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Trauma Group Therapy: The Role of Attachment and Therapeutic Alliance, by Karina P.M. Zorzella, M.A., Robert T. Muller, Ph.D., and Catherine C. Classen, Ph.D. Estimated Time to Complete this Activity: 90 minutes Learning Objectives: The reader will be able to: 1. Describe common relational patterns demonstrated by traumatized clients. 2. Describe how attachment impacts therapeutic alliance in trauma group therapy. 3. Describe how attachment can affect the perception of group climate in trauma group therapy. Author Disclosures: Karina P.M. Zorzella, Nothing to Disclose Robert T. Muller, Nothing to Disclose Catherine C. Classen, Nothing to Disclose

INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 64 (1) 2014 ZORZELLA ET AL. TRAUMA GROUP THERAPY

Trauma Group Therapy: The Role of Attachment and Therapeutic Alliance KARINA P. M. ZORZELLA, M.A. ROBERT T. MULLER, PH.D. CATHERINE C. CLASSEN, PH.D.

ABSTRACT Attachment has increasingly been identified as central to therapy process and outcome. Attachment theory proposes that an individual’s prior interactions with attachment figures develop into templates that will guide the way they form connections and perceive their relationships with others. This study examined clients’ ratings of their relationship with the therapist as well as their ratings of group climate at multiple discrete points during treatment. These variables were examined in relation to attachment classification prior to therapy. Participants were 62 women attending the Women Recovering from Abuse Program (WRAP), a primarily group-based day-treatment program for childhood interpersonal trauma, at Women’s College Hospital in Toronto, Ontario, Canada. Results demonstrated that clients’ perceptions of relationships in group therapy varied as a function of attachment classification.

A

ttachment has emerged as an important factor associated with therapy process and outcome (Davila & Levy, 2006). In the context of trauma, attachment has received increased attention in

Karina P. M. Zorzella and Robert T. Muller are affiliated with the Department of Psychology at York University in Toronto, Canada. Catherine C. Classen is with the Women’s College Research Institute in Toronto and the Department of Psychiatry at the University of Toronto.

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the literature as childhood abuse is thought to disturb attachment (Muller & Rosenkranz, 2009) and consequently compromise an individual’s capacity to relate to others in a meaningful way (Herman, 1992; Pearlman & Courtois, 2005). Attachment theory proposes that the child’s early interactions with caregivers develop into templates that guide the way the individual forms connections and perceives relationships with others. Since people with different attachment patterns engage in relationships differently, attachment is likely to color the connection that clients form with their therapists. Research has shown that clients’ attachment patterns influence the quality and development of the therapeutic alliance over time (Daniel, 2006). Considering that childhood abuse occurs within relationships and healing is only possible in the context of trusting relationships, it is important to understand the factors that might influence the quality and development of the therapeutic relationship in trauma therapy. The purpose of the current study was to examine therapeutic alliance in the context of trauma group therapy, as a function of clients’ attachment classification. The adult attachment classification system was developed based on studies using the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985) and comprises three main categories: free-autonomous (secure), dismissing (avoidant), and preoccupied (resistant/anxious/ambivalent). The unresolved classification (disorganized) was given to individuals who demonstrated lack of resolution with respect to the loss of an attachment figure, or to other traumatic events, in the AAI (Main & Goldwyn, 1991/1998). ATTACHMENT AND CHILDHOOD TRAUMA

Attachment difficulties have long been reported in trauma studies. Studies have pointed to a high prevalence of insecure attachment in abused and neglected children (Carlson, Cicchetti, Barnett, & Braunwald, 1989; Egeland & Sroufe, 1981), formerly maltreated individuals (Muller & Lemieux, 2000), and adult incest survivors (Alexander et al., 1998). Similarly, the high incidence of unresolved attachment among individuals with a history of childhood abuse, and its association with severe psychopathology, have led



