Psychology and Psychotherapy: Theory, Research and Practice (2015), 88, 240–253 © 2014 The British Psychological Society www.wileyonlinelibrary.com
The role of attachment style, attachment to therapist, and working alliance in response to psychological therapy Peter J. Taylor1*, Julia Rietzschel2, Adam Danquah3 and Katherine Berry4 1
Institute of Psychology, Health & Society, University of Liverpool, UK Wigan and Leigh Recovery Team South, Wigan, UK 3 Pennine Care NHS Foundation Trust, Department of Psychological Therapies, Lancashire, UK 4 School of Psychological Sciences, University of Manchester, UK 2
Objectives. Working alliance (WA) has been shown to be an important process influencing the success of therapy. The association of clients’ underlying attachment representations with WA and the subsequent success of therapy has increasingly been recognized. This study explores the association between adult attachment representations, specific attachment to the therapist and WA in patients receiving psychological therapy. Method. Fifty-eight participants due to receive therapy were recruited from primary care psychological services. Participants completed self-report measures of attachment, WA, and psychopathology. Results. Patients with greater secure attachment to the therapist showed significantly greater WA. In a subset of participants completing therapy, change in outcome was also correlated with baseline attachment towards the therapist. Conclusions. The study suggests that attachment towards the therapist is an important predictor of WA. The results suggest that in terms of WA, attachment to the therapist may be more important than pre-existing attachment representations.
Practitioner points A more secure attachment to the therapist was associated with greater WA and improvement in therapy. Clinicians should be mindful of signs of an insecure attachment to themselves, reflecting a difficulty around trusting the therapist and viewing them as a secure base. Missed sessions and an ongoing reluctance to disclose personal information to the therapist may be signs of an insecure attachment. This may be the case even in cognitive–behavioural approaches to therapy where relational processes are not necessarily a focus of therapy. Incorporating attachment processes in the formulation, including attachment to the therapist, may provide one way of exploring these issues in therapy.
*Correspondence should be addressed to Peter J. Taylor, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB, UK (email: [email protected]
Attachment and alliance in psychotherapy
Attachment theory has been highly influential in guiding and informing clinical practice (Wallin, 2007). This theory suggests that early interactions with primary caregivers lead to the development of mental representations (Internal Working Models) that guide expectations about the self and others in interpersonal relationships (Bowlby, 1973). These mental representations are believed to remain important throughout the lifespan and it has been suggested that the process of psychotherapy itself may also be influenced by adult attachment representations (e.g., Bowlby, 1988). This study reports on an investigation of the relationship between adult attachment representations and therapy processes and outcomes. Working alliance (WA) is an important process factor common across all schools of therapy. It is characterized by three core components: (1) bond or shared trust and mutual acceptance between patient and therapist, (2) shared and mutually valued goals or outcomes of therapy, and (3) agreement on the tasks of therapy needed to achieve the goals (Bordin, 1979; Horvath & Greenberg, 1989). It is well established that WA is a predictor of psychotherapy outcome (e.g., Horvath, Del Re, Fl€ uckiger, & Symonds, 2011; Horvath & Symonds, 1991). Consequently, understanding the factors which determine and influence WA may provide a means of enhancing the efficacy of psychological interventions. Adult attachment representations in adulthood can be conceptualized in terms of two dimensions: attachment anxiety and attachment avoidance (Brennan, Clark, & Shaver, 1998). Anxiety reflects a fear of rejection and abandonment in relationships, whereas avoidance corresponds to discomfort in close relationships and reluctance to depend on others. Individuals who report low levels of attachment anxiety and avoidance are generally considered to have secure attachment, whereas those with high levels of anxiety and/or avoidance are considered to have insecure attachment. As the attachment system is believed to play a central role in guiding interpersonal relationships including those that develop within therapy, attachment representations may play an important role in determining WA during therapy. Results from a recent meta-analysis (Diener & Monroe, 2011) and a systematic review (Smith, Msetfi, & Golding, 2010) indicated that individuals with greater attachment security displayed stronger WA than individuals with attachment insecurity. However, when Smith et al. (2010) reviewed research findings by attachment dimension (i.e., anxiety and avoidance), they identified greater inconsistencies in the literature and concluded that there was not sufficient evidence to support a significant relationship between specific attachment dimensions and WA. These inconsistent findings may occur because psychotherapy processes are also influenced by attachment experiences specific to the therapist. For example, it has been suggested that the therapist themselves may act as a secure base, from which the work of therapy can be undertaken (Mallinckrodt, Porter, & Kivlighan, 2005). This idea mirrors findings in the wider psychological literature that general or global attachment patterns may be distinct from (though related to) relationship-specific attachment patterns (Jerga, Shaver, & Wilkinson, 2011). There is evidence to suggest that relationship-specific attachment patterns are a better predictor of relationship outcomes than more global attachment patterns (Cozzarelli, Hoekstra, & Bylsma, 2000) and therefore may be stronger predictors of alliance and therapy outcomes. Mallinckrodt, Coble, and Gantt (1995) developed the Client Attachment to Therapist Scale (CATS) which yields three subscales: Secure, Avoidant-Fearful, and PreoccupiedMerger. The latter subscale is similar to the construct of attachment anxiety, whilst the Avoidant-Fearful subscale measures aspects of attachment avoidance and anxiety. Studies using the CATS suggest that secure attachment towards the therapist is
Peter J. Taylor et al.
