The overall aim of this thesis was to explore therapeutic action in psychoanalytic psychotherapy from different perspectives (patient, therapist, observer), using different methodological approaches (qualitative and quantitative). Study I explores patients’ views of therapeutic action with grounded theory methodology. The results indicated that talking openly in a safe therapeutic relationship led to new relational experiences and expanding self-awareness. Hindering factors included difficulties “opening up” and experiencing something missing in treatment. Study II investigates experienced therapists’ views of therapeutic action. The development of a close and trusting relationship was perceived as the core curative factor. Patients’ fear of closeness hindered treatment from the therapists’ perspective. Study III involves the development and psychometric examination of a new rating scale for patient-therapist attachment (Patient Attachment to Therapist Rating Scale; PAT-RS). Inter-rater reliability was good for three of the subscales (Security, Deactivation, Disorganization), but poor for one (Hyperactivation). Patterns of correlations with other measures suggest construct validity for the reliable subscales. Study IV examines the relationships between secure attachment to therapist, alliance, and outcome. Linear mixed-effects models, controlling for therapist effects, treatment length and patient-rated alliance, indicated that secure attachment to therapist relates to outcome. Further, the unique variance associated with secure attachment to therapist predicted continued gains in functioning during follow-up. The results of this thesis suggest that the development of a secure attachment to the therapist is a central mechanism of therapeutic change. The results are discussed in relation to established notions of therapeutic action in psychoanalytic psychotherapy. Two tentative process models that may be useful for clinical practice and future research are proposed. / <p>At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: Epub ahead of print.</p>

Deaf individuals typically have access to 2 types of therapeutic services: interpretive (with an interpreter) and noninterpretive (with a sign-fluent therapist). Previous research indicates that the presence of an interpreter may hinder development of working alliance and attachment. There is a lack of empirical evidence assessing the effect of working alliance and attachment based on whether or not therapy incorporates an interpreter. The working alliance theory and the attachment theory were the theoretical foundations for this study. This study examined the difference between the strength of working alliance and attachment to the therapist given the presence or absence of an interpreter in therapy for Deaf individuals (N = 39) utilizing the Working Alliance Inventory and the Client Attachment to Therapist Scale. A multivariate analysis of variance was utilized to examine the differences between interpretive and noninterpretive services. The results indicated that individuals who received noninterpretive services had stronger working alliance and attachment with their therapist, which suggests that the type of therapy services Deaf individuals receive should strongly be considered. Accordingly, an increase of sign-fluent therapists would promote social change by providing more appropriate services that would remove barriers that hinder working alliance and attachment to the therapist.