using the intraclass correlation coefficient (ICC);
using Krippendorf’s alpha; and using Lin’s concordance.
For reflective functioning, the ICC was .73, Krippendorf’s
alpha was .79, and Lin’s concordance was .71.
Fully Unconditional Model and Unconditional Growth
Model
The results for the fully unconditional model and the
unconditional growth model are presented in Tables 3
and 4.
Preliminary Analyses
Before exploring the predictors central to the current study,
a conditional model involving factors which, on the basis of
previous research, were expected not to contribute signifi-
cantly to therapist effectiveness, was analysed. The predic-
tors in this model were therapist gender, age, and orienta-
tion (type of therapy practiced). As expected, none of these
factors contributed significantly to the explanation of thera-
pist effectiveness. A comparison of this model with the
unconditional model was non-significant (χ2 = 6.993, df = 8,
p > .500). This indicates that adding therapist gender, age,
and orientation did not improve the adequacy of the model.
Therefore, these variables were discarded for subsequent
analyses.
Therapists saw clients for widely differing numbers
of sessions. Hence it was considered important to test the
effect of number of sessions on outcome. When number of
sessions was added to the unconditional model, the effect
on outcome was non-significant (p = .230). Hence, number
of sessions was excluded from further analyses.

Table 1  Descriptive statistics Variable Name N Mean SD Minimum Maximum

Level one (therapy sessions) Session 4760 5.25 5.62 2 43

OQ-45 4760 77.60 23.83 8 164
Level two (clients) Initial severity 1001 80.39 23.30 10 153
No of sessions 1001 4.76 4.71 2.00 43.00
Level three (therapists) Therapist age 25 37.88 10.77 24 56
ECR anxiety 25 3.47 0.69 2.11 5.00
ECR avoidance 25 3.75 0.82 1.78 5.22
Reflective functioning (RF) 25 6.12 1.09 4 7.5

Table 2  Correlations between Age No. of clients ECR avoidance ECR anxiety RF Years of
therapist variables experi-
ence

Age 1.000
No. of clients 0.261 1.000
ECR avoidance −0.169 0.261 1.000
ECR anxiety −0.010 −0.262 0.220 1.000
RF −0.314 −0.185 0.057 0.091 1.000
Years of experience 0.712 0.464 0.135 −0.041 −0.363 1.000

Table 3  HLM results for the fully unconditional model

Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 76.82 0.84 91.24 24 <.001

Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 13.60 184.92

Client (level 2) unexplained variance (r0) 19.94 397.63 9975.34 945 <.001
Therapist (level 3) unexplained variance (u00) 1.55 2.40 41.58 24 .014

HLM model: OQtij = γ000 + r0ij + u00j + etij

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Adm Policy Ment Health (2017) 44:614–625 619

Table 4  HLM results for the unconditional growth model

Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 77.46 0.89 86.91 3738 <.001

OQ slope (γ100) −0.84 0.30 −2.84 24 .009
Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 13.30 176.72

Client (level 2) unexplained OQ slope variance (r1) 4.57 20.84 2339.23 945 <.001
Therapist (level 3) unexplained OQ Slope Variance (U10) 0.65 0.42 130.97 24 <.001

HLM model: OQtij = γ000 + γ100*SESS_Ttij+r1ij*SESS_Ttij + u10jSESS_Ttij + etij

Initial severity of client disturbance was considered
likely to affect outcome. Therefore, initial severity was
added to the unconditional model as a level two predictor.
Initial severity had a significant effect both on the level of
the intercept for outcome (p < .001) and also on the slope
(p < .001). It will be noted that the effect on slope was in
the direction that more severe clients had greater improve-
ment, presumably because they had more room to improve.
A comparison of this model with the unconditional
model yielded the following model comparison statistics:
χ2 = 1351.14953, df = 2, p < .001, indicating that the addi-
tion of initial severity as a predictor significantly improved
the model. Hence, initial severity was retained as a level
two predictor in subsequent analyses. Results of this analy-
sis are presented in Table 5.
Reflective Functioning and Therapist Effectiveness
The study aimed to examine the relationship between
capacity for reflective functioning, as measured by the
reflective functioning scale, and therapist effectiveness.
There was a significant fixed effect for reflective function-
ing (p < .001). The addition of reflective functioning to the
model provided a markedly significant improvement over
the previous model (χ2 = 12.46303, df = 1, p < .001). The
effects of reflective functioning and attachment on therapist
effectiveness are detailed in Table 6, below.
The findings support the relationship between capacity
for reflective functioning and therapist effectiveness.
The trajectories for clients of therapists with low,
medium, and high reflective functioning are presented in
Fig. 1. The high reflective functioning group consists of
those therapists with a score of 7 or higher. The medium
reflective functioning group contains therapists scoring
higher than 5 and lower than 7. The low reflective func-
tioning group consists of therapists scoring 5 or lower
(i.e. lower than “normal reflective functioning”). It is evi-
dent from the slopes that symptom severity decreased
significantly over time for clients of therapists in the high
reflective functioning group. In other words, these thera-
pists were effective. The level of symptoms for clients of
therapists with medium levels of reflective functioning also
decreased over time, but to a lesser extent than for those of