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to further investigation of this particular classification (Bailey, Moran, & Pederson, 2007; Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004; Fonagy et al., 1996; Liotti, 2004; Pearlman & Courtois, 2005). Research suggests that the failure to consolidate memory following trauma underlies the development of PTSD and the lack of coherent speech, characteristic of unresolved states of mind (Stovall-McClough & Cloitre, 2003). Individuals with unresolved attachment patterns and a history of trauma often have highly dysregulated emotions, dissociative behaviors, and disjointed interactional patterns (Pearlman & Courtois, 2005). Unresolved attachment is also related to psychopathology, including borderline personality disorder (BPD), dissociative symptoms, anxiety disorders, emotional distress, and suicidal behaviors (Bailey et al., 2007; Cloitre et al., 2004; Fonagy et al., 1996; Patrick, Hobson, Castle, Howard, & Maughan, 1994). Unresolved attachment in women with a history of childhood abuse is also thought to predict posttraumatic stress disorder and to be associated with severe symptoms (Cloitre et al., 2004). TREATMENT RELATIONSHIPS IN TRAUMA THERAPY

Individuals with a history of childhood abuse demonstrate interpersonal difficulties that stem from a disturbed sense of self and other (Muller, Lemieux, & Sicoli, 2001), which in turn influence their capacity to form a strong alliance with the therapist (Pearlman & Courtois, 2005). Finding safety in relationships can be a challenge for them and they often re-enact themes of powerlessness, shame, guilt, distrust, and abusive patterns within the therapeutic relationship (Herman, 1992; Tyson & Goodman, 1996). Re-experiencing dissociated traumatic experiences can suddenly disrupt their awareness and self-regulation, and this might also lead to interpersonal difficulties (Hegeman & Wohl, 2000). Alexander and Anderson (1994) described relational patterns and difficulties commonly displayed by traumatized clients from different attachment groups, which are likely to influence the developing alliance in individual therapy. Secure clients are better able to express emotions and resolve interpersonal conflicts, and they show higher self-esteem. Preoccupied clients demonstrate dependence and neediness, and they are prone to strong emo-

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tional reactions such as anxiety and anger. Dismissing (avoidant) clients exhibit discomfort with intimacy and denial of distress. Unresolved (disorganized) clients present higher levels of disorganization, distress and depression, dissociation, and difficulties with impulse control. When interactions with caregivers involve prolonged experiences of abuse, a “traumatic bonding” between victim and victimizer might develop as caregivers are a source of both care and abuse. The development of propitious therapeutic alliance is deemed central to positive therapy outcome in individual therapy (Horvath & Luborsky, 1993). The importance of a strong alliance in group therapy has been demonstrated (MacKenzie, 1983; Piper, Ogrodniczuk, Lamarche, Hilscher, & Joyce, 2005), and, in fact, therapeutic alliance may be as instrumental in group therapy as it is in dyadic therapeutic relationships (Mallinckrodt, Coble, & Gantt, 1995). The multilevel interactions in group therapy require a different perspective on the concept of alliance (MacKenzie, 1997; Muran & Barber, 2010; Yalom, 2005), and it is important to examine not only how group members experience their relationship with the therapist but also how they experience other group dynamics that unfold in the group context (MacKenzie, 1983). Clients’ perception of group dynamics is also thought to reflect their early attachment patterns. Prior research showed that while anxiously attached individuals pursued security–love goals in their interactions with group members and were oversensitive to threats and cues of rejection, individuals with high levels of attachment avoidance pursued distance and self-reliance goals in their interactions and held a negative view of group members (Rom & Mikulincer, 2003). It has also been suggested that group cohesion weakens the effects of members’ attachment anxiety and exacerbates the effects of members’ avoidance during group tasks. That is, the presence of a sense of attachment security in the group relationships is associated with a reduction of activating strategies in the anxious group and an increase of deactivating strategies and dismissal of supportive behaviors in the avoidant group. Similarly, Chen and Mallinckrodt (2002) demonstrated that high levels of avoidance were associated with low levels of attraction to the group and increased levels of hostility and disengagement from group members.



