I teach mentalization theory and practice, attachment theory and practice and psychotherapy with young adults at the psychological departments at Stockholm University and Uppsala University.

Dissertation title

When psychotherapy does not help ...and when it does: Lessons from young adults' experiences of psychoanalytic psychotherapy. (2017). Download here.

Young adult psychotherapy patients' experiences of psychotherapies where goals were not met, or the patients dissatisfied, were the starting point for an exploration of hindrances in psychodynamic psychotherapy. I analysed the material from a developmental perspective, as well as from the broader perspective of psychodynamic theory, including mentalization and attachment theory.

A selection from Stockholm University publication database

• Teoretiska perspektiv på anknytning vid patientmöten: Varför är vissa så svåra att hjälpa? [Patients who are difficult to help. Attachment perspectives]

  2022. Camilla von Below. Läkartidningen 119

  Article

  Attachment theory and research show that a patient’s attachment pattern, shaped in close relationships, affects A) the ability to describe symptoms in a structured and detailed manner, and B) the ability to trust physicians’ conclusions and concerns. If physicians are observant of patients’ unstructured, intense or avoidant communication during consultation, they can adjust their communication accordingly and avoid misunderstandings and excessive health care consumption. A patient with insecure ambivalent attachment needs initial empathic listening, whereas a patient with insecure avoidant attachment benefits from a respectful distance. Since insecure attachment is associated with lack of trust combined with difficulties understanding own psychical and psychological symptoms, physicians need to fill in the gaps more carefully than usual. Understanding attachment theory will be of help and is discussed in the article. 

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• Therapeutic encounters at the onset of the COVID-19 pandemic: psychodynamic therapists' experiences of transition to remote psychotherapy

  2022. Katrin Ahlström (et al.). Psychoanalytic Psychotherapy

  Article

  The COVID-19 pandemic crippled many parts of society as it spread throughout the world beginning in early 2020. Overnight, whole societies were forced to change their way of life, because of social distancing and lockdowns. For therapists, the pandemic meant that in-person sessions were no longer possible and many switched to different forms of synchronous remote communication by telephone, online audio or video link. The aim of this study was to explore psychodynamic therapists’ experiences over time of forced transitions to telepsychotherapy. Five therapists were interviewed at the beginning of the pandemic and at a one-year follow-up. The data were analysed by applying thematic analysis with a phenomenological approach. Initially, the therapists struggled with technical and safety issues. The loss of the therapy room and of access to non-verbal nuances contributed to impaired contact with the patients and more superficial conversations. The therapists experienced that the very nature of psychodynamic psychotherapy was affected, even if telepsychotherapy could give some new opportunities. One year later many of the difficulties remained, but the therapists developed better coping strategies and were back to the therapy focus. One implication of this study is that telepsychotherapy needs to be integrated into psychotherapy training and supervision.

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• Demanding and effective

  2021. Maria Bragesjö (et al.). European Journal of Psychotraumatology 12 (1)

  Article

  Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants' experiences in receiving this type of intervention remotely.

  Objective: Investigate participants' experiences of receiving CIPE early after trauma.

  Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim.

  Results: One overarching theme labelled as 'demanding and effective' was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure.

  Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.

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• When 'good outcome' does not correspond to 'good therapy'

  2021. Melissa M. De Smet (et al.). European Journal of Psychotherapy 23 (2), 156-176

  Article

  In the present paper we examine four cases in which the assumption that good outcome necessarily means good therapy did not hold. Cases were selected that reported good pre-post outcome (i.e., clinically reliable decrease in symptom severity) but a negative (disappointing) therapy experience, drawn from a randomized controlled trial (the Ghent Psychotherapy Study) and a naturalistic outcome study (the Stockholm Young Adults Psychotherapy Project). Analysis of these seemingly contrasting findings made it possible to identify three distinct patterns of client experience of outcome. Implications for research and practice are discussed.

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• Anknytning i psykoterapi

  2020. Camilla von Below.

  Book

  Ur bokens förord:

  Anknytningsteorin förenas här med klinisk praktik. Camilla von Below förmedlar aktuell forskning, visar på bredden och djupet i anknytningsteorin, men även på dess begränsningar. Med många kliniska exempel gör hon anknytningsteorin och dess empiri levande och användbar för dig som möter vuxna patienter i psykoterapi och psykologisk behandling.

  Författaren beskriver anknytningsteori i relation till mentalisering och affektteori, liksom hur man kan se på anknytningsmönsters stabilitet och förändring under livet. Hon visar även hur anknytningsteori kan vara till hjälp för att skapa en terapeutisk relation, liksom hur hinder och svårigheter i det terapeutiska samspelet kan förstås. Betydelsen av terapeutens anknytningsmönster får ett särskilt fokus, med uppmuntran till självreflektion och utveckling.

  Tack vare bokens breda anslag kan den kombineras med läsarens egen teoretiska och terapeutiska referensram.

  Målgruppen är yrkesverksamma och studerande inom psykoterapi och psykologisk behandling. Boken kan med behållning även läsas av andra som arbetar med mänskliga relationer, samspel och samtal.

  ”Som psykolog och psykoterapeut har jag nytta av anknytningsteorin på flera sätt. För det första genom att jag lyssnar på hur en patient berättar och vad det säger om hennes eller hans förhållningssätt till sitt inre och sin förståelse av sina problem. För det andra bidrar teorin med en förståelse av hur svårigheter kan ha uppstått och vad som hindrar patienten från att komma vidare. För det tredje – och i mitt tycka det mest inspirerande – ger anknytningsteori en förståelse för det relationella samspelet och samskapandet i terapi. Terapeuten får hjälp att förstå alliansbrott, brister och rena haverier i den terapeutiska relationen och att utmana sig själv i att göra på nya sätt.”

