Psychotherapy 2014, Vol. 51, No. 3, 404 – 412

© 2014 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0031989

The Insecure Psychotherapy Base: Using Client and Therapist Attachment Styles to Understand the Early Alliance Cheri L. Marmarosh

Dennis M. Kivlighan, Jr.

George Washington University

University of Maryland

Kathryn Bieri, Jean M. LaFauci Schutt, Carrie Barone, and Jaehwa Choi This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

George Washington University The purpose of this study was to test the notion that complementary attachments are best for achieving a secure base in psychotherapy. Specifically, we predicted third to fifth session alliance from client- and therapist-rated attachment style interactions. Using a combined sample of 46 therapy dyads from a community mental health clinic and university counseling center, the client- and therapist-perceived therapy alliance, attachment anxiety, and attachment avoidance were examined at the beginning of therapy. The results of an Actor–Partner Interdependence Model (APIM; Kenny & Cook, 1999, Partner effects in relationship research: Conceptual issues, analytic difficulties, and illustrations. Personal Relationships, 6, 433– 448.) indicated that there was no direct effect of either client or therapist attachment style on therapist or client early ratings of the alliance. One significant interaction emerged and indicated that client-perceived alliance was influenced by therapist and client attachment anxiety. The client-perceived early alliance was higher when more anxious therapists worked with clients with decreasing anxiety. The client early alliance was higher when less anxious therapists worked with clients with increasing anxiety. The findings partially support the notion that different attachment configurations between the therapist and client facilitate greater alliance, but this was the case only when assessing client-perceived early alliance and only with regards to the dimension of attachment anxiety. There were no significant main effects or interactions when exploring therapist-perceived alliance. Implications of the findings are discussed along with recommendations for future study and clinical training. Keywords: attachment, therapy alliance, therapy outcome

fall more within the avoidant spectrum, and they tend to have internal representations of themselves as self-sufficient and of others as unavailable (Bowlby, 1988; Holmes, 2001; Wallin, 2005). Clients who fall within the more anxious and avoidant attachment spectrums, more insecurely attached, often seek treatment due these internal representations, which can have a negative impact on their sense of selves, their perceptions of others’ motivations, and relationship satisfaction. They often experience difficulties regulating emotions, maintaining intimate relationships, and feeling satisfied with career (Fonagy et al., 1996; Mikulincer & Shaver, 2005, 2007). According to Bowlby, a client’s ability to benefit from therapy is based on the client’s ability to develop a secure attachment to the therapist and learn to rely on the therapist during times of duress, fostering a secure base from which clients can explore their current issues and develop new ways of coping (see Daniels, 2006 for a review). A sense of felt security in the therapy relationship, similar to a child’s felt security in childhood, facilitates exploration and growth within the therapy treatment (Bowlby, 1988; Wallin, 2005). The secure psychotherapy relationship helps clients by allowing them to safely express internal representations of self and others in treatment, which can then help clients begin to have insight into their automatic reactions triggered in interpersonal relationships, facilitate their ability to tolerate painful or new emotions that are experienced, and ultimately change these internal

Bowlby (1988) was the first to apply attachment theory to psychotherapy and describes how clients relate to their therapists similar to the way they relied on attachment figures in early childhood. He argued that some clients come to treatment with a history of feeling abandoned in relationships, focusing on others to manage their emotions, and experiencing overwhelming anxiety when alone. These clients fall within the more anxious or preoccupied adult attachment spectrum, and they tend to have internal representations of themselves as not worthy and of others as abandoning or rejecting (Bowlby, 1988; Holmes, 2001; Wallin, 2005). Other clients come to treatment avoiding dependency, fearful of intimacy, and minimizing their symptoms. These clients

This article was published Online First March 31, 2014. Cheri L. Marmarosh, Professional Psychology, George Washington University; Dennis M. Kivlighan, Jr., Department of Counseling, Higher Education, and Special Education, University of Maryland; Kathryn Bieri, Professional Psychology, George Washington University; Jean M. LaFauci Schutt and Carrie Barone, Department of Counseling and Human Development, George Washington University; Jaehwa Choi, Educational Leadership, George Washington University. Correspondence concerning this article should be addressed to Cheri L. Marmarosh, Professional Psychology, George Washington University, 1922 F Street, Suite 103, Washington, DC 20052. E-mail: marmaros@ gwu.edu 404

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SECURE PSYCHOTHERAPY BASE

representations (Holmes, 2001; Slade, 1999; Sperling & Lyons, 1994; Wallin, 2005). According to attachment theorists, it is because the psychotherapy endeavor recreates the opportunity for clients to explore prior injuries they are able to create a cohesive narrative that helps explain their avoidance or anxiety. Clinical researchers have studied attachment theory in psychotherapy, and they have focused heavily on the clients’ attachments and how these attachments influence commitment to treatment, the alliance, transference, and symptom change. Only a few studies have addressed the interactions between the clients’ and therapists’ attachment styles. The results of these studies have revealed conflicting findings, with some researchers stating that contrasting attachment styles are optimal for clients’ growth, and others arguing that certain contrasting attachment styles actually hinder the treatment. In essence, not all therapists foster the secure base in treatment. The current study is designed to speak to these contradictory findings and continue to explore how the therapists’ and clients’ adult attachments influence the early therapy alliance.

