Table 3 Example excerpts

Master Theme I: P managing interactions with T through self-effacing and submissive behaviours (Elizabeth, Sandra, Helena)

 Theme A «P feeling rebuked by T; P non-assertive to avoid verbal abuse; P becoming submissive» (Elizabeth)

  Context: T and P exploring a conflict between P and a fellow patient during a group therapy session

P: I feel that I’m being rebuked by the therapist. I feel rebuked, and I really hate that. /…/ It ruins my trust in her. Rebukes are in a way an insult to my intelligence, right? Because I do understand that it’s childish, but… things get really big [in treatment], right? Things that you would (blows) back home. /…/ Well, I’m really uhm (.) straightforward as a person, but I’m also scared to step on other peoples’ toes (.). And maybe… when I was a little girl, if I protested, I got hit, right? And I feel that… nobody has hit me (.) my husband hit me once, and that’s the biggest insult I’ve ever experienced, and I actually threatened to kill him. And being rebuked to me, it’s like being punched in the face. That’s why I always get insecure about whether or not to speak my opinion, because I’m scared of, not being physically violated but getting hit verbally. (Elizabeth)

  T: But what if you could try to turn things around? What you’re saying right now is really good; that you want to be there for others and so forth, but what if you could turn things around a bit and think that you’re all adults? Of course, it’s important that those things are addressed, that you say them out in the open. And I really think that you’re addressing important topics [in group therapy]. And she heard all of what was said. Uhm, and whether she decides to consider it or not, I think that’s up to her …and something that may have to be worked on with her individually…

  P: (overlapping) Yes

  P: For sure. I haven't felt that

  P: Mm

 Theme B «P fearing to fail therapy and upset T; P other-orienting to find ‘correct’ answers» (Sandra)

  Context: T and P exploring P’s emotions in relation to a social media incident

P: I think it works because when she asks questions, I think about them for quite a long time. Because I don’t know what to answer- I know what to answer, but I don’t dare saying. And then it turns into that I start thinking about how I can express myself correctly so that it doesn’t come out wrong. And there it is, the constant fear of saying something wrong. Across all relationships, really. /…/ I talked to a friend just now, like you said, my thoughts are like «What am I supposed to answer that’s correct?». (Laughing). That’s what’s so exhausting, in life generally. That I’m always like «Am I saying something wrong now?», «Am I doing something wrong now?», «Are you angry with me?», «You are, you are, you are». (Sandra)

  P: I was just about to throw up. I get physically ill

  T: Because of what happened?

  P: Mm

  T: That’s a pretty strong reaction to something, so…

  P: Yeah, it’s goes rather deep

  T: Yes, how do you feel about that? Do you, do you understand why it’s so deeply rooted?

  P: (shaking head)

  T: Any thoughts… or ideas?

  P: I’m afraid to make mistakes

  T: What happened to you in the past when you made mistakes?

  P: (.) (inaudible) punished for it

  T: Yes. Things that weren’t your fault? Right?

  P: But I can’t get myself to think like that… I really can’t help it. (laughing)

 Theme C «P feeling violated by T; P contempting T but pretending to participate; P increased self-contempt» (Helena)

  Context: T and P discussing whether or not P’s total exercise time weekly exceeds what is allowed in treatment

P: There you go! Scornful! Like «get your act together». it’s all over my face, «seriously?» (sighing). Can you see the gaze I’m giving her? bit contemptuous. Like «Seriously. Come on. What are we doing here?». I’m not pleased here; I can see that. But I participate, and play along, but I’m not at all happy about it. /…/ It comes out as self-contempt, you know, since I’m a liar for not saying anything about it. Instead it comes out as «I’m completely stupid, and I’m really sick» and… Yeah. (Helena)

  P: Yes, and I lift weights for about 45 min, then perhaps 30 min of weights, and 30 min cardio

  T: (interrupting) You lost me there, one more time?

  P: I do 45 min of cardio

  T: You just said half an hour

  P: Yes, but I exercise more than once a week

  T: Yes, each time?

  P: Yes, each time. And I also do 30-min weights and 30 min cardio on one occasion (laughing)

  T: Yes, that’s 2 h. No, that’s 1 h of jogging, half an hour weights, and half an hour cardio, that’s 1 h

  P: That’s 1 h. And then I also do 45 min of weights, during one occasion

  T: Yeah? Then it’s 3 h

  P: Yes, and

  T: (interrupting) Then you have 1 h 15 min left for exercise if you are to use 4 h [weekly]

  P: Yeah, and then I do weights for 1 h

 Theme D «P submitting to T to gain approval» (Elizabeth, Helena)

  Context: T and P disagreeing as to whether compulsive exercise is part of P’s eating pathology

P: Look at that. I’m actually sitting there lying. I remember sitting there lying. Because all of a sudden, by the end of that session, I had a compulsive exercise disorder. I almost admit it. But it (stuttering) was pure lying. /…/ No, I had just said that «no, I don’t [find exercise problematic]… I’m really conscious of that», and then I suddenly said «but I can also hear that the eating disorder comes and tells me that I have to exercise». So, I’m really saying «no, but yes…». /…/ Because I’m trying to please her /…/ I want to be a good patient. I want to be good and say what I’m supposed to. (Helena)

  P: I really feel that when the bulimia doesn’t stick, the eating disorder comes and tells me that I can also use exercise as a means for losing weight, right?