associated with better WA, whereas avoidant-fearful attachment is associated with poor WA (Fuertes et al., 2007; Janzen, Fitzpatrick, & Drapeau, 2008; Mallinckrodt et al., 2005; Romano, Fitzpatrick, & Janzen, 2008; Sauer, Anderson, Gormley, Richardson, & Preacco, 2010). Previous studies have tended to either investigate associations between attachment to therapist and alliance/outcomes or associations between client general attachment patterns (not specific to therapist) and alliance/outcomes, but have not explored the differential effects of attachment to therapist versus general attachment style (e.g., Eames & Roth, 2000; Goldman & Anderson, 2007; Sauer, Lopez, & Gormley, 2003; Tasca, Balfour, Ritchie, & Bissada, 2007). The primary aim of the current research was to explore the relationship between attachment (both pre-existing representations and attachment to the therapist) and WA within the context of psychological therapy. This is of clinical value, as it provides therapists with an idea of the extent to which they need to consider attachment (to themselves and pre-existing patterns) in the development of WA. A more secure attachment to the therapist would be expected to help the patient view the therapist as secure base from which they can negotiate shared goals and tasks of therapy and build up trust with the therapist (Mikulincer, Shaver, & Berant, 2013), so developing a strong WA. In contrast, more insecure attachment to the therapist would be expected to disrupt these processes and impair the development of WA. An avoidant attachment would likely be especially problematic as it relates to negative expectations of others (e.g., as rejecting or untrustworthy; Bartholomew & Horowitz, 1991), which would be a block to developing an opening and trusting relationship with the therapist. A preoccupied style may be less problematic, but to the extent that a patient’s fear of rejection and desire to stay close to the therapist creates friction with therapeutic boundaries and distracts from the main tasks of therapy, may still hinder the WA. Attachment with the therapist would be expected to have a more proximal and therefore stronger relationship with WA than more global adult attachment styles, since both attachment to the therapist and WA are characteristics of that particular relational context. Attachment representations may be related to improved therapy outcomes as a result of the relationship with greater WA. A number of studies have found that patterns of attachment predict therapy outcomes (Byrd, Patterson, & Turchik, 2010; Daniel, 2006; Forbes, Parslow, Fletcher, McHugh, & Creamer, 2010; Joyce, Ogrodniczuk, Piper, & Sheptycki, 2010; Saatsi, Hardy, & Cahill, 2007; Stalker, Gebotys, & Harper, 2005), although others have reported non-significant findings (Daniel, 2006; Kirchmann et al., 2009; Ravitz, Maunder, & McBride, 2008; Sauer et al., 2010; Strauss et al., 2006). Consequently, the relationship between attachment and therapy outcome remains currently unclear. A further aim of this study was therefore to explore the relationship between attachment representations and therapy outcomes. To our knowledge, there is also only one published study which has used attachment towards therapist as a predictor of outcome (Sauer et al., 2010). Sauer et al. (2010) found that secure attachment to therapist was significantly associated with greater reduction in distress, whereas global attachment anxiety and avoidance were not related to change in distress.
Overview of study aims and hypotheses This study sought to extend understanding of the relationship between both global and relationship-specific attachment, WA, and psychotherapy outcome. In line with previous
Attachment and alliance in psychotherapy
research, the study uses a two-dimensional measure of adult attachment, whereas attachment towards the therapist is assessed by the three subscales of the CATS. The following hypotheses were made: 1. Both adult attachment style and attachment to therapist will be associated with WA, but attachment to the therapist will be a better predictor of WA than adult attachment style avoidance and anxiety. 2. Greater attachment security to the therapist will be associated with greater WA whilst greater attachment avoidance or preoccupied attachment will be related to lower WA. 3. Improvements in symptoms will be associated with greater attachment security and lower attachment insecurity in both adult attachment style and attachment to the therapist.