Client Attachment and the Early Therapy Alliance Many researchers have examined client attachment and the psychotherapy process, with a significant amount of research focusing on the relationship between client attachment and the therapeutic alliance (Diener & Monroe, 2011; Eames & Roth, 2000; Kanninen, Salo, & Punamaki, 2000; Kivlighan, Patton, & Foote, 1998; Mallinckrodt, Coble, & Grant, 1995; Marmarosh et al., 2009; Satterfield & Lyddon, 1995; Sauer, Lopez, & Gormley, 2003). A recent meta-analysis of 17 empirical studies revealed that clients’ comfort with intimacy and dependency, and their attachment security, had a positive relationship with the therapeutic alliance, whereas insecure attachments had a negative relationship with the alliance (Diener & Monroe, 2011). The impact of the client attachment not only influences clients’ ratings of the alliance, but it also influences therapists’ expectations of the alliance. In an analog study, Lyon, Gelso, Fischer, and Silva (2007) found that actors portraying securely attached clients received the highest therapist-expected ratings of the working alliance, whereas the actors portraying avoidant–fearful attachments received lower expected ratings of working alliance. The actors portraying a client with a preoccupied attachment style received the lowest ratings of expected alliance by therapists watching the video. Therapists are influenced by the actor’s portrayal of different attachment styles, with more secure actors eliciting the most positive expectations.

Therapist Attachment Style and the Early Therapy Alliance Many researchers have examined the relationship between therapist attachment style and therapy alliance (Black, Hardy, Turpin, & Parry, 2005; Dunkle & Friedlander, 1996; Sauer et al., 2003). Black et al. (2005) focused only on therapist ratings and found that therapists’ ratings of attachment security were positively correlated with therapists’ perceptions of the early alliance, whereas therapist attachment anxiety was negatively correlated with positive alliance. Furthermore, insecure therapist attachment style positively correlated with more therapist-rated problems. Sauer et al. (2003) found that therapist attachment anxiety was positively

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related to client-reported alliance early in treatment, but over the course of treatment, it had a negative effect on the alliance. The authors proposed that the positive relationship between therapist attachment anxiety and alliance early in the treatment was due to more anxiously attached therapists focusing on forming and maintaining a positive relationship with the client and possibly avoiding conflict. Not all studies have consistently found a relationship between therapist attachment and the alliance in treatment. Ligiéro and Gelso (2002) found no statistically significant relationship between therapist attachment style and alliance as rated by the therapists or supervisors. Daniels (2006) proposes that there are discrepancies across studies with regards to the relationship between therapist attachment and therapy process. In addition to differences in measurement and procedures explaining the discrepancies, she suggests that therapist attachment may not be as prominent in the treatment as client attachment. She argues that therapist attachment needs are less likely to be at the forefront of the therapy relationship, less activated in the treatment, compared with the clients’ attachment needs. Although this is a possibility, it does not explain why some studies have found a significant relationship between therapist attachment and alliance (Sauer et al., 2003) and why therapist attachment has been significantly related to countertransference (Ligiero & Gelso, 2002), depth of sessions (Dozier, Cue, & Barnett, 1994), and empathy (Rubino, Barker, Roth, & Fearon, 2000). Despite the inconsistent findings with regards to therapist attachment and the alliance, many researchers have found that therapist attachment style is activated in the therapeutic dyad (Black et al., 2005; Dozier et al., 1994; Dunkle & Friedlander, 1996; Mohr, Gelso, & Hill, 2005; Rubino et al., 2000; Sauer et al., 2003). For example, researchers have found a significant relationship between therapists’ attachments and their countertransference reactions (Ligiero & Gelso, 2002). Dozier et al. (1994) examined case managers’ interaction style with psychiatric patients. They found that deactivating case managers, more avoidantly attached, intervened in less depth and perceived less dependency in patients, whereas more hyperactivating case managers, more anxiously attached, intervened in greater depth and perceived greater dependency needs in their patients. In a study examining 77 training therapists, Rubino et al. (2000) found that the level of therapist anxiety negatively related to level of empathy in response to therapeutic ruptures, making these therapists less likely to be secure bases for some of their clients.

