A meta-analysis of the relation between patient adult attachment style and the working alliance

An updated meta-analysis of the relation between adult attachment style and working alliance

Objective: Previous meta-analyses have shown that client-rated working alliance is negatively correlated with attachment anxiety and attachment avoidance. The purpose of this study is to provide an updated meta-analysis of the relation between alliance and the two dimensions of attachment insecurity. Method: Random effects models were used to examine the relation between the working alliance and attachment anxiety and the relation between the working alliance and attachment avoidance. Results: The overall relation between alliance and attachment anxiety was r = -.09 (p = .01, k = 33, I2 = 43.7%). The overall relation between alliance and attachment avoidance was r = -.13 (p < .001, k = 33, I2 = 44.7%). There was no evidence that these relations varied across study characteristics such as client race or the number of therapists in the study. Conclusion: The results support the negative relations between client-rated alliance and both dimensions of client-rated attachment insecurity. Further research is needed to identify the factors that moderate this relationship, using a more diverse sample of study characteristics and a wider range of measures.

Can Patients With Narcissistic Personality Disorder Change? A Case Series

ABSTRACT

The study was set out to establish the potential for psychotherapy to effect improvements in patients with narcissistic personality disorder (NPD). Eight patients with NPD who improved in treatment were identified. Consensus clinician/investigator diagnostic scores from before and after the psychotherapies were retroactively established on the Diagnostic Interview for Narcissism (DIN) and the Diagnostic Statistic Manual for Psychiatric Disorders, 5th Edition (DSM-5) Personality Disorder Section II criteria. Psychosocial functioning (work or school, romantic relationships) before and after the psychotherapies was retroactively evaluated as well. At the completion of the therapies after 2.5 to 5 years, all patients had improved, no longer met DIN or DSM-5 criteria for NPD, and showed better psychosocial functioning. Symptomatic improvements were associated with large effect sizes. In conclusion, changes in NPD can occur in treatment after 2.5 to 5 years. Future research should identify patient characteristics, interventions, and common processes in such improved cases that could help with development of treatments.

Applying the Rupture Resolution Rating System to emotion-focused couple therapy

Alliance ruptures and their repair are robustly associated with outcomes in individual therapy. Little is known about these processes in couple therapy, despite the acknowledged challenges of nurturing the alliance when working with two parties in conflict. One factor contributing to this gap in the literature is the lack of an instrument to capture ruptures and repair in couple therapy. We adapted the Rupture Resolution Rating System (3RS) to identify ruptures and repairs in couple therapy at the within-system (between the two partners) and the between-system (between each partner and the therapist) levels. Sessions from one couple with good outcome and one couple with poor outcome were coded. Couples were in therapy to deal with emotional injury. Rupture-repair events in both the within-system and between-system were common. The couple with the poor outcome showed greater levels of rupture with the therapist. The injured partners (vs. injurer partners) demonstrated higher frequencies of ruptures.

Therapy matchmaking: Patient-therapist match in personality traits and attachment style

OBJECTIVE

This study examined the relationships between patient-therapist similarity and therapy outcome. We aimed to explore whether patient-therapist match in personality and attachment styles leads to a better therapy outcome.

METHOD

We collected data from 77 patient-therapist dyads in short-term dynamic therapy. Patients' and therapists' personality traits (Big-5 Inventory) and attachment styles (ECR) were assessed prior to beginning therapy. Outcome was measured on the OQ-45.

RESULTS

When patients and therapists scored either high or low on neuroticism and conscientiousness we found a decrease in symptoms from beginning to end of therapy. When patients' and therapists' combined scores were either high or low on attachment anxiety, we found an increase in symptoms.

CONCLUSION

Match or mismatch on personality and attachment style in therapy dyads contributes to therapy outcome.

Client-counselor behavioral and inter-brain synchronization among dismissing and secure clients and its association with alliance quality and outcome

Objective This study aimed to explore whether behavioral synchrony (BS) and inter-brain synchrony (IBS) could serve as potential biomarkers for alliance quality or outcomes among clients with different adult attachment styles. Method: We assessed the clients' self-report working alliance and clinical outcomes as well as simultaneously measured BS using motion energy analysis (MEA) and IBS with functional near-infrared spectroscopy (fNIRS) among 37 secure (N = 21) or dismissing (N = 16) clients with their counselors during the first psychological counseling meeting. Results: Dismissing dyads manifested significantly higher late-stage counselor-led and client-led IBS (p = .018) than secure dyads. Adult attachment style served as the moderators in the correlation of both whole-stage client-led BS with bond dimension of alliance (p = .015) as well as in the correlation of both whole-stage no-lag IBS with CORE-10 score changes (p = .022). Moreover, increases in the whole-stage client-led BS were significantly associated with decreases in early-stage, late-stage and whole-stage no-lag IBS (all ps ≤ 0.01). Conclusion: These findings revealed the potentially impeding role of interpersonal synchrony in alliance quality for dismissing clients, at least during the first psychological counseling meetings. They also might partially validate the relationship between different modalities of interpersonal synchrony.

The experience of closeness and distance in the therapeutic relationship of patients with different attachment classifications: an exploration of prototypical cases

Background

Individuals with different attachment classifications (Secure, Avoidant and Preoccupied) may experience emotional closeness differently, in their intimate relationships but also as clients in psychotherapy. However, evidence for this assumption almost exclusively comes from research with self-report questionnaires.

Aims

In this paper, we use observer-rated measures to explore in depth how patients with different attachment classifications experience closeness and distance from the therapist in different phases of therapy.