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• “We Just Did Not Get on”. Young Adults’ Experiences of Unsuccessful Psychodynamic Psychotherapy – A Lack of Meta-Communication and Mentalization?

  2020. Camilla von Below. Frontiers in Psychology 11

  Article

  In order to avoid suboptimal psychotherapy, research needs to highlight and analyze obstacles in such treatments. This clinically oriented article brings together empirical material of unsuccessful psychotherapy with young adults; empirical material on the therapists’ views of the same therapies; and theoretical perspectives on mentalization, therapeutic alliance, and young adulthood. Through a secondary qualitative analysis, it presents a tentative process model of how suboptimal psychotherapy with young adults develops, how it could be handled clinically, and possibly prevented. In three studies, experiences of young adult patients (aged 18–25; n = 27), in psychoanalytic therapy at an outpatient clinic, who did not improve from therapy (defined as no reliable and clinically significant symptom reduction) and/or were dissatisfied, and their therapists, were analyzed. Patients described experiences of not being understood and not understanding therapy, whereas therapists described patient non-commitment. These results were compared from the developmental perspective of mentalization in young adulthood. The primary grounded theory analyses and secondary analysis resulted in a tentative process model of the development of suboptimal psychotherapy with young adults. Suboptimal therapy is described as a vicious circle of therapist underestimation of patient problems, therapeutic interventions on an inadequate level, and diverging agendas between therapist and patient in terms of therapeutic alliance, resulting in pseudo-mentalizing and no development towards agency. A benign circle of successful therapy is characterized by correct estimation of patient problems, meta-communication, and the repair of alliance ruptures. One clinical implication is that therapists of young adult patients need to establish verbal and nonverbal meta-communication on therapy progress and therapeutic alliance. The importance of the patients’ present mentalization capacity and adjusted interventions are demonstrated in an example. Research in the field should be process-oriented and investigate the effect of meta-communication and interventions targeted to foster therapeutic alliance based on this theoretical model, particularly for young adults.

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• “It was like having half of the patient in therapy”

  2019. Andrzej Werbart (et al.). Psychotherapy Research 29 (7), 894-907

  Article

  Objective: To explore therapists’ experiences of therapeutic process in psychoanalytic psychotherapy with nonimproved young adults. Method: Eight nonimproved cases were identified according to the criterion of reliable and clinically significant change in self-rated symptoms. Transcripts of therapist interviews (8 at baseline and 8 at termination) were analyzed applying grounded-theory methodology. Results: A tentative conceptual process model was constructed around the core category Having Half of the Patient in Therapy. Initially, the therapists experienced collaboration as stimulating, at the same time as the therapeutic relationship was marked by distance. At termination negative processes predominated: the patient reacted with aversion to closeness and the therapist experienced struggle and loss of control in therapy. The therapists described therapy outcome as favorable in form of increased insight and mitigated problems, while core problems remained. Conclusions: This split picture was interpreted as a sign of a pseudo-process emerging when the therapist one-sidedly allied herself with the patient’s capable and seemingly well-functioning parts. The therapists’ experiences could be compared to the nonimproved patients’ “spinning one’s wheels” in therapy. The therapists seem not to have succeeded in adjusting their technique to their patients’ core problems, despite attempts to meta-communicate.

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• When psychotherapy does not help

  2017. Camilla von Below.

  Thesis (Doc)

  The process and outcome of psychoanalytic psychotherapy have been studied for a long time. However, the experiences of patients, particularly in therapies where goals were not met, have not yet been the target of extensive research. Psychoanalytic psychotherapy with young adults might face particular challenges. The overall aim of this thesis was to explore the experiences of young adults in psychoanalytic psychotherapy, with a particular focus on differences between suboptimal therapies and therapies with generally good outcome. The setting was naturalistic, and perspectives of the patient, therapist and observer were combined. Qualitative and quantitative methods were used. Study I explored experiences of psychotherapy process and outcome among seven patients in psychoanalytic psychotherapy, who expressed dissatisfaction. Interviews at termination and 18 months later were analysed using grounded theory and compared to therapist experiences. Patients experienced abandonment with their problems in and after therapy, since therapy according to the patients lacked connections to daily life, as well as flexibility, activity and understanding from the therapist. Therapists presented a different picture of the same therapies, mainly focused on the difficulties of the patients. Study II analysed the experiences of 20 non-improved or deteriorated young adult psychotherapy patients at termination of therapy and 36 months later. Non-improvement and deterioration were calculated based on the reliable change index on self-rating scores. The grounded theory analysis of interviews established spinning one’s wheels as a core category. The relationship to the therapist was described as artificial, although at times helpful. Participants experienced their own activity in life and active components of therapy as helpful, but thought focus in therapy was too much on past experiences. Study III explored the experiences of 17 young adult patients, in psychoanalytic individual or group therapy, overcoming depression. The analysis of interviews from therapy termination and 18 months later indicated that finding an identity and a place in life were perceived as intertwined with symptom relief. Negative experiences included difficulties to change oneself, fear of change, and problems in therapy, such as too little activity on the therapist’s part.

  The results were discussed in relation to young adulthood, therapeutic alliance, mentalization, and attachment. The conclusion was expressed in a comprehensive process model of suboptimal therapy with young adults, with suggested ways to prevent such a development. The therapist’s meta-communication and correct assessment of the patient’s mentalization capacity from moment to moment are proposed as crucial. Regarding clinical implications, therapists of young adult patients need to establish meta-communication on therapy progress, as even experienced therapists might be unaware of dissatisfaction or deterioration. Meta-communication could be considered part of the treatment itself, as it may foster mentalization and good outcome. Further, the period of young adulthood entails decisions and developing an adult life, and therapists need to make room for this by active interventions.

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Show all publications by Camilla von Below at Stockholm University