 Theme E «P attempting to self-assert; P fears hurting T and experiences increased guilt; P withdraws assertive attempts» (Helena)

  Context: T and P discussing whether or not P’s total exercise time during a week exceeds what is allowed in treatment

P: I clearly state that I’m scared to make mistakes right there. And I’m usually not like that. «I actually worsen from your regime». I say that clearly there and then. But then I laugh, right? Because I’m not supposed to criticize her. Because it’s really important for me to say «Look, no offence, but I feel that what you’re doing here is a bit silly». Because normally I’m very relaxed in relation to exercise. /…/ I don’t want to hurt her feelings, right? I don’t want to say to her «Look, your regime is not working, it makes me more disordered, done». But I can’t say that to her because then she will feel incompetent. /…/ I automatically think that she needs to leave the session feeling good. That’s something I have very strongly in me. (Helena)

  P: It’s good to jog, or it’s good for my heart. But I hate jogging

  T: For how long do you jog?

  P: (hesitating) Say, 1 h. And I lift weights a lot; I like that

  T: Is that 1 h, too?

  P: No (laughing) Today it was (laughing) (inaudible)

  T: (laughing)

  P: No, but I’m talking about (inaudible) during exercise. We are just exercising legs and upper body (inaudible) just to make use of it, and that’s 30 min, so then I still have 45 min I can use. And then I turn into four and a half [years old]… normally I don’t hurry when I exercise, but now I feel a bit like «I have to reach this» and «I can’t take any breaks»

 Theme F «P experiencing T as too forceful; P becoming overwhelmed and passive» (Elizabeth)

  Context: T and P discussing the aftermath of a previous trauma exposure session

P: Perhaps I feel she’s missing out on the fact that (.) that I’m not really interested, because so much is being said to me, you know? /…/ Yeah, I feel that I’m not active enough in treatment, really. I liked her, but I was very much told things, right? And that might suit some people, I think, that it’s totally fine to some, but when I look at it retrospectively, I feel that I need to be more actively involved in treatment /…/ I feel that I’m being talked to, to a large degree. And I don’t get responses to what I’m saying. (Elisabeth)

  T: What you’re talking about now is really interesting, Elizabeth. Definitely. You mentioned that you experienced a horrible nightmare. You said you felt persecuted after our latest session. How have you been since, in general?

  P: Well, I’ve felt much more depressed than usual

  T: To the extent that you cannot endure it?

  P: Yeah. You can drag me through anything, and I’ll endure it in a way, but

  T: (interrupting) But did you expect to get a stronger reaction than you actually did?

  P: Yes

  T: Yes. So, you’re really a bit surprised that you didn’t

  P: (interrupting) Yeah. To be able to bring it out and look at it. I think that the thing you did where I split into two—the little one and the grown-up—it helped a bit

  T: Perhaps you experienced a bit more control?

  P: Yeah

  T: And also, the fact that you’ve now become a grown-up

Master Theme II: P preferring either closeness or distance to T to be able to open up (Elizabeth, Sandra, Martha, Maria)

 Theme G «P distancing from T to be able to open up about affect-laden, trauma-related topics» (Maria)

  Context: T and P addressing P’s dissociative experiences

P: I feel that I was met in a very good manner, uhm. I was being met with understanding, I guess. /…/ yeah, well, she has a lot of expression in her face, uhm, you might not see it /…/ And that’s one thing. But I guess it has to do with what she’s like as a person, too /…/ Yeah, it’s really, it’s like a therapist-patient relationship in a way /…/ And I’ve learnt that, when it’s like that I can be more open. /…/ Yeah, because, uhm, it’s become a learnt situation, I have so much more difficult being open to other people. /…/ It’s in a way a person that I don’t have to adhere to in my daily life either. (Maria)

  P: I wrote down a little bit about how (fetching notebook) afterwards how (looking in notebook), uhm, no, it was, I became, I really became very down (inaudible), pushed from a cliff in a way, getting a lot of depressive thoughts, that’s really what it is, thoughts I’ve been having (inaudible), a painful, all-consuming experience took all of me, so I feel (laughing) that I become so damn