Table 5  HLM growth model taking account of average initial severity of client per therapist
Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 77.87 0.89 86.74 3738 <.001

OQ slope (γ100) −2.05 0.60 −3.40 24 .002
OQ slope per initial severity score (γ110) −0.20 0.02 −11.57 944 <.001
Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 19.87 394.69

Client (level 2) unexplained OQ slope variance (r1) 3.49 12.16 2571.84 944 <.001
Therapist (level 3) unexplained OQ slope variance (u10) 2.40 5.75 155.20 24 <.001

HLM model: OQtij = γ000 + γ100*SESS_Ttij + γ110*SESS_Ttij*INITSEVij + r1ij*SESS_Ttij + u10j*SESS_Ttij + etij

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620 Adm Policy Ment Health (2017) 44:614–625

high reflective functioning therapists. Low reflective func- Interaction Between Reflective Functioning
tioning therapists had negligible effect on client symptoms. and Attachment

Estimation of Effect Size
Estimates of variance accounted for are problematic in
multilevel models (McCoach 2010; Widman 2011). It
is not possible to calculate a direct equivalent to ­R2 for
multilevel models. The most widely used method of esti-
mating the variance accounted for, proportional reduc-
tion in variance (Bryk and Raudenbush 1992), suggests
that 70.5% of the variance in therapist effectiveness is
accounted for by reflective functioning.
Attachment Style and Therapist Effectiveness
Attachment style did not make a significant contribution to
the model as can be seen in Table 6, below.
Although attachment did not have a significant direct effect
on therapist effectiveness in the initial analysis, when inter-
actions were examined, a significant interaction between
attachment and reflective functioning was found, in terms
of their effect on therapist effectiveness. Inclusion of the
interaction term also resulted in significance for attachment
anxiety, which was not significant when the interaction
term was not included. Details of the interaction are pre-
sented in Table 7, below.
The nature of the interaction was examined by taking a
median split of therapists on their ECR anxiety scores and
plotting the relationship between RF and effectiveness for
the two groups. The resultant graph is presented below in
Fig. 2.
The effectiveness scores on the vertical axis represent
aggregated slopes from client OQ trajectories, so the more

Fig. 1  OQ score trajectories for

clients of low, medium and high
RF therapists. Greater negative
slope means greater improve-
ment

Table 6  Effect of reflective functioning and attachment on therapist effectiveness

Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 76.77 0.86 89.43 968 <.001

OQ slope (γ100) −0.86 0.13 −6.88 21 <.001
RF (γ101) −0.45 0.11 −4.15 21 <.001
ECR avoidance (γ102) −0.03 0.18 −0.16 21 0.87
ECR anxiety (γ103) −0.27 0.18 −1.48 21 0.16
OQ slope per initial severity score (γ110) 0.80 0.02 52.78 968 <.001
Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 13.09 171.56

Client (level 2) unexplained OQ slope variance (r1) 9.85 97.06 4644.22 968 <.001
Therapist (level 3) unexplained OQ slope variance (u10) 0.41 0.17 81.63 21 <.001

HLM model: OQtij = γ000 + γ100*SESS_Ttij + γ101*SESS_Ttij*RFj + γ102*SESS_Ttij*ECR_AVDj + γ103*SESS_Ttij*ECR_ANXj + γ110*SESS_Ttij*INI