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Group climate is a concept that has been widely studied in group psychotherapy and refers to the attributes of the group environment, as perceived by group members, that promote or hinder the efforts of its members to reach specific goals (Burlingame, MacKenzie, & Strauss, 2003; Johnson, Burlingame, Olsen, Davies, & Gleave, 2005; MacKenzie, 1983; Tschuschke & Greene, 2002). It is measured by examining group members’ perception of engagement, conflict, and avoidance in the group as a whole. In the current study, we investigated trauma clients’ perception of their relationship with the therapist and of group climate over the course of group therapy, and how this related to pre-therapy client attachment classification. TERMINATION

Bowlby’s (1979) ideas regarding reactions to separation and loss can help explain typical reactions displayed by clients faced with therapy termination. Hammond and Marmarosh (2011) demonstrated that anxiously attached individuals relied on hyperactivating strategies (e.g., intense cries of distress and strong effort to obtain comfort), and avoidantly attached individuals resorted to deactivating strategies (e.g., denial of painful feelings associated with loss, devaluing importance of relationship) to cope with therapist loss in group therapy. Similarly, a study by Kanninen, Salo, and Punamäki (2000) showed that perception of alliance became more negative towards the end of therapy for dismissing individuals undertaking trauma group therapy. The authors suggested that this might reflect their difficulty with the upcoming separation and their need to deny stress and devalue the relationship that they would soon lose. THE CURRENT STUDY

In the current study, we examined whether trauma clients’ experience of their relationship with the therapist and their perception of the group climate differed over the course of a group-based treatment program as a function of pre-therapy attachment classification. We hypothesized that clients’ experience of in-treatment

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relationships will vary as a function of their attachment classification, with secure individuals demonstrating a more positive experience compared to insecure individuals. Considering that preoccupied clients are generally characterized as dependent and prone to strong emotional reactions (Alexander & Anderson, 1994), we expected a notable fluctuation in their perception of treatment relationships. In the dismissing group, we expected a relatively stable pattern from the beginning to the middle of group therapy with a decrease towards the end, as demonstrated by previous research (Kanninen et al., 2000). With respect to the unresolved group, we expected lower ratings of treatment relationships over the course of therapy in comparison to clients with other attachment classifications. We hypothesized that the high levels of disorganization associated with the unresolved attachment classification would interfere with their perception of intreatment relationships. METHOD Participants

Participants were 62 women 18 years or older (mean of 40 years; range 24–64) with a history of childhood abuse, who self-referred to WRAP – Women Recovering from Abuse Program (Classen et al., 2009; Duarte-Giles et al., 2007) at Women’s College Hospital in Toronto, Ontario. Women attending WRAP struggle with coping in their daily lives, and they report a variety of mental health difficulties as well as unsuccessful previous experiences with the mental health system (Duarte-Giles et al., 2007). The inclusion criteria specified that participants must be at least 18 years old, have a history of childhood trauma, and be considered appropriate for group-based treatment at the time of assessment. This depended on their demonstrated ability to tolerate an intensive interpersonal process as well as prior therapy experience related to trauma or abuse. Exclusion criteria for the program included medical instability, extreme eating disorders, addiction, and suicidal ideation. Fifty-eight percent (n = 293) of 507 women who self-referred met criteria for the program and were invited to participate in



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the research study while they were placed on a waitlist for the program. Of 180 participants who agreed to participate in the study, 80 (44.4%) attended research and clinical assessment sessions and entered WRAP. Participants who completed the attachment assessment and whose attachment recordings were audible and intelligible were included in the analyses (n = 62). Of these 62 participants, 33% of the women were married. With respect to employment, 25% were fully employed, 15% had part-time jobs, and 60% were unemployed. Regarding education, 76% had at least a college diploma. In terms of income, 76% earned less than $40,000. The ethnic composition of the participant group was 54.5% Caucasian, 9.1% African-Canadian, 6.8% Asian, 2.3% First Nations, 2.3% Hispanic, 2.3% Filipino, and 22.7% who designated themselves as “other.” In this sample, participants had experienced multiple types of trauma, which included emotional abuse and neglect (96.5%), sexual abuse (90%), physical neglect (77%), and physical abuse (65.5%). Program