Method

Three patients' and their therapists' narratives about the therapeutic relationship at three time points during therapy were extracted and analyzed with two transcript-based observational measures: The Patient Attachment Coding System (PACS), which classifies patients' attachment according to their discourse behavior, and the therapeutic-Distance Scale-Observer version (TDS-O), which assesses the therapeutic relationship in terms of closeness, distance, autonomy and engagement. Cases were chosen from a larger research project due to their different prototypical attachment classification on the PACS. The narratives were obtained from Relationship Anecdote Paradigm (RAP) interviews in which the patients and their therapists narrated separately about meaningful interactions with each other, at early, middle and late phases of therapy. In addition, we followed patients self-report of the alliance and symptoms (OQ-45).

Results

Although all patients reported experiencing discomfort with feeling distant from the therapist the therapeutic distance, the secure patient was able to reflect on his feelings and, in the therapist's recollection, was able to share them with the therapist. This allowed the therapist to harness these feelings for the benefit of the therapy. The avoidant and the preoccupied patients both experienced the therapist as distant, but the avoidant patient prevented closeness by a minimal expression of feelings, and the preoccupied described strong frustration with the therapist in a one-sided manner that prevented collaborative processing and left the therapist confused.

Discussion

It appears that patient discourse is a stable (trait-like) component of attachment, while the therapeutic-distance is a process (state-like) component that may change along therapy. The discourse of insecure patients may hinder therapists' ability to adjust the therapeutic-distance to patients' needs. Therapists' knowledge about the ways patients with different attachment classifications communicate their proximity wishes may improve their attunement.

The first session matters: Therapist responsiveness and the therapeutic alliance in the treatment of borderline personality disorder

OBJECTIVES

The focus of the present research is to investigate the impact of therapist responsiveness at the very first session of therapy on the evaluation of therapeutic alliance from the therapist's perspective and from patient's perspective in the context of guideline-based treatment for borderline personality disorder.

DESIGN

The study has a correlational and longitudinal design applied to a 10-session therapy in a naturalistic setting.

METHODS

A total of four trained raters evaluated therapist responsiveness during the first session of therapy. After each therapy session, therapists and patients filled out the short form of the Working Alliance Inventory measuring working alliance; the sample included 13 therapists and 47 patients. Correlational analysis as well as hierarchical linear modelling exploring the relationship between first session therapist responsiveness and working alliance were performed.

RESULTS

The global evaluation of responsiveness revealed a significant relationship with the temporal evolution of the alliance rated from the therapists' perspective.

DISCUSSION

There is the necessity to further explore therapist appropriate responsiveness which could potentially explain several psychotherapy research results. Moreover, it could help in finding alternatives in order to facilitate patients' early engagement in therapy as well as facilitating the building process of therapeutic alliance. Finally, an effort should be made in order to study more individualized operationalization of responsiveness.

Changes in the Risk of Sexual Reoffending: The Role and Relevance of Perceived Self-Efficacy and Adult Attachment Styles in Correctional Treatment

According to the Risk-Need-Responsivity (RNR) model, treatment effectiveness increases when treatment addresses all three associated core principles. While researchers have focused on the risk and need principles, responsivity remains under-investigated. The theoretical foundation of the RNR model and former research indicates low perceived self-efficacy and inadequate adult attachment styles as potential responsivity factors that can impede treatment of the underlying risk factors. This study assesses firstly whether these factors predict treatment attrition, and secondly changes in the assessed risk of sexual reoffending. Participants were N = 146 men sentenced for sexual offenses in a German social-therapeutic correctional facility. Younger age, higher number of previous convictions, and higher scores on the interpersonal facet of the Psychopathy Checklist-Revised are associated with a higher risk of treatment attrition. Unemployment prior to incarceration was found to be an aggravating factor, whereas substance abuse emerged as a mitigating factor, according reducing the risk of reoffending. Neither pre-treatment self-efficacy nor attachment styles revealed as responsivity factors in this study. Future studies should examine if the consideration of these factors during treatment might impact treatment outcomes.

Attachment Manifestations in Daily Interpersonal Interactions

The predominant focus in attachment research on trait-like individual differences has overshadowed investigation of the ways in which working models of attachment represent dynamic, interpersonally responsive socio-affective systems. Intensive longitudinal designs extend previous work by evaluating to what extent attachment varies over social interactions and the functional processes that underlie its fluctuation. We examined momentary activation of attachment orientations in the stream of peoples' daily lives and how those patterns were linked to interpersonal behavior. Based on an event-contingent, ambulatory 7-day assessment protocol (N=263; 3,971 interactions) operationalized using Contemporary Integrative Interpersonal Theory, we examined whether contextually activated working models accounted for patterns of interpersonal (anti-)complementarity. Our analyses revealed that the situational activation of working models varied as a function of interpersonal perceptions of warmth, which were linked to greater state security and lower levels of anxious or avoidant expectations. These reactivity patterns, in turn, accounted for interpersonal complementarity. Avoidant attachment was linked to diminished and secure attachment to enhanced expressions of warmth. The analyses were robust even when controlling for momentary positive and negative affect and closeness of the relationship. Attachment expectations wax and wane across daily social interactions, and such fluctuations are reflective primarily of a process in which perceptions of others' warmth activate secure attachment expectations and lower insecure ones.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s42761-022-00117-6.

Proof of Concept of the Contribution of the Interaction between Trait-like and State-like Effects in Identifying Individual-Specific Mechanisms of Action in Biological Psychiatry

Background: Identifying individual-specific mechanisms of action may facilitate progress toward precision medicine. Most studies seeking to identify mechanisms of action collapse together two distinct components: pre-treatment trait-like characteristics differentiating between individuals and state-like characteristics changing within each individual over the course of treatment. We suggest a conceptual framework highlighting the importance of studying interactions between trait-like and state-like components in the development of moderated mediation models that can guide personalized targeted interventions. Methods: To facilitate implementation of this framework, two empirical demonstrations are presented from a recent clinical trial and neuroimaging study. The first examines limbic reactivity during an emotional face task; the second concerns striatal activation in a monetary reward task. Results: In both tasks, considering the interaction between trait-like and state-like components predicted treatment outcome more robustly than did the trait-like or state-like components examined individually. Conclusions: These findings suggest that the extent to which state-like modulation of neural activations can serve as a potential treatment target depends on the pre-treatment, trait-like levels of activation in these regions. Thus, the interaction between trait-like and state-like components can serve as a promising path to the development of personalized interventions within a precision medicine framework in which mechanisms of action are individual-specific.