TSEVij + r1ij*SESS_Ttij + u10j *SESS_Ttij + etij

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Adm Policy Ment Health (2017) 44:614–625
Table 7  Interaction between RF and attachment anxiety
Coefficient SE t-ratio
Reflective functioning 1.615328 0.520387 3.104
ECR avoidance 0.000862 0.135746 0.006
ECR anxiety 4.011969 1.099564 3.649
Interaction between −0.665152 0.166683 −3.991
ECR anxiety and RF
HLM model: OQmtij = γ0000 + γ0001 + γ0100*INITSEVtij + γ1000*SESSIO
Nmtij + γ1010*SESSIONmtij*RFij + γ1020*SESSIONmtij*RFXANXij + γ1030
*SESSIONmtij*ECR_AVDij + γ1040*SESSIONmtij*ECR_ANXij + γ1100*
SESSIONmtij*INITSEVtij + e0tij + r00ij + r10ij *SESSIONmtij + u000j + u100j
*SESSIONmtij + εmtij
Fig. 2  Relationship between RF and effectiveness for high and low
attachment anxiety therapists
negative the value, the greater the effectiveness. Positive
values indicate deterioration rather than improvement. As
can be seen from the graph, although higher RF leads to
greater effectiveness for both high and low anxiety thera-
pists, the effect of RF on effectiveness is considerably
greater for the therapists with high attachment anxiety than
it is for those with low anxiety. Furthermore, for the thera-
pists with the lowest RF, higher attachment anxiety reduces
their effectiveness, whereas for therapists with higher RF,
higher attachment anxiety increases their effectiveness.
Discussion
Consistent with previous findings (Baldwin and Imel 2013;
Lambert 2013a) this study showed that psychotherapy out-
comes varied according to therapist. More importantly, this
investigation identified therapist variables associated with
client outcome. Therapists with higher reflective function-
ing capacities had significantly better client outcomes than
therapists with lower reflective functioning. Contrary to
expectation, therapists with higher attachment security did
not have better client outcomes.
621
Reflective Functioning and Therapist Effectiveness
df p value
The findings support the significance of reflective function-
15 .007 ing for therapist effectiveness. Therapist reflective function-
15 .995 ing is thought to facilitate growth in the client’s reflective
15 .002 functioning. It is thus considered by some to be founda-
15 .001 tional to the process of change in psychotherapy (Fonagy
and Bateman 2006). Therapist reflective functioning may
therefore be considered a common factor across therapies.
The finding that therapist reflective functioning predicts
therapist effectiveness further develops our understanding
of the role of common factors in the process of psycho-
therapy (cf. Wampold 2001). The investigation of common
factors has become important in light of the results of a
recent meta-analysis of the effects of therapist competence
in, and adherence to, specific therapies. This analysis found
that the effect size for adherence was .02, and for compe-
tence was .07 (Webb 2012). Considering the importance
of reflective functioning in therapy, it is unsurprising that
therapists with higher reflective function (regardless of
orientation) are more able to facilitate growth in the reflec-
tive functioning of their clients. This is, to our knowledge,
the first empirical study to provide evidence that therapist
reflective functioning is an important factor in therapist
effectiveness. This result indicates that therapist reflective
functioning affects therapist effectiveness, independently of
their attachment representation.
The significant association between reflective func-
tioning and therapist effectiveness found in this study is
consistent with results reported in a study that used the
patient therapist form of the AAI (Diamond et al. 2003).
That study, which used a case-study approach due to a very
small sample size, involved the scoring of therapists’ reflec-
tive functioning on the patient-therapist adult attachment
interview (PT-AAI). In that study, whenever a therapist
scored 4 or above for reflective functioning on the PT-AAI,
the client’s reflective functioning increased from pre-ther-
apy to post-therapy.
The results reported here also support results reported
in a study investigating therapist use of personal counsel-
ling (Rizq and Target 2010). That study found that thera-
pists “with higher levels of reflective functioning (who
were more likely to be secure/earned secure) appeared to
use their experience of being a client in therapy as a spring-
board to understanding the more subtle and complex psy-
chological needs of their clients” (Rizq and Target 2010,
p. 476).
The interaction between attachment anxiety and reflec-
tive functioning in this study is consistent with the idea
that mentalizing provides a buffer that protects against
the harmful effects of attachment trauma in earlier life
(Eagle et al. 2009). Reflective functioning may indeed be
indicative of a certain level of earned security. This study