WRAP was designed to address the trauma-related difficulties commonly experienced by women with a history of childhood abuse. WRAP is a stage one treatment model (Herman, 1992) that addresses issues of safety, affect regulation, self-care, stabilization, skill building, education, and support, with the main focus being the here-and-now experience. The WRAP intake model is continuous and slow–open, in which one or two new clients may be starting treatment at the beginning of each week, and one or two clients may be finishing treatment at the end of each week. This model is thought to facilitate the transmission of knowledge through mentorship between senior and new members. Further, it ensures that groups have a sufficient number of participants. This 8-week day treatment program combines distinct group modalities with specific goals such as: addressing individual and group issues to facilitate interpersonal learning; increasing affect regulation skills through psychoeducation and bodily sensation awareness; and developing less destructive ways of thinking and behaving. Clients attend two

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to three groups daily, for four half-days a week, and individual therapy sessions once weekly. Therapy in WRAP was provided by eleven female therapists from the fields of psychology, social work, psychiatry, occupational therapy, art therapy, and nursing. These therapists were predominantly experienced master’s-level clinicians with clinical training with trauma populations. Procedure

Data were collected by master’s-level graduate students at various time points: during two research sessions prior to the clinical assessment sessions, during the course of WRAP, and post WRAP. The attachment assessment was conducted prior to the clinical assessment phase, and the therapeutic alliance and group climate measures were administered at 8 time points after the Community Forum group. This is an open discussion group, led by two co-therapists, that encourages members to express their thoughts and feelings about current life situations and to reflect on relationships they have developed in their lives as well as on relationships in the group. Community Forum is the first group offered each morning during the 8-week period. Because this is an ongoing group and new members join the group at the beginning of each week, clients completed the measures at each of the eight time points in different weeks. Each client completed the alliance measure twice in week 1, once in weeks 3 and 4, twice in week 5, and once in weeks 7 and 8. The group climate measure was completed once in weeks 1 and 2, twice in week 3, once in weeks 5 and 6, and twice in week 7. Although clients attended the Community Forum daily for 8 weeks, totaling 40 sessions in the entire program, each of the measures utilized in this study was administered eight times. This is due to the fact that other process measures, not part of the current study, were also completed by clients after sessions of the Community Forum throughout the program. Measures

Adult Attachment Projective Picture System (AAP). The AAP (formerly known as Adult Attachment Projective; George & West,



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2001, 2008; George, West, & Pettem, 1997) was used to assess participants’ attachment patterns. The AAP is a projective measure, validated against the Adult Attachment Interview (AAI), comprising eight drawings that represent events which activate the attachment system. Research has demonstrated the AAP to be a reliable and valid measure of attachment in clinical and normative samples (George & West, 2001; George et al., 1997). Moreover, it has strong concurrent validity with the AAI (Main & Goldwyn, 1991/1998), and it shares its four major adult attachment classification groups: Secure, Dismissing, Preoccupied, and Unresolved. The inter-judge reliability for secure versus insecure classifications was .93 and for the four attachment groups was .86. AAP–AAI convergence for secure versus insecure classifications was .92 and for the four attachment groups was .85 (George & West, 2001). California Psychotherapy Alliance Scales – Patient Version (CALPAS-P). The CALPAS (Gaston, 1991; Gaston & Marmar, 1993) was used to assess participants’ perception of their relationship with the therapist. The CALPAS comprises four scales, each containing six items and measuring a specific dimension: Patient Commitment (PC); Patient Working Capacity (PWC); Therapist Understanding and Involvement (TUI); and Working Strategy Consensus (WSC). The TUI scale of the CALPAS was administered in order to assess the extent to which clients feel that the therapist understands their suffering and points of view, demonstrates non-judgmental acceptance, intervenes tactfully, does not use therapy for his/her own purposes, and expresses commitment to help them overcome their difficulties. On all six items, clients rate their experience in the therapy session just completed, utilizing a seven-point scale. The CALPAS has been found to be a valid predictor of therapy outcome (Marmar, Gaston, Gallager, & Thompson, 1989; Safran & Wallnar, 1991; Tichenor & Hill, 1989), and has demonstrated concurrent validity with other instruments measuring similar constructs. The alpha coefficients associated with the four CALPAS scales ranged from .43 to .70 and Cronbach’s alpha for the TUI scale was .58. The four scales were moderately correlated, with correlations ranging from .37 to .62, which suggests that they assess four relatively distinct alliance constructs (Gaston, 1991; Safran & Wallnar, 1991; Tichenor

