Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 23, 47–65 (2016) Published online 2 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1937

The Role of Therapist Attachment in Alliance and Outcome: A Systematic Literature Review Amy Degnan,1 Annily Seymour-Hyde,1 Alison Harris2 and Katherine Berry1* 1 2

School of Psychological Sciences, University of Manchester, Manchester, UK Greater Manchester West Mental Health Foundation Trust, Prestwich, UK

Objectives: This review examined the impact of therapist attachment style on therapeutic alliance and outcomes. Methods: Systematic search procedures yielded 11 studies for inclusion that measured associations between therapist attachment style and alliance and/or outcome. Results: There is some preliminary evidence that therapist attachment style and interactions between therapist and client attachment style contribute to alliance and therapy outcomes. However, methodological weaknesses and heterogeneity across studies highlight the need for more rigorously designed research in this area. Conclusions: There is sufficient evidence to suggest that therapists need to pay attention to the influence of their own attachment style in therapeutic processes and that there is merit in pursing this area of research further. The review is important in highlighting key design issues to consider in future studies. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message: • Therapist attachment style has the potential to influence therapeutic alliance and client outcome. • Improvements in therapeutic practice might be achieved if therapists have greater knowledge of their own attachment styles and how these interact with their clients’ attachment styles to influence the psychotherapy relationship and outcomes. • From the outset of their careers, therapists should receive training and supervision to enhance the awareness of their individual attachment experiences and how these play out during the therapeutic process. Keywords: Attachment, Alliance, Therapy Outcome, Therapist

Bordin (1994) outlines three components that constitute the quality of the therapeutic alliance: (a) therapist and client agreement on the goals of therapy; (b) therapist and client agreement on the tasks of therapy; and (c) emotional bond between the therapist and client. Meta-analytic studies show that the working alliance is an important predictor of outcome, with alliance–outcome effect size estimates typically reported in the range of 0.22–0.26 (Horvath, Del Re, Flückiger, & Symonds, 2011; Martin, Garske, & Davis, 2000). Given the importance of the working alliance to therapeutic outcomes, research has focused on identifying key factors that improve or weaken the alliance during therapy. Evidence suggests that characteristics of both clients and therapists influence the development of the alliance (Norcross, 2011). However, research has traditionally placed greater focus on client characteristics. *Correspondence to: Dr Katherine Berry, School of Psychological Sciences, The University of Manchester, 2nd Floor Zochonis Building, Brunswick Street, Manchester, M13 9PL, UK. E-mail: [email protected]

Copyright © 2014 John Wiley & Sons, Ltd.

Bowlby’s (1988) attachment theory offers a useful framework within which to explore the therapeutic alliance. Attachment is defined as a persistent affectional bond an individual forms with a significant other. Bowlby asserted that the attachment figure provides a ‘secure base’ with which the individual can explore the world and is used as a ‘safe haven’ during times of distress. Bowlby proposed that, as a result of interactions with caregivers during infancy and childhood, individuals develop affect-laden mental representations of the self in relation to significant others and expectations about how others behave in social relationships. From observational studies of infant–mother interactions, Ainsworth, Blehar, Waters and Wall (1978) identified three different attachment patterns (secure, insecure avoidant and insecure anxious-ambivalent) that relate to different internal working models and methods of regulating distress. If the infant receives sensitive caregiving that is responsive to his or her needs, a secure attachment style develops. This is associated with a positive image of the self and others, adaptive strategies for coping with distress, behaving autonomously and the ability to develop

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48 and value intimate relationships. However, if infants receive insensitive caregiving or primary caregivers are unresponsive to distress, they either escalate their levels of distress in order to have their attachment needs met, which is associated with a preoccupation and desire for closeness in relationships (anxious-ambivalent), or they learn to deactivate their attachment system, which is associated with a dismissive approach to affect and an avoidance of close relationships (avoidant). Although internal working models are hypothesized to be self-perpetuating, there is evidence to show that changes in attachment patterns can occur, in either a positive or negative direction, as a result of life stressors and changes in key relationships (Waters et al., 2000). Bowlby (1988) argued that the psychotherapy relationship may provide an important mechanism to help the client move from insecure to secure attachment. Bowlby suggested that the role of the therapist is to act as an attachment figure by creating a secure base to enable exploration of attachment-related experiences and to provide a corrective emotional experience to disconfirm insecure working models. More recent research indicates that clients can develop more secure attachments as a result of therapy (Taylor, Rietzschel, Danquah, & Berry, in press). The hypothesis that the therapist functions as an attachment figure has led theorists and researchers to question whether the therapeutic relationship can truly be construed as an attachment relationship. Mallinckrodt, Daly, and Wang (2009) and Mallinckrodt (2010) described five key characteristics of attachment relationships and reviewed evidence to evaluate whether the therapeutic relationship met these criteria. The criteria consist of the following: (1) an attachment figure is a target for proximity seeking; (2) an attachment figure is a safe haven to provide comfort in times of distress; (3) an attachment figure provides a sense of security from which the individual can explore; (4) the individual experiences separation anxiety when the attachment figure is not available; and (5) the attachment figure is stronger and wiser than the individual. Mallinckrodt (2010) presented evidence that provides empirical support for the first four criteria (Janzen, Fitzpatrick, & Drapeau, 2008; Joyce, Piper, Ogrodniczuk, & Klein, 2007; Romano, Fitzpatrick, & Janzen, 2008; Vogel & Wei, 2005) and argued that the fifth element is not essential for adult attachment relationships. Mallinckrodt concluded that although therapeutic relationships will not always meet these criteria, therapeutic relationships do have the capacity to be attachment relationships with the potential to modify insecure internal working models. There is growing recognition that client attachment security is associated with better working alliance and more favourable treatment outcomes (Diener & Monroe, 2011; Smith, Msetfi, & Golding 2010), and an increasing number of empirical studies have examined the effect of therapist attachment on alliance and outcome. Evidence suggests that Copyright © 2014 John Wiley & Sons, Ltd.

parents’ attachment patterns predict their ability to be sensitive and responsive caregivers and function as a ‘secure base’ for their children (van IJzendoorn, 1995). In the same way, one would expect therapist attachment patterns to influence their capacity to act as effective attachment figures and establish secure working relationships with their clients. In accordance with the greater number of empirical studies investigating client attachment styles, literature reviews have largely focused on the influence of client attachment patterns in therapy (Daniel, 2006; Diener & Monroe, 2011; Smith et al., 2010), and there is no existing synthesis or critical appraisal of evidence in relation to the influence of therapist attachment style on alliance and outcome.

AIMS OF THE REVIEW The aim of this paper is to review empirical studies that have examined the relationship between therapist attachment and therapeutic alliance and/or outcomes. A synthesis and critical appraisal of this evidence base will highlight the extent to which therapists should consider their own attachment experiences in therapeutic practice as well as the potential value of carrying out further research in this area. A critical appraisal of existing studies will also help to identify key issues to consider in designing future studies.

METHOD Inclusion Criteria To be included in the study, the articles had to conform to the following criteria: (a) published in the English language; (b) published from 1980 up to and including the year 2014; (c) included a validated measure of the therapist attachment style; and (d) included a validated measure of alliance or therapy outcome. Studies were excluded if they examined group or couple alliance and if they sampled participants under the age of 18 years.