Methods Participants Participants were recruited from four primary care psychological therapy services in the North West of England, UK. To be included in the study, participants had to have a reasonable level of English and commence cognitive–behavioural therapy (CBT) at the above services between June 2011 and April 2012. The therapists working at these four services identified patients due to start therapy that met these criteria. Eligible patients were invited to take part in the study by their therapist at the first appointment and/or by receiving information in the post prior to attending their first appointment. Of the 82 eligible patients who agreed to being referred to the study, 58 (70.73%) completed the first questionnaire set and were included in the study. No information was recorded for patients who were asked but declined the invitation to take part in the study and so the characteristics of this group remain unknown. Participants comprised 22 males and 36 females with a range of mental health problems. Participants’ ages ranged from 18 to 74 years (M = 40.07, SD = 13.59). The majority of participants described their ethnicity as White British (n = 55; 94.83%), with a small number as White European (n = 3; 5.17%). Participants were predominantly employed (n = 26; 44.80%), with the remainder being unemployed or in receipt of incapacity benefits (n = 24; 41.38%), retired (n = 5; 8.62%), or students (n = 2; 3.45%). Just over half of the participants (n = 38; 65.52%) reported that they had previously received some form of psychological therapy. Of those who took part, 37 (63.79%) completed the second questionnaire set mid therapy. Those participants who completed the second set of measures did not differ from those who did not complete the second set of measures on baseline attachment or symptoms measures nor on the majority of demographic variables. There were, however, a greater proportion of females amongst those who completed the mid-therapy measures (19/37 vs. 3/21, p = .04). Twenty-two participants (37.93%) completed therapy, although three of these did not return the final questionnaire prior to the end of data collection period, leading to a sample of 19 participants who completed the follow-up measures. The 19 participants who completed the therapy and the final questionnaire set did not differ from the 39 participants who dropped out on any of the baseline measures nor on the majority of demographic measures. There were, however, a greater proportion of females amongst those who dropped out (28/39 vs. 8/19, p = .04). Those who dropped out
Peter J. Taylor et al.
following the mid-therapy assessment also did not differ significantly on WA than those completed therapy. The 58 participants were seen by 17 CBT therapists (2 males and 15 females). The majority of therapists (n = 13; 77.22%) saw one to three patients each, with the remainder seeing four to nine patients. The age of therapists ranged from 24 to 52 years (M = 35.67, SD = 9.12). Therapists’ post-qualification experience ranged from 6 months to 9 years. For the 22 participants who completed therapy, the mean number of sessions attended was 13.45 (SD = 6.58).
Measures Clinical Outcomes in Routine Evaluation – Outcome measures The Clinical Outcomes in Routine Evaluation (CORE; Evans et al., 2000) is a 34-item selfreport questionnaire designed as an outcome measure for psychological therapies covering the domains of subjective well-being, problems/symptom, and functioning. Following the recommendations of Lyne, Barrett, Evans, and Barkham (2006) the 28-item scale, which excludes risk-related items, was used in this study. Items are rated on a 5point Likert scale ranging from 0 (not at all) to 4 (all the time). Good 1-week test–retest reliability (r = .87–.91), convergent and discriminant validity have been demonstrated for this scale (Cahill et al., 2006; Evans et al., 2000; Pirkis et al., 2005). In this study, Cronbach’s alpha for the 28 non-risk item scale was a = .93 at baseline and a = .97 at the end of therapy.
Experiences in Close Relationships Scale The experiences in close relationships (ECR; Brennan et al., 1998) is a 36-item self-report measure of adult attachment representations, which assesses feelings and experiences within the context of romantic relationships. It comprises two 18-item subscales, avoidance and anxiety, which are widely regarded as the two principal dimensions of adult attachment. Items on the two subscales are rated on a 7-point Likert scale ranging from 1 (disagree strongly) to 7 (agree strongly), with higher scores reflecting more insecure feelings about close relationships. Multiple studies support both the reliability and validity of the ECR subscales (see Mikulincer & Shaver, 2007 for a review). In this study, internal consistency estimates for attachment avoidance and anxiety at baseline were a = .94 and a = .92, respectively. Working Alliance Inventory – Client version The working alliance inventory (WAI; Horvath & Greenberg, 1989) is a 36-item self-report measure of patients’ perspective on the quality of the therapeutic WA. The instrument is based on Bordin’s (1979) pan-theoretical model of the WA and has three different subscales (Bonds, Goals, And Tasks), which are highly inter-correlated. Factor analysis supports the use of the overall WA score as a unitary variable (Tracey & Kokotovic, 1989). Items are rated on a 7-point Likert scale ranging from 1 (never) to 7 (always), with higher scores reflecting a stronger WA. The WAI has demonstrated good concurrent validity (Tichenor & Hill, 1989). In this study, the WAI yielded an internal consistency estimate of a = .95.
Attachment and alliance in psychotherapy
Client Attachment to Therapist Scale The CATS (Mallinckrodt et al., 1995) is a 36-item self-report measure used to assess the therapeutic relationship from the perspective of attachment theory. It comprises three continuous subscales: Secure (14 items), Avoidant-Fearful (12 items), and PreoccupiedMerger (10 items), which are rated on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly agree). Test–retest reliability collected over 2–5 weeks was high for the subscales (Mallinckrodt et al., 1995). Concurrent validity has also been demonstrated (Mallinckrodt et al., 2005). In this study, Cronbach’s alpha for the Secure, Avoidant-Fearful, and Preoccupied-Merger subscales were a = .86, a = .78, and a = .89, respectively.
Procedure Participants were asked to complete questionnaires at three different time points. At the beginning of therapy, participants received the CORE and ECR with instructions to complete these before the second therapy session. In line with previous research (e.g., Sauer et al., 2010) the WAI and CATS were administered after session 3 to be completed before session 5. The CORE was readministered at the end of therapy (i.e., after the second-last or last therapy session). Participants completed all questionnaires by themselves and returned them to the researcher by post. Therapy was provided within services linked to the nation-wide Improving Access to Psychological Therapies programme. All therapists were trained in providing CBT to a professional standard and were receiving ongoing, regular supervision to help ensure the quality of their clinical work and adherence to the model. The CBT provided was not manualized, and no formal quality checks on what type of therapy being provided were built into the study. However, therapists were required by services to provide therapy which included combinations of core features of CBT, including joint goal-setting, the development and provision of a cognitive–behavioural formulation of the patient’s difficulties, regular monitoring, and the challenging of cognitions through behavioural or cognitive means.