  T: (interrupting) To think about it in a way, that’s right, yes

  P: Uhm, not really, uhm when I experienced it, I felt that I really wasn’t’ present (reaching paper towels to wipe tears)

  T: Oh

  P: Yes (laughing while crying)

  T: And that activates something, the experience that you’re not really there

  P: Yes

 Theme H «T self-disclosing; P feeling closeness and blurred professional boundaries; P more interested and opening up» (Elizabeth, Sandra)

  Context: T and P explore the topic of self-care

P: There it is, you see that I become more interested, because now, she tells me about herself /…/ and «my job is to help others», and «I have kids», right? She gives a little bit of herself. And even though I understand that it’s a bad idea to become best friends with your therapist… it’s not bad. For me, I can easily separate a friend from a therapist, right? But as you can see here, I become more active, and I immediately become more interested. And I actually said that to her. «I trust you more when you tell me things about yourself, too». Right? /…/ Because, in a way, you tell me that «you’re (.) a person, not just a patient», or a number in line, right? /…/ Yes, I’m more interested. It changed instantly when she started talking about herself. (Elizabeth)

  T: We have to tidy up and be the master of our own house first before we are able to help others (P and T talking at the same time, inaudible)

  P: Uhm. I do understand that I have to do things differently than what I’ve done before

  T: That applies to me too. My job is to help other people, really, or try to help other people. And I have children, of course, that I need to help, too

  P: Yes

  T: But I’m bound to look after myself in the middle of all of this, too. Or it will not end well

 Theme I «T providing reciprocity and intonation; P feeling close and trusting; P opening up» (Martha)

  Context: P and T touching on P’s trauma narrative when they work on maladaptive thoughts

P: That’s (therapist’s name). /…/ She was able to do that. /…/There was something about her and me. I found something in her that was so true. /…/ There was a connection between her and me. I can’t explain what it was. But I trusted and trust her completely. She made me hear and listen, and I believed her. /…/ There was something with her that made, her whole being in a way, she made me understand that she believed me, she listened to me, and it was like, after ten sessions she suddenly merged three words from another session. So, she was genuinely interested in me. /…/ And we had a few of those, we had many good moments together. I’m not sure that everyone get to experience that. But she was… she was (therapists’ name) (laughing). I’ve tried to figure out [if she reminded me of someone], almost like «what is it that she has that no one else has?». I shouldn’t say that no one else has that, but she, she came through for me and touched me. /…/ No, but I think that we (hesitating), I choose to believe that we were a very good match, that she was genuinely interested and (hesitating)… She was very much inside my mind, I mean, at times even more on my inside than she was supposed to, inside of what I was telling her. And I guess that made me feel that she really meant it. Yes, she meant it. It wasn’t like «that’s it for today». /…/ And that’s… yeah, that’s the difference between a therapist and a therapist. (Martha)

  P: Locked me out… when they’d locked me up, wondered where I was, but they always found me again. My God. There were no child protective services back in those days. Damn it

  T: (inaudible)

  T: For sure. I haven’t felt that. I mean, I I’ve been angry at my mum and dad but (heavy breathing, hand on chest) wow, wow… wow

  T: I hope and believe that a few of the reasons that (inaudible), is that we have challenged a few of those thoughts. Because if you accept that «I’m the one who’s not good enough», then

  P: (interrupting) That’s what I’ve done over time, although I in a way… I haven’t done that, but at the same time I have, do you get that? Because I’ve tried so hard to become the opposite. And then it came to all of that (pointing at text on whiteboard)

  T: Yes, because that’s what happens very often when one has the feeling that «I’m never good enough» (inaudible) that you’re supposed to push yourself all the time, so that you can be good enough for someone. Or be important enough for someone. Significant enough. And that can also be a good thing, not that it’s necessarily

  P: (interrupting, laughing) is crazy (sighing) Yes

  T: So that became a lot to…

  P: (drying tears) I guess it did. Yes, it did. (sighing). It really did

Master theme III: P joining T’s verbal, reflective interventions and detaching from T’s experiential techniques during trauma work (Elizabeth, Sandra, Martha, Maria)

 Theme J «P becoming overwhelmed during associative trauma-related processing; P emotionally unavailable to T» (Elizabeth, Sandra, Martha, Maria)

  Context: P and T going through P’s reactions during and following trauma exposure

P: Uhm, I’ve had a few of those. It’s like a hole, like I said to begin with, that you sort of walk down in a, uhm, deep, deep, deep down, everything becomes dark, nothing means anything. Nothing, uhm. /…/ No, I don’t think [I’m scared when that happens] /…/ When that happens, everything turns dark. But scared? No, I don’t think so. /…/ I think I had some of the same, or, was experiencing the same feeling, but I was not, I wasn’t depressed, if you get what I mean, I just experienced some of the same. /…/ I don’t have much contact with my body, really. /…/ I guess I get what I need, yes. /…/ It was really like, to talk about it, and in a way put things in order a little bit. (Maria)

  P: It’s like the feeling that you just, like capitulate, so it’s very strong feelings (inaudible) it didn’t mean anything, and all the rules I have about food, none of it meant anything

  T: And to think about the difficulties, and, what you’ve been through during childhood, right, and still experience

  P: Yes, like that. And right there and then, everything became dark. It was like something that (crying). But there’s so much feelings in it

  T: And did tears come, or was there anything?