Therapist Attachment, Client Attachment, and the Therapy Alliance Although many empirical studies have focused on the influence of either client or therapist attachment styles, few studies have focused on the interaction between the client and therapist attachments. One of the first studies to document the interaction effect was Dozier et al. (1994) who studied the impact of 18 case managers’ attachments on their response to clients with different attachment patterns. The results revealed that more insecure case managers intervened with more depth and perceived more dependency when working with clients who engaged in hyperactivating strategies. The opposite was true of the insecure case managers when they worked with clients who engaged in deactivating strat-

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egies. In essence, the more insecure the case managers were, the more likely they were to react in accordance with this immediate presentation of the client, as hyperactivating or deactivating. Interestingly, the secure case managers were not pulled into the complimentary reaction to the client and were able to engage with the client in a way that challenged the client’s insecure attachment patterns. Secure therapists adopted a style that facilitated a corrective experience. Mallinckrodt (2010) suggests that these secure therapists were better able to flexibly meet the needs of these different clients without getting pulled into any one response. Tyrrell, Dozier, Teague, and Fallot (1999) followed-up on this study and explored the interaction of client and therapist attachment on the therapy alliance with 54 clients and 21 case managers. They found that less avoidant/deactivating case managers formed stronger alliances with more avoidant/deactivating clients compared with less avoidant/deactivating clients. They also found a nonsignificant trend that more deactivating case managers formed weaker alliances with more avoidant/deactivating clients than with less deactivating clients. Tyrrell et al. (1999) indicated that, similar to Dozier et al. (1994), the alliance increases when the client and therapist combine in a noncomplementary way (i.e., a more anxious therapist with a more avoidant client and a more avoidant therapist with a more anxious client). More recent studies have not supported this theory of noncomplementarity. Sauer et al. (2003) did not find any significant effects when they studied the interactions between client and therapist attachments, and Rubino et al. (2000) only found a trend where more anxious therapists were less empathic with fearful and secure clients compared with more dismissing and preoccupied clients. Romano, Fitzpatrick, and Janzen (2008) studied the initial sessions of 59 volunteer clients working with trainee therapists. These researchers found no significant interaction between client and therapist attachment with regards to the alliance, but they did find that counselor attachment moderates the relationship between client attachment and session exploration. Specifically, they found a negative relationship between clients’ attachment anxiety and session depth when the counselor reported moderate to high levels of attachment avoidance. In essence, having a more avoidant therapist and a more anxious client related to less session depth. This finding challenges the notion that noncomplementary attachments are necessarily beneficial to treatment process and outcome. These findings also support prior research where attachment avoidance in the therapist related to less empathy (Rubino et al., 2000; Westmaas & Silver, 2001), more emotional distancing (Mikulincer & Shaver, 2005), hostile countertransference in dyads with anxious clients (Mohr et al., 2005), and rejecting interpersonal behaviors (Bartholomew & Horowitz, 1991). All of these studies offer us a complex picture of how client and therapist attachment dimensions interact and how some therapy relationships are more insecure than secure bases. It appears that additional studies are needed to fully understand how the client and therapist attachment dimensions influence psychotherapy process and what actually facilitates a secure base in treatment. The few studies that have explored the interactions between therapist and client attachment have often relied on small clinical samples with a significant drop-out rate (Sauer et al., 2003), case managers rather than therapists (Tyrrell et al., 1999), and nonclinical “client” populations such as students in a counseling course (Romano et al., 2008). The current study is an attempt to address many of the

limitations of prior studies by focusing on a larger sample of clients engaged in actual psychotherapy over the course of treatment. The current study will also study the impact that both the client and therapist attachments have on the early working alliance using a method that accounts for the unique aspects of the dyad, and actor–partner interdependence model (APIM).

Research Question We predict that there will be an interaction effect between the clients’ pretreatment level of attachment anxiety and avoidance and the therapists’ attachment anxiety and avoidance on the early working alliance ratings made by both therapists and clients. To explore these interactions, path analysis within a structural equation modeling (SEM) framework will be used to analyze the APIM (Kenny, Mannetti, Pierro, Livi, & Kashy, 2002). Krasikova and LeBreton (2012) argue that the psychotherapy relationship should be understood at the level of the dyad, and that although dyadic designs and analytical methods have been used in research on close relationships (e.g., Kenny, 1996), these methods are needed to study the psychotherapy relationship. We expect that using this type of analysis will help us tease apart which relationships are more secure as evidenced by a stronger alliance and which ones are less so.