Statistical analyses and data screening Scales with over 10% missing data were excluded from analyses whilst scale means were imputed for missing values in scales with ≤10% missing data (n = 25 instances of imputation). All variables were checked for violations of parametric test assumptions which revealed positive skewness for the CATS preoccupied subscale. This variable was subjected to log transformations which resulted in normal distributions. Pearson correlation coefficients and regression analyses were conducted to explore associations between relevant variables. There was no indication of multicolinearity, influential cases, or heteroskedasticity in the regression analysis. Residuals appeared normally distributed and homoscedastic, but as an extra check of robustness, bias-corrected and accelerated bootstrapped confidence intervals were also generated for regression coefficients, with 10,000 resamples (Carpenter & Bithell, 2000). Regression analysis using clustered, robust standard errors (Rogers, 1993), was also undertaken to account for the possible non-independence of data associated with clients sharing the same therapist. This approach adjusts for the possible inter-correlation of residuals between cases sharing the same therapist by adjusting standard errors (which might otherwise be affected by the non-independence) to accommodate this possibility.
Peter J. Taylor et al.
Results Participant characteristics As not all participants completed the mid-therapy or post-therapy measures (and due to missing data) the numbers included in analyses vary between n = 57 (for correlations between pre-therapy measures) and n = 18 (for correlation analyses including posttherapy measures). Descriptive statistics and correlations between study variables are presented in Table 1. One gender difference was observed on the Avoidant-Fearful subscale of the CATS, with men scoring significantly higher on avoidance towards the therapist (M = 25.94, SD = 7.77) than women (M = 18.33, SD = 5.63), t(34) = 3.36, p < .01. Age was significantly negatively correlated with attachment anxiety at baseline, r = .37, p < .01, indicating that attachment anxiety decreased with increasing age. Furthermore, individuals who previously had psychological therapy (M = 1.22, SD = 0.14) reported lower levels of preoccupied attachment in the relationship with the therapist than those who had no previous experiences of therapy (M = 1.42, SD = 0.20), t(12.57) = 3.00, p = .01.
Relationships between attachment and working alliance There were no associations between baseline adult attachment style and WA (see Table 1). However, there were large significant correlations between secure attachment towards the therapist (positive relationship), avoidant-fearful attachment towards the therapist (negative relationship), and WA. A multiple regression analysis was undertaken to test whether attachment to the therapist would explain variance in WA over and above what could be accounted for by adult attachment style. Adult attachment style avoidance and anxiety were entered in an initial step. The three CATS subscales were then entered in
Table 1. Descriptive statistics and inter-correlations between study variables Measure
69.80 24.77 1. ECR Attachment Avoidanceb 76.07 22.16 2. ECR Attachment Anxietyb 3. Pre-COREb 65.14 21.04 4. CATS Secureb 68.93 9.90 5. CATS Avoidant-Fearfulc 22.14 7.72 6. CATS Preoccupied1.28 0.18 Mergera,c 208.74 29.35 7. WAIc 8. CORE Changed 26.05 20.26
.34* .54** .14 .23 .07
.56** .12 .34* .32
.06 .26 .16
.21 .17 .49*
Note. For correlations with completers only (i.e., those including CORE change), pre-ECR attachment anxiety was subjected to a square transformation to correct for mild negative skew. ECR = Experiences in Close Relationships; CORE = Clinical Outcomes in Routine Evaluation; CATS = Client Attachment to Therapist Scale; WAI = Working Alliance Inventory. a Results based on transformed variable, geometric mean for this variable is 3.60; bN = 57–56; cN = 37–35; d N = 18–19 (therapy completers only). *p < .05; **p < .01.
Attachment and alliance in psychotherapy
Table 2. Results of regression analysis predicting working alliance
Predictors Step 1 ECR Attachment Avoidance ECR Attachment Anxiety Step 2 ECR Attachment Avoidance ECR Attachment Anxiety CATS Secure CATS Avoidant-Fearful CATS Preoccupied-Merger
DF for step
DR2 for step
Bootstrapped 95% CI b
.01 .03 .61** .29 .06
.01 .03 .47 .20 .06
0.33 0.22 0.84 2.66 0.90
0.28 0.36 2.82 0.17 0.39
Note. df for step 1 = 2, 31; df for step 2 = 3, 28; n = 34. ECR = Experiences in Close Relationships; CATS = Client Attachment to Therapist Scale. *p < .05; **p < .01.
