The therapist's attachment representation and the patient's attachment to the therapist

Abstract

This study examines the relationship between the therapist's own attachment representation (Adult Attachment Interview, AAI) and the patient's attachment relationship to the therapist (client's attachment to the therapist, CATS). The attachment representations of n=22 psychotherapists who treated n=429 patients were assessed. A general effect of the secure/insecure therapist attachment status on the attachment of the patient to the therapist was not found whereas the more specific effects expected could be confirmed: The more preoccupied the therapist's attachment status was, the more the patient experienced a preoccupied-merger attachment to the therapist. The more dismissing the therapist's attachment status was, the more the patient experienced an avoidant-fearful attachment to the therapist. In summary, not the general security/insecurity of the therapist's attachment representation but rather the type of the insecurity is associated with the subjective patient's attachment-related experience of the therapeutic dyad.     

Patient Attachment Orientation and the Early Working Alliance-A Study of Patient and Therapist Reports of Alliance Quality and Ruptures

This study investigated the relationship between attachment orientation in adult patients and the early therapeutic alliance. Attachment was measured by self-report following the first session of therapy. The alliance was studied using patient and therapist ratings of its quality and reports of ruptures following early sessions. The sample comprised 30 clinical psychology outpatients treated by 11 experienced therapists. Correlation and multiple regression statistics provided partial support for the hypothesized relationships between attachment orientation and reports of alliance quality and ruptures. In line with predictions, fearful attachment was associated with lower alliance ratings (significantly with patient ratings at sessions 3 and 5 and therapist ratings at session 2) and secure attachment was associated with higher alliance ratings (significantly with therapist ratings at session 5). Preoccupied attachment and dismissing attachment were associated with improvement in alliance ratings over time, although there was some question about the reliability of these findings. Additionally, the frequency of rupture reporting varied with attachment orientation. Preoccupied attachment was associated with more frequent reports of ruptures and dismissing attachment was associated with fewer reports of ruptures. Implications for clinical understanding and future research are discussed.     

Predictive validity of patient and therapist attachment and introject styles

This study assessed introject and attachment styles of patients and therapists, and the match of these styles in patient/therapist dyads, to determine their relation to various psychotherapy process and outcome measures. The INTREX was used to measure introject style (affiliation and autonomy) and the Relationship Scale Questionaire to measure attachment style (secure, fearful, preoccupied, dismissing). Therapists with more affiliative (self-loving) and secure styles achieve better outcome results compared to therapists with less affiliative (self-hating) and insecure styles. Further, the greater the difference in introject and attachment styles within the patient/therapist dyad, the better the outcome.     

Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa

Objective: This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa. Method: Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale. Results: Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT. Conclusions: As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.     

Attachment representation and illness behavior in somatoform disorders

Somatoform disorders are characterized by high health care utilization and conflictual interactions with health care providers. The aim of the present study was to explore whether patterns of insecure attachment are a prominent feature of somatoform disorder. In addition, the links between insecure attachment and health care utilization were evaluated. Thirty-seven patients with an International Classification of Diseases, 10th Revision diagnosis of somatoform disorders and 20 healthy control subjects matched for age, sex, and education were administered the Adult Attachment Interview. Psychological symptoms and health care utilization were assessed using various self-report measures. There was a clearly higher incidence of insecure attachment in the somatoform group compared with the nonclinical control subjects. In the somatoform group, dismissing attachment occurred approximately twice as frequently as the preoccupied pattern of attachment. The results provide evidence for an association between health care utilization and insecure attachment. Insecure attachment in somatoform disorder may underlie problems in interpersonal functioning and in health care behavior.     

The relationships between adult attachment,theoretical orientation,and therapist-reported alliance quality among licensed psychologists

Objective: Attachment anxiety has been depicted as an undesirable therapist characteristic based on findings that preoccupied therapists, relative to those with other attachment styles, report more ruptures in the therapeutic alliance. What has not been considered, however, is the extent to which attachment dynamics are related to theoretical orientations and how attachment styles and theoretical orientations combine to predict therapists' perceptions of the quality of their alliances. Method: The present surveyed 290 licensed psychologists nationally. Results: Results revealed that even within a sample of primarily secure psychologists, higher 15 levels of attachment anxiety correlated positively with the endorsement of psychodynamic orientations, and negatively with the endorsement of cognitive-behavioral orientations and self-reported alliance quality. Endorsement of cognitive-behavioral orientations, in turn, correlated positively with therapist-reported alliance quality. Conclusion: The results are discussed in terms of the extent to which attachment dimensions should be considered in therapists' understandings of their therapeutic alliances.     