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& Hill, 1989). The alpha coefficients for the TUI scale ranged from .73 to .90 for our sample. Only the TUI subscale was administered in the current study since its primary objective was to examine the relational processes developed between client and therapist. Group Climate Questionnaire (GCQ). The GCQ (MacKenzie, 1983) was used to assess clients’ experience of group functioning and relationships. Rather than measuring clients’ experience and personal relationship to the group, the GCQ measures clients’ experience of the group as a whole. Its twelve items are subdivided into three scales: Engagement, which measures the extent to which a client experiences the group to have a positive working atmosphere and interpersonal involvement as well as connection between members; Conflict, which measures the extent to which a client experiences tension between group members; and Avoidance, which measures the extent to which a client experiences group members to be avoiding important topics. On all twelve items, clients rate their experience in the therapy session just completed on a 7-point scale. This measure has been used in a variety of group settings, and its construct validity has been studied extensively (Burlingame et al., 2003; Johnson et al., 2005; Tschuschke & Greene, 2002). The Cronbach’s alphas for the GCQ subscales ranged from .70 to .94 for Engagement, from .36 to .92 for Avoidance, and from .69 to .88 for Conflict (Johnson et al., 2005; Kivlighan & Goldfine, 1991). For our sample, the Cronbach’s alphas ranged from .61 to .76 for Engagement, from .35 to .63 for Avoidance, and from 65 to .94 for Conflict. RESULTS

Preliminary analysis of the data revealed missing cases that were noticeably larger at time points 7 and 8. More than half of clients with missing data at time points 7 and 8 attended the sessions but failed to complete the measures after the sessions. A higher percentage of missing data was observed in the dismissing group (50%) compared to the unresolved group (31.25%). To retain these cases, a general linear mixed model for repeated measures data was chosen because this method accounts for missing data at multiple time points as well as unequal cell sizes.



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Because the groups were led by two co-therapists, and because the therapeutic alliance measure (TUI scale) was completed separately for each of them, t-tests of clients’ ratings were conducted to verify whether clients experienced their relationship with each therapist differently. No statistically significant differences between ratings of the relationship with each co-therapist were observed and, therefore, the main statistical analyses were conducted with the mean scores. Clients’ Attachment Classifications

In terms of attachment, participants were classified as follows at the time of the first data collection (pre-clinical assessment): 3 secure, 10 dismissing, 1 preoccupied, and 47 unresolved. Analyses

The initial sample was composed of 62 participants, but because participants with secure and preoccupied attachment styles were too few in number (three and two, respectively), they were excluded from the analyses. The analyses were conducted on ratings of participants classified as unresolved (n = 47) and dismissing (n = 10) prior to therapy. The data were analyzed with a mixed linear model for repeated data. The dependent variables perception of the relationship with the therapist (mean scores on the California Psychotherapy Alliance Scales – Patient Version therapist understanding and involvement scale) and perception of group climate (mean scores on each of the Group Climate Questionnaire scales – Engagement, Conflict, Avoidance) were analyzed in relation to the independent variable, attachment style. Clients’ time point in therapy (1–8) was entered as the within-subjects effect, and attachment style was entered as the between-subjects effect on the perception of the relationship with the therapist and perception of group climate variables. The generalized eta squared (ηg2) was used as a measure of effect size as it has been claimed to be the most appropriate measure of effect size in repeated measures designs (Olejnik & Algina, 2003). In the Therapist Understanding and Involvement (TUI) scale, analyses yielded a significant between-subjects effect for attachment, F(1, 218) = 13.21, p = .000, ηg2 = .024, indicating that unre-