a second step. The results of this analysis are reported in Table 2. The second step made a significant improvement to the model in explaining variance in WAI scores. However, only the secure CATS subscale made a significant unique contribution. The overall model explained 67% of the variance in WA scores. These results suggest that a more secure attachment to the therapist is related to greater WA, beyond what is explained by adult attachment style. The presence of shared therapists within the data may have violated the assumptions of independence of cases. We therefore repeated the above analysis using clustered, robust standard errors (Rogers, 1993) to account for the effect of shared therapists. Equivalent findings emerged, with CATS secure being the only significant predictor, B = 1.93, p < .01, and the model accounting for a similar amount of the variance in WA, n = 34, F(5, 14) = 29.10, p < .01, R2 = .67. It is possible that the potential conceptual overlap between attachment to the therapist and the bond subscale of the WAI may account for the findings above. To explore this possibility, we calculated the correlations among the three subscales of WAI (Bond, Task, and Goals) and the CATS subscales. Notably, Spearman’s correlations for both CATS secure (Bond r = .70, Task r = .72, and Goal r = .77) avoidant-fearful (Bond r = .72, Task r = .57, and Goal r = .50) and preoccupied subscales (Bond r = .21, Task r = .25, and Goal r = .37) were similar across the three WAI subscales. This suggests that the observed relationship between attachment to the therapist and WA was not purely an artefact of overlap between the CATS subscales and the WAI bond subscale.
Relationships between attachment and symptom change There was a significant reduction in CORE scores from pre- (M = 62.26 SD = 16.16) to post scores (M = 36.21 SD = 26.09), Z = 3.53, p < .01, dwithin = 1.11). Change in symptoms was not significantly correlated with adult attachment style but was correlated with CATS secure and CATS Avoidant-Fearful subscales, suggesting a positive relationship between secure and less avoidant attachment to the therapist and greater improvement in symptoms (see Table 1).
Peter J. Taylor et al.
Discussion This study explored the relationship between attachment representations (both global and specific to the therapist) and WA in patients receiving psychological therapy. The first hypothesis was partially supported, with attachment security to the therapist, but not adult attachment style, being strongly, positively related to WA. Moreover, attachment to the therapist remained related to WA even when adjusting for the shared variance with adult attachment style. The second hypothesis was partially supported with only greater attachment security to the therapist emerging as a significant predictor of WA in the regression analysis, although attachment avoidance to therapist was negatively correlated with WA. Hypothesized relationships between attachment towards the therapist and the change in symptoms were also supported. The results confirmed that patient attachment towards the therapist has a strong association with the quality of the WA. In keeping with previous findings (Mallinckrodt et al., 2005; Romano et al., 2008; Sauer et al., 2010), secure attachment towards the therapist significantly predicted better WA, whilst avoidant-fearful attachment towards the therapist predicted poorer WA and preoccupied-merger attachment was unrelated to WA. The secure and avoidant dimensions of the CATS were strongly correlated (r = .66) which may account for why avoidant-fearful attachment to the therapist was no longer related to WA when controlling for other attachment variables. An aspect of a secure attachment with a therapist is the ability to perceive the therapist as a secure base from which the often difficult and painful tasks of therapy can take place (Mikulincer et al., 2013). As such a more secure attachment may better enable consistency between therapist and patient on the goals and tasks of therapy. Where this attachment security is lacking, patients may struggle to feel safe and supported enough within the therapy relationship for them to then engage with the goals and tasks of therapy. Replication of these results in a larger sample would allow for more complex analyses, such as path analyses and structural equation modelling, which would help to explore these more complex mediational relationships. The preoccupied-merger attachment dimension appears unrelated to WA. It may be that patients high in this attachment dimension tend to experience more difficulties relating to therapeutic boundaries due to their underlying concerns about rejection and desire to remain close to the therapist, rather than experiencing any doubts about the goals and tasks of therapy itself. The non-significant relationship between adult attachment style and WA is consistent with the findings of a recent review (Smith et al., 2010), where the majority of studies examining constructs of attachment anxiety and/or attachment avoidance found no significant association with WA. Consequently, it may be that overall attachment security, and particularly, attachment security with the therapist, is what matters for developing a strong WA. It is also possible that the stronger relationship between the CATS subscales and WAI compared to the ECR reflects the fact that the CATS and WAI were completed at the same time point, whilst the ECR was completed at an earlier time point. However, it seems unlikely such a bias could fully account for the large differences between the correlations that the ECR and the CATS (avoidance and secure subscales) had with the WAI. Future research could attempt to better adjust for such methodological artefacts by measuring all study variables at multiple times points. The results of this study suggest that despite being a task-focussed therapy where there is typically less direct emphasis upon the patient–therapist relationship than other models, CBT does not side-step the importance of attachment to the therapist in
Attachment and alliance in psychotherapy