Is there an elephant in the room? A study of convergences and divergences of adult attachment measures commonly used in clinical studies

Objective: In view of the persisting conceptual confusion related to the convergence of attachment measures, we investigated several common measures within a clinical and a non-clinical sample, tested the convergence/divergence of different measures, and tried to find a dimensional model. Method: 175 patients with panic disorder/agoraphobia and 143 matched non-clinical individuals completed seven self-report attachment measures/ clinical self-reports and were interviewed by applying the Adult Attachment Interview (AAI), the Adult Attachment Rating (AAR) and the Adult Attachment Projective (AAP). Results: The categorical and most dimensional attachment measures differentiated between the samples. The convergence of the categorical measures was low, whereas we found moderate to high correlations between similar scales in the dimensional self-report measures. Expectedly, the convergence of dimensional and categorical attachment measures was low. In a factorial (exploratory as well as confirmatory) model, four independent dimensions were extracted reflecting self-rated attachment anxiety and avoidance, the categories of the AAI and those of the AAP, indicating significant differences between the measures. Discussion: Measures of adult attachment are only partially convergent, underlining the need for clarification of which aspect of attachment is actually being assessed in individual clinical investigations. The question remains whether the different measures are in fact related to one construct.

Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa

Anorexia nervosa-focussed family therapy (FT-AN) is the first-line treatment for adolescent anorexia nervosa (AN), but the predictors of poor treatment response are not well understood. The main aim of this study was to investigate the role of attachment and mentalization in predicting treatment outcome. The secondary aims of the study were to investigate therapeutic alliance at 1 month as a predictor of outcome, and to test the associations between alliance and baseline attachment and mentalization. 192 adolescents with AN and their parents were recruited as they began family therapy in out-patient specialist eating disorder services. Self-report measures of attachment, mentalization, and emotion regulation were completed at the start of treatment by adolescent patients and one of their parents. Self-reported alliance scores were collected at one month. Higher scores on the Certainty Scale of the Reflective Functioning Questionnaire, completed by parents, which indicate over-certainty about mental states, were the strongest predictor of poor outcome (Odds Ratio: 0.42, CI: 0.20-0.87). Similarly, for adolescents, higher Lack of Clarity scores on the Difficulties in Emotion Regulation Scale, representing being unclear about one's feelings, were predictive of positive treatment outcome (OR: 1.10, CI: 1.00-1.21). Higher alliance scores at 1 month predicted positive outcome, and were associated with attachment security and mentalization. These novel findings suggest that, particularly in parents, a tendency towards excessive certainty about mental states in others may predict poor outcome in FT-AN. Further research is warranted to replicate the finding and characterise families at risk of poor outcome.

Assessing Self-Definition and Relatedness in Level of Personality Functioning

The two polarities model (TPM) of personality organizes psychological assessment and psychotherapy and connects to personality disorder diagnosis using the DSM-5 Alternative Model for Personality Disorders (AMPD). The authors developed scales assessing the TPM from an existing self-report measure for level of personality functioning (LPF), a core component of the AMPD. Iterative content analyses of the LPF measure yielded scales for Autonomy and Communion corresponding to dimensions of the TPM. The scales were refined via internal consistency analyses using a measure of psychological attachment and studied in development and validation samples. Associations with relevant external criteria were explored in a series of multiple regressions. The new content-based LPF scales were illustrated with a case vignette. Although the new Autonomy/Communion scales await further validation prior to clinical use, initial evidence suggests that they may bridge the nomological nets of the TPM and AMPD and potentially offer clinical utility in assessment and treatment planning.

COVID-19 Related Traumatic Distress in Psychotherapy Patients during the Pandemic: The Role of Attachment, Working Alliance, and Therapeutic Agency

The early months of the COVID-19 pandemic have been a challenging time for many psychotherapy patients. To understand why certain patients were more resilient, we examined the role of patients' attachment anxiety and attachment avoidance, as well as collaborative therapy experiences (perceived working alliance and therapeutic agency) in their online sessions on their COVID-related traumatic distress over a three-month period. A total of 466 patients in online psychotherapy completed a survey during the first weeks of the pandemic, and 121 of those completed a follow-up survey three months later. Lower distress at follow-up was predicted by patients' lower attachment anxiety and higher therapeutic agency in their online sessions after controlling for baseline distress and time of survey completion. Higher working alliance predicted less distress at follow-up only for patients with high attachment anxiety. For patients with low attachment avoidance (i.e., more securely attached), higher therapeutic agency predicted less distress. These findings suggest that patients' attachment anxiety and therapeutic agency may play significant roles also in online therapy during COVID-19 in patient's experienced traumatic distress, and that working alliance and therapeutic agency may be differentially important for patients with different levels of attachment anxiety and avoidance.

Evaluation of a short version of the Experiences in Close Relationships-Revised questionnaire (ECR-RD8): results from a representative German sample

BACKGROUND

Attachment insecurity is a prominent risk factor for the development and course of psychiatric and psychosomatic disorders. The Experiences in Close Relationships - Revised (ECR-R) questionnaire is a widely used self-report to assess attachment related anxiety and avoidance. However, its length has the potential to restrict its use in large, multi-instrument studies. The aim of this study was to develop and evaluate a brief version of the ECR-R, and provide norm values for the German population.