  P: Yes, I cried. I couldn’t hold anything back. I was a bit stressed and I just (crying), uhm

  T: And was it the same?

  P: (interrupting) was the same thing, mm (crying). It was

  T: It’s good that it’s better now, what do you think have contributed to that during the weekend?

  P: Things went a bit better, uhm like, it was Wednesday, and Fri-, no I guess Thursday was a bit better, I think/…/ And then it just settled in a way. It’s incredibly painful to experience that

 Theme K «T and P reflecting on P’s post-trauma responses; P staying with the topic; P increasing understanding of self» (Martha, Maria)

  Context: T and P exploring how childhood trauma may affect self-worth

P: I really (stuttering), you know that’s how it’s been, in a way. Logically. But it feels good to go through things step-by-step and I really felt that it felt very good to like… I felt good about many things that we did. Not just in this session, but generally to get things into order, as I would call it. Things that have felt illogical, or things that have been said to me. And then I get to hear «that, that, and that… equals this». And it felt so good to get some of my experiences confirmed, for instance, with physical abuse and that, and where I’ve ended up today. It feels very good to frame it. Do you understand what I mean? /…/ Being affirmed. And «this was not right», and also «when you’ve experienced that, this may happen» right? And I’ve been thinking a lot about this from time to time. But when it is not validated… Because all confirmation you’ve ever had is total opposite. Yes, you do know it, of course, but the body doesn’t want to. The feeling and (stuttering) (.) Really, the whole body is protecting itself (Martha)

  T: Yes, and when that happens it’s difficult to establish a sense of «I’m good enough». Because that’s a way of showing that you aren’t good enough, «they hit me because I’m not good enough»

  P: Yes. They hit me for anything, really. If I had out my shoes on the wrong way /…/ We’re talking about things that you wouldn’t logically punish a child for doing. No. I believe it has nothing at all to do with that. Yes

  T: (inaudible) not just your actions, but also you being wrong

  P: That’s how I felt. Because no matter what I did or didn’t do, it was all wrong. What I did wrong yesterday could for instance be that if I put my shoes to the left, I did what my mother told me to do and put them to the right. And then, when I put them to the right the next day it was wrong, I should’ve put them to the left. Really, there were always, I never knew (stuttering) what was the rule. Because there were no rules, the rules kept changing./…/ The changed according to what felt good to her, and then, she needed someone to scream at, yell at, and hit, and that was me. It was like, that was not the exception, but rather, the rule

 Theme (diverging case) «T deepening and containing P’s emotional experiences in a composed manner; P opening up and exploring; P increased trust and stronger bond with T» (Alice)

  Context: P and T exploring P’s relationship to her mother

P: Uhm, I remember that it became a bit chaotic because I didn’t, I’m not that used to crying that much, and especially not in front of people, but she got something out of me that (.) meant something for our shared relationship in therapy, she really showed me that she understood what’s the issue, and how that’s an issue. It definitely did something to our relationship. It became, it really came to that I worked more with what she, uhm, she tried to evoke (.) at least during that time, but I don’t know, being listened to, understood, getting in contact with my tears, and she’s still composed and (laughing) meeting my eyes when I look at her and, yes, available and helpful even though I started crying. (Alice)

  P: Yes, she, every time we talk about that stuff, she always becomes uhm upset /…/ Guilt, really. And we have talked a lot about it, uhm, and yeah, she feels a lot of guilt about not being there for me, or that she has more than enough of her own stuff to struggle with, and then she goes

  T: (interrupting) and perhaps there is shame there, too?

  P: Yeah, I think so. She had me when /…/, she was very young

  T: Mm. Yes. But she ends up embracing you, listening to how it was for you, feeling the pain, she could’ve well have reacted in another way, not having the courage to do it, feeling too ashamed, that she couldn’t deal with, not wanting to know, or rejecting you, but she doesn’t

  P: No. No, she’s the best (laughing) one could have

  T: Can you manage to get hold of some feelings inside of you when you think of your mother? «She’s the best» you say, and then there are tears. Can you feel something in your stomach?

  P: Yes, I’m just so happy that I have her

  T: Can you feel any warmth in your stomach? That’s often a sensation of joy (.) a warm sensation in the stomach