influencing WA. This raises the question of whether a greater focus on the therapeutic alliance and developing attachment security within this would be beneficial in CBT. Those therapist competencies and interpersonal skills likely to influence attachment and WA have been regarded as ‘non-specifics’ or ‘common factors’ but could form a more active and operationalized component of the CBT model (Wright & Davis, 1994). A greater focus on formulating WA within CBT is apparent (e.g., Gilbert & Leahy, 2007). Our findings highlight the importance of drawing on attachment theory to understand therapeutic processes. Response to treatment was unrelated to the adult attachment style dimensions. This is consistent with past research using the ECR (Ravitz et al., 2008; Sauer et al., 2010). Other studies using different dimensional attachment measures such as the Adult Attachment Scale (AAS; Collins & Read, 1990) or Relationship Styles Questionnaire (RSQ; Bartholomew & Horowitz, 1991) have observed significant relationships between adult attachment style dimensions and study outcome (e.g., Forbes et al., 2010; Joyce et al., 2010). It has been argued that the two-factor (avoidance and anxiety) attachment model is preferable to more complex models like those of the RSQ or AAS (Brennan et al., 1998), although future research contrasting these different measures would be beneficial in clarifying the comparative strengths and weaknesses of these measures. Whilst the ECR focuses on romantic relationships, these attachment patterns are believed to reflect broader underlying orientation towards others and the self, and this measure is typically associated with outcomes extending beyond romantic relationships, including psychiatric diagnoses and dissociation (Riggs et al., 2007). Notably, the ECR has been used in a number of previous studies focussing on therapeutic relationships (Taylor, Rietzschel, Danquah, & Berry, 2015). Thus, we expected the ECR to capture dimensions of attachment representations relevant to contexts beyond romantic relationships (including therapeutic relationships). Nonetheless, future research may consider using alternative measures of attachment that focus on other relational contexts (e.g., the Adult Attachment Interview). Several limitations of this study require note. First, it has been argued that secure attachment towards the therapist and high-quality WA may measure similar constructs (e.g., Mallinckrodt et al., 2005), suggesting that the significant relationship between the two variables in this study may not be conceptually very meaningful. However, Mallinckrodt et al. (2005) also argue that attachment to the therapist has distinct elements not accounted for by WA (e.g., openness to in-session exploration) and have shown empirically that these constructs differ in terms of their relationship with other variables. Second, this study lacked a control group which meant that the reductions in attachment anxiety and avoidance cannot be attributed to the therapeutic intervention alone. Based on the results of this study, it would be useful to adopt a randomizedcontrolled design to further explore changes in attachment within CBT. The study also did not take account of therapists’ attachment styles, which have been shown to interact with patient’s own attachment patterns in influencing the course of therapy (Mikulincer et al., 2013). Third, although therapists were required to adhere to a CBT model, no direct ratings of adherence were taken and so it is possible that there may be differences in the CBT provided by different therapists. The CBT provided was not manualized and so reflects the treatment that a typical patient receiving CBT in the United Kingdom could expect, increasing the ecological validity of the study. Fourth, as the sample was relatively homogenous, particularly with regards to race, the generalizability of our findings to more diverse non-White British samples also needs to be assessed. Finally, due to the relatively small sample size and missing data, some of the analyses may have lacked power to identify
Peter J. Taylor et al.
smaller effects. For example, the correlation between CATS preoccupied-merger subscale and ECR anxiety was moderate in size (r = .32) and may have been significant in a larger sample. In general, the small sample size and high attrition rate mean that these results should be viewed as preliminary. WA was not significantly related to completion of therapy, but there was higher reported WA in completers (M = 213.11 vs. 204.12) which may have been significant in a larger sample. The results of this study have several clinical implications. Patients’ specific attachment to the therapist rather than adult attachment style characteristics may influence WA and psychotherapy outcome. Therapists may therefore want to be mindful of patients’ attachment towards them and in particular monitor for signs of insecurity in this relationship. This may take the form of the patient struggling to perceive the therapist as a containing influence or secure base and so find it hard to explore difficult feelings or emotions. Measures such as the CATS may represent a valuable clinical tool that could support therapists’ assessment of patient attachment. In addition to establishing a ‘secure base’, therapists may want to monitor the therapeutic alliance for any signs that could indicate avoidant-fearful attachment towards the therapist, such as reluctance to make personal disclosures, difficulties trusting the therapist, and an overly compliant interpersonal style. If identified, these issues may need to be directly addressed to help patients succeed in therapy. In addition, the present results raise the possibility that activities aimed at improving the patient’s attachment security to the therapist may benefit WA more generally. Approaches are likely to vary from patient to patient, but a key factor will be the development of a formulation that takes the patient’s attachment to the therapist into account (McBride & Atkinson, 2009). For example, the model of self and others underlying the attachment should be assessed and form part of the formulation. Based on this formulation, therapists may then need to adapt the therapy they provide based on the client’s attachment needs. For example, insecure clients may hold a negative model of others (Bartholomew & Horowitz, 1991) which they may apply to the therapist (e.g., seeing therapist as hostile or unreliable) and so the therapist may need to explicitly note and comment on these processes in an empathic and non-judgemental way. Potential triggers for attachment problems, such as therapist leave or the end of therapy may also need to be discussed well in advance to avoid later ruptures. Identifying significant anxieties or concerns and discussing these early on with an appropriate degree of reassurance may be important in enabling some patients to feel contained and see the therapist as a secure base (Byng-Hall, 1995). Increasing therapist availability in the initial sessions may also aid the development of a secure attachment for some patients (e.g., Byng-Hall, 1995).
References Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a fourcategory model. Journal of Personality and Social Psychology, 61, 226–244. doi:10.1037/002235188.8.131.52 Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252–260. doi:10.1037/h0085885 Bowlby, J. (1973). Attachment and loss: Vol. 1. Separation anxiety and anger. London, UK: Hogarth Press. Bowlby, J. (1988). A secure base: Parent–child attachment and healthy human development. London, UK: Routledge.
Attachment and alliance in psychotherapy
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46–76). New York, NY: Guilford Press. Byng-Hall, J. (1995). Creating a secure family base: Some implications of attachment theory for family therapy. Family Process, 24, 45–58. doi:10.1111/j.1545-5300.1995.00045 Byrd, K. R., Patterson, C. L., & Turchik, J. A. (2010). Working alliance as a mediator of client attachment dimensions and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 47, 631–636. doi:10.1037/a0022080 Cahill, J., Barkham, M., Stiles, W. B., Twigg, E., Hardy, G. E., Rees, A., & Evans, C. (2006). Convergent validity of the CORE measures with measures of depression for clients in cognitive therapy for depression. Journal of Counseling Psychology, 53, 253–259. doi:10.1037/0022-0184.108.40.206 Carpenter, J., & Bithell, J. (2000). Bootstrap confidence intervals: When, which, what? A practical guide for medical statisticians. Statistics in Medicine, 19, 1141–1164. doi:10.1002/(SICI)10970258(20000515)19:93.0.CO;2-F Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58, 644–663. doi:10.1037/002235220.127.116.114 Cozzarelli, C., Hoekstra, S., & Bylsma, W. (2000). General versus specific mental models of attachment: Are they associated with different outcomes? Personality and Social Psychology Bulletin, 26, 605–618. doi:10.1177/0146167200267008 Daniel, S. I. F. (2006). Adult attachment patterns and individual psychotherapy: A review. Clinical Psychology Review, 26, 968–984. doi:10.1016/j.cpr.2006.02.001 Diener, M. J., & Monroe, J. M. (2011). The relationship between adult attachment style and therapeutic alliance in individual psychotherapy: A meta-analytic review. Psychotherapy, 48, 237–248. doi:10.1037/a0022425 Eames, V., & Roth, A. (2000). Patient attachment orientation and the early working alliance: A study of patient and therapist reports of alliance quality and rupters. Psychotherapy Research, 10, 421–434. doi:10.1093/ptr/10.4.421 Evans, C. E., Mellor-Clark, J., Margison, F., Barkham, M., Audin, K., Connell, J., & McGrath, G. (2000). CORE: Clinical outcomes in routine evaluation. Journal of Mental Health, 9, 247–255. doi:10. 1080/jmh.18.104.22.168 Forbes, D., Parslow, R., Fletcher, S., McHugh, T., & Creamer, M. (2010). Attachment style in the prediction of recovery following group treatment of combat veterans with post-traumatic stress disorder. The Journal of Nervous and Mental Disease, 198, 881–884. doi:10.1097/NMD. 0b013e3181fe73fa Fuertes, J. N., Mislowack, A., Brown, S., Gur-Arie, S., Wilkinson, S., & Gelso, C. J. (2007). Correlates of the real relationship in psychotherapy: A study of dyads. Psychotherapy Research, 17, 423–430. doi:10.1080/10503300600789189 Gilbert, P., & Leahy, R. L. (2007). The therapeutic relationship in the cognitive behavioural psychotherapies. New York, NY: Routledge. Goldman, G. A., & Anderson, T. (2007). Quality of object relations and security of attachment as predictors of early therapeutic alliance. Journal of Counselling Psychology, 54, 111–117. doi:10.1037/0022-022.214.171.124 Horvath, A. O., Del Re, A. C., Fl€ uckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. doi:10.1037/a0022186 Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. doi:10.1037/0022-0126.96.36.199 Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139. doi:10.1037/00220188.8.131.52 Janzen, J., Fitzpatrick, M., & Drapeau, M. (2008). Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact. Psychotherapy: Theory, Research, Practice, Training, 45, 377–390. doi:10.1037/a0013310
Peter J. Taylor et al.
