title: Mind the gap: In-session silences are associated with client attachment insecurity, therapeutic alliance, and treatment outcome.
abstract: The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa.
  
  
  
  69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N = 175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed.
  
  
  
  Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment.
  
  
  
  The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.
authors.affiliation: a Department of Psychology , University of Copenhagen , Copenhagen K , Denmark.
authors.forename: Sarah I F
authors.identifier: 0000-0003-0190-002X
authors.initials: SIF
authors.lastname: Daniel
authors.affiliation: a Department of Psychology , University of Copenhagen , Copenhagen K , Denmark.
authors.forename: Sofie
authors.identifier: 0000-0003-3871-1580
authors.initials: S
authors.lastname: Folke
authors.affiliation: a Department of Psychology , University of Copenhagen , Copenhagen K , Denmark.
authors.forename: Susanne
authors.initials: S
authors.lastname: Lunn
authors.affiliation: a Department of Psychology , University of Copenhagen , Copenhagen K , Denmark.
authors.forename: Matthias
authors.initials: M
authors.lastname: Gondan
authors.affiliation: a Department of Psychology , University of Copenhagen , Copenhagen K , Denmark.
authors.forename: Stig
authors.identifier: 0000-0002-0536-1820
authors.initials: S
authors.lastname: Poulsen
mesh_terms: D000328:Adult; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D001068:Feeding and Eating Disorders / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D009769:Object Attachment; D011575:Psychoanalytic Therapy / Q000379:methods*; D000078462:Therapeutic Alliance; D016896:Treatment Outcome; D014705:Verbal Behavior; D055815:Young Adult
keywords: alliance; attachment; cognitive behavior therapy; eating disorders; in-session silence; process research; psychoanalytic/psychodynamic therapy