Method Participants Two different samples from two studies were combined for the current manuscript. One sample was from a university-based community mental health clinic and one from a university-based counseling center (Marmarosh et al., 2009). Both samples were approved by two internal review boards. These two data sets were combined to increase the sample size and explore the relationships between attachment interactions and treatment outcome using hierarchical linear modeling. Forty-eight therapy dyads at a university-based community mental health clinic participated in the present study. These dyads completed treatment measures, and clients attended at least five sessions of therapy. Of the 48 clients that participated to termination, 28 were female and 20 were male. Twenty-eight were Caucasian, three were Asian American, eight were African American, five were Latin American, three indicated other, and one did not respond. The average age of client participants was 29.81 (SD ⫽ 8.50), with the youngest being 19 and the oldest being 60 years of age. Therapists were graduate students in training, and the average age was 27.45 (SD ⫽ 5.21) with the youngest being 22 and the oldest being 44 years of age. Twenty-five therapists were female and eight were male. Twenty-three therapists were Caucasian, one was Asian American, two were Latin American, three were African American, and four indicated other. Therapists rated their use of three different theoretical models: analytic/dynamic, humanistic, and cognitive– behavioral. They were asked to “rate the extent to which you believe in and adhere to the following theories and therapeutic techniques of the following therapies on a scale of 1 ⫽ low to 5 ⫽ high.” The mean for analytic/dynamic was 4.47 (SD ⫽ .51), 2.97 for humanistic (SD ⫽ 1.09), and 3.10 for cognitive– behavioral (SD ⫽ .94).

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Twenty-one therapy dyads at a Mid-Atlantic University counseling center completed treatment measures and at least five sessions of therapy. This dyad data was a subset of data used in a study of attachment and the real relationship (Marmarosh et al., 2009). Of the 21 clients that participated to termination, 15 were female and six were male. Twenty were Caucasian and one was Asian American. The average age of client participants was 23.38 (SD ⫽ 8.51), with the youngest being 18 and the oldest being 53 years of age. Therapists’ average age was 34.64 (SD ⫽ 7.04), with the youngest being 24 and the oldest being 44 years of age. Eleven therapists were female and three were male. Ten therapists were Caucasian, one was Asian American, one was Latin American, one was African American, and one was Multiracial. Therapists rated their use of three different theoretical models: analytic/dynamic, humanistic, and cognitive– behavioral. They were asked to “rate the extent to which you believe in and adhere to the following theories and therapeutic techniques of the following therapies on a scale of 1 ⫽ low to 5 ⫽ high.” The mean for analytic/dynamic was 3.57 (SD ⫽ 1.22), 3.57 for humanistic (SD ⫽ .65), and 3.36 for cognitive– behavioral (SD ⫽ 1.08). The combined 69 clients in the dyads were treated by 46 different therapists. Both clinics did not have a limit on duration of treatment, and the average number of sessions was 33.65 (SD ⫽ 31.13). The minimum number of sessions was five, and the maximum was 137 sessions. The type of psychotherapy offered in both settings was diverse. Both clinics provided psychodynamic, cognitive– behavioral, and integrative psychotherapy. The community-based clinic was more heavily influenced by psychodynamic theory, whereas the college counseling center was more integrative. The APIM used in this study controls for within-dyad nonindependence, but it does not account for within-therapist nonindependence that occurs when therapists see more than one client. Because the majority of therapist in our sample saw only one client, we opted to perform a dyad-level analysis. Therefore, when a therapist saw more than one client, we randomly selected one of her or his clients to use in the APIM analysis. This resulted in 46 unique therapist client dyads for our APIM analysis.

Measures Experiences in Close Relationships Scale. Client and therapist anxiety and avoidant attachment style dimensions were measured using the Experiences in Close Relationships Scale (ECR-S; Brennan, Clark, & Shaver, 1998). This is a self-report measure of adult attachment that assesses two dimensions of attachment— anxiety and avoidance. The ECR-S is a 36-item measure of attachment style that asks respondents to agree or disagree on a 7-point scale with items tapping attachment anxiety (e.g., “I worry about being abandoned,” “I worry that romantic partners will not care about me as much as I care about them”) and avoidance (e.g., “I prefer not to show a partner how I feel deep down,” “I am very comfortable being close to romantic partners” [reverse scored]). The construct validity of these scales in relation to predictions derived from attachment theory has been established in scores of studies (see review by Mikulincer & Shaver, 2003). Brennan et al. (1998) reported Cronbach alphas of .94 and .91 for the Avoidance and Anxiety scales, respectively. In the present study, Cronbach’s

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alpha were .91 for Avoidance and .90 for Anxiety for the client’s measure and .89 and .86, respectively, for the therapist’s measure. Working Alliance Inventory Short Form. Client and therapist working alliance was measured using the therapist and client versions of the Working Alliance Inventory Short Form (WAI-S; Tracey & Kokotovic, 1989). These 12-item measures are based on the original measure composed of 36 items (Horvath & Greenberg, 1986, 1989), and contain three subscales (four items each) measuring client–therapist agreement on goals, agreement on tasks, and bond. The WAI has been vigorously studied over the years and has been found to be highly reliable (Kivlighan & Shaughnessy, 2000). The instrument has been soundly validated through the demonstration of its relation to treatment outcomes, client characteristics, and therapist technical activity (see Constantino, Castonguay, & Schut, 2002; Kivlighan & Shaughnessy, 2000). A number of studies have provided support for the WAI-S, and most recently, Busseri and Tyler (2003) have supported the interchangeability of the short and original forms for the client version and for the total and subscale scores. The total score was used in this study, and the alpha coefficient was .94 for the client version and .95 for the therapist version.