Search Procedure A literature search was conducted using the electronic databases Medline, PsycINFO, PsycARTICLES, Scopus and Web of Science. The search was conducted using the following terms: therapist attachment AND alliance OR therap* relationship OR outcome, counsellor attachment AND alliance OR therap* relationship OR outcome, therapist insecure attachment AND alliance OR therap* relationship OR outcome, therapist secure attachment AND alliance OR therap* relationship OR outcome, therapist interpersonal style AND alliance OR therap* relationship OR outcome and therapist relational style AND alliance OR therap* Clin. Psychol. Psychother. 23, 47–65 (2016)

Therapist Attachment, Alliance and Outcome relationship OR outcome. The search sets were entered for searching in the title and abstract of articles, except for Web of Science. The latter did not offer searches of article abstracts, and therefore, terms were entered in the ‘topic’ field. Figure 1 illustrates the selection of studies through the different phases of the systematic search. The database search produced 2258 records in total. The reference manager software ENDNOTE was used to remove duplicates, resulting in 685 records for screening. Examination of review articles/chapters and checking of reference sections identified another two publications for potential inclusion. In all, 688 records were screened, of which 651 were immediately excluded as they did not meet inclusion criteria. The remaining 36 studies were retrieved in full and examined further. All searches revealed that no similar systematic review had previously been published. A total of 11 articles were deemed suitable for inclusion in the review.

RESULTS Data Synthesis A meta-analysis was not feasible as the effect sizes for non-significant results were often not reported and

49 attempts to contact authors via email for omitted data were largely unsuccessful (only two out of seven authors with the missing data responded). We therefore used a non-quantitative narrative approach to synthesize study findings (Mays, Roberts, & Popay, 2001) and, where available, reported effect sizes in Table 1. This approach involved describing and critically appraising the reviewed studies and combining the evidence into a narrative within a coherent theoretical framework.

Descriptive Characteristics of Studies Table 1 displays a summary of the descriptive characteristics of the reviewed studies in date order. Four studies were survey designs and recruited therapists who were already conducting therapy with clients; therefore, although participants were asked to complete the measures at specific times, one cannot ascertain when they were completed. Six studies were naturalistic in design, with three recruiting dyads of therapists and clients from their current caseload and two assigning clients to therapists; all but one of these studies (Tyrell, Dozier, Teague, & Fallot, 1999) reported the time point in which the measures were completed. One study (Bruck, Winston, Aderholt, & Muran, 2006) was a randomized controlled trial (RCT) in

Figure 1. Flow diagram of systematic search

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Clin. Psychol. Psychother. 23, 47–65 (2016)

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19 therapists at university hospital and 59 outpatients (each therapist treated between one and nine patients) with primary diagnosis of anxiety disorder; 91% co-morbid diagnosis

2. Petrowski et al. (2011), Germany

3. Schauenburg 31 therapists and et al. (2010), 1381 inpatients, Germany at two psychotherapy hospitals, with severe sychiatric disorders (affective, anxiety, adjustment/ stress, eating, disorders, obsessive– compulsive, psychotic; majority

27 therapists and 67 clients from university counselling centres with diagnosis of mild depression and/or anxiety (with issues in relationships, academic studies or identity formation)

Sample

1. Wiseman and Tishby (2014), Israel

Reference and country

Multimodal inpatient psychotherapy: psychodynamic, behavioural and disorder-specific interventions, one-to-one and roup sessions at least weekly, average

One-to-one, average treatment duration of 69 days

One-to-one weekly sessions of psychodynamic therapy over 1 year

Therapy

Longitudinal (naturalistic inpatient cohort)

Longitudinal study (naturalistic cohort)

Longitudinal (naturalistic cohort)

Design

AAI therapist rated (used security– insecurity and dismissing– preoccupied dimensions, rated 6–24 months post-therapy)

AAI client and therapist rated (used security– insecurity and dismissing– preoccupied dimensions, rated pretherapy)

ECRS client and therapist rated completed at intake and at Session 28

Attachment measure

Table 1. Descriptive characteristics and key findings of the reviewed studies

HAQ client rated (used mean score of 11 items from one retrospective rating after the last therapy session)

HAQ client rated (used two subscale scores ‘relationship satisfaction’ and ‘outcome satisfaction’, rated at the point of discharge)

OQ-45 client rated at intake and five time points during therapy



Key findings

When treated by low-avoidant therapists, low-avoidant clients were likely to decrease to a greater extent in terms of symptoms than highavoidant clients treated by lowavoidant therapists. — Anxiety patients with a more insecure attachment with highly preoccupied and disorganized features evaluated the relationship with a more dismissing therapist as more helpful than that with a more preoccupied therapist. SCL-90-R No main effects (GSI) and of therapists’ IIP, attachment client rated; dimensions. IS therapist However, higher rated (all measured at attachment the start and security of the end of therapist was therapy) associated with both better

Outcome measure

Alliance measure

(Continues)

Security versus insecurity HAQ patient = 0.10 HAQ therapist = 0.09 GSI = 0.02 IS = 0.44 Dismissing versus preoccupied





Correlation /effect size (r)

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Therapy

12 therapists and 281 inpatients with severe psychiatric disorders (depressive, anxiety, eating, somatoform, adjustment/stress, obsessive– compulsive; 20.6% co-morbid personality disorder) recruited as part of a larger study by Schauenburg et al. (2010)

59 students from university counselling courses and 59 clients with a range of problems (relationship difficulties, selfesteem, career concerns, existential concerns, anxiety, depression, academic concerns, substance abuse)

5. Romano et al. (2008), Canada

Copyright © 2014 John Wiley & Sons, Ltd. One-to-one short-term common factors counselling, average duration of 14 sessions

Multimodal inpatient psychotherapy: psychodynamic, behavioural and disorder-specific interventions, one-to-one and group sessions at least weekly, average duration of 12 weeks

had more than one duration diagnoses; 41.1% of 12 weeks had co-morbid personality disorder)

Sample

4. Dinger et al. (2009), Germany

Reference and country

Table 1. (Continued)

Longitudinal study (naturalistic cohort)

Longitudinal (naturalistic inpatient cohort)

Design

ECRS client and therapist rated (used avoidance and anxiety subscale scores, rated pre-therapy)

AAI therapist rated (used security– insecurity and dismissing– preoccupied dimensions)

Attachment measure

WAI client rated (computed mean score of weekly ratings over Sessions 5–9 on total, goal, task and bond)

IES client rated (used weekly ratings of ‘alliance with individual therapist’ subscale across full treatment duration)

Alliance measure





Outcome measure alliance and outcome in more severely impaired patients. Therapists’ attachment security was not related to alliance, but higher attachment preoccupation of therapists was associated with lower levels of alliance quality. In addition, an interaction of attachment preoccupation and patients’ interpersonal problems explained variations of the alliance development curve over time. Therapists’ global attachment orientations did not interact with working alliance. In addition, therapist and client global attachment orientations did not significantly predict alliance in the regression analysis, either as

Key findings

(Continues)

Anxiety WAI-Total = 0.08 WAI-Bond = 0.08 WAI-Goal = 0.05 WAI-Task = 0.08 Avoidance WAI-Total = 0.10 WAI-Bond = 0.12 WAI-Goal = 0.11

HAQ patient = 0.16 HAQ therapist = 21 GSI = 0.30 IS = 0.16 —

Correlation /effect size (r)

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26 therapists from psychiatric medical centre and 26 outpatients with mixture of Axes I and II diagnoses (mood, anxiety, adjustment disorders, cluster C personality disorder, personality disorder not otherwise specified)

491 accredited psychotherapists

7. Black et al. (2005), UK

Sample

6. Bruck et al. (2006), USA

Reference and country

Table 1. (Continued)