METHODS

A screening version of the original ECR-R was developed through principal components analysis of datasets from several previous studies. In a representative sample of 2428 randomly selected individuals from the German population, we compared fit indices of different models by means of confirmatory factor analyses (CFA). We investigated the convergent validity of the screening version in an independent convenience sample of 557 participants. Correlations between the short and the full scale were investigated in a re-analysis of the original German ECR-R evaluation sample.

RESULTS

CFA indicated a satisfactory model fit for an eight-item version (ECR-RD8). The ECR-RD8 demonstrated adequate reliability. The subscales correlated as expected with another self-report measure of attachment in an independent sample. Individuals with higher levels of attachment anxiety, but especially higher levels of attachment avoidance were significantly more likely to not be in a relationship, across all age groups. Correlations between the short and the full scale were high.

CONCLUSIONS

The ECR-RD8 appears to be a reliable, valid, and economic questionnaire for assessing attachment insecurity. In addition, the reported population-based norm values will help to contextualize future research findings.

Relationships Between the Therapeutic Alliance and Reactions to Artistic Experience With Art Materials in an Art Therapy Simulation

In art therapy, art-making plays an important role in the therapeutic relationship. To better understand the triangular relationship between the art therapist, the client and the artwork, this study investigated the association between the therapeutic alliance and reactions to artistic experiences with art materials in an art therapy simulation. The simulation consisted of a series of 6-8 sessions in which art therapy students were divided into teams composed of a permanent observer (art therapist) and creator (client). The client's role was to self-explore through art- making, and the art therapist's role was to accompany the client. Thirty-four students, all women, who played the art therapist role, and 37 students (one male) who played the client participated in the study. Of these participants, there were 24 pairs where both participants filled out all the questionnaires. A short version of the Working Alliance Inventory (WAI) was completed by the clients and the art therapists on the second session (T1) and on the penultimate session (T2). The clients also completed the Art-Based Intervention Questionnaire (ABI) at T2. Significant positive correlations were found between indices of the WAI for the art therapist and the client and the clients' reactions to the artistic experience with art materials on the ABI. The evaluation of the emotional bond between the art therapist and the client at the start of the simulation significantly predicted the client's reactions to the artistic experience with art materials at the end of the simulation and explained 45.4% of the variance for this variable. These findings highlight factors related to the development and influence of the therapeutic alliance, as well as the role of the artistic experience in art therapy and lay the groundwork for further research.

Long-term changes in attachment patterns after psychotherapy in outpatients with Axis I and personality disorders vs. Axis I disorders only

BACKGROUND

Adult attachment can be self-reported by rating anxiety of deception and avoidance of emotional closeness. There are few studies of changes in adult attachment patterns after psychotherapy.

AIM

This study investigated how attachment anxiety and avoidance mean scores changed from pre-treatment to follow-up in patients with Axis I disorders only vs. patients with Axis I and comorbid personality disorders (comorbid group) after outpatients psychotherapy.

METHOD

Of 156 patients with pre-treatment evaluation, 64 (41%) participated in follow-up 6 years later. Axis I and personality disorder interviews were performed at pre-treatment and follow-up, and the participants self-reported attachment patterns at both time points.

RESULTS

At both pre-treatment and follow-up, the Axis I group had significantly lower attachment avoidance scores than the comorbid group, while no significant between-group differences were observed for attachment anxiety. After adjustment, neither the Axis I nor the comorbid group showed any significant reductions in attachment anxiety or avoidance over time. The pre-treatment attachment scores were the only significant predictors of the follow-up scores.

CONCLUSION

Neither attachment anxiety nor avoidance were amenable to change over time. These findings may be associated with the psychotherapy given. Pre-treatment attachment scores were the only significant predictors of these scores at follow-up. © 2020 John Wiley & Sons, Ltd.

Working alliance and attachment orientations in the patient-oncologist relationship

OBJECTIVE

Accumulating research suggests that the working alliance (WA) is a key component in the patient-oncologist relationship. Attachment theory provides a useful framework for understanding this alliance within the oncological setting, where patients' attachment systems are often activated. This study examined the association between attachment orientations of both dyad members (i.e., patient and oncologist) and patients' WA experience. It also probed whether this link was mediated by patients' attachment-related attitudes towards the oncologist, using a recently developed measure.

METHOD

Oncologists and their respective patients (N = 113: 103 patients, 10 oncologists) were sampled at oncological clinics. Eligible patients filled out online measures of the WA, attachment-related attitudes, and attachment orientations. The later was also completed by oncologists.

RESULTS

Structural equation modeling demonstrated that both patients' and oncologists' avoidant attachment orientation inversely predicted patients' WA experience, via patients' experience of feeling unsupported by their oncologists.

CONCLUSIONS

Findings suggest that attributes of both members of the patient-oncologist dyad are related to patients' WA experience, and that attachment-related attitudes towards oncologists occur within this relationship. Oncologists' understanding of patients' unique attachment behaviors, as well as their own such behaviors, could improve cancer patients' quality of care and illness outcomes. Results represent another step forward in fully exploring whether oncologists can serve as attachment figures for their patients.

Ruptures and Repairs in Group Psychotherapy: From Theory to Practice

The group climate, cohesion, and alliance with the leaders are critical elements of effective group psychotherapy. Although there has been significant attention to these curative mechanisms, there has been less attention to ruptures in the group relationships or the repair of them. The current special issue is devoted to theory, research, training, and practice regarding ruptures and repairs in group treatment. Contemporary and more traditional theorists describe how ruptures facilitate change in group therapy. Researchers apply the empirical findings on ruptures in individual therapy to group therapy and describe how ruptures can be measured. Group therapists also address how group leaders can contribute to ruptures and their subsequent repair. This introduction to the special issue concludes with the implications for practice and a call for future research that will help us fully understand how ruptures affect group process and outcomes in group work.