Procedure The sample consisted of both therapists and clients. First, we describe the procedures for the therapist sample, and then we describe the procedures for the clients. Therapist procedures. Training therapists in both universitybased clinics were asked to participate at the start of the academic year. All participating therapists completed a demographic questionnaire, questionnaire about their orientation, and the ECR-S before seeing clients. Participating therapists also completed a packet of measures between the third and fifth session of therapy that included the therapist rating of the working alliance after their clients agreed to participate in the research. Client procedures. Participating clients were asked to complete the ECR-S and other measures at the start of their therapy treatments. Participating clients were also asked to complete the WAI-S between the third and fifth sessions and at termination. Clients were paid for their time and effort when they completed the final measures. Clients in both clinics completed additional measures as well that are not included in this study and were not the focus of the current research study.

Statistical Analysis Path analysis within an SEM framework was used to analyze the APIM (Kenny et al., 2002). Figure 1 depicts the APIM paths examined in this study. As seen in the figure, we constructed one APIM for client and therapist attachment anxiety, attachment avoidance, interactions, and client and therapist working alliance ratings. The APIM contains four actor effects: (a) client attachment anxiety and client working alliance, (b) client attachment avoidance and client working alliance, (c) therapist attachment anxiety and therapist working alliance, and (d) therapist attachment avoidance and therapist working alliance; four partner effects: (a) client attachment anxiety and therapist working alliance, (b) client attachment avoidance and therapist working alliance, (c) therapist attachment anxiety and client working allia-

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Figure 1. APIM for client and therapist attachment anxiety and attachment avoidance and client and therapist working alliance. Covariances among the six predictors variables were estimated, but these covariances are not depicted in the figure.

0.23, ␤ ⫽ .03, t ⫽ 0.19, for client attachment avoidance b ⫽ ⫺1.35, ␤ ⫽ ⫺.19, t ⫽ ⫺1.19). In addition, both interaction effects were not significant (for client and therapist attachment anxiety interaction b ⫽ ⫺1.71, ␤ ⫽ ⫺.19, t ⫽ ⫺1.20, for client and therapist attachment avoidance interaction b ⫽ ⫺0.58, ␤ ⫽ ⫺.08, t ⫽ ⫺0.47). The APIM accounted for 25% of the variance in client-rated working alliance. Both actor effects were not significant (for client attachment anxiety b ⫽ ⫺0.08, ␤ ⫽ ⫺.01, t ⫽ ⫺0.07, for client attachment avoidance b ⫽ ⫺0.70, ␤ ⫽ ⫺.11, t ⫽ ⫺0.70) as were both partner effects (for therapist attachment anxiety b ⫽ 0.26, ␤ ⫽ .03, t ⫽ 0.18, for therapist attachment avoidance b ⫽ ⫺1.54, ␤ ⫽ ⫺.16, t ⫽ ⫺1.02). In addition, the client and therapist attachment avoidance interaction effect was not significant (b ⫽ 0.90, ␤ ⫽ .14, t ⫽ 0.85). However, the client and therapist attachment anxiety interaction effect was significant (b ⫽ ⫺3.86, ␤ ⫽ ⫺.46, t ⫽ ⫺3.09). This significant interaction is displayed in Figure 2. As seen in the figure, when therapist attachment anxiety is low, increasing levels of client attachment anxiety are related to higher client working alliance ratings. Also as seen in the figure, when therapist attachment anxiety is high, increasing levels of client attachment anxiety are related to lower client working alliance ratings.

nce, and (d) therapist attachment avoidance and client working alliance; and four actor–partner interaction effects: (a) client and therapist attachment anxiety interaction and client working alliance, (b) client and therapist attachment anxiety interaction and therapist working alliance, (c) client and therapist attachment avoidance interaction and client working alliance, (d) client and therapist attachment avoidance interaction and therapist working alliance. All variables were centered before computing interaction terms to reduce multicolinearity. The APIM accounts for the nesting of clients and therapists within counseling dyads by specifying a correlation between error terms associated with clients’ and therapists’ ratings of the working alliance. This correlation models the nonindependence of errors between the clients and therapists in a dyad (Kenny et al., 2006). Because this APIM model is saturated, fit statistics are irrelevant.