Copyright © 2014 John Wiley & Sons, Ltd. —

One-to-one manualized short-term dynamic psychotherapy (n = 27) or CBT (n = 19); total 30 sessions (26/46 client–therapist dyads with complete data, 43% attrition rate)

Therapy

Cross-sectional (survey) (491/1400 therapists responded to survey, 36% response rate)

Longitudinal (RCT)

Design

ASQ therapist rated (used subscale scores; confidence, preoccupations with relationships, need for approval, relationships as secondary and discomfort with closeness)

RSQ client and therapist rated (used secure, preoccupied, fearful and dismissive subscale scores, rated pre-therapy)

Attachment measure

ARM therapist rated (used mean score, rated concerning clients in general)

WAI-12 client and therapist rated (used overall mean score, weekly ratings, Sessions 1–9)

Alliance measure



SCL-90R, IIP and PTC, client rated; GAS, IIP and TTC, therapist rated (all measured pre-therapy and posttherapy)

Outcome measure main effects or in interaction. Therapist secure attachment style significantly predicted working alliances and therapistrated IIP. Therapist fearful attachment style negatively predicted outcomes on the therapistrated IIP, and dismissing attachment style negatively predicted outcomes on both therapist-rated and patientrated IIP. Therapist selfreported secure attachment style was significantly positively correlated with therapist-reported general good alliance. Selfreported anxious attachment styles were significantly negatively correlated with good alliance and significantly positively correlated with

Key findings

(Continues)

Secure ARM = 0.44 Insecure discomfort closeness ARM = 2.6 Relationships as secondary ARM = 0.18 Need for approval ARM = 0.28 Preoccupation ARM = 0.32

WAI-Task = 0.06 Secure WAI = 0.34 IIP = 0.54 TTC = 0.47 GAS = 0.35 SCL-90 = 0.30 Fearful GAS = 0.041 Therapistrated IIP = 0.38 Dismissing Client-rated IIP = 0.30 Therapist-rated IIP = 0.62

Correlation /effect size (r)

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13 students from university and community counselling centres and their 17 clients (17 dyads with complete data; four therapists contributed to two clients, nine contributed to one client)

Sample

9. Ligiero and 50 university Gelso (2002), students USA on counselling or clinical psychology course and their supervisors

8. Sauer et al. (2003), USA

Reference and country

Table 1. (Continued)

One-to-one psychoanalytic treatment, average of 5.4 sessions

One-to-one, 4× psychodynamic, 5× CBT, 5× eclectic, 3× systemic therapy, minimum seven weekly sessions

Therapy

Cross-sectional (survey; 135 therapists sent surveys; 73 met criteria, 63 agreed; 56 [88%] therapists and 51 [94%] supervisors returned surveys; 50 dyads with complete data)

Longitudinal (naturalistic outpatient cohort)

Design

RQ therapist rated (used secure, fearful, preoccupied and dismissive)

AAI client and therapist rated (used avoidance and anxiety subscales, rated after Session 1)

Attachment measure

WAI-12 therapist and supervisor rated (used total scores and goal, task and bond subscale scores, rated at one time point between Sessions 3 and 9, taking

WAI client and therapist rated (used total score, rated after Sessions 1, 4 and 7)

Alliance measure





Outcome measure

Therapist attachment style did not correlate with working alliance (nonsignificant results not reported).

the number of therapistreported problems in therapy. Anxiously attached therapists had a significantly positive effect on the client working alliances after the first session but significant negative effects over time.

Key findings

(Continues)

Anxiety Client WAI T1 = 0.40, T2 = 0.28, T3 = 0.24 Therapist WAI T1 = 0.05, T2 = 0.02, T3 = 0.11 Avoidance Client WAI T1 = 0.33, T2 = 0.07, T3 = 0.16 Therapist WAI T1 = 0.04, T2 = 0.13, T3 = 0.06 Insecurity Client WAI T1 = 0.4, T2 = 0.16, T3 = 0.21 Therapist WAI T1 = 0.01, T2 = 0.10, T3 = 0.0 —

Correlation /effect size (r)

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Sample

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BDI = 0.10 11. Dunkle and Friedlander (1996), USA

73 students from university counselling centres or training clinics and their 73 clients, with a range of problems (depression, romantic, academic, marital/ family concerns)

10. Tyrell et al. 21 clinical case (1999), USA managers and their 52 clients with severe psychiatric disorders (schizophrenia, schizoaffective, bipolar, depression; 48% co-morbid substance abuse disorder)

Reference and country

Table 1. (Continued)

One-to-one therapy

One-to-one community case management programme, average treatment duration of 31 months, range 7–69 months

Therapy

Cross-sectional (survey) (73/252 client–therapist dyads responded to survey; 29% response rate)

Crosssectional/ retrospective

Design

AAS therapist rated (used depend, anxiety and close subscale scores, rated at one time point from Sessions 3 to 5)

AAI client and therapist rated (used autonomous– non-autonomous and deactivating– hyperactivating)

Attachment measure

WAI-12 client rated (used goal, task and bond subscale scores, rated at one time point from Sessions 3 to 5)

into account the last three sessions combined) WAI client rated (used overall mean score)

Alliance measure

GLS, Relationship QOL, Relationship Satisfaction,

Outcome measure

Clients who were more deactivating with respect to attachment had better alliances and functioned better with less deactivating case managers, whereas clients who were less deactivating worked better with more deactivating case managers (more likeminded)

Correlation /effect size (r)

(Continues)

Close WAI-Total = 0.39 WAI-Bond = 0.41 WAI-Task = 0.34 WAI-Goal = 0.32 Depend WAI-Total = 0.42 WAI-Bond = 0.44 Therapist comfort WAI-Task in developing = 0.37 close relationships WAI-Goal predicted strong = 0.36 Anxiety Close and depend subscales positively correlated with total working alliance and its individual components.

Hospitalizations, GAF, BDI Deactivating versus hyperactivating WAI = 0.07 GLS = 0.02 Relationship QOL = 0.08 Relationship Satisfaction = 0.10 Hospitalization = 0.06 GAF = 0.23

Key findings

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emotional bond WAI-Total early in treatment. = 0.16 WAI-Bond = 0.22 WAI-Task = 0.09 WAI-Goal = 0.12

Note: ‘—’ denotes that authors did not report this information. AAI = Adult Attachment Interview (George, Kaplan, & Main, 1985); AAIn = Adult Attachment Inventory (Simpson, Rholes, & Nelligan, 1992); AAS = Adult Attachment Scale (Collins & Read, 1990); ARM = Agnew Relationship Measure (Agnew-Davies, Stiles, Hardy, Barkham, & Shapiro, 1998); ASQ = Attachment Style Questionnaire (Feeney, Noller, & Hanrahan, 1994); BDI = Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erlbaugh, 1961); ECRS = Experiences in Close Relationships Scale (Brennan, Clark, & Shaver, 1998); GAF = Global Assessment of Functioning (American Psychiatric Association, 1994); GAS = Global Assessment Scale (Endicott, Spitzer, Fleiss, & Cohen, 1976); GSI = Global Severity Index; HAQ = Helping Alliance Questionnaire (Bassler, Potratz, & Krauthauser, 1995); IES = Inpatient Experience Scale (Sammet & Schauenburg, 1999); IIP = Inventory of Interpersonal Problems (Horowitz, Alden, Wiggins, & Pincus, 2000); IS = Impairment Score (Schepank, 1995); PTC = Patient-Rated Target Complaints (Battle et al., 1966); QOLI = Quality of Life Interview (Lehman, 1988); OQ-45 = Outcome Questionnaire (Lambert, et al., 1996); RQ = Relationship Questionnaire (Bartholomew & Horowitz, 1991); RSQ = Relationship Scales Questionnaire (Griffin & Bartholomew, 1994); SCL-90R = Symptom Checklist 90 Revised (Derogatis, 1983); TTC = Therapist-Rated Target Complaints (Battle et al., 1966), WAI-12 = Working Alliance Inventory Short Form (Tracey & Kokotovic, 1989); WAI = Working Alliance Inventory (Horvath & Greenberg, 1989). T1= Time Point 1; T2= Time Point 2; T3= Time Point 3.