13
622
suggests that reflective functioning may not only protect,
but transform attachment anxiety from a negative to a
positive factor in terms of therapist effectiveness. Having
high reflective functioning enabled therapists in this study
who reported high levels of attachment anxiety to outper-
form therapists with lower attachment anxiety, so that what
might have been considered to be a setback was trans-
formed into an asset.
The finding that reflective functioning predicts thera-
pist effectiveness may also clarify the findings of a study
in which psychotherapy students who demonstrated signs
of emotional disturbance on self-report measures initially
performed less effectively than their peers. However, after
training, their effectiveness improved so that it matched
their peers (O’Donovan and Dyck 2005).
Assuming emotional disturbance to be similar to attach-
ment anxiety (cf. Esbjorn et al. 2012), we might conclude
that the effectiveness of trainee therapists who showed
signs of emotional disturbance would depend on their
level of reflective functioning. If they lacked sufficient
reflective functioning to deal with their attachment anxi-
ety, they might not be able to exploit their own develop-
mental history in an interpersonally constructive way.
They might therefore perform relatively ineffectively as
therapists. However, if the process of training they under-
went included elements which led to an improvement in
their level of reflective functioning, then their effectiveness
might be expected to also improve.
The findings have implications for optimising therapeu-
tic outcomes, the selection of therapy training candidates,
and enhancing therapy training experiences. The findings
suggest that enhanced reflective functioning is important
in determining the effectiveness of therapists. In select-
ing candidates for training, consideration may be given to
selecting candidates who are able to demonstrate the req-
uisite components of effective therapists. The findings also
suggest that programs aimed at enhancing reflective func-
tioning may well contribute to therapist effectiveness.
It is not surprising that reflective functioning is relevant
to effective therapy. It could be asserted with some justifi-
cation that reflective functioning is the core of what thera-
pists do! “All therapy requires mentalizing on the part of
the patient and the therapist” (Allen and Fonagy 2006, p.
xix). It is therefore intuitive that being able to understand
the mental processes of oneself and others means being
able to provide better therapy.
Research Limitations
An important limitation of this study relates to the natu-
ralistic design. Clients were not randomised to therapists.
For the most part, assignment to therapist was based on
13
Adm Policy Ment Health (2017) 44:614–625
therapist availability, which means that it is unlikely that
assignment factors biased outcome. However, we can-
not exclude the possibility that there was some intentional
assignment that could have confounded findings. We con-
trolled for those factors that we knew predicted outcome
but there may have been variables we did not measure that
confounded results.
A second limitation derives from sample size. Although
this study found significant results, the number of therapists
constituting level three of the analysis was not large. This
meant that we had insufficient power to detect small effects.
A study using a larger sample might find significant results
regarding attachment style.
A further limitation derives from variability in the num-
ber of clients seen by each therapist, which in this study
ranged from 4 to 209. It could be argued that the small
numbers for some therapists increased the risk that the
slope is not a reliable estimate of therapist effectiveness
because small samples increase the risk that a particular
group of clients have atypical recovery trajectories. To the
extent that recovery prospects relate to initial severity, con-
trolling for initial severity mitigates this problem to some
extent. However, this study does not investigate the effec-
tiveness of each individual therapist, but factors predicting
the trend across therapists in terms of effectiveness. In that
process, the pooling of estimates from all the therapists
means that the inclusion of therapists with lower numbers
of clients helps to increase the power of the estimation of
the effect of predictor variables, irrespective of the accu-
racy of estimation at the individual therapist level (B. E.
Wampold 2012, personal communication). It would, how-
ever, be a problem if the number of clients per therapist
varied in a systematic, non-random way that affected out-
come. This does not appear to be the case, given that num-
ber of clients per therapist is non-significant as a predictor