Results Preliminary Analyses Table 1 includes the means, standard deviations, and correlations of variables used in the study. Attachment and anxiety scores were normally distributed, and there were no univariate outliers. The APIM accounted for 12% of the variance in therapist-rated working alliance. Both actor effects were not significant (for therapist attachment anxiety b ⫽ ⫺2.27, ␤ ⫽ ⫺.22, t ⫽ ⫺1.40, for therapist attachment avoidance b ⫽ ⫺0.40, ␤ ⫽ ⫺.04, t ⫽ ⫺0.23) as were both partner effects (for client attachment anxiety b ⫽

Discussion Prior research findings have been inconsistent with regards to how client and therapist attachments interact, influence the alli-

Table 1 Means, Standard Deviations, and Correlations for Client Pretreatment Avoidance, Client Pretreatment Anxiety, Therapist Avoidance, Therapist Anxiety, and Working Alliance Variable 1. 2. 3. 4. 5. 6. ⴱ

Client avoidance Client anxiety Therapist avoid Therapist anxiety Client WAI Therapist WAI

p ⬍ .05.

ⴱⴱ

p ⬍ .01.

M (SD)

1

2

3

4

5

6

3.54 (1.37) 3.96 (1.39) 2.25 (1.07) 3.17 (.98) 61.78 (9.17) 54.90 (10.11)

—

.03 —

⫺.12 .13 —

⫺.03 .03 .28ⴱ —

⫺.09 ⫺.02 ⫺.16 ⫺.03 —

⫺.03 .10 ⫺.13 ⫺.28ⴱ .25ⴱ —

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Figure 2. Interaction effect for client and therapist attachment anxiety and client working alliance.

ance, and predict treatment progress. A few researchers indicate that clients with more attachment avoidance are better served with secure therapists, who also fall within the more anxious spectrum, whereas more anxiously attached clients are better served with secure therapists, who also fall within the more avoidant dimension (Bernier & Dozier, 2002; Dozier et al., 1994; Tyrrell et al., 1999). Although these studies support noncomplementary attachments, Romano et al. (2008) found that more avoidant therapists with more anxious clients, noncomplementary attachment styles, had a negative impact on the session depth. Researchers have also found that therapists with more avoidant dismissing attachment styles are more likely to be rated by their supervisors as having more hostile countertransference with their clients (Mohr et al., 2005), less empathy (Rubino et al., 2000; Westmaas & Silver, 2001), and more emotional distancing in treatment (Mikulincer & Shaver, 2005). It is not clear whether noncomplementary attachment styles are always more helpful to all clients. The current study attempted to address the contradictory findings with regards to noncomplementary attachments by asking “What are the effects of clients’ pretreatment attachment anxiety and avoidance on the early therapy working alliance while accounting for the effects of therapists’ anxiety and avoidance?”

Client-Perceived Working Alliance Change and Attachment Style Using APIM, we found only one significant interaction effect with regards to the early alliance and that interaction was that the client level of attachment anxiety interacted with therapist level of attachment anxiety. Specifically, we found that when therapist attachment anxiety is low, increasing levels of client attachment anxiety are related to higher client working alliance ratings. On the other hand, when therapist attachment anxiety is high, increasing levels of client attachment anxiety are related to lower client working alliance ratings. In essence, the best ratings of client-rated alliance occur when therapist and clients have opposite intensities on the dimension of attachment anxiety. Therapists with the most anxiety have better client-perceived alliances when clients reported less attachment anxiety. Therapists with the least anxiety have better client-perceived alliances when clients had more attachment anxiety. We did not find a parallel interaction with regards to therapist avoidance and client avoidance, and we did not