Sample Reference and country

Table 1. (Continued)

Therapy

Design

Attachment measure

Alliance measure

Outcome measure

Key findings

Correlation /effect size (r)

Therapist Attachment, Alliance and Outcome

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55 which participants were randomly assigned to one of two therapy groups, although the data were combined and analysed across groups. The majority of the studies (n = 7) assessed the alliance in one-to-one therapy, two studies delivered multimodal therapy (one-to-one and group therapy) and one study assessed the alliance in a psychiatric case management programme. The therapeutic orientations reported in the studies (n = 9) were varied and included psychodynamic, psychoanalytic, humanistic, existential, cognitive, cognitive–behavioural, cognitive–analytic, eclectic, systemic or family, and interpersonal therapies. Five studies included therapists that were recruited from university counselling centres, three from psychiatric hospitals, one from a psychiatric medical centre and one from community services. One survey study recruited accredited psychotherapists and did not specify the type or location of therapy (Black, Hardy, Turpin, & Parry, 2005). The number of reported therapy sessions ranged from 3 (Dunkle & Friedlander, 1996; Ligiero & Gelso, 2002) to 33 (Wiseman & Tishby, 2014). Five studies used student therapists from university courses, five studies used professional psychotherapists, and one used clinical case managers. Therapists’ level of experience varied within and between studies, with the duration ranging from no experience (Sauer, Lopez, & Gormley, 2003) to 33 years of experience (Petrowski, Nowacki, Pokorny, & Buchheim, 2011). All studies apart from one (Schauenburg et al., 2010) used predominantly female therapists in their sample. Of those studies reporting the ethnicity of the therapists (n = 5), each included therapists from a range of ethnic backgrounds, although in every study, the vast majority were White Caucasian. All 10 studies reported using therapists from a variety of ages, which ranged from 22 to 60 years across the studies. Seven out of the 10 studies reported the clients’ presenting problems; two studies included clients with a range of problems and concerns, and five comprised clients diagnosed with severe psychiatric disorders, including mood/anxiety disorders, eating disorders, personality disorders, psychotic disorders and substance abuse disorders (see Table 1 for more details).

Measurement of Attachment There are two major paradigms in adult attachment research that are associated with different methods of assessment. From a developmental psychology perspective, Main and colleagues devised the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985), which measures attachment ‘states of mind’ on the basis of the coherence, flexibility and completeness of the individual’s narrative in describing parent–child relationships. In the AAI, individuals are classified with respect to attachment Clin. Psychol. Psychother. 23, 47–65 (2016)

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56 as secure-autonomous, insecure-dismissive (a type of avoidant attachment) or insecure-preoccupied (a type of anxious attachment). These three categories are analogous to those originally identified by Ainsworth et al. (1978). A fourth disorganized-unresolved classification was later identified, which is associated with loss, abuse or trauma and characterized by a confused narrative. Both Kobak (1989) and Waters et al. (2005) have developed methods of calculating continuous scores from the AAI. Kobak (1989) describes two attachment dimensions: autonomous versus non-autonomous and deactivation versus hyperactivation. The latter dimension places greater emphasis on emotion regulation strategies as opposed to discourse elements. Individuals high in hyperactivation are preoccupied with attachment relationships, whereas individuals high in deactivation have a tendency be dismissive towards attachment-related relationships (Main & Goldwyn, 1984). Waters et al. (2005) describe secure-versus-insecure and dismissiveversus-preoccupied dimensions. The second paradigm is associated with social psychology and assesses individual differences in attachment, predominantly in the context of romantic relationships, through the use of self-report measures. Hazan and Shaver (1987) translated the three categories of attachment in infancy (secure, avoidant and anxious-ambivalent) of Ainsworth et al. (1978) into individual adult attachment styles using brief forced-choice questionnaires. Most researchers now recognize Hazan and Shaver’s paradigm as being too simplistic, and several multi-item Likert-type response scales have been developed that measure the

Figure 2.

original three categories along continuous dimensions. One important development in the self-report tradition was Bartholomew and Horowitz’s (1991) attempt to integrate the two paradigms of attachment research. They argued that Main and colleagues’ dismissive attachment and Hazan and Shaver’s avoidance attachment were measuring two different types of avoidance respectively motivated by defensive self-sufficiency (dismissive avoidance) and avoidance of rejection (fearful avoidance). Bartholomew’s (1990) four-category model incorporates both types of avoidance and defines four attachment patterns (secure, fearful, preoccupied and dismissive) that can also be conceptualized as two intersecting dimensions (model of self and model of others; Figure 2). Most recent research using factor analyses suggests that two orthogonal dimensions underlie self-report measures, which can be conceptualized in affective–behavioural terms (anxiety and avoidance) or cognitive terms (model of self and model of others; Brennan, Clark, & Shaver, 1998). As detailed in Table 1, the reviewed studies used a diverse range of measures to assess therapist global attachment patterns. For ease of interpretation and consistent with most recent adult attachment literature (Brennan et al., 1998), this review organized the findings relating to insecure attachment under the dimensions of anxiety and avoidance. Attachment avoidance includes avoidance (Experiences in Close Relationships Scale [ECRS; Brennan et al., 1998] and Adult Attachment Inventory [AAIn; Simpson, Rholes, & Nelligan, 1992]), dismissive (AAI, Relationship Questionnaire [RQ; Bartholomew & Howowitz, 1991] and Relationship Scales Questionnaire [RSQ; Griffin

Bartholomew’s (1990) model

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Clin. Psychol. Psychother. 23, 47–65 (2016)

Therapist Attachment, Alliance and Outcome & Bartholomew, 1994]), fearful (RQ and RSQ), relationships as secondary and discomfort with closeness (Attachment Styles Questionnaire [ASQ; Feeney, Noller, & Hanrahan, 1994]) and deactivating (AAI). Attachment anxiety includes anxiety (ECRS, AAIn and Adult Attachment Scale [AAS; Collins & Read, 1990]), preoccupied (AAI, RQ and RSQ), preoccupation with relationships and need for approval (ASQ) and hyperactivating (AAI). Higher scores on the latter dimensions indicate greater levels of insecure attachment. Secure attachment includes secure (RQ and RSQ), depend and close (AAS) and confidence (ASQ). Higher scores on these dimensions indicate greater levels of secure attachment.

Measurement of Alliance and Outcome Out of the 11 reviewed studies, six measured only client ratings of the alliance, one assessed only therapist ratings, two measured both therapist and client ratings and one examined therapist and observer ratings. The most common measure of alliance, used in six studies, was the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Only four out of the 11 studies used outcome measures for analyses relating to therapist attachment. For more specific details of alliance and outcome measures used in the reviewed studies, see Table 1.

REVIEW OF STUDY FINDINGS All 11 studies used correlation or regression analyses to examine relationships between therapist attachment, alliance and outcome; nine reported significant findings.