Insecure attachment and alexithymia in young men with mood symptoms

According to attachment theorists, affect regulation and quality of attachment are closely linked. As a personality trait associated with deficits in the cognitive processing and regulation of affects, alexithymia has been hypothesized to correlate with insecure attachment. To test this hypothesis, we studied the relationships between alexithymia, adult attachment style, and retrospective memories of separation anxiety symptoms during childhood in 100 young men with clinically significant mood symptoms. The most common DSM-IV diagnosis (N = 72) was adjustment disorder with depressed mood, with anxiety, or with mixed anxiety and depressed mood. Each participant completed the Twenty-Item Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory (BDI), the state form of the State-Trait Anxiety Index (STAI), the Attachment Style Questionnaire (ASQ), the Relationship Questionnaire (RQ), and the Separation Anxiety Symptom Inventory (SASI). Alexithymic traits were more pronounced in those participants who had patterns of insecure attachment and who reported more severe symptoms of separation anxiety during childhood, independently of the severity of their current anxiety and depressive symptoms. Among the subgroup of participants with insecure attachment styles, those with preoccupied or fearful patterns had a higher prevalence of alexithymia (65% and 73%, respectively) than those with a dismissing pattern (36%). These data suggest a role for early developmental factors in the etiology of alexithymia     

Parental attachment and its impact on the development of psychiatric manifestations in school-aged children

BACKGROUND: Few studies have examined the relationship between the attachment styles of the primary caregivers and the behavioral problems of their school-aged children. This study was performed to identify the impact of insecure attachment patterns of parents on the development of their children's psychiatric manifestations and disorders. SAMPLINGS AND METHODS: We included 494 2nd to 3rd graders and their primary caretakers. A relationship questionnaire was applied to identify the parental attachment patterns. We investigated the children's mental and behavioral problems by using the Korean Child Behavior Checklist. For objective psychiatric diagnoses, we interviewed 130 high-risk subjects using the Korean Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and Lifetime version. RESULTS: Those parents judged to be preoccupied had children with more internalized symptoms than those who were judged to be secure (p< 0.01); dismissing/avoidant parents had children with higher scores on Attention problems (p = 0002), and fearful/avoidant parents had children with more externalized symptoms (p < 0.01). Moreover, children with insecure attachment type parents revealed more psychiatric morbidity than children with secure parents (p = 0.042). CONCLUSION: Parental insecure attachment was associated with the development of the psychopathologies and psychiatric illness of their children.     

Commentary on Dinger et al.: Therapist's attachment, interpersonal problems and alliance development over time in inpatient psychotherapy

This short article is a commentary on a research study investigating therapist and client attachment styles and their relationship to alliance development in a 12-week psychodynamic psychotherapy program for nonpsychotic inpatients. The relationship is complex; unsurprisingly, securely attached therapists with less distressed clients formed the strongest alliances. A significant proportion of therapists were insecure, almost entirely in the preoccupied or hyperactivating mode. It is argued that collusive relationships between such therapists and similarly overaroused clients may be common. Therapists need both to accommodate to their client's attachment style and to confound it if positive change is to result. Therapist self-scrutiny is likely to be a precondition for such positive outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Client attachment to therapist: Relation to client personality and symptomatology, and their contributions to the therapeutic alliance

This study examined the relation of client attachment to the therapist to diverse facets of the therapeutic alliance, client personality, and psychopathological symptoms, as well as the relative importance of therapeutic attachments, personality, and symptomatology in predicting the alliance. Eighty clients in ongoing therapy completed measures of client attachment to therapist (CATS), personality (6FPQ), psychopathological symptoms (BSI), and therapeutic alliance (WAI-Short, CALPAS, HAQ). Secure and Avoidant-Fearful attachment to the therapist correlated positively and negatively, respectively, with total and subscale alliance scores. Preoccupied-Merger therapeutic attachment was unrelated to the alliance. Exploratory analyses suggested however that the relationship between Preoccupied-Merger attachment and the alliance was moderated by the extent to which clients were distressed. Clients' therapeutic attachments were unrelated to basic personality dimensions. Preoccupied-Merger attachment to the therapist correlated significantly with several symptom dimensions. Clients' therapeutic attachments emerged as superior and more consistent predictors, relative to client personality and symptomatology, of the therapeutic alliance.     