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find support for a significant interaction between therapist avoidance and client anxiety (Romano et al., 2008). In general, the findings partially support Bernier and Dozier’s (2002) argument that opposite or contrasting interpersonal orientations in the therapist and client are optimal for the process of psychotherapy early in the therapy relationship. One possible explanation of the findings is that there is an optimal amount of arousal that facilitates the clients’ perceptions of the early alliance. Therapists who are less hyperactivating, those who reveal less attachment anxiety in adult romantic relationships, facilitate more positive alliances with clients who are more hyperactivating in their romantic relationships and may require more emotion regulation in the sessions. A client with elevated attachment anxiety is more inclined to benefit from having a therapist who is less anxious in adult relationships. On the other hand, therapists who tend to engage in more hyperactivating strategies, those higher on attachment anxiety, may facilitate more engagement with clients who are less hyperactivating and report less attachment anxiety, but not necessarily more deactivating. These less anxiously attached clients may benefit from the therapists’ attunement to their needs or active engagement of emotions in the therapy. It is also possible that these clients may be less swayed by the therapists’ hyperactivating strategies, as these clients may be more secure. In essence, the client may be more secure than the therapist and therefore are more forgiving when the therapist lacks attunement or possibly becomes emotionally deregulated in the sessions (Mikulincer & Shaver, 2007). Attachment anxiety, in and of itself, may not necessarily be hurtful or toxic to the early therapy relationship. It appears to depend on the attachment needs of the client and how the relationship evolves over time. Sauer et al. (2003) found that therapist attachment anxiety positively related to client-perceived alliance early in treatment. We found similar results but only with clients who are lower on attachment anxiety before starting therapy. Our results indicate that greater therapist attachment anxiety may not be helpful to clients with greater attachment anxiety. Having both the therapist and client engaging in more hyperactivating strategies appears to reduce the alliance early in treatment. The question that remains is how these attachment interactions influence alliance over time. Dinger, Strack, Sachsse, and Schauenburg (2009) investigated therapist attachment (using the AAI) and weekly alliance ratings of 281 psychotherapy patients treated by 12 therapists. Multilevel regression models showed that therapist attachment anxiety was associated with lower levels of alliance quality over time. This study suggests that therapist attachment anxiety might have a positive relationship with the alliance early in the treatment for some clients owing to more anxiously attached therapists overly focusing on maintaining a positive relationship with the client. Although there is a honeymoon phase in the beginning of the therapy, these authors indicate that attachment anxiety in the therapist will eventually erode the relationship over time. Our results indicate that this honeymoon may only occur for those clients with less attachment anxiety at the start of the therapy. Therapists and clients high on attachment anxiety at the start of therapy may be more at risk early on.

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Limitations Although our findings are important and add more clarity to our understanding of the interactions between the clients’ and therapists’ attachments, there are limitations to the study. Unlike Dinger et al. (2009), we were not able to use the APIM model to explore the impact of attachment interactions on alliance over time or symptom change. We relied on an APIM that requires both therapist and client complete the same measures. We were only able to explore the early alliance using this method. Research is needed to assess changes in alliance and clients’ symptoms to determine how attachment interactions are related to treatment process and eventual outcome. Another limitation of the study is the use of self-report measures. We are limited to understanding only aspects of the therapist and client that are available or that they are willing to report. Aspects of their attachment styles that remain out of awareness are less accessible and therefore underreported with self-report measures. In addition, attachment can be measured using non–selfreport assessments such as the Adult Attachment Interview (AAI). As a matter of fact, studies that found that more avoidant therapists had better outcome with more anxious clients relied on the AAI to assess attachment (Dozier et al., 1994; Tyrrell et al., 1999). Studies that did not support this interaction relied on self-report measures of attachment dimensions (Romano et al., 2008; Sauer et al., 2003). It is possible that the AAI is tapping into different aspects of attachment, given it is focusing on the early caregiving relationships and unconscious processes, whereas the self-report measures, such as the ECRS, are influenced by one’s cognition and emphasize current adult romantic relationships. The ECRS focuses on romantic adult attachment, and this is distinct from the AAI that focuses on adult memories of childhood attachments. Future studies need to include multiple methods of assessing attachment that include both self-report and structured interview. In addition, it is important to gather information about the therapy alliance, client symptoms, and symptom change from diverse sources. It is possible to gather assessments from the therapists, neutral observers of the treatment, and supervisors. Similar to prior studies (Romano et al., 2008), we relied on novice clinicians who were still engaged in training. The use of novice clinicians may impact the generalizability of the findings, as novice therapists may be more inclined to react to the clients’ attachment styles. These therapists, with less clinical experience, are likely to be drawn into their clients’ hyperactivating or deactivating behaviors. More experienced clinicians are more likely to be able to separate their own reactions, identify clients’ attachment patterns, focus on technique, and engage with clients differently based on the clients’ needs. As a matter of fact, Daly and Mallinckrodt (2009) conducted interviews with 12 experienced clinicians and found that these therapists naturally matched the attachment needs of the clients at the beginning of the therapy and later adjusted the therapeutic distance depending on the needs of the client. In essence, therapists said they would move away from more anxious clients and toward more avoidant clients over the course of the treatment. Unfortunately, this study did not explore the therapists’ attachment style nor did it look at actual therapy cases. The therapists explained what they would be inclined to do after reading clinical vignettes of anxious and avoidant clients. It is important because it is possible that therapists who are extreme

on the dimensions of anxiety or avoidance are really exposing an inability to be flexible with all clients. More secure therapists may be better able to offer a wide range of interventions to clients based on their unique needs (Mallinckrodt, 2010). In many studies relying on dimensions of anxiety and avoidance, we do not know whether the individual is simply elevated on attachment anxiety but would be considered secure or whether the individual is elevated on attachment anxiety and would fall within the preoccupied domain. This is a significant issue when using dimensions of anxiety and avoidance and not considering the interaction between anxiety and avoidance or the level of anxiety and avoidance. A final consideration is the lack of control in this study with regards to the type of therapy treatment, the clients’ diagnoses and levels of functioning, and the styles of supervision. All of these factors can influence the therapy process and outcome but were not examined in this study. Therapists varied in their therapeutic approaches and provided nonmanualized interventions. This is the type of psychotherapy provided in most clinics and counseling centers.