Effects of Therapist Secure Attachment on Alliance Seven of the reviewed studies investigated the effect of therapist secure attachment on the alliance. There is evidence from three studies to support the positive influence of therapist attachment security on the quality of the alliance (Black et al., 2005; Bruck et al., 2006; Dunkle & Friedlander, 1996). Together, these studies found smallto-medium significant positive correlations between therapist attachment security and the alliance, through higher scores on the confidence (ASQ), secure (RSQ) and close (comfortable with intimacy; AAS) dimensions. This result was demonstrated in different settings, including a survey of accredited psychotherapists (Black et al., 2005), an RCT of psychotherapists and outpatients at a psychiatric medical centre (Bruck et al., 2006) and a survey of therapist– client dyads from university counselling centres (Dunkle & Friedlander, 1996). These findings provide preliminary evidence to suggest that more securely attached therapists form stronger alliances with their clients. Copyright © 2014 John Wiley & Sons, Ltd.

57 Two of the studies with significant findings used early session ratings of the working alliance on the WAI; one measured the overall alliance (Bruck et al., 2006), and the other measured its components (Dunkle & Friedlander, 1996). Interestingly, the latter study by Dunkle and Friedlander found that greater therapist comfort in developing close relationships was predictive of the bond component of the working alliance, but not the goal and task components. The authors speculate that interpersonal factors such as attachment-related behaviours might be more important in the early phases when the therapeutic bond is being formed, whereas developing goals and working through tasks may be more relevant later in therapy. However, it is unclear whether these components of the alliance are more relevant later in the therapeutic process, as the alliance was measured early in therapy in both these studies and the third study (Black et al., 2005) measured therapist reports of the therapeutic alliance in relation to their clients in general, rather than a specific client. The significant positive relationships for secure attachment were found when the alliance was rated by both the client (Dunkle & Friedlander, 1996) and the therapist (Black et al., 2005; Bruck et al., 2006). However, although the study by Bruck and colleagues found a significant influence of therapist attachment security on therapist ratings of the alliance, there were no significant findings in relation to the client-rated alliance. One possible explanation for the divergent results might be due to shared method variance inflating the correlations between therapist-reported measures of attachment and alliance. The use of a ‘general’ measure of alliance in Black and colleagues’ study is also problematic as it does not take into account variations in alliance that might be expected when considering therapists’ relationships with different clients. The results in relation to secure attachment are further complicated by the fact that four studies failed to show a direct association between therapist attachment security and the alliance, when rated by clients (Dinger, Strack, Sachsse & Schauenburg, 2009; Petrowski et al., 2011; Schauenburg et al., 2010) and therapists and their supervisors (Ligiero & Gelso, 2002). Two studies (Dinger et al., 2009; Schauenburg et al., 2010) involved relatively large samples that comprised psychiatric inpatients with severe mental health problems; the ongoing and multimodal treatment package they were receiving potentially confounds the specific influence of individual therapist attachment on alliance and outcomes and thus might explain the absence of direct effects in these settings. One study (Petrowski et al., 2011) had a relatively small sample of 59 outpatients and 19 therapists and assessed attachment security using the Waters et al. (2005) method of scoring the AAI, which may not have concurrent validity with other methods of scoring. The only study to measure the observer perspective of the alliance (Ligiero & Gelso, 2002) used therapists’ supervisors as observers Clin. Psychol. Psychother. 23, 47–65 (2016)

58 who may have been biased towards more positive alliance. This study also sampled student therapists who may have had relatively limited experience to objectively rate alliance and/or be less ‘open’ about or aware of their own levels of insecure attachment (Ligiero & Gelso, 2002).

Effects of Therapist Secure Attachment on Outcome Out of the 11 reviewed studies, two (Bruck et al., 2006; Schauenburg et al., 2010) measured the relationship between therapist attachment security and outcomes; both used professional therapists and patients with psychiatric disorders. Consistent with their findings in relation to alliance, Bruck and colleagues demonstrated a direct relationship between therapist attachment security and improved outcomes, whereby higher therapist attachment security (RSQ secure) moderately correlated with improved patient interpersonal problems and target complaints following therapy. Although Schauenburg et al. (2010) found no direct influence of therapist attachment security on alliance or outcome, dimensional therapist attachment security on the AAI interacted with patients’ pre-therapy impairment to predict retrospective client-rated alliance. Specifically, therapists with higher attachment security had better alliances with patients who reported greater interpersonal distress and symptom load pre-therapy. Higher therapist attachment security diminished the negative impact of patient-rated pre-therapy symptoms on post-therapy symptoms. Together, their findings suggest that more securely attached therapists are better able to adapt their behaviour in order to appropriately fit the needs of more severely impaired patients, which facilitates improved alliance and outcomes. However, the opposite was found for therapist-rated outcome measures, whereby more secure therapists had better retrospective alliances when treating clients who they rated as less severely impaired pre-therapy.

Effects of Therapist Insecure Attachment on Alliance Ten of the 11 reviewed studies measured the relationship between therapist attachment insecurity and alliance, but only three found that therapist insecure attachment styles were associated with the quality of the alliance (Black et al., 2005; Dinger et al., 2009; Sauer et al., 2003). Black et al. (2005) found small negative correlations between therapist insecure attachment dimensions and ‘general’ alliance to suggest that high therapist attachment avoidance (ASQ discomfort with closeness and relationships as secondary) and anxiety (ASQ need for approval and preoccupation with relationships) both have a detrimental effect on therapists’ perspectives of alliance with their clients. Evidence from two longitudinal studies (Dinger et al., 2009; Sauer et al., 2003) suggests that therapist attachment Copyright © 2014 John Wiley & Sons, Ltd.

A. Degnan et al. anxiety can have a negative effect on the development of the client-rated alliance. Sauer et al. (2003) found that therapist attachment anxiety was positively related to firstsession client-rated alliance but demonstrated a negative influence on the alliance as therapy progressed, resulting in significantly lower alliance quality in later sessions. The authors hypothesize that anxiously attached therapists (AAIn anxiety) receive high initial ratings of the working alliance because they make extra efforts to ensure that the client feels good about the therapeutic relationship in attempts to fulfil their own attachment needs. Despite attempts to replicate these findings, Dinger et al. (2009) showed that higher therapist attachment anxiety (AAI dismissing–preoccupied) was associated with lower overall alliance quality and the expected decline of alliance quality over the course of therapy was only demonstrated in anxiously attached therapists treating patients who were interpersonally distressed before therapy. In contrast to Sauer and colleagues, Dinger and colleagues found that all patients had an initial increase in alliance ratings, not only those with higher attachment anxiety. The authors propose that therapists with higher degrees of attachment preoccupation have a tendency to display hyperactivating attachment behaviours, such as clinging and minimizing distance, due to fear of abandonment and desire for closeness, which might lead the client to experience the therapeutic alliance more negatively. The inconsistent findings might be attributed to differences in methodological approaches. First, the studies used different attachment measures (self-reported AAIn versus AAI) that likely tap into different attachment constructs. Second, Dinger and colleagues measured the alliance on a weekly basis, which is a more sensitive measurement of alliance development when compared with Sauer and colleagues’ measure that rated the alliance after three early therapy sessions. Third, the relationship dynamics are likely to be different in Dinger and colleagues’ study, which comprised psychotherapists and psychiatric inpatients undergoing multimodal treatment, compared with Sauer and colleagues’ sample of volunteer therapist–client dyads in individual psychotherapy at university and community counselling centres. The majority of studies (n = 9) failed to find a direct association between therapist insecure attachment and alliance, when rated by either clients (Bruck et al., 2006; Dunkle & Friedlander, 1996; Petrowski et al., 2011; Romano et al., 2008; Schauenburg et al., 2010; Tyrell et al., 1999) or therapists (Bruck et al., 2006; Ligiero & Gelso, 2002; Sauer et al., 2003). Three of these studies reported null findings in relation to both therapist secure attachment and therapist insecure attachment (Ligiero & Gelso, 2002; Petrowski et al., 2011; Schauenburg et al., 2010) and the limitations of these are discussed in the previous section. Two of these studies found evidence of associations with therapist secure attachment and alliance, but not insecure attachment Clin. Psychol. Psychother. 23, 47–65 (2016)