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Figure 1. Therapist Understanding and Involvement (CALPAS) – Pre-Therapy Attachment

solved clients rated their therapists more positively (M = 5.46; SD = .88) than did dismissing clients (M = 4.98, SD = .82; see Figure 1). Group climate. On the Engagement subscale, analyses yielded a significant between-subjects effect for attachment, F(1, 122) = 4.96, p = .028, ηg2 = .018, indicating that unresolved clients perceived more engagement among group members (M = 54.23, SD = 7.72) than dismissing clients (M = 51.35, SD = 7.79; see Figure 2). On the Conflict subscale, analyses yielded a significant effect for time, F(7, 77) = 4.08, p = .001, ηg2 = .020, indicating that there were differences in clients’ ratings of conflict in the group over time. Post hoc analyses using the Bonferroni criterion for significance revealed that clients experienced more conflict in the group at session 6 (M = 56.11, SD = 13.07) than at session 8 (M = 43.83, SD = 4.39), p = .017. Analyses also showed a significant effect for the interaction of time by attachment, F(7, 60) = 2.43, p = .029, ηg2 = .037, indicating that clients’ ratings of conflict in the group were different when different attachment groups were compared. Analyses of simple effects of time within each level of attachment revealed a significant effect for time within the dismissing group, F(7, 62) = 3.31, p = .005, indicating that ratings



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Figure 2. Engagement (GCQ) – Pre-Therapy Attachment

of conflict in the group within this attachment group changed over time. Similarly, a significant effect for time within the unresolved group was found, F (7, 58) = 3.48, p = .004, indicating that ratings of conflict in the group within this attachment group changed over time as well. Post hoc analyses revealed that ratings at session 1 (M = 50.12; SD = 8.10) were higher than at session 8 (M = 40.32; SD = 4.39), p = .003. Analyses of the simple effects of attachment within each level of time yielded a significant effect for attachment at session 1, F(1, 47) = 4.09, p = .049; session 3, F(1, 41) = 6.68, p = .013; and session 6 F(1, 41) = 4.30, p = .044; indicating that clients’ ratings of conflict in the group varied according to their attachment group at sessions 1, 3 and 6. Post hoc analyses revealed that at session 1, clients with unresolved attachment experienced more conflict in the group (M = 50.28, SD = 8.38) than clients with dismissing attachment (M = 40.81, SD = 3.29), p = .043. At session 3, clients with dismissing attachment experienced more conflict in the group (M = 56.20, SD = 11.77) than clients with unresolved attachment (M = 47.05, SD = 7.82), p = .019. Similarly, at session 6 clients with dismissing attachment (M = 62.16, SD = 13.26) experienced more conflict in the group than clients with unresolved attachment (M = 50.05, SD =12.44),

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Figure 3. Conflict (GCQ) – Pre-Therapy Attachment

p = .038; see Figure 3). Analyses of scores on the Avoidance subscale were not significant. DISCUSSION

The current study examined clients’ experience of the relationship with their therapists and their perceptions of group climate over the course of an intensive group program for women with a history of childhood abuse. As hypothesized, our results suggest that clients’ experience of therapy relationships vary as a function of their attachment classification. In part, the results support findings in the literature regarding the impact of client attachment classification on perception of the therapeutic relationship (Daniel, 2006; Kanninen et al., 2000; Muller, 2009, 2010; Muller & Rosenkranz, 2009) as well as group processes (Chen & Mallinckrodt, 2002; Rom & Mikulincer, 2003). Our findings suggest that clients’ experiences of in-treatment relationships varied as a function of attachment classification over the course of trauma group therapy. Approximately 2.4% of the variance in the perception of alliance to the therapist and 1.8% of the variance