Movement and Emotional Facial Expressions during the Adult Attachment Interview: Interaction Effects of Attachment and Anxiety Disorder

INTRODUCTION

Adult attachment is commonly associated with emotion regulation. Less is known about the nonverbal embodiment of adult attachment.

OBJECTIVE

We hypothesized that dismissing attachment is related to less movement and fewer facial expressions of emotions, whereas preoccupied attachment is associated with more negative emotional facial expressions. Moreover, the interaction of attachment and the presence of an anxiety disorder (AD) was explored.

METHODS

The sample included 95 individuals, 21 with AD without comorbidity, 21 with AD and comorbid major depression (AD-CD), and 53 healthy controls. We analyzed nonverbal behavior during a part of the Adult Attachment Interview (AAI) asking about the family and parental figures. The movements of the interviewees were captured via Motion Energy Analysis. Facial expressions were coded according to the Facial Action Coding System using the OpenFace software. We compared individuals with secure, dismissing, and preoccupied states of mind (assessed with the AAI) with regard to the frequency and complexity of movements and the frequency of the facial expressions such as happy, sad, and contemptuous.

RESULTS

As expected, dismissingly attached individuals moved less often and with lower complexity than securely attached. For emotional facial expressions, a main effect of the disorder group and interaction effects of attachment by disorder were found. In the AD-CD group, dismissingly attached patients showed comparatively fewer happy facial expressions than securely attached individuals.

CONCLUSIONS

Reduced movement specifically seems to be related to dismissing attachment when interviewees talk about significant parental figures. Facial expressions of emotions related to attachment occurred when maladaptive emotion regulation strategies were intensified by a psychological disorder.

Achieving successful resolution of alliance ruptures: for whom and when?

Contemporary theories and the empirical literature stress the importance of successful resolution of alliance ruptures for the process and outcome of treatment. Yet, little empirical work has examined what leads to successful resolutions. The aim of the present study was to examine which patients are more likely to achieve successful resolutions of ruptures and under which circumstances.

Sixty-five patients completed measures assessing their trait-like pretreatment characteristics (alliance expectations and general attachment orientation), and state-like changes in treatment (working alliance, therapist serving as an attachment figure, and the implementation of common factor techniques). Successful resolutions were coded using observer behavioral coding at four time points.

State-like changes, but not trait-like characteristics significantly contributed to successful resolution. Stronger working alliance and the therapist as an attachment figure, and the implementation of common factors techniques were found to contribute to successful resolutions.

The current findings emphasize the importance of the process that occurs within treatment, and the therapeutic context in which the resolution process take place for the ability to achieve successful resolutions.

Effectiveness of a university counseling intervention based on a psychodynamic approach

The study examined the effectiveness of a brief psychodynamic counseling intervention on psychological distress and general life satisfaction in a sample of 124 students by comparing pre- and posttreatment data. The authors also tested the moderating role of pretreatment attachment styles. Results showed that most participants (57%) can be classified as a nonclinical population, whereas only a minority of participants belong to a clinical population (17%) and a subclinical population (26%) according to the Symptom Checklist 90 Revised (SCL-90-R). Psychodynamic counseling intervention was shown to be associated with a decrease in the Global Severity Index and the anxiety and depression subscales of the SCL-90-R. Clinical effectiveness was greater for participants belonging to the clinical group. General life satisfaction increased significantly for all students. The authors found no moderation effect of attachment styles. Brief psychodynamic counseling intervention was associated with a reduction of psychological distress and an increase in life satisfaction.

Changes in clients and therapists experiences of therapeutic distance during psychodynamic therapy

Attachment theory provides a framework for examining closeness-distance experiences in the development of the therapeutic relationship.

OBJECTIVE

To examine changes in clients' and therapists' experiences of therapeutic distance along with psychodynamic therapy.

HYPOTHESES

Clients' and therapists' comfort with closeness and distance will increase, and the client's autonomy and engagement will increase with time.

METHOD

A total of 67 clients and their 27 therapists underwent Relationship Paradigm interviews in which they told narratives about their experience with each other, three times during therapy. The narratives were rated on the Therapeutic Distance Scale-Observer (TDS-O) version.

RESULTS

Growth curve analysis of the TDS-O ratings showed that clients decrease in perceiving therapists as too distant and increase in engagement. Therapists showed a decrease in perceiving clients as too close and an increase in granting autonomy and engagement. A clinical illustration depicts these experiences in a client-therapist dyad.

CONCLUSIONS

Therapists' awareness of clients' changing needs of closeness and autonomy may enhance attunement.

Differential effects of adult attachment in cognitive-behavioural and psychodynamic therapy in social anxiety disorder: A comparison between a self-rating and an observer rating

Different measures of attachment are usually weakly correlated. In a subsample of an RCT comparing short-term cognitive-behavioural therapy (CBT) and psychodynamic therapy (PDT), we examined the association between attachment and outcome using two attachment measures. The sample comprises 148 patients with social anxiety disorder who were treated in the SOPHO-NET trial. Pretreatment attachment was assessed using the Adult Attachment Prototype Rating (AAPR) and the Bielefeld Questionnaire of Client Expectations (BQCE). Regression models were used to predict the therapeutic alliance (HAQ) at session 8, the Liebowitz Social Anxiety Scale (LSAS) at the end of therapy and a 6-month follow-up. Attachment groups (secure, avoidant, and ambivalent) classified with the AAPR and the BQCE were not significantly correlated (Cohen's κ = 0.08). Only the BQCE was associated with the HAQ indicating avoidantly attached patients showing lower HAQ scores than securely attached (Cohen's d = 0.722). Regarding the AAPR, we found an interaction effect of treatment and attachment related to the post-treatment LSAS scores. Post hoc tests revealed that securely attached patients in CBT had lower scores than securely attached in PDT (d = 0.922) and, on a trend level, avoidantly attached in CBT (d = 0.782). We conclude that attachment-outcome associations are affected by the applied measure. The identified differential effects suggest that psychotherapists should adapt the interventions on the attachment of their patients.