Therapist Attachment, Alliance and Outcome and alliance (Bruck et al., 2006; Dunkle & Friedlander, 1996). Bruck et al. (2006) sampled a relatively small number of patients and therapists (n = 26), and therefore, Type 1 errors cannot be ruled out. As discussed above, the authors also only found effects for therapist ratings of alliance, which are likely to be inflated due to common method variance. Dunkle and Friedlander’s (1996) study had a larger sample of 73 patients and staff, but although associations between insecure attachment dimensions approached significance in the final regression model predicting alliance, a greater proportion of the variance was explained by therapists’ secure attachment. Three of the studies with null findings in relation to therapist insecure attachment did not measure or report therapist attachment security (Romano et al., 2008; Sauer et al., 2003; Tyrell et al., 1999). Romano et al. (2008) speculated that their non-significant results were due to the sample of clients with less severe problems, whose levels of distress might have been too low to activate the attachment systems of both members of the dyad. The therapists in the Tyrell et al. (1999) study were psychiatric case managers who had relatively long-standing relationships with patients; thus, findings may not be generalizable to more traditional therapeutic relationships. As discussed above, Sauer et al. (2003) found effects for insecure attachment and alliance when rated by clients, but not therapists. Akin to the study by Ligiero and Gelso (2002), the therapists in the latter study were relatively inexperienced and therefore may lack objectivity in rating alliance.

Effects of Therapist Insecure Attachment on Outcome Four studies (Bruck et al., 2006; Schauenburg et al., 2010; Tyrell et al., 1999; Wiseman & Tishby, 2014) examined the relationship between insecure attachment and outcome. However, in line with the findings in relation to secure attachment, only the study by Bruck et al. (2006) showed a direct link between therapist insecure attachment and poorer outcomes, when rated by patients with severe psychiatric disorders and their therapists. In their study, small-to-medium correlations showed that higher therapist attachment anxiety (RSQ preoccupied) was related to worse patient-reported global functioning and psychiatric symptoms and higher therapist attachment avoidance (RSQ fearful and dismissing) was related to reductions in patient-reported global functioning and greater interpersonal problems, as rated by both patients and therapists.

Interaction Effects between Therapist and Client Attachment on Alliance and Outcomes The absence of a direct effect of therapist attachment on alliance and outcomes in the reviewed studies might be Copyright © 2014 John Wiley & Sons, Ltd.

59 explained by findings of significant interactions between therapist and client attachment patterns to produce a combined influence on the alliance and outcomes. Three studies investigated interaction effects and alliance (Bruck et al., 2006; Petrowski et al., 2011; Tyrell et al., 1999) and three studies examined interactional effects and outcomes (Bruck et al., 2006; Tyrell et al., 1999; Wiseman & Tishby, 2014). All six studies found some evidence of effects. Two additional studies assessed the attachment styles of both clients and therapists but failed to find interaction effects (Romano et al., 2008; Sauer et al., 2003). Although the Tyrell et al. (1999) study found no direct influence of therapist attachment deactivation (AAI deactivating–hyperactivating) on working alliance and patient outcomes, it showed that the attachment style of therapists and clients interact to produce a combined effect on alliance and outcome. Results suggested that less deactivating therapists with respect to attachment formed stronger alliances when working with more deactivating patients than with less deactivating patients. In terms of outcomes, it was found that more deactivating patients reported higher general life satisfaction when working with less deactivating therapists. This study suggests that matching therapists and patients with dissimilar attachment styles (i.e., avoidant versus anxious) can enhance the therapeutic relationship and lead to more positive therapeutic outcomes. On the basis these findings, Tyrell and colleagues highlight the importance of balancing the interpersonal and emotional strategies of client and therapist and of taking into account both attachment states of mind when building the therapeutic relationship. They argue that a ‘mismatch’ of therapist and client attachment styles enables the disconfirmation of the clients’ usual interpersonal and emotional strategies and the adoption of novel and more functional behaviours that serve positive therapy outcomes. However, as discussed above, their study involved a community sample of case managers and patients with several psychiatric disorders, rather than therapists and clients in the context of psychotherapy relationships. Furthermore, as the vast majority of therapists in this study were rated as secure, the autonomous–non-autonomous dimension (AAI) was excluded from the analysis. Bruck et al. (2006), as discussed previously, also investigated the degree to which interactions between therapist and client attachment styles on the RSQ predict the working alliance and outcome. Consistent with Tyrell et al. (1999), they found that greater dissimilarity between therapist and client attachment styles determines better alliance and outcome. More specifically, greater differences between therapist and client self-reported secure attachment styles (RSQ secure) rated pre-therapy were associated with improvements in the working alliance and patient interpersonal problems, global functioning and symptomatic distress, as reported by therapists postClin. Psychol. Psychother. 23, 47–65 (2016)

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60 therapy. In addition, greater differences in avoidant attachment styles (RSQ fearful and dismissive) were associated with improvements in therapist-reported global functioning, client-rated psychiatric symptoms and target complaints reported by both clients and therapists, and greater dissimilarity in attachment anxiety (RSQ preoccupied) was related to improvements in therapist-reported global functioning. However, in contrast to their findings with regard to secure attachment, they did not find any significant influence of dissimilarity in therapist and client insecure attachment styles on the working alliance. Therefore, the beneficial effects of dissimilarity in attachment style in terms of the alliance were based exclusively on therapists having more secure attachment styles relative to patients, which suggests that the more secure the therapists are relative to the patient, the better the working alliance. Petrowski et al. (2011) attempted to replicate the latter findings in a sample of professional psychotherapists and anxiety outpatients. In line with Tyrell and colleagues, the results showed no direct influence of therapist attachment style on the alliance, but therapist and patient attachment dimensions on the AAI interacted to predict the client-rated helping alliance. Patients with higher insecure attachment (AAI secure–insecure) evaluated the alliance with therapists higher in avoidant attachment (AAI dismissing–preoccupied) as more satisfying than therapists higher in anxious attachment (AAI dismissing– preoccupied). This would suggest that anxious clients with high attachment insecurity establish better alliances with therapists who are more avoidant with respect to attachment. Interestingly, the opposite interaction effect did not occur; more securely attached therapists (AAI secure–insecure) did not have stronger alliances with either more avoidant or anxious patients (AAI dismissing– preoccupied). Petrowski and colleagues assert that highly insecure patients with ambivalent and disorganized attachment experiences characterized by unresolved trauma would probably benefit from working with a nonintrusive and more dismissing therapist. Such therapists, they argue, would provide a corrective and predictable emotional experience and facilitate the adoption of an autonomous role to cope with attachment threats. Wiseman and Tishby (2014) did not assess therapeutic alliance but explored interactions between therapist and client attachment anxiety and avoidance scores (on the ECRS) on outcomes in psychodynamic therapy in university counselling centres. These authors found that therapist avoidant attachment moderated the association between client avoidant attachment and outcome. More specifically, when treated by low-avoidant therapists, low-avoidant clients were likely to experience greater improvements in symptoms than high-avoidant clients treated by low-avoidant therapists. This finding is in contrast to the above studies, as it suggests the benefits of Copyright © 2014 John Wiley & Sons, Ltd.