Jerga, A. M., Shaver, P. R., & Wilkinson, R. B. (2011). Attachment insecurities and identification of atrisk individuals following the death of a loved one. Journal of Social and Personal Relationships, 28, 891–914. doi:10.1177/0265407510397987 Joyce, A. S., Ogrodniczuk, W. E., Piper, W. E., & Sheptycki, A. R. (2010). Interpersonal predictors of outcome following short-term group therapy for complicated grief: A replication. Clinical Psychology and Psychotherapy, 17, 122–135. Kirchmann, H., Mestel, R., Schreiber-Willnow, K., Mattke, D., Seidler, K.-P., Daudert, E., & Strauss, B. (2009). Associations among attachment characteristics, patients’ assessment of therapeutic factors, and treatment outcome following inpatient psychodynamic group psychotherapy. Psychotherapy Research, 19, 234–248. doi:10.1080/10503300902798367 Lyne, K. J., Barrett, P., Evans, C., & Barkham, M. (2006). Dimensions of variation on the CORE-OM. British Journal of Clinical Psychology, 45, 185–203. doi:10.1348/014466505X39106 Mallinckrodt, B., Coble, H. M., & Gantt, D. L. (1995). Working alliance, attachment memories, and social competencies of women in brief therapy. Journal of Counseling Psychology, 42, 79–84. doi:10.1037/0022-0184.108.40.206 Mallinckrodt, B., Porter, M. J., & Kivlighan, D. M., Jr. (2005). Client attachment to therapist, depth of in-session exploration, and object relations in brief psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 42, 85–100. doi:10.1037/0033-3220.127.116.11 McBride, C., & Atkinson, L. (2009). Attachment theory and cognitive-behavioural therapy. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 434–460). New York, NY: The Guilford Press. Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics and change. New York, NY: The Guildford Press. Mikulincer, M., Shaver, P. R., & Berant, E. (2013). An attachment perspective on therapeutic processes and outcomes. Journal of Personality, 81, 606–616. doi:10.1111/j.1467-6494.2012. 00806.x Pirkis, J. E., Burgess, P. M., Kirk, P. K., Dodson, S., Coombs, T. J., & Williamson, M. K. (2005). A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures. Health & Quality of Life Outcomes, 3, 1–12. doi:10.1186/1477-7525-3-76 Ravitz, P., Maunder, R., & McBride, C. (2008). Attachment, contemporary interpersonal theory and IPT: An integration of theoretical, clinical, and empirical perspectives. Journal of Contemporary Psychotherapy, 38, 11–21. doi:10.1007/s10879-007-9064-y Riggs, S. A., Paulson, A., Tunnell, E., Sahl, G., Atkison, H., & Ross, C. A. (2007). Attachment, personality, and psychopathology among adult inpatients: Self-reported romantic attachment style versus Adult Attachment Interview states of mind. Development and Psychopathology, 19, 263–291. doi:10.10170S0954579407070149 Rogers, W. H. (1993). Regression standard errors in clustered samples. Stata Technical Bulletin, 13, 19–23. Retrieved from http://www.stata-press.com/journals/stbcontents/stb13.html Romano, V., Fitzpatrick, M., & Janzen, J. (2008). The secure-base hypothesis: Global attachment, attachment to counselor, and session exploration in psychotherapy. Journal of Counseling Psychology, 55, 495–504. doi:10.1037/a0013721 Saatsi, S., Hardy, G., & Cahill, J. (2007). Predictors of outcome and completion status in cognitive therapy for depression. Psychotherapy Research, 17, 185–195. doi:10.1080/10503300600779420 Sauer, E. M., Anderson, M. Z., Gormley, B., Richardson, C. J., & Preacco, L. (2010). Client attachment orientations, working alliances, and responses: A psychology training clinic study. Psychotherapy Research, 20, 702–711. doi:10.1080/10503307.2010.518635 Sauer, E. M., Lopez, F. G., & Gormley, B. (2003). Respective contributions of therapist and client adult attachment orientations to the development of the early working alliance: A preliminary growth modelling study. Psychotherapy Research, 13, 371–382. doi:10.1093/ptr/kpg027 Smith, A. E. M., Msetfi, R. M., & Golding, L. (2010). Client self-rated adult attachment patterns and the therapeutic alliance: A systematic review. Clinical Psychology Review, 30, 326–337. doi:10. 1016/j.cpr.2009.12.007
Attachment and alliance in psychotherapy
Stalker, C. A., Gebotys, R., & Harper, K. (2005). Insecure attachment as a predictor of outcome following inpatient trauma treatment for women survivors of childhood abuse. Bulletin of the Menninger Clinic, 69, 137–156. doi:10.1521/bumc.18.104.22.168508: Strauss, B. M., Kirchmann, H., Eckert, J., Lobo-Drost, A. J., Marquet, A., Papenhausen, R., & H€ oger, D. (2006). Attachment characteristics and treatment outcome following inpatient psychotherapy: Results of a multisite study. Psychotherapy Research, 16, 573–586. doi:10.1080/1050330060 0608322 Tasca, G., Balfour, L., Ritchie, K., & Bissada, H. (2007). Change in attachment anxiety is associated with improved depression among women with Binge Eating Disorder. Psychotherapy: Theory, Research, Practice, Training, 44, 423–433. doi:10.1037/0033-322.214.171.1243 Taylor, P. J., Rietzschel, J., Danquah, A., & Berry, K. (2015). Changes in attachment representations during psychological therapy. Psychotherapy Research, 25, 222–238. doi:10.1080/10503307. 2014.886791 Tichenor, V., & Hill, C. E. (1989). Comparison of six measures of working alliance. Psychotherapy, 26, 195–199. doi:10.1037/h0085419 Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Journal of Consulting and Clinical Psychology, 1, 207–210. doi:10.1037/1040-35126.96.36.199 Wallin, D. J. (2007). Attachment in psychotherapy. New York, NY: The Guilford Press. Wright, J. H., & Davis, D. (1994). The therapeutic relationship in cognitive-behavioral therapy: Patient perceptions and therapist responses. Cognitive and Behavioral Practice, 1, 25–45. doi:10.1016/S1077-7229(05)80085-9 Received 17 June 2014; revised version received 1 October 2014