Effect of Attachment Style on Selective Attention in Panic Disorder

Introduction: Given the heterogeneity of results in the attentional bias to threatening information in patients with panic disorder, we investigated the attentional bias toward threat and the moderating effect of attachment styles in a female-only sample of panic patients and a nonclinical control group.

Methods: Female panic patients (n = 47) were compared to a female control group (n = 47) using a modified Dot Probe Task with body-related and interpersonal threat as well as attachment positive words.

Results: An attentional bias toward threat words was not replicated. Furthermore, there was no moderation effect on attentional bias by attachment styles. However, high attachment avoidance was associated with faster reaction times (RT) in attachment positive compared to attachment threat trials in both groups. In the patient group, attachment anxiety was associated with faster RT in panic threat trials compared to attachment positive trials. Anxiously attached controls reacted faster to attachment positive vs. attachment threat trials.

Discussion: No attentional bias was found in the present study. However, the findings suggest that attachment avoidance and attachment anxiety differently influence attention responses to trials that include different emotional stimuli in clinical and nonclinical, female participants. Attachment insecurity may modify attention when processing trials including both, threat and positive stimuli.

Enhancing the "Broaden and Build" Cycle of Attachment Security in Adulthood: From the Laboratory to Relational Contexts and Societal Systems

Attachment theory emphasizes both the importance of the availability of caring, supportive relationship partners, beginning in infancy, for developing a sense of safety and security, and the beneficial effects of this sense of security on psychosocial functioning and physical and mental health. In this article, we briefly review basic concepts of attachment theory, focusing on the core construct of attachment security and present evidence concerning the ways in which this sense can be enhanced in adulthood. Specifically, we review findings from laboratory experiments that have momentarily enhanced the sense of attachment security and examined its effects on emotion regulation, psychological functioning, and prosocial behavior. We then review empirical findings and ideas concerning security enhancement by actual relationship partners, non-human symbolic figures, and societal systems in a wide variety of life domains, such as marital relationships, psychotherapy, education, health and medicine, leadership and management, group interactions, religion, law, and government.

Attachment in OCD: A meta-analysis

INTRODUCTION

It has been proposed to extend the cognitive-behavioural model of obsessive-compulsive disorder (OCD) with attachment theory to shed light on the affective and developmental factors underlying the disease. With a growing number of empirical studies on the subject, this meta-analysis aims to quantify a possible relationship between attachment insecurity and OCD.

METHODS

A systematic search was conducted for studies in adult populations of patients with OCD as well as general populations displaying symptoms of OCD. Effect sizes of attachment anxiety and attachment avoidance were calculated separately. Covariates of demographic variables were used in meta-regressions.

RESULTS

Sixteen studies were included. Meta-analyses showed an association of medium to large effect size (Hedges' g = 0.69; 95 % CI 0.58 - 0.80; p < 0.001) between OCD and attachment anxiety, and an association of medium effect size (Hedges' g = 0.47; 95 % CI 0.39 - 0.54; p < 0.001) between OCD and attachment avoidance. Effect sizes in OCD population and general population studies did not differ significantly.

DISCUSSION

Robust effect sizes of both attachment anxiety and avoidance in relation to OCD symptomatology corroborate an attachment-centred view of OCD. These findings furthermore suggest that integrating cognitive and attachment-based therapeutic approaches to OCD may benefit patients in which developmental or emotional factors hinder successful treatment.

Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder

This article identifies guiding principles in effective psychotherapies of patients with narcissistic personality disorder (NPD) and cautions against some common pitfalls. Individual psychotherapies of NPD patients were examined by both authors, who tested whether or not some principles, recommended in the literature, effectively promote these therapies and help these patients in moving forward with their lives and with effective therapy use. The authors identify a number of principles that were associated with more positive therapy development: helping patients identify goals and direction of their therapies, promoting a sense of agency, promoting a shift of focus to sense of vulnerability, and anticipating difficulty in developing and maintaining the treatment alliance. Common mistakes in these treatments are engaging in a power struggle with the patient, overindulging the grandiosity of the patient, directly challenging the grandiosity of the patient, and ignoring treatment-interfering behaviors. Identification of principles of effective therapies with NPD patients can help with the development of more effective treatment approaches for NPD.

Understanding the use of attachment theory applied to the patient-provider relationship in cancer care: Recommendations for future research and clinical practice

Patient attachment styles may inform how patients react differently to the stress of being diagnosed with cancer, as well as how patients may desire to interact and be supported by their provider. The objectives of this study were two-fold: 1) to conduct a systematic scoping review to clarify how attachment theory is utilized and applied within the current body of research on the patient-provider relationship within cancer care, and 2) add to the existing body of literature by introducing an integrated model of patient attachment styles and patient-provider relationships for use in clinical and scholarly work. A systematic search of multiple databases including PubMed, Google Scholar, PsychInfo, and WorldCat was conducted using variations and combinations of keywords related to patient-provider relationship, attachment style, and cancer. The nine studies included in the review were published from 2011 to 2019. The majority of studies had participant samples with multiple cancer diagnoses (n = 5) and examined attachment as an independent or predictor variable (n = 6). Results suggest that a secure attachment was predictive of a better working alliance, more perceived support, less general distress, higher levels of trust and satisfaction with healthcare providers when compared to patients with an insecure attachment style. Data from the current review suggest that using an attachment theory framework can improve the understanding of the patient-provider relationship. We propose a conceptual model that aligns patient attachment style and patient-provider relationship types to be utilized in clinical practice in future research to tailor patient-centered cancer care.