similarity of client and therapist attachment, although only in the case when therapists and their clients are both low in avoidance. The authors highlight that their contrasting findings may be accounted for by the relatively low levels of insecure attachment in their therapist sample compared with other studies, but the use of different attachment measures across studies means it is difficult to compare samples. From the results thus far, conclusions cannot be drawn in relation to the interaction between therapist and client attachment styles and their effects on the alliance and outcome. The three earlier studies (Bruck et al., 2006; Petrowski et al., 2011; Tyrell et al., 1999) pointing to the beneficial effects of a mismatch each had methodological issues and inconsistent findings. It does not make intuitive sense that an insecure attachment style in the therapist could be beneficial to an alliance with the client. One might predict that configuration in differing insecure styles would lead to relationship distress (where each person confirms the other’s worst fears about close relationships), and Wiseman and Tishby’s (2014) recent study would seem to support this hypothesis. However, two of the earlier studies (Bruck et al., 2006; Petrowski et al., 2011) assessed attachment dimensionally, rather than categorically. This means that a ‘mismatch’ could involve, for example, a highly preoccupied client with a therapist who would be classified as securely attached in a categorical system but might be slightly on the dismissing end of a continuum. Therefore, a ‘mismatch’ between client and therapist attachment does not indicate that the therapist is insecurely attached or that the ‘mismatch’ is so dramatic that it would cause relational distress. Although attachment security is likely to be most important in terms of allowing the therapist to adapt their interpersonal style, a ‘mismatch’ may make it easier for the therapist to gradually shift into an attachment style that challenges maladaptive patterns associated with the client’s insecure attachment style. Daly and Mallinckrodt (2009) found that experienced therapists adopt a strategy with insecurely attached clients in which they initially ‘go along with’ the client’s interpersonal patterns to promote engagement (e.g., remaining relatively distant with a dismissing client) and gradually adapt the therapeutic distance in order to challenge the client’s attachment insecurity.

DISCUSSION The above review provides a synthesis of research that examines the influence of therapist attachment style on the alliance and outcome. In summary, although there was some evidence that therapist attachment style is important to alliance and outcomes, the findings are by no means consistent across the reviewed studies. Of the seven studies that measured attachment security, only Clin. Psychol. Psychother. 23, 47–65 (2016)

Therapist Attachment, Alliance and Outcome three demonstrated associations between therapist attachment security and therapeutic alliance. Ten of the 11 reviewed studies measured the impact of therapist insecure attachment dimensions on the alliance. Results from two studies suggest that anxiously attached therapists establish poorer working alliances with their clients. One additional study demonstrated that therapist attachment anxiety is positively related to the alliance early in therapy but has a negative effect on the alliance over time. There was only evidence from one study to show that therapist attachment avoidance has a negative effect on the quality of the alliance, but this study assessed ‘general’ alliance across all cases as opposed to alliance in one specific therapeutic relationship. Out of four studies, just one found a direct impact of therapist attachment style on therapeutic outcomes; therapist attachment security was related to improved outcomes, and therapist attachment avoidance and anxiety were individually associated with worse outcomes. However, preliminary findings suggest that these relationships may not be straightforward and that therapist attachment styles and client factors interact to influence the alliance and outcomes. Two of the reviewed studies showed that therapist attachment style has a greater influence on alliance and outcomes when clients have more severe presentations. In one study, therapist secure attachment predicted better alliance and outcome in more severely impaired patients. The other study showed that therapist attachment anxiety negatively affects the development of the alliance when treating more interpersonally distressed clients. Finally, results from three studies may suggest that matching therapist and client with dissimilar attachment styles is beneficial in terms of more positive therapeutic alliance and outcomes. However, the exact nature of this ‘matching’ varied across studies, with one more recent study even finding evidence for therapist and client similarity leading to better outcomes, at least in the case of low attachment avoidance. A critical appraisal of studies highlights that the lack of consistent findings across studies and the null findings cannot be taken at face value. Limitations of the individual studies have been highlighted in the body of the review in an attempt to explain discrepant findings. Here, we summarize the limitations with a view to guiding future researchers in designing studies in this area.

Methodological Considerations Of most importance concerns the diverse range of validated tools used to measure attachment and alliance, which potentially tap into different constructs. Seven studies used different measures from the self-report tradition, and although four studies used the AAI, these were not consistent in the scoring methods used to assess attachment constructs. Self-report measures and interview Copyright © 2014 John Wiley & Sons, Ltd.

61 measures such as the AAI may assess different components of the attachment system and may thus have equal value (Crowell, Fraley, & Shaver, 1999). It is therefore important to carry out research investigating the way in which both measures relate to alliance. Researchers should, however, endeavour to use a consistent method of scoring the measures. Dimensional approaches to scoring may be preferable to categorical measures as the former captures more variation within the data. Researchers should also opt for measures that include a secure dimension and the two main forms of insecure dimensions (anxiety/preoccupied versus avoidant/dismissing), as all three have been associated with alliance. Similar discrepancies were apparent in the measurement of alliance (Catty, 2004). Even when the wellestablished WAI was used, it was scored differently across the six studies, and only three measured its individual components (goal, task and bond). As a result, it is unclear what aspects of the alliance are most relevant in therapist attachment and psychotherapy literature. Early findings (Dinger et al., 2009; Dunkle & Friedlander, 1996) suggest that the bond component is most influenced by therapist attachment behaviours; however, these interpretations are tentative and are based on studies with different alliance measures. Moreover, results are discrepant across and within the reviewed studies depending on the perspective of the alliance. For example, two out of the four studies that used therapist-rated alliance showed significant associations between therapist attachment and alliance (Black et al., 2005; Bruck et al., 2006). However, although Bruck and colleagues found an influence of therapist attachment on therapist reports of alliance, they failed to find any effects for the client-rated alliance. As discussed above, significant findings in relation to therapist reports of the alliance and outcomes must be treated with caution due to shared method variance, and future studies should measure alliance from the client perspective or observer perspective to avoid this potential confound. The reliability of alliance reports may be particularly problematic in clients or therapists with insecure attachment patterns. For example, people with avoidant attachment styles might report positive alliances due to a lack of insight into their inabilities to develop interpersonal relationships, and those with anxious attachment styles might report stronger alliances in response to the importance they assign to attachment relationships and desiring to be closer to others. It would be beneficial for future studies to draw comparisons between observer, therapist and client perspectives of the alliance as well as the alliance ratings of different attachment groups. There are also issues with the samples used across the studies. Most studies have relatively small sample sizes, which restricts the generalizability of findings and increases the possibility of Type II errors. Even in studies Clin. Psychol. Psychother. 23, 47–65 (2016)