variable. Furthermore, the small and non-significant corre-
lation between reflective functioning and number of clients
(r = −.185, p = .377) indicates that differences in numbers
of clients have probably not contaminated the most signifi-
cant result in this study, the connection between reflective
functioning and therapist effectiveness. Nevertheless, the
possibility that variations in numbers of clients may have
subtly affected the results in some way cannot be com-
pletely excluded.
Finally, therapeutic intervention is a possible confound.
We did not control for intervention and it is possible that
more reflective therapists used more effective interventions
and it was this, rather than their reflective functioning, that
resulted in better client outcomes. We think this unlikely
given the weight of evidence for broad equivalence of ther-
apeutic interventions with high prevalence disorders (Lam-
bert 2013b; Wampold 2001), but it cannot be excluded.
Adm Policy Ment Health (2017) 44:614–625
Directions for Future Research
The findings of this study need replication, preferably with
a larger sample and ideally with clients randomly assigned
to therapists. If reflective functioning is an important ingre-
dient in therapist effectiveness, then the extent to which
training can enhance reflective functioning is a question
that needs to be answered. If it can be shown that particu-
lar methods of training enhance reflective functioning,
this would have significant implications for the training of
psychotherapists. Steps in that direction have already been
taken by Canadian researchers, who report that a train-
ing program did indeed increase the reflective functioning
of student therapists (Ensink et al. 2013). This interest-
ing research assessed reflective functioning using a video
vignette system known as the Therapist Mental Activity
Scale (TMAS: Maheux et al. 2012). This scale is a revision
of the Countertransference Rating System (CRS: Norman-
din and Bouchard 1993). Although the authors state that the
scale, which derives from the French psychoanalytic tradi-
tion going back to Pierre Marty (Marty and Michel 1963)
has been modified/to make it “fully compatible with Fon-
agy’s model” (Maheux et al. 2012, p. 527), it is not clear
how successful this revision has been in terms of the extent
to which this scale relates to the reflective functioning
scale. It is also therefore not clear how that research relates
to the research presented here. The only published com-
parison of the system on which this scale is based, known
at the time as the Mental States Rating System (MSRS),
found that they “share some aspect of a core mentalization
process and that each illuminates a specific component”
(Bouchard et al. 2008, p. 47). That comparison also found
that only reflective functioning significantly predicted
attachment. If the new modification means that the thera-
pist mental activity measured by the TMAS is indeed the
same entity as the reflective functioning measured by the
Reflective Functioning scale, then that study meshes very
with this study in indicating ways of training more effective
therapists. Future research needs to clarify the relationship
between the TMAS and the Reflective Functioning scale.
In addition to assessing the effect of specific training on
reflective capacity, future research should also investigate
the extent to which the therapeutic alliance is a mediating
variable in the relationships reported here.
Conclusion
While it has become increasingly clear over the past two
decades that some psychotherapists are more effective than
others (Bergin 1963; Beutler 1997; Blatt et al. 1996; Brown
et al. 2005; Crits-Christoph and Mintz 1991; Lafferty et al.
1989; Lambert 1989; Luborsky et al. 1986, 1997, 1985;
623
Lutz et al. 2007; Najavits and Strupp 1994; Okiishi et al.
2003, 2006; Shapiro et al. 1989).This growing body of
research indicates that differences in therapist effective-
ness are not explained by differences in the level of thera-
pist experience, education or training. However, there has
been a gap in our knowledge regarding what makes ther-
apists effective. The findings from this study suggest that
one of the characteristics that make therapists effective is a
well-developed ability to mentalize. While not surprising,
this has implications for our understanding of the thera-
peutic process, and for the selection and training of thera-
pists. Research into reflective functioning has suggested a
significant role for mentalizing in protecting people from
the effects of attachment trauma and overcoming childhood
difficulties (Bateman et al. 2009). This paper suggests that
people characterized by high levels of mentalizing and an
understanding and integration of adverse experiences may
be among those who make good therapists.
Compliance with Ethical Standards