Mapping evidence from systematic reviews regarding adult attachment and mental health difficulties: a scoping review

OBJECTIVE

The aim of this scoping review was to map evidence gathered through systematic reviews regarding adult attachment and mental health difficulties. This review highlights established, emerging, and inconsistent findings, suggesting areas for future research, and implications for theory and practice.

METHODS

A systematic search for meta-analyses and systematic reviews measuring adult attachment and concerning mental health difficulties was conducted. In total, 17 studies met the selection criteria.

RESULTS

Findings were presented according to four identified themes, (1) measurement of attachment; (2) measurement of mental health difficulty; (3) intrapersonal processes related to attachment and mental health difficulties; and (4) interpersonal processes related to attachment and mental health difficulties.

CONCLUSIONS

This review highlights the connection between attachment style and mental health difficulties, and suggests that relationships can facilitate both mental health and illheath. However, the mechanisms through which insecure attachment confers risk for mental health difficulties require further research.

Kurzversion des Bielefelder Fragebogens zu Partnerschaftserwartungen (BFPE-12)

Zusammenfassung. Die Kurzfassung des Bielefelder Fragebogens zu Partnerschaftserwartungen (BFPE-12) ist ein Selbstrating zur Messung partnerschaftsbezogener Bindungsaspekte. Neben der Messung der Dimensionen Akzeptanzprobleme, Öffnungsbereitschaft und Zuwendungsbedürfnis können Personen Bindungsmustern zugewiesen werden. Die vorliegende Studie evaluiert Faktorenstruktur und psychometrische Eigenschaften des Instruments anhand einer aktuellen bevölkerungsrepräsentativen Stichprobe. Die Stichprobe umfasst N = 1574 Personen. Es wurden soziodemographische Variablen, der BFPE-12, die Kurzform des Depressive Experiences Questionnaire Self-Criticism sowie der Patient Health Questionnaire-4 erhoben. Es wurden explorative und konfirmatorische Faktorenanalysen durchgeführt und interne Konsistenz, Itemstatistiken und Korrelationen mit Außenkriterien bestimmt. Explorative und konfirmatorische Faktorenanalyse bestätigten die angenommene Faktorenstruktur (RMSEA < .08). Die interne Konsistenz der drei Skalen war akzeptabel (α > .7). Starke Akzeptanzprobleme und geringe Öffnungsbereitschaft korrelierten hypothesenkonform mit Selbstkritik, Ängstlichkeit und Depressivität. z-Werte, t-Werte und Prozentränge werden berichtet. Insgesamt kann für den BFPE-12 konstatiert werden, dass er eine mehrfach evaluierte Faktorenstruktur und akzeptable psychometrische Eigenschaften aufweist.

Using Attachment to Better Understand the Therapy Alliance: The Attachment Based Alliance Questionnaire

Questionnaires on the therapeutic alliance are available, but most show inflated scores, limited variability, and few significant findings on the bonds domain. Results of a study of 251 clinical couples, on the development of an Attachment Based Alliance Questionnaire (ABAQ), are presented. Factor analysis (EFA and CFA), show that a one-factor or two-factor structure fit the data, with more support for a one-factor model. Both models map closely with attachment constructs. Results also show that the ABAQ is predictive of changes couples make early in therapy and demonstrated adequate reliability and validity. The ABAQ provides a tool for clinicians as they learn how to attune to relationships in couple therapy and is helpful to researchers in understanding the alliance.

Effects of Therapeutic Alliance and Metacognition on Outcome in a Brief Psychological Treatment for Borderline Personality Disorder

Objective: The therapeutic alliance is possibly a crucial factor in treatment for borderline personality disorder (BPD). Among predictors of therapeutic alliance, aspects that have not yet been considered are metacognition or the patient's capacity to be aware of mental states. We therefore explored whether metacognition predicted alliance and if metacognition and therapeutic alliance together predicted outcome in brief treatment for BPD. Method: In a secondary analysis of a randomized controlled trial, we included N = 36 patients with BPD in the current study. The original trial assessed the effects of a 10 session psychiatric standard treatment with or without the added the Plan Analysis and the Motive Oriented Therapeutic Relationship. We assessed the therapeutic alliance session by session (Working Alliance Inventory), metacognition at session 1 (using the Metacognitive Assessment Scale-Revised) and outcome (using residual gains on the Outcome Questionnaire-45.2 between sessions 1 and 10). Results: A more differentiated capacity to understand the mind of the others at treatment onset predicted an increase of therapist-rated alliance over time. Therapist rated alliance was the only significant outcome predictor (B = -0.85, R Squared = .12). Conclusions: More differentiated metacognition predicted therapeutic alliance which in turn affected outcome, thus making metacognition a relevant therapy target early in therapy for BPD. Future studies should expand this investigation to patients with better functioning, treated with different modalities and with longer treatments.

The Relationship between Adult Attachment and Mental Health Care Utilization: A Systematic Review

OBJECTIVE

Several studies have shown a relationship between individual attachment and various aspects of treatment utilization in individuals with medical problems as well as mental health disorders. This review systematically evaluates existing literature targeting the relationship between attachment and all aspects of treatment utilization, such as engagement, participation, and completion, in adults with mental health problems.

METHOD

A computerized search of PsycINFO, Medline, Embase, PubMed, and Healthstar and a manual search were employed. Of 5733 titles, 105 abstracts were selected. Of these, 18 studies met full inclusion criteria. The quality of studies was evaluated and scored according to 9 characteristics.

RESULTS

Most studies supported an association between attachment and treatment engagement and participation. In general, attachment anxiety was associated with higher engagement and participation in services while attachment avoidance was associated with less. Data regarding attachment dimensions and treatment completion were less conclusive.