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in the perception of engagement in the group were predicted by attachment. While alliance to the therapist seemed to increase over time for the unresolved group, perception of engagement in the group seemed reasonably static. Considering the sevenpoint rating scale of the therapeutic alliance measure, we might conclude that clients demonstrated a strong early alliance that only improved over time. Unlike the weekly changes occurring in group composition, therapists remained the same over the course of treatment, and this might have created a sense of consistency that allowed for alliance growth. Contrary to our hypothesis, the unresolved group, when compared to the dismissing group, seemed to have had a positive experience of their relationship with the therapist as well as of group relationships in an open format group therapy that aimed at interpersonal learning. This is an interesting finding, given that the unresolved attachment classification has been associated with anxiety disorders and borderline personality disorder (Fonagy et al., 1996) and with great relational difficulties (Alexander & Anderson, 1994; Pearlman & Courtois, 2005). Although these clients fear relationships and are the most fragile, these findings suggest that they are still able to experience such relationships positively when they are provided in a context that is aimed toward maximizing a sense of safety and security. Specifically, unresolved clients seem to experience therapy relationships positively in an open interpersonal group therapy setting that is intended to promote interpersonal growth and to provide opportunities for clients to express their thoughts and feelings, connect with others, and renegotiate old negative relational patterns. These findings not only support previous findings about the benefit of group therapy for trauma survivors but also serve to highlight the importance of attending to the relational issues stemming from childhood abuse with clients in group therapy. The intensive nature of the current program and its goals to provide care for the specific needs of women with a history of abuse likely contributed to the creation of sense of safety and this, in turn, might have been reflected in the way they perceived the connections they formed in the program. However, it might be difficult, if not impossible, to disentangle the connection clients developed with treatment providers from the connection they developed with

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the program as a whole. While the development of a sense of safety within therapeutic relationships is paramount to survivors’ recovery, future research should examine the extent to which this translates into positive outcome. Clients with dismissing attachment appeared to have a more troubled experience of therapy relationships. Not only did they report lower ratings of group engagement and alliance with the therapist in comparison to the unresolved group, but they also experienced more conflict in the group. Somewhat surprisingly, while dismissing clients’ ratings of conflict followed an uneven pattern, unresolved clients’ ratings were rather stable, with a drop toward the end of the therapy. Our results suggest that approximately 3.7% of the variance in Conflict was predicted by the interaction between attachment and time. Observations from individual therapy suggest that the difficulties commonly experienced by dismissing clients are primarily in the realm of intimacy, self-disclosure, and emotional and interpersonal responsivity (Alexander & Anderson, 1994; Muller, 2009, 2010; Pearlman & Courtois, 2005; Saunders & Edelson, 1999). Further, findings from group therapy research have suggested that cohesive groups that lack structure are likely to be a source of great anxiety for dismissing clients (Rom & Mikulincer, 2003). One might have expected an uneven pattern of conflict ratings to be more characteristic of the unresolved group who lack a consistent attachment strategy rather than the dismissing pattern, which is an organized (i.e., consistent) pattern. These findings raise interesting questions that warrant further research. Given the low number of participants falling into the dismissing attachment category, we should be cautious interpreting these findings. A plausible interpretation is that attending unstructured therapy sessions, whose main goal is to promote interpersonal learning within an intensive group therapy program, might have elicited emotional dysregulation that interfered with the participants’ experience. It may be that an 8-week program does not provide enough time for dismissing clients who, by nature, devalue relationships to work through the complexities of building trust in therapy. Moreover, navigating interpersonal tension in the group might have been particularly challenging for dismissing clients. Although conflict is an important aspect