Conflict of interest No conflicts of interest were involved.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
Human Research Ethics Committee of Queensland University of Tech-
nology and with the 1964 Helsinki declaration and its later amend-
ments or comparable ethical standards, and were approved by the
Human Research Ethics Committee of QUT.
References
Allen, J. G. (2006). Mentalizing in practice The handbook of mentali‑
zation-based treatment (pp. 3–30). Hoboken: John Wiley & Sons
Inc.
Allen, J. G., & Fonagy, P. (2006). The handbook of mentalization-
based treatment. Hoboken: John Wiley & Sons Inc.
Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Findings and
methods. In M. J. Lambert (Ed.), Bergin and Garfield’s hand‑
book of psychotherapy and behavior change (6th ed., pp. 415–
456). Hokoben: John Wiley & Sons.
Bateman, A., Fonagy, P., Allen, J. G., & Gabbard, G. O. (2009).
Theory and practice of mentalization-based therapy. Textbook
of psychotherapeutic treatments (pp. 757–780). Arlington, VA:
American Psychiatric Publishing, Inc.
Bergin, A. E. (1963). The effects of psychotherapy: Negative results
revisited. Journal of Counseling Psychology, 10, 244–250.
Beutler, L. E. (1997). The psychotherapist as a neglected variable in
psychotherapy: An illustration by reference to the role of thera-
pist experience & training. Clinical Psychology: Science and
Practice, 4(1), 44–52.
Black, S., Hardy, G., Turpin, G., & Parry, G. (2005). Self-reported
attachment styles and therapeutic orientation of therapists and
their relationship with reported general alliance quality and prob-
lems in therapy. Psychology and Psychotherapy-Theory Research
and Practice, 78, 363–377. doi:10.1348/147608305x43784.
13
624
Blatt, S. J., Sanislow, C. A. III, Zuroff, D. C., & Pilkonis, P. A.
(1996). Characteristics of effective therapists: Further analyses
of data from the National Institute of Mental Health Treatment
of Depression Collaborative Research Program. Journal of Con‑
sulting and Clinical Psychology, 64(6), 1276–1284.
Bouchard, M.-A., Target, M., Lecours, S., Fonagy, P., Tremblay,
L.-M., Schachter, A., et al. (2008). Mentalization in adult attach-
ment narratives: Reflective functioning, mental states, and affect
elaboration compared. Psychoanalytic Psychology, 25(1), 47–66.
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report
measurement of adult attachment: An integrative overview
attachment theory and close relationships (pp. 46–76). New
York: Guilford Press.
Brown, G. S., Lambert, M. J., Jones, E. R., & Minami, T. (2005).
Identifying highly effective psychotherapists in a managed
care environment. American Journal of Managed Care, 11(8),
513–520.
Brumbaugh, C. C., & Fraley, R. C. (2007). Transference of attach-
ment patterns: How important relationships influence feelings
toward novel people. Personal Relationships, 14(4), 513–530.
Bryk, A. S., & Raudenbush, S. W. (1988). Toward a more appropri-
ate conceptualization of research on school effects: A three-level
hierarchical linear model. American Journal of Education, 97(1),
65–108. doi:10.2307/1084940.
Bryk, A. S., & Raudenbush, S. W. (1992). Hierarchical linear mod‑
els: Applications and data analysis methods. Thousand Oaks,
CA: Sage Publications, Inc.
Choi-Kain, L. W., & Gunderson, J. G. (2008). Mentalization: Ontog-
eny, assessment, and application in the treatment of border-
line personality disorder. The American Journal of Psychiatry,
165(9), 1127–1135.
Crits-Christoph, P., & Mintz, J. (1991). Implications of therapist
effects for the design and analysis of comparative studies of psy-
chotherapies. Journal of Consulting and Clinical Psychology,
59(1), 20–26.
Diamond, D., Stovall-McClough, C., Clarkin, J. F., & Levy, K. N.
(2003). Patient-therapist attachment in the treatment of border-
line personality disorder. Bulletin of the Menninger Clinic, 67(3),
227–259.
Doerfler, L. A., Addis, M. E., & Moran, P. W. (2002). Evaluat-
ing mental health outcomes in an inpatient setting: Convergent
and divergent validity of the OQ-45 and BASIS-32. Journal of
Behavioral Health Services & Research, 29(4), 394.
Eagle, M., Wolitzky, D. L., Obegi, J. H., & Berant, E. (2009). Adult
psychotherapy from the perspectives of attachment theory and
psychoanalysis attachment theory and research in clinical work
with adults (pp. 351–378). New York: Guilford Press.
Ensink, K., Maheux, J., Normandin, L., Sabourin, S., Diguer, L.,
Berthelot, N., et al. (2013). The impact of mentalization train-
ing on the reflective function of novice therapists: A randomized
controlled trial. Psychotherapy Research, 23(5), 526–538. doi:10
.1080/10503307.2013.800950.
Ensink, K., & Mayes, L. C. (2010). The development of mentalisa-
tion in children from a theory of mind perspective. Psychoana‑
lytic Inquiry: A Topical Journal for Mental Health Professionals,
30(4), 301–337.