CONCLUSIONS

The review suggests a clear relationship between attachment and stages of treatment engagement and participation in a variety of psychiatric populations and treatments. The 2 attachment dimensions appear to have opposite effects, with possible risks for either treatment over- or underutilization. Clinical implications are discussed.

The relationship between attachment orientations and the course of depression in coronary artery disease patients: A secondary analysis of the SPIRR-CAD trial

OBJECTIVE

The relationship between attachment orientations and the recovery from depressive symptoms in patients diagnosed with coronary artery disease (CAD) with and without a psychotherapeutic intervention was examined in this study.

METHODS

In a multicenter trial of 570 depressed CAD patients (SPIRR-CAD), assigned to usual care plus either a stepwise psychotherapy intervention or one information session, 522 patients provided attachment data at baseline. Attachment was measured with the Relationship Scales Questionnaire (RSQ), yielding four attachment orientations. The primary outcome was change in Hospital Anxiety and Depression Scale depression (HADS-D) scores from baseline to follow-up at 18 months. Secondary outcomes were HADS-D scores at 1, 6, 12, and 24 months.

RESULTS

Independent of treatment assignment, attachment was related to change in depression at 18 months (p < 0.01) with secure attachment resulting in a significant reduction (-2.72, SE = 0.27) in depression compared to dismissive-avoidant (-1.51, SE = 0.35, p = 0.040) and fearful-avoidant (-0.65, SE = 0.61, p = 0.012) attachment. Patients with anxious-preoccupied attachment showed changes similar to secure attachment (-2.01, SE = 0.47). An explorative subgroup analysis across all assessment time points revealed patients with a dismissive-avoidant attachment benefitted from psychotherapy (average mean difference = 0.93, SE = 0.47, p = 0.048).

CONCLUSION

Attachment played an important role for improvement in depressive symptoms. Only dismissive-avoidant patients seemed to benefit from the intervention. The lack of improvement in fearful-avoidant patients shows a need for specific interventions for this group.

TRIAL REGISTRATION

www.clinicaltrials.govNCT00705965; www.isrctn.com ISRCTN76240576.

Changes of attachment characteristics during psychotherapy of patients with social anxiety disorder: Results from the SOPHO-Net trial

Objectives

Within a randomized controlled trial contrasting the outcome of manualized cognitive-behavioral (CBT) and short term psychodynamic therapy (PDT) compared to a waiting list condition (the SOPHO-Net trial), we set out to test whether self-reported attachment characteristics change during the treatments and if these changes differ between treatments.

Research design and methods

495 patients from the SOPHO-Net trial (54.5% female, mean age 35.2 years) who were randomized to either CBT, PDT or waiting list (WL) completed the partner-related revised Experiences in Close Relationships Questionnaire (ECR-R) before and after treatment and at 6 and 12 months follow-up. The Liebowitz Social Anxiety Scale (LSAS) was administered at pre-treatment, post-treatment, and at 6-month and 1-year follow-up. ECR-R scores were first compared to a representative healthy sample (n = 2508) in order to demonstrate that the clinical sample differed significantly from the non-clinical sample with respect to attachment anxiety and avoidance.

Results

LSAS scores correlated significantly with both ECR-R subscales. Post-therapy, patients treated with CBT revealed significant changes in attachment anxiety and avoidance whereas patients treated with PDT showed no significant changes. Changes between post-treatment and the two follow-ups were significant in both conditions, with minimal (insignificant) differences between treatments at the 12- month follow-up.

Conclusions

The current study supports recent reviews of mostly naturalistic studies indicating changes in attachment as a result of psychotherapy. Although there were differences between conditions at the end of treatment, these largely disappeared during the follow-up period which is line with the other results of the SOPHO-NET trial.

Trial registration

Controlled-trials.com ISRCTN53517394

Alliance Rupture and Resolution in Dialectical Behavior Therapy for Borderline Personality Disorder

The aim of this exploratory study was to investigate alliance rupture and resolution processes in the early sessions of a sample of clients who underwent 1 year of standard dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were three recovered and three unrecovered clients drawn from the DBT arm of a randomized controlled trial that compared the clinical and cost-effectiveness of DBT and general psychiatric management. Alliance rupture and resolution processes were coded using the observer-based Rupture Resolution Rating Scale. Unrecovered clients evidenced a higher frequency of withdrawal ruptures than recovered clients. Withdrawal ruptures tended to persist for unrecovered clients despite the degree of resolution in the prior session, unlike for recovered clients, for whom the probability of withdrawal ruptures decreased as the degree of resolution increased. This study suggests that alliance rupture and resolution processes in early treatment differ between recovered and unrecovered clients in DBT for BPD.

Relationships between patients' attachment characteristics and views and use of psychiatric treatment

This study explored the influence of attachment on psychiatric treatment by considering attitudes towards and the use of psychotropic medication and psychotherapy in patients with depressive and anxiety disorders. Adults referred to a psychiatrist completed self-report measures and participated in a diagnostic interview based on DSM-IV criteria. Those with depressive, anxiety or adjustment disorders were included (n = 124). Patients reported the types and dosage of current psychotropic medication as well as number of different psychiatrists and psychologists/counselors they had seen in the past 10 years. Multiple regression analyses were used to examine relationships between attachment anxiety and avoidance and the variables capturing treatment use and attitudes towards treatments. Attachment anxiety was positively associated with the number of current psychiatric medications and with both the number of psychiatrists and the number of psychologists/counselors seen. Attachment avoidance was negatively associated with the number of current psychotropic medications and beliefs about the efficacy of psychotherapy. The findings suggest that patients' attachment characteristics play a role in their views and choices regarding treatments. Developing treatments sensitive to the needs of insecurely attached individuals may lead to improved treatment outcomes.