Perceptions of schizophrenic patients and their therapists: application of the semantic differential technique to evaluate the treatment relationship

This study is an attempt to evaluate the treatment relationship with schizophrenic patients by examining the patients' and their therapists' perceptions of themselves and each other, which are hypothesized to reflect features of the relationship. One hundred fifty-eight schizophrenic patients and 11 psychiatrists who maintained a supportive relationship with the patients as a therapist estimated their perceptions using the semantic differential (SD) technique with 17 adjective pairs. Eight composite scales with sufficient internal consistency were constructed from the estimations. The interrelationship among the perceptual elements, which was represented by correlation analysis of the composite scale scores, seemed consistent with our clinical experience. A factor-analytic study of the scales yielded 3 orthogonal factors that could be assumed to characterize the treatment relationship. The patient-therapist cooperation factor indicated the degree of trust between the two participants, supposedly the affective or relational aspect of the therapeutic alliance. The therapist passivity factor reflects the therapist's passive role-taking and the clinical stability of the patient. The patient strength factor was related to the condition-related and characterological strength of the patient. It is demonstrated that the estimations performed by patients and therapists are valid and useful for evaluation of the treatment relationship in the current status.     

Functional connectivity changes following interpersonal reactivity

Attachment experiences substantially influence emotional and cognitive development. Narratives comprising attachment‐dependent content were proposed to modulate activation of cognitive‐emotional schemata in listeners. We studied the effects after listening to prototypical attachment narratives on wellbeing and countertransference‐reactions in 149 healthy participants. Neural correlates of these cognitive‐emotional schema activations were investigated in a 7 Tesla rest‐task‐rest fMRI‐study (23 healthy males) using functional connectivity (FC) analysis of the social approach network (seed regions: left and right Caudate Nucleus, CN). Reduced FC between left CN and bilateral dorsolateral prefrontal cortex (DLPFC) represented a general effect of prior auditory stimulation. After presentation of the insecure‐dismissing narrative, FC between left CN and bilateral temporo‐parietal junction, and right dorsal posterior Cingulum was reduced, compared to baseline. Post‐narrative FC‐patterns of insecure‐dismissing and insecure‐preoccupied narratives differed in strength between left CN and right DLPFC. Neural correlates of the moderating effect of individual attachment anxiety were represented in a reduced CN‐DLPFC FC as a function of individual neediness‐levels. These findings suggest specific neural processing of prolonged mood‐changes and schema activation induced by attachment‐specific speech patterns. Individual desire for interpersonal proximity was predicted by attachment anxiety and furthermore modulated FC of the social approach network in those exposed to such narratives.     

Therapeutic alliance, cohesion and outcome in a long-term analytic group. A preliminary study

We studied the ongoing relationship of patients and their therapist in a long-term, analytic group. The therapeutic alliance was rated weekly and group cohesion was rated every month, by patients and therapist. The patients' symptoms (SCL-90-R) and interpersonal problems (IIP-C) were rated every third month during therapy (self-reports). There was a steady increase in the alliance ratings by patients and therapist during the first 2 years of therapy. This differs from findings in short-term therapies, where the alliance quickly reaches a high level and then remains stable throughout therapy. Therapist ratings of early alliance correlated significantly with positive symptomatic outcome, but did not predict interpersonal change. Patients' alliance ratings did not predict change. Early cohesion ratings did not predict change. The concordance between the patients' and the therapist's alliance ratings was highest between 16 and 30 sessions, and was essentially maintained throughout therapy. An early concordance of patient and therapist alliance ratings predicted a better symptomatic outcome. The measures of therapeutic alliance and cohesion used in this study seem to address different elements in the group process.     

Peur de l’intimité dans la relation amoureuse adolescente : implication de l’attachement parental et de l’attachement romantique

Teen dating is a developmental stage questioning dramatically the relationships to be expected with others, especially when feelings of tenderness and love are involved. It mobilizes parental attachment and the internal working models related to it, while being colored by the emerging romantic attachment and its brand new internal working models. Attachments are deeply shaped by a dynamic interaction whereby the self tries to figure out how to reach security and autonomy still taking the other into account. This considered, intimacy also implies a dynamic feature: on the one hand, closeness and sharing of feelings and/or experiences, and on the other hand, individuality and maintaining of one's ego. However, just like attachments may be insecure, a fear of intimacy cannot be underestimated during dating. Eventually, bearing in mind the societal and cultural components of attachment and intimacy, gendered explanations cannot be ignored, especially during adolescence.