Esbjorn, B. H., Bender, P. K., Reinholdt-Dunne, M. L., Munck, L. A.,
& Ollendick, T. H. (2012). The development of anxiety disor-
ders: Considering the contributions of attachment and emotion
regulation. Clinical Child and Family Psychology Review, 15(2),
129–143.
Farber, B. A., Metzger, J. A., Obegi, J. H., & Berant, E. (2009). The
therapist as secure base attachment theory and research in clini‑
cal work with adults (pp. 46–70). New York: Guilford Press.
Fonagy, P. (1998). An attachment theory approach to treatment of the
difficult patient. Bulletin of the Menninger Clinic, 62(2), 147.
13
Adm Policy Ment Health (2017) 44:614–625
Fonagy, P. (2015). Mutual regulation, mentalization, and therapeu-
tic action: A reflection on the contributions of Ed Tronick to
developmental and psychotherapeutic thinking. Psychoanalytic
Inquiry, 35(4), 355–369. doi:10.1080/07351690.2015.1022481.
Fonagy, P., Bateman, A., & Bateman, A. (2011). The widening
scope of mentalizing: A discussion. Psychology and Psy‑
chotherapy: Theory, Research and Practice, 84(1), 98–110.
doi:10.1111/j.2044-8341.2010.02005.x.
Fonagy, P., & Bateman, A. W. (2006). Mechanisms of change in men-
talization-based treatment of BPD. Journal of Clinical Psychol‑
ogy, 62(4), 411–430.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon,
G., et al. (1996). The relation of attachment status, psychiatric
classification and response to psychotherapy. Journal of Consult‑
ing and Clinical Psychology, 64, 22–31.
Fonagy, P., Steele, M., Steele, H., & Moran, G. S. (1991). The capac-
ity for understanding mental states: The reflective self in parent
and child and its significance for security of attachment. Infant
Mental Health Journal, 12(3), 201–218.
Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective
functioning manual, version 5, for application to adult attach‑
ment interviews. London: University College London.
Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item
response theory analysis of self-report measures of adult attach-
ment. Journal of Personality and Social Psychology, 78(2),
350–365.
George, C., Kaplan, N., & Main, M. (1985). The adult attachment
interview. Unpublished manuscript, University of California at
Berkeley.
Holmes, J. (2011). Attachment in the consulting room: Towards a the-
ory of therapeutic change. European Journal of Psychotherapy
& Counselling, 13(2), 97–114. doi:10.1080/13642537.2011.570
013.
Lafferty, P., Beutler, L. E., & Crago, M. (1989). Differences between
more and less effective psychotherapists: A study of select thera-
pist variables. Journal of Consulting and Clinical Psychology,
57(1), 76–80.
Lambert, M. J. (1989). The individual therapist’s contribution to psy-
chotherapy process and outcome. Clinical Psychology Review,
9(4), 469–485.
Lambert, M. J. (2013a). The efficacy and effectiveness of psycho-
therapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook
of psychotherapy and behavior change (6th ed., pp. 274–351).
Hokoben: John Wiley & Sons.
Lambert, M. J. (2013b). Outcome in psychotherapy: The past and
important advances. Psychotherapy, 50(1), 42–51.
Lambert, M. J., Morton, J. J., Hatfield, D., Harmon, C., Hamilton, S.,
Reid, R. C., Shimokowa, K., Christopherson, C., & Burlingame,
G. M. (2004). Administration and scoring manual for the out‑
come questionnaire-45. Orem, UT: American Professional Cre-
dentialing Services.
Luborsky, L., Crits-Christoph, P., McLellan, A. T., Woody, G., Piper,
W., Liberman, B., et al. (1986). Do therapists vary much in their
success? Findings from four outcome studies. The American
Journal Of Orthopsychiatry, 56(4), 501–512.
Luborsky, L., McLellan, A. T., Diguer, L., Woody, G., & Seligman,
D. A. (1997). The psychotherapist matters: Comparison of out-
comes across twenty-two therapists and seven patient samples.
Clinical Psychology: Science and Practice, 4(1), 53–65.
Luborsky, L., McLellan, A. T., Woody, G. E., O’Brien, C. P., & Auer-
bach, A. (1985). Therapist success and its determinants. Archives
of General Psychiatry, 42(6), 602–611.
Lutz, W., Leon, S. C., Martinovich, Z., Lyons, J. S., & Stiles, W. B.
(2007). Therapist effects in outpatient psychotherapy: A three-
level growth curve approach. Journal of Counseling Psychology,
54(1), 32–39. doi:10.1037/0022-0167.54.1.32.
Adm Policy Ment Health (2017) 44:614–625
Maheux, J., Berthelot, N., & Normandin, L. (2012, 2012). Therapist’s
mental activity scale: A preliminary validation study and devel‑
opment of the codification manual. Paper presented at the Thera-
pist’s mental activity scale: A preliminary validation study and
development of the codification manual.
Marty, P., & de M’Uzan, M. (1963). La pensée opératoire. Interven-
tion sur le rapport de M. Fain et Ch. David: Aspects fonction-
nels de la view onirique. Revue Française de Psychanalyse, 27,
345–356.
McCoach, D. B. (2010). Hierarchical linear modeling. In G. R. Han-