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62 with large samples of clients (Dinger et al., 2009; Schauenburg et al., 2010), there is an issue of nonindependence in the data where therapists treated more than one client, and significance levels may be inflated as a result. Another limitation concerns the high attrition rates in cohort studies (Bruck et al., 2006; Sauer et al., 2003) and low response rates in survey studies (Black et al., 2005; Dunkle & Friedlander, 1996), which reduce the number of representative dyads with complete data in the analyses and introduce bias in terms of better quality alliance and outcomes. Although common in clinical settings, future studies can control for this by including all participants in the analysis or following up on participants who disengage from therapy. More than half of the reviewed studies (Dinger et al., 2009; Dunkle & Friedlander, 1996; Ligiero & Gelso, 2002; Romano et al., 2008; Sauer et al., 2003) included therapists who were undergoing training and thus presumably learning how to be more responsive and adapt their interpersonal styles to meet their clients’ needs and benefit the alliance. This means that findings may not generalize to more experienced clinicians. Similarly, therapeutic orientation differed within and across the reviewed studies. Therapists with different therapeutic orientations may approach therapeutic relationships differently on the basis of their underlying theoretical models. Future studies should therefore report the level of training or therapeutic orientations and, where appropriate, control for these in the analyses. Studies also varied in terms of the therapeutic setting (inpatient versus outpatient) and the severity of patients’ problems. It is therefore important for future research to also report and control for clinical setting and severity of problems. Assessing the effects of therapist attachment style on alliance and outcome is further complicated by the fact that most therapists were rated as more securely attached than the clients and the majority were classified as ‘secure’ (Bruck et al., 2006; Dinger et al., 2009; Ligiero & Gelso, 2002; Schauenburg et al., 2010; Tyrell et al., 1999). This is in line with previous research (Montagno, Svatovic, & Levenson, 2011) showing that the majority of therapists have lower than national norms on selfreports of attachment avoidance or anxiety. Although this is expected in a study of healthy therapists, future research would benefit from using larger samples of therapists with variations in the degree of attachment measured on continuous dimensions to overcome problems with floor effects in attachment measures. Limited variation in attachment is problematic as it makes the effects of therapist attachment style difficult to detect. This bias might partially explain why there are more mixed findings in the empirical literature on therapist attachment compared with client attachment, where variations in client attachment styles predict variations in therapy outcome (Smith et al., 2010). Copyright © 2014 John Wiley & Sons, Ltd.

Another important factor to consider in designing future studies is the different time points in which the alliance was rated. As the quality of the therapist–patient relationship is likely to change over time, the impact of therapist attachment on the alliance may differ depending on when the alliance is assessed. Two studies that assess alliance at multiple time points indicate that the alliance is initially high and then declines over the course of therapy (Dinger et al., 2009; Sauer et al., 2003). One cannot guarantee exactly when the measures were completed in studies where participants were sent surveys, despite requests for the measures to be completed at specific time points (Dunkle & Friedlander, 1996; Ligiero & Gelso, 2002). Inferences cannot be made about the influence of time when participants are asked to make one-off retrospective ratings (Petrowski et al., 2011; Schauenburg et al., 2010) or asked to comment on ‘general’ alliance across all cases (Black et al., 2005). Multiple weekly alliance ratings are more sensitive measures than singlepoint retrospective ratings, which are also likely to be influenced by outcomes. Future studies should, therefore, adopt a prospective design to assess differences in therapist attachment styles in terms of the development of alliance over the entire treatment duration, in addition to the quality of the alliance at single time points. On the basis of the available evidence, one cannot conclude that therapist characteristics caused positive or negative changes in alliance or outcomes. Associations between attachment, alliance and outcomes are most likely dynamic and bidirectional, with alliance also exerting an influence on therapist attachment behaviours. However, the precise nature of the associations between alliance and outcomes requires the use of longitudinal designs controlling for potentially important confounds. Finding ways to predict and facilitate positive therapy outcomes is essential in psychotherapy research. Despite this, the present review indicates that very few studies have measured the impact of therapist attachment on outcome. Future studies should therefore administer outcome measures to examine how attachment and alliance interact and systematically relate to therapeutic outcomes.

Clinical Implications Despite the pressing need for more methodologically rigorous studies investigating associations between therapist attachment and alliance, this review suggests that there is some preliminary evidence that therapists’ attachment security may impact on the therapeutic alliance. There is some evidence that the therapeutic bond aspect of alliance may be most affected by attachment security and that adverse effects of therapist attachment insecurity on client perceptions of alliance may be more evident in therapy with more complex clients. Therapist insecure attachment anxiety may be more important Clin. Psychol. Psychother. 23, 47–65 (2016)

Therapist Attachment, Alliance and Outcome than avoidance, but one cannot rule out the impact of attachment avoidance due to methodological problems with the studies reviewed. Given that there is some evidence for associations between therapist attachment and alliance, therapists do need to be sensitive to their own attachment experiences and how these play out when delivering therapy. Improved knowledge of one’s own attachment style through training courses and supervision might help therapists to understand attachment-related behaviours in therapy, guide intervention, pace sessions and deal with any ruptures in therapeutic relationships (Wallin, 2009). The finding that associations between attachment and alliance were evident in some therapists earlier on in their training suggests that attachment issues need to be on training and supervision ‘agendas’ from the outset of therapists’ careers. This review provides some preliminary evidence to suggest that it is important to consider the interaction between client and therapist attachment styles for a good therapeutic alliance. However, on the basis of the reviewed studies and the discussed methodological issues, it is unclear whether matching (or mismatching) therapist and client attachment styles is beneficial. It makes intuitive sense that therapist insecure attachment style would adversely affect the therapeutic alliance and the delivery of effective interventions. However, a ‘mismatch’ between client and therapist attachment may allow the therapist to challenge maladaptive patterns associated with the client’s insecure attachment style. The ability of securely attached therapists to adapt their interpersonal style to meet the attachment needs of the clients at different points in the therapeutic process is likely to be optimal for positive outcome. A fruitful avenue for psychotherapy research would be to determine how therapists would utilize greater knowledge of their individual attachment style to facilitate the formation of alliance with their clients. Mallinckrodt (2010) asserts that therapists should initially match the client’s interpersonal style to facilitate engagement and then as therapy progresses create a mismatch to explore and challenge their interpersonal style. Research on couples therapy suggests that therapist insecure attachment style can change following emotionfocused training (EFT; Montagno et al., 2011). EFT (Palmer-Olsen, Gold, & Woolley, 2011) teaches therapists to pay attention to their emotion and attachment processes during therapy. Depth of therapist emotional processing in sessions has been found to predict better therapeutic outcomes in both cognitive–behavioural therapy and interpersonal therapy (Coombs, Coleman, & Jones, 2002). Working with emotions is likely to elicit attachment discomfort in insecurely attached therapists, triggering avoidance in avoidant attached therapists and over-involvement in more anxiously attached therapists. Findings pointing to positive associations between secure Copyright © 2014 John Wiley & Sons, Ltd.

63 attachment and improved outcomes may be mediated, at least in part, by skill and comfort with emotional and interpersonal processing in sessions. Future work like this is needed to develop training programmes for therapists to be skilled in exploration of their own and their client’s attachment styles and how they interact to produce more positive alliance and outcome.

CONCLUSIONS The present review provides a synthesis and critical appraisal of research that examines associations between therapist attachment styles and therapeutic alliance and/or outcome. There is some preliminary evidence that therapist attachment may be associated with alliance, which would justify the pursuit of further research in this area and a consideration of therapists’ own attachment styles in therapeutic practice from the outset of clinical training. However, a critical appraisal of the existing studies indicates methodological problems, and the authors therefore call for more methodologically rigorous studies to strengthen the existing literature.

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The Role of Therapist Attachment in Alliance and Outcome: A Systematic Literature Review.

This review examined the impact of therapist attachment style on therapeutic alliance and outcomes...
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