Patient-therapist attachment in the treatment of borderline personality disorder

The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.     

The Relationship Among Attachment Representation,Emotion-Abstraction Patterns,and Narrative Style: A Computer-Based Text Analysis of the Adult Attachment Interview

The main aim of this research was to test the discriminant capacity of computer-based, linguistic text measures which are economically compilable (Emotion-Abstraction Patterns, Mergenthaler, 1996; Computerized Referential Activity, Mergenthaler & Bucci, 1999) in differentiating between complex attachment representations in the Adult Attachment Interview (Main & Goldwyn, 1994). The study of N = 40 healthy controls produced the consistent result that, of the two insecure attachment categories, the group ‘dismissing’ (n = 10) showed the lowest means on all text measures, whereas the group ‘preoccupied’ (n = 10) showed the highest means. The mean of the attachment group ‘secure’ (n = 20) lay between these groups. This ranking is consistent with the results of studies which had another research focus, showing deactivation or hyperactivation of attachment-relevant information in both insecure attachment groups, as well as flexibility in the ‘secure’ group. We also discuss whether the coincidence of language markers for emotion and abstraction, as well as Computerized Referential Activity, is adequate to operationalize the construct of coherence in narrative style.     

Adult attachment, alexithymia, and symptom reporting: an extension to the four category model of attachment

OBJECTIVE: A previous study using a three-category attachment model found that avoidant attachment was associated with increased symptom reporting, and that this relationship was largely mediated by negative affectivity and alexithymia. The present study aimed to advance on these findings by using a four-category model of attachment to determine which aspect of avoidant attachment (fearful or dismissing) is related to symptom reporting, and via which mediating variables. METHOD: One hundred and forty-two male and female undergraduates, aged 17-44, completed questionnaire measures of attachment style, alexithymia, self-esteem, positive and negative affectivity, and symptom reporting. RESULTS: Fearful and preoccupied attachment styles, negative affectivity, and alexithymia were all significantly associated with increased symptom reporting, while the dismissing attachment style was not. Regression analyses showed that the relationship between fearful attachment and symptom reporting was partly, but not fully, mediated by alexithymia and negative affectivity, while that between preoccupied attachment and symptom reporting was mediated mainly by negative affectivity. Low self-esteem was associated with symptom reporting only via its association with negative affectivity. CONCLUSIONS: Fearful and preoccupied attachment styles are both associated with symptom reporting via a negative model of the self and increased negative affectivity, but alexithymia is an additional predictor of symptom reporting in individuals with fearful attachment. This difference is thought to be linked to the model of others developed in early interactions with caregivers.     

Therapeutic Attachment with College-Aged Women

Therapeutic attachment can help a college-aged woman deal with separation from her mother, making the transition from dependence to mutually supportive peer relationships. An insecure relationship experience with the mother replays in treatment as a patient resists therapeutic influence. Serving as a secure base, a therapist can help a young woman let go of potentially self-fulfilling negative expectations and develop trust that she can find responsive caregiving, internalizing a capacity to love and be loved. Using two case examples that illustrate different attachment styles, one anxious and the other avoidant, I explore my struggle to deal with the injury of feeling discounted while seeking opportunities for connection. Examining our interaction, I consider the patient's and my own role in perpetuating patterns of insecure attachment. By helping a young woman to better understand her mother as a separate person and to express autonomy within the treatment relationship, therapists can foster healthier attachments while supporting individuation.     

新兵成人依恋与积极心理品质的关系

目的：探讨新兵成人依恋与积极心理品质的关系。方法选取某部1962名男性新兵,均完成新兵积极心理品质评估问卷（PMCS －R）和成人依恋量表（AAS）的评估。结果新兵中安全型依恋者为74．3％,先占型为10．3％,拒绝型为3．4％,恐惧型为3．5％;安全型依恋类型新兵的积极心理品质总均分[（3．89±0．60）分]高于非安全依恋类型[（3．49±0．61）分],差异有统计学意义（t ＝11．05, P ＜0．05）;积极心理品质各分量表得分及总均分与依恋亲近、依恋依赖得分呈正相关（ r ＝0．312～0．394,0．194～0．247;P ＜0．05）;与依恋焦虑得分呈负相关（ r ＝－0．307～－0．213,P ＜0．05）。结论新兵成人依恋与积极心理品质密切相关。     

Therapeutic alliance in schizophrenia: The role of recovery orientation,self-stigma,and insight

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.