cock & R. O. Mueller (Eds.), The reviewer’s guide to quantita‑
tive methods in the social sciences (pp. 123–140). Routledge:
Taylor & Francis.
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood:
Structure, dynamics, and change. New York: Guilford Press.
Mohr, J. J., Gelso, C. J., & Hill, C. E. (2005). Client and counselor
trainee attachment as predictors of session evaluation and coun-
tertransference behavior in first counseling sessions. Journal of
Counseling Psychology, 52(3), 298–309.
Najavits, L. M., & Strupp, H. H. (1994). Differences in the effective-
ness of psychodynamic therapists: A process-outcome study.
Psychotherapy: Theory, Research, Practice, Training, 31(1),
114–123.
Nolte, T., Guiney, J., Fonagy, P., Mayes, L. C., & Luyten, P. (2011).
Interpersonal stress regulation and the development of anxi-
ety disorders: an attachment-based developmental framework.
Frontiers In Behavioral Neuroscience, 5, 55–55. doi:10.3389/
fnbeh.2011.00055.
Normandin, L., & Bouchard, M.-A. (1993). The effects of theoretical
orientation and experience on rational, reactive, and reflective
countertransference. Psychotherapy Research, 3(2), 77–94.
O’Donovan, A., & Dyck, M. J. (2005). Does a clinical psychology
education moderate relationships between personality or emo-
tional adjustment and performance as a clinical psychologist?
Psychotherapy: Theory, Research, Practice, Training, 42(3),
285–296.
Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003).
Waiting for supershrink: An empirical analysis of therapist
effects. Clinical Psychology & Psychotherapy, 10(6), 361–373.
Okiishi, J. C., Lambert, M. J., Eggett, D., Nielsen, L., Dayton, D. D.,
& Vermeersch, D. A. (2006). An analysis of therapist treatment
effects: Toward providing feedback to individual therapists on
their clients’ psychotherapy outcome. Journal of Clinical Psy‑
chology, 62(9), 1157–1172. doi:10.1002/jclp.20272.
Rizq, R., & Target, M. (2010). ‘If that’s what I need, it could be what
someone else needs.’ Exploring the role of attachment and reflec-
tive function in counselling psychologists’ accounts of how they
use personal therapy in clinical practice: a mixed methods study.
British Journal of Guidance & Counselling, 38(4), 459–481.
625
Rogers, C. R. (1957/2007). The necessary and sufficient conditions
of therapeutic personality change. Psychotherapy: Theory,
Research, Practice, Training, 44(3), 240–248.
Sauer, E. M., Lopez, F. G., & Gormley, B. (2003). Respective con-
tributions of therapist and client adult attachment orientations
to the development of the early working alliance: A prelimi-
nary growth modeling study. Psychotherapy Research, 13(3),
371–382.
Saxon, D., & Barkham, M. (2012). Patterns of therapist variability:
Therapist effects and the contribution of patient severity and risk.
Journal of Consulting and Clinical Psychology, 80(4), 535–546.
Shapiro, D. A., Firth-Cozens, J., & Stiles, W. B. (1989). The question
of therapists’ differential effectiveness. A Sheffield psychother-
apy project addendum. The British Journal of Psychiatry: The
Journal of Mental Science, 154, 383–385.
Todd, S. Y., Crook, T. R., & Barilla, A. G. (2005). Hierarchical lin-
ear modeling of multilevel data. Journal of Sport Management,
19(4), 387.
Vermeersch, D., Lambert, M., & Burlingame, G. (2000). Outcome
questionnaire: Item sensitivity to change. Journal of Personality
Assessment, 74(2), 242–261.
Wampold, B. E. (2001). The great psychotherapy debate: Models,
methods, and findings. Mahwah: Lawrence Erlbaum Associates
Publishers.
Webb, C. A. (2012). Processes of symptom change in psychother‑
apy: Investigating the role of therapist adherence, competence
and the therapeutic alliance. 3542902, University of Pennsyl-
vania, Ann Arbor. Retrieved from http://gateway.library.qut.
edu.au/login?url=http://search.proquest.com/docview/117104
4627?accountid=13380; http://sf5mc5tj5v.search.serialssolu-
tions.com/?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-
8&rfr_id=info:sid/ProQuest+Dissertations+%26+Theses+F
ull+Text&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&rft.
genre=dissertations+%26+theses&rft.jtitle=&rft.atitle=&rft.
a u = We b b % 2 C + C h r i s t i a n + A . & r f t . a u l a s t = We b b & r f t .
aufirst=Christian&rft.date=2012-01-01&rft.volume=&rft.
issue=&rft.spage=&rft.isbn=9781267713940&rft.btitle=&rft.
title=Processes+of+symptom+change+in+psychotherapy%3A
+Investigating+the+role+of+therapist+adherence%2C+compet
ence+and+the+therapeutic+alliance&rft.issn=.
Widman, T. (2011). Factors that influence cross-validation of hier‑
archical linear models. Ph.D., Georgia State University, United
States—Georgia. Retrieved from http://gateway.library.qut.edu.
au/login?url=http://search.proquest.com/docview/887699684?ac
countid=13380.
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