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of group therapy process (MacKenzie, 1997), the tasks of developing healthy patterns for interpersonal conflict resolution and coping with possible negative feelings about others and one’s self might have been more dysregulating to clients with this attachment pattern. It might have been difficult for them to cope with their own and others’ trauma re-enactments, and associated dysregulation, that ultimately resulted in interpersonal tension. Their tendency to hold negative models of group members and to project their hostility onto them might have also contributed to the way they perceived conflict in the group. Since examining the impact of group composition on clients’ perception of therapy relationships was beyond the scope of the current study, we cannot ascertain whether clients perceived conflict accurately or as a function of their coping style. Clients with both unresolved and dismissing attachment experienced more engagement and less conflict in the group toward the end of therapy, which might indicate that they experienced group members as cohesive and aligned toward similar goals during their termination phase. Nevertheless, the increased number of missing data at time points 7 and 8 suggests that ending therapy might have been a difficult process for them. Attachment theorists assert that the impending loss of the “secure base” associated with the termination stage of therapy activates the individual’s attachment system, which brings on strong reactions and feelings (Daniel, 2006; Hammond & Marmarosh, 2011; Kanninen et al., 2000; Muller, 2010; Zilberstein, 2008). In order to deal with the stress of the imminent separation, clients often resort to defenses that will minimize the emotional dysregulation they might experience at the end of therapy. In this study, missing sessions as well as not completing the measures during the final weeks of therapy, and therefore not reflecting on the relationships that they would soon lose, could be understood as a defense to deal with the stress of the upcoming separation and loss. It is important to note that this aspect of termination might have been particularly difficult for clients with dismissing attachment, considering the larger amount of their missing data compared to that of unresolved clients. This is consistent with previous studies on group therapy showing that dismissing clients coped with the stress of termination by minimizing the importance of

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their relationship with the therapist (Kanninen et al., 2000; Hammond & Marmarosh, 2011). Hammond and Marmarosh (2011) suggest that other factors, such as clients’ level of psychopathology, should also be examined when interpreting clients’ reactions to therapist loss. Following this rationale, future research should also consider clients’ trauma-related psychopathology (e.g., dissociation), as it is likely to impact their perception of therapeutic relationships. The challenge of treating trauma survivors with a dismissing attachment has been documented in the literature and includes difficulties with interpersonal closeness and need to exert selfsufficiency and independence at times of distress. While literature on specific intervention strategies with these clients is still very limited, techniques have been proposed recently by Muller (2009, 2010) that focus squarely on the psychotherapy relationship and ways the therapist can respond to enactments that occur when painful emotions or feelings of vulnerability arise for the client. Unlike dismissive clients, unresolved clients seem less likely to reject interpersonal closeness and seem more able to use relationships and respond well to empathic connection with others in therapy, despite their struggles and fears of being in relationships. Our findings suggest the need to attend to clients’ attachment-related needs and difficulties when providing treatment to individuals with trauma histories, both in individual and group therapies. Despite some meaningful findings, this study has a number of limitations. First, the small sample size likely reduced the power of the analyses and suggests the need for replication. In addition, only unresolved and dismissing attachment styles were compared, with the dismissive group having a small sample size. Second, this study focused solely on whether client attachment influenced perception of relationships in therapy. Further research on group composition, particularly in terms of therapists’ and other group members’ attachment styles, could shed light on important therapy processes as well as on outcome. It is unclear at this point the extent to which group composition impacted group dynamics as well as clients’ perception of therapy relationships. Third, given that WRAP is composed of a range of group modalities, it would be helpful to expand on the topic of clients’ experiences



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in groups that have different goals and structures, as well as over the course of WRAP in its totality. Fourth, replication of this study could be enhanced by including other extensively studied alliance components, such as client experience of agreement on therapy goals and tasks. Fifth, research is needed to determine to what extent WRAP’s open and continuous intake model impacts client perception of relationships in therapy. Finally, this study did not address the extent to which clients’ attachment and perception of treatment relationships might have been colored by such factors as gender, culture, and psychopathology. Further research on whether these variables impact the way individuals navigate relationships and react and cope with trauma and stress is much needed.

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