Implications for Research, Practice, Training These findings demonstrate the importance of assessing therapist factors that interact with client variables. When studied independently, therapist and client attachment have different relationships with the alliance. In the past, researchers have found that therapist attachment influences treatment (Dozier et al., 1994; Romano et al., 2008; Tyrrell et al., 1999), yet some have found that therapist attachment does not have a significant relationship with therapy processes measured (Ligiero & Gelso, 2002; Sauer et al., 2003). One possible explanation is that therapists are not triggered by the therapeutic relationship the same way clients are triggered (Daniels, 2006). Our findings suggest that therapist attachment does not have a main effect on the early alliance, but it does interact with the client’s attachment anxiety. Despite the therapist ratings of the early alliance being unrelated to their attachment anxiety or avoidance, we did find that therapist attachment influences the clients’ perceived alliance. This mirrors the many studies that have shown that therapist attachment influences treatment. When considering the interactions between the client and therapist, our findings are consistent with the prior studies suggesting that more anxiety may be helpful to a client with less anxiety but that too much anxiety between the therapist and client or too little anxiety between the therapist and client may inhibit the alliance. Future studies are needed to explore the different types of interventions that therapists with different attachment patterns actually use when working with more insecure clients. Researchers have found empirical support for the influence of therapists’ attachment styles on their abilities to develop and maintain positive therapeutic alliances (Black et al., 2005; Sauer et al., 2003), engage empathically in response to ruptures (Rubino et al., 2000), cope with hostile countertransference (Mohr et al., 2005), and facilitate better outcomes with more severely ill clients (Schauenburg et al., 2010). We do not know exactly how therapist attachments interact with clients’ attachments to influence the actual therapy processes in the room. Rubino et al. (2000) explored the relationship between therapist attachment and empathic responses to ruptures in videotapes of actors portraying

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SECURE PSYCHOTHERAPY BASE

different attachment styles, and the results indicated that therapist anxiety negatively related to empathy. This study has never been replicated with actual therapy clients during treatment. Therapists’ ability to identify and repair ruptures in treatment has been shown to be extremely critical to successful psychotherapy (Safran & Muran, 1996; Safran, Muran, & Eubanks-Carter, 2011). Although many studies have addressed the importance of the rupturerepair sequence, not much attention has been given to how therapists’ attachments influence this process. It is likely that therapists with different attachment styles will be more or less aware of different types of ruptures and engage in more or less repairs with different types of clients. Specifically, one could hypothesize that clients with more attachment anxiety working with therapists with more attachment anxiety would endure more ruptures and experience fewer repairs given that both are more likely to be flooded with their own emotional needs. This lack of attunement is likely to erode the therapy relationship and could lead to less development of the alliance and progress in treatment. It is likely that two more anxious in the therapy dyad has a more toxic impact on the alliance early on compared with two people who are more avoidantly attached in the therapy dyad. A more avoidant client and therapist may experience less ruptures, as they engage in more deactivating strategies and rely less on each other for emotional regulation. The treatment may be more detached and emotionally disengaged, but both experience this as fine. According to Daniels (2006), therapists “will have to address the beliefs and expectations stemming from prior insecure relationships that stand in the way of establishing a secure working relationship” (p. 973). We agree, and our findings demonstrate that therapists with more attachment anxiety may hinder the early alliance for clients who come to treatment with the same struggle. This is even more significant because many clients come to treatment with high adult romantic attachment anxiety, and these clients tend to come to treatment with increased symptoms and more compromised abilities to regulate their emotions. The last thing they may need is to work with a therapist who also struggles with high attachment anxiety in their own intimate relationships. Once we have a clearer understanding of how therapists’ attachments interact with clients’ attachments in treatment, we need to implement training interventions that will help therapists who have a valence for more attachment anxiety work with different clients (Bennett, 2008). Training therapists to be aware of their attachmentbased beliefs and expectations is critical, and it helps therapists to recognize how their relationship histories can influence their ability to regulate emotions, empathize, and be curious with clients who could be a challenge for them. This insight has the potential to facilitate more successful treatments for clients who struggle in relationships and come to treatment seeking a secure base.

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Received July 4, 2012 Revision received December 10, 2012 Accepted December 